What do you think? (9 y/o Sheltie) -Smokey has passed

[tuccillo]

Hi Folks,

My 9 year old, male (neutered), 33 lb. Sheltie was reluctant to go on walks and his coat started looking shabby including some thin spots above his shoulders and neck and "rat tail". Our vet found very low thyroid levels and put him on thyroxin. His creatinine levels were high and she also put him on a low protein diet. He may have also been consuming a bit more water than normal but was not that noticeable. After a week on the thyroxin and low protein diet, he started to consume a very noticeable amount of water and we started tracking his water consumption. Over a 3 week period his water consumption went from about 3 cups a day to 7.5 cups per day. After 3 weeks on thyroxin and the low protein diet we had him retested. The thyroid levels were much better and his energy levels and willingness to walk were much, much improved - he was like his old self. The creatinine level looked good but his ALKP was high (1035). Our vet thought this might be due to having had Heartworm (Trifexis) the morning of the test . A week later, we had him tested for Cushings via the ATCH Stim test. He came back as "high normal" with a value of 18. His ALKP was retested and was at 907. His urine was tested and the specific gravity was low. Our ver suggested we get a consult from an internist and that will happen this week. He does not have a "pendulous belly" but the rest of the symptoms seem to me to be Cushings even though the ATCH stim test was "high normal". Any thouhgts? Thanks.

[lulusmom]

Hi and welcome to the forum,

Based on the information you have provided thus far, I am not seeing cushing's. The fact that the increase in peeing and drinking occurred after putting your dog on thyroxine leads me to believe the dose may have been too high. When the dose is too high, the dog becomes hyperthyroid and the hallmark symptom of hyperthyroidism is excessive drinking and peeing. Can you tell us what dose of thyroxine she was started on and how much it was reduced. Can you also please round up all of the testing that has been done so far and post the results here? With respect to the bloodwork, we need only see the highs and lows and please include the normal reference ranges.

Was a complete thyroid panel done or did your vet make the diagnosis based strictly on the T-4 hormone? Hypothyroidism is one of the most common health issues in Shelties and the two symptoms you mentioned, being the coat and no interest in exercise are common in hypothyroidism. Hypothyrodism also causes elevations in ALKP. The fact that the ALKP improved after treatment would not be the norm for a dog with untreated cushing's.

Looking forward to hearing more about your girl's medical history. I'm sorry for the reasons that brough you to us but I'm glad you found us. We'll do everything we can to help you get your baby girl back on track.

Glynda

[tuccillo]

Thanks so much for your reply.

He started out with a thyroxin dose of 0.3 twice a day and after 3 weeks it was reduced to 0.2 and then a week later to 0.1. It did not reduce his water consumption (which has been accelerating). He is back to 0.2 twice a day.

After 3 weeks, the TT4 number was 3.2 and a week after that it was 1.8 (that was the day he had the ATCH Stim test and he did not have the thyroxin that morning plus the dose had been reduced). See numbers below also. Our vet did not think the dose was too high but was checking by having us reduce the dose. She initially did a complete thyroid test - I dont have the numbers from the initial testing. She said his creatinine level was high in the initial testing and put him on a low-protein diet. The two follow-up thyroid tests (at 3 weeks and 4 weeks) were for TT4 only.

After 3 weeks the number were as follows (picking out the abnormal numbers only). He had had his Trifexis that morning before the test - our vet thought that this might have affected the liver numbers. His creatinine was normal after 3 weeks.

ALT: 122, normal 10-100
BUN: 6, normal 7-27
ALKP: 1035, normal 23-212
GGT: 17, normal 0-7
TT4: 3.2


After another week (4 weeks after he started the thyroxin) ,the numbers were as follows:

ALKP: 907, normal 23-212
TT4: 1.8
CORT: 4.5 baseline
BUN: 4, normal 7-27
CORT: 18.0 after ATCH, normal 6-18

Our vet is perplexed and sent us to an internist, who we will see on thursday. While his water consumption might have been a tad higher than normal when this first started, it really accelerated over the last month. We started tracking it 3 weeks ago (one week after thyroxin and low protein diet began) and it has gone from less than 3 cups per day to 7.5 cups per day. He is getting me up in the middle of night to go out and pee - this is something we have never seen from him before. He has much more energy since he has been on the thyroxin - basicly he is a new dog - so that part is good. The water consumption has us very concerned. Basicly he is peeing every 2 hours or so. Previously we had to bride him with treats to get him to pee - if I had to guess I would say he used to drink about 2 cups a day. He eats dry dog food.


Hi and welcome to the forum,

Based on the information you have provided thus far, I am not seeing cushing's. The fact that the increase in peeing and drinking occurred after putting your dog on thyroxine leads me to believe the dose may have been too high. When the dose is too high, the dog becomes hyperthyroid and the hallmark symptom of hyperthyroidism is excessive drinking and peeing. Can you tell us what dose of thyroxine she was started on and how much it was reduced. Can you also please round up all of the testing that has been done so far and post the results here? With respect to the bloodwork, we need only see the highs and lows and please include the normal reference ranges.

Was a complete thyroid panel done or did your vet make the diagnosis based strictly on the T-4 hormone? Hypothyroidism is one of the most common health issues in Shelties and the two symptoms you mentioned, being the coat and no interest in exercise are common in hypothyroidism. Hypothyrodism also causes elevations in ALKP. The fact that the ALKP improved after treatment would not be the norm for a dog with untreated cushing's.

Looking forward to hearing more about your girl's medical history. I'm sorry for the reasons that brough you to us but I'm glad you found us. We'll do everything we can to help you get your baby girl back on track.

Glynda

[Steph n' Ella]

I noticed the water concuption go up in my Ella after she got her thyroid numbers up. I think it is a function of her not being so lethargic and sleepy that now she is actually up and around while she is thirsty :/ I haven't figured out what is triggering her excessive thirst, but I know for now it is not Cushings.

As for her thinning hair, I did get some of it to grow back. Mostly I've found that the hypothyriodism makes her skin so oily and waxy that the hair can't grow. Lots of baths and "de-greasing" the bald spots has helped (though right now the rat tail is back). I put a little astringent on a cotton ball and rub...

http://www.cleanandclear.com/products/astringents-toners

[tuccillo]

Smokey has always had a "bald spot" on the end of his nose right before his snoot. It might be more accurate to say that it was covered with very thin white hair and the underlying skin was pink so it looked "bald". Over the last year that area had really gone bald and expanded. Since he has been on thyroxin, hair is growing back. He still has a bit of a "rat tail" (actually not that bad) but it may be too early to tell if it is filling out. The water consumption is very troubling to us.



I noticed the water concuption go up in my Ella after she got her thyroid numbers up. I think it is a function of her not being so lethargic and sleepy that now she is actually up and around while she is thirsty :/ I haven't figured out what is triggering her excessive thirst, but I know for now it is not Cushings.

As for her thinning hair, I did get some of it to grow back. Mostly I've found that the hypothyriodism makes her skin so oily and waxy that the hair can't grow. Lots of baths and "de-greasing" the bald spots has helped (though right now the rat tail is back). I put a little astringent on a cotton ball and rub...

http://www.cleanandclear.com/products/astringents-toners

[Steph n' Ella]

Ella was the same! Bald on her little nosey! Now her hair is back too. These replacement hormones are just like a miracle!

[tuccillo]

We took Smokey to an internist and she took a blood and urine sample. Apparently his T4 number is up to 5.6 - he is taking a dose of 0.2 thyroxine twice a day. The internist suggested we take him off the thyroxine for 2 weeks and see what happens to his water consumption. She agreed with our vet that it is not obvious what is going on. A culture from the urine sample is still pending to check for an infection.


Thanks so much for your reply.

He started out with a thyroxin dose of 0.3 twice a day and after 3 weeks it was reduced to 0.2 and then a week later to 0.1. It did not reduce his water consumption (which has been accelerating). He is back to 0.2 twice a day.

After 3 weeks, the TT4 number was 3.2 and a week after that it was 1.8 (that was the day he had the ATCH Stim test and he did not have the thyroxin that morning plus the dose had been reduced). See numbers below also. Our vet did not think the dose was too high but was checking by having us reduce the dose. She initially did a complete thyroid test - I dont have the numbers from the initial testing. She said his creatinine level was high in the initial testing and put him on a low-protein diet. The two follow-up thyroid tests (at 3 weeks and 4 weeks) were for TT4 only.

After 3 weeks the number were as follows (picking out the abnormal numbers only). He had had his Trifexis that morning before the test - our vet thought that this might have affected the liver numbers. His creatinine was normal after 3 weeks.

ALT: 122, normal 10-100
BUN: 6, normal 7-27
ALKP: 1035, normal 23-212
GGT: 17, normal 0-7
TT4: 3.2


After another week (4 weeks after he started the thyroxin) ,the numbers were as follows:

ALKP: 907, normal 23-212
TT4: 1.8
CORT: 4.5 baseline
BUN: 4, normal 7-27
CORT: 18.0 after ATCH, normal 6-18

Our vet is perplexed and sent us to an internist, who we will see on thursday. While his water consumption might have been a tad higher than normal when this first started, it really accelerated over the last month. We started tracking it 3 weeks ago (one week after thyroxin and low protein diet began) and it has gone from less than 3 cups per day to 7.5 cups per day. He is getting me up in the middle of night to go out and pee - this is something we have never seen from him before. He has much more energy since he has been on the thyroxin - basicly he is a new dog - so that part is good. The water consumption has us very concerned. Basicly he is peeing every 2 hours or so. Previously we had to bride him with treats to get him to pee - if I had to guess I would say he used to drink about 2 cups a day. He eats dry dog food.

[lulusmom]

We took Smokey to an internist and she took a blood and urine sample. Apparently his T4 number is up to 5.6 - he is taking a dose of 0.2 thyroxine twice a day. The internist suggested we take him off the thyroxine for 2 weeks and see what happens to his water consumption.

Normal reference range for T4 is 1.0 - 4.0 so yep, 5.6 is definitely high. This was my first suspicion so I'll be very interested to see if the excessive drinking and peeing resolves in the next week or so. Just out of curiosity, did you give Smokey his dose of thyroxine 4 hours before the specialist did the blood test?

[tuccillo]

The internist did want to know when he was given the morning dose of thyroxine. We tried to time it based on his appointment and it worked out that they drew blood about 4.5 hours after the dose. What is odd is that his TT4 number was 3.2 after 3 weeks at a dose of 0.3 twice per day and blood drawn 5 hours after his morning dose. He is growing a lot of new hair on the bald spot on his nose, which is good.


Normal reference range for T4 is 1.0 - 4.0 so yep, 5.6 is definitely high. This was my first suspicion so I'll be very interested to see if the excessive drinking and peeing resolves in the next week or so. Just out of curiosity, did you give Smokey his dose of thyroxine 4 hours before the specialist did the blood test?

[tuccillo]

He has been off the thyroxine for 7 days. His energy levels are still good. His water consumption has dropped from 7.5 cups per day to 4 cups per day, and still dropping. When we first started tracking his water consumption he was at 2.8 cups per day - that was after one week on thyroxine. We were asked to keep him off of the thyroxine for 2 weeks and then call the internist.



Normal reference range for T4 is 1.0 - 4.0 so yep, 5.6 is definitely high. This was my first suspicion so I'll be very interested to see if the excessive drinking and peeing resolves in the next week or so. Just out of curiosity, did you give Smokey his dose of thyroxine 4 hours before the specialist did the blood test?

[molly muffin]

So it would appear that the thyroxine was contributing factor in the water increase. Does the internist want to retest after 2 weeks?

Sharlene

[tuccillo]

I don't know yet. I was also asked to collect urine sample every 3 days for the 2 weeks to look at the specific gravity. On his walk this morning he seemed a little tired - hard to say for sure yet. I will see how he does tomorrow. I would like to believe that his issues are thyroid only but it is hard to believe that he was dramatically overdosed at 0.2 mg/day for a 33 lb dog. Also the high ALKP numbers don't appear to be correlated with a thyroxine overdose based on Google searches.


So it would appear that the thyroxine was contributing factor in the water increase. Does the internist want to retest after 2 weeks?

Sharlene

[tuccillo]

He has been off thyroxine for almost 3 weeks. During the first two weeks, urine samples taken every 3 days showed his urine specific gravity increase from 1.010 to 1.025. The internist wants to keep him off thyroxine for a total of 4 week and then repeat blood tests for TT4, FT4, and TSH as well as check his liver enzymes, presumably ALPK, which has been high. His water consumption is down to 2.7 cups per day from a high of 7.5 cups per day when he was taking 0.2 mgs of thyroxine twice per day. His energy levels are still good, perhaps down a little bit. He still has a lot of flakes in his fur but hair has regrown on his nose. Other thinning spots on his neck are looking better.



I don't know yet. I was also asked to collect urine sample every 3 days for the 2 weeks to look at the specific gravity. On his walk this morning he seemed a little tired - hard to say for sure yet. I will see how he does tomorrow. I would like to believe that his issues are thyroid only but it is hard to believe that he was dramatically overdosed at 0.2 mg/day for a 33 lb dog. Also the high ALKP numbers don't appear to be correlated with a thyroxine overdose based on Google searches.

[lulusmom]

Any number of conditions, whether chronic or not, can cause transient decreases in T4 hormone. Once the offending condition has resolved, the T4 usually normalizes so, given your great report on Smokey's improvements since discontinuing the thyroxine, I think that may have been what happened. Since your vet didn't seem to be able to put the pieces together, I'm glad he referred you a specialist who could. If this truly is the scenario, consider yourself extremely lucky. I'll be looking forward to your next update.

Glynda

[gummysmurf]

Not to discount any of the other symptoms, but was the urine actually cultured to see if anything would grow? A UTI will also cause excessive drinking, and I bet an infection will skew some of the numbers in the blood lab results too.

In my case my dog had cushings PLUS a UTI, so he was drinking lots and lots. (and it took several repeat cultures before they found the bacteria in his urine)

[tuccillo]

Hi Folks,

We wound up waiting a total of 6 weeks (instead of 4 weeks) after we stopped the thyroxine to have blood taken again for a thyroid panel and liver enzyme test (perhaps others). I wanted to wait until his water consumption leveled off. The internist is having the blood work done in Michigan, I believe. His water consumption has leveled off at 1.6 cups per day. His energy levels are pretty good, down a bit perhaps, and much better than when we first started on the thyroxine. The hair on his nose looks good and the thin spots on his neck are filling in. His tail looks better. He still has a fair amount of flaking in his coat, however. It will be several days before we hear the results of the blood work.


Any number of conditions, whether chronic or not, can cause transient decreases in T4 hormone. Once the offending condition has resolved, the T4 usually normalizes so, given your great report on Smokey's improvements since discontinuing the thyroxine, I think that may have been what happened. Since your vet didn't seem to be able to put the pieces together, I'm glad he referred you a specialist who could. If this truly is the scenario, consider yourself extremely lucky. I'll be looking forward to your next update.

Glynda

[tuccillo]

Tes, the urine was cultured and came back negative. He has been off the thryoxine for 6 weeks and blood was just drawn for new testing. Please see my other post from today. I will post his test results when they come back - hopefully in a few days.


Not to discount any of the other symptoms, but was the urine actually cultured to see if anything would grow? A UTI will also cause excessive drinking, and I bet an infection will skew some of the numbers in the blood lab results too.

In my case my dog had cushings PLUS a UTI, so he was drinking lots and lots. (and it took several repeat cultures before they found the bacteria in his urine)

[molly muffin]

Crossing fingers for good results on the test. It sound like there is improvement to be seen, so that is really good!

Sharlene and Molly Muffin

[tuccillo]

We got the test results back from DCPAH at Michigan State University. Please recall that he has been off thyroxine for 6 weeks. The MSU endocrinologist's diagnosis was "hypothyroidism due to lymphocytic thyroiditis". Some of the numbers are as follows:

TT4: 5 nmol/L, normal 11-60
TT3: 0.0 nmol/L, normal 0.8 - 2.1
Free T4 by dialysis: 1 pmol/L, normal 6-42
FT3: >29.8 pmol/L, normal 1.2-8.2
TSH: 127 mU/L, normal 0-30


His ALKP number is still high at 353 (down from 1000 when he was on 0.2 mgs of thyroxin twice per day). Normal range is 23-212. The internist didn't seem concerned about this. It is not clear to me why thyroxine would cause this number to go up. It was 208 when we first took him to our vet for testing (back in Sept).

The internist and our vet suggested putting him back on thyroxine at 0.2 mg ONCE per day. We started that this morning. His energy levels seem to be "winding down a bit" but his coat is still looking better. His water consumption has hit steady state at 1.5 cups per day. It was at 7.5 cups per day when he was taking 0.2 mgs of thyroxine TWICE per day. We will continue to monitor his water in consumption.

His weight has been up and down. He was at 36 lbs when we first brought him in. A switch to a low protein diet (with lower calories) plus the thyroxine dropped his weight to 32 lbs after 4 weeks. We upped the amount of food and went back to regular senior dog food, at the recommendation of the internist, and he is back up to 37 lbs. He is a bit heavy now and we are cutting back a bit on his food.

The internist wants to recheck his thyroid levels again in 4 weeks. She did not rule out doing additional tests based on what we see in 4 weeks.

Seems to me that there is something else going on because what would appear to be a normal thyroxine dose increased his water consumption by 5x and also resulted in a much higher ALKP number (208 -> 1000). Perhaps he is just very sensitive to thyroxine and was dramatically overdosed before (at 0.2 mgs TWICE per day)?


Crossing fingers for good results on the test. It sound like there is improvement to be seen, so that is really good!

Sharlene and Molly Muffin

[lulusmom]

Hi and thanks for the update. I have always felt that the dose of thyroxin was too high and was responsible for the increase in drinking and peeing. Now that I know how much he weighs, it makes perfect sense. Recommended dosing is .1mg per 10 lbs and your dog's healthy weight is most certainly under 40 lbs. I am glad to see the specialist has restarted the thyroxin on .2mg "once" a day and hopefully that will be the magic dose.

Glynda

[tuccillo]

Hi and thanks for the update. I have always felt that the dose of thyroxin was too high and was responsible for the increase in drinking and peeing. Now that I know how much he weighs, it makes perfect sense. Recommended dosing is .1mg per 10 lbs and your dog's healthy weight is most certainly under 40 lbs. I am glad to see the specialist has restarted the thyroxin on .2mg "once" a day and hopefully that will be the magic dose.

Glynda

Thanks so much for your reply. Our vet originally started him out on 0.3 mg twice per day and it was cut back to 0.2 mg twice per day and that was the dosing when he was taken off of the thyroxine. The internist suggested we restart him at 0.3 mg once per day and our vet suggested 0.2 mgs once per day: we went with 0.2 mgs once per day. Is there normally this much "slop" in the dosing?

[tuccillo]

Hi and thanks for the update. I have always felt that the dose of thyroxin was too high and was responsible for the increase in drinking and peeing. Now that I know how much he weighs, it makes perfect sense. Recommended dosing is .1mg per 10 lbs and your dog's healthy weight is most certainly under 40 lbs. I am glad to see the specialist has restarted the thyroxin on .2mg "once" a day and hopefully that will be the magic dose.

Glynda

Smokey has been on 0.2 mgs once per day for almost a week. His water consumption has been pretty constant between 1 and 1.5 cups per day. Energy levels are still good and fur continues to look better than before. As you pointed out, the poor dog was probably being overdosed by 3x. We won't know for sure until another blood test after a month or so.

[molly muffin]

It really does sound like you made the right decision in going with the .2 mgs. I think it was an over dosing situation and yep, it does happen.
The thing with any medicine is that while there are recommended ranges for medication per weight. Every dog can react differently to any medication. That is why we have to really pay attention when a new medicine is introduced and do testing to follow up if we notice anything abnormal.
You have done all of this and done it really well too.

Sharlene and Molly Muffin

[tuccillo]

It really does sound like you made the right decision in going with the .2 mgs. I think it was an over dosing situation and yep, it does happen.
The thing with any medicine is that while there are recommended ranges for medication per weight. Every dog can react differently to any medication. That is why we have to really pay attention when a new medicine is introduced and do testing to follow up if we notice anything abnormal.
You have done all of this and done it really well too.

Sharlene and Molly Muffin

Hopefully our experience will contribute in some way to the "knowledge pool" of this group. I don't think the story is completely over yet but I have reached a couple of tentative conclusions. While it appears in retrospect that he was dramatically overdosed with thyroxine based on the high water consumption, the follow-up blood tests by our vet did not seem to indicate this based on the TT4 number. The numbers varied from 3.6 to 1.8 over a one week period. Only when a separate test by the internist showed a value of 5.6 did it become clear that he was overdosed. The lesson I learned is that there may be considerable variation in the blood test results and we should have been responding to his symptoms much sooner. I also didn't realize that there was a considerable "lag" in the response to changing the dosage. When we reduced his dosage from 0.3 to 0.2 twice per day his water consumption continued to increase. We subsequently learned that the effect of the thyroxine takes weeks to wash out of his system. I believe it is unlikely he has cushings. He apparently does have a thyroid issue and is more sensitive to thyroxine than the "average" dog.

[tuccillo]

Hopefully our experience will contribute in some way to the "knowledge pool" of this group. I don't think the story is completely over yet but I have reached a couple of tentative conclusions. While it appears in retrospect that he was dramatically overdosed with thyroxine based on the high water consumption, the follow-up blood tests by our vet did not seem to indicate this based on the TT4 number. The numbers varied from 3.6 to 1.8 over a one week period. Only when a separate test by the internist showed a value of 5.6 did it become clear that he was overdosed. The lesson I learned is that there may be considerable variation in the blood test results and we should have been responding to his symptoms much sooner. I also didn't realize that there was a considerable "lag" in the response to changing the dosage. When we reduced his dosage from 0.3 to 0.2 twice per day his water consumption continued to increase. We subsequently learned that the effect of the thyroxine takes weeks to wash out of his system. I believe it is unlikely he has cushings. He apparently does have a thyroid issue and is more sensitive to thyroxine than the "average" dog.

Apparently Smokey's gallbladder ruptured. The internist gave him low odds of surviving the surgery and we reluctantly decided to put him to sleep. Not a good day.

[cheydogger]

I am so sorry to hear about Smokey. I am sending thoughts and prayers your way.

Hugs,

Ro

[lulusmom]

I am so very sorry for your loss. My thoughts and prayers are with you.

Godspeed Sweet Smokey

[labblab]

I, too, am very saddened to read of your loss today. Smokey's name has now been added to our special memorial list of honor:

http://www.k9cushings.com/forum/showthread.php?t=2865

We hope it may bring you some comfort to know that he will always be remembered here, alongside our other precious ones who have passed on to Rainbow Bridge. We will always be here to listen should you care to return to share more thoughts and memories of your own.

Sending many hugs today, in honor and memory of your dear boy.
Marianne

[Boriss McCall]

I am so sorry for your loss. :(

hugs

[mytil]

I am so very sorry about your little sweetie pie. My heart is with you and please stay with us - in case you need big shoulders to lean on.

((((hugs))))
Terry

[NoonelovesmelikeNorman]

I am very sorry to hear of smokey's passing. With heartfelt sympathy.

[tuccillo]

I am very sorry to hear of smokey's passing. With heartfelt sympathy.

Thanks everyone for your thoughts.

Jim

[molly muffin]

Oh no :( I'm soooo sorry.
Thinking of you and your family.

Hugs,
Sharlene

[Bo's Mom]

I am so terribly sorry to read about Smokey's passing. ((((HUGS))))