My doggie has been on treatment for cushings - Brownie has passed

[Marce]

Her name is brownie, I am not sure of the breed she is a stray I took in a couple of years ago, which I now love with all my heart. She looks like a shiatsu pekingese mix, relatively small, though she has gained some weight as of late. Last year she was diagnosed with cushing's. All of her heir on her back fell out and her skin was black and constantly itching. I researched all about the subject as I could not find a Vet who knew what Cushing's was, I am currently living in Peru. I found a Vet who had an idea and started her on 30mg of Trilostane daily a few months back, imported from the UK as they don't sell the medication here.

After a few months all her hair grew back, and she seemed to be getting back to normal. This is a history of her ACTH Stimulation test results.

Date. | Basal | 3 Hr | 8 Hr
--------------------------
02/22 | 4.64 | 0.62 | 3.37
03/16 | 3.04 | 0.28 | 3.11
05/30 | 2.02 | 0.54 | 2.86
08/27 | 4.28 | 0.49 | 0.11
11/12 | 4.70 | 0.14 | 0.24


When I received the last one I got a recommendation from the vet to readjust her dosage. So I began googling all about medication readjustment and I read that one should make sure that the test results are accurate before readjusting the dosage as one can overdose the patient. They cited that the ACTH should be taken 2-4 hours after Trilostane dosage to get an accurate result. We had never done this, I had always given her her medication around 10am the previous day, and they would pick her up at 8 am in the morning to take the test. So the test was administered roughly 22 hours after taking the meds. Reading that it could be a false result alarmed me and I told the Vet that I wanted to retake the test giving her the medication in the morning as I had read, and these were her results that I got a few minutes ago, taken 2 hours after dosage.

11/26 | 0.41 | 0.13 | 0.55


That seems way too low!! I'm not sure how to read this, does this mean that in the mornings she is below threshold (<1.8) and at nights she exceeds it (>4.5)? Should I be looking at the basal cortisol levels or the 3 hour or the 8 hour to measure if she is below threshold? I don't know what to do. Her Vet should have known that she needed to be on meds before testing! I no longer trust her and I cannot find a decent vet around here, so I need to make these decisions myself now.

Lately she has started scratching again, and I can feel bumps in her back that itch her as she gets pleasure and starts moving her legs involuntarily when I scratch her there. Also shes had a raw sore in her belly that hasn't healed for weeks, I put neosporin on it to help it but hasn't healed yet. Also the past few days she has been limping when we go out to walk in the mornings and seems more tired. I thought nothing of it, but now I think It may be related to her low levels of cortisol in the mornings. Could this be a sign that she is being affected by it? What should I do, please help!

I am thinking of splitting up her 30 mg pills into thirds and giving her 10mg of the powder mixed in with her food in the mornings and 10mg at night. Lowering her total dosage to 20mg, and splitting so as to balance her out. Is this correct? Or do I need to take more drastic measures? Maybe stop her medication for a period of time before doing this?

What should I do, I need help!

[Blaze's Mom]

Hi Marce! Welcome to a wonderful place to be!! I am pretty new to this whole thing too, so I don't have any answers for you, but the experts will be along shortly, I promise. They are a wealth of information. I just wanted to say hi and welcome you here. You will definitely find a great group of people and a home here. It is a tough situation, but there is light at the end of the tunnel. My sheltie, Blaze, was recently diagnosed and we are going to an Internal Medicine Specialist on Friday. We hope to find out more information there. I can tell you that you will bombarded with questions about all the bloodwork and symptoms and anything else you can tell about your precious Brownie. The questions are asked lovingly as they can be a lifesaver to us. Hang on, read up, and know that we are all here for you!!

Trish and Blaze

[frijole]

Boy am I glad you found this site! We're going to hit you with a bunch of questions but hang with us and we will help you ok?

First off - do NOT split the pills. If you read the information on the packet it specifically says do NOT split them..

What has me confused is the acth test results. The acth test is a two hour test not an 8 hour test. The 8 hr test is the LDDS (low dose dex suppression) and it is only used to diagnose cushings - not to monitor trilostane/vetoryl!

So I don't think that any of those test results are even valid!

How much does your dog weigh? You have only been on the 30 mg dosing daily right? No changes at all over the last 2 months?

I want to see if the dosage is right for your dog's weight.

Kim

[frijole]

I wanted to provide you with more information on what the acth test is. It is a TWO hour test and while sometimes it is used to diagnose cushings, it is the ONLY test that is used to monitor the effectiveness of cushings meds like vetoryl/trilostane.

How Is an ACTH Stimulation Test Performed?


Your veterinarian will begin the test by drawing a small amount of blood from your pet to check the baseline (“starting”) cortisol level. Afterward, a very small amount of ACTH is given by injection. A repeat blood sample is taken 1 to 2 hours after the injection to measure the cortisol level and determine if the body’s response is appropriate. The blood samples are submitted to a diagnostic laboratory, and results are generally available within a few days.


https://www.vetsecure.com/natomasamc.com/articles/211

http://www.k9cushings.com/forum/showthread.php?t=196

It looks to me as if your vet is doing the LDDS test which is only used to diagnose dogs with cushings. I can tell from the test results that your dog has pituitary type cushings by the way.

So you are right - your vet is clueless. Luckily your dog has not suffered from overdose. The lethargy you mentioned could be from a high dose but it also could be from the cushings not being controlled.

That is why I asked your dog's weight.

Kim

[Marce]

Thank you guys for being so welcoming! I'm so happy I found this place. Hopefully I can learn all about this so I can help my brownie. Hope your Blaze gets well too Trish :)

Kim- she has actually gained weight recently, like few couple of pounds out of nowhere. She weighs 14 pounds currently.

I'm calling them ACTH because that's what I though the were giving her, but now I do not know. Don't know what the Spanish translation for ACTH is so I assumed it that was it. I have been trusting these Vets to know what they are doing, and now I am pretty certain they don't. So they may indeed be administering the diagnosis exam over and over.

Here are all the documents I have received from them for various tests they have done. They are in Spanish but one can get the gist of them regardless.

https://www.dropbox.com/sh/tugib1jysg0g5jg/3533ECuAt_

I'm going to stop giving her meds for the time being until I can get this sorted out.

[frijole]

You are in luck! I speak a bit of Spanish!

[molly muffin]

Hello and welcome! Really glad you found us. Yes, do listen to Kim, really the only ones that should be doing anything with the trilostane inside the vetroyl medicine would be a compounding pharmacy.
Just as a note, make sure that the vet has given you prednisone to have on hand, just in case of a crisis. It may never need to be used, but you'll feel 10 times better just to have it, especially since you are basically teaching your vet as you too learn.
It does look like the LDDS test, with the 8 hour results. Great for before you start to get a diagnosis, not so good afterwards when you want to know what the cortisol is doing in reaction to the medication.
I wonder if there is a problem getting the ACTH agent in Peru?
However, the good thing is that yes, it doesn't look like there has been any over medicating. Still it's good to be on top of things like that.
I wonder Kim, if they can't get the agent to do the ACTH test, if the LDDS Could be substituted? Have you ever heard of that?
There are lots of people here who have quite a bit of experience with vetroyl and cushings. The years combined would probably earn them all a doctorate. :)
Others will be along soon to ask questions, say hello, etc.
In the meantime I extend a warm hand in welcome. Brownie sure is a cute little thing!

Sharlene and Molly Muffin

[frijole]

While I wait for the documents to open up - please tell us what symptoms your dog had that led to the diagnosis..... like huge appetite, drinking gallons of water a day, peeing in the house, etc. Thanks.

[frijole]

OK I read the documents and they indicate that they found fungal spores and are treating with antibiotics.

Here's what I can tell you - the skin issues may or may not be related to the cushings. Cushings dogs are prone to skin issues and if the vetoryl was working then it would resolve. Also dogs with cushings take longer to heal then normal dogs because their immune systems are compromised.

Back to the cushings and the trilostane. Most vets have learned that it is best to start with a small dose and then test with the acth test to see if it is enough. If not then the dosage can be increased and you do another acth test.

A dog weighing 14 lbs would start at 10 mg or 20 mgs a day. So 30 is on the high side - however signs of low cortisol would be vomiting, diarrhea. Lethargy could be a sign that the cortisol is starting to go too low.

That is why I asked about the original symptoms that led to the diagnosis. If Brownie had a huge appetite has it returned to normal? If Brownie drank a ton of water has that returned to normal? I'm looking for progress. :)

The acth test numbers typically look like this:

Pre - 1.5 Post - 4.5

The second number is the most important. It tells you how much cortisol is being produced by your dog. Cushings is caused by the adrenal glands overproducing cortisol. Pituitary cushings is caused by a pituitary tumor near the brain (not cancerous) sends messages to the adrenal glands to produce cortisol even though the body does not need it. Think of it as 'bad wiring'.

The goal of giving the trilostane is to reduce the amount of cortisol to a level of between 1.0 and 5.0 on the acth test. (the 2nd number on the test)

The only way that you can tell if the drug is working is to do a real acth test. That is why I sent the documentation in hopes you could print it and give it to them!

Kim

[Marce]

It all started with a fungus like thing on the lower end of her back, and it got bigger, and bigger, and her hear started falling out in that one spot and her skin got black. Then it started growing and growing, I told the vets o do all the tests possible that money was not a concern. They vets thought it was a skin bacteria and for eight months I watched my brownie deteriorate and the vets could do nothing. I read online about Cushings and asked them to do a test. She had Cushings. I asked the vets why they didn't test for that that It would have been obvious to anyone who knew of the disease, they told me it never crossed their mind. So I left them and looked for new vets, the current ones. I told them about Cushings and they seemed to be informed of the subject. I researched medicines and told them I wanted to give her Trilostane, which they didn't know about being that they didn't sell it here, but once they read abut it they confirmed it was the right medicine to give her. A few months later and my brownie was getting back to normal, with her white hair growing back. Right now she looks like she did back then before this all started.

At her worst she would drink tons of water too, I did notice that.

Here are some pictures of the whole journey, from the pictures I took when I first found her. To the point where she took the Cushings diagnosis.

https://www.dropbox.com/sh/tugib1jysg0g5jg/7YD9qhmYs1/Photos

[Marce]

She was vomiting a few weeks back and I took her to the Vet and they said It could be something she ate. She has also been getting diarreah on and off. And lethargy now as well. It does seem she has been overdosing based on these symptoms then. I am going to take her tomorrow to another Vet to get a real ACTH test.

[frijole]

I'm searching for some other photos to share with you to compare... in the meantime did they ever do a complete blood panel? Normally cushings dogs have high liver enzymes (alk phosphate is the main one that is high)?

[Marce]

I think that's the one in the BioChemistry folder. It says FOSFATASA ALCALINA which is Alkaline Phosphate at 59.9. Though it says its within range. AST and ALT are high, don't know what those are.

[frijole]

Wow... your vets are clueless! Yes - if she's had diarrhea and vomit then the dose is too high. How long has this been going on? How long was she on the trilostane before she had the vomit/diarrhea?

The good thing is that it doesn't stay in the system long so you simply quit giving it and in a day or so she should start to feel better. So no more trilostane for now.

I am searching for some photos of dogs with skin issues for you to look at and see if they look similar. It might take me a while.

If the alk phos is normal then I question if it is cushings. There is a disease called atypical cushings that is easy to treat and it causes skin issues. Sometimes it is caused by giving steroid medications. Has Brownie had any drugs with steroids?



Kim

[frijole]

OK... the skin issue caused by cushings is called canine calcinosis cutis. Here are photos from some members whose dog had it. It does need to be treated so I can understand your concern. Does your dog's skin look like this?

http://www.k9cushings.com/forum/album.php?albumid=473

http://www.k9cushings.com/forum/album.php?albumid=445

Also you can google canine calcinosis cutis and see lots of other photos if it helps. Kim

[Marce]

That's good news, I am stopping the Trilostane for now. She had a vomiting attack once about three to four weeks back, threw up a bunch of times within an hour or two. She had never vomited before. She hasn't since.

She has had allergy attacks about five times since I've had her, when we are out walking she would get all fidgety and scratchy and shaky and I know she is having an attack, and she starts getting swollen up and I've taken her to the Vets and they give her Cortisol injections. But this has been after the Cushings not certain if it was before. Maybe once but cannot be sure.

The skin problem progressed for 8 months, and reverted when starting Trilostane. Now she looks like she did in that picture with the all white hair. It definitely helped her

[Marce]

That looks really bad, it didn't look like that, it was different. This is the worse that she has gotten, black skin and hairloss:

https://www.dropbox.com/s/v1b4pxjb7mge75y/IMG_0793.jpg

https://www.dropbox.com/s/3vqnlefvgivghuz/IMG_0846.JPG

Now she looks like this:

https://www.dropbox.com/s/5gh08ezc18ek83o/IMG_0387.JPG

Here are all the photos:

https://www.dropbox.com/lightbox/home/Brownie/Photos

[frijole]

I think that's the one in the BioChemistry folder. It says FOSFATASA ALCALINA which is Alkaline Phosphate at 59.9. Though it says its within range. AST and ALT are high, don't know what those are.

For some reason all the files weren't there the first time I looked but they are now! Interesting to me is that the earlier blood work that was done in February the alk phos WAS elevated and the other two were normal.

This and the photos and your description of the water intake AND the many many LDDS tests make me believe your dog does have cushings :)

Brownie's tummy is round like a cush dogs. By the way Brownie is adorable!

I searched a database of international internal med specialists but could not locate any in Peru. Typically the universities where they teach the vets have good knowledge and technology... is this an option?

[frijole]

She has had allergy attacks about five times since I've had her, when we are out walking she would get all fidgety and scratchy and shaky and I know she is having an attack, and she starts getting swollen up and I've taken her to the Vets and they give her Cortisol injections. But this has been after the Cushings not certain if it was before. Maybe once but cannot be sure.



!!!!! They gave a dog with cushings a cortisol shot?!!!! That is a total no no. That is like giving a diabetic a bunch of sugar to eat. Cortisol is what your dog is over producing and overdosing on. No more of those!

[Marce]

Thank you :) She is. That's a good idea, I'm gonna try some universities. Yep they gave her Cortisol, a few times. They told me it was the lesser of two evils that she could die If the swelling doesn't go down. Is there an alternative way treatment for an allergy attack that I could suggest next time?

[frijole]

There probably is but I don't know! I think checking with the university is a good start.

I'd take all those test results (to save time and money) and explain everything to them. And most important, get a real acth test done. I know if they do the other test to diagnose they have to be able to get the acth gel. It is expensive I will warn you. If you can locate where to get it we can save you money because they can reuse the gel and freeze it for future testing. Alot of vets don't know this trick ;)

Do keep us posted ok? We become very attached. :)

Kim

Buena suerte y abrazos para Brownie!!!

[SoggyDoggy]

Quick question here Kim, If Brownie is having these attacks, looks to be on too high a dose, when Marce takes her to the vet, perhaps the vet giving the cortisol is what has stopped here from having the crisis? Could it be that they have inadvertantly saved her even while not knowing what they are doing? Just wondering. Would the cortisol dose not work the same as a dose of Prednisolone? Being so new to all of this myself, I could be totally off base, but this was the first thing that popped into my head, so I am just wondering. :confused:

[Marce]

Thank you so much Kim for all your help, you have no idea how much you have helped me and my Brownie. I will let you guys know how it goes :)

[Marce]

That's an interesting theory Soggy. Indeed it would make sense.

[frijole]

Quick question here Kim, If Brownie is having these attacks, looks to be on too high a dose, when Marce takes her to the vet, perhaps the vet giving the cortisol is what has stopped here from having the crisis? Could it be that they have inadvertantly saved her even while not knowing what they are doing? Just wondering. Would the cortisol dose not work the same as a dose of Prednisolone? Being so new to all of this myself, I could be totally off base, but this was the first thing that popped into my head, so I am just wondering. :confused:

My laptop connection died so I had to switch pc's!

I'm laughing at the irony but you could be right. Not sure of the timing of the lethargy vs the shot etc. I'm also not convinced that the dose is too high until I see an acth test. Normally it'd be obvious before 2 months but it could be that the cortisol has declined over time and therefore the lethargy.

Once a dog is regulated they shouldn't get the shots - better clarify that! :)

[frijole]

Thank you so much Kim for all your help, you have no idea how much you have helped me and my Brownie. I will let you guys know how it goes :)

Glad to help. I found this site over 7 years ago when my girl Haley was diagnosed by a clueless vet so I have a soft spot in my heart for those with clueless vets! :D True story.

[labblab]

Thank you :) She is. That's a good idea, I'm gonna try some universities. Yep they gave her Cortisol, a few times. They told me it was the lesser of two evils that she could die If the swelling doesn't go down. Is there an alternative way treatment for an allergy attack that I could suggest next time?

Welcome from me, too! I am so glad Kim was here last night to talk with you! She's already given you a ton of good info, so right now I only have this little bit to add. I have a dog who suffers from allergies, too, and she's had one acute episode where her whole head swelled up and she had hives all over her chest. When I rushed her into the vet, she was given a cortisone shot, too, in order to relieve the swelling and inflamation. If a dog's airways swell up from an allergic attack, it's true that it can actually be life-threatening. So in this case, your vets are probably doing the right thing. Even though you don't want to be treating a Cushing's dog with steroids for an extended time period, an emergency injection may be necessary.

I know that epinephrine (adrenaline) injections are also given to halt acute allergic reactions. Many humans who are at risk carry around "epi-pens" in order to have the ability to self-inject in an emergency. But I don't think ephinephrine has the same anti-inflammatory properties that cortisone does. So I guess that's where it becomes a judgement call by the vet as to whether or not the cortisone is the better treatment depending on how your dog is presenting at the time of the attack.

Acute allergic episodes can be very scary, that's for sure. So in that instance, a temporary shot of steroids may really be necessary.

Marianne

[frijole]

Awesome Marianne! I'm glad you found this thread also due to your knowledge of trilostane! Kim

[Marce]

Hi guys, its been a while. Let me tell you of brownies progress. I was not able to find any ACTH stim tests here in Peru so I've been keeping her on a steady dosage 15mg in the morning and 15mg at night. A few days ago month they gave her a biochemistry exam and the results are of very high values indicating liver problems, she also got an echo and it shows a shrinking liver.

2/25/2013 (latest)

AST: 228
ALT: 144
ALP: 590
BUN: 29
UREA: 61

5/21/2012

AST: 80
ALT: 64
ALP: 60
BUN: 14
UREA: 33

2/22/2012 (trilo treatment started)

AST: 39
ALT: 47
ALP: 178
BUN: 20
UREA: 43

It's a marked increase. Her vet gave her a prescription of antioxidants and Ursodeoxycholic acid to help with her liver. He also a tells me I should wean her off of trilostane and keep her of, his logic being that her hepatic health is much more important than her cushings right now, and trilostane could be what is causing these liver problems. I asked him if the cushings itself can hurt her liver, he tells me no, it is a completely separate from her hepatic problems.

But I read online that cushings itself, the high cortisol count, affects the liver directly and can cause elevated enzymes. Could it be that the elevated counts are from the cushings and not from the trilo? What will be more harmful to her? The trilo or the extra cortisol? So I'm at a loss of what to do. I will be following the vet's advice for the time being, hopefully her enzyme levels get better, but now im worried all her cushings symptoms will come back, her hair will fall out, her skin will get oily and rashy and she will start to non-stop scratching like she used to. Any advice regarding cushings treatmemts to a patients with hepatic problems would be super appreciated. I'm really scared for my brownie right now. I have seen her have moments of shakes and shallow breaths, I just hope I didn't catch her high levels too late :(

EDIT:

Reference ranges:

AST: 1-49
ALT: 1-57
ALP: 10-101
BUN: 9-26
URA: 20-55

[Squirt's Mom]

Hi Marce,

Do you by any chance have the normal values for these levels you posted? That would help us a great deal.

Your vet is wrong about the liver not being affected by Cushing's. It is one of the main organs that is affected. However, liver disease can present with the same signs as Cushing's, including elevated cortisol, yet not be Cushing's. Has Brownie had an abdominal ultrasound? If not, can she get on there in Peru? If she can, I would have one done asap if at all possible to look at the liver. A biopsy may need to be done at the same time.

I can share a little about liver values -

• ALKP (ALP) is important in metabolism and is found in liver cells.
High levels indicate bile duct obstruction, Cushing's, liver disease,
certain cancers and may be due to certain drugs such as steroids or
phenobarbital. Low levels indicate starvation or malnutrition.

• AST is important in the breakdown and elimination of nitrogen.
High levels indicate muscle damage, heart muscle damage, liver
damage, toxin ingestion, inflammation and various metabolic
disorders. Low levels indicate starvation or malnutrition.

• ALT is also important in the metabolism of nitrogen and is most
often associated with the liver. High levels indicate liver damage,
toxin ingestion, Cushing's disease and various metabolic
disorders. Low levels indicate starvation or malnutrition.

• GGT is also important in nitrogen metabolism and is found
within liver cells. High levels indicate bile duct obstruction, liver
disease, pancreatitis, Cushing's and can be caused by high levels
of steroids. Low levels indicate starvation and malnutrition.

As you can see, Cushing's is listed as a cause for all of these values along with other considerations. So Cushing's DOES have an impact on this organ, no question about it.

The flip side is this, tho - if a pup has liver disease, none of the treatments used for Cushing's should be used with that pup. So the first step is to find out why those values are elevated. Is the liver diseased or is something else going on? I would think it highly unlikely that the Trilo is causing these elevations tho if there is liver disease present, it may be aggravating it.

Please let us know what you decide to do about further testing on the liver and especially how Brownie and you are doing, 'k?

Hugs,
Leslie and the gang

[lulusmom]

It is difficult to tell how severe the liver values are without the normal reference ranges but I can tell that Brownie does appear to have something other than cushing's affecting her liver. While cushing's does impact the liver, it does not kill liver cells. Excess cortisol messes with metabolic functions and with respect to the liver, it causes an over accumulation of glycogen which actually causes the liver to enlarge. If Brownie's liver has become smaller on imaging, that is definitely what you usually see with primary liver disease. As liver cells are destroyed, the liver shrinks. At this point, I think your vet made a good call to stop treatment and focus on treating the liver. The medication your vet has prescribed is commonly used to treat hepatitis. Did he also prescribe an antibiotic?

Ask your vet about adding milk thistle to the treatment regimen. Also you should feed Brownie several small, low fat meals to ease the workload on the liver. Is Brownie still eating normally? There are any number of sites you can access to educate yourself on canine liver disease so that you have a better understanding of what is happening to Brownie. Here's a url to a good source of info:
http://canineliverdiseasefoundation.org/?cat=8

Glynda

[goldengirl88]

Marce:
I just want to welcome you and say please listen to the experienced people on here, as this can affect your dogs health. I read some of your posting , but admit when I got to the part of you splitting up the capsule and putting it in her food I went into panic mode and wanted to immediately email this. Dechra told me the pills should never even so much as be punctured by your dogs teeth!!! This Vet doesn't know anything about treating Cushings. This is dangerous, as this is a powerful drug. I don't want to scare you, but you need to follow the direction of the experienced people on here. I haven't been on here that long, but know you can fully trust these people on here. I don't want anything to happen to your baby. Not trying to sound mean, but I am scared of the situation you are in. God Bless you and your baby.

[Marce]

Hi Marce,
Do you by any chance have the normal values for these levels you posted? That would help us a great deal.


Thank you Leslie. These are the reference ranges for those values:

AST: 1-49
ALT: 1-57
ALP: 10-101
BUN: 9-26
UREA: 20-55


2/25/2013 (latest)

AST: 228
ALT: 144
ALP: 590
BUN: 29
UREA: 61

5/21/2012

AST: 80
ALT: 64
ALP: 60
BUN: 14
UREA: 33

2/22/2012 (trilo treatment started)

AST: 39
ALT: 47
ALP: 178
BUN: 20
UREA: 43

As you can see she was normal before the trilo, then three months after the trilo the ALP got better, but AST and ALT started to get elevated, then a year later all were elevated.



Your vet is wrong about the liver not being affected by Cushing's. It is one of the main organs that is affected. However, liver disease can present with the same signs as Cushing's, including elevated cortisol, yet not be Cushing's. Has Brownie had an abdominal ultrasound? If not, can she get on there in Peru? If she can, I would have one done asap if at all possible to look at the liver. A biopsy may need to be done at the same time.

Yep she got an ultrasound this is what it said, translated from spanish:

Image size liver conservative, sharp edges, regular surface, parenchyma homogeneously mixed granular echotexture with slightly increased echogenicity, portal vessels and liver vessels gauge conservative. Distended gallbladder wall conservative anechoic content.
Image conservative splenic size 9.19 mm thick, sharp edges echogenicity conservative parenchyma homogeneous fine granular echotexture.
Images conservative renal size with 31.46 mm and the right length 33.99 mm left, surfaces regular cortico medullary differentiation decreased slightly, slightly thickened cortices with increasing medium echogenicity.
Image without gastric distension, minimal fluid content, thickened wall with prominent folds. Bowel loops without bloating, gas content and mucoid in transit conservative wall.
Image pancreatic apparently normal.
Image distended bladder wall conservative anechoic content with small amount of sediment.

All this talk of conservative sizes means it is reduced.


As you can see, Cushing's is listed as a cause for all of these values along with other considerations. So Cushing's DOES have an impact on this organ, no question about it.

The flip side is this, tho - if a pup has liver disease, none of the treatments used for Cushing's should be used with that pup. So the first step is to find out why those values are elevated. Is the liver diseased or is something else going on? I would think it highly unlikely that the Trilo is causing these elevations tho if there is liver disease present, it may be aggravating it.

Please let us know what you decide to do about further testing on the liver and especially how Brownie and you are doing, 'k?

Hugs,
Leslie and the gang

My poor brownie, I will be taking her to get her liver problems diagnosed in more detail. Will keep you guys updated, thanks Leslie.

[Marce]

It is difficult to tell how severe the liver values are without the normal reference ranges but I can tell that Brownie does appear to have something other than cushing's affecting her liver. While cushing's does impact the liver, it does not kill liver cells. Excess cortisol messes with metabolic functions and with respect to the liver, it causes an over accumulation of glycogen which actually causes the liver to enlarge. If Brownie's liver has become smaller on imaging, that is definitely what you usually see with primary liver disease. As liver cells are destroyed, the liver shrinks. At this point, I think your vet made a good call to stop treatment and focus on treating the liver. The medication your vet has prescribed is commonly used to treat hepatitis. Did he also prescribe an antibiotic?

Interesting, so its likely its not the cortisol. He did not prescribe an antibiotic, would this be something to help with the liver somehow?




Ask your vet about adding milk thistle to the treatment regimen. Also you should feed Brownie several small, low fat meals to ease the workload on the liver. Is Brownie still eating normally? There are any number of sites you can access to educate yourself on canine liver disease so that you have a better understanding of what is happening to Brownie. Here's a url to a good source of info:
http://canineliverdiseasefoundation.org/?cat=8

Thank you I will do this. Right now she is eating three small meals of Royal Canin Hepatic, as per doctor's orders. Thanks for the url Glynda :)

[Marce]

Marce:
I just want to welcome you and say please listen to the experienced people on here, as this can affect your dogs health. I read some of your posting , but admit when I got to the part of you splitting up the capsule and putting it in her food I went into panic mode and wanted to immediately email this. Dechra told me the pills should never even so much as be punctured by your dogs teeth!!! This Vet doesn't know anything about treating Cushings. This is dangerous, as this is a powerful drug. I don't want to scare you, but you need to follow the direction of the experienced people on here. I haven't been on here that long, but know you can fully trust these people on here. I don't want anything to happen to your baby. Not trying to sound mean, but I am scared of the situation you are in. God Bless you and your baby.

Thank you Tipper's mom. I used to give her half the open cap for a couple of months. I hope that wasn't the cause of the liver problems. :(

Now my mom, who works pharmaceutical manufacturing in the US, is sending me the powder from the 120mg trilostane caps re-packaged into 15mg caps. It comes out much cheaper this way. Do you guys see any danger to doing this?

[frijole]

Glynda and others - I'm on a quick fly by and can't respond but please read the entire thread before saying anything positive about the vet... poor dog. :( No acth tests in Peru - been doing ldds everytime instead.

Marce - I was wondering what happened to you. I'll be back tonight to check in. Hugs, Kim

[Marce]

Glynda and others - I'm on a quick fly by and can't respond but please read the entire thread before saying anything positive about the vet... poor dog. :( No acth tests in Peru - been doing ldds everytime instead.

Marce - I was wondering what happened to you. I'll be back tonight to check in. Hugs, Kim

Yep :(. Though I recently found a document by pure luck on the internet that describes ranges for alternate testing of just the 4-hour post-pill resting cortisol (no ACTH stim test needed). I will be using this method to test her levels from now on.

(second table towards bottom of the page)
http://www.fvmace.org/FVMA_83rd_Annual_Conference/Proceedings/Cushing%E2%80%99s%20Disease%20a%20case-based%20review.html

[goldengirl88]

Marce:
You need to call Dechra. When I was going to have Tipper's pills repackaged they told me that if the pharmacist uses any fillers the drug will not work properly. There cannot be any fillers in the new capsules, nothing at all. They really cautioned me on this. This could cause the readings to be skewed. Good luck and let us know what is going on. God Bless You and Your Baby.
Patti

[Rural doggie]

Yep :(. Though I recently found a document by pure luck on the internet that describes ranges for alternate testing of just the 4-hour post-pill resting cortisol (no ACTH stim test needed). I will be using this method to test her levels from now on.

(second table towards bottom of the page)
http://www.fvmace.org/FVMA_83rd_Annual_Conference/Proceedings/Cushing%E2%80%99s%20Disease%20a%20case-based%20review.html

Thanks for posting that link, Marce! My dog seems to have a bad reaction to the stim tests, so I'll talk over this option with my vet.

[Marce]

Marce:
You need to call Dechra. When I was going to have Tipper's pills repackaged they told me that if the pharmacist uses any fillers the drug will not work properly. There cannot be any fillers in the new capsules, nothing at all. They really cautioned me on this. This could cause the readings to be skewed. Good luck and let us know what is going on. God Bless You and Your Baby.
Patti

Ah that's perfect, yes there are no fillings being added, its just the powder split into smaller pieces.

[Marce]

It's been a while since I posted here. Brownie has been pretty much stable with Trilostane. This week she has been very lethargic, not wanting to walk when taken outside. Yesterday she started throwing up multiple times, and had diarrhea. Got some labs done and this is what I got back:

https://i.imgur.com/XtPLdGI.jpg

Notice her Creatinine levels. Last labs done Oct 2015 had her at 1.7. Now she is at 7.2. Now I fear she is experiencing Acute Kidney Failure. The vet tells me that it is weird that her creatinine levels would spike like that if she was fine before, and that if she was experiencing Stage 4 Kindey Failure like this she would be in a worse off shape, and so thinks its a lab failure, and so wants to re-test her Monday.

Have any of you guys had experience with this? I know Trilostane elevates Creatinine levels, could this be due to this and if we stop administering it might go down? Or should I prepare to say goodbye to her?

[Marce]

It's been a while since I posted here. Brownie has been pretty much stable with Trilostane. This week she has been very lethargic, not wanting to walk when taken outside. Yesterday she started throwing up multiple times, and had diarrhea. Got some labs done and this is what I got back:

https://i.imgur.com/XtPLdGI.jpg

Notice her Creatinine levels. Last labs done Oct 2015 had her at 1.7. Now she is at 7.2. Now I fear she is experiencing Acute Kidney Failure. The vet tells me that it is weird that her creatinine levels would spike like that if she was fine before, and that if she was experiencing Stage 4 Kindey Failure like this she would be in a worse off shape, and so thinks its a lab failure, and so wants to re-test her Monday.

[Squirt's Mom]

MODERATOR NOTE: I have merged your post asking about kidney failure into your baby's original thread. We like to keep all the history about each pup in one place so it is easier to look back thru the history. Thanks!

[Harley PoMMom]

That upward spike in the creatinine is worrisome. Has the vet mentioned having IDEXX SDMA kidney test performed? I also see her glucose is elevated and her WBC also, did the vet say anything about those two levels? Is her phosphorus elevated?

I'm including a link with info regarding that IDEXX SDMA test: https://www.idexx.com/small-animal-health/solutions/articles/case-study-discovering-disease-with-sdma.html

Hugs, Lori

[labblab]

Marce, I'm sorry to say that with the combination of letheragy, vomiting, and diarrhea alongside very highly elevated BUN and creatinine, I'm afraid Brownie is truly experiencing kidney failure. I don't think this sounds like a simple lab error. If she is lethargic, vomiting, and has diarrhea, why is your vet saying that she doesn't seem to be very sick???? Those symptoms are classic for renal failure.

If her creatinine and BUN are truly this elevated, her body is being overwhelmed by a toxic overload that has to be relieved, I believe, by IV therapy. Other blood chemistries may also be quite imbalanced, as well, and in need of treatment.

If these results are genuine, I'm afraid that Brownie is only going to worsen and perhaps quite rapidly. How is she doing now?

Marianne

[Marce]

Thank you for your responses. I am very worried. She was not eating or drinking or peeing over the weekend, then on monday they gave her fluids and gave her a corticoid, and she bounced back that night. Started eating again, and drinking, and vomiting and lethargy stopped and she kinda looks like she's back to her old self since then. I was hoping it was Addisson's. Her cortisol was down to 1 (she takes trilostane) maybe it has been even lower for a while now without me noticing.

Took another biochemistry test 4 days after the previus one and her BUN shot up to 160 from 103 (maybe cause she was only wanting to eat meat for the couple of days after her apetite stopped) but oddly her Creatinine went down from 7.2 to 5.7. How can this be, is this normal?

This is the result of her electrolytes test, her phosphorous is elevated.

CLORO : 116.5 mEq/L ( 110.0 – 124.0 mEq/L )
POTASIUM : 5.2 mEq/L ( 3.9 – 5.1 mEq/L )
SODIUM : 178.9 mEq/L ( 140.0 – 152.0 mEq/L )
PHOS : 14.5 mg/dl (1.9 – 7.9 mg/dl )
CALCIUM : 8.26 mg/dl (9.0 - 10.8 mg/dl)

I also put together some of her lab history in excel and chart form. From 2012 - 2013 her cortisol was going up and down trying to find the right dosage of trilostane for her. Red is elevated values.

https://i.imgur.com/TuY9j4T.png

Thank you again for your responses.

[Marce]

Whatever it was it seems to have been temporary. Her Cretinine is down to 2.88 and her BUN to 50. She seems to be getter better, im thinking it was the Trilostane.

[molly muffin]

I am so glad to hard she is doing better and that the creatinine has come down. Is she eating, drinking and everything okay now too?

[Harley PoMMom]

The elevated phosphorus can make a dog feel very nauseated, when the phosphorus is high a binder is needed.

[labblab]

You know, it may well be the case that she was overdosing on the trilostane. I keep forgetting that elevated creatinine and BUN can accompany an Addisonian crisis and lead to an initial misdiagnosis of kidney failure.


[During Addisonian crisis] The blood panel will come back showing elevations in the renal parameters (BUN and creatinine) and thus with the elevated potassium is suggestive of acute renal failure, a condition with an extremely poor prognosis. The veterinarian may become suspicious of another diagnosis as the patient will respond well to fluid administration and most renal failure patients do not respond as well..
In combination with the lethargy, vomiting, and diarrhea, an Addisonian crisis is certainly a possibility. The fact that Brownie has rebounded so nicely while off the trilostane surely does make it seem as though overdosing was the culprit. I would be very cautious about starting Brownie back on trilostane until you actually see reemergence of overt Cushing's symptoms and even then, certainly at a lower dose.

Marianne

[Marce]

Thank you everyone for the help when I needed it.

Brownie passed away Sunday morning. She lost her battle with Cushing's disease. The medicine she was taking contributed to an Acute Renal Failure and she passed due to her ongoing Pulmonary Hypertension which she was too weak to fight. Friday she began heavy labored breathing. Once every one to two seconds, and had to use her stomach muscles to breathe. She hadn't eaten, drank, or peed for a few days. She was weak and I imagine exhausted of all the labored breathing.

I lay next to her with my face in front of hers looking at her eyes, and began petting her, telling her how much of a good girl she was. and looking at my eyes her breathing became more shallow until it stopped, she just wanted to rest. She left with her most loved human in front of her, being comforted and loved, hearing words that made her remember better times.

I will miss you Brownie. Thank you for spending your time with me. You brought immeasurable happiness to my life, as I hope I did to yours. I love you.


In Memory of Brownie, a compilation of videos I took throughout her life in case anyone wants to see what she was like when she was live and well:

https://www.youtube.com/playlist?list=PL27QQtVQ5cDunBMPVGExQSBoFbZ6xJPLO

[molly muffin]

What a wonderful set of videos detailing Brownies life and what a great time you had with her and the joy she brought you.
I'm very sorry to hear of her passing and send you my sincerest condolences.

We have added Brownie to our In Loving Memory thread in honor of those who have passed. It is located here: http://www.k9cushings.com/forum/showthread.php?t=7676

[Joan2517]

Oh, I am so sorry for your loss of Brownie...he was so lucky to have you with him at the end.

[PennysDad]

OMG, I am so very sorry for your loss. Sending you so much love an good vibes. Some day I am sure you will be able to go back and think how lucky you and Brownie were. When we are with our dogs, they are as happy as they possibly can be, just because we are there. What an incredible blessing.

Wishing you more laughter and less tears in the coming weeks.

Jeff

[budindian]

I am so sorry for your loss. I am going thru similar situation, I lost my precious furbaby three weeks ago, its a hard loss. Be good to yourself.

[Tammysmom]

So very sorry for the loss of your sweet Brownie. Such a cutie. Since the day you took her in, you gave her what she wanted and needed the most. Love. Please take care of yourself. Brianna

[mytil]

My heart goes out to you and I am so very sorry!

Thank you so much for posting the link to the videos - what a treasure and what a cutie pie. She certainly had a very happy life with you and I know will be keeping an eye on you.

(((((hugs)))))
Terry

[scoora]

I am so very sorry to hear of the loss of your sweet Brownie!

[Allison]

I[m sorry for your loss of Brownie. From her videos, she seemed like such a playful and loving dog. Our adopted senior dog, whom we lost to Cushings, also had a zest for life.

It's good you were able to have time to say goodbye. Being able to do this with our pets has helped tremendously with my grief, although my heart still ached. But those moments become special.

You have an incredible collection of videos. I didn't take near enough of our pets, but mostly have photos. It's nice to be able to see them in motion and remember all of how they acted. Videos do this.

Thank you for sharing. Again, I'm sorry for your loss. Hugs!


Brownie passed away Sunday morning. She lost her battle with Cushing's disease.

I lay next to her with my face in front of hers looking at her eyes, and began petting her, telling her how much of a good girl she was. and looking at my eyes her breathing became more shallow until it stopped, she just wanted to rest. She left with her most loved human in front of her, being comforted and loved, hearing words that made her remember better times.

I will miss you Brownie. Thank you for spending your time with me. You brought immeasurable happiness to my life, as I hope I did to yours. I love you.

In Memory of Brownie, a compilation of videos I took throughout her life in case anyone wants to see what she was like when she was live and well:

https://www.youtube.com/playlist?list=PL27QQtVQ5cDunBMPVGExQSBoFbZ6xJPLO

[Angus2223]

I am also sincerely sorry for your loss. You were both blessed to have one another. One day at a time....
God Bless,

Jessica

[judymaggie]

I am so sorry for your loss -- Brownie had a wonderful life with you right up to the last moment!