5 yr old Chihuahua just diagnosed Cushings

[Beth]

Hi everyone, I'm new here and am so thankful to have found this forum. My 5 year old Chihuahua girl, Lola, was just diagnosed with Cushings disease. My husband and I have noticed her putting on weight (especially in her "pot belly" over the past months as well as darkened skin on her belly, excessive water consumption and urination and she's always hungry. So I did a little research on these symptoms and read about the possibility of Cushings so off to the vet we went.

He ran a CBC first showing an elevated alk. phosphatase (576) so he ordered an ACTH test to be done. After reading countless amounts of info on the net I see that this wasn't necessarily the best test to start with, but, it was what he did. The results of the ACTH test showed, as he told me, that she was positive for Cushings. He then prescribed Vetoryl. Upon receiving a copy of her labs, I see that her post ACTH cortisol level was 21.8 with a ref. range of 8.0-17.0.

I picked up the medicine on Thursday, but our vet is out of the office until Monday and we don't want to start using it until we've talked with him so we understand it better. We read the inserts in the package and they sound terrifying! Such nasty side effects and worrisome possibilities have us so scared. But it seems as though we really have no other options, and of course we just want to help our baby girl.

My Chihuahua boy has had hepatic MVD since he was a baby and I learned early on the tremendous value that dedicated forums like this one offer. My boy was not expected to live past 2 years old but with tireless research, my liver shunt forum, and his trooper like attitude I am proud to say that he is now almost 6 years old and doing quite well.

Lola is a warrior. I truly believe this. She is only 5 and I just can't imagine losing her. We will do whatever is needed to help her. I surely appreciate the amount of information I've already read here and look forward to learning more and getting to know everyone.

Thanks for reading
Beth

[labblab]

Dear Beth,

Hello and welcome to you and Lola! We are very glad you've found us and will do anything we can to help.

First off, there's nothing at all wrong with your vet's decision to perform an ACTH. One of the drawbacks to the ACTH is that it sometimes misses a "positive" result when a dog actually does have Cushing's. But a plus is that when it is positive, it is more likely to genuinely reflect the presence of Cushing's -- it is less likely to be falsely skewed by other, nonadrenal illnesses. I am assuming that there are no other abnormalities in Lola's labwork that implicate other problems such as diabetes, kidney issues, low thyroid?

So Lola exhibits some classic symptoms and has now tested positive on the ACTH. One limitation of that test, though, is that it cannot distinguish between the pituitary and adrenal forms of the disease. Since adrenal Cushing's can actually be cured by surgery, this is information that some owners are anxious to learn. At this stage, probably your best diagnostic in that regard would be an abdominal ultrasound. Not only does the imaging provide useful information about the adrenals, but it also supplies info about the presence or absence of issues with other internal organs. In many ways, it lends further validation to the diagnosis by ruling out other problems and confirming any abnormalities with the adrenal glands. Has your vet mentioned the possibility of an ultrasound to you? It usually does involve a referral to a specialty practice.

Assuming you do end up treating with Vetoryl, can you tell us hiw much Lola weighs and also what dose of Vetoryl you have been given? Dosing recommendations have shifted dramatically downward fairly recently, and current advice is to start with no more than 1 mg. per pound. With Lola, this may mean needing to have a custom dose compounded.

Once again, welcome, and I look forward to reading more about your girl!

Marianne

[Squirt's Mom]

Hi Beth and welcome to you and Lola! :)

5 is a bit young to have Cushing's but not unheard of however for this reason I would want to look a bit further for a reason the cortisol might be elevated before starting treatment. See, cortisol can be elevated for any number of reasons that have nothing to do with Cushing's. These tests can only tell us that it is elevated but not why.

My Squirt had five positive tests but an ultrasound found a tumor on her spleen and when it was removed, her cortisol returned to normal and remained that way for some years. Cortisol is the body's natural response to stress of any kind - internal or external. So I always highly recommend the ultrasound as part of the diagnostic phase. As Marianne said, it can tell you so much about many organs.

I am assuming Lola has been in good health otherwise...no other health issues that you know of, not on any meds?

I'm glad you found us and look forward to following Lola's journey. Ya'll are family here now and we will be with you every step of the way. Never hesitate to ask question and we will do our best to help.

Hugs,
Leslie and the gang

[Beth]

Thank you so much Marianne and Leslie for your replies. I'm glad you mentioned the ultrasound, as I was thinking about that. My vet has not brought it up but I read about it being a good diagnostic tool. I guess one obstacle might be her small size. She is ten pounds, and I was told by the specialist that did ultrasound to my other Chi's liver that it was like looking for something the size of a pen tip in something the size of a nickel! (then again, he's smaller than Lola at only 4 pounds). So I'm wondering if that will be an issue here, but still I will certainly ask my vet when we talk to him Monday. Especially if there is a possibility that it is actually something else causing the elevated cortisol levels. Her only other abnormal CBC test result was elevated Lipase (755 with a range of 77-695).

As for the Vetoryl, the way he's prescribing it is one 10 mg capsule per day. But we have so many questions still, like I read how important ACTH re-testing is at 10 days, and he didn't mention this. Is that right about the re-testing?

Unfortunately, Lola has some other issues. She has sinus/breathing problems. We've had her x-rayed and checked for collapsing trachea but the vet said he found nothing there. However, she literally sometimes sounds like a severely brachycephalic dog when she is not. Sometimes, if she's really worked up, she has a hard time getting her breath and it's scary. When she was a young pup she had a severe sinus infection and started putting her tongue off to the side out of her mouth between her teeth and it sort of stayed that way. Almost like her tongue is too big for her mouth. We treat her with homeopathic sinus meds as well as benadryl. We had a different vet claim it was her being overweight that causes her breathing difficulty, but our current vet (the one who's basically cared for her since puppyhood) says that he doesn't think weight is the only issue, but still gave no other explanation other than it's just how she's built.

So that and her other current symptoms being the pot belly with darkened belly skin, hair thinning/loss on her chest, sides and under her arms, excessive thirst/urination and crazy appetite. I have noticed how in my reading that most dogs are older than her when diagnosed so that does concern me and cause me worry about other possibilities. Thus far the vet has said that she is "text book cushings" but like you mentioned about Squirt, Leslie, I wonder if there is something else amiss.

Thanks again for your replies and kind welcome, I'm certainly grateful for them and your knowledge!

Beth

[Squirt's Mom]

...hair thinning/loss on her chest, sides and under her arms

This is another anomaly. Cushing's hair loss is typical confined to the other end - tail, butt, back legs; a "rat tail" is a common sign in cush pups. Not that all cush pups follow the rule book, mind you! We've had some here that you could actually hear saying, "Oh, yeah? Well, watch this!" ;):p Does the CBC show a result for T4?

[Beth]

This is another anomaly. Cushing's hair loss is typical confined to the other end - tail, butt, back legs; a "rat tail" is a common sign in cush pups.

Really? I didn't know that. So with Squirt, was she showing signs of Cushings? I'm really interested because I'm wondering if Lola is dealing with something "other" like Squirt. Her T4 results were 0.8 with a range of 0.8-3.5

Also, since her Lipase was elevated, I'm worried that there might be something there (pancreatic?)

[Squirt's Mom]

Squirt was panting, acting less interested in things and doing what I called "hiding" - she would lay under furniture instead of following me around. But I just put it off to her getting older (she was almost 10 the first time I heard the word Cushing's) plus a recent move. When she went for a dental they pre-blood work came back with elevated cortisol.

With the thyroid (T3) borderline, you might want to look into a full thyroid panel. It could be off due to Cushing's but it may be that the thyroid is getting whacky and hypothyroidism mimics Cushing's in many ways.

Lipase I'm not sure about; when it and amylase are both elevated then pancreatitis is certainly a consideration but I'm not sure about the Lipase alone.

[Beth]

Ok I see. Lola sort of acts that way also. She always seems tired and uninterested except when it comes to food and she has very little stamina when it comes to taking a walk. She also gets "twitchy" or "trembly" like her legs are weak or something.

That is also a very good thought about hypothyroidism...I will pursue this with the vet as well. Thank you so much, you have been helping me tremendously already!!

[Junior's Mom]

Hi Beth, welcome to the forum. Just to put your mind somewhat at ease about the age thing. My dog had just turned 5 when cushings became suspect. I had one vet tell me it COULDN'T be cushings because of his age. I have waited a year to start treatment as his symptoms weren't too bad at first.
Cush dogs tend to be prone to pancreatis, so a lower fat diet is recommended. My Junior had high lipase, cholesterol and triglycerides last year. His amylase was in the high end of normal. I had a pancreas test done to rule out any problems. I switched his food to 10% fat, and started giving salmon oil (omega 3's) every day. His levels came down to normal.
I hope your baby is well.

[labblab]

Hi again, Beth. Yes, one of the puzzles re: Cushing's diagnostics is that many symptoms, on their own, can be shared with other illnesses. So that's why you do have to look at the total picture and decide which diagnosis offers the best explanation. In Lola's case, on an individual basis, many of her problems could also be caused by something else. But collectively, they are pretty much all consistent with Cushing's.

As Junior's mom has said, Cushpups are prone to pancreatitis and also excessive steroid levels, own their own, can increase lipase. Her increased ALKP is definitely associated with Cushing's. Thyroid levels can also be depressed with Cushing's, which would be consistent with her low-normal thyroid reading (which, if caused by Cushing's, may elevate again upon effective treatment). As Leslie says, hair loss on the chest is not so commonly reported wth Cushing's, but hair loss on the sides definitely is (usually described as symmetrical body hair loss). My own Cushpup had two huge bald areas on his flanks in addition to loss on his haunches. Darkened skin can by caused by low thyroid, but also by Cushing's. And of course, we already know about the significance of excessive hunger, thirst, urination and muscle weakness that makes it harder for dogs to jump up or tolerate previously normal exercise regimens.

So yes, Lola's symptoms could individually be caused by something else. But the collection of symptoms in conjunction with the positive ACTH point to Cushing's in my own mind. As I said earlier, though, if it were me, I'd feel more comfortable if an ultrasound was also performed prior to starting treatment. It would be an additiional source of information that could further clarify the Cushing's diagnosis or instead identify some other problem that has been missed thus far. It takes a high-resolution ultrasound to clearly view the adrenals, though, and most general practice vets do not have equipment this sophisticated. That is why a specialty referral is often necessary.

Bottom line is that for me personally, I do think that Lola's complete symptom profile is indeed consistent with Cushing's. But it would be nice to have the additional information and peace of mind that could be supplied by an ultrasound. By the way, if and when she does start Vetoryl treatment, the 10 mg. capsule daily sounds like a reasonable place to begin. And standard monitoring protocol is to perform the first monitoring ACTH around two weeks into treatment (or at least a baseline cortisol at that early stage to ensure that her level has not dropped too low), and then a full ACTH at the 30-day mark.

Marianne

[addy]

Hi and Welcome,

My own pup had thinning hair under her arms and on her back and sides as well, her hair on her tummy never grew back from being shaved from her ultra sound. Cushings will usually spare the legs and head so I dont think it unusual if you see thinning hair on her sides. Actually, it reminds me of a picture on the Dechra site.

http://www.dechra-us.com/Files/dechraUSA/downloads/Client%20Literature/Vetoryl%20Client%20Brochure%20-%20English.pdf

it shows a pup before treatment, at 3 months and then nine months.
page down to read through and view the photos.

When a Cush pup's hair thins and becomes sparse, you may also start seeing dry skin, dandruff scales, greasy hair and oil deposits. These may be easier to notice on a pup with light skin and hair. Since they are prone to infections use may also start seeing skin infections.

Gotta run, just wanted to give you a heads up on the hair loss.

[Beth]

Thank you all so much for your responses! My hubby and I are reading each post with eager interest and we are so appreciative to know about each different experience.

So tomorrow (Monday) we'll be calling her vet during his "office time" (before appts) and we have made a list of points and questions that we want to cover with him and thanks to you wonderful and knowledgeable folks we've been able to compile a very good list so far!

[spdd]

Hi & welcome to the forum. This Cushing diagnosis is difficult and my experience with this forum for a few months plus several different possible scenarios has kept me very well informed. I've been dealing with issues since May of this year and we still don't have things normalized yet. I had my dog on Vetoryl (Trilostane) but have since stopped until we get things resolved.

I'll tell you how terrific this forum is. Sharlene is actually going to meet me this Wednesday at an IMS office to see things through with "mah boy" Keesh & myself as she has far more knowledge then I do and will ask all the right questions.... how's that for going above and beyond here??? :D

Sure hope that you are able to resolve your issues quickly, and with Lola being so young, she has that going for her.

[molly muffin]

Hello Beth, welcome to you and Lola.

I think the main thing and it is what we all worry about, is ruling out anything else that might be causing the cortisol to be elevated. So, if glucose is normal, then you can probably rule out diabetes. You'll check with the vet about thyroid, and consider the possibility of an ultrasound to give you a good idea of what is going on inside. At 10lbs it will be easier to see than with your 4lb baby boy, but not as easy as a 40lb ready. We didn't have any problems seeing on my 18.6lb shih tuz/llahso dog. It's just important that whomever would do the ultrasound has experience with the machine and smaller dogs and that it is high res, so shows everything.

I think you are making fine progress, it isn't the easiest disease to get a diagnosis for and ruling out other possibilities is always a good first step before starting medication. Once you have done that, then you can feel a bit more confident in the cushing specific tests, like the ACTH or LDDS.

Welcome :)
Sharlene and Molly Muffin

[Junior's Mom]

Hi Beth, how is Lola doing?

[Beth]

Hi everybody, I haven't been able to get back on for a while due to some really difficult things going on, but now I can so I thought I'd post an update on Lola before I begin reading through the threads I've missed.

She has been on the Vetoryl for one month as of yesterday. My vets course of action was to have her on 10mg daily for 30 days then have her resting cortisol tested which we did yesterday. Results of that were 2.4 which according to the vet is where we are wanting them to be. We are finally seeing things like her walking away from the food bowl when she's full and not being so ravenous all the time. She has lost 1 lb so is down from 10.6 lbs to 9.4 lbs. We are shooting to get her around 6-7 lbs at this time. Her thyroid was checked and is normal.

The vet was considering having her go up to 15mg since her water drinking and eating haven't lessened too much, however, as the days pass, she is lessening them even more so he's willing to wait another month and encourages weight loss in the mean time. He doesn't see the value in the ultrasound with her particular case but said if we want do that with a specialist, that he'd be on board. My husband and I vary on opinion here.

I still don't like her taking this drug everyday. It scares me that it's a human chemo therapy drug and the insert showing the trial statistics are worrisome. But on the other hand, I can't just do nothing either. I thought we were working toward a maintenance dose, but it doesn't seem that way. So that's pretty much all for now. I'm still controlling her sinus/respiratory issues homeopathically and have started her and Bruce on a new supplement called Platinum Performance plus which I'm seeing good results from.

Thanks for reading and again for all your much appreciated advice and words of wisdom.

[Budsters Mom]

Hi Beth,
Cortisol levels often continue to drop beyond the 30 day mark when taking Vetoryl. It did for my little guy! Waiting another month is a good idea. 2.4 is exactly where you want Lola to be. As far as an ultrasound, they can be extremely valuable. I would want to get one done anyway.

All of us hate giving our pups such heavy duty drugs. If there was something effective and safer, we'd all be using it. xxxxx

[Squirt's Mom]

Hi Beth,

Vetoryl (Trilostane) is taken daily for life - there is no maintenance phase with this drug. Lysodren has two phases - the loading phase in which the med is given twice a day until signs indicate the load is achieved and then the maintenance phase where the med is given 2-4 times a week. Lysodren is the only Cushing's med to have a two-phase dosing schedule and the only one with a maintenance dosing. Vetoryl (Trilostane) is given daily - once, twice or three times a day based on the control of the signs.

[labblab]

Welcome back, Beth!

I just want to clarify that the 2.4 represents a resting cortisol alone, and not the result of an ACTH stimulation test? If so, there is really no way to know whether this dose of Vetoryl is optimal for Lola. A resting cortisol of 2.4 does give you some degree of security that Lola is not being overdosed currently -- as long as she is behaving as though she is well. If she were to begin acting "off" with loss of appetite, vomiting, or diarrhea, a resting cortisol alone cannot give you the complete picture as to her adrenal status. And you cannot safely increase her dose without first performing the two-part ACTH stimulation test. Bottom line: in the absence of the full test, you really do not yet know whether or not her cortisol reserves reflect proper control.

All treatment protocols with which I am familiar stress the necessity of performing a full ACTH test at least by the 30-day mark. I urge you to discuss this monitoring testing with your vet, and for Lola's safety, I certainly would not increase her dose any further until the ACTH testing is performed.

Marianne

[Beth]

Oh I see, thank you Squirt's mom for clearing that up for me...I must've gotten them mixed up when I first was researching them.




All of us hate giving our pups such heavy duty drugs. If there was something effective and safer, we'd all be using it. xxxxx

I know we're all in that same boat! Thanks :)

[labblab]

Beth, I think we were writing at the same time. I want to make sure you saw my reply re: the ACTH testing that was posted right before your response to Leslie...

Marianne

[Beth]

Hi Marianne, yes I think we were both typing at the same time!

Yes, the 2.4 was just a resting cortisol.

I agree about the ACTH because that is also what I read and I believe it even says something about doing this test in the actual Vetoryl literature. I'm glad you brought this up, because when I was talking to my husband this (he got the call from the vet today, not me) he and I were getting so mixed up and arguing over what I had read and what he thought and of course what the vet keeps saying. The only thing the vet said about the ACTH was that we wouldn't be doing it again at the 30 day mark (this was back at the beginning of treatment) because it's too costly and not necessary. But here's the thing...I WANT the test, I'm the one paying for it, so I don't think I should be made to feel like a jerk for wanting it. Plus, like several of my human doctors, he doesn't understand that I'm gleaning good info from sources like this forum on the net. I'm not saying he has to agree with everything but at least consider it? My hubby says we can just switch vets, but it's been a nightmare going through vets when Bruce was first dx with HMVD and Lola was along for that ride and no vet thought anything at all about her symptoms, (including my current vet) after examinations until I actually listed and pointed them out to him! Sheesh, sorry for getting so long winded.

[labblab]

Beth, good for you for being such a good advocate for Lola!!!!!!!!

Here is a link to Dechra's U.S. Product Insert for Vetoryl that discusses very specifically the need for monitoring ACTH testing, and also the dosing decisions that relate to the test results.

http://www.dechra-us.com/files/dechraUSA/downloads/Product%20inserts/Vetoryl.pdf

We can supply you with tons more resources re: the necessity of appropriate monitoring testing if that would be a help to you. It worries me significantly that your vet is blowing this off, because it is truly standard treatment protocol. Contemplating increasing Lola's dose without performing the appropriate testing is really risky, as he ought to well know...:(

[labblab]

Here's another Dechra publication that can be helpful to you (it's easier to read the chart if you print it out and view it on paper!):

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

[molly muffin]

You're a good advocate for Lola and you're absolutely correct. If you want the test, you are paying for it, and that is the end of the discussion.

However, ;), just to be onry, you can say, I choose to follow the protocol of the manufacturer of the drug and the recommendation of the top cushings endocrinologist in the country. (Dr. Peterson, Dr. Feldman, Dr. Bruyette, etc).

Literature and recommendations available for print out to take to your vet if needed and to convince hubby if needed also.

My husband use to say I come armed with a book and ready for battle, when an argument came up. LOL It does help to have backup if you have to pull it out. :D:D

You can do this. Sounds like the symptoms are getting better for Lola, which is great. Just keep that beady eye on her and as Marianne said, you notice anything, go for the full ACTH now rather than later.

hugs,
Sharlene and Molly Muffin

[Beth]

Thank you for the links Marianne, I've already done some printing and I really like the chart layout, I'll be taking that with me to the vet for sure.

And thank you Sharlene for the pep talk. I really had to dig in my heels to get what I wanted and needed for Bruce and at this point I'm ready to take no prisoners, for pete's sake these are my babies and Lola deserves every chance we can get for her!!!