Bowzer - cushing's disease and skin problems

[Bowzer's mom]

Bowzer is taking 10 mgs of Trilostane. He weighs 22 pounds. He's 14 years old. He eats raw food (which I buy frozen at the pet store) some days and canned grain-free food other days (beef, chicken, and salmon).

He has a follow up appointment with the vet on Tuesday, to have an ACTH to see how the Trilostane is working for him.

I am wondering if he is getting better or worse. His panting is definitely reduced. I hardly ever hear him pant anymore. He no longer appears to have a potbelly....on the other hand, when you pet him you feel more bones and fur than anything else. I THINK he is drinking less water, although it's hard to tell for sure.

He still seems to ask to go outside a lot, but I'm not sure if he's actually using the bathroom all those times or if he's just going out for fun. Sometimes he'll bark to go out and when I get to the door, he'll walk away instead of going out. (This happens more often than you'd think!) Today, I'm going to try to remember to watch to see how many times in a day he's actually using the bathroom. If I can keep track of how many times he uses the bathroom today, would someone here have an idea of if that's normal or not?

He's still a bit more irritated (impatient) than he used to be when he was younger, but not necessarily more than before he started Trilostane.

He's not as hungry as he used to be before we started the Trilostane.

But the symptoms that worry me the most right now are related to his skin and fur. When he was younger, he'd occasionally get dry flaking skin (like dandruff) and I'd give him a little extra virgin olive oil with his food for a few days and it would go away. Well, I'm now giving him olive oil, salmon, and coconut oil (not all three in one day. I rotate.) with his food every day, and the dandruff is not going away, although it may be looking at least a little better. (His fur is looking nicer though. More slick. More like it was when he was a puppy.)

He has always had a problem with mats, but they have been worse lately. (He's got really long fur!) Yesterday, as gently as I could, I brushed his fur, carefully cutting out the mats. Under some of the mats, there was a red, raw place. No, I didn't cut his skin with the scissors. Under one of the mats was what appeared to be what was left of a scab, all broken up into tiny little fragments. Just tiny dots of dried blood on his skin. Is there anything I can do about his skin and fur? I'm guessing this is related to the Cushings. Is this calcinois cutis? Or just thin skin that easily breaks? (Or is that one and the same?) I've never seen raw skin on him before. This is something new.

I read on one website this morning about applying DMSO to the skin for calcinoisis cutis. Have any of you heard of this, and does it help? Are there other things I can do to help his skin?

Is the fact that his skin is starting to thin so much and get these raw places on it a sign that he's not taking enough Trilostane? Or too much?

As mentioned above, he does have an appointment with the vet on Tuesday, but I'd love to hear what some of you have to say about what you recommend regarding his treatment before I go, in case I want to mention any of your suggestions to the vet.

Oh, one more question. He's been on Animax ointment for his ears for years, just in the fall and spring, as needed, for inflammation and eczema in his ears. (He has seasonal allergies.) Yesterday after I noticed the raw places on his skin, I googled animax to see if I could put some of that on his skin. What I noticed was that one of the side effects of Animax is Cushing's disease. :-( Should I throw the tube away and never use it again? Or has it already done any damage it's going to do and doesn't matter now? Even though he's been on it for years, it's never been a daily medication. We just gave it to him when his ears flared up, maybe 10 or so days a year. Is there something else we can use for his itchy ears instead?

Thanks!

[Junior's Mom]

Welcome Bowzer and family. It sounds like you have been a great pet parent so far. Bowzer is lucky to have you. There are many knowledgable people who will speak directly to the questions you have, as well as ask many of their own.
They will want to know what tests you have had done, and what the results were. Any abnormalities in bloodwork, and what led you to the cushings diagnosis.
It's great that you are seeing improvements. One way to track the water, is to measure out, and mark the bowl when you fill it up. You will then be able to know how much Bowzer is going through each day.
I know nothing of animax, but if you have read it can cause cushings, does that mean it is a steroid? Long term steroid use can cause a different type of cushings, which is resolved when the animal is weaned off the steroid. Regardless, anything questionable, I would stop using it, till you know for sure.
As far as treating the ears, I have had great success with a product called sea greens powder, from a company called Holistic Blend. They are based in Canada, but they should ship internationally. The sea greens gets rid of the smell, and gunk and itch for one of my dogs who is prone to this.
If you can get copies of all the tests, and post on here, that would be great.
I'm glad you started with a low dose of trilostane, it is much easier on the dog that way.
Tracey

[Squirt's Mom]

Hi and welcome to you and Bowser! :)

Yes, the Animax would have had an effect on the Cushing's tests and in your shoes, I would stop giving the Trilostane for now. The reason I suggest you stop giving the Trilo is this med - the Animax - contains a corticosteroid so there is no way we can know if the tests that diagnosed the Cushing's are accurate or not. They would read the drug the same as the natural cortisol produced by the body.


Animax, a generic for Panalog, is a combination antimicrobial, antifungal, and corticosteroid...

Meds that contain a corticosteroid can cause a form of Cushing's called Iatrogenic. Iatrogenic is cured by slowly weaning the pup off the steriod. Once the steroid is out of the system, the pup usually loses all cush signs and the cush tests will be negative. Iatrogenic Cushing's is caused by external factors like medicines that contain steroids. Once those external factors are removed, the Iatrogenic form is cured. ;)

I'm sorry you have apparently wasted time and money on testing that was basically useless. Your vet should have known not to test while your baby was on a steroid but we are constantly amazed by vets. :D The ACTH can be useful in determining this form and here is a link to Dr. Peterson's blog - he is a well known and respected Endocrinologist - talking about the ACTH to test for Iatrogenic Cushing's.

http://endocrinevet.blogspot.com/2011/02/diagnosing-canine-cushings-disease.html


(The ACTH) Best test to diagnose iatrogenic hyperadrenocorticism in dogs. If the dog has clinical and laboratory features consistent with Cushing’s syndrome (e.g., polyuria, polydipsia, polyphagia, pot-belly, truncal hair loss, high serum alkaline phosphatase) but has a recent history of glucocorticoid use, this is the test of choice. If the cortisol response to ACTH stimulation is low-normal or blunted in this dog, the diagnosis would be iatrogenic Cushing’s, rather than the naturally occurring disease. None of the other pituitary-adrenal function tests can make this differentiation.

I wouldn't even think of using DMSO just yet. That is a powerful treatment and may not be needed since the diagnosis is now in question because of the Animax ointment. ;)

It would help us a great deal if you could get copies of the actual tests done to diagnose Bowser and post them here. On the CBC (or similar test) that shows things like ALP, ALT, BUN, CHOL, etc. we only need to see those results that are abnormal - too low or too high - along with the little letters that follow the numbers and the normal ranges for each value. Your entry for these will look something like this example -

ALP 1300 ug/dl 150-400 (for example)

On the ACTH, LDDS or any other cushing's specific tests we will want to see all the info given, including any comments from the vets.

I am glad you found us and look forward to seeing those test results and learning more about the both of you. The most important thing I have to tell you today is - you and Bowser are no longer alone. You are now part of our family here and we will be by your side all the way. All you need to do is holler and someone will be along to help any way we can - even if it's just to listen and hold your hand a while.

Hugs,
Leslie and the gang

[Bowzer's mom]

Tracey, thanks for mentioning the Seagreens powder! I'll check into that!

Lesley, just to clarify, in the past month, I'd say Bowzer has only had the Animax put in his ear maybe twice. (Once was yesterday, before I read online that a side effect is Cushing's disease.) It has never been a daily medication for him. Seriously, we only give it to him about 10 days out of ever year (rough 5 in the spring and 5 in the fall). A small dosage does wonders for him.

At the time he had his original labwork done (which I'll post as soon as I can get it from the vet), he had been off the Animax for over a month. Probably considerably longer than that. In fact, I pointed out to the vet that that was the best Bowzer's ears had looked in years....(and that was without the Animax). It was at this same visit that the vet began to suspect Cushings, with several labs to follow over the next couple of weeks. The vet and I discussed how Bowzer's body was making it's on steroids (well, too much of them) because of the Cushings and that's why his ears looked so good. It wasn't until after we put him on Trilostane that his one of ears began looking yucky again.

Although the Animax may have caused the Cushings, I don't think it interfered with the original lab results, since he'd been off the Animax at that time.

Based on this, do you still think I need to take him off the Trilostane now, even though his appointment to see how the Trilostane is working (ATCH test) is in 2 days? Should I postpone that lab?

Thanks!

[lulusmom]

Hi and welcome to the forum

Was Bowser being treated with Animax at or shortly before the time of diagnosis? If not, I don't think treating for 10 days a year would cause the chronic overt symptoms associated with cushing's. It could, however, skew test results. What is Bowser's breeding? Aside from recurring ear problems, has he had any other issues? Is he on any other medications?

With respect to the current skin issues, the description you gave doesn't sound like calcinosis cutis but your vet would be the best source of information. I'm a rescuer and have seen some dogs with horribly matted fur and often times, the skin is really raw under the mats. Once the mat works it's way closer to the skin, it becomes painful.....it's like somebody grabbing your hair at the roots and pulling as hard as they can and the tension continues to get stronger. Cushing's does cause thin skin so I would think a mat could cause the rawness you describe. Cushing's also compromises the immune system which can leave a dog open to demodex mange. I've cared for three cushdogs and one of them, a shelter dog, had ringworm and demodectic mange. It was so bad that when she was bathed, sheet of hair and skin would peel off. Your vet can do a simple skin scraping and check under a microscope while you are at the office.

We'll be looking forward to seeing copies of test results that Leslie and Tracey have already requested from you. It's always difficult to provide meaningful feedback without a more complete picture of the diagnostics.

Glynda

[Bowzer's mom]

Thanks, Glynda.

No, he wasn't on the Animax at the time of diagnosis, because his ears looked so good they didn't need it. He'd been off of it for at least a month, probably longer, at that time.

He's part Cocker Spaniel and part Pekinese.

[molly muffin]

Hello and welcome.

I probably wouldn't take him off the trilostane since it's only 2 more days and would see what the ACTH test shows. I wouldn't however, give him any more Animax. If he was on it at any time around when his testing was done though, Leslie is right, it could mess with the results. So, you'll need to review when any testing was done vs when Animax was given. He hasn't had any problems with the trilostane has he? Not eating, diarrhea, vomiting?

Some of the others who have used trilostane quite a bit and have years of experience with cushings will be able to tell you what their thoughts are on the Animax and cushings diagnosis. Make sure that when you do the test on Tuesday, the trilostane is giving as usual in the morning, with a bit of food and the test is done within 4 - 6 hours of that dosage.

In addition to the panting and thinning skin, prior to cushing diagnosis, did you notice if Bowser was eating like crazy (you'd think he was starving all the time), drinking large amounts of water? You'd know this because you'd be refilling the water bowl constantly. Along with the pot belly and panting, these would be symptoms consistent with cushings.

Sometimes things Look like cushings but aren't. Do you know if the vet ruled out diabetes and thyroid problems before moving to cushings? This should always be done as they have the same symptoms. Diabetes in particular they can be eating, but losing weight. (you mentioned he feels boney now?)

As for the skin, any time you have a internal problem, it seems to manifest on the skin, so sores, red skin, can be calcinois cutis. That along with any muscular weakness is some of the last things to clear up as the cortisol becomes under control. You said Bowser has long hair, what breed is he? One thing is that with the sores, you have to be careful of not getting yeast infections in it (very common) and that would mean that the air needs to be able to get to it to keep it dry and not moist.

These are just my preliminary thoughts. The more you can tell us, the better we can give you feed back. One thing that you will want to do, is to have copies of all testing done on Bowser, leading up to and including cushings testing. You'll just want to have your own file records, to refer back to and have available if ever needed. Some people also keep a journal of symptoms and just make a note of anything they noticed during the day.

I know this can be confusing, with so much information out there. However, it's just a matter of having the most knowledge possible about cushings, about treatments, about testing protocols, etc. The more You know the better voice you will be for Bowser and the better able to manage his medical care. All quite doable. :)

Oh good I see that Glynda was writing at the same time I was.

Welcome
Sharlene and Molly Muffin

[Squirt's Mom]

If it had been a while since he's had the Animax used on him when the cushing's testing was done, then it may not have had an effect on the results. But I always worry when I see that steroids have been in use and then the pup is diagnosed with Cushing's and put on treatment, so I have to speak up for my own peace of mind. ;)

[Bowzer's mom]

I'm positive he wasn't on Animax at the time of his diagnosis and original lab work, because if he had been, the vet and I would not have had the conversation about being amazed at how well Bowzer's ears looked without Animax. That conversation was at the initial visit when I took him in because he was having potty accidents in the house.

Yes, he was drinking a lot of water. We have three pets, and three water bowls, and they all drink from one another's (well, the two dogs can't get to the cat's bowl, but the cat does drink from the dogs' bowls)...but that was something my husband and I had noted to ourselves and then I'd mentioned at the vet at the first visit (for the Cushings) that it seemed we were always filling up those water bowls! (When I mentioned it to the vet, I had no clue it was a sign of anything! I'd never heard of Cushings at that time.) In fact, we'd just bought a larger bowl, so now we have four bowls and three pets! Every time I would look, several times a day, the bowls would be empty! I don't notice myself filling them as often since he's been on the Trilostane, but I wish I'd made some sort of record pre-Trilostane of how often I was filling them so I'd have something to compare it to.

Bowzer was never a really huge eater, I guess, but yes, his appetite has reduced.

When I go to the vet on Tuesday, I'll ask them to make copies for me of his original lab work and post it.

Thanks for all your help, everyone!

[lulusmom]

Hi again. I forgot to mention a great product for dogs with chronic ear infections. It was recommended to me by a Cocker Spaniel lover with lots of experience. It's called K9 Ear Solutions and it contains isopropyl alcohol, boric acid, gentian violet, colloidal silver. I've had excellent results with it. It dries up hot spot like nobody's business too. You can get it online and the two most reasonable sites are Amazon and Vitacost. I use Vitacost for all of my supplements and quite a few of their canine products as well. Nobody ships faster either. I like both of these sites because the price is usually much better but I like them even more because you can usually read tons of credible reviews on the products you are interested in. See the urls below for product info on both sites:

http://www.amazon.com/For-Animals-K9-Ear-Solutions/dp/B000OUY5L6

http://www.vitacost.com/Liquid-Health-K-9-Ear-Solutions#

[Bowzer's mom]

I take it back. Bowzer just ate a ton of food. I was late feeding him this morning because I was waiting to hear back from all of you regarding whether to give him his Trilostane today or not....but when I did feed him, he ate a lot!

Thanks for the product suggestion for the eczema in his ears!

[Squirt's Mom]

Here is a spreadsheet one of our members put together to help track water intake. It's a bit more difficult when pets other than the cush pup are drinking from the same bowl but it will still let you know how much water is being taken in by them and we can be fairly safe in assuming the cush pup will be the one to cause any changes we see.

http://www.k9cushings.com/forum/showthread.php?t=3583&highlight=water+spreadsheet

[Bowzer's mom]

Yesterday Bowzer had his ACTH. Our vet just called. She said his pre ACTH numbers (before she gave him the cortisol) were normal - which she said was good, but the number after she gave him the cortisol was 77, which she said was extremely high.

She agreed with me that clinically he's looking good, but of course she's worried about that 77.

He's currently on 10 mg of Trilostane a day. (Weight = 22 lbs) She suggested I give him a dose of 7.5 mgs twice a day, so he'll be getting a total of 15 mgs, but spread out over two dosages.

Can anyone tell me more about why his pre ACTH levels were normal, but the number an hour later (or whenever the second sample is taken) was so high?

[molly muffin]

When she says "normal" what does that mean in numbers to her?

You are in the U.S.? so the measurement is in ug? or is it in nmol?

For instance, in the U.S. most measurement is in ug, so normal range according to the manufacture and what they should be looking for is a pre no lower than 1.54 ug and post of 1.54 - 5.0ug or up to 9.0 ug if symptoms are controlled

This makes the 77 number mighty confusing, unless you are in nmol.

Sharlene and molly muffin

[Bowzer's mom]

Yes, I'm in the US...and I have no idea as to the answers of your other questions. It's too late to call the vet back tonight. I'll try to call tomorrow.

I know she said that the second reading should have been somewhere around 14 or 17, I think, instead of 77.

[Bowzer's mom]

What exactly does the "pre" number tell you? I mean, what can you learn about the pet from knowing that number? Is it a measure of how much cortisol is in his body before you start the lab? If so, isn't that the most important of the two numbers, since that's the picture of how he's doing when he's not at the vet having a lab done?

(I'm sure all the above must be incorrect, or there would be no reason to do the second part of the lab. But I'm trying to understand what the two parts of the test measure and what that means in everyday life for the pet.)

[frijole]

The 2nd number is the one that matters. It is the amount of cortisol in the system. That 77 can't be right unless the unit of measure is nmol which we don't see often in the US. Anyway if it is nmol then that number is PERFECT and not high at all.

Please don't give any increase until we have a chance to sort this out. You cannot trust anyone - not even a vet to tell you "normal" "good" etc on these tests because we see errors all of the time.

Please go get copies of all the tests and type the numbers here so we can help you. How are you giving 7.5 mg? Did you have the pills compounded or are you opening up capsules? That is a HUGE no no and so please tell me your vet didn't suggest that.

You said your dog looks good - are there any symptoms of cushings still? Normally you don't increase a dosage without a reason. Please get back to us with answers. We will help you. Kim

[frijole]

What exactly does the "pre" number tell you? I mean, what can you learn about the pet from knowing that number? Is it a measure of how much cortisol is in his body before you start the lab? If so, isn't that the most important of the two numbers, since that's the picture of how he's doing when he's not at the vet having a lab done?

(I'm sure all the above must be incorrect, or there would be no reason to do the second part of the lab. But I'm trying to understand what the two parts of the test measure and what that means in everyday life for the pet.)

The first one is not normally significant. Here's more info:

https://listserv.tamu.edu/cgi/wa?A2=ind0203&L=cushings-pets&P=R19896&D=1&H=0&O=D&T=1

[Bowzer's mom]

Thanks for the info about the ACTH test!

Yes, we are compounding the Trilostane.

The vet emailed me a copy of Tuesday's lab report. (She's supposed to be emailing me the other labs as well.)

Time 1: 12:10. Time 2: 2:10


Cortisol sample 1: 3.9 Reference range: 1.0 -5.0 ug/dl
Cortisol sample 2: 77.1 Reference range: 8- 17 ug/dl

Clinical signs:

Bowzer hardly ever pants anymore. Before we started treatment, he panted quite a bit.

He seems to be using the bathroom and drinking less, but it's hard to say for sure. I kept a record of every time he went out to use the bathroom on Sunday. I wrote down 5 times: 8:25 AM, 9:00 AM, 11:30 AM, 5:00 PM, and 8:30 PM. The next morning, his first time out to use the bathroom was 5:30 AM. I have no idea if about 5 times a day is excessive, or normal.

He lost his potbelly. He seems to be mostly skin and bones now.

He still shows signs of being impatient.

[lulusmom]

The acth stimulation test is done to test adrenal function. The pre cortisol number you posted represents circulating cortisol in the blood while at rest. This is called the basal cortisol. Once that blood draw is done, a stimulating agent is then injected and an hour later a second or post blood draw is done. Dogs with cushing's have an exaggerated response to the stimulating agent due to the increased thickness of the adrenal cortex, which is the part of the adrenal gland that secretes cortisol. In Bowzer's case, I'd say his adrenal cortex is beyond thick considering how much cortisol was dumped in response to the stimulating agent. We've seen post stimulated numbers of greater than 50 ug/dl but never any as high as 77 ug/dl. :eek::eek: I'm not sure that many labs even provide a reading that high and usually state 50+. I think Bowzer just hit a new high for us and if I had a blue ribbon, I'd send it to you. :D:p:D

I think I forgot to ask before but did your vet determine which form of cushing's Bowzer has? Pituitary is most common with 80% to 85% dogs with a tiny tumor/lesion on the pituitary gland. 15% to 20% have an adrenal tumor. Also did you ever have the vet look at Bowzers raw skin to determine what is going on? Excess cortisol compromises the immune system and with the huge amount Bowzer is producing, my concern is that it's likely to have an even more profound effect on the immune system. This leaves a dog predisposed to demodex mites. We all have demodex mites but our immune system keeps them in check. When the immune system is weakened, the mites are unchallenged and there is a massive population explosion. Raw, bloody skin, hair loss nd secondary bacterial and yeast infections are not uncommon so make sure you talk to your vet.

Glynda

[frijole]

Holy crap I can't believe it truly was 77. For sure Bowzer gets first place for highest cortisol level ever recorded. Thanks Glynda for chiming in. Kim

[Bowzer's mom]

Not so sure I'm that happy about winning THIS blue ribbon! lol

The lab is ANTECH Diagnostics.

I put coconut oil on his skin/fur and it cleared his skin right up...except one ear (I didn't put it on his ears.) His ear(s) gets inflamed from seasonal eczema.

Yes, the vet did an ultrasound and said she couldn't see anything wrong in his abdomen....but she also said he was squirming around quite a bit.

I'm curious to see what the ACTH, etc, results were from his first labs. I thought the vet's office was going to email me those today as well, but I called to make the request close to closing time, so maybe they'll send those tomorrow. If not, I'll go over there.

So why are his clinical signs down, if his test measured so high?

On a day to day basis (when he's not at the vet having a lab done), what would cause him to produce too much cortisol? Anything besides stress? What I'm not understanding is that if the levels on the test before the cortisol was given to him were low, then doesn't that mean his levels are low on a day to day basis? Is it just that they will continue to get worse, if not brought under better control?

[frijole]

You asked what would cause the cortisol to increase like that - it's the adrenal glands. :p Seriously with cushings the body is telling your dog to produce cortisol when it is already high. So it's either a pituitary tumor sending that message or an adrenal tumor that is active depending on the type of cushings. Stress doesn't help things but it's the cushings that is causing the high reading on the test.

OK so you are on a pretty low dose of trilostane yet your dog's symptoms are improving right? You aren't dealing with urination in the house etc. With a reading of 77 normally the instructions would be to increase the dosage but if he is improving I would almost wonder if something didn't go haywire with that test. We've been here for decades reading these tests so when you posted that we were all like :eek::eek::eek::eek:

I say leave it alone and see if he continues to improve and do another acth test to see where the levels are in a month or so. Otherwise if symptoms of peeing and skin get worse then you pretty much know the cortisol is not controlled.