Willie - newly diagnosed, 10 y.o Boston Terrier

[Zoogirl]

My Willie was diagnosed with Cushing's on 11/28. He is a 10 year old neutered Boston Terrier. I have had him since he was 8 weeks old He has been healthy up until recently.

From what I have read, so far, it seem you like lots of history and detail...so I will try to give as much as I can remember. Hopefully I do not bore you.

I took Willie in Nov. 23 for his annual exam, and was also concerned about some changes in his behavior. He was waking at night 2-3 times to drink and then waking me up to be let out. He was putting on weight, and always hungry. He would gobble up his food as fast as he could, and then push his brother away from his food and eat that too, unless I stopped him. When I scheduled the appointment, I was convinced I was going to bring him home with a diagnosis of diabetes.

The vet listened to my concerns, and mentioned she wanted to test for diabetes, thyroid, and also ALT test. She indicted based upon my description, plus Willie's pot belly she was leaning toward Cushing's.

After reading about Cushing's I felt that this exactly fit Willie. He also has hind leg weakness, which I had not even mentioned to the vet. He has been unable to jump on the bed anymore, I was attributing this to age, and weight. He had also had a few accidents in the house a few months prior, which I thought were due to a change in my schedule.

Initial abnormal test results were
ALT 290 normal range 12-118 iu/l
Alk phosphatase 1601. 5-131 iu/l
GGT. 34 1-12 iu/l
Bun 35 4-27 iu/l
Phosphorus 6.6 2.5-6.0 mg/dL
Platelet count 582 170-400

Urine results
Protein 1+
Microalbuminuria 12.0 Normal <2.5

Based upon these results. The vet suggested an ACTH test. Results were as follows

Sample 1 6.0 Range 1.0-5.0 g/dL
Sample 2 32.2. Range 8.0-17.0 g/dL

Based upon these results Willie was started on Vetoryl 30 mg per day. His current weight is 33.1. Lb (15 kg). The vet stated this was on the low end of the dosing guidelines, but preferred to start low and work up rather than create problems of to high initial dosing.

Over the next3 weeks I saw little change in his symptoms. I was out of town at the 14 day mark so we decided to wait on the next cortisol level testing. While I was out of town, he went from constant hunger, to food stealing and scavenging. Based upon this we increased the dose of Vetoryl to 30 mg twice a day.

The dose increase was Friday December 20. By Sunday I thought we had the solution. Sunday and Monday night he slept through the night, for the first time in months. He was not begging for food all day long.

Then Tuesday night he walked away without finishing his meal (eating 2/3) I though it was because mealtimes were messed up due to the Holiday. Wednesday morning he took one bite of food and walked away. When I let him out, he peed on the deck, rather then walking down the steps. He was obviously lethargic. As the day went he got more lethargic. I did not give him any doses of Vetoryl Wednesday, concerned about and Addisonian crisis. After much debate, I decided not to got to the re vet, based on knowing that he was not vomiting, and was still following me around the house, but with effort. In the early morning hours he vomited 3x.

I brought him to the vet, without an appointment right away in the morning. Arriving before they even opened this morning. They gave Willie IV fluids, dexamethazone, and monitored him all day. His electorolytes were just barely to drop below normal. So I'm glad I brought him in right away this morningHe is doing great now tonight.
We did discuss getting a decadron kit for him. He is off all Vetoryl right now, so I did not pick it up today.

Is it typical to have difficulty finding correct dosage?
Do the ACTH level corespondent with severity of the disease? If so is where is a post stim level of 32 on the spectrum?
Should we have given the 30 mg dose longer time to be effective?
Is 30-60 mg standard dosing for a 33 lb dog? The new plan is once he is ready to restart meds we will try a 40 mg dose. She is having 20 mg pills compounded, to be given twice a day.
Do most people keep decadron on hand for Addisonian crisis? If so how do you discern when is the time to use?
Once the right dose is found do most dogs stabilize on it for awhile?

Thank you soo much for reading all this. I'm sure I missed some details, just ask if something doesn't make sense. I'm sure I have other questions too....but it was a long night with a sick dog, then a long day with me worried when they kept him all day. So my brain is not firing on all cylinders right now.

[Renee]

Welcome to the forum. I am fairly new as well. Always a sad reason that prompts one to find this place, but what a wonderful and supportive place this is!

Did you get an LDDS test done in addition to the ACTH? An ultrasound?

You were very smart to withhold the vetoryl given Willie's reaction. I am concerned that your vet jumped from 30mg once per day, to 30mg twice per day, without benefit of an ACTH test. That is a 100% increase on the dosage, which must have been very hard on his body! My personal opinion would have been to increase in a 10mg increment, if at all.

My pug just started vetoryl a week ago. She is 18 pounds, and we are doing 10mg twice per day. Everyone here will tell you, start slow and work your way up.

[doxiesrock912]

Everything that your vet was right on target until he/she doubled the dose. Especially without doing another ACTH test. Never let them change the dose without doing that testfirst and following the guidelines. The dog must have their Vetoryl with a meal within 4-6 hours of performing the test. No exceptions.

Many dogs do better on twice a day dosing which was also a good idea. This has worked the best for Daisy Mae.

If your vet is unsure of how to proceed, please encourage them to contact the vets on staff at Dechra, the manufacturer of Vetoryl. They have helped many because each dog responds differently.

Hope that Willie feels better soon!

[goldengirl88]

I too am concerned about the jump in dosage to twice the original amount. Please never let anyone dose your dog without having an ACTH test. You can save yourself a lot of heartache by doing it the correct way. Your dog should only be getting 1mg per lb following Dechra. Once you give a dose, you then have to have and ACTH within 2 weeks. You must be giving the dog food before the second ACTH if giving Vetoryl as it needs some fat to absorb correctly. If you do not feed your dog on the second ACTH and there after your dog can be overdosed. The very first ACTH is when you do not feed them, all ACTH testing after that requires a meal before and the test must be completed within 4-6 hours after giving the Vetoryl. Please ask your vet to contact Dechra and get the correct protocol for this drug. These are very powerful drugs that you do not want to be giving more than necessary. Please keep a daily dog diary and get copies of all tests performed. We are here always to help and support you so when you aren't sure of something please ask and get help. Blessings
Patti

[Zoogirl]

Thank you for your insights and concern.

Willie is doing well now. Back to his extreme hunger, but I expected that.

I spoke again with the Vet, and got the electrolyte values. His Na was 139 with a normal value of 141-151, and his Cl was 101 on normal of 102-120. His K was normal at 5.0. So based upon this he was not in a true "crisis" nor shock, but she did treat aggressively with the fluids and a small dose of steroid due to the vomiting and based on his progression of symptoms despite having had 3 Vetoryl doses held at that time.

We are going to review how he is doing again next week and re-evaluate if/when he can be restarted on Vetoryl. Is it your recommendation he have another Atch before a re-restart?

Also thanks for the advice about food both with Meds and testing.He does/did eat with both doses. The vet went over testing protocol. Since it will be done on days I work, I will bring him, his Meds and his food to the clinic. They dose him and give breakfast. Then will test 4-6 hours later. I can pick him up anytime after.

Thanks

[lulusmom]

Hi and welcome to you and Willie.

Others have already got you started on the right foot but I wanted to answer some of your questions that may not have been answered. Please see below:


Is it typical to have difficulty finding correct dosage?

It is rare that a dog starts on a particular dose and stabilizes on it and most dogs do require an adjustment in the first 30 days. At the end of thirty days, a dog should have had at least two acth stimulation tests in that time. You cannot adjust the dose based on symptoms alone and doubling a dose when switching to twice daily dosing is not recommended. Most dogs do fine on once daily dosing but because of Vetoryl's short half life, some dogs are not well controlled throughout the day so symptoms never resolve. The first thing that should have been done before switching to twice daily dosing was an acth stim test to see how effective the initial dose was. If the acth stimulation test showed that pre and post cortisol levels were within the therapeutic range dictated by Dechra but symptoms had not resolved, then one would suspect that perhaps twice daily dosing wold be necessary. Otherwise, you adjust the once daily dose. It is ill advised to double the dose when switching to twice daily because at some point there is an overlap between the morning and evening dose, which may drop cortisol too low. I believe that is exactly what happened to Willie. It is recommended that you increase the daily dose by a bit and divide in half. For instance you would bump up the 30mg to 40mg and give 20mg in the morning and 20mg in the evening. That is the dose your vet is now recommending. Had she done that, Willie would probably have been spared the ordeal and your wallet would have a lot more money in it. I hope she gives you a break on the er bill because she screwed up big time by breaching protocol that was established to ensure that treatment is facilitated safely and effectively. She breached it not once but three times. To recap, 1. She didn't do a stim test to determine where Willie's cortisol levels were on once daily dosing. 2. She switched Willie to twice daily dosing without knowing whether he was a dog who needed twice daily dosing, therefore inconveniencing you and making treatment more expensive. 3. She arbitrarily doubled the dose without the benefit of an acth stim test to guide her, placing Willie at risk. All in all, you and Willie are very lucky because it could have been a lot worse.


Do the ACTH level corespondent with severity of the disease? If so is where is a post stim level of 32 on the spectrum?

A post stimulated level of 32 ug/dl is definitely consistent with cushing's and given Willie's classic and overt symptoms, one could assume that the disease has progressed for some time. We usually see post stim numbers under 30 but we've seen them as high as 50 ug/dl on rare occasions. Cushing's progresses at a snail's pace and often pet owners don't really notice the symptoms, or they chalk it up to old age. It's not until a once housebroken dog starts having accident in the house that alerts the pet owner that something is not right. It's very possible that Willie has had cushing's for a year or two.


Should we have given the 30 mg dose longer time to be effective?

Unfortunately there is no way to answer that question without the benefit of assessing the 14 day acth stim test. We've seen a cortisol drop well into the 30 day mark on the initial dose, so depending on where the post stimulated cortisol level is, a vet may take a wait and see approach. However, if the post cortisol showed that the current dose is having little impact on cortisol, an increase in dose would be recommended. It's all about the results of the acth stim test.


Is 30-60 mg standard dosing for a 33 lb dog?

1mg per pound is a great place to start so it was a good move on your vet's part to start Willie on 30mg. Doubling the dose, even though split BID was a bad idea and an even worse idea to do so without assessing an acth stim test.


The new plan is once he is ready to restart meds we will try a 40 mg dose. She is having 20 mg pills compounded, to be given twice a day.

This would have been the appropriate dose when Willie was switched to BID dosing so 20mg twice daily seems logical to me.


Do most people keep decadron on hand for Addisonian crisis? If so how do you discern when is the time to use?


Decadron is dexamethasone, which is a synthetic glucocorticoid. Most members have prednisone on hand, which is also a synthetic glucocorticoid. You would consider giving these drugs if a dog was showing overt signs of low cortisol, such as vomiting, diarrhea, not eating or drinking, extreme lethargy and/or inability to stand. Always call your vet immediately if you see any of these signs or if after hours, call the er vet. You can administer the decadron but because Vetoryl can lower aldosterone as well, electrolytes need to be checked.


Once the right dose is found do most dogs stabilize on it for awhile?

My dogs were stable on the same dose for two years but all dogs are different so there is no guarantee other dogs will do as well as mine did. It is known that some dogs can start to become symptomatic again a year or two after stabilizing and there are also dogs who, out of the blue, will crash with low cortisol, so you never know. That is why routine acth stimulation tests should be done.

I know you are frazzled, addled and waiting for the next shoe to drop. We've all been on that roller coaster ride, some of us more than once, Just know that you are in the company of people who have walked in your shoes, who will help you help Willie through this rough patch and hopefully put all the bad stuff behind you. You're not alone on this journey.....we're here to hold your hand and help you learn how to become the best advocate you can be for Willie.

Glynda

P.S. If it were me, I would want an acth stim test done before starting treatment. They are very expensive but very necessary. Most vets use Cortrosyn as the stimulating agent and we call it liquid gold because that's what drives the ridiculous price. Your vet may not know that you don't have to use the entire vial of Cortrosyn but rather just 5ug per kg. In Willie's case, one vial would give you three acth stim tests. That's a huge savings and it's well worth your time to make sure your vet knows this and is willing to split the vial and store the remaining agent for future use. I have provided a url to Dr. Mark Peterson's veterinary blog where he provides instructions on how to reconstitute and store the cortrosyn. I would recommend that you print it out and have it handy for your discussions with your vet.

http://endocrinevet.blogspot.com/2012/03/how-to-dilute-and-store-cortrosyn-for.html

[doxiesrock912]

Absolutely do the ACTH before restarting and start on the lowest dose possible that will be effective. Best to start low and increase.
I'm glad that he's feeling better.

[Renee]

Glynda! Amazing job answering those questions.. and I am going to share that blog with my vet. I wonder what her opinion will be?

[Zoogirl]

Thanks for you great responses.

Glynda your answers were of of great help, in will definatly print the information about how to store the Cortrosyn between test.

I suspect you are correct about him having Cushingsfor some time. I had started to call him "old man" and attribute symptoms to age. It wasn't until the Pu/pd and appetite became so excessive that I became suspicious. I feel so bad that missed the symptoms and I then delayed the diagnosis for him.

The vet did give me a break on the charges for the emergent visit. She did not charge for the exam, nor for the 9 hours of monitoring (she said he could have left after 2-3 if I would have been able to stay home with him. But, since I had to work they preferred to watch him all day). Only charge was fluids and injection. I have been with this vet for 15 years and very happy with them. On the next visit I will discuss their past experience treating Dogs with Cushing's.

Thanks for all your advice. It really helps to hear from people who have been through this journey.

Steph

[molly muffin]

Hi Steph, I just want to welcome you and Willie to the forum. Glynda has absolutely gave you all the pertinent information that you need right now. Good job on providing the test results. :)

We have several Bostons on the forum, and I'm sure some of them will be stopping by eventually too. We're all in and out all the time around here. :)

Also, never worry about popping in when you have a question or worry, someone usually shows up, even at odd hours of the night. :)

Welcome again!
Sharlene and Molly Muffin

[lulusmom]

Hi Steph.

Don't beat yourself up over ignoring some of the early symptoms of cushing's. Unless a dog has an adrenal tumor and surgery is an option, there is no cure for cushing's. The goal of treatment is to remedy problematic symptoms and if they weren't a problem for you or Willie a year ago, chances are an experienced vet wouldn't have opted to confirm or start treatment until the more overt symptoms were apparent. Most of us had never heard of cushing's so there is no reason to tie some of the symptoms of aging with a disease we'd never heard of. Right? Some of us didn't ignore it but had vets that kept telling us don't worry about it. My first cushdog was only three years old when diagnosed and she had huge symptoms for over a year, including calcium oxylate stones, requiring two surgeries within 11 months apart. I couldn't spell cushing's back then and apparently my gp vet couldn't either. At least I had an excuse as my chosen field is in insurance. :D Needless to say, my once cherished vet, who had been caring for my dogs for 15 years was kicked to the curb; however, I soon learned that he wasn't an anomaly. There are a good number of general practitioners who don't have a good grasp of the disease or the treatments.

We pet owners are our own worst critic and have a tendency to heap the guilt on ourselves. That's understandable because we make all of the decisions for our dogs because they can't speak for themselves. It would be great to have a crystal ball but since we don't, we have to learn as we go. The good news is that you've come to the right place to learn. If you love your vet, then help her learn. You won't be the first one to do that and you won't be the last. Just remember that if you are dealing with cushing's, no matter how much you love your vet, never place blind faith in her or anyone else to make the right decisions for Willie. She's already failed Willie once so it's up to you to make sure that she does things right from hereon in. We can help you with that. A good start would be to print out Dechra's technical brochure that has all of the information your vet needs to properly monitor Willie's treatment. You can find that brochure at http://www.dechra.co.uk/Files/Filer/RelatedDownloads/vetoryl_technicalbrochure.pdf It may be a bit technical for you so let us know if you have any questions. I recommend that you give a copy of it to your vet so that she understands proper protocol so that what happened to Willie will never happen to another dog.

A very important thing you need to remember is that on the morning of an acth stimulation test, make sure you give Willie his morning dose with food and have him to the vet within 3 to 5 hours of dosing. Try to make sure the timing is the same for all subsequent tests.

You're probably on overload right now so I'll stop here. It's not easy for us to wrap our heads around this disease but I promise the light bulb will come on at some point. We love to answer questions so please ask away.

Glynda

[Renee]

Just wanted to stop in and say I am one of those that is working with my vet that does not have a lot of cushings experience. I opted to stay with her because of my trust and faith in her. That said, I never, ever allow her to make a decision without my input, and I make sure I am as educated as possible when making any decisions. As a bonus, she is very open to consulting with specialists, and has not been going about this blindly. She has probably read just as much as I have on cushings, and she calls to check on Tobey at least once a week or more since we started this journey.

[Zoogirl]

The past 2 days, Willie has had an incredible amount of energy. It is great to see him acting like he feels so well again. He is playing with chew toys or bringing me the ball non stop. I understand this is a reaction to the dexamethazone he was given on Thursday, and is a short lived turn around. He is still starving, and PU/PD.
I'm trying to understand the paradoxical effect of the steroid injection. The same type (cortico) of steroid that is causing all the long term problems and symptoms, is now making him feel so much better. I have seen steroids provide energy bursts before (not in Willie he has never been on steroids before.) so I know it's related. Does anybody have a good explanation as to why the long term overproduction of the corticosteroids was causing him to be less interested in play and affiliative with both his brother and I. But now the 1x dose has changed that behavior.

I also am wondering about him nose. His nose always looks really touch and flakey. Almost like it is dry and chapped all the time. I cannot put anything on it because he just licks it off. It has deep lines in it. It does not seem to bother him. I created an album and put a picture in there, along with a picture of my other dog Gus to compare. Is a dry flakey nose common?

Thanks
Steph

[Renee]

I think for the most part the nose thing is a myth. Some dogs just have a dryer nose than others. its not always a sign of poor health.

That said, you may try rubbing ointment into the nose, and then using a soft cloth to wipe away the crusties when they soften. I use A&D or even carmex on my pug's nose to soften it up, then wipe it with a soft cloth that has been dampened with warm water. His nose is always dry, but keeping it from crusting up too badly has helped.

If he's a heavy sleeper, you could put something on while he sleeps too.