New from Poland -need help for my dog Moby

[Joanna]

Hello
My name is Joanna, from Poland in Europe, i have a dog golden retriever called Moby (Mobi), in June he will be 10 years old, he was diagnosed with Cushing in October,but he hasn't got lost of typical symptoms - he has only very big apetite. Cortisol in his first urine test was 8,41 ug/dl, then we did The Low Dose Dexamathasone Suppression Test, the cortisol was 6,54 after 4hours 2,00, after 8hours 1,96 - the test confirm the Cushing ,in my vet opition this is pituitary Cushing so he told me that vetoryl may not be effective. I asked him if we could try with this Vetoryl. We started with small dose 60mg, after 3 weeks we did urine test the cortisol was 15,4; my vet decided to try with 120mg dose, after 3 weeks the cortisol was over 20ug/dl. I don't know why the cortisol has increased after Vetoryl. We did The low dose test again on Monday, tomorrow we will go to vet to see these blood test. Moby isn't on Vetoryl since 19 January. Moby has also increased liver levels, his alkaline phosphatase now is 610,6 U/l :(. I don't know what to do, is there any others drugs for Cushing - for pituitary Cushing? i read about drug called Anipryl - what do You think will it help? or maybe we have to continue with Vetoryl? Did You heard about situation that Vetoryl didnt't help or increased cortisol?
What about alkaline phosphatase is it very high?
Moby weight is about 40 kg - almost 90 pounds,
please help me:(
best regards
Joanna with Moby

[labblab]

Hello Joanna! Welcome to you and Moby. I am so glad you've found us, and we will try out best to help you with information and suggestions. First, though, I apologize for starting out with some new questions for you...

First, what made you decide to test for Cushing's in the first place? Does Moby have any other symptoms at all besides the big appetite and the elevated ALKP level? The reason why I ask is that even though he did test "positive" on the first LDDS, that test can be affected by other illnesses or abnormalities besides Cushing's. In other words, a dog can test positive even though he does not really have the disease. It is for that reason that the accompanying symptoms are so important. If a dog does not have many classic symptoms, it makes one wonder whether the Cushing's diagnosis is correct.

However, assuming for the moment that Moby does have Cushing's, I don't know why your vet would say that Vetoryl does not work very well for pituitary Cushing's. Perhaps it is because the wording of the official FDA approval of Vetoryl here in the U.S. relates to treatment of adrenal Cushing's. However, actual experience in the real world is that Vetoryl can work just as well for treatment of pituitary Cushing's. And since the majority of dogs suffer from pituitary Cushing's, actually the majority of the Vetoryl users in the world are successfully giving it to dogs with the pituitary form of the disease.

So if Moby is not responding well right now, I think we need to look further. One big thing I have noticed in what you have written is that there is no mention of ACTH stimulation testing. This is a type of blood test that is used to diagnose Cushing's (as is the LDDS). But it is also the best available method to monitor the success of trilostane treatment. I know there are some worldwide shortages of the drug that is used to perform this test, so perhaps this is why your vet has not been able to give it to Moby. But this presents a big problem as far as interpreting his post-treatment test results. It sounds as though your vet has been judging the Vetoryl on the basis of repeated UC:CR tests (Urine Cortisol:Creatinine Ratio). Unfortunately, the urine test cannot be used in this way. Its main purpose is as an initial diagnostic test -- with a few exceptions, you generally cannot use it to judge how well trilostane is working after starting treatment. Here is a quote from a Dutch research study that showed that even after "successful" trilostane treatment, the UC:CRs for the Cushing's dogs did not necessarily dip back within a normal range. In fact, the study showed that when the UC:CRs for treated dogs did dip back into normal range, this might indicate that the dogs were actually being overdosed on the trilostane.


The UCCRs of 11 dogs that initially were dosed insufficiently (range, 7.5–79.0 × 10−6; median, 31.0 × 10−6) did not differ significantly from UCCRs when the dosage was optimal (8.2–72.0 × 10−6; median, 33.0 × 10−6). Post-ACTH cortisol concentrations did not correlate significantly with UCCRs at rechecks during trilostane treatment. Long-term follow-up indicated that the decrease in UCCR below the upper limit of the reference was associated with hypocortisolism.

Conclusion and Clinical Importance: The UCCR cannot be used as an alternative to the ACTH stimulation test to determine the optimal dose of trilostane, but might be helpful in detecting dogs at risk for developing hypocortisolism during trilostane treatment.


http://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.2009.0374.x/abstract

Now, I agree that one odd thing about Moby is that his UC:CR actually kept increasing after starting treatment, whereas the dogs in this study generally did show a decrease (although not necessarily back into normal range). But regardless, it does not seem as though we can judge the success or failure of the Vetoryl treatment on the basis of the UC:CR results alone. Perhaps more importantly, how did Moby do behaviorally while taking the Vetoryl? Did his appetite normalize? Did he otherwise seem healthy?

You say that your vet is going to perform another LDDS test now that Moby has been off the Vetoryl for about ten days. I am not sure as to the purpose for this, unless it is to attempt to reverify the original diagnosis? While being actively treated, the LDDS cannot be used to monitor the effectiveness of any given dose of Vetoryl.

So once again, welcome, and I will look forward to learning more about Moby and the reasons for his original testing.

Marianne

[Joanna]

Hello:)
Moby has got the control blood test - morfhology and liver function tests in September, everything was ok except liver test, especially alkaline phosphatase was increased over 250, so the vet suggested that increased alkaline phosphatase can provide Cushing syndrome ( it was firt time i heard about this illness), we did urine test UC:CR was 41,1 and cortisol 8,41 so vet told me that we have to do LDDS to know for sure if it's Cushing or not. In my vet opinion LDDS test shows that's Cushing so we started to take drugs.
Moby hasn't got any other symptoms, he is rather lively , one thing that is disturbing - it's his huge apetite.After dosing Vetoryl it doesn't decreased.
I am worried about this increased cortisol levels and alkaline phosphatase after dosing Vetoryl. UC:CR increased also from 41,1 to over 50.
Vet decided to do ultrasound, to check his adrenals, tomorrow we will be talking about this.
You asked about ACTH stimulation testing? Vet doesn't mentioned about this, i don't know if it's possible to do this, i will asked him tomorrow.
i read lots of positive informations about Vetoryl, i was happy that we have chance to fight with this illness , but know i am sad and doubting if there is any chance to decreased cortisol levels.
You suggested that that test can be affected by other illnesses or abnormalities, what else it could be besides Cushing?
Thank You very much and sorry for my bad English:)
Joanna

[labblab]

Just wanted to come back again after re-reading your initial post. When I wrote to you before, I was assuming that the urine testing you were referring to was the UC:CR (Urinary Cortisol:Creatinine Ratio). But stupidly, I didn't really pay close attention to the numbers you had written. I am now thinking that the urine testing was solely for the level of the cortisol alone. So perhaps I was mistaken about the test, but even so, that does not change the fact that you cannot rely upon urinary cortisol levels for evaluating the effectiveness of Vetoryl treatment. The results of urinary cortisol levels can be highly variable depending upon a lot of factors. Can you tell us more specifically how the urine tests were performed?

[labblab]

We were writing at the same time, so thank you very much for this additional information. And your English is wonderful!!! I wish that I could write even half as well in a second language!! :) :)

Unfortunately, I do not have the time to write any more right now. But I will come back later on, OK? And I'm certain that in the meantime, you'll also receive other welcomes, too.

So, I will be back...

[molly muffin]

Hello and welcome to the forum.

Marianne has gotten off to a good start.
I agree that the ACTH is the test that needs to be done to actually monitor cortisol levels, and after vetroyl is started it is the only monitoring test that can accurately tell you how the vetroyl is working.
The ultrasound is another good option, especially if you want to look at what the liver, adrenal glands, gall bladder, spleen are like. It can help to determine if any other problems are going on that would have affect the LDDS results.
We'll be interested to see what the vet says tomorrow. Has thyroid been looked at too?

Welcome again
Sharlene and Molly Muffin

[labblab]

Hi again, Joanna, and I apologize for taking so long to get back to you. You may already be on your way in to see the vet, so I may be too late in suggesting these things for you to discuss with him today. But at least you can be thinking about them yourself.

First off, I am surely not an expert at lab testing :o, but if you were comparing the cortisol components alone, I don't think they have much validity when viewed outside the complete UCCR ratio. The creatinine part of the ratio is there to provide a frame of reference for the cortisol, to equal out other urinary factors that could make the cortisol alone seem unusually high or low. In humans, for instance, I think urinary cortisols are really only examined when an entire 24 hours worth of urine can be collected for examination of the output over an entire day rather than a single sample in isolation. So I don't know whether Moby's UCCRs were elevating as much as the cortisol component alone, but it is the entire ratio that you are wanting to look at in making an assessment. Also, were the urine samples collected at home or at the vet? If they were collected under any type of stressful situation, that alone could account for the elevated cortisol level.

Secondly, abdominal ultrasounds can be very helpful diagnostic tools. But I just want to warn you that Vetoryl treatment itself usually causes the adrenal glands to enlarge. So if your vet is thinking that adrenal enlargement on an ultrasound would help confirm the diagnosis, at this point, it could be the medication itself that has caused any enlargement.

Lastly, even assumimg that Moby truly does have Cushings, I am not sure that I would be treating him at this point, regardless, if he were my dog. What you have described to us is a generally happy, lively dog with a big appetite and some moderate elevation in the ALKP. At his age, unless the appetite presents a big problem for you, it seems as though the medication and the testing are more burdensome than the symptoms themselves. Systemic internal damage from Cushing's is generally very slowly progressing. For younger dogs with many years ahead of them, the decision to treat is both for symptom reduction and also to slow further damage in the future. But for an older dog, in my own mind, quality of current life becomes the most important issue. And aside from the appetite, it sounds as though Moby's life is quite good.

As you can see from my avatar, I am a retriever-lover, as well. And with our big dogs, I know that by age ten, we are already entering their senior years :o. That is why I say that, if Moby were mine, I don't believe I would start treating him until more worrisome or uncomfortable symptoms emerge. But that is just my own personal opinion and others may feel differently.

By the way, is the ravenous appetite even new for him? Both of my non-Cushing's labrador retrievers will eat anything, at any time, that they can get their mouths around. They must be part pig!!! :eek:

Marianne

[Joanna]

hello again:)
Thanks to everyone especially to Marianne and Sharlene for helping me and posting lots of helping advices,
sorry for posting so late, i haven't got time to posting earlier, my 3 years old son is very absorbing:)
We were in vet on Friday evening, we got the LDDS results, it diagnosed Cushing again, so vet is sure that's CS.We decided to buy Vetoryl again 120mg ( it will take some time,about one week beacuse i have to buy it in UK).i asked about ACTH test, we will do it after starting dosing vetoryl, to see if it's really work or not.
I got also some medicine on Moby's liver, hope the alkaline phosphatase will decrease.
What do you think about liver diet?Do you prefer Canine Food like Royal Hepatic rather that cooked food? Is there any natural suplements for liver?
Thanks once again, i will let You know about ACTH results
Best regards
Joanna:)

[goldengirl88]

Joanna:
Some of us use the following for the liver support; Milk Thistle, Denamarin, S Adenosyl. Hoping some of this can help you. Blessings
Patti