To treat or not to treat with little in way of symptoms

[miamc8]

Hello,
My name is Maria and my little dog is Penny who is 8 in June and weighs just over 16 pounds. A few weeks back we noticed that she was a bit lethargic and not interested in her usual activities with some loose stools. This went on for 5 days. I felt something was not right and I took her to vet. On 2/18/14 this is her blood work:

Reference range
Glucose 114 - 65-130 mg/dL
BUN 15 - 6-29 mg/dL
Creatinine 0.9 - 0.6-1.6 mg/dL
T4 2.1 - 1.0-4.0 ug/dL

Cholesterol 279 - 150-275 mg/dL
Amylase 284 - 300-1500 U/L
Lipase 1051 - 0-425 U/L

ALP 541 - 10-84 U/L
GGT 6 - 0-10 U/L
ALT 48 - 5-65 U/L
AST 22 - 16-60 U/L

So based on these results, vet started her on Denamarin, prednisone, and Baytril for liver support, inflammatory/immune problem, and infection. After a few days on the prednisone, her lethargy and disinterest were gone and she was basically back to her normal self and has remained so these past few weeks.

On 03/11/14, vet did another blood work. Think on with regards to ALP that she had just finished a 16 day taper of prednisone so ALP is probably mainly reflective of that I think.

Reference Range
Glucose 111 - 65-130 mg/dL
BUN 10 - 6-29 mg/dL
Creatinine 0.7 - 0.6-1.6 mg/dL


Cholesterol 223 - 150-275 mg/dL


ALP 3536 - 10-84 U/L Verified by repeat analysis
GGT 13 - 0-10 U/L
ALT 171 - 5-65 U/L
AST 31 - 16-60 U/L

Based on this vet decided to do LDDS with results:

Cort 0 hr 4.2 - 1.0-10.00 ug/dL
Cort 4 hrs 0.3
Cort 8 hrs 2.0 - 0.0-1.4 ug/dL

Vet says this is indicative of pituitary dependent disease. Now, she is on Denamarin and metronidazole vet says for any biliary duct inflammation. We have not done any US yet. Penny has really not shown any of the other symptoms such as fur loss, pot belly, vomiting, abnormal thirst or urinating. Her stools are back to normal and her energy is good. Vet gave me the Vetoryl 30 mg once a day but says the decision at this point to treat is mine as she has really no symptoms at this point. So here I sit wondering what is best for my baby. Anyone treating essentially a symptom free dog with Vetoryl. Also, I am a non-Hodgkins lymphoma survivor with my very own benign brain tumor so I'm very torn at putting her on drugs with serious side effects. Thanks for any thoughts.

[Harley PoMMom]

Hi Maria,

Welcome to you and Penny! So sorry for the circumstances that brought you here but glad your found us.

Strong obvious symptoms do play a huge part of a diagnosis for Cushing's. Although Penny's LDDS test results are indicative for Cushing's, any non-adrenal illness can create false positive results. Since Penny is not displaying the usual Cushing's symptoms, if this were me, I would not begin treatment with the Vetoryl.

Cushing's is when a dog's body produces excessive amounts of cortisol. Generally a dog with Cushing's is peeing rivers, drinking buckets of water, and has a ravenous appetite. To me it is odd that when Penny was given the prednisone that she was acting more like her ole self, so I am wondering if her symptoms could be attributed to Addison's, which an ACTH stimulation test could rule out. Also, was any thyroid problem looked into and elimated?

Was an urinalysis done, and if so, could you post those findings? I believe an ultrasound would be my next suggestion, as it can be a very useful diagnostic tool. An ultrasound may be able to show any abnormalities with the internal organs, so if the vet is thinking an obstruction or gall bladder issue, this might be found with an ultrasound.

Vetoryl is a strong drug and with Penny not having strong clinical Cushing's symptoms I completely understand why you are hesitate to start Penny on it, and if Penny were my dog, I wouldn't begin any treatment for Cushing's.

Hugs, Lori

[goldengirl88]

Welcome to the forum. Sorry your sweet Penny is having problems. She is so cute. What jumped out at me was her lipase number. She is 1051and since it is an enzyme that is produced by the pancreas to digest fat, that you could talk to your vet about pancreatitis. Blessings
Patti

[Squirt's Mom]

Hi and welcome to you and Penny! :)

I'm with Lori - no way I would start treatment without pretty strong signs and I would want the things she mentioned ruled out. Also, I would want to know more about her liver function and pancreas function. The liver values are elevated, or rising, and the Lipase was very high. Was the Amylase normal?

I'm glad you found us and look forward to learning more about the both of you. Congratulations on being a survivor! :cool::cool::cool: I can barely imagine the battle you fought and continue to fight.

Hugs,
Leslie and the gang

[molly muffin]

Hello and welcome to the forum.

I am with the others. This isn't screaming cushings at me. I'm more concerned about pancreatis and liver function based on these test results, even gall bladder, which you'd need an ultrasound to really look at and could be a next step for you.

You want a wash out period between giving prednisone and doing cushings testing also.

I definitely wouldn't start cushing medication until these other issues are addressed.

I notice that your vet gave you 30mg vetroyl for a 16lb dog. Dechra is now recommended 1mg/1lb and that is a safer dosage to start at. University of Davis I think recommends 1mg/2kg. So, even lower.

Those are my preliminary thoughts. Welcome to the forum. :)

Sharlene and molly muffin

[goldengirl88]

Hello from me too. I just wanted to speak to the 30 mg Vetoryl dose also. It has been seen on here over and over again that dogs get in trouble when started on too high of a dose. I would take care of all the other issues first, and not treat for Cushing's now. Blessings
Patti

[miamc8]

I'm back. Sorry it took so long to get back on here. Penny is still doing well. She was tested for pancreatitis and it was not that. My vet has been gone on vacation from mid June to mid September. I was given a referral to a specialty center so am contemplating that. I was thinking about another blood check in September to see what is going on and if anything is looking any different. The only thing she has going on right now is some exercise intolerance. She is still running around okay, but seems to take longer to recover from the exertion. I have not started the Vetoryl.

Thanks much for all your thoughts on my Penny. Again, apologies for not getting back to you sooner.

[addy]

September would be six months, I think since the last bloods? It would not hurt to recheck her blood work with the specialty clinic, if the vets there are knowledgeable;):). Specialty clinic does not always equal competent:o:o:o:o Not that I am trying to scare you off with that comment;);)

So, Penny has had no further issues, just mild exercise intolerance?
I think Lori's suggestion last March of an ultrasound is still a good one if you can afford it if her blood work is still showing abnormalities.

[molly muffin]

I agree that if it is possible to get an ultrasound to look at the gall bladder that might be worthwhile. If it is gall bladder sludge, then it is possible she would need a medication to break that up. IF that is the culprit and that high ALKP sort of makes me wonder. It would also affect the liver numbers as the sludge can cause a bile duct blockage. That is something to ask the vet about, special or other wise.

Welcome back!
Sharlene and molly muffin

[miamc8]

The referral to the specialty clinic is for the ultrasound. We also have another dog and 2 cats, one of whom is diabetic, so the money only goes so far between the 4 of them and the diabetic cat needs dental work which is more pressing as he needs a tooth out. Will probably stick to plan of doing blood work and maybe ultrasound, if nothing has changed in numbers, come September when regular vet returns. Its just one of those nights when I can't seem to get to sleep. Good job I have no where to be in the morning. Bye for now.

[molly muffin]

You do have your hands full with 4 animals to try and keep healthy. Oh poor kitty, yes that is important if they need a tooth out.

Some nights do just seem to be like that don't they. Then the next day you feel like a zombie half the time. :)

Sharlene and molly muffin

[miamc8]

Hey I'm back again. 13 year old diabetic cat had 2 teeth out, but is still doing well. Penny is still doing okay though seems to have developed itchy skin, but no hair loss or bald spots. No lumpy skin. We have a vet appointment next week for blood work. Her energy level is still good and she is still very perky. No problems with food or water. No pot belly. Will get back on here after blood results come back. Later.

[molly muffin]

Yay glad to hear that Penny is still doing so well. That is wonderful news and that the gang is still hanging in there, teeth out and all. :)

hugs

[miamc8]

Guess I spoke too soon. I found a lump over last weekend, so off to vet we go this afternoon. She was holding her own on blood work in December. Otherwise, she is the same with no other symptoms except for this lump. Keep your fingers crossed for my little girl. Thanks.

[Wrighton]

An ultrasound saved our girl's life. The cost varies greatly between vets. Admittedly my vet's was not as detailed as the specialist's but it did show the gallbladder with a mucoscele . The specialist's US are $425 and my local vet charged $20. Again , not the same quality, but good enough to send us on. Maybe you could check around.

Just a thought. We had no signs of gallbladder until the US.

Gail and Icy

[molly muffin]

Might just be a lipoma. My girl has a couple. They aspirated to check the cells and confirm.

Let us know what is going on.

[miamc8]

Here I am again. I know I'm sporadic, but with 4 animals things are hectic. Penny has a lipoma so that is okay. Bad news is that she has panting and skin problems on her belly that vet thinks are related to the Cushings. We did blood work and vet says its time to start Vetoryl with progression of symptoms and continued elevation of alk phos. I haven't got a copy of this week's blood work yet. I think he is on track so will be giving it a go after she has finished her antibiotics. She still has good energy and her quality of life is good in general, so we will see how she does.

[labblab]

Just want to reconfirm that if Penny still weighs around 16 pounds, she should not be started on a dose of Vetoryl (trilostane) that exceeds 20 mg. at the most. The recommended starting formula is 1 mg. per pound. So if your vet wants to use brandname Vetoryl, the most conservative way to start is giving one 10 mg. capsule daily -- or at most, no more than two. In reading back, I see he originally wanted to start at 30 mg. and that is too high. If you need documentation to present to him, let us know and we will give you links to print out.

Marianne

[miamc8]

I did bring up the dosage with him and he is adamant that this is the way to go, so if you would send the links that would be great. I've got some time before starting it so I can investigate further. From what I've seen its 1-3 mg per pound starting, so this would put her at just under 2 mg per pound. I'm sure this varies from dog to dog and one size does not fit all. He has a lot of experience with Cushing's dogs and I feel comfortable deferring to him. Its probably going to be at least 10 days before we start the Vetoryl. Thanks for the input.

[labblab]

Regarding dosing, take a look at this reply with embedded links posted on our Trilostane FAQs thread. You can even print it out to discuss further with your vet.

http://www.k9cushings.com/forum/showthread.php?p=1251#post1251

Marianne

[molly muffin]

There is no way to know how a dog will respond to the medication, some need more, some need less. We just had a dog crash on 30mg (20lb dog) in a matter of days, then again we've had 20lb dogs end up needing 40mg and more. You don't know, which is why it is safer to start lower and work up as needed, once you know how they will react.

I'm sure your vet thinks he knows best, but there is a reason that the manufacturer now says to start at the low end.

He might be right and 30 is where you end up but no need to be risky with it.

Hope all the furbabies are doing well and you are getting some sleep.

[miamc8]

I'm back. I managed to talk to the consulting vet for Vetoryl in our area and she said 10 mg for 15 pound dog, but even I think that would probably not be enough so talked with my vet again and we agreed to start her at 20 mg. Have just returned from getting pills. Staff at vets say they have a lot of dogs on this drug in their clinic who are doing well, so I am feeling comfortable with this. Thanks again for your thoughts. Fingers crossed.

[miamc8]

Hey, So Penny started on the Vetoryl 20 mg and did well symptom wise, but ACTH test said she was really sensitive to it so vet dropped her down to 10 mg. She has been on 10 mg for 30 days and ACTH test said cortisol was back to normal so now we have no more tests for three months. She seems to be a happy little dog right now and that is all we can ask for.

[labblab]

That is great that Penny is doing well :), and that is truly the most important indicator of all. However, I just want to clarify what your vet means by saying that her cortisol is now back to "normal." The normal range for a dog without Cushing's is much higher than the desired therapeutic range for a dog being treated with trilostane.

It would be very helpful if you could get the actual numbers for both her monitoring tests. As long as she is doing well, it may be a moot point. But if you start to see symptoms rebounding, it will be very important to know whether her cortisol is already running higher than is really desired for a Cushpup. That info will be important when making decisions about future dosing changes.

Marianne