Newly Diagnosed Boston Terrier

[bberube]

Good Afternoon All,
Hope things are well. Allow me to introduce myself: My Name is Barbara and I'm owned by a 8ish year old Boston Terrier named E.T. We're unsure of his age & history as he's a rescue. In January I noticed an increase in urination length, increased thirst, & appetite. I had a Westie several years ago (Barney) who unfortunately, had Cushing's disease so am quite knowledgeable about the symptoms. I brought ET to the vet who was a huge disappointment as she performed the wrong tests (ie a ACTH Stim Test instead of a Low Dose Dex since he was not receiving treatment for the condition). All this aside, I switched vets to one who treated Barney. ET is 28 pounds and is on 60 mg of Vetoryl daily. Apparently his values were quite high. I've noticed that the symptoms have pretty much subsided but he is still lethargic and quiet. So far in four weeks, he's had about three (3) ACTH Stim Tests as per Canadian protocol for newly diagnosed patients. His cortisol values are consistently decreasing (Thank Dog!) as well as his ALT and ALKP. However, this boy doesn't/can't walk far. I understand that muscle wasting in the hind legs is a symptom. He'll walk long enough to do his business and then that's it. This pretty much has been since Sunday. After about a minute, he'll sit down on the pavement and one needs to coax him to continue. Since we have another dog (Mercy - another rescue), I test ET by paying attention to Mercy to generate a reaction and, sure enough, ET starts barking at me for attention, etc. Unfortunately, I believe he ate something that disagreed with him on Sunday evening and had a few bouts of diarrhea Monday and part of Tuesday which has since subsided. I've been in contact with the vet who wants me to monitor him and send her updates today. Just seven days ago ET had an ACTH Stim Test, in addition to regular biochemistry and hematology tests and all results came back excellent. His cholesterol is even coming down slowly. Not sure what to think. I was wondering if I should be considering introducing a medication for his lameness and what the consensus is from other members. Is anyone treating this issue and what is the best approach. To be perfectly honest, I don't feel like subjecting my Angel to another ACTH Stim Test so soon. As I said, he's not vomiting, has a healthy appetite, but lots of gas... which I believe is from the Low Fat diet he's on.

Any help/direction would be greatly appreciated.

Thank You so much,



Barbara & ET (Extra Terrific)!!

[Harley PoMMom]

Hi Barbara,

Welcome to you and E.T.! Bless you for giving E.T. a forever home, and it sounds like he has found a very loving home too. A starting dose of 60 mg for E.T.'s weight of 28 lbs is a bit high and with the diarrhea it could be that E.T.'s cortisol has dropped too low. Has the vet asked you to stop the Vetoryl because the Vetoryl should not be given to a dog that is showing signs of being unwell. Vetoryl drops cortisol very quickly and it is known that it will continue to do so for up to 30 days. We've actually seen dogs here who's cortisol continued to drop, sometimes too low, after 30 days while being on the same Vetroyl dose.

If you could get copies of all monitoring and diagnostic tests for Cushing's and post those results here that would be a great help.

We are here to help in any way we can so do not hesitate to ask all the questions you want.

Hugs, Lori

[Junior's Mom]

Welcome to the forum. Your dog has been started on a very high dose of vetoryl. It should be no more than 1mg/lb. While the quick drop in cortisol can have them feeling yucky for a while as their body adjusts to it, lethargic, and loose stools is a sign of too low cortisol, which can be life threatening.
Please do not give your dog any more vetoryl. Take him in for another stim test, and have his electrolytes checked as well. Did your vet give you any prednisone for an emergency. He may need this asap.
When you can, could you collect all the tests that have been run so far, and post just the abnormal results as well as the references ranges.
The goal in treatment is not the same cortisol range as for a normal dog, so your vet may not be looking at the right numbers.
Also, vetoryl has to be given with a meal to be properly absorbed, and the stim test must be started no later than 4 hours after the dose is given.
I hope E.T. improves. Please keep us updated.
Tracey

[goldengirl88]

Welcome to the forum. I know you said you had another dog with Cushing's and are familiar with it. Would you be able to post the abnormal readings from the testing you have had done and the normal scale from the lab as they are all different. My first question is was he started on 60 mg of Vetoryl from the beginning? The normal starting dose is 1 mg per pound and that is over double of what he weighs. The second question is did the vet not tell you to stop the Vetoryl when he started with the diarrhea? You never give trilostane to a sick dog, and one of the signs of the cortisol going low is diarrhea, so that is a concern. When was his last stim and what were the numbers? Has you dog had an ultra sound to check the adrenals and the other organs? Did your dog have any other issues going on when tested for Cushing's? If so that can skew the results. Has your dog been tested for diabetes or thyroid disease? They share similar symptoms as Cushing's. There is muscle wasting involved with Cushing's, which in turn weakens the legs. Another concern is you saying your dog is unable to walk, and just makes it to potty. That can also be a sign of low cortisol as can the lethargy you mentioned. How long has your dog been on the Vetoryl? Is it one dose of 60mg or 2 doses of 30 mg? I am just uncomfortable with this dose, it is high for a dog of 28 lbs with the symptoms you say he is displaying. The vet should have told you to stop the Vetoryl when you called her about the diarrhea, not to monitor the dog. If you have not had an stim for a while I would stop the Vetoryl, and get a stim, and check electrolytes. He is showing some of the signs of Cushing's, but we need to see the numbers from the testing to know what is going on. If you don't get copies of tests now is a good time to start that as you will need your own file to refer to often. In some instances smaller dogs can need a higher dosage of trilostane, but starting out a dog that weighs 28 lbs on 60 mgs is something I just would never do. The others will be on soon to ask questions also. We need to do that in order to really find out what is going on. Were you told what type of Cushing's your dog has? You will get great help and support here, this forum has a lot of experience. We are here to help and support you so you are not alone in this. Blessings
Patti

[labblab]

Hi Barbara,

Welcome to you and ET! As has already been said, it will really help us a lot if you can post the actual numbers for all of ET's ACTH tests, including the initial diagnostic test performed by the original vet. Actually, the ACTH can indeed be used for diagnostic purposes as well as monitoring. In terms of diagnostics, the LDDS and the ACTH have different pluses and minuses, and clinicians have different preferences as to which is most appropriate for any specific dog or circumstance.

But diagnostics aside, I am surprised to hear that ET has already had three monitoring ACTH tests within the first month of treatment. That certainly means, though, that you are able to closely trace the progression of the cortisol. Therefore, I am assuming that up to this point, the 60 mg. dosing has not lowered his cortisol to a level deemed worrisome by your vet. However, as all have said, cortisol can continue to decrease throughout the first month even when the dose is unchanged.

Is there a particular reason why your vet chose to perform weekly tests? Traditional protocol as recommended by the brandname drug manufacturer is to test initially at the 10-14 day mark, and then again at the 30-day mark (unless problems arise). So I am just wondering whether ET exhibited any irregularities prior to this that prompted the more frequent testing.

I'm glad the diarrhea seems to have resolved, although the combination of the diarrhea and more pronounced lethargy since Sunday do raise question marks. It is normally the 30-day test that prompts an upward dosing adjustment if deemed necessary. Since ET is already on a hefty dose, no increase may ever be warranted and it may well be the case that a decrease may actually be called for. But once again, if we can see those actual testing numbers, they will guide our feedback and suggestions to you.

Marianne

[Trixie]

Hi Barbara-(I'm a Barbara too) and welcome..
I have to agree with Patti's post. I think your dose of 60mg for a 28 pound dog is too high. We've seen this time and time again here on the forum where the dog does well on a high dose for a few weeks and then little by little lethargy starts, then diarrhea and no appetite and the dog begins to crash.
Starting the medication at the 1mg per pound rule may take a bit longer to get symptoms under control, and tweaking the dose after acth tests may happen but it is safer and the dog adjusts better to the treatment.
I would be very careful right now as you are starting to see some adverse reactions which could be a result of getting too much vetoryl. Weakness in the legs can be a Cushings symptom and it can also be an adverse reaction of having the cortisol go too low. The number drop can continue to drop the first few months.
Hope ET continues to do well and will feel better each day..to be safe you might just want to reassess the high dose with your vet.

Barbara

[Renee]

Hello and welcome. Many boston babies are members here too.

Everyone has asked great questions, and I hope you are able to answer them - but I have a few of my own too.

When your previous pup had cushings, were you using vetoryl at that time, or lysodren? Are you familiar with the vetoryl protocols?

Did you do any other diagnostics besides the ACTH?

Do you know if you are dealing with PDH or ADH?

Did he start out on 60mg, or have you worked up to that dose over the last month?

I get worried when someone (or a vet), encourages aggressive treatment because values are quite high or not. Really, the cortisol values do not directly relate to the dosage needed, as each dog is different.

Finally, I know I am repeating others... but, we love to see actual test results. Please round up your ACTH figures, if you can, and post those too. :)

[bberube]

Thank you so much for all your informative replies. I'm not sure if the Canadian & American protocols are different in four weeks E.T. has had a couple of ACTH Stim Tests. Our vet does not feel confident in decreasing his dose at this point in time. She is a very vigilant professional and rather err on the side of caution (and not expense - lol). I believe since ET was exhibiting symptoms for a few months post consultation, that she understood my concern and wanted him controlled immediately. I don't have his numbers but recall her saying that his values were very high. When we had our consult on Thursday, March 27th, he was already losing fur, urinating for a minute at a time, drinking a heck of a lot more than usual and even chewing his ceramic bowl after eating supper. She understood that in spite of spending thousands of dollars on testing with our former vet, I arrived no further ahead. ET had an abdominal ultrasound mid March and he has bladder stones and an adrenal nodule. The stones may require surgery down the road but not until his values are stable.

I found out recently that one of my guests over the weekend fed E.T. marinated pork on Sunday evening. I'm not thrilled as you can hear.
I gave E.T. 1/4 tab of antidiarrhea medication last night and as of 6:10 pm last night, the diarrhea subsided.

I also read somewhere that cortisol can mask certain conditions and am wondering if ET essentially has arthritis....

Keep the replies coming. Will apprise everyone as I find out info. My other dog is being admitted tomorrow to have his teeth cleaned so will chat with the vet as well.

[labblab]

It will be great if you will request copies of ET's test results when you see the vet tomorrow. Without knowing the actual numbers, all we can do is speculate as far as the appropriateness of this dose. But as Renee had said, the size of the initial dose is not based on the pre-treatment cortisol level, but instead on a dog's weight and then subsequent response via monitoring tests. The drug can be metabolized very differently on an individual basis, and a small dog may end up requiring a larger dose than a much bigger dog. The actual test numbers and behavior of the dog tell the story.

Marianne

[bberube]

Thank you again. Was wondering if there are any consequences to not giving him his pill tomorrow morning? This little boy has had a stim test almost every week... four hours at a time.

He had his chloride and potassium checked twice in one week because it was borderline. The vet then realized that his values have always been the same, even with the other veterinarian.

[bberube]

We treated Barney with Anipryl several years ago... I remember hearing that the dose he was on was high for his weight. I was wondering if ET would require a repeat ACTH Stim test to ascertain his value or would a random cortisol sample yield the results? Heading home... ET's diarrhea has subsided.... his appetite is normal and he hasn't vomited whatsoever. My vet said that vomiting would be symptomatic of medication intolerance. He chased my Mother to the door when leaving this afternoon barking at her as usual. His hind legs were a little stiff last night when he jumped off the sofa. I need to rationalize having him undergo another stim test seven days later. Is there no other way? All of these procedures are taxing on the animal, not to mention my pocketbook. Each Stim test is $250 CAD not to mention biochem and hematology... ultrasounds run about $460.00. I would NEVER begrudge my Angel anything but I've paid for two (2) separate vets in the course of as many months... so far spending over 4k on tests.

Just trying to gain perspective. As I mentioned earlier, I'll be seeing the vet tomorrow when I bring in Mercy to have his teeth cleaned.

Best,

[bberube]

I sent my last message prematurely...

When our vet called last week with ET's results, she said that he is not Addisonian and the results confirmed it. She is extremely bright and will speak with her in depth tomorrow.

[labblab]

How is he doing this evening? Is he back to how he was behaving prior to Sunday or is he still "off?" When a dog is acting ill, the most prudent course is to withhold the drug until behavior normalizes again. Unless you were planning to have an ACTH test performed tomorrow, withholding the morning dose should pose no problem.

I admit to being confused now, though, as to the number and timing of the monitoring ACTH tests, since you've mentioned two, three, and weekly tests. Can you tell us the exact number, and at least the approximate timing since beginning treatment? This will have a bearing on the path moving forward. Barring problems, when was your vet planning to test next?

Marianne

[labblab]

We were typing at the same time (I am being very slow with hunting and pecking on my tablet!). So here's a bit more clarification...

Even though ET was not technically Addisonian a week ago, it is possible that his numbers were on the low side and have dropped even further. Without knowing the numbers, we cannot help judge that. Also, how many weeks after starting treatment was last week's test? If it was significantly short of a month, then there is added reason to expect that ET's cortisol may indeed have dropped even further. This is why I am continuing to pester you for more specific info about the number and timing of the tests.

[Renee]

I am concerned and confused as well, because some of this information seems to be contradictory - and, bright as your vet may be.... it does not sound like she is following protocol.

Vetoryl dosing is based on weight. The conservative approach is 1mg per 1lb in weight. So, at 28 pounds, ET should have either started on 20mg or 30mg (or a combination between 20-30, if you were to use compounded trilostane).

Assuming no adverse reactions, the next stim test would have been 10-14 days after starting medication. Then, continuing to assume no adverse reactions, a second stim test at 30 days (2 weeks after the first stim), would have been done.

Then, and only then, would a dosage increase be considered, depending on the results of the 30 day stim test. And, of course, depending on the symptoms.

I wonder if your vet is concerned about possible addison's, since she started him on such an aggressive dose? I am confused about why your vet is testing every week? If she is concerned about addison's, and this is why she is testing every week... well, then, that right there indicates that she knows she may have been too aggressive on the dosing. You say she errs on the cautious and not increasing expenses... but, that is exactly the opposite of what she has done. Her dose recommendation is quite risky and the multiple stim tests are quite expensive.

Just to reassure you - even if there are no adverse reactions in the beginning, this does not mean 'everything is okay'. The cortisol continues dropping, and may not get too low until a few weeks into treatment. This could be why the diarrhea didn't show up until a few weeks after starting.

[goldengirl88]

Also about the stiffness in the back legs. Cortisol can mask other problems such as arthritis, it is just like getting a shot of steroids when you go to the Dr. and you feel like a million bucks for a while. Since your dog was on a high dose and the cortisol is really coming down, or down too far, this could be bringing the arthritis in the legs to light again and your dog could be hurting.

[molly muffin]

I am in Canada too, as is Juniors mom, and have both a vet and an IMS. The protocol is the same for testing in both Canada, the US, Europe, across the board and are as stated above 10 - 14 days then 30 days.

They use to start dogs out at a higher dose than the 1mg/1lb but in recent years, especially with all the research done in the U.S. since it was approved there they have found that it is safer to start at the 1mg/1lb ratio due to the number of dogs that crashed on initially starting higher.

If your vet has any questions about this, then she should refer to Dr. Peterson, who is one of the worlds leading researchers in cushings and a consultant vet for Dechra the makers of vetroyl (the main ingredient is trilostane). Dechra is located in UK and since my vet didn't even know the name Dechra, your vet might only be familiar with whomever is the supplier she uses.

University of Davis is another of the leading Universities doing cushings research in north america and also follows a conservative starting dose. It is not intolerance of the drug, if this wasn't shown to occur immediately upon first or second dosage, but much more common is too large of a dose and every dog is different and some show more sensitivity and do better on a lower dosage. There is always two things to go by, the number and the dog themselves. If there is arthritic issues then perhaps being a tad higher while controlling symptoms is the desired final dosage. So many things to take into consideration.

However, one of the symptoms of cortisol dropping too low is the diarrhea, lethargy, vomiting, wobbly and unable to stand (this is a life threatening stage as electrolytes can be involved at this point) so watch for anything like that.

Hope some of that helps clarify. ACTH can be used as a diagnostic test in addition to the LDDS test. (low dex) So your first vet having done that doesn't mean they are wrong. We have had both done prior to starting any treatment and I personally prefer to know the cortisol levels prior to going into treatment so you do have that on your side. You know.

Make absolutely sure that your vet is using the range for dogs on trilostane treatment as the proper range to look at and not the lab range given on the test results as normal. The ranges differ once treatment starts.

Sharlene and molly muffin

[Junior's Mom]

How is ET? Is he feeling any better? Did you withhold the vetoryl?
Tracey

[goldengirl88]

How is ET doing? How are his back legs? Hope everything is working our for him. Blessings
Patti

[bberube]

Good Afternoon,
Hope things are well. Thank you so much for your replies regarding my Boy. I wanted to update everyone about E.T.'s visit last Thursday to the vet's:
My concerns regarding E.T.'s lameness were addressed as we were not sure if it was related to the Vetoryl or not. His knees are the problem whereby they are arthritic. I was told that if ET didn't have so many health issues, surgery may have been suggested. All this to say that his Vetoryl dose has been decreased from 60 to 30 mg and will retest in 3-4 weeks along with a biochem and hematology workup. He will also have another abdominal ultrasound to see if his adrenal nodule has increased and where exactly is his bladder stone. Poor Guy!

ET was given a medication for osteoarthritic pain - I can't remember the name but it starts with an "O". I remember Barney going for Adequan injections way back when but believe it was before he was diagnosed with Cushing's. Would anyone be able to give me names of medications used to treat arthritis that have minimal side effects for canines suffering from Cushing's?

Thank you in advance,
Barbara & E.T.

[Harley PoMMom]

Was an ACTH stimulation test done? Since E.T. Vetoryl dose was changed an ACTH stimulation test should be scheduled within 10 - 14 days.

For arthritis: Glucosamine Chondroitin Sulfate with MSM, wild salmon oil, Adequan, Duralactin...This site has info regarding arthitis meds: Supplements & Diet Guidelines for Dogs with Arthritis (http://www.dogaware.com/health/arthritissupps.html)

Hugs, Lori

[bberube]

Hi Lori,
ET was started on 30 mg last Friday so was told that a repeat stim test should be performed by the end of the month. Do you think it's best to wait an extra week or so in order to ensure that the 60 mg is long gone???

[Harley PoMMom]

I am assumng that since E.T.'s dosage was adjusted downward that the 60 mg of Vetoryl was too much?? However; since we do not know the actual numbers of the most recent ACTH stimulation test, it's hard to provide any meaningful feedback.

How is E.T. acting? Also, how are his symptoms?

Hugs, Lori

[bberube]

Hi Everyone,
Hope everyone is well. ET was indeed switched to 30 mg of Vetoryl. His diarrhea subsided after a day or so and before he switched doses. I will get copies of his values next week when we visit again with Mercy (Shepherd x).

ET is doing well. The vet also prescribed something for arthritic related pain which seems to be working and I'm only giving him half the dose. We changed dose last Friday (May 9th). He's scheduled for a repeat ACTH Stim test early June. She asked for the end of this month but would like to ensure that the dose is accurate given that he was on double the dose initially and the price of course $250 not to mention biochemistry and hematology, etc, etc.

[bberube]

Thank you, Lori. I just saw your post re repeat ACTH Stim test after changing doses. There are SO MANY variables to consider with regard to treating this awful condition.

When Barney was diagnosed, Anipryl was the drug of choice. His ALKP continued to climb post diagnosis & treatment.

ET seems controlled at the moment. He has more energy, barks at me for attention and his appetite has returned to normal, so is his water intake. Will keep monitoring him, as always.

I've decided to continue purchasing ET's Vetoryl from the vet for now. She was very concerned about these virtual pharmacies that are cropping up, particularly, www.thepetpharmacy.ca. Will revisit at another time.

[bberube]

Allow me to backtrack a little for those who have questions:

ET was left untreated for a few months as our former vet was unable to make the diagnosis. When he presented to our new vet (and Barney's vet years ago), he was urinating for a minute at a time, eating all his food at mealtime and even chewing the bowl, increased water intake, & fur loss. The only symptom that he didn't have was panting, which he has now but, the Quebec temps have been relatively high - even for me (lol). Our former vet, however, did recommend an abdominal ultrasound which he had performed on March 17th. ET has an adrenal nodule (quite small) and has tiny stones in his penis. His liver was a little rounded as well.

We had our consultation on March 27th and she reviewed all of ET's documentation from the ultrasound and previous laboratory data and the following day ET was admitted for an LDDS. Received a call on March 29 to say that the results indicated Cushing's and they were "very high". He started the medication the following day and had his repeat stim test April 7th. I was told that we would monitor his adrenal nodule for now as well as his stones. Was also told that the LDDS indicated pituitary dependent Cushing's. Perhaps the nodule was an incidental finding.

He had another stim test on April 14th along with urinalysis and biochem and hematology. Our vet only performed these the second time around given the sheer number of blood tests this Angel had with our former vet. Was told that his ALT and ALKP were NOW within normal limits and that his cholesterol was starting to decrease which was excellent. Was also told that his chloride was low so suggested that we return every 3-4 days to test it as well as potassium. They have stayed on the low side and were the same as with the previous vet. ET has his last Stim test ~ two (2) weeks ago and his cortisol was still dropping. The only reason his dose was changed last week was due to my concern about the lethargy. By the time I visited the vet, ET's diarrhea had subsided but she requested a stool analysis just the same. So far no word.

Again will get the numbers and post next week. My head is still spinning because while ET was undergoing a battery of tests, I added my Shepherd mix (Mercy) to the mix because he was having other issues so am having difficulty keeping everything straight.

Your feedback has been invaluable.

[bberube]

AMENDMENT: Was told that his ALKP and ALT were "NOW" within normal limits....

[molly muffin]

It is hard to keep things straight when you have multiple dogs with issues. I get copies of all test results from my vet and put them in my home file and I keep a running entry on this forum of test results so as to know they are always at least somewhere that I can find them. :)

Glad that the vetroyl dosage was reduced. I just feel more comfortable with a lower dose.

My dog also has an adrenal nodule, small that we are going to monitor.

Sharlene and molly muffin