Casey - 10.5 y/o lab/hound mix - Diagnosed and looking for guidance

[swipers]

Hey folks,

My wife and I have a 10.5 y/o, 60lb lab hound mix who was recently diagnosed with Cushing's. Our vet is good and attentive but I'm not sure how familiar he is with Cushing's, he seems to rely on Google and his textbooks as much as I do. This is a modest sized community so we're somewhat limited in veterinary options. We are close to starting Casey on Vetoryl but I wanted to run some things by the forum first to get your opinions. This whole thing as been confusing and I'm overwhelmed with information from researching this on my own.

She demonstrates the following symptoms: panting, thirst, ravenous hunger, has urinated in the house a few times but now that we're hyper-vigilant about letting her out more often we haven't run into that issue again. She's able to make it through the night without urinating (I think we had one overnight accident a month or so ago). She also had a urinary tract infection early a few months back.

Symptoms she does not exhibit: her coat is fine, energy is ok - maybe she has slowed down a bit but she's always been a bit of laid back dog, no bloated belly, not sure if her skin is thinning - it seems fine.

Food is the craziest. She's obsessed and will go to great lengths to steal food, get into garbage, etc... She mostly presents as a happy dog, no obvious signs of discomfort.

We had some tests done and I'll share the results here. I'm not quite sure what to post so let me know if I'm missing anything. We had blood work, a urinalyses and the low dex test done.

http://i.imgur.com/e8Q5iPy.jpg - biochemistry, hematology, endocrinology
http://i.imgur.com/vGCrF1J.jpg - urinalysis
http://i.imgur.com/tvnypC2.jpg - low dex test results

We don't know if we are dealing with pituitary or adrenal.

Vet wants to start her on 60mg of Vetoryl. Her symptoms seem relatively mild relative to other Cushing's cases I've read about. Side effects of the meds are kind of terrifying so I'm trying to weigh out the risks. Is medication the right way to go? How dangerous is untreated Cushing's?

I have a million more questions but maybe I'll stop here for now, lol. Any assistance is greatly appreciated.

[Harley PoMMom]

Hi and welcome to you and Casey!

Getting copies of those tests and posting the results here would be great, we only need to see the values that are abnormal with the reference ranges and units of measurement, for the chemisrty/CBC blood panel it will look like this (my numbers are random)...ALT 150 U/L (5-100)

Now for a LDDS test there should be 3 blood draws; a baseline or resting number, a 4 hour draw, and a 8 hour draw and we need those units of measuement too which probably looks like this...ug/dl.

Could you also post the findings of her urinalysis? Dogs with Cushing's usually have diluted urine, which means a low urine specific gravity (USG), and sometimes a regular urinalysis will not pick up the bacteria that is present so an urine culture and sensitivity test should be done so the correct antibiotic can be rx'd for that particular bacteria.

Cushing's is one of the most difficult diseases to diagnose and unfortunately, it is also one of the most misdiagnosed. There isn't just one test that is conclusive, so a vet has to rely on more than one diagnostic and validation test.

Non-adrenal illnesses such as diabetes, any thyroid issue, liver problems should be ruled out before starting any treament for Cushing's. Diabetes, thyroid and liver problems do share some of the same symptoms as Cushing's and non-adrenal illnesses can create false positive results on all Cushing tests.

Cushing's is a slow progressing disease so you do have time for a confirmed diagnosis. Also Cushing's is not a death sentence, once a pup is being treated and controlled they can live out their normal life-span.

The starting dose of Vetoryl is based on a dog's weight and in Dechra's product insert the starting dose recommended is 1 mg - 3mg per lb of a dog's weight so if Casey weighs 60 lbs than 60 mgs is a reasonable dose, and we have seen less adverse effects when the initial dose is started at the low end of the doage scale.

I am providing a link for you that has information regarding Vetoryl/Trilostane: Trilostane/Vetoryl Information and Resources (http://www.k9cushings.com/forum/showthread.php?t=185) Please feel free to print anything out.

Lysodren/Mitotane and Vetoryl/Trilostane are generally the two medications used to treat Cushing's. Both can have adverse side effects and one is no safer than the other. Lysodren has been around for many, many years and for decades it has been used, off label, for Cushing's and still is. Trilostane/Vetoryl was FDA approved for the treatment for Canine Cushing's in 2008.

These are strong drugs but life savers for our dogs with Cushing's, please do not fear using one of them but a pet parent does need to educate themself with the protocols of treating a dog with Cushing's. Success in treatment depends on keen owner observation and a vet/IMS that is knowledgeable and experienced in treating dogs with Cushing's.

We are here for you both so please ask all the questions you want. ;)

Hugs, Lori

[swipers]

Hi Lori,

Thanks for your response. If you take a look at my original post there are three links that will take you to scans of the lab reports with the results of all recent tests - blood, urinalysis and LDDS. I wasn't sure which results were pertinent so I figured posting the full lab reports would be the most helpful. The links seem to be working but if they aren't displaying for you let me know and I'll post the information manually. Thanks again.

[Harley PoMMom]

Those links are not working for me, sorry...:(:o If you could post the abnormal values along with the results from that LDDS test that would help us to provide you with better feedback.

[molly muffin]

Hello and welcome to the forum.

I have typed out the abnormal test results of blood, the urine specific gravity and the LDDS results, so they are easily viewable by members. This is the best way to get them seen as soon as possible.

Chloride - 107 mmol (108 - 119)
ALT - 124 IU/L (18 - 121)
ALP - 163 IU/L (5 - 160)
Lymphocytes - 5.8 (1.0 - 4.8)

Urine Cortisol - 411 nmol
Urine Cortisol/Creatine ratio - 168.

Interpretation
<34 hyperadrenocoricism is highly unlikely and investigation of other ause of the dogs clinical signs is recommended.
>34 Hyperadrenocorticism is possible, hower a urine sample collected from a stressed dog or a dog with nonadrenal illness can have an increased ratio.

Urine Specific Gravity: 1.005

LDDS
base - 81 nmol (28 - 120)
4 hour - 123
8 hour - 74

Glucose was normal so diabetes is not suspected.
I don't see a T4 on the results, do you know if the eliminated the possibility of thyroid?

60lbs starting at 60mg is the recommendation for starting trilostane. Since no one knows how their dog will react to any medication, all the warnings still apply. Lethargic (wobbly can't walk), not eating, vomiting, diarrhea, stop and get her to the vet.

To give Trilostane, you want to give it in the morning (unless you are doing a split dose of morning and evening, which would be 30mg in am and 30mg in pm) then all is given with her breakfast in the morning and when you do the ACTH test, which should be around 14 days first one, then it should be conducted 4 - 6 hours after her morning dose with food.

Should you start treatment. These results are consistent with cushings. Remember what you are aiming for is to control symptoms, sounds like with Casey you would know by her appetite and to control the cortisol that is in her body and that can cause further damage.

Trilostane should help with those two things. When you run into problems is when too much is given to start out with and you get into trouble. Otherwise, many dogs have been treated for a very long time on these drugs and do well.

Welcome again to the forum
Sharlene and molly muffin

[swipers]

Picking up the meds today but I'll probably wait until Sunday when I can be home all day to start. Sorry, there are a lot of questions below. I just want to get all of my ducks in a row before I start Casey on the medication.

Looking at the diagnostic sheet Lori linked to for Vetoryl it looks as though we stopped the tests at the LDDS stage. Is it important to keep going with the testing - we didn't do the high dex, endogenous ACTH or the ultrasound.

Is there anything in Casey's current test results (posted above) that would indicate either pituitary or adrenal as the source of the cushing's? Is is important the differentiate between the two types prior to starting treatment? I know adrenal can be operable but I'm not sure if we would go that route anyway - probably just treat with medication.

I thought I read something about having prednisone on hand in case there is an adverse reaction to the Vetoryl but now I can't find the source of the info. Was I dreaming or should I talk to the vet about this?

Thanks so much,
Sean

[swipers]

... and thanks for typing out all the info from the med reports, Sharlene. Much appreciated.

[Harley PoMMom]

Based on Casey's LDDS test results a differential between the adrenal and pituitary Cushing's can not be made. When a dog is being treated with Lysodren it is beneficial to know whether the dog has an adrenal tumor or if the tumor is pituitary based because with an adrenal tumor it usually takes a larger than normal dose of Lysodren to load.

An ultrasound, IMO, is a really good diagnostic tool because all the internal organs may be seen and any potential problems could be found, such as pancreatitis, gall bladder mucoceles, kidney/liver issues...etc

IMO, it is always a god idea to have prednisone on hand when treating a dog for Cushing's, whether that treatment is with Trilostane or Lysodren.

We are here for you both and will help in any way we can.

Hugs, Lori