Raised blood cortisol level=cushings?

[ajaxandalphie]

Hi I'm new to the forum. I just had my 3yr old Sheltie tested for thyroid, but the result came back and he has raised cortisol instead(10, normal is up to 4 I believe?). He also has Pott belly appearance /muscle wasting and is generally lethargic(but always has been a low energy dog). He is overweight with a huge appetite. He does not have other symptoms like overdrinking/urinating, skin or hairless problems. His CBC and ALP are all normal. T4 is normal but at the lower range.

my vet decided to prescribe him with a two week trial on trilostane. My question is, is this diagnosis too rushed for cushings? He's so young. We will be going back in two weeks for a re-measure of his blood cortisol level. Needless to say I'm deeply worried. :(

[labblab]

Welcome and yes, you have every right to be concerned about making a Cushing's diagnosis and beginning treatment based solely on an elevated resting cortisol level. Cushing's cannot be confirmed on that basis. Resting cortisols can vary greatly from day-to-day, even hour-to-hour, in all dogs whether or not they have Cushing's. Cortisol tends to rise and fall within daily circadian cycles, and other external factors (such as stress) can cause the level to rise at the time of a test even when there is nothing physiologically wrong. And in the presence of an illness other than Cushing's, the baseline cortisol can be elevated as well. Abnormally low resting cortisols can point to the possibility of Addison's, but the reverse is not true: the resting cortisol for a Cushpup may fall anywhere within a normal/elevated range and it requires specialized diagnostics of adrenal response (the ACTH stimulation test or the LDDS) in order to gauge whether there is an abnormality present. Here's a quote that may help:



Basal cortisol concentrations, when used alone, are not reliable in the diagnosis of hyperadrenocorticism in dogs. Because of the episodic nature of cortisol secretion in dogs, basal cortisol concentrations fluctuate throughout the day, resulting in a high degree of overlap of values in normal dogs, dogs with nonadrenal illness, and dogs with hyperadreno-
corticism. The sensitivity of basal cortisol determinations in the diagnosis of hyperadrenocorticism is only about 0.5 (approximately 50% of dogs with the disease have high random cortical concentrations), whereas the specificity can be extremely low in dogs with severe nonadrenal illness. This severely limits the usefulness of basal serum cortisol concentrations in the diagnosis of hyperadrenocorticism. Plasma or serum cortisol values are only useful after dynamic stimulation with ACTH or suppression after dexamethasone.

http://www.researchgate.net/profile/Mark_Peterson11/publication/6294531_Diagnosis_of_hyperadrenocorticism_in_dogs/file/60b7d52acf3ee6045e.pdf

It sounds as though your dog does have a couple of symptoms that are consistent with Cushings, but does not fit the profile in many other ways. So this is far from an open-and-shut case of the disease. In my own opinion, you would absolutely need more diagnostic testing prior to starting any medication. If it were me, I would print out this quote and take it with me for further discussion with my vet prior to proceeding any further.

Marianne

[mytil]

I do agree with Marianne here. And I would add that I would suspect your vet does not have a great deal of experience in correctly treating Cushing's to order a trial treatment of Trilostane based upon these results.

Take a moment to read through this - http://www.kateconnick.com/library/cushingsdisease.html and these links as well....http://www.k9cushings.com/forum/showthread.php?t=180.

Terry

[ajaxandalphie]

Thank you Marianne and terry. She's probably not experienced like you said. I asked her if there should be further testing to be done first but she said using the trilostane counts as a test. She is starting him on a very low initial dose once every two days for two weeks. should I go with it or try another vet? I read through some posts on the forum it seems she is using treatment as diagnosis.

If he does have cushings, and if we get it under control, will he still have a normal life expectancy?

[labblab]

I would definitely shift to a different vet. It is both incorrect and can be very dangerous to give trilostane to a dog without an appropriate diagnosis, no matter what the dose is. And the every-other day dosing also makes no sense, even for dogs who are known to have the disease. The drug does not remain active in the bloodstream beyond 24 hours, so one day your dog would receive treatment and the cortisol would be suppressed; the next day the cortisol would spike upwards again. That type of dosing rollercoaster makes no sense. Nothing about this scenario sounds good, and I would not feel at all comfortable sticking with this vet.

And yes, with proper treatment, a Cushpup can live out a normal lifespan. :)

Marianne

[labblab]

Just wanted to come back and add that when a complicated diagnosis such as Cushing's is involved, sometimes you can save money in the long run by consulting up-front with a vet who has received specialized training in disorders of this kind. This type of vet is an "Internal Medicine Specialist," or "IMS." Their initial fees may be higher than a regular vet's, but they can help pinpoint the testing that is most appropriate and start you off with appropriate treatment. This can save you money on lengthy, unnecessary diagnostics further down the road. They are not found everywhere, but here's a link that can help you find out if there is one in your area.

http://www.k9cushings.com/forum/showthread.php?t=182

University vet schools can also be very good sources for consultation. Barring seeing a specialist, if you have other vets available in your area, I would "interview" them by calling beforehand and asking whether they have had experience with successfully treating dogs with Cushing's. Although in your dog's case, it may turn out that Cushing's isn't even involved.

Marianne

[ajaxandalphie]

I see. I really don't have extra time right now until early august to go see a specialist. Do you think it's ok to wait another two weeks? I will look into finding a internal med specialist in my area.

Ajax physically fit the description of cushings, but displays no other symptom for now. But we did recall sometime last year he had some black spots on his belly we thought was due to diet change. It's disappeared since then.

my vet said two day period is so she won't over dose him just in case. But from what you said it seems this therapy might not prove anything at all!

[My sweet Ginger]

Hi, Marianne and other more experienced members will take care of the specifics from here on but out of curiosity, what was the dosage your vet prescribed for Ajax and how much does he weigh? Please do not start him on trilostane yet.

[ajaxandalphie]

I have no idea, I asked about dosage she simply said it's too complicated to explain to me in a few words.

maybe I should break down the capsule(she grinded the pill) and give it to him daily instead of every two days?

[labblab]

OK, this is getting crazier by the minute!!! :( :( :(

There is no dosage amount listed on the bottle or box? And do you mean the vet took a tablet and crushed it up and then put it into a capsule herself? :eek:

No, No, No it is not OK to open a prepared capsule and divide the contents yourself. But beyond that, I am totally baffled as to how the vet prepared the medication to give you in the first place. The medication should have been prepared in final form (capsule, tablet or liquid) by a pharmaceutical company or a compounding pharmacist. Your vet should not be altering the product herself to redispense in a different manner. Why would she be grinding up a pill to put into a capsule? Plus, what can be complicated about telling you what the dosage amount is? It is simply a number.

Given everything you've told us, I absolutely would not give Ajax any medication at this point. Cushing's is a very slow-moving disease and you can certainly wait another couple of weeks before pursuing additonal diagnostics. Actually, this will give you additional time to read more about the disease and treatment yourself, including the seriousness of giving a dog trilostane. To start you off, here's a link to the U.S. Product Insert for brandname Vetoryl:

http://www.dechra-us.com/files/dechraUSA/downloads/Product%20inserts/Vetoryl.pdf

And here you'll find more links about Cushing's and trilostane treatment:

http://www.k9cushings.com/forum/showthread.php?t=185

[My sweet Ginger]

Wait, wait wait. Are you sure she ground the pills herself? I thought they come in powder form in capsules. I mean I've never seen them as my pup used Lysodren but that's not what I have been reading on here. And how insulting she brushed you off like that! She couldn't take time it takes try to explain it to you?
DO NOT open the capsules yourself and if I were you I wouldn't do anything until I see an IMS or a vet who's much more experienced.
What's the instruction on the bottle?

[labblab]

I see we've started a new page. Song and I are telling you the same thing (thank you, Song!), but please be sure and go back to also read my reply posted at the bottom of the first page.

Marianne

[My sweet Ginger]

Yes, please make sure you read Marianne's:) post as she included very important links for you to read.

[ajaxandalphie]

She took some pills from the trilostane box (120mg) and told her assistant to crush it into her dosage. and when I told her Ajax hates taking meds she put it in a capsule.

I will hold off on giving him the meds until we go see a specialist. He's too important to risk the side effects.

[labblab]

Omigosh, I am horrified to hear how the vet prepared the medication! :eek: :eek: :eek: :eek:

No wonder she didn't tell you the dosage amount, because by preparing the powder in that manner, there would be no way of knowing with any accuracy what dosage amount was actually being given!! Plus, by altering the form of the medication in that manner, it might render it totally ineffective.

I must tell you, IMO, that is really a total breach of safe and proper veterinary procedure. Have you been seeing this vet for long? It frightens me enormously to think that she has been treating other patients in this manner!! Based on her actions -- lack of appropriate diagnostics and mishandling of medication -- she probably should be reported to your local licensing board!

[ajaxandalphie]

Actually I've only started seeing her recently because she is close to our house. I thought since blood testings are done in outside labs it didn't matter where I do it. I wasn't expecting cushings though! I will book an internal med specialist tomorrow.

All of your advice are truly appreciated. I hope even if Ajax does have the beginning symptoms of cushings he will be well managed because it's early and I will be educated about it here!

I know it's not the end of the world but I have to admit I cried quite a bit after hearing his test result. It's comforting to know there are many others who have experience in dealing with it.

[labblab]

Just wanted to add (so you'll know going forward) that if your vet was using solid trilostane pills rather than capsules, that means she had ordered a compounded version of the drug rather than using brandname Vetoryl which is manufactured by a pharmaceutical company. As Song says, Vetoryl only comes as a powder that is prepackaged in capsules that are not intended to be opened.

Compounded pills are made up on an individual basis by individual pharmacies. They can serve a very important purpose when a dog requires a dose that is not available in the four dosing strengths of manufactured Vetoryl capsules. But this also means that if your vet is using a compounder, she can request a prepared pill in any dose that a dog needs. So there is no reason at all for her to be grinding up pills herself and repackaging them. That is simply not acceptable.

[Squirt's Mom]

Oh my word! I am HORRIFIED by what I am reading here! :eek::mad::eek::eek: How irresponsible, arrogant, and dangerous of this vet to treat your baby or any baby in such a fashion! I would do just as Marianne suggested and report this action asap before she kills someone's baby. Oh this is just awful! I am so so sorry you have had this experience from the get go. Please don't let this color your actions going forward - this vet is NOT the norm...in fact, she is probably the worst representative of her field I have seen here in a long, long time. :mad: Run, do not walk, but RUN from this vet as fast as you can and never let her administer so much as a butt wipe to your precious boy again. Get his records and RUN!

Do not, under any circumstances, give that medicine to your baby. I would take it back and demand a full refund while getting his records. The very fact that she wouldn't explain the dose is scary and I'm not sure even legal. ggrrrrrrrrr

Ajax will be fine waiting - MUCH better off than being treated by this monster for sure! So don't worry about waiting. The main job right now is to get him with a different vet who will work with you as team, not tell you "it's too complicated to explain". :rolleyes::mad:

The main thing is that you and Ajax are in the best of hands here and we will help you all we can. You are not alone.
Hugs,
Leslie and the gang

[labblab]

We surely understand why you feel worried and upset. But like Leslie says, now you've got a ton of company here to walk alongside you and Ajax every step of the way (no matter what his diagnosis turns out to be!). ;) :)

[My sweet Ginger]

Absolutely. She ought be reported.
I'm no more frightened for your Ajax because this board has his back;) but am frightened for your vet's future Cushings patients.:eek:
Yeah, she needs to be more educated on Cushings and being reported might be the fastest and safest venue for her and future pups.

I'm super glad you and Ajax stumbled(?) onto this site, too. I always think of us the lucky ones.
Now that you've got Marianne and Leslie on board and more to come by later, you are in excellent hands.

[ajaxandalphie]

I am very lucky to have stumbled onto this forum, and grateful! I will need to go back to her to print out his lab tests, then I'll running far FAR away. do you think the specialist will ask to do it again anyway？ I read that I should collect his morning urine sample on the day of the appointment, Just in case?

[molly muffin]

Hello. I just want to welcome you to the forum too.
Every specialist is different but if you have a copy of the lab results then they might not rerun the test.
When you call to get the appointment, with a small animal internal medicine speacialist (IMS) ask them how many cushings dogs they have treated, and what their success rate is.
I am in Canada and often here as in the UK it is more difficult to get a vet with up to date knowledge of what is going on in the cushings world. Current testing protocols and research is being done in the U.S. and even there, you get some vets that are not up on the medication, testing protocols, etc.
However, it is often the vets who end up getting dogs in trouble and this medication and the reason that so many of us were horrified at how your vet treated the medication and dosage, is that while it is a life saver for many dogs, it can be dangerous to the dogs health and life, if the wrong dosage is given. And overdose of vetroyl/trilostane is a risk when treated frivolously.

You are here, you have a wealth of knowledge now at your fingertips and that is a good thing.
Welcome again.

Sharlene and molly muffin