Sydney 9 Year Old Boston Terrier Cushing's?

[kvl22]

Greetings,
First, I want to thank everyone for sharing all of their information on this board. It has been a great place to learn about Cushings. My dog, Sydney is going to have her low dose dexamethasone suppression test tomorrow. I am feeling very anxious and nervous. I want to know what is wrong with her, but I also do not want to accept that there is anything wrong. She is my heart dog, and it has been a long couple of weeks with her not feeling weird. I also am kicking myself in the butt for not thinking something was seriously wrong sooner. There have been signs, or should I say odd things happening that I just discounted. In May I noticed her fur was not as soft as it once was. I noticed that she had never healed up from skin scrape that was done in the previous fall. I asked the vet about it and they just discounted it too. We ran a blood panel in May, but nothing to the vet was really out of whack. We just ran another blood panel and things do not seem to be way bad. Yet, they have progressed.

In May: EOS K/uL was fine (0.10-1.49)
PLT 518 K/uL (175-500)
ALT 97 U/L (10-100)
ALKP 337 U/L (23-212)
GGT U/L was fine (0-7)
CHOL mg/dL was fine (110-320)


Now at the end of July: EOS 1.83 K/uL (0.10-1.49)
PLT 716 K/uL (175-500)
ALT 260 U/L (10-100)
ALKP 590 U/L (23-212)
GGT 13 U/L (0-7)
CHOL 331 mg/dL (110-320)
MONO was low .29 K/uL (.30-2.00)
LYM was low .47 K/uL (.50-4.90)
Cl was low 108 mmol/L (109-122)
MCHC 39.4 g/dL (30.0-37.5)
RDW 19.3 % (14.7-17.9)
But, boy, she is asking very strange now. She won't go outside on her own, she will literally hold the urine until I get home and walk outside with her. She is lethargic. She drinks a lot. She stares at the walls and seems lifeless. She doesn't greet me at the door when I come home. The list can go on and on...I am beyond upset and can't stop thinking about all of it. And the worse part is that I am not even for sure if she has Cushings. I keep seeing everyone else's blood work number, and it just seems that Sydney's ALT and ALKP aren't climbing as high as I would expected in 2.5 months time.

[addy]

Hi and Welcome,

I am so sorry Sydney is not well and I know how anxious you must feel about the upcoming tests. My pup did not have very high elevations in the beginning. Actually it took her a good nine months or more for her Alp to climb but she also had inflammatory bowel disease. I asked an endocrinologist about that and he said not all Cush pups have high elevations in those values.

As you have probably have read, Cushings is very hard to diagnosis and non adrenal illnesses can cause false readings on the various tests. History and symptoms play a big role in diagnosis.

Usually, a dog has a huge appetite, is drinking and peeing buckets, their urine is dilute, skin problems, hair loss frequent infections are just some of the symptoms. My girl started off with skin coat issues and we waited a year to treat her as her IBD was more worrisome than her Cushing symptoms at the time.

The fact Sydney is holding her urine as she is makes me wonder if there is not something else going on.

I would want to be sure of the diagnosis, so be thorough, take your time and tell us the tests results as you receive them, ok?

[Harley PoMMom]

Hi and welcome to you and Sydney from me as well! Could you edit your post to include the reference ranges and units of measurement for those values you listed, as an example; ALT 150U/L (5-50)...thanks!!


But, boy, she is asking very strange now. She won't go outside on her own, she will literally hold the urine until I get home and walk outside with her. She is lethargic. She drinks a lot. She stares at the walls and seems lifeless. She doesn't greet me at the door when I come home. The list can go on and on...

We love details, so if you would list all the changes in Sydney's demeanor it may help us to provide better feedback, ok?

And, please stop being so hard on yourself, dogs with Cushing's are generally seniors and symptoms can go years without a confirmed diagnosis because many times the symptoms are attributed to old age. Cushing's is a slow progressing disease so one does have time to get a confirmed diagnosis.

Hugs, Lori

[kvl22]

Thanks for the positive thoughts, I appreciate it. As for odd behavior or things that have happened here is chronological listing.

May 2013
A benign tumor was removed from her front left leg, it took forever for it to heal and hair to grow back.

July 2013
Odd skin issue on left side appeared. At first we thought it was ringworm but the test came back negative. The vet decided it was a bad reaction to a bug or spider bite. Yet, the area that the skin scrape was done has had very little hair ever regrow and took a long time to heal.

May 2014
Hair missing on tip of tail

Weird almost like mushroom skin has grown on top of her nose

Hair very coarse, hair under her belly is very thin and seems almost hairless.

hair under her collar has fallen out or a very bad hair colic has developed

She has lost the ability to jump up on the bed

Weird behaviors with rawhides. She loves to chew on bones, rawhides, greenies etc. But whenever I give her one she obsessively chews it until its gone or shredded. I started monitoring "bone time" and placing time limits on it. Whenever she has a bone away she always ends up panting, breathing heavy, and her pigment was a red tone.

July 2014
Moaning and groaning when stooping to go potty

Listless and lethargic, sleeps a lot

Eyes are just not as bright as they usually are

She is/was a spitfire, always wild and running through the house. I have not seen that for a few weeks now.

No longer meeting me at the door when I come home

Staring into space or staring at the walls in the evenings when she usually would be sitting on my lap

No longer willing/wanting/perhaps able to go outside into my backyard using the dog door to go potty.....I am now carrying her outside to my front yard, placing her in the grass where she quickly potties and then she walks immediately back towards the house and wants back inside. Please note: in the past the front yard was off limits unless she had her harness on. She is a people lover and always runs off to if anyone is outside. Now she could care less if anyone, or even a rabbit is out there with her. She just wants to do her thing and get back inside. Also, if I put her in the grass in my backyard, she refuses to go potty.

Along with the coming inside from the front yard, there is one small step up from coming into the house. She hasn't been solid when using that step. It's like she is almost off balance.

This is a odd one. She has had her dog bed at the end of my bed on the floor since she got it for Christmas in 2013. It has stayed there until recently. Every night, while I am asleep, she moves it by tugging at it until it is right next to where I am asleep. I wake up and literally have to be careful, as she is right next to me on the floor as I am afraid I will step on top of her.

I think her belly looks swollen, although its hard to tell as she has always been very stout/stocky.

She weighted 17.4 pound in May and in July was the same weight. So no real loss or gain in weight.

I have noticed her gulping water down at night when I am home from work. But the water bowl doesn't get touched much during the day while I am at work. It was exactly the same this evening as it was this morning. Same goes for the food. I free feed, and she is mostly a grazer, so I have not noticed much of a difference there either.

This is all the oddness/weirdness that I know of at this time. I just feel so bad for her, as she seems miserable. I am so afraid that she is going to have seizures or any of the other bad symptoms that I have been reading about on this forum. I also am not convinced that the issues are cushings related. I have been doing nonstop Internet searches trying to see what else it could be. Thanks for all your help and information. This is a great forum.

[molly muffin]

Hello and welcome to the forum from me too. Everyone has covered a great deal already, I think that if you have the option I would go to see an IMS. (Internal medicine specialist) The blood values being off is not a normal sign of cushings, although the ALT and ALKP being mildly raised can be.
While some of the symptoms due seem like cushings, I think a second opinion from a specialist to see if they can figure this out might be worthwhile before jumping into cushings treatment.

Sharlene and molly muffin

[Harley PoMMom]

I agree with Sharlene in that some of Sydney's symptoms could be due to Cushing's but also to other non-adrenal illnesses such as a thyroid problem, has Sydney's thyroid levels been checked recently? Normally this is on a regular chemistry blood panel and is listed as "T4"

Hugs, Lori

[molly muffin]

Hi, how did the test go with Sydney? When do you get the results? Did they address any of things we had concerns about?

Hope all is going well
Sharlene and molly muffin

[kvl22]

Hi everyone,

Sorry for not updating sooner. The 8 hour low dex test came back positive for cushings. However, it did not determine the type. I also wanted to let everyone know that I had a T4 test done and it was within normal ranges. Sydney is going to have a CT scan on Thursday morning. If it does not show which type of cushings, they will proceed with the 8 hour high dex the same day.

It seems that her symptoms are getting worse. It's odd as everything I've read says its a slow progression. But her legs are loosing strength fast. She's having a very difficult time going up or down the 1 step off my porch to the yard. She's also become a vampire in that she's up all night. I have hard wood floors, and her walking around sounds like a horse trotting throughout the house. I usually get up with her and try to settle her down. I'm taking it day to day, but it's really hard. I am so sad that she isn't feeling well or acting like herself. I'm also afraid of the next step. I'm afraid of the drugs. I'm afraid of their effects on her. I don't want her to suffer while we are trying to get the dosage right.

Thanks for asking about!

Kristen and Sydney

[molly muffin]

Hi, did they mention doing an ultrasound to take a look at the adrenal glands, liver, and other organs? That would be a next step for me.

Sharlene and molly muffin

[kvl22]

Hi everyone,

Just a quick update...

Sydney had a ultrasound yesterday morning. The results can back inconclusive. However, they did send them out to radiologist office to get a 2nd set of eyes on them.

They also did the 8 hour high hose dex test. Those results are to come back later this afternoon.

Thanks,
Kristen

[addy]

let us know ok?

[molly muffin]

Did you get the test result today?

ugh, I just hate when they say inconclusive, hopefully the other set of eyes will be able to tell better what they are seeing.

Sharlene and molly muffin

[kvl22]

Hi everyone,

The 2nd set of eyes on the ultrasound by a radiologist did indeed indicate that Sydney has pituitary based Cushing's. Furthermore, the 8 hour high dex results also showed pituitary based Cushing's. The ultrasound also did show that her spleen, kidneys, and bladder are fine. Her liver is enlarged. Both adrenal glands are enlarged.

We are going to start off on 10mg of Vetrol one times a day as soon as the meds get in as they had to be ordered. Then we will go back in 8-10 days for a ACTH test. If things are reduced to a normal range we will stay on the 10 mg dose and go back in another 2 weeks for another ACTH test. If they results are higher, we will up the meds and test in another 8-10 days. This process will continue until she stabilizes and symptoms start going away. I will always have to keep an eye on her and if she stops eating, stops drinking etc. I will need to get her into the vet asap.

I am happy that we got a diagnosis but also fear of the future. And I also am sad that this is a disease that can not be cured.

Thanks,
Kristen

[Harley PoMMom]

Just a word of caution, we have seen a dog's cortisol continue to drift downward during the first initial 30 days of treatment. So the recommendation is often made to not increase the Vetoryl dose further during the first month of treatment as long as some symptom resolution is being seen and there has been improvement in the "post" ACTH result.

Hugs, Lori

[addy]

I'm glad Lori mentioned that. When I started treating my girl over 4 years ago, we did change the dose after the first ACTH test. Lately, the vets have been waiting.

So let us wait to see how it goes. You will both be fine. We are here for any questions and moral support.

[molly muffin]

10 mg is a good start dose and you shouldn't, I say shouldn't, you still have to be vigilant, run into any problems. I would let it go probably for 30 days before going up in dosage. That is my thought though. It all rather depends on what she is doing at this first cortisol test that will in a couple weeks and how her body is responding.

We're here, any time at all.

Sharlene and molly muffin

[kvl22]

Thanks for information on the 30 days. I wonder why that happens for the first 30 days? I would think the meds would start to get things going in the right direction?

I really appreciate all your help and information. This forum is great and full of very caring people.

Thanks,
Kristen

[molly muffin]

Yep they do get things going in the right direction - down. So, you just want to be careful and not up the dose when the cortisol might be continuing to drop on the same dose, since it's a fine tuning to get them on just the right dosage to get the cortisol where you want it and keep it there, without any risk of going too low.
You'll know more after the first test.

hugs
Sharlene and molly muffin

[labblab]

Dechra, the manufacturer of brandname Vetoryl, now formally recommends that the medication dose not be increased until after the first month of treatment has passed even if the cortisol level has not yet been reduced to the optimal treatment range at the time of initial testing. For the safety of the dog, the dose should be decreased at the initial 10-14 day testing if the ACTH result is too low. But otherwise, no dosing changes are now advised until cortisol levels have stabilized at the 30-day mark. This is for the reason already stated: cortisol levels can continue to move downward during that first month, even when the dose remains unchanged. Therefore, you do not want to increase the dose until you know what the maximal effect of the current dose turns out to be. In real life, I think vets do sometimes still go ahead and increase after the initial ACTH if the dog is not showing any symptom improvement whatsoever and the cortisol remains highly elevated. But based on our cumulative experience here throughout the years, I do think the majority of dogs are better served (and less overdoses occur) by holding off on a dosing increase until that 30-day mark has been passed.

Here is a link to Dechra's Treatment and Monitoring Flowchart that details this recommendation. Hint: the flowchart is easier to read if you print it out as a paper copy.

http://www.dechra-us.com/files//dechraUSA/downloads/Client%20Literature/47902_VETORYL_10mg_Treatment_and_Monitoring_Brochu re_Update_3_2_ps.pdf

Marianne

[kvl22]

Thanks for the links and info. I got a box of the 10 mg this afternoon. I'm supposed to give Sydney her first pill tomorrow morning. I'm afraid to do it. I'm worried about side effects. I'll be at work all day long. What can I expect? Will she get sick from them? Like sick to her tummy? Should I come home from work at noon and check on her? Will the drugs make her lethargic? My vet was out of the office today so the office assistant gave them to me without much info. Should I wait until the weekend to start them so that I can be home?

Yes, I'm a hot mess tonight worrying about her....

Thanks,
Kristen

[Harley PoMMom]

We do see less adverse side effects when the dose is started low, so with Sydney's weight of 17.4 lbs I believe starting her dose of Vetoryl at 10mg is a good plan.

Some dogs may get an upset tummy from the Vetoryl but this is usually because the dose is too high. If Sydney acts like her tummy is upset than I would ask her vet about giving her pepcid ac before her Vetoryl dose.

We are here for you and do understand how scary this can be, however I believe you and Sydney will do just fine. If you have any questions at all please do not hesitate to ask them, ok? ;)

Hugs, Lori

[kvl22]

Do you think it's ok to go to work all day after giving her the pill in the morning? Or should I wait to start on Saturday when I can be home?

Thanks
Kristen

[molly muffin]

Sydney should be okay but I think you will feel better if you can run home at lunch and check on her. When you are worrying there isn't much that can make you feel better other than seeing for yourself.
I am not saying it is necessary just that I think it will give you more peace of mind if you do so.

Hang in there
Sharlene and Molly muffin

[molly muffin]

Checking in to see how Sydney is doing on her meds.

Sharlene and molly muffin

[pansywags]

Hoping for the very best for your Sydney. I just love Bostons!

[kvl22]

Hi everyone,

Well, today is day 6 on the meds. I have seen vast improvement! She is totally back to acting like herself. Her energy level has really increased. Her hair even seems better, much softer. I think I am crazy as I know its to soon, but it even seems to be growing back. Also, her nights and days are no longer messed up, she is sleeping through the night again. I have not noticed any decrease in her water intake. She never did get to be a nonstop eater, so her food intake has remained the same. I am not sure if we just never got to that point with the symptoms. Additionally, her pot belly is still very apparent. However, I know that it might never go away, and I am being realistic...we are only on day 6 of the meds. But the best break through happened this morning. She actually got up on her own and used the dog door to go to the bathroom in the backyard. Prior, I have been taking her out front, as for some strange reason she was refusing to use the dog door/backyard. I am watching her very closely, and even the slightest oddity I am questioning my vet on. But, so far, so good....

Does anyone know if the back legs will regain strength? Or is the weakness permanent damage? I just feel so bad for her, as she tried 3 times last night to jump up on my recliner to sit in my lap. And all 3 times she only made it about 1/2 way and then fell to the ground. It always reminds me of a fly hitting a windshield, its violent looking. And I am afraid that one of these days she is going to hurt herself from falling. I always reach out to grab her to catch her but its always so awkward that I sometimes cant help her. Or I am afraid that I am going to squeeze her in the process and hurt her.

Hope all your pooches are doing great!
Kristen

[molly muffin]

I'm very glad to hear that Sydney is doing so well. This is good.

If you don't have her on a joint support, such as dasuquin, then I would get her started. You can get them in treat form, which helps.

It won't help her muscle strength, but will support the joint/cartilage. If you teach her that instead of trying to jump, that she waits to be picked up and put on the couch then that might work. My molly is so embarrassed that after she fails at a jump, she won't let you pick her up, but if when she knows she isn't feeling so hot, then she'll wait for someone to pick her up.

They all have their own little quirks and personalities, but that is an idea for you.

Sharlene and molly muffin

[Mackenzie]

I am happy to read that Sydney is having such great results! It's very encouraging for me because my Mackenzie is on the verge of a Cushing's diagnosis and I am nervous about what comes next. Reading about such a quick turnaround is wonderful. I am sending you positive vibes for continued improvements!

I agree with Sharlene -- it may be best if you teach Sydney to wait calmly or offer you a different behavior in order to be lifted onto your lap. If you reach out to her while she is jumping, she might interpret that as encouragement. Try asking her to sit or lie down or give paw (whatever is comfortable for her) before you pick her up. Alternatively, you could stack up some doggy stairs! My boy is a hind leg amputee, so I am always mindful of the stress on his remaining limbs.

[Dixie'sMom]

Hi! I'm Suzie. That's great news about Sydney. I haven't begun treatment for my doxie Dixie yet, so I'm very encouraged by how well Sydney is doing. I will continue to follow your journey. YAY SYDNEY!

[molly muffin]

Oh love her avatar photo! She's a cutie.

Sharlene and molly muffin

[Harley PoMMom]

So happy to read that Sydney is doing well on treatment. It takes a while to see improvement with the muscles in the back legs. I have read that having them walk backwards may help to regain muscle strength.

Hugs, Lori

[kvl22]

Hi everyone,

Okay we had our first ACTH test done on Monday. Our results just came back today. I would appreciate any thoughts that you might have on them.

4.2 before
12.9 after

My vet is wanting to keep her on the same dose, and test again in 30 days. However, if I notice any of her symptoms worsening or returning, we will do one then.

Also, for anyone who has had the ACTH test done....how did you dog react to the test? The last couple of days have been baffling. She is barely eating and sleeping much of the time. I asked my vet about it. She doesn't think Sydney's level have dropped low and is not in danger of Addison's. She thinks perhaps she is just settling down from the excitement of being back at the vet for a long period of time. I also was concerned about the fact that the ACTH test had to be performed on a empty stomach. As the medicine when given really needs to be taken with food. But they had to give her the meds on Monday with an empty stomach to do the test. This really seemed to break our routine, and I was wondering if anyone else had experienced anything odd from doing the ACTH test?

Hope everyone is doing well....

Kristen

[Harley PoMMom]

The monitoring ACTH stimulation test should never be performed on a fasted dog, it makes the results invalid. Trilostane/Vetoryl HAS to be given with food to be properly absorbed. I am very worried about Sidney because since the ACTH stim test was done when Sidney was fasted his cortisol could be lower than what those results show.

I am including an excerpt from Dr. Peterson's blog. Dr Peterson is a renown Cushing's expert and also is a contributor to Dechra's continuing education site:
The dog should never be fasted on the morning of the test. Trilostane is a fat-soluble drug and must be given with food to help increase its absorption. Full article can be found here: Protocol for ACTH Stimulation Testing to Monitor Dogs on Trilostane Therapy: Timing, Feeding, and ACTH Preparation All Matter (http://endocrinevet.blogspot.com/2013/11/protocol-for-acth-stimulation-testing.html)

If this were me, I would notify the vet ASAP and ask that another ACTH stimulation test be done free of charge since they had you go against the proper protocol for monitoring ACTH stimulation tests.

Hugs, Lori

[kvl22]

Hi everyone,

Well, we just got the results from our 30 day test. And both my vet and I were a bit surprised by the results.

The first result was 7.1 and the 4 hour post was 16.9.

Sydney has been just fine with taking the meds. However, I have noticed that her symptoms often return in the evening/night. She sleeps a lot, gets real spacey and in general just doesn't act like herself. But during the day she is back to her crazy self. I have not noticed any decreases in the amount of food or water that she intakes. Her hind legs seem to be gaining strength but I did start her on the Dasuquin. Maybe that is helping? So all in all she seems better, thus I was not expecting the numbers to increase. My vet has decided to bump Sydney up to 20 mg per day vetoryl. However, it will be given 10mg in the morning and 10mg at night, preferably 12 hours a part. She is wanting to see if this might improve the evening or nighttime hours. We will do another test at the 10-14 day mark, ACTH test. Then adjust if needed, or stay on the same dose and test again at 30 days.

Oh, I did talk to my vet about fasting vs not fasting prior to the ACTH test. She has just been great with me and all of my questions. I even had her questioning the way it was being done. So, since Purdue University Vet School is in our town, she called them. They interestingly responded that they have done the test both ways, depending on the situation. This time when we had it done, we did not fast. So....is that why the numbers increased? As this was more of a true depiction? Granted Sydney was being a brat and wasn't happy going back to the vet, so she wouldn't eat as much as she normally does that morning.
Thanks for the info,
Kristen

[lulusmom]

Kristen, if you read Lori's post above, she provided a link to Protocol for ACTH Stimulation test for monitoring treatment with Vetoryl. This is one of Dr. Mark Peterson's blogs for veterinarians. Dr. Peterson is a renown endocrine specialist who frequently contributes to Dechra's (manufacturer of Vetoryl) online continuing education for veterinarians. Dr. Peterson knows the drug like the back of his hand and he very clear states in this blog that "The dog should never be fasted on the morning of the test. Trilostane is a fat-soluble drug and must be given with food to help increase its absorption". Perhaps the person at Purdue did not understand that your vet was asking about an acth stimulation test for purposes of monitoring Vetoryl treatment? It is true that if you are doing an acth stimulation test for purposes of diagnosing cushing's or addison's, it should probably be a fasted test; however, again, when monitoring Vetoryl treatment, you never, ever fast a dog as the drug will not be absorbed and the results will be invalidated. You might as well flush your money down the toilet.

Please see Lori's post above and use the link she has provided to learn about proper protocol. I would highly recommend that you provide this link to your vet or print out the blog and give it to her.

Glynda

[kvl22]

Does anyone have any official documentation or links where it's not a blog or a comment to a blog? I've googled the heck out of this for the past couple of weeks. And I need something more substantial than a blog. Why doesn't the manufacturer of the drug make guidelines or suggestive guidelines? I'm a web administrator, I've read blogs and read the one in the link. But I need something more official. Blogs are nontechnical documents. And don't think it's not that I don't trust or believe you or the blog. I'm just more of a black and white person without room for gray. I lost my dad when he was 54 years old to cancer, so I understand the importance of testing and following protocols. Also from that experience, I understand about thinking outside of the box. However, I need something more substantive than a blog.

Also does my last test get discounted even though we didn't fast on it? Those numbers are from Sydney when she hasn't been fasted.

Thanks,
Kristen

[lulusmom]

Kristin, Dr. Peterson is world renown, is more published than most of the world's expert endocrinologists, he lectures frequently across the globe on cushing's and Vetoryl, and has authored chapters in The Textbook of Veterinary Internal Medicine used in most, if not all, teaching hospitals in North America. Very few people in the veterinary world have such a distinguished bio. We don't provide links to any reference material that is not credible nor do we provide citations to resources that are not based in science, particularly if we are recommending that you provide that information to your vet. You can take Dr. Peterson's blog to the cushing's bank and I would absolutely shocked if your vet and the folks at Purdue do not immediately recognize his name. However, just in case you need proof, here is link to a list of his publications, which may not be all inclusive:

http://www.drmarkepeterson.com/journal-publications/

[lulusmom]

Kristen, if your vet doesn't believe you, then I highly recommend you ask him/her to contact the manufacture and get it from the horse's mouth. The Vetoryl package insert specifically says to administer the drug with food for proper absorption. You can find all of that information in our Helpful Resource section but for ready reference, I've include a link to Dechra U.S. contact information below:

http://www.dechra-us.com/Default.aspx?ID=365

You may be able ask them yourself. Sometimes they talk to pet owners and sometimes they don't.

[labblab]

Hi Kristen,

I have contacted Dechra directly in the past as have other members and their response has consistently been to feed a meal along with the Vetoryl on the morning of a monitoring ACTH test (as Glynda says, this is a different situation than a diagnostic ACTH which may be the source of the confusion with Purdue). If I can find something in writing from Dechra that directly addresses ACTH testing, I will add that here later today. But yes, you and/or your vet can also get confirmation of the protocol by calling Dechra yourselves. I think with a general question of this nature, they will talk with you directly as the pet owner. Most definitely they will confirm the proper protocol with your vet.

As far as the effect of fasting on Sydney's result, it is the opposite of what you are thinking. Because this last test was performed after a meal, the results would likely have been even higher had she fasted. This is because if fasted, the drug would not have been metabolized as efficiently and therefore there would have been less suppression of cortisol.

Marianne