New Member. 11 Year Old Yorkie Suspect Cushings Need Advice

[drexnjanfree]

I am a new member as of today but have been using your site to gain knowledge regarding canine Cushings.

I am a human RN and have a 11 year old Yorkie who is a rescue dog. I was a foster home for a rescue group but totally fell in love with my Gizmo or "Gizzy" as he has become to my husband and I. Gizzy was "special" from the start. After lots of medical problems, lots of vet visits, and mostly lots of LOVE between Gizzy, me, my husband, my other animals and over a year of being his foster Mom I knew that he would not be going to anyone else's home except mine. We made the decision to make him out 6th "Forever Boy" about one year ago and have never regretted it for a moment. He is pure love and I can't imagine life without him.

Gizzy was an owner surrender at the age of 9 years old. I drove almost 300 miles one way to pick him up from his previous owner who had fallen on hard times and could no longer care for him. He was is rough shape. He hadn't seen a vet (no vaccinations, no dental care, no flea or tick or heartworm prophylaxis) in 7 plus years. I took him straight to my vet. Infection from dental decay rampant, Heartworm Positive likely for sometime, hypothyroidism, malnourished.....the list goes on. Antibiotics first to clear up rampant infections was the first priority. Then dental and most of his teeth were to disease to save so lots of extractions. After that we started the treatment to rid Gizzy of his heartworms that lasted weeks. Hypothyroidism diagnosis soon afterwards.

The first night I brought him home he had a siezure. I have seen seizures in humans but never in dogs and it scared me. The owner didn't disclose epilepsy and I thought he was dying and call my rescue coordinator who was thankfully very well aware of what was happening and talked me though what was happening. Gizzy started on Phenobarbital the next day. Controlled for a while, then seizures came back so doubled his dose. He now takes 30 mg twice a day along with Soloxine also twice a day. Shortly after increasing his Phenobarbital he started really gaining weight. He was 9 lbs when we got him and now he is 15 lbs. The weight gain happened fairly quickly. He also drinks all the time, and has a RAVENOUS appetite. He will literally eat ANYTHING including clumps of dirt, lettuce, you name it. He acts like he is starved and steals food from my other animals and grabs it from my hand if not careful. He also drinks constantly and urinates all the time. If I don't take him out every hour on the hour he will not be able to hold it. He urinates a large volume every time. He is very hyperactive too and restless. He is sweet and not aggressive unless food is involved but he literally GOES 24-7 non-stop and has trouble settling down. When I got him he was very lethargic but once the infections cleared up he became a happy playful boy but not as hyper as he is now. He has a very round belly and all his weight is settled there. He also has a "sway backed" appearance....the only way I can describe it. He has absolutely ZERO heart tolerance. Even though he is very energetic if I take him out on a hot day he will immediately show signs of stress such as panting almost immediately, coughing and wheezing and slows down to the point I will have to carry him. He also pants a lot under normal conditions but X 100 if hot outside. I have researched all of this stuff and immediately thought "He has Cushings." I scheduled an appointment to discuss with my Vet. Let me first say that I absolutely ADORE my Veterinarian. He is the epitomy of the kind, loving, small town practice that you might read about in a book like "All Creatures Great and Small." I live in a very rural area of TN and he is a small town vet in a nearby town. He has taken care of ALL my animals over many years and I really adore and trust him. However, I have expressed my concerns about my Gizzy on a couple of occasions and he doesn't think he has Cushings. He cites that the prevailing reason is that my Gizzy isn't losing his hair. He actually WAS losing his hair (and it was very dry and coarse) until he started the thyroid medications. Also, the skin on his belly is very thin in appearance. I don't know if he has the capability to run all of the recommended tests in his office or not.

I have read the postings here about how dogs can have both hypothyroidism AND Cushings but some dogs can have "Sick Euthyroid Syndrome" as a result of having Cushings and once treated for Cushings they will have normal thyroid function again without medication. I also know that because he takes Phenobarbital for his seizures that the long term side effects of phenobarbitol cause a lot of the same symptoms and blood test seen in Cushing's. Things like excessive drinking, urination, voracious appetite, enlarged liver, elevated liver enzymes can be indicative of Cushings OR can also be seen in an otherwise healthy dog on phenobarbital.

I'm concerned because I want the best for my Gizzy and a proper diagnosis and fear that my great country vet may not be able to accurately diagnose my medically complex little guy. I am seeking advice from this forum.......There is a group of Veterinary Specialists in Nashville but they require a referral from the family Veterinarian and won't accept new patients without this. I think my Vet will give me a referral but I wish I could just take him without it, get a proper diagnosis and KNOW for certain what is going on.

I welcome any and all suggestions, comments, advice, etc.

Thanks in advance,

Jan, Gizzy's Human Mom

[Squirt's Mom]

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[labblab]

Dear Jan,

Welcome to you and Gizzy! What a gift you are giving this little guy by embracing him with your heart and your home. Gosh, I have a whole slew of questions for you but I don't have a whole lot of time to type right now. So I'll just start with those that are uppermost in my mind.

My Cushpup is no longer living, but I am currently mom to an epileptic non-Cushpup who is being treated with phenobarb. And I must tell you that during the first month of phenobarb treatment before my Peg adjusted to the effects of the medication, she looked exactly like my Cushing's dog in many ways, particularly the excessive thirst, urination, hunger and also lethargy. We have been very lucky in that Peg's behavior quickly normalized to a very large extent. However, based on what we've experienced with Peg, I do have a couple of questions to ask you because you are right -- there is quite an overlap in the symptoms produced by Cushing's and the side effects of phenobarb.

First, it sounds as though Gizzy has been taking the phenobarb for around a year. Has he had his phenobarb level checked during this time period? That sounds like a pretty high dose of phenobarb for a dog of his weight, and if his level is at the upper end of the therapeutic range, I'm guessing that might account for a greater likelihood of unwanted medication side effects.

Also, I am curious about the diagnosis of hypothyroidism. Phenobarb skews thyroid readings downward such that it requires more than just a simple low T4 level to make an accurate diagnosis of hypothyroidism in a dog treated with the drug. Aside from the weight gain, many of the symptoms you are describing could be associated with a dog whose thyroid function is actually being oversupplemented. So can you tell us more about the timing and nature of the diagnosis in Gizzy in conjunction with the initiation of the phenobarb? Really, there are two aspects that I am wondering about. Low thyroid levels can produce seizures, so if Gizzy truly suffered from untreated hypothyroidism prior to the start of phenobarb, it is possible that thyroid supplementation might have cured the seizures all on its own. However, if the hypothyroidism was diagnosed AFTER starting the phenobarb as sounds to be the case, I am wondering about the accuracy of the diagnosis as discussed above, and also about the appropriateness of the amount of supplementation that he is currently receiving -- once again, because assessment of true thyroid function in a dog taking phenobarb is not simple.

These questions spring to my mind because these are issues I am struggling with, myself. When Peg first started seizuring, I was so hoping that she would turn out have low thyroid because that is such an easy "fix." That was not the case, but after much discussion, we and our vet decided to have a full thyroid panel performed prior to starting the phenobarb so that we would have a pretreatment baseline against which to compare future readings. Peg's T4 level is now much lower than it was prior to starting the phenobarb, but since she does not exhibit symptoms consistent with hypothyroidism, we are assuming this is a medication effect with her and have not repeated the full panel. If she ever does start showing symptoms, however, I know that it will become a bit of a puzzle to accurately judge her genuine thyroid function. :o

For what it's worth, take a look at this list of symptoms of excess thyroid hormone in dogs:


Weight loss [does not fit Gizzy]
Increased appetite
Unkempt appearance
Poor body condition
Vomiting
Diarrhea
Increased thirst (polydipsia)
Increased urine (polyuria)
Rapid breathing (tachypnea)
Difficulty breathing (dyspnea)
Heart murmur; rapid heart rate; particularly an abnormal heart beat known as a "gallop rhythm"
Hyperactivity


http://www.petmd.com/dog/conditions/endocrine/c_dg_hyperthyroidism

OK, I'll stop here for now. But once again, welcome to you both. And I apologize for asking you a bunch of questions that are not directly related to Cushing's. But we have found out through the years that many times it is very important to rule out other conditions prior to focusing solely on Cushing's in terms of diagnostic testing.

Marianne

[molly muffin]

Welcome to you and Gizzy, Jan.

Marianne has covered many all the things that I think you need the answers too prior to starting any cushings meds. Gizzy is certainly a complicated case.

One way that I think you could get your vet to easily give you a referral to the specialists would be to ask to go see them for an ultrasound. Also you can ask him if he is able to do the LDDS and the ACTH testing at his clinic, as you feel that you need to get to the bottom of what is going on, medication for the seizures, thyroid or/and cushings.

I can tell that Gizzy is your little heart baby and what a special little guy he is.

Sharlene and molly muffin

[Squirt's Mom]

Can't add anything to what Marianne and Sharlene have said but I wanted to thank you for taking Gizzy into your heart and home. I know his former family is pleased, whether they say so or not, that someone who cares so much is now taking care of him and I am sure he will flourish under your gentle touch.

[drexnjanfree]

Oh my, I am THRILLED to see all this most helpful information after my initial post. THANK YOU SO MUCH! It is evident I found the right place to get the help and information I need. Thanks to all of you. Today is a holiday and my vet office is closed but I have dug through the records, emails I sent to my rescue contacts about Gizzy from when I first got him.

I got him on 3/15/2013. He weighed 9.2 lbs. First trip to the vet that day. I don't have the actual values but did write that liver values were "slightly elevated". At this point in time he was on no meds of any kind. He started Clindamycin for dental infections that day ALONG WITH all his vaccinations which likely stressed him. He also began treatment for worms/parasites.

3/15/2013. He had his first seizure that night. Could have been stressed induced. I spoke with his owner and she told me he did have some seizures in the past but they were not frequent and her vet said he didn't think he had epilepsy. That sounded very suspect to me but with rescues you can never assume you are getting an accurate history. I know from experience with many dogs that sometimes owners are afraid a rescue won't take the dog if they are too sick so they lie. I am not judging them......just stating fact.

3/18/2013. He had dental cleaning and extractions. Had pre-surgery labs done. No liver function results, I have all the others and all are WNL but just CBC with Differential stuff and I can report specific values if you tell me what you need to see.

3/25/2013. Return vet visit, repeated CBC with diff and stated heartworm treatment with first injection.

4/23/2013 Weight 10.0 lbs. Routine presurgical blood panel, second heartworm treatment. Urinalysis.

On that date his HCT was slightly elevated but only 55.4, HgB was 18.6. Lymphs 2.35 (low), ALT 144 (high)All other values WNL

In the days to come the seizures continued, I documented each one. He had one about every 4-5 days. On some days he had two and on one day he had 4 seizures.

On 4/26/13 we returned to the vet and he was started on 15 mg Phenobarbital daily. No seizures for several weeks but then they started again while he was still taking the Phenobarbital.

5/22/13 Recheck by vet and final heartworm treatment.

He continued his heartworm treatment which was completed on 6/24/2013 and he was heartworm negative. Yey! But still having seizures so Phenobarbital increased to 15 mg twice a day.

He began having other things I noticed like his hair became very fragile and dry and he was gaining lots of weight and increasing activity.

8/12/2013 Weight 12.5 lbs. I took him in to discuss weight gain, hair, continued seizures, etc. (weight 12.5 lbs) and a Thyroid panel was done revealing hypothyroidism. He was started on Throxine/Soloxine .2mg tabs TWICE a day. The vet said he was going to intentionally give him a higher than normal dose of the medication to hopefully get the weight off of him. He said that was likely to happen but it didn't. Gizzy continued to gain weight.

Thyroid panel results. TT4= 0.9 ug/dl
Other labs that day
GLU 108 G/DL
LIPA 2022 U/L (normal is 200-1800)
TBIL 0.5 MG/DL
TP 6.6 G/DL
GLOB 3.6 G/DL
ALB/GLOB 0.8
BUN/CREA 15

They also did a THORAX xray that day which was normal to my knowledge

9/17/13 Recheck. TT4 result 5.4 ug/dl Weight 12.5 lbs

1/27/2014 He had diarrhea for several days and I took him in when it didn't resolve. They did a fecal test, which was negative but he was having a lot of gas and they thought something was going on so started him on Metronidazole Liquid which cleared up his symptoms.

3/6/2014 Annual exam, he needed to have 3 more teeth extracted and a dental. His weight was 13.8 lbs

He had to go back since then about 6 weeks ago again for diarrhea and same treatment as on 1/27/2014. His weight was 14.9 lbs.

Again, many thanks to all who have posted a response.

Jan and Gizzy

[Squirt's Mom]

Another member's baby has seizures and they are using some different meds from what we normally see, like phenobarb and bromide, so I wanted to be sure you saw Spencer's thread.

http://www.k9cushings.com/forum/showthread.php?t=6171

[drexnjanfree]

Thank you. I read all Spencer's thread and some commonalities for sure.

[labblab]

Thanks for all this additional info. I have not had the chance to carefully review things, but two big questions still stand out for me. You have not made mention of monitoring blood testing of Gizzy's phenobarb level. It is really, really critical that this be done so as to minimize risk of causing liver damage from toxic levels of the drug. The first test should be done within the first month of treatment, and then at a minimum every six months thereafter even when a dose remains unchanged, and certainly again after dosing changes. Until I hear more, I am concerned that your vet may have doubled the dose of phenobarb based solely on lack of seizure control as opposed to blood levels. This is not safe practice since even at high doses, some dogs simply do not respond satisfactorily to phenobarb and changes to other drugs must be made. I will feel a lot better if you tell me that Gizzy's phenobarb levels have been checked throughout this year right along with chemistry panels to monitor liver enzyme levels.

Secondly, this recommendation by your vet really scares me:


The vet said he was going to intentionally give him a higher than normal dose of the medication to hopefully get the weight off of him.
There are so many physical issues associated with hyperthyroidism that I am worried that your vet would think this is a good weight loss strategy. Can you please give us the normal range for your lab's thyroid readings so we can better assess how high or low Gizzy's readings have been. Also, I want to stress again that T4 readings will be artificially lowered by phenobarb. So every T4 reading post-phenobarb probably underrepresents Gizzy's true thyroid function. In order to know whether low T4s represent a genuine problem for a dog on phenobarb, additional thyroid parameters need to be tested. Here's an info page from Michigan State's Vet School that answers a number of questions associated with administration of a thyroid panel that is broader than the T4.

http://www.dcpah.msu.edu/sections/endocrinology/Thyroid_Canine.php#05

Marianne

[drexnjanfree]

THANK YOU SO MUCH LABLAB for the additional info. I too am concerned about the lack of Phenobarbital levels and am going to ask that this be done. As well as repeat thyroid levels. Today is a holiday so my vet isn't open but am going to take him in tomorrow armed with lots of new information thanks to this group.

I posted 3 pictures of him in a newly created album called Gizzy to illustrate his weight gain. I also have videos of his seizures but that isn't my primary concern now.

Here is a link to his photo album in case that is helpful in any way.

I think the best thing for me to do is to ask for that referral to an IM specialist. I'm increasingly believing that while my small town vet is great for my other 5 dogs and kitties that my Gizzy has to many co-morbidities to be properly diagnosed. Hopefully there won't be any push back when I ask for the referral.

THANK YOU AGAIN SO MUCH!!!!! I see a light at the end of the tunnel and that gives much so much hope!

Jan and Gizzy

http://www.k9cushings.com/forum/album.php?albumid=915

[labblab]

In advance of your discussion with your vet, here's a link with really concise and helpful info about phenobarb treatment and monitoring:

https://www.idexx.com/pdf/en_us/smallanimal/diagnosticedge/de-october-2012/catalyst-phenobarbital-white-paper.pdf

Also, I don't know whether you live anywhere near Knoxville, but if so, the University of Tennessee Vet School might be another good referral option for you. Vet schools obviously offer the entire range of diagnostic specialists, and prices are often more reasonable than those charged by privately owned practices.

http://www.vet.utk.edu

Also, you can use this webpage to locate other small animal internal medicine specialists ("SAIMs") who may be nearby you:

http://www.acvim.org/PetOwners/FindaSpecialist.aspx

Marianne

[labblab]

Just wanted to add that if you are going to move forward with a specialty referral, you may want to hold off and let them order and oversee any additional testing. That way, you won't run the risk of having to repeat or duplicate testing in the event that they want to follow any different protocols or use any specialized labs for analysis.

[Dixie'sMom]

I just wanted to say hello to you and Gizzy. I have been reading what's going on with him and he is one lucky boy to have you for a Mom and forever home. I will continue to follow along his story. He is such a cute little fellow!

[drexnjanfree]

Good idea! Thank You

[drexnjanfree]

Great resource, thank you!

[drexnjanfree]

My Gizzy's urine Cortisol/Creatinine ratio test is back and his ratios were "high" per the Vet staff though they didn't give me an exact value. He will have a Low Dose Dexamethasone test next week which will hopefully be confirmatory. Thanks again for all the great information and posts here. They have been so very helpful!

Jan and Gizzy

[molly muffin]

We're hanging with you every step of the way!

hugs
Sharlene and molly muffin