My Lab, Luna

[matta21]

Hello everyone. My name is Maria. I moved from Miami, Fl to Barcelona, Spain 4 years ago. I have a 6 year old Lab that has been diagnosed with Cushings. Well, actually today it will be confirmed. The vet did the low-dose dexamethasone suppression test and results come out today. Blood tests came out ok except her creatine which is double of what it should be. We have to take her out every 2 hrs because she is drinking soooo much water. I have been doing so much research trying to understand this disease. The Vet will most likely give her Vetoryl and now I know I MUST insist she start on a low dose. She weighs 35kilos (74lbs). Seems to be very bloated lately which I believe is one of the side effects. How much do you suggest I start with? 60mgs per day? Would it be better to split it in two? Morning and evening?

I have also been doing a lot of research as to natural alternatives to use additionally. Is anybody using natural remedies that seem to help? Some of the suggestions for excessive thirst are: phosphatidyl serine and arsenicum. Has anyone tried them with their dogs? What about these so called CUSHEX DROPS that claim to help dogs with Cushings? There are others called SUPRAGLAN as well. Is this pure marketing? I personally hate to take medications as I know they all help with one thing, but affect others. I understand this disease is serious; therefore have no choice but to give her the vetoryl.

Anyway, I am glad I found this site. Makes me feel I am not alone. I will keep everyone posted as to the results. Thanks!!

[LauraA]

Hi Maria. I am sure others will be along shortly and would love to see your test results for Luna - they are great at interpreting them :) Whilst starting the meds is scary if you start conservatively then there is less chance of overdosing and side effects - the recommended starting dose is 1mg to 1 pound.

Some prefer the split dose but my girl does fine on a morning dose only. Just remember that the test to monitor her levels need to be done within the 4-6 hour period after she has has had her Vetoryl (with food of course :) ). So if you do one dose it is best to do it in the morning unless your vet is a 24 hour vet.

My girl was at the stage when she had no control at all over urinating, very thanking the Vetoryl cleared that up hehe. Just remember that Cushings can be managed and is not a death sentence. I would start at 60mg, it is a lot easier to increase the dose and tweak it than have to deal with an overdose.

There are a few different liver supplements that are commonly used, I am sure members will tell you the names of them. I use flax seed as well. The meds do a great job of getting the cortisol down and therefore less stress on other organs, this is why a good vet is all important. And they members here and on the facebook page are truly the greatest bunch of caring and informative people
:D

[labblab]

Hello and welcome! As you can see, I am a Lab-lover, and I have a six year-old Luna, too!! :)

Before discussing other issues, I want to first ask you about the elevated lab reading. Is it creatinine that is elevated for Luna? Can you give us the actual number for this and any other lab abnormality, along with the unit of measurement and the normal range?

If Luna's creatinine is elevated above the normal range, this can be an indicator that she is suffering from kidney damage. And kidney damage to the extent that creatinine is too high may make Vetoryl an unsafe medication choice. The manufacturer specifically warns against using the drug in dogs with significant kidney or liver damage because it will not be metabolized and excreted properly from the body.

Plus, renal disease can cause some of the very same symptoms as Cushing's and may even affect the accuracy of test results. In particular, the low dose dex test is known to render "false positives" in the face of other nonadrenal illness.

It would be great if you can get ahold of all Luna's diagnostic test results and post any that are abnormal, including the low dose dex test as soon as you hear how it turns out.

Thanks so much in advance!
Marianne

[matta21]

Hi Marianne and Laura, Thanks for your responses and support.

Well, the creatinine result came out at 0,93 and the "normal" number must be around 0,2.

As far as her last blood tests:
hematies: 6,59 (5,5-8,5)
Hemoglobin: 18g (12-18)
Hematocrit: 51,9% (37-55)
VCM: 78,7 fl (60-77)
HCM:27,3 pG (19,9-24,5)
CHCM: 34,7 g (32-36)
RDW: 13% (13,4-16,9)

Plaquetes: 207 (200-450)
MPV: 12,3 fl (5,5-8,5)

Leucocites: 5,22 (it has been going down) (6-17)

Linfocits: 20 (12-30)
Monocits: 6 (3-10)
Basofils: 0 (0-1)
Eosinofils: 2 (2-6)
Neutrofils: 72 (60-75) What I don't quite understand is why the Leucocite reading is low being that the others are within range?

Protein lab:
Totals: 8,76 (5,4-7,5)

On the Bio test the only two things that are out of range are:
Colesterol: 405 (106-367)
Triglicerids: 301 mg (50-100)

As far as kidney damage I believe we ended up discarding this because of the lab results. Which are the red flags on lab results to believe it could be kidney damage? I did read it somewhere, but I am sooo overwhelmed with so much info that i forgot. My husband thinks I am going nuts!! hahaha!

As soon as I get the low dose test I will post! Thanks :)

[labblab]

Thanks so much for this additional info. The reporting units for Luna's creatinine are very different from what I am used to seeing here in the U.S., so I am not sure how to evaluate that degree of elevation. But here's an explanation as to why abnormally elevated creatinine can be significant:


A creatinine test reveals important information about your kidneys.

Creatinine is a chemical waste product that's produced by your muscle metabolism and to a smaller extent by eating meat. Healthy kidneys filter creatinine and other waste products from your blood. The filtered waste products leave your body in your urine.

If your kidneys aren't functioning properly, an increased level of creatinine may accumulate in your blood. A serum creatinine test measures the level of creatinine in your blood and gives you an estimate of how well your kidneys filter (glomerular filtration rate).
Another indicator of kidney function on blood tests is BUN level. Both the creatinine and BUN would typically be reported on the same panel as the cholesterol and triglycerides. Is this where the creatinine was reported for Luna? Measures of liver function are also usually included on that panel (ALKP, ALT, GGT, etc.).

Was a urinalysis performed on Luna? Was there any blood or protein noted in her urine? These abnormalities can also be associated with kidney problems of various types.

Marianne

[matta21]

Yes, its a shame that reporting units are different as it makes if difficult to understand. They have done three urine analysis and they have come back negative for urine infection. No blood or protein in her urine.

As far as the BUN level, I dont see it anywhere. Maybe they call it different here.

The only thing I see on the panel that you mentioned is ALT and it says:
GPT (Alt) 253 UI/L (10-88). I will ask vet about this number as it seems extremely high. There is another one that says GOT (Ast) and it is also high. 182 (10-85). These show on the same panel were numbers for colesterol and triglicerades are. The creatinine shows here as well and it says: 1,5 mg/dL (0.5-2) which seems normal, but they did a separate one that says ratio protein/creatinine and this is were it shows very high: ratio protein/creatinine 0,93. It says under 0,2 normal, over 0,5 abnormal and she has 0,93!

It is all very confusing and frustrating. She was a happy dog and in a matter of 10 days she became completely lethargic. Ate very little, drank little for the first week or so, but then she suddenly began drinking tons of water. She just wanted to sleep and would stand up to drink water. After 2 more blood tests and urinalysis nothing showed up. No leishmania, no infection on the blood. Did a scan to see kidney and seemed fine. We gave her antibiotic for 10 days...nothing. Then vet tried a different antibiotic and she began to get better. She must have had an infection that was not detected.... Now she is alert and goes out for walks, but we can tell she is uncomfortable. She is not herself. Is obsessed with drinking water and very hungry although labs tend to be good eaters.

Anyway, I will be calling vet in about an hour. See what results tell us. Thanks again!

[Squirt's Mom]

Any mention of liver or gall bladder in the scan?

[labblab]

Yes, I have the same question as Leslie given those elevations in ALT and AST -- I am wondering about Luna's liver. Thanks for this additional information. I see now that Luna's level of creatinine in her blood is normal, so that is a relief in terms of kidney function. I am not sure what to make of the protein/creatinine ratio since that is usually a urine test here and it is designed to measure any protein that is being passed into the urine (it's the overall ratio that is important and not the individual levels of the protein and creatinine looked at independently).

Regardless, I must tell you that your description of the rapid onset of Luna's symptoms is not characteristic of Cushing's at all, especially the first week without thirst or appetite. It sounds much more as if something made her acutely ill and perhaps the increase in her liver values, thirst and urination have now resulted. Is it possible that she might have eaten something toxic or been exposed to something toxic?

Marianne

[matta21]

Yes, I agree that the symptoms that she began with had nothing to do with Cushings. The first thing we thought was that she ingested something, but nothing showed on the blood tests. I have to say Luna was diagnosed a year ago with a sublingual melanoma. They had to remove one nail and part of the bone so this was our second thought, but again nothing showed up on the tests. The vet did a scan and we ended up discarding this. He looked at kidneys and tests came out fine.

As far as the liver numbers being pretty high the Vet said yesterday that Cushings can sometimes do this. He is pretty convinced that it is Cushings at this point. Here are the results for the low dose dexa:

1. Cortisol 3,7 ug/dL (1,08-7,8) Before injecting the low dose dexa. Seems normal, but he said this depends on the time of the day. Maybe at another time it would have been high...

2. Cortisol 1,01Ug/Dl (should be over 1,5)
3. Cortisol 1,9 Ug/DI (should be over 1,5)

I don't know it the tests elsewhere are the same. Hopefully they are !

Based on Lunas weight (34 kilos) he said she should go on 120mg per day, but I said I wanted to start off with a lower dose and he was supportive.

This morning she took the first pill with food. How long should it take before her thirst gets back to normal? Days? Weeks? I suppose each dog is different.

Let me know what you think about results pls.

BTW, how can I upload a photo? Thanks!

[LauraA]

Took my girl about 4-6 weeks for her drinking to go back to normal. Fortunately she stopped wetting herself within a week, she and I were both sick of all those baths 😉 Her panting took longer and even now she is still prone to panting in summer. The first stim test at around 10-14 days will let you know if you need to increase or decrease the dose. If it is on the lower side it may take a bit longer for the symptoms to ease.

[matta21]

Liver and gall bladder seemed normal in scan. He, however said spleen had a different tone as liver when it should have a different color...

[matta21]

Took my girl about 4-6 weeks for her drinking to go back to normal. Fortunately she stopped wetting herself within a week, she and I were both sick of all those baths 😉 Her panting took longer and even now she is still prone to panting in summer. The first stim test at around 10-14 days will let you know if you need to increase or decrease the dose. If it is on the lower side it may take a bit longer for the symptoms to ease.
Thanks Laura. Yes, we must be patient!

[matta21]

Any mention of liver or gall bladder in the scan?
Liver and gall bladder seemed normal in scan. He, however said spleen had a different tone as liver when it should have a different color...

[matta21]

http://www.k9cushings.com/forum/picture.php?albumid=928&pictureid=7109[/IMG]

[LauraA]

Maria he is so majestic. What a beautiful boy you have :)

[Squirt's Mom]

Let me share my baby's story with you - she had five tests to diagnose Cushing's. The LDDS, HDDS, ACTH, UTK panel and two ultrasounds. After the second US I was told about a tumor on her spleen. Once the tumor and half her spleen were removed, her cortisol returned to normal - making all those tests false-positives due to that tumor.

Cortisol is the body's natural response to stress whether internal or external. These tests can only tell us if the cortisol is elevated but NOT why. Cushing's is one of, if not THE, most difficult canine condition to correctly diagnose in part due to this little fact of the normal action of cortisol when the system is stressed. Liver disease, gall bladder blockage, bile duct problems, kidney disease and many other condition mimic Cushing's and cause false positives on the testing.

We see very high elevations in ALP (ALKP) but not typically that high in the AST or ALT...which causes me to think more toward liver or gall bladder and I would want a bile acid test before starting any treatment for Cushing's. I would want this baby tested and looked at from stem to stern because she does not fit the typically cush profile. This condition just doesn't come on suddenly. ;)

[matta21]

Today is second day Luna takes her 60mg Vitoryl. No changes yet of course. In regards to her non stop drinking. She has many accidents in the house even though we take her out every 2-3 hrs! We were doing it at night too (taking her out), but just can't keep up. We are barely getting any sleep. Would it be ok to restrict her water at night? As soon as she comes back from walks we have to fill her water bowl again. Would it be dangerous to give her water at 10pm and then not give her again until 6am? Sounds mean, but as I said it has become very difficult to take her out so often....

[matta21]

Maria he is so majestic. What a beautiful boy you have :)
Thanks Laura. She is lovely!!! :)

[matta21]

Let me share my baby's story with you - she had five tests to diagnose Cushing's. The LDDS, HDDS, ACTH, UTK panel and two ultrasounds. After the second US I was told about a tumor on her spleen. Once the tumor and half her spleen were removed, her cortisol returned to normal - making all those tests false-positives due to that tumor.

Cortisol is the body's natural response to stress whether internal or external. These tests can only tell us if the cortisol is elevated but NOT why. Cushing's is one of, if not THE, most difficult canine condition to correctly diagnose in part due to this little fact of the normal action of cortisol when the system is stressed. Liver disease, gall bladder blockage, bile duct problems, kidney disease and many other condition mimic Cushing's and cause false positives on the testing.

We see very high elevations in ALP (ALKP) but not typically that high in the AST or ALT...which causes me to think more toward liver or gall bladder and I would want a bile acid test before starting any treatment for Cushing's. I would want this baby tested and looked at from stem to stern because she does not fit the typically cush profile. This condition just doesn't come on suddenly. ;)
Thanks so much for your advice. I will share this with my husband. If she has began treatment could we still do a bile acid test? The vet did say during the eco that the liver and spleen had the same tone. There was no differentiation. He recommended we do a biopsy before we came to the conclusion that it was cushings....yikes. What to do now??

[Squirt's Mom]

NO it is NOT ok to restrict water! It is very dangerous in fact for a cush pup. A dog with Cushing's, and other conditions that effect the kidneys, does not pee because they drink so much. It is the opposite - they HAVE to drink to stay hydrated because they pee so much. These pups are going to pee regardless of the water intake so they can quickly become dehydrated without a ready supply of water.

What should you do now? Based on my experience, I would stop the treatment and pursue the findings on the US. Then if all that checked out and further testing still supports a diagnosis of Cushing's, restart treatment. BUT that is just what I would do. Others here may have a different approach. I tend to be overly cautious with my babies. ;)

[matta21]

Ok. Thats what I thought about the water! I believe others would recommend the same thing, as to stop treatment and check for any liver and gall problems specifically. We will talk to vet monday morning. I will keep you posted. Thanks again for sharing your opinion with us.

[matta21]

Hello! It has been 5 days since Luna began taking vitoryl and my husband is trying to convince me to increase the dosage. Yes, she is taking a low dose for her weight (74 lbs/34kg...taking 60mg per day). He wants to increase it to 90mg. I am sure that the vet will have no problem saying yes, since he wanted to start her on 120mg per day based on the vitoryl package dosages. Yes, its been ONLY 5 days and we can't expect for the medicine to perform any miracles, but I am starting to wonder if 60mg is too little for her anyway. She continues to drink water non stop and cant hold the urine. :confused:Any thoughts? Should I stick to the 60mg dosage and wait for the results or should we increase it to 90mg?

[labblab]

This is just my personal opinion, but I would say you could try increasing to 90 mg. with your vet's permission. I would not increase beyond that, though, until you have performed the first monitoring ACTH test.

Marianne

[matta21]

Spoke with vet today and we will increase dose to 90mg starting tomorrow. I will keep you posted. Thanks.

[matta21]

Its been 16 days since we started her on vitoryl. She is still drinking a LOT of water and doing lots of pipis. No change whatsoever. We increased dosage to 90 mg 9 days ago. We will give it another 10 days and if this doesn':(t get better, we might have to consider increasing dose to 120mg which was what the Doctor wanted....

[Squirt's Mom]

Be sure to do the ACTH before making such a big increase. ;)

[labblab]

I am really sorry you're not seeing improvement yet. But I do believe you should perform another ACTH before increasing further. For safety's sake, you need to know where the cortisol level is. It is possible for cortisol levels to drop too low even in the absence of obvious outward signs. Plus, it is possible that something else besides Cushing's is helping to fuel the excessive thirst and urination. The manufacturer of Vetoryl wants monitoring testing to be performed two weeks after beginning treatment. In any case, you should wait no longer than a month, and that is where you will be in another ten days. It simply is not safe to continue dosing at any amount without knowing the effect on the cortisol.

Marianne

[matta21]

Well, my husband spoke with vet and he wants to increase to 120mg without doing the ACTH test. He wants us to give her 60mg in the morning with food and another 60mg at 2-3pm with food again for another 15 days and if there is an improvement with the water intake and urines THEN he wants to do an ACTH test to see where cortisol level is. He says that since we started on a very low dose for her (60mg/day on a 34kilo dog), its not worth it to do an ACTH test now. There has not been any improvement.

Does this make sense? I would have preferred to do the ACTH anyway and space the vitoryl. 60mg in the morning and 60mg in the evening.

My husband says I am being silly and that we must trust our vet....

Yikes!! :(

[labblab]

I am not a vet, but what your own vet is suggesting does not make sense to me. First, if dogs are dosed twice rather than once daily, the accepted protocol is to dose as close to 12 hours apart as possible. So unless you are giving the morning dose at 2 a.m., it makes no sense to me to dose again mid-afternoon rather than at dinnertime or early evening.

Beyond that, I don't understand his reasoning that it is not "worth it" to perform an ACTH at this point. Without finding out where her cortisol is now, it is impossible to know what is going on internally with her. In the absence of improvement in thirst/urination is he planning on just increasing the med over and over again until she keels over? It may be that Luna does not suffer from Cushing's at all, and that's why the medication isn't having any effect. Alternatively, it may just take a longer time to see outward improvement even if this lower dose is the right one for her. The manufacturer's own recommendation is to leave the initial dose unchanged for a full 30 days because cortisol levels will continue to drop during that entire time even when the dose is not increased.

If you are asking my opinion, I think it is very dangerous to increase Luna's medication so abruptly yet again within this two-week time frame without first getting the results of an ACTH. Since you are the one paying for the test, I don't know why your vet would have any reason to hesitate or object. From what you've written, I'm guessing your husband will not be very happy if you insist on an ACTH now, only to discover that Luna's cortisol level is still too high and an increase is indeed warranted. But I can promise you the expense will be far greater if she requires ER care or hospitalization to reverse the effects of an Addisonian crisis stemming from a trilostane dose that is too high. Perhaps your vet would be willing to contact Dechra directly to ask their opinion in this situation. The fact that your vet is describing the 60 mg. that Luna started taking as a "very" low dose means that he is not aware of the most recent changes in dosing recommendations by Dechra and other specialists worldwide.

Marianne

[Renee]

I think you are getting excellent advice - but, I would like to add that I think it is unreasonable to expect significant improvement in just a few days or weeks.

My pug started at 20mg per day and over the course of 3-4 months, worked her way up to 40mg per day and is now controlled. We saw varying small improvements in the first 4-6 weeks with some rebounding back and forth, then more significant improvement as time went on.

It's very dangerous to keep increasing and increasing so quickly in the hopes of eliminating symptoms very fast. Even with her cortisol in the correct range, which we don't know if it is, it may take a while for the symptoms to show improvement. She didn't get cushings overnight, nor will she get better overnight, no matter how quickly you get her cortisol dropped.

[doxiesrock912]

I second that Renee. It takes time for symptoms to improve. Sometimes seeks. Every dog responds differently. Please do not increase again. Give it time and ALWAYS do an ACTH test before an increase.

This medication is serious business. You must be careful.

[matta21]

Thanks so much for your responses and advice. I showed my husband the new lower starting dose for verotyl published by DECHRA and he paid attention this time. He is a FACTS guy if you know what I mean. So next week we plan to ask to do the ACTH test and if dose needs to be increased to give her no more than 90mg and give it some time. NOT the 160mg that vet suggested.

Thanks again and have a good weekend :)

[matta21]

http://www.vetsonline.com/news/product-news/140722-new-lower-starting-dose-for-vetoryl.html

[doxiesrock912]

The Dechra literature that comes with the medication is no longer accurate.
They advise to start low, 1mg for each pound and increase very slowly.

It takes time for the medication to build up in their systems. Also. Cortisol levels change throughout the day naturally.

Many vets recommended dosing twice a day versus once a day.
Before you increase, I'm going to suggest that you try the same dose, but give half in the morning and the other glad 12 hours later.

This worked wonders for Daisy. Vetoryl leaves their bodies fairly quickly so giving it twice a day ensures that they'll have it in their system for a longer period of time.

[labblab]

Wow, thanks SO MUCH for this link!!!!!!!!!!!!!!!!!!! We've been waiting and waiting to see this dosing change officially acknowledged and announced by Dechra, so this is huge news for us all!! :) :) :) :)

Also, do you mean you are planning to revert back to the 60 mg. over the weekend? If you are planning to have the ACTH done as soon as next week and Luna has been taking the 90 mg. with no apparent problems for ten days now, you may want to just leave her on the 90 for a couple more days until the test. This may sound crazy after I've been warning you about her dropping too low, but if you switch her back to 60 mg. again right before the test, it'll be harder to judge the true effect of either dose had it been given consistently during the 10-14 days prior to the testing.