Hello - and perplexing blood test results (Sammy is at peace)

[SuperCupcake64]

Hi! I'm the mom of Sammy, an approximately 11 year old terrier mix. I knew when I adopted him a year ago that he had Cushings, and my vet suspected he had been Cushingoid for quite some time without ever having been treated. He started on trilostane and has had regular ACTH stim tests. While his cortisol levels got better, they are still high despite gradual increases of the medication. He has also never lost any weight despite being on a reduced calorie diet.

A few weeks ago, Sammy had a few spontaneous accidents in the house (he's very dignified, and this is unlike him). I took him to my vet, who ran blood work, checked his thyroid, did a urine culture, and also did another ACTH stim. They did an ultrasound of his prostate, kidneys, and adrenal glands. Here's the weird thing: not only is his cortisol level high (7.1), his potassium is quite elevated. His BUN is also abnormally high.

One of my vets thinks perhaps he has a functional ureter obstruction, which would account for the BUN reading, elevated potassium, incontinence, and also an episode of possible bloody urine (I have 3 dogs, so it's hard to tell which one it was). She would like to have someone scope his ureter or perhaps do a dye study. The other vet thinks that because he went for so long without treatment for Cushings--and because his adrenal glands are super enlarged and have mineral deposits--it's more likely that he is not producing enough aldosterone and needs Florinef or monthly injections of DOCP in addition to the trilostane.

I'd love to know if anyone else out there has faced this or has any advice. I'm also wondering if perhaps given his current set of symptoms (other than the peeing in the house and possible blood in urine, he is not acting any differently), he might benefit from a different diet. He currently eats Acana Ranchlands (switched from Orijen Red due to fewer calories).

Thanks in advance for any help you can provide! :):)

[labblab]

Hello and welcome to you and Sammy! I'm sorry you are having these new issues, however. First off, if all of Sammy's symptoms were well-controlled, a post ACTH of 7.1 would now be considered to be quite acceptable as opposed to being high. Levels up to around 9 are now within the therapeutic range as long as clinical signs are under control, and it is not unusual for dogs to require ongoing dosing alterations in order to maintain desired levels. However, with the issues that are going on for him now, I understand why his cortisol level is a factor you are considering.

Is he taking any other medication right now? We know that trilostane itself has the potential to lower aldosterone (and increase potassium). On its own, it should not raise potassium to abnormally high levels, but in combination with other medications that have the same potential (such as certain ace-inhibitors), the effect can be cumulative.

I am assuming the ultrasound did not reveal any significant kidney abnormalities? Has protein or blood been noted on his urinalyses? I am not familiar with obstructions of the ureter, so I cannot judge the wisdom of your vet's recommendation in that regard. As far as the other vet's suggestion re: supplemental mineralcorticoids, all I can tell you is that we have never had a dog here who has been prescribed both trilostane and a mineralcorticoid simultaneously. The only time we have seen Florinef or Percoten prescribed is when a dog is experiencing Addisonian symptoms and the Cushing's treatment has been suspended either temporarily or permanently. I don't believe I would pursue that option without first consulting Dechra (manufacturer of brandname Vetoryl) in order to get their assessment as to the plausibility of that explanation of the problem and recommendation for treatment.

I do believe (or think?) that feeding a really high protein diet can increase the BUN level. I know that Orijen is generally a high protein product line. I am guessing the Acana is more moderate protein (I feed one of my dogs the Acana chicken version). Has there been any difference in the BUN level since making the dietary change? Just a thought...

Bottom line, I don't know that anything I've said is of much help to you! But I am still really glad you've found us, and we will be very anxious to follow along with Sammy's diagnostics, no matter what you decide to do.

Marianne

[SuperCupcake64]

Thanks for your response! The ultrasound showed that his kidneys are indeed abnormal--one is small, the other has cysts. His adrenals are huge and have mineral deposits. All of his other lab results are consistent with Cushings. The abnormal BUN is new, as far as I can tell. He does not have thyroid issues or diabetes. Sammy's coat was not significantly improved by going on trilostane, nor did his weight decrease at all. The cortisol level improved, but never lower than 7.1 (I think). The only "new" symptoms are increased thirst again, incontinence, and the possible suspected issue of blood in the urine.

He is on no other medications, just trilostane (.5 mg am and pm). They have me ordering it through a compounding pharmacy so that they can easily titrate the dose. I have had at least one instance of a faulty batch with that medication. He does take dosequin, too, and I was giving him fish oil for his coat.

The vet who wants to treat him as though he has Addison's said that she used to see high potassium and high cortisol when dogs were primarily being treated with lysodren. She said she has never seen it since using trilostane. Sammy's Cushings went untreated for a long time, however.

Orijen is very high in protein, and Acana is less so. I was wondering whether or not diet might be a factor. I used to give him melatonin and flaxseed meal, but stopped when it seemed like his Cushings still wasn't being controlled effectively. I had this idea that trilostane was a magic drug and that it would reverse all his issues!

I'll definitely get in touch with the company that makes trilostane and talk to them about the Addison's meds. That's a great idea.

[molly muffin]

How are things going with Sammy?

[ShibaMom]

Yes, I'd love to hear how Sammy's doing.
I'm newer here, too. Welcome!

I'm curious if the trilostane dosage you listed was a typo - is 0.5 mg twice a day really what he's on?

Hope to hear from you soon,
Samantha

[SuperCupcake64]

Hello!

I'm sorry it's taken me so long to respond. Just to reiterate, Sammy is possibly 11-12 and likely had untreated Cushings for a while before I adopted him. My vet diagnosed pituitary type and put him on compounded trilostane because it was cheaper. Yes, he was taking .5 ml 2x per day, but really I think that amounted to 50mg 2x/day. His ACTH stim never went below 7.3. He has more affect than he used to, but he has never lost weight (he probably weighs 20 lbs more than he should) and has muscle wasting. The trilostane seemed to improve his coat and water consumption but never affected his weight. My home vets did an ultrasound of his adrenals and said they were both very enlarged with mineral deposits. He is happy but his weight is affecting his joints and his kidney function seems to be declining.

Here, the plot thickens. After his elevated potassium and sudden onset of accidents in the house, I took Sammy to an internal medicine specialist for a second opinion. He did an ultrasound and feels that Sammy has adrenal type with possible metastasis to an adjacent lymph node. He recommended that Sammy be on the brand name Vetoryl because the absorption is better and increased his dose to 60 mg 2x/day. He also said Sammy likely had less than a year to live.

I repeated the ACTH stim at my own vet a few weeks later and it was elevated, 8.1, though his drinking was down and no more accidents in the house. (I do think the brand name was indeed more effective.) My home vet did a third ultrasound, sees no adrenal tumor--just two very enlarged adrenals--and still feels strongly that it is pituitary type and that Sammy is not responding as well to trilostane because his adrenals are dramatically compromised from untreated Cushings before I adopted him.

What my home vet now wants to try is switching him to lysodren from trilostane in the hopes that it will help Sammy lose weight and improve his quality of life. It will also help if he has an adrenal tumor. I'm really nervous about lysodren, as my vet originally compared it to a nuclear bomb. In general, Sammy is loving and happy but his arthritis is worsening due to his weight. I don't know if I should switch him or not. :confused: I want him to have the best possible quality of life.

Any advice is welcome! Thank you!!

[Squirt's Mom]

I only have a second right now but wanted to tell you the MOST important thing about your post -

DO NOT start the Lysodren without a washout period between the two drugs. 30 days is recommended. Vetoryl (Trilostane) has a much shorter life in the body than Lyso so it is leaving much more quickly. However, the effects of the Trilo may linger longer and we do NOT want these two drugs to mix in the body. So do NOT let your vet put your baby immediately on Lyso from Trilo. ;)

Second - Lyso is my preferred treatment. I am much more comfortable with it than with Vetoryl. But I'm the oddball with this as I am with most things. :D

[SuperCupcake64]

Wow, thank you--none of the three vets who have been involved with this have said that!

This whole thing has been distressing for a number of reasons. First, I adopted Sammy knowing he had untreated Cushings, but have no idea how old he really is or how long he had Cushings before he was under a vet's care. Second, the vets had different diagnoses based on the ultrasound. This does not fill me with confidence.

The specialist says it really doesn't matter what drug he's on because of his conclusion that Sammy has an adrenal tumor. My home vets say to try Lysodren on the premise that his adrenals are compromised anyway and so they simply cannot do the job they are supposed to do.

I'm also wondering, given his high potassium levels, if I should be considering a kidney-friendly diet.

I'm relieved to hear that you prefer Lysodren. Why?

[SuperCupcake64]

Just to be completely clear, the only real symptoms Sammy has is that he cannot lose weight (he weighs at least 20 lbs more than he should), he has some muscle wasting, hair loss, and some increased drinking. Brand name trilostane helped but it wasn't reflected in the ACTH stim.

I have more numbers if any of that is helpful. I know this is convoluted, and for that I apologize! I'm confusing myself!:D

[Squirt's Mom]

Personally, I don't like "new and improved" anything. In my experience, it rarely is an actual improvement. The best way to get me to stop using a product is to put those words on the package. :D So there's that aspect of my personality to consider. ;)

When Squirt was first diagnosed and I started reading about the treatments, I wanted to use Trilostane (Vetoryl), which my vet had never heard of at that time (around 2008), because it was supposed to be "safe". Because our diagnostic phase was involved I had time to learn more and watch dogs on the forum taking both drugs. I realized pretty soon that the new drug wasn't all that "safe" after all, it just worked differently.

As fate had it, Squirt started out Atypical and when her cortisol did start to rise, Lyso was what was recommended (and still is for Atypical pups)...and I was glad. There hasn't been a whole lot of change in how it's used or in what to expect with it. We are still learning about Vetoryl. I also understand much better how Lyso works in the body.

[SuperCupcake64]

Thanks for helping me understand better. It's really hard to know if trilostane has helped Sammy. His cortisol levels definitely came down but his diagnosis and moving in with me happened at the same time. All the rescue told me was that he had a "peeing problem," and he does produce copious amounts of pee. He is peeing less on the higher dose of non-compounded trilo for sure. He has never seemed that hungry to me.

So the only symptoms that really remain are the hair loss (his coat is better) and this excessive weight. Sounds like it might be worth a try to see if he does better on lyso. How long has your dog been on it?

The vet I've known the longest suggested that he might have atypical Cushings but I didn't really understand what that meant. How does it differ from pituitary and adrenal?

[molly muffin]

Atypical cushings the cortisol is not elevated but other sex hormones are. In that case they put them on melatonin and flax seed. It takes several months sometimes (at least 3 - 4) to see results. It doesn't affect if they have high cortisol but usually does help if they only have other high hormones.

[labblab]

Just to be completely clear, the only real symptoms Sammy has is that he cannot lose weight (he weighs at least 20 lbs more than he should), he has some muscle wasting, hair loss, and some increased drinking. Brand name trilostane helped but it wasn't reflected in the ACTH stim.

Hmmmmm...I am not sure I understand why your vet thinks it is worth it to switch to Lysodren if the main reason is Sammy's weight. I don't really know a reason why Lysodren will do a better job of that than the trilostane. Both with dogs and humans, once the excess weight is there, it can take quite a while to shed it again. :o

Muscle weakness, poor coat, and weight loss are all issues that can take some time to improve. If I am understanding things correctly, Sammy has only been on trilostane for less than two months altogether, and on brandname Vetoryl for much less time. His current ACTH result would actually be acceptable long-term as long as you were satisfied with symptom resolution. Obviously, not all his problems have resolved yet, but as I say, some of them may just take time.

This is just my nonprofessional opinion, but I don't believe I'd abandon the Vetoryl yet. I just don't know any reason why you'd see any quicker improvement with the weight loss on Lysodren.

Marianne

[Harley PoMMom]

Hello!

IThe trilostane seemed to improve his coat and water consumption but never affected his weight. My home vets did an ultrasound of his adrenals and said they were both very enlarged with mineral deposits.


Trilostane is known to enlarge the adrenal glands.

Concerning his weight, does Sammy seem to be hungry all the time?


Here, the plot thickens. After his elevated potassium and sudden onset of accidents in the house, I took Sammy to an internal medicine specialist for a second opinion. He did an ultrasound and feels that Sammy has adrenal type with possible metastasis to an adjacent lymph node. He recommended that Sammy be on the brand name Vetoryl because the absorption is better and increased his dose to 60 mg 2x/day.

60 mg of Vetoryl twice a day for a 20 lb dog seems really high to me, and could be the reason his potassium is elevated. Is his sodium level low, and are there other levels on the chemistry panel that are abnormal?


I repeated the ACTH stim at my own vet a few weeks later and it was elevated, 8.1, though his drinking was down and no more accidents in the house. (I do think the brand name was indeed more effective.) My home vet did a third ultrasound, sees no adrenal tumor--just two very enlarged adrenals--and still feels strongly that it is pituitary type and that Sammy is not responding as well to trilostane because his adrenals are dramatically compromised from untreated Cushings before I adopted him.

Why does the vet think his adrenals are compromised? If it is because they are so large/plump, like I mentioned before, Trilostane can do that.


What my home vet now wants to try is switching him to lysodren from trilostane in the hopes that it will help Sammy lose weight and improve his quality of life. It will also help if he has an adrenal tumor. I'm really nervous about lysodren, as my vet originally compared it to a nuclear bomb. In general, Sammy is loving and happy but his arthritis is worsening due to his weight. I don't know if I should switch him or not. :confused: I want him to have the best possible quality of life.

Any advice is welcome! Thank you!!

My main concern right now is Sammy's high potassium levels, and hopefully his vet will address that promptly.

Hugs, Lori

[SuperCupcake64]

Sammy facts:

I adopted Sammy in September 2013. He has been on compounded trilostane since then. He weighed about 47-48 lbs when I got him, and is now up to 50 lbs even though he only eats a cup of food a day and no treats. He should probably weigh more like 30 lbs. He is large and in charge! :):) He started at about 25-30 mg 2x/day, and was gradually increased to 50 2x/day.

When he started having accidents inside the house a month or so ago, including possible bloody urine (I have other dogs, so I wasn't sure it was him)--an internal med specialist switched him to the brand name Vetoryl, 60 mg 2x/day. No more accidents, repeated ACTH showed a slightly higher cortisol level.

Here are some numbers from his tests over the past year (I have more where these came from):

2/3/2015
Sodium 149
Potassium 6.2
Na / K Ratio 24
Chloride 114

1/31/15
Sodium 149
Potassium 5.8
Na / K Ratio 26
Chloride 108

ALT 345 18 - 121 U/L H
AST 82 16 - 55 U/L H
ALP 608 5 - 160 U/L H
GGT 25 0 - 13 U/L H
Bilirubin - Total 0.2 0.0 - 0.3 mg/dL
Bilirubin -
Unconjugated
0.1 0.0 - 0.2 mg/dL
Bilirubin -
Conjugated
0.1 0.0 - 0.1 mg/dL
Cholesterol 358 131 - 345 mg/dL H
Amylase 1,032 337 - 1,469 U/L
Lipase 330 138 - 755 U/L
Creatine Kinase 373 10 - 200 U/L

7/21/14
Sodium 150
Potassium 5.7
Na / K Ratio 26
Chloride 111

and the results of his ACTH stim: (most recent was 8.3)
1/31/15
Pre ACTH 3.4 ug/dL, post 7.3

9/20/14
Pre ACTH 4.0 ug/dL, post 8.1

5/17/14
Pre ACTH 3.6 ug/dL, post 9.1

My dilemma is really whether switching him from trilo to lysodren makes sense. The internal med guy thinks it's possible he could respond differently to a different drug, but that he has an adrenal tumor and nothing will change that (he is not a surgical candidate). My general vets feel he does not have an adrenal tumor, just super enlarged adrenals, and that it could possibly make a difference.

I don't care about his weight other than that it affects his joints. His diet is really calorie controlled and it has not helped things in the least. He also loses a lot of hair and drinks more than my other dog. Really, my primary concern is making sure that he has the best quality of life he can possibly have and that I am not overlooking something. The disagreement between the vets is perplexing and I am the only one who is going to make sure there is appropriate follow-through on his medical care!

(If you can't tell, I adore my pets and will do anything for them--I think I see lots of people on here who can relate!!)

Sorry for all the information. I have more if I'm overlooking something!

[SuperCupcake64]

Sammy does not seem hungry all the time. He drinks and pees more than my other dog. His kidney and liver levels are definitely elevated (I gave some numbers above, his BUN has also increased over the past year).

Regular vet ultrasound (these vets are good and I trust them): they see two extremely enlarged adrenal glands, bilateral, with mineral deposits.

Internal med ultrasound: One small adrenal plus an adjacent enlarged lymph node that he said the other vets were mistaking for an adrenal gland, plus an enlarged lymph node on the other side compensating for the nonfunctioning adrenal.

Completely different readings, same dog.

[Harley PoMMom]

Just to be completely clear, the only real symptoms Sammy has is that he cannot lose weight (he weighs at least 20 lbs more than he should), he has some muscle wasting, hair loss, and some increased drinking.

For some reason I skipped over that word "more" that followed the 20 lbs :o I apologize for that big error on my part...geeze sometimes my feeble gets lost on its own. :o:o:eek:

I do very much appreciate the added information and now I see why his Vetoryl dose was increased.

And dang, those different ultrasound reports, they do have me scratching my head. :confused:


2/3/2015
Sodium 149
Potassium 6.2
Na / K Ratio 24
Chloride 114

1/31/15
Sodium 149
Potassium 5.8
Na / K Ratio 26
Chloride 108

7/21/14
Sodium 150
Potassium 5.7
Na / K Ratio 26
Chloride 111



Sorry but I'm gonna be a pest again, for those values above could you edit your post and add the reference ranges for them, sorry, and thanks!

Yep, we totally see that you adore and love your dogs very much, and yes, we completely understand why you do.

Hugs, Lori

[SuperCupcake64]

For some reason I skipped over that word "more" that followed the 20 lbs :o I apologize for that big error on my part...geeze sometimes my feeble gets lost on its own. :o:o:eek:

I do very much appreciate the added information and now I see why his Vetoryl dose was increased.

And dang, those different ultrasound reports, they do have me scratching my head. :confused:

Sorry but I'm gonna be a pest again, for those values above could you edit your post and add the reference ranges for them, sorry, and thanks!

I think it's my fault--I'm so confused by the different opinions that I'm confused myself! It's been a weird road.

No problem with adding the reference ranges. I so appreciate you taking time to look at them! I'll add them below.

[SuperCupcake64]

Originally Posted by SuperCupcake64 View Post
2/3/2015
Sodium 149 (144 - 160 mmol/L )
Potassium 6.2 (3.5 - 5.8 mmol/L )
Na / K Ratio 24
Chloride 114 (109 - 122 mmol/L)

1/31/15
Sodium 149 (144 - 160 mmol/L )
Potassium 5.8 (3.5 - 5.8 mmol/L )
Na / K Ratio 26
Chloride 108 (109 - 122 mmol/L)

7/21/14
Sodium 150 (144 - 160 mmol/L )
Potassium 5.7 (3.5 - 5.8 mmol/L )
Na / K Ratio 26
Chloride 111 (109 - 122 mmol/L)

And for good measure, also from his 1/31/15 bloodwork:
Glucose 90 (63 - 114 mg/dL) 92
BUN 34 (9 - 31 mg/dL H)
Creatinine 1.3 (0.5 - 1.5 mg/dL)
BUN / Creatinine Ratio 26.2
Phosphorus 5.6 (2.5 - 6.1 mg/dL)
Calcium 11.1 (8.8 - 11.2 mg/dL)
Sodium 149 (142 - 152 mmol/L)
Potassium 5.8 (4.0 - 5.4 mmol/L)
Na / K Ratio 26 (28 - 37 L )
Chloride 108 (108 - 119 mmol/L)

[SuperCupcake64]

Hello -

Thanks again for your help and support so far! In addition to Sammy the Super Terrier mix, I have Maizie the Beautiful Border Collie mix (who unbeknownst to me, had heartworm when I adopted her! She's fine now). I need to start measuring Sammy's water consumption so I have a baseline, but I can't figure out how to do that when they drink from the same bowls. I tried telling them to drink from their own bowls but they won't listen to reason. ;);)

Should I just measure generally and assume that any change is due to Sammy rather than Maizie?

I also had Griffin the Great Wheaten Terrier, but I lost him to progressive and unrelenting dementia a few weeks ago just shy of 15 years of age. After a year of incontinence and disorientation, Griffin is in a better place, but I'm not ready for Sammy to join him any time soon.

[Wally P's Mom]

That's a tough one and also a good one. When I had multiple daschunds, I didn't have the pleasure of measuring water consumption. I do now for my single daschund. One idea is to keep your dogs segregated or measuring the bowl after anybody drinks. You would then have your before and after weights for each drink. Subtracting them would tell you how much for that gulp and adding each gulp would give you the total consumed by that dog. It will be a PIA, but it would give you the data you are looking for.

[Squirt's Mom]

MODERATOR NOTE: I have merged your post about water consumption into Sammy’s original thread. We normally like to keep all posts about each pup in a single thread as it makes it easier for members to refer back to the pup's history when needed. Thanks!

[Squirt's Mom]

From the Everything Else section as a sticky post at the top of that board -

http://www.k9cushings.com/forum/showthread.php?t=3583&highlight=water

[SuperCupcake64]

I'm so sorry for the double post. I had found that spreadsheet when I was perusing this amazing site--so helpful! I just wasn't sure how to measure water intake when two dogs use the same bowls.

In any case, the internal med dr emailed me and said he believes Sammy really does have an adrenal tumor so basically I have 3 options:

1) keep him on trilo and declare his Cushings controlled;
2) increase his trilo assuming his Cushings is uncontrolled to see how he tolerates it; and
3) switch him to lyso on the basis that some dogs do better with it, but with the knowledge that it probably won't make any difference to his long-term survival.

The general vets (who have a great reputation) still feel it's pituitary type.

If there is no real advantage to switching medications, and assuming for a moment that he does have an adrenal tumor (the internal specialist thought it could be benign, but also thought it might not be), what else can I do to help him live as long and healthily as possible as regards diet or other supplements? I give him 3 mg of melatonin with his late-night snack and used to give him flaxseed meal, but I have not been lately.

No clear-cut answers here. Sigh. I just want to do the best thing for my dog, but I don't know how to figure out what that is!:confused:

[Squirt's Mom]

With water logging with more than one dog, you assume the other dog drinks a normal amount of water. So lets say the other dog should drink 1 cup a day and your cush baby should drink the same. BUT you are logging 8 cups of water a day. You can assume those extra cups are being consumed by the dog with Cushing's since the other is drinking normally at 1 cup a day. ;)

[SuperCupcake64]

Thanks again for the advice. After talking with both my vet and the internal medicine specialist, I am going to try keeping Sammy on vetoryl and increase the dose to 70mg 2x/day. Is there anything else I should add to support kidney and liver function? He currently takes 3 mg of melatonin at night but no milk thistle or flaxseed, etc.

[Harley PoMMom]

Adding krill oil, I believe, is a good supplement to give as it has anti-inflammatory properties and lowers triglycerides. I've also read that it provides support for dogs with kidney disease.

Milk thistle is another supplement I would add as it may help the liver.

One concern I have is Sammy's elevated potassium level, has the vet mentioned addressing this?

Hugs, Lori

[Squirt's Mom]

Why are you increasing the dose? What is the current dose? Is the vet aware you are increasing the dose?

[SuperCupcake64]

The specialist wants to increase the dose from 60 mg 2x/day to 70 mg 2x/day because his symptoms are still not controlled--lots of water drinking and peeing and no weight loss whatsoever after 1.5 years on this drug. We have increased the dose really slowly, though. Sammy doesn't seem sick per se, just arthritic from several years of carrying lots of excess weight and occasional accidents in the house.

My regular vet agrees that it's worth a try. They don't seem concerned about the potassium level anymore, for some reason.

I'm adding milk thistle and changing him from salmon oil to krill oil.

I'll be taking him in for an ACTH stim in about 2 weeks after I increase the dose. Any concerns or things I should ask about?

[Harley PoMMom]

It is quite possible that he has what is called renal medullary washout. To simplify things, it means all the stuff (solute) his kidneys need to concentrate his urine has been washed out for a very long time so the kidneys will take some time to recover. A small number of dogs being treated for Cushing's may never have a resolution of pu/pd, so that's a possibility too.

Lori

[SuperCupcake64]

That's really interesting. When I adopted him, he had likely had Cushing's for quite some time, so I imagine it wreaked havoc on his body. Anything I can do to support his kidney health?

[molly muffin]

Yes, cortisol can indeed wreck havoc on the body. Sam-E is also good for the liver. As far as kidneys, it is hard to deal with kidney issues and cushings, but keeping an eye on the numbers on his urine analysis is good start. Maybe some of the others are aware of kidney supplements that could help too.

We do an Omega 3 supplement.

[Harley PoMMom]

Krill oil is a good supplement to give as it has anti-inflammatory properties. I have read that CoQ10 supports the kidneys when in renal failure.
CoQ10 is reported to have renoprotective effect in experimental AKI in animals[11] and humans with chronic kidney disease http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4323914/


Here's a link to another study: Renal preservation effect of ubiquinol, the reduced form of coenzyme Q10. (http://www.ncbi.nlm.nih.gov/pubmed/20878200)

Lori

[SuperCupcake64]

Great, Lori, thanks. I've started krill oil and milk thistle and will perhaps throw in CoQ10 for good measure. One of the benefits of having a dog with Cushings is that he doesn't bat an eyelash when I throw new things on top of his food. All I ever had to do to get him to take the compounded trilostane liquid was say "Open" and he squints his eyes shut and opens his mouth as wide as it can go!

[Harley PoMMom]

All I ever had to do to get him to take the compounded trilostane liquid was say "Open" and he squints his eyes shut and opens his mouth as wide as it can go!

Awww!! he is such a good boy! I have never had a dog do that for me, I've had to hide medication in food, like cheese or deli meat, in order for my boys to take it.

[SuperCupcake64]

Hello again. :)

I am now giving Sammy CoQ10, krill oil, and milk thistle. He is also receiving 60 mg of vetoryl 2x/day. This spring, he has started shedding like crazy (I have no idea if he shed before he had Cushings, because I didn't own him then). His skin is also terribly flaky. Has anyone else had issues with flaky skin and Cushings? Anything I can do about it?

[molly muffin]

Skin and coat tend to go through cycles. You are giving excellent supplements already that should eventually help the skin and coat. Once they cycle through and he is at a better cortisol level, then hopefully these issues will go away.

[ShibaMom]

I second/third the CoQ10 for kidneys. I'm doing lots of research right now due to my non-cushpup having early kidney disease, and it's highly recommended.
Your baby is sure in good hands!

[SuperCupcake64]

Aw, thanks. I've always been pretty diligent about caring for my animal loves, and I'm so inspired by the participants in this forum! Lots of lucky dogs out there. :)

Sammy weighs 50 lbs (he probably should weigh 30). I'm giving him 500 mg of krill oil per day and 100 mg of CoQ10 (both human grade that I got at Costco). The milk thistle is formulated for dogs and I'm just following the directions. Think I'm giving him enough krill oil/CoQ10?

Thank you so much for your help. Sammy has been living with Cushings for 1.5 years in my care and who knows how long before I rescued him. I want him to be as healthy as possible!

He is having his first ACTH stim on Friday since his Vetoryl dosage was increased yet again two weeks ago. Fingers crossed that there is some improvement!

[Harley PoMMom]

I found this article to be informative regarding omega-3, it also lists the potential side effects: http://veterinarymedicine.dvm360.com/journal-scan-omega-3-fatty-acids-how-much-too-much?rel=canonical

This one is geared toward humans but has interesting material, it also mentions that "omega-3/omega-6 ratio": http://www.hsph.harvard.edu/nutritionsource/omega-3/

[SuperCupcake64]

Those are helpful, thanks! I think I'll try increasing the krill oil to 1000 mg and leave the CoQ10 where it is currently. They'll probably do bloodwork on him tomorrow too, so it will be interesting to see if there is any improvement...

[Harley PoMMom]

For the CoQ10, the dogaware site has some good info: http://dogaware.com/health/kidneysupps.html

[SuperCupcake64]

Thank you! Looks like I'm giving him enough CoQ10, but it's not in two doses. Once the dogs get through the bottle I bought, I'll see if I can get it in smaller amounts. Sammy is lucky that he doesn't have a bowl with more supplements than food--there are so many things I could give him!

[molly muffin]

It's funny sometimes, we are better about making sure our furbabies get the supplements that might help them then we are about making sure we take our own.

I agree, it sure can turn into a lot of pills. molly gets a couple too with her meds and I have to bundle them up into wet dog food balls so she'll take them.

[SuperCupcake64]

I got the results of Sammy's most recent ACTH stim/bloodwork. Despite going up to 60mg of brand-name trilostane (30 mg 2x/day), he is a little worse. As a result, he has now been increased to 70 mg (35 2x/day) of compounded trilo (it's cheaper). Sammy weighs 50 lbs. Here are the results (just the abnormal levels--the number on the left is the most recent, followed by the normal range, and then the previous results from 1/31/15 and April 2014). Any observations or thoughts?

Cortisol - Pre ACTH 8.3 ug/dL 4.4 3.4
Cortisol - Post ACTH 9.4 ug/dL 8.1 7.3

Potassium 6.0 (4.0 - 5.4 mmol/L) 6.2 5.8
Na / K Ratio 24 (28 - 37 L) 24 26
Chloride 105 (108 - 119 mmol/L) 114 108
Anion Gap 27 (11 - 26 mmol/L) 24

ALT 216 (18 - 121 U/L) 345
AST 52 (16 - 55 U/L) 82
ALP 449 (5 - 160 U/L) 608
GGT 14 (0 - 13 U/L) 25

Cholesterol 294 (131 - 345 mg/d) 358
Creatine Kinase 232 (10 - 200 U/L) 373

[molly muffin]

Yes I see why you went up to 70mg, as the cortisol is not where you want it to be yet.

Still it's a lot so there has to be some other reason that he is resistant to it, either it is an adrenal tumor, notoriously hard to get control of those buggers or something else. Renal or other chronic illness involved.

The high protein in the diet does make the BUN go up, mine goes up if she has tripe, which is higher protein less phosphorus. But I understand when trying to control calories that it can be tough to get something that works for that and isn't as high of protein.

[SuperCupcake64]

Thanks, Charlene. The trilo definitely has helped, but he is still not low enough. I'm not sure what the elevated cortisol pre-stim was about. He has not been that high since he started medication in fall 2013. Could it be an error?

His liver numbers look much better, however, since I started the milk thistle. His ALT and ALP are improved. I've read in some places that I can't give it all the time. Is that true? Also, I've been giving him Herbsmith milk thistle--pure thistle in powdered form. Has anyone had better luck with Denamarin (isn't that the one that combines milk thistle and SAM-e)? Or maybe I should stick with what I've been doing--following the vet's recommendation for increasing the trilo and keeping the krill oil (500 mg 2x/day), CoQ-10 (100 mg 1x/day), and ground milk thistle?

His creatinine is on the increase, however. Should I consider a kidney-friendly diet? He currently eats Acana Ranchlands plus a range of Merrick wet food just as a small topper.

Thanks so much for your support and help. I do kinda wonder if the specialist was correct and Sammy has an adrenal tumor after all.

Jen

[SuperCupcake64]

Actually, now that I look again at his BUN, Creatinine, and the BUN/Creatinine ratio, it's really not too bad (again, from left to right, may 2015, range, jan 2015)

BUN 29 (9 - 31 mg/dL) 34

Creatinine 1.4 (0.5 - 1.5 mg/d) 1.3

BUN / Creatinine Ratio 20.7 26.2

His GGT is better as is his creatine kinase. Maybe something I'm doing is helping Sammy?

[Harley PoMMom]

Regarding the Milk Thistle, I too have read that taking a break is recommended, I found this post from Leslie

About the milk thistle - most pups handle it just fine but be sure to run it by your vet before you start using it. Milk thistle works best in a cyclic pattern as in giving it for 3 months in the spring and fall, and off of it for 3 months in the summer and winter. Basically, give it for 3 months then don't for the next 3, then back on it. Squirt took it for some time but I didn't know about cycling it and she took in daily all that time. She started throwing it back up - the capsule would be dissolved but the herb came back up still in the capsule form! :eek: I tried a liquid form after she had a break from it but it still made her sick and I haven't tried it again since. Like I said, tho, most dogs do just fine with it!

Hugs,
Leslie and the gang

Although her creatinine is within the normal ranges it is trending upward, and along with her elevated Potassium, I would definitely want to keep an eye on it, though those elevations could be attributed to the Trilostane.

How are Sammy's sympytoms?

Hugs, Lori

[SuperCupcake64]

Thank you so much, Lori. What would elevated potassium and creatinine suggest to you, if it weren't simply due to the trilostane?

As regards symptoms, that's the weird thing: his symptoms are always present and seem to ebb and flow regardless of his medication dosage. He has not lost a single pound since I adopted him a year and a half ago, despite the fact that he is on a seriously calorie-controlled diet. He pants all the time. He drinks a lot and sometimes has accidents in the house, especially in the morning. Lately he has been losing a lot of hair. His skin is flaky but generally okay, and he loves his meals but is not ravenous. His weight is definitely a concern for me because it's exacerbating his arthritis. In the last year, he's stopped doing most stairs and doesn't like to run after balls anymore.

My concern is that his resistance to trilostane suggests that the specialist was right--that Sammy does have an adrenal tumor that is possibly cancer. (My own vets did two ultrasounds and did not see an adrenal tumor.) So I guess I'm thinking that the supplements I give him are really for that--to help him fight possible cancer and to improve kidney and liver function. Do his numbers suggest that at least perhaps the latter is improving slightly?

It's amazing to me how much dissent there has been among the various vets involved. And of course the specialist and my own vets disagree about whether his Cushings is pituitary or adrenal dependent. I only wish he had come into my life a little sooner so that I could have helped him earlier! He really is the greatest dog. He loves being petted, he loves his walks, and he adores long naps on his bed.

[SuperCupcake64]

About a week ago, Sammy got a new shipment of trilostane from the compounding pharmacy. A day or so later, he threw up. He has thrown up a few times over the course of the week--not regularly, just occasionally. Tonight I found vomit in the kitchen that I assume was from him (I have another dog, however), and he refused his bedtime snack. He is incredibly lethargic. I will take him to the vet ASAP tomorrow, but is this worth taking him to the ER tonight?:(

TIA for any advice. I'm really worried.

[molly muffin]

I would not give any more trilostane for sure and take him in first thing for blood work, ACTH, electrolytes.

[SuperCupcake64]

Thank you, Sharlene. He would not eat this morning so that's exactly what I did. His breath smells horrible, so I'm really worried about kidney dysfunction. This literally started right after the new batch of compounded trilostane, which was also very hard to get out of the bottle. I thought it was just a faulty top, because I've used this pharmacy for 2 years and have never had an issue, but now I'm terribly afraid I've been poisoning him for a week without knowing what I was doing. I'm so distraught.

They're keeping him today, doing bloodwork, and possibly giving him IV fluids.

[SuperCupcake64]

BUN and creatinine were both significantly elevated, but he's doing a little better after the IV fluids. He wouldn't eat at the vet, but he ate for me here at home. He's resting tonight and going back for more IV fluids in the morning. The thing is, this all coincided with a new batch of trilostane. I pried the top off of it today and found that it hadn't been emulsified properly--there was a huge wad of sticky, gummy powder right where I was putting the syringe to get it. Vet is trying to figure out if the kidney thing is the primary problem or if it is secondary to Addison's. Could a week of too much trilo lead to kidney issues?

[labblab]

Gosh, I am so sorry about Sammy's problems! I am only guessing, but I would suspect that the kidney abnormalities are connected to Sammy having gone Addisonian due to a trilo overdose. If so, it would be the imbalances in his body chemistries that have caused the renal abnormalities. Elevated creatinine and BUN can indeed result. But hopefully all that will be corrected and normalize again with the additional hydration and any other necessary supplemental treatment.

Sending huge healing hugs to you both!
Marianne

[SuperCupcake64]

It's been a worrisome few days. Sammy is not having an Addisonian crisis, but he has not eaten since Thursday night and his creatinine and BUN are high (as of Friday at 4, about 3.8 and 84 respectively). After his values didn't come down after spending Friday at my vet, I transferred him at my vet's recommendation to an emergency hospital. He has been on continuous IV fluids since 8 am Friday. They did his blood work today around 4 pm, and his BUN was down to 63, but his creatinine was up to 4.3. He seems like he is getting better, though. This morning when I went to see him, he would not pay much attention to me and turned his head away from food. Tonight, he practically leapt out of the cage to see me, wanted to go for a walk, and was interested in the food I brought--he even put the scrambled egg in his mouth a few times, though he would not eat.

I am still angry at the possibility that the trilo overdose assaulted his kidneys. The emergency folks say probably not, but it all seems way too coincidental. He was doing super well until I got the weird batch of medication.

My vet says we treat the patient, not the numbers, and that if we can get him happy and eating, the rest of it is less important. Sammy seems almost back to himself except for not eating. Anyone else been through a renal dysfunction crisis and come back from it?

Jen (and Sammy)

[Buffy & Trixie's Mom]

Hi. Buffy, here. My present dog doesn't have Cushing's, but my previous two babies did -- siblings.

My present Buffy (MN Collie-mix, age 7) has WBC issues, so blood lab values are a topic of interest to me at this time. I might be able to dig up some resources for you.

Love to help you.

Buffy & his Mom

[labblab]

When you say Sammy did not go Addisonian, have the vets performed an ACTH stimulation test in addition to checking his blood chemistries? Cortisol may drop way too low even though potassium and sodium levels are OK. I don't know whether low cortisol alone would cause these renal abnormalities since it would seem as though electrolyte imbalances would be the more likely culprit. But I am just wondering whether the cortisol truly has been checked.

Marianne

[SuperCupcake64]

They did a resting cortisol, not an ACTH stim. His resting cortisol was 27 (I guess the normal range is something like 1-3--I was a little upset at the time, so I didn't write it down, but his value was much higher than the range). He has never been totally controlled during the two years I've been lucky enough to have him in my life. Because the resting cortisol was so high, they didn't think Addison's was a factor.

It appears what we're looking at is advanced renal dysfunction. I'm surprised his creatinine hadn't come down when I saw him last night, because he really was back to himself. If he were eating, I wouldn't think anything was wrong. And at least last night he put stuff in his mouth. I'm going back to the hospital shortly with more things to try. They'll check his kidney values later this afternoon, and hopefully the creatinine will be down this time. It's really hard to wrap my mind around the severity of this when he seems so much better (with the exception of not eating, which he has not done since Thursday night).

If only he would eat.

[labblab]

OK, then, thanks so much for this info and I have to agree then that Addison's seems to be ruled out.

I'll surely be hoping Sammy's creatinine starts dropping again and that he'll start eating for you. Lack of appetite is so hard to watch! :o

Marianne

[molly muffin]

Has he ever exhibited problems with kidneys prior to this? Or has he had problems with his creatinine and BUN? BUN can raise due to a number of things but creatinine is very kidney specific, and it is possible that this might come down with treatment but it takes longer for it to do so and depends on what is actually going on with the kidneys.

I know it is weird that it came on so suddenly with this new batch of trilsotane. Did you talk to the pharmacy about it?

There is a facebook page for dogs with kidney problems.

https://www.facebook.com/groups/211455130573/

That might be informative.

Hope he is doing better today.

[SuperCupcake64]

My vet called the pharmacy and they just said I needed to shake it every time I use it. I've been giving him liquid trilo for 2 years and I know this very well. This was simply not mixed. The entire neck of the bottle was caked with powder.

Regardless, it doesn't change the fact that Sammy's creatinine is high. He had elevated creatinine in the spring, and had had one suspected episode of blood in his urine. But no significant changes until now. He has had numerous ultrasounds in the 2 years I've had him and nothing is normal. Everyone has a different opinion as to why.

His IV therapy will continue through the day and I will talk to the vet later and find out whether his creatinine has come down at all. If it has not, my guess is that they will just tell me to bring him home.

I went to see him this morning and since he had shown a little interest in the scrambled egg, I brought him hard boiled eggs and a cheese omelette. He seemed like he was going to eat it but again dropped it out of his mouth. This is day 3 with no food, just lots of IV fluids and bowls of water.

Thanks for the link. I'll check it out. I'm so upset about what feels like a sudden change (he was doing hydrotherapy to increase his strength and his coat had come back in beautifully). I feel totally helpless.

[Harley PoMMom]

The increased creatinine may well be from the Trilostane overdose, and with time the creatinine may come down. How are the other kidney markers looking, such as the phosphorus, potassium, anion gap, chloride, and albumin?

Hugs, Lori

[SuperCupcake64]

I know his phosphorus is high. Not sure about the other numbers. When I see him, he is acting like himself except for the not eating. I don't want to keep him in the hospital endlessly if it's not helping him. He is not on his trilo anymore, either, so his hair is starting to fall out again and his skin is flaky. I know he is not healthy and his time will certainly come, but I'd like to give him a chance at least to stabilize and get better. His kidney numbers have probably been on the rise anyway, but so many of the symptoms are the same as his Cushing's symptoms that I didn't notice a difference until the vomiting a week ago and then the inappetence a few days ago.

Thanks, everyone. I'm so distraught about this.

Jen (and Sammy and Maizie)

[molly muffin]

Of course you are distraught. I would be too. :( Hopfully he will start eating again. Are they going to try any appetite stimulants with him?

So hoping he can bounce back from this.

[SuperCupcake64]

They tried an appetite stimulant yesterday but no go. Not sure if they tried one today. The kidney disease FB page was helpful. I might try syringe feeding him. I'm thinking that unless they tell me his creatinine is dropping with continuous fluid therapy and hospitalization, I might bring him home tonight and do subcutaneous fluids at night and IV fluids during the day for the next two days at my own vet. The hospital is 30 minutes away and it's a really stressful environment. Unless it's doing him obvious good I'm not sure I should keep him there.

[Harley PoMMom]

If the phosphorus is elevated this could make him nauseated and not want to eat, to decrease the phosphorus level a binder is needed and a diet that is low in phosphorus.

Hoping Sammy is feeling better soon.

Hugs, Lori

[SuperCupcake64]

Thanks for the support. We are on day 3 with no food. He thought long and hard about eating tonight in the hospital, however!

His numbers came back tonight and it was good news:

BUN 39 (down from 89)
Creatinine 3.4 (down from 4.3 yesterday and 3.8/3.9 Thursday and Friday)
Phosphorus 7.5 (down from 11 yesterday)

So the trend is positive even though he still won't eat, is drinking incessantly, and his creatinine is high. He is going to stay in the hospital with IV fluids one more day and then I will take him home to figure out what comes next. And, hopefully, get him to eat. So worried about the little guy, but am grateful for some positive news.

[molly muffin]

Oh this is great. Even if not eating yet, well, of course he needs to eat and get nutrition but it is a positive sign that those numbers have decreased and are coming back into line with where they need to be. Which sort of makes me wonder even more about that trilostane compound being a culprit in this whole scenerio.

Still we'll take every bit of good news and hope this trend continues and he starts eating. :)

[SuperCupcake64]

Great news: Sammy's kidney values continue to come down, and he is out of the hospital and getting IV fluids at my home vet during the day. We started syringe feeding him today and he is tolerating the food beautifully so far, what little he's had, and he is trying to take pieces of food in his mouth.

They did another ultrasound in the hospital, and the general consensus is that Sammy does have an adrenal mass and thus adrenal type Cushings. This explains why the trilo never worked well. With his kidney issues, he won't be having trilostane again anyway. Once we get through this we will have to figure out how to manage his Cushings.

In the meantime, one day at a time, and today was a good day.

[Squirt's Mom]

Great news that our Sammy boy is home again! :cool::cool::cool: I bet just being with you and in familiar surroundings will do wonders for him. Keep in touch and let us know how things are going. For right now, I would focus on getting his strength back then you can take some time to think about how to address the adrenal tumor.

Hugs,
Leslie and the gang

[SuperCupcake64]

As of yesterday morning, about 10 am central time, Sammy is at peace. Over the course of the week I thought he was getting better--he spent the day at the vet for IV fluids to help his kidneys and the evenings snoozing at home and getting lots of love. But he never started eating on his own again. He had 4 days of syringe feeding to help him keep up his strength, but no matter what food he was offered he would not chew and swallow it. Around 2 am on Saturday, something happened. His breathing was rapid, he was panting loudly, he vomited. I was up with him all night as he went from water bowl to water bowl wanting to drink but just standing over it. I syringed a little water into his mouth from time to time. By the time my vet opened, it was pretty clear that whatever had happened was something from which he was not going to come back. He was dying in the exam room. We were able to stop his suffering and I was able to see him at peace one more time.

During his final days, we were able to confirm that his Cushings was most likely caused by a pheochromocytoma (his adrenals looked so awful on the ultrasound that it was hard to determine if it was pituitary or adrenal type). He was not in good shape when I got him and would not have been a good surgical candidate.

This is the worst part of loving a pet. Sometimes I think as as brave as one has to be to let go, the real act of bravery is allowing yourself to love in the first place.

When I adopted Sammy, I knew I would not have enough time with him. He was old (not sure how old, but best guess was 10-11 when he came into my life). He had Cushings, was obese, and had other issues too. Thanks to the advice of people on this forum and my own research, his coat came back beautifully and he did well enough that I almost forgot my time with him was borrowed. His funny appearance (he almost looked like a wombat!) and joyful expression made everyone smile. He was confident, very much his own animal. He was truly a unique dog.

My son and I are grieving our loss. My dog Maizie, who knew before I did that something awful had happened, is also mourning in her own way. Having lost two other dogs in the past two years, I know from experience that every day will be a little bit better. But boy, is this hard.

Thank you for your help and support through this process. Sammy's medical situation was always odd, and having people to whom I could reach out was invaluable.

Jennifer (and Maizie, and Sammy in heaven)

[labblab]

Oh Jennifer, I cannot tell you how sorry I am about Sammy. I know you wish that your time together could have been longer, but he left this world knowing that he was beloved. So even though your time was short, you granted him the gifts of love and peaceful release. I do believe those are the greatest gifts that are within our power to share, although our own hearts are left aching here on this earth.

Even in the midst of your own loss, I see that you have been taking the time to write to other members in support of their own losses or challenges. Thank you from the bottom of my heart, and I hope you will continue to remain with us in order to share more special memories of Sammy, as well.

Fare thee well, sweet boy. You will always be remembered and honored by your family here, and your mom will always be welcomed back with open arms.

Marianne

[Squirt's Mom]

I am so sorry to hear this, Jennifer, and know your heart is shattered. Sweet Sammy left this life knowing he was loved thanks to you, and he will carry that love with him always. I firmly believe we will see our babies again one day.

Our deepest sympathies,
Leslie, Trinket, Brick, Sophie, Fox, Redd, and all our Angels

[spdd]

I am so sorry to read this about Sammy. My deepest condolences. It is so hard I know. Rest In Peace Sammy.

[apollo6]

I am so sorry for the loss of your sweet Sammy. Find comfort in knowing for awhile Sammy had love, joy , a family.
Sonja ,Angel Apollo

[SuperCupcake64]

Thank you so much. It's been a difficult few days. Sammy was really suffering in his final hours, and so at least I have the comfort of knowing I tried everything I could and that now he is at peace and running free.

Jen

[judymaggie]

Jennifer -- My sincere condolences to you and your son at the loss of your dear Sammy. A big hug sent to Maizie!

[SuperCupcake64]

Thank you! Maizie needs hugs. She knew before I did that something was really, really wrong. I will definitely pass along extra love.

[molly muffin]

Jennifer so very sorry to hear this but I agree with Marianne, his last years was spent knowing he was loved and would be taken care of. That is the most important thing in the world right there.
Poor Mazie, they grief too so lots of belly rubs and hugs and special cuddles.

my sincerest condolences

[SuperCupcake64]

Thank you, Sharlene. It has been so helpful to talk to people who understand how devastating it is to lose a beloved pet.

[Wally P's Mom]

I have been down your road, too with my Wally. You loved your guy, just like I loved mine. My they find each other and run and play together until they meet us again.

God Bless.
Marge

[SuperCupcake64]

That is a lovely thought. :-)