3 yr old Pit Mix with Cushing's

[LongBeach2015]

So my Belle girl was diagnosed with Cushing's about a month ago. She is only 3 years old so it took about 6 months to come to this diagnosis. The first vet I visited told me not to worry about her hair loss because some dogs lose their hair due to their breed and genetics. That put me as ease until more symptoms started to show up; excessive thirst, urination, panting, pimples in the areas of hair loss, and weight gain. The next vet I visited agreed with me that it could be Cushing's and he did tests to confirm.

He put Belle on Ketoconazole 2 pills twice a day-200mg. She seems to be doing ok on this medication. She did throw up on one occasion. Two weeks into the meds the vet did a ACTH Stem test. I read on another thread on this site that when on Ketoconazole the ACTH tests are not necessary??? He also did a test to check her liver function. According to the vet she is improving, but her liver levels are a bit high so she is now taking Milk Thistle once a day. I am new to this and not sure about all the lingo (example: "liver levels").

I am concerned that her taking Ketoconazole is not going to be as efficient as my vet thinks. He says that she is so young and her condition is not very advanced so this medication is the best option.

Here is the email the vet sent me (pasted directly from the email)

_________________________________________

Attached is Belle's result:
Cortisol - Pre ACTH 1.9 ug/dL
Cortisol - Post ACTH 3.2 ug/dL

1 - 5 ug/dL is a desired pre- and post-ACTH cortisol on lysodren therapy however we are using Ketoconazole to suppress overall corticosteroid production. At this point I would keep her at the 2 tablets/daily in addition to Milk Thistle as a liver protect-ant. Let's not increase the dose for now. I think the weight loss is most likely due to the introduction of the new medication but also because she in not seeing side effects from her condition (Crushing). I think her skin has some improvement and she looks healthier and more lean. Please re-check with us if there are any issues (Jaundice for example) as this may be a side effect of the Ketoconazole. I will be in the office to nite call us if any additional questions. I will prescribe some predisone just in case her cortisone levels get to low from the Ketoconazole. Keep the prednisone on hand. Let's recheck in a month and stay on current dose of Ketoconazole 2 tablets 2x daily.
_______________________________________________

Thoughts or advice? thanks :)

[Harley PoMMom]

Hi and welcome to you and Belle!

Sorry for the reasons that brought you here but glad you found us. It would help a lot if you could get copies of the tests that were done on Belle and post all abnormal values here along with the reference ranges and units of measurement...e.g..ALT 150 U/L (5-50)...Thanks! We are especially interested in the results from all tests that were performed to diagnose Belle's Cushing's.

Does Belle have any other health issues? Is she taking any herbs/supplements/medications? How are her symptoms now?

Cushing's is one the most difficult diseases to get a confirmed diagnosis for, and unfortunately it is often misdiagnosed. Other non-adrenal illnesses, such as diabetes and thyroid problems, do share some of the same symptoms as Cushing's and should be ruled out.

The two preferred medications prescribed for Cushing's are Vetoryl/Trilostane and Lysodren/Mitotane, so I am puzzled as to why Belle was started on Ketoconazole. Ketoconazole is rarely used for Cushing's any longer due to it's lack of efficacy and it's adverse effect on a dog's liver which is already being overworked from Cushing's.

Please know we will help in any way we can, so do not hesitate to ask all the questions you want. ;)

Hugs, Lori

[LongBeach2015]

Thank you Lori for replying so quickly! I will call the vet tomorrow and request the results from the initial tests that diagnosed her with Cushing's. Belle does not have any other health issues except that she gets UTIs frequently and had severe mange when I adopted her and was on Ivermectin to treat it (not sure if this effected her organs).

I started noticing she was losing her hair about 9 months ago. We just moved so I thought it could be stress or mange again but when it did not stop I took her to the vet. They old me it was not mange. According to them it was most likely her breed and not to worry. A few months later she started getting pimples in the areas of hair loss. Took her to a new vet and this one diagnosed her with Cushing's. Other symptoms include heavy panting, excessive eating, and frequent urination.

The vet told me he could do a test to determine which type of Cushing's she has but either way he wanted to put her on Ketoconazole so we did not do that test. Not sure if this was the right move.

I am a full time college student and only working part time so I am going to a low cost vet. I wish I would afford better treatment for Belle. I want to do everything I can. She seems to be improving on the Ketoconazole but I am very concerned with the damage it can do to the liver. I am not sure about the units of measurement. Hopefully the images below will clarify that.

I added an image of her blood panel and ACTH results. I hope you can see them. I cannot figure out how to attach a document sorry:(

http://i988.photobucket.com/albums/af5/Charlotte_Pugh/acthresults.jpg


http://i988.photobucket.com/albums/af5/Charlotte_Pugh/bellebloodpanel.jpg

thanks again!

[labblab]

Hello and welcome from me, too! I have only a moment to write this morning, but wanted to tell you that I am going to send an email to a noted endocrinologist who generously fields questions that are "stumping" us here. I want to ask him about ketoconazole, since as Lori says, it is used so rarely these days. We simply have very little experience with evaluating it here. But since Belle seems to be responding well, it may be a reasonable choice for her under the circumstances. I'd like some feedback from him, since he will be very much aware of the pluses and minuses.

So stay tuned, and I'll post again once I get a response from him.
Marianne

[ShibaMom]

Hi LongBeach,

I'm newer here too, but wanted to welcome you, even if it's not for happy reasons. I'm sorry your baby is going through such challenges! I know it's really hard to deal with financially, too. You're in incredible hands, here, as the folks in this community have many years of experience, plus the benefit of hearing/seeing the results of different treatment results for many different situations.

I'm curious, just for clarification - was the ACTH stim test done (that you posted results for) before or after treatment? If after, can you get and post the results from before any treatment? This will better help those who are reviewing Belle's case.

How is Belle doing now, after the treatment began, and after the posted ACTH stim results? Have you seen a reduction in her symptoms? I hope so!!

Regards,
Samantha

[LongBeach2015]

Hi,

Thank you all! So the ACTH stem test was done after two weeks of treatment on the Ketoconazole. The vet said her cortisol levels are at a 10 and they should be a 4. This was the reason why he says she has Cushing's. He also told me that she had a high level of fatty something or other and asked if I give her any rich foods. He was concerned that she may end up with pancreatitis and told me to watch the treats.

The pimples she was getting seem to have gone away for the most part but her hair does not look better at all. If anything it looks like she has lost more hair. She has had really goopy eyes lately which might be related to her UTI which she is on antibiotics for. Not too sure about that. I noticed last night the underneath of her paws between her toes is really red and damp. I have never seen this before on her and I inspect them quite frequently. I took her to the beach yesterday and I am thinking maybe the salt water irritated them?

I am working on attaching the results from the initial testing that was done.

thanks!

[LongBeach2015]

Hi again!

Here are the initial tests that were done to diagnose Belle with Cushing's.

http://i988.photobucket.com/albums/af5/Charlotte_Pugh/20150216_160254.jpg (http://s988.photobucket.com/user/Charlotte_Pugh/media/20150216_160254.jpg.html)

http://i988.photobucket.com/albums/af5/Charlotte_Pugh/20150216_160310-1.jpg (http://s988.photobucket.com/user/Charlotte_Pugh/media/20150216_160310-1.jpg.html)

http://i988.photobucket.com/albums/af5/Charlotte_Pugh/20150216_160326-1.jpg (http://s988.photobucket.com/user/Charlotte_Pugh/media/20150216_160326-1.jpg.html)

http://i988.photobucket.com/albums/af5/Charlotte_Pugh/013d4579-f1f7-4d96-af95-7b124e3fb888.jpg (http://s988.photobucket.com/user/Charlotte_Pugh/media/013d4579-f1f7-4d96-af95-7b124e3fb888.jpg.html)

http://i988.photobucket.com/albums/af5/Charlotte_Pugh/f2247f19-445b-4522-a3a3-3070d4d2297c.jpg (http://s988.photobucket.com/user/Charlotte_Pugh/media/f2247f19-445b-4522-a3a3-3070d4d2297c.jpg.html)

http://i988.photobucket.com/albums/af5/Charlotte_Pugh/20150216_160428-1.jpg (http://s988.photobucket.com/user/Charlotte_Pugh/media/20150216_160428-1.jpg.html)

Thanks!
-Belle's Mom Char :)

[molly muffin]

Well it does look the cortisol has responded to the Ketoconazole. It's come down at least.
The ALT isn't that high, out of range.
Was it high prior to starting Ketoconazole? How is her potassium now?

and welcome to the forum :)

[labblab]

Finally, I am back! Sorry it has taken me so long. I have two things I want to talk over. One is the ketoconazole treatment, but I want to start first with Belle's diagnosis. I have looked over the lab sheets you've included, and I am feeling very concerned as to how your vet has diagnosed Cushing's. Her symptoms are certainly consistent with the disease, so she may well have it. But I do not see evidence of any diagnostic testing that has established that to be the case. Is it true that the first ACTH stimulation test was only performed in February after the treatment had begun? In the January lab results, the only abnormalities I am seeing are an elevated baseline cortisol (at 10.6 ug/dl), a slightly low potassium level, and mildly elevated red blood cell-related counts (which could result solely from dehydration).

This is the huge problem: you absolutely cannot diagnose Cushing's using a baseline cortisol level alone. This is because there is a tremendous amount of variation in baseline cortisols even among normal dogs, especially if they are under stress (like being tested at the vet's office!). If Cushing's is suspected and you want to test cortisol, you absolutely have to advance to the ACTH stimulation test as a diagnostic, or else an alternative diagnostic blood test, the LDDS. Also, I am not seeing evidence in the January testing of any of the other lab abnormalities that are typically associated with Cushings, such as high ALKP (ALP on one of your sheets) or cholesterol. Belle's ALKP is actually fairly low, which is very unusual with Cushing's. If there are any other diagnostic tests that were performed in January, please do let us know. Because what you have shown us here is simply inadequate to arrive at a Cushing's diagnosis.

So that is the main problem :o. Moving on to the ketoconazole, I checked with an endocrinologist specialist, Dr. David Bruyette, who has been very helpful with answering some questions for us here. We are just not that familiar with ketoconazole treatment, so I wanted to get some guidance from him. He has confirmed that it is an older treatment that preceded trilostane and as Lori has said above, in countries where trilostane is available, trilo is now prescribed more often because it is effective for more dogs and carries less risks of side effects such as the liver dangers associated with keto.

Keto treatment does require the same ACTH monitoring as does trilostane and Lyosdren because cortisol can be driven too low, but you do not have the same worries about electrolytes (potassium and sodium levels) going too low with keto because it does not affect aldosterone production (another adrenal hormone) in the same way as do trilostane and Lysodren. The trade-off, though, is that you have to watch the liver values very closely with keto due to the potential for liver damage. As far as the ACTH monitoring, you are looking for the same 1-5 ug/dl post-ACTH range as for Lysodren. So Belle's recent ACTH result is therapeutic (assuming she truly does have Cushing's), and it is certainly a good thing if her symptoms seem to be improving since starting the drug.

In terms of her liver, one thing that has caught my eye is that her 2-10 ALT reading (ALT is a liver-specific level) was mildly elevated at 124. But a second reading apparently dated just five days later on 2-15 is down to 43. It looks as though the results were perhaps performed by two different labs? And I'm not sure why she was retested within five days? Anyway, that ALT elevation is the kind of thing that you would be nervous about with the keto -- you want to make sure it is not elevating higher.

So bottom line, if Belle truly has Cushing's, it does seem as though she is responding favorably to the keto, but with the need to keep a very watchful eye on the liver health. Like Lori, though, I am not sure why keto was the treatment choice your vet made, especially since you still have to perform the expensive monitoring ACTH tests, regardless. Maybe he thought the drug itself would be cheaper for you, because I would guess that generic keto may be less expensive than brandname Vetoryl (trilostane). But it is possible to buy compounded versions of trilostane that may not be much/any more expensive than the keto would be.

Bigger issue, though, is the lack of a confirmed diagnosis from what I can see here. So let's start with that -- are there any test results that we are missing? If she is truly improving on the keto, that may be back-door support for the Cushing's. But I'd sure like to see some confirmatory testing, too.

Marianne

[LongBeach2015]

Thank you so much for all of the information you have given me! I truly appreciate it!

I requested all of Belle's test results from the vet and I posted what they gave me. So to the best of my knowledge she only had the one test done in January that made my vet come to the Cushing's diagnosis and then the ATCH test two weeks after treatment began. He told me that her levels were originally at a 10 when they should be at a 4.

So at this point I am not sure what to do. What tests would you recommend to confirm the crushing's diagnosis?

When I brought her into the vet her hair loss was completely symmetrical and now it is starting to change. She is loosing hair in tiny patches on her back and her skin in those places is dry and flaky. From what the vet told me hair loss in Cushing's is symmetrical. Could this be something different?

Thanks :)
-Char

[Squirt's Mom]

Based on how the current vet has approached diagnosing and treating your sweet girl, I would be finding another vet ASAP myself and starting all over. ;)

[LongBeach2015]

thank you for your input! We decided to go to a new vet and he immediately wanted to take her off all meds and re-test for Cushing's. He was shocked that my previous vet did not do the ACTH test before putting her on the medications. We go back next week for the re-tests. I will update then.

[tokonski]

go to Ytube and search Dr. Becker on Cushing's Disease. There are 3 videos to listen to. It was very informative.

[Squirt's Mom]

Oh I am so glad to hear this! Please let us know what you and the new vet learn. Good for you being a strong advocate for your baby! :cool: