New Member - Boxer starting Vetoryl

[Jules916509]

I am in a similar situation with our "granddog", Duke. He is an 11 year old Boxer. He started drinking excessive amounts of water (up to 4 liters) a day. After the blood work, it was confirmed he has the pituitary version of Cushings. We just started with a treatment of vetoryl. How soon can I expect to see some improvements? His back and hind legs are so weak. He is lethargic and seems off his game. He has been a vibrant healthy dog. I don't want to think about putting him down, but I also don't want to extend his suffering

[Jules916509]

Our boxer has thryroid condition and takes a daily supplement and has just been diagnosed with Cushings. since the diagnosis, he has slowed down immensely. He has trouble getting up and down stairs and on and off of his bed. He is extremely sensitive to medication and the original dosage made his very sick...weak, diarrhea, vomiting. We have had his prescription recompounded and started a milder dose last night. We were told to continue his thyroid meds as well. How long might it be before we see some improvement? This has been devastating to watch

[labblab]

Sorry I have only a moment to post, but I have moved your replies to form a thread that is your very own. Welcome!

Marianne

[pansywags]

Hi, welcome to the forum, and I'm very sorry about the reasons that brought you here but we are here to help you and Duke.

First, do you have copies of the test results (blood, urine, etc.) that we can review?

Second, how much does Duke weigh and how much Vetoryl was prescribed initially and for his current revised dosage?

Third, other than Duke's excessive water consumption, were there other symptoms that led you to bring him to the vet for diagnostics?

I'm sure others will be chiming in with additional questions soon.

[Jules916509]

I don't have the test results with me, but can get the information from my veterinarian.

We started Duke at 60mg every other day. He got so incredibly sick that we recompounded them and he is now taking 10mg once a day.

The primary reason for his tests were his excessive drinking and urinating in the house. The doctor asked us to measure his water intake for several days and we averaged them. He drank nearly 4 liters of water a day...almost compulsive about it.

He currently weighs 85 pounds. His back legs are very weak at present and he seems wobbly, for lack of a better term.

I'm grateful to have an outreach group.

Thanks

[Jules916509]

The cortisol results for Duke were 1.5 at 0 hours; 1.0 at 4 hours; and2.1 at 8 hours.

[Harley PoMMom]

Hi and welcome to you and Duke!

Those results you posted (1.5 at 0 hours; 1.0 at 4 hours; and2.1 at 8 hours) are from a low-dose dexamethasone suppression (LDDS) test and are indicative to Cushing's, however they do not distinguish if the Cushing's is the adrenal or pituitary type. Was any other testing performed to diagnose the Cushing's? Did he have a recent blood panel done, and if so could you post all abnormal values that are listed? Is Duke taking any other herbs/supplements/medications?

Excessive drinking/urinating are also symptoms of diabetes and/or UTI, have these been ruled out? The common clinical symptoms seen in dogs with Cushing's are: excessive drinking and peeing, I mean peeing rivers and drinking buckets upon buckets of water; voracious appetite, they are like little hoover vacuum cleaners looking for any crumb they can find; panting; loss or thinning of coat; skin issues; and/or muscle wasting. Besides the increased drinking/urinating does Duke display any of those other symptoms?

How is Duke feeling today? Is he eating normally, any vomiting? How about his stools, any diarrhea?

Please know we are here to help in any way we can so feel free to ask all the questions you want.

Hugs, Lori

[Jules916509]

Thanks for your support, Lori. I am devastated today. Duke can hardly get around and seems so lethargic. He's only taken three doses of the vetoryl so far, but seems worse than ever. In two weeks since the diagnosis it's been a steady decline. Our usually happy go lucky dog is just flat. He's not one to whine so I don't know where he is uncomfortable, other than his weakness in his back. The excessive drinking and peeing have been better, but to what end? To answer your questions, our vet ran tests and ruled out diabetes. I'm looking for any help you could give with Duke. He doesn't exhibit the voracious appetite you describe at all. We have to coax him. By the way, I am also giving him Carpequin for the back legs but it doesn't seem to be helping. Sorry for rambling, but I've been up most of the night wrestling with what to do next. Thanks for any advice you may have.

[labblab]

I am so sorry Duke is doing so poorly! I am just brain-storming here, but here are a couple of thoughts to throw out. One possibility is that Duke does not actually have Cushing's at all. The LDDS is indeed a Cushing's diagnostic, but it can be vulnerable to "false positives" in the presence of illness or injury other than Cushing's. It appears as though the only overt symptoms that Duke has that are consistent with Cushing's are excessive thirst/urination and weakness. How about any other abnormal readings on his labwork? Cushpups can typically exhibit certain elevations in liver enzymes and cholesterol, and also a pattern of abnormal readings on white blood cell counts. How about any abnormalities re: urinalysis results: dilute urine, infection, protein or blood in the urine?

As far as that LDDS, if the results are accurate, I do believe it is actually consistent with pituitary Cushing's. Since the 4-hour reading was only 1.0 (lower than the normal range), the suppression is consistent with pituitary Cushing's even though neither the 4 nor 8-hour readings were less than 50% of the baseline. If Duke truly has a pituitary tumor, it is possible that it is larger than usual and is placing pressure elsewhere in his brain. This might account for the increasing lethargy, dullness, and loss of appetite. Unfortunately, an enlarging brain tumor can only be positively identified through expensive imaging of the head.

Another possibility, though, may be that Duke does not have Cushing's at all. If there is nothing in his labwork that points in a specific direction, one very helpful diagnostic would be an abdominal ultrasound using high resolution equipment (this may necessitate a referral to a specialty practice). An ultrasound can show specific abnormalities in internal organs such as the the liver, kidneys, spleen, pancreas, gallbladder and adrenal glands, and the imaging can indicate whether any changes are consistent with Cushing's as opposed to some other internal problem that may be contributing to elevated cortisol levels.

I think if Duke were mine, I'd try to get an ultrasound performed ASAP.

Marianne

[Jules916509]

Thanks for the quick response, Marianne. None of the news sounds too optimistic. I will call the doctor this morning, but I don't have the resources for extensive testing. I am at my wit's end. It has been such a quick downfall.

[labblab]

I definitely understand the financial constraints. I suspected my own Cushpup had an enlarging pituitary tumor, but the high cost of the head imaging was a big reason why we never found out for certain.

Although not necessarily cheap, an abdominal ultrasound is much less expensive than a head MRI or CT, though. You really do get a lot of bang for your buck because so many organs can be imaged. You want to make sure the money is well spent if you proceed, however, so that's why you want the ultrasound performed (and interpreted) by professionals with specific training and high-end equipment.

I totally get it as to why you are feeling awfully desperate right now. If only our furkids could talk!! But it may still be the case that Duke may be suffering from some sort of acute illness (like pancreatitis?) that can be treated and remedied if it can only be identified. Pancreatitis does come to my mind due to the vomiting, diarrhea, loss of appetite, pain and lethargy. It is thought that Cushpups may be especially vulnerable to pancreatitis. There is a special blood test that can diagnose pancreatitis in dogs even when there are no other obvious pancreatic abnormalities in their bloodwork. This is the Spec cPL test, and you might ask your vet about having that run evn before doing anything else. IDEXX Labs has both a "Snap" version of this test as well as a more comprehensive version.

My non-Cushpup Lab was diagnosed with pancreatitis by that test even when her other pancreatic enzyme levels were totally normal. She had been vomiting with diarrhea and wouldn't eat. Just as a shot in the dark, my vet ran that test and it came back highly elevated. We were stunned, but then we knew what to treat and she ended up being fine.

Marianne

[Jules916509]

Quick note. I spoke with the veterinarian, and they are doing some blood work on Duke for us this morning. She said she suspects he may have Addison's rather than Cushing's. I am so incredibly confused at this point! Do you know what symptoms he may display with Addison's? She also suspects the Vetoryl may be causing his lethargy and weak back/legs. Have any of you heard of this?
I am conflicted as to what to do.

[labblab]

Yes, actually, Addison's and Cushing's do share some overlapping symptoms, but the vomiting/diarrhea/lethargy are characteristic of Addison's. Here's a list of symptoms:

Lethargy
Lack of appetite (anorexia)
Vomiting
Weight loss
Diarrhea
Shaking
Increased frequency of urination (polyuria)
Increased thirst (polydipsia)
Depression
Dehydration
Weak pulse
Collapse
Low temperature
Blood in feces
Hair loss (alopecia)
Painful abdomen

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

If Duke has naturally occurring Addison's instead of Cushing's, I would think all of his symptoms could be attributed to the Addison's. The definitive blood test for Addison's is the ACTH stimulation test (which is also used to diagnose and monitor Cushing's treatment).

Naturally occurring Addison's did not even occur to me due to the positive LDDS. But I actually don't know how an Addison's dog would typically test on the LDDS -- that test is not used to diagnose the disease.

Please keep us updated! If this turns out to be Duke's problem, his treatment will definitely shift away from trilostane, and he will instead need supplemental prednisone. But the disease can be managed successfully.

Marianne

[Jules916509]

Just heard from my husband, who took the boy in for labs. Different doc says he's not in crisis mode and his blood work"looked good"...no details. She gave him a bag of fluids sub q and he perked right up. She wants him off the vetoryl for a couple of weeks. She wants to get him to "ground zero" . She is unavailable for the remainder of the day, but I will stop by tomorrow and get details. Really frustrating! Thanks for your support!

[labblab]

I definitely understand and condone stopping the trilostane. However, it sounds as though he has been taking it for such a short time (and at such a low dose at 10 mg.), that even though it may have exaggerated the problem, it seems unlikely to me that it caused it. However, did Duke only get ill after starting the medication, and not before? Trilostane can certainly induce an Addisonian state by lowering both cortisol and aldosterone production too severely. But what I am thinking now is that maybe the vet is suspecting naturally occurring Addison's disease as opposed to Cushing's? Either way, the labs today should have included at least a baseline check of cortisol, potassium, and sodium levels.

Since Duke has been so unwell and perked up with the sub-Q fluid, I am worried that he is going to be in need of more intervention than just stopping the trilostane. I think your vet really needs to perform an ACTH stimulation test either sooner or later. This test is diagnostic for both Cushing's and Addison's, and if Duke remains unwell, I don't think you want to wait for two weeks to check his adrenal function as it relates to cortisol production.

Marianne

[Jules916509]

I've made an appointment with the doctor tomorrow morning. I will definitely ask that she perform the tests you suggested (if she hasn't already). I feel blessed to have your forum as a resource for Duke's diagnosis and treatment.
Thank you all so much!

[Jules916509]

Good morning. I am trying to put together a list of questions and concerns for my appointment this morning. I'm taking your suggestions for tests along as well.
My primary question is whether the Addison or Cushing syndrome could manifest quickly. We started this nightmare with a question about Duke's excessive (almost compulsive) drinking and urinating in the house. Otherwise, he was a happy playful old boy. Now, we are at this point today. And, my primary concern is the weakness and wobbling in his back end.
With regard to the ACTH test, I thought that test was done originally. I may be mistaken, but isn't that the one done at 4 and 8 hour intervals? This is all so overwhelming to me.
My question is whether either of these syndromes could manifest this quickly with such symptoms.
I would hate to think our treatment plan (however limited)has led to this point.
I don't want to rush to considering euthanasia but don't want to see our dear family member suffer.
If you can offer any other suggestions regarding questions I should ask this morning,I'd welcome them.
I'm terribly confused and conflicted at this point when the doctor was so confident of her Cushing diagnosis two weeks ago and now unsure.
Forgive the rambling post and thanks for all your patience and information on this troubling journey we are on.

Jules

[Squirt's Mom]

I would also ask the vet to consider DI, diabetes insipidus. It is a rare form of diabetes that has nothing to do with blood sugar but rather with how the body processes water.

[labblab]

I am far from an expert on Addison's disease (or on anything, for that matter!). But between the two disorders, I do think an acute onset of symptoms is more likely with Addison's than with Cushing's. This is certainly the case when Addison's symptoms are caused by a trilostane overdose. I believe naturally-occurring Addison's can also manifest in an acute, crisis state. Cushing's is more typically a syndrome with slower, chronic changes seen over time. Hind-end muscle atrophy is common, but it does not appear overnight. Nor does sudden excessive thirst/urination. There is usually a more gradual build-up.

Acute onset of vomiting and diarrhea is not typical of Cushing's in any event, so that is why I am wondering whether Duke only became ill after starting the trilostane. It will be interesting to see whether that improves now that the trilo has been discontinued.

It will be important for you to find out today what testing was performed yesterday. Since the initial report was that the bloodwork was "good," that would seemingly rule out an Addison's crisis. But that really depends on how comprehensive the testing was. I am assuming a blood chemistry panel was done in order to insure that the potassium and sodium levels were in proper balance. But another important question was whether Duke's cortisol level was also checked, either via a resting cortisol level or a full ACTH stimulation test. If Duke did not appear to be Addisonian on tests of his blood chemistries and cortisol, then he was not overdosed on the trilo nor does he have the disease in its own right. So you have to look elsewhere for an explanation as to why is suddenly feeling so poorly.

In the absence of overdose, I suppose he could just be having a GI medication reaction to the trilo. If so, he ought to improve now that you've stopped the drug. If he doesn't improve, I think something else must be going on, which brings us back full circle. One concern I've had all along is that it seems as though your vet diagnosed Cushing's solely through one diagnostic -- the LDDS -- which can be vulnerable to false positives. If it was not done yesterday, I do think you want a full ACTH stimulation test performed prior to resuming Cushing's treatment and also to confirm that Addison's is not part of the picture in any form.

So the main questions I would have for the vet today are:

Exactly what testing was performed yesterday and what were the results?

Aside from the LDDS, were there any other laboratory abnormalities that pointed to Cushing's at the time of the initial diagnosis?

If an ACTH stimulation test has not yet been done, when can it be scheduled?

If Duke remains acutely unwell, what are your options re: possible additional diagnostics such as the spec cPL test for pancreatitis, or an abdominal ultrasound?

Marianne

[Jules916509]

Funny how things change. After a very brief stroll this morning and breakfast, Duke has been flat. While standing to eat his back legs gave out and he has had a hard time standing. We got him to his bed and he is resting. I think it may be time to consider putting him down - as painful as that seems. I'm afraid there is something else going on besides the syndromes discussed here. And I hesitate to begin a series of tests and treatments that will only delay the inevitable . Thank you so very much for your help and advice

[labblab]

Before you make the decision to let him go, I really do encourage you to at least get an ACTH stimulation test done. If Duke's cortisol reserves are too low either due to trilostane or natural Addison's, this is a condition that can be remedied easily and inexpensively, especially if his blood chemistries are OK. All he would need is some daily supplemental prednisone. And the rebound can be miraculously quick -- within 24 hours even, if that is the problem.

If the testing seems out of the question to you, you might even ask the vet to try giving Duke a couple of days of rescue doses of prednisone, just to see if that perks him up.

Marianne

[pansywags]

It may help the vet (and us) to have a timeline of the onset of all symptoms, tests and treatments, something like the list below, which I made up from some of what you've told us about Duke along with fabricated dates. I would go all the way back to his thyroid diagnosis including any symptoms that led you to test and what treatment he has been on. Things you want to consider including are changes in appetite (and of course water consumption), activity level, skin and coat, panting/exercise intolerance, indoor accidents, and general temperament. With so much going on, it will help you keep track of Duke's changes on an ongoing basis. I found it was easy for me to lose track of details while I was so terribly worried about my dog.

Mid Feb - frequent urination starts
March 3 - urinalysis (abnormal values here)
March 3 - CBC (abnormal values here)
March 7 - first noticed hind leg weakness and wobbling
March 10 - LDDS (values here)
March 13 - Started Vetoryl 60mg every other day
March 15 - vomiting, diarrhea, lethargy
March 30 - decreased vetoryl to 10 mg

[Jules916509]

Our vet is now questioning that the Cushings/Addisons is the culprit. His back weakness was of concern and she has decided it has nothing to do with either syndrome, but is probably more disc related. We discussed the options and we have decided to do some hospice type treatment that may help both. We are giving him prednisone, which has given him added mobility and less distress in his back and hind legs. I committed to seeing if this could give him some comfort before putting him down.
I'm happy to report he is looking forward to walks now, his appetite is voracious, he is engaged with the neighbor's dogs, and sleeping without whining. The downside is he is drinking and urinating a ton again. We will revisit our choices. Not sure if this was the right choice, but we are so glad to have him for a bit longer.
Thanks for all your advice and support

[LtlBtyRam]

I hope things start heading in the right direction. Please keep us posted.

[pansywags]

I hope you get some more quality time with Duke. Keep us posted.

[Harley PoMMom]

Glad to hear that the prednisone is helping Duke, and since it is giving him relief it may be that Marianne's intuition of Addison's is correct.

Please do keep us updated ;)

Hugs, Lori

[labblab]

I'm so glad the prednisone made such a difference for Duke, and I hope it's continuing to do so! Since it has made such a big difference across the board, it does still make me wonder whether Addison's is in play.

I'm sorry about the excessive thirst and urination, but that may be due to a higher dose of pred than he really needs. What dose is he getting? If prednisone is used to offset low cortisol, the daily dose that's needed is really fairly low. The "rescue" dose formula is .25 mg. per kg. (and 1kg. equals 2.2 lbs.). So if, for example, Duke weighs 50 pounds, he would only need approx. 5 mg. of prednisone to replace what he is missing. Any more pred than that, and you can produce Cushing's symptoms (because it is more steroid than his body needs for normal daily functioning).

Anyway, please do let us know how things are going for you guys.

Marianne

[molly muffin]

I have been away for a bit, but have been reading the threads, just no time to respond.

Prednison substitutes as a natural occurring cortisol, they act the same in the body, so Addison which could cause the drinking, the DI Leslie mentioned, would both cause the increase in drinking/urination, but if he has arthritis, or if he has disc problem or other issue causing the leg weakness, then the prednison and cortisol will help him to feel better.

It does all come down to quality of life for the time they have with us and that is all we can really aim to give them. You're doing an excellent job in a very difficult situation.