Cushings progression

[AbbyZ]

Hi All,
I just found this site and I have a mini dachshund named Oliver who is 9 years old. He has a very involved medical history that began about 4.5 years ago. I had mentioned to the vet that he was drinking a lot but otherwise fine. She did blood work at that time that came back showing normal thyroid and normal sugar but his liver values were a little elevated. At first we watched this but the continued to increase and he was put on Denamarin. When they continued to rise the vet did a bile acid test that was abnormal. She referred us to an internal medicine doctor who said he clinically looked good but because his tests were so abnormal he did an ultrasound that looked normal and a biopsy. To everyone's surprise Oliver already had some fibrosis but no cause for the liver disease could be determined (at that time he had no Cushings). They put him on prednisone and he developed Iatragenic Cushings and they had to stop the prednisone and he has been on Atopic since. For a couple of years all was well and about a year ago Ollie became very lethargic, very thirsty, peeing accident etc- all the classical Cushings symptoms. At this point we went back to Veterinary Hospital and saw new internal medicine doctor as our original doctor moved away. She did another Ultrasound and a Cushings work up and the Ultasound showed enlarged adrenals with one much larger than the other, and Cushing stim test was positive for Cushings. He was put on a low dose of Trilostane (compounded at Diamondback) and over the next 6 months the dosage needed increasing. This past fall not only was his Cushings values normal but his liver values looked a lot better. About a month ago he developed sever diarrhea that was almost all blood. He became dehydrated and was given fluids and put on metronidazole (by his regular vet). He recovered fine but when vet got his labs back his liver values shot all the way up and we went back to internal medicine doctor. His Cushings test was abnormal again (I don't know the values but was told it was very off) and his dose of Trilostane is being increased from 13mg 2xs a day to 16mg 2xs day. He has not started the new dose yet since it has just been shipped. His current meds are Atopica, Ursodial, Trilostane, Denamarin, famotadine, and Melatonin. I am very worried about my boy because he just doesn't seem to be feeling well at all. He tries to play but gets too out of breath and just lays down, he recently stopped wanting to go outside, and he is drinking a lot but in the past day or so has a much lower urine output. He is still hungry all time and has not stopped eating and he is generally still very happy. Why is his Cushings so hard to control?? sorry this post is so long. Any input is appreciated.

[AbbyZ]

Hi All,
I'm new here and have a mini dachshund named Oliver. My boy has a complicated medical history. At age 4.5 he was diagnosed with autoimmune hepetitis caught very early due to our astute vet. She referred him to an internal medicine doctor who did a biopsy which to everyone's surprise showed considerable fibrosis. The vet put him on prednisone and although it helped, he developed iatragenic Cushing's and we needed to stop the steroids. He was put on Azithioprine but showed no improvement and was then put on Atopic which was working for a while and then stopped working. He was them put on a combination of the two and for two years all seemed stable. About 1.5 years ago he became lethargic and had difficulty walking. Excessive appetite, panting, laying separate and on cool tile floor.... what I now know are all the classic signs of Cushings. The internal medicine doctor confirmed Cushing's (Ultasound and Cushing' stim test) and Trilostane was added to his arsenal of meds. It took 8 months of increasing doses before he was stable and doing well (that was this past Nov). About a month ago he developed severe bloody diarrhea and was treated for colitis by regular vet. She did blood work and liver values were through the roof so...back to Internal Medicine doctor. She did more labs and another Cushing stim test and his stim test was abnormal again (I don't know the values but was told it was waaaay off). His dose of Trilostane is being increased to 16mg 2xs day and we are waiting for the meds to arrive (compounded at Diamondback). I am really worried about my boy. He is happy and wants to play but gets too winded and tired to run. He is still drinking huge amounts and always hungry, however I have noticed that he is not peeing very much? He also no longer wants to go outside and when I put the leash on him he lays down on floor and I have to carry him outside. His current meds are Denamarin, Atopica, Trilostane, Ursodial, Melatonin, and famotadine. I'm really scared that he seems to stop to okay on meds and then they stop working. Any input is appreciated. He's my love and I can't imagine anything happening to him.

[labblab]

Hello Abby, and welcome to you and Oliver. I am very sorry, though, that he is feeling so poorly right now. I apologize for not having time to write more at the moment, but wanted to at least explain that I have now approved your membership and also both posts that you had tried to let us view earlier. Even though there is duplication of some info, I am leaving both posts in place because each one does contain a bit of new info, as well. So this way, we are getting the full introduction.

Once again, welcome!
Marianne

[Harley PoMMom]

Hi Abby,

Welcome to you and Oliver! Gosh I am sorry for the reasons that brought you here but sure glad you found us and we will help in any way we can.

Oh my, poor sweet Oliver sure does have a lot going on and you are doing an amazing job in taking care of him, he is lucky to have a mom that loves him so much and is so devoted.

It would help us a great deal if you could get copies of all the tests that were done on him and post only those values that are marked abnormal with the reference ranges and units of measurement...e.g...ALT 150 U/L (5-50)...thanks! Also, would you post the results of any diagnostic and monitoring tests that were performed? Was an urinalysis done and if so could you post those findings too? How much does Oliver weigh? He is off the prednisone, right? And if so, was the prednisone tapered down, and how long ago was his last dose of prednsione?

I see an ultrasound was done, and the adrenal glands were visualized as one being much larger than the other which is indicative to the adrenal type of Cushing's. Were any other abnormalities mentioned with the other internal organs, such as gallbladder, pancreas, intestines or kidneys?

I'm sorry your boy is not feeling well but his appetite is healthy which is a good sign. Hopefully once we get the answers to those questions I asked we will be able to put all our heads together and figure out what is going on with dear Oliver. Please hang in there with us.

Hugs, Lori

[AbbyZ]

Lori,
Thanks for the prompt reply. I will ask for copies of his test when we go back in a few weeks for the repeat stim test. They will be repeating it after he's on the new dose for a few weeks. To answer a few of your questions- Oliver has been off the prednisone for a couple of years. When Oliver goes for his stim tests, as a matter of course the vet does urinalysis and blood work. back in Late Oct. early Nov. his stim test and his labs were normal for the first time and we were doing the happy dance. About a month ago when he had the problem with bloody diarrhea our regular vet saw him and did blood work. When the labs came back she said his liver values looked high again. I don't know what the values were when he had his stim test last week, I just know the stim test was abnormal and they wanted to raise his Trilostane dose. He has had several ultrasounds not just because of his Cushings, but because of his liver. Several years ago his liver looked good on Ultasound but in the last two years it is enlarged, but otherwise looked ok. I will try to get as much info as I can and I'll post it when I get it.

[molly muffin]

The liver values might have been elevated due to his having what appears or have been a gasto upset. That can throw everything off. Are his poops back to normal? Did they visualize his heart and kidneys on the ultrasound too. If his liver is enlarged it then presses on other areas which might be the cause of the out of breath issue. And just will make him feel yuck and not want to do much.

[AbbyZ]

Sharlene- thanks for the response. His poops are back to normal for the past couple of weeks. His liver is enlarged and his belly is always very swollen so I know he has discomfort all the time. He no longer likes to be on a lap. He lays on his side on the cool tile a lot. He also started losing his fur in small patches. I know those are symptoms of Cushings but it feels like we've been trying to manage his symptoms for so long and the poor baby seems to improve for a short time and then the meds stop helping.

[molly muffin]

How is Oliver doing?

[AbbyZ]

Oliver is so so. We started the higher dose of Trilostane Monday but so far he's no different. In fact he seems to very slowly be slowing down. Walking is harder, he is still happy but in obvious discomfort. Very restless at night and can't get comfortable. He developed something on his snout and I thought it was either a growth from Cushings or a cut. For the past week he has a black raised tag (scab) on his little beezer that keeps bleeding. He tries to play ball but he gets too tired after one round and he stops and lays down. Still hungry though! They are repeating his test when we go back in about a week. I'm nervous that he might not be responding to the meds anymore and if that is the case I hope there are other options.

[AbbyZ]

Today Oliver went back to the vet for another check after being on the increased dosage of Trilistane. I requested his last few ACTH tests and his last set of labs and ultrasounds. I won't have the results of the ACTH test until tomorrow or Saturday. I do have his blood work results from today and ultrasound report.
Acth from 1/13/15
Pre values were 1.8
Post values were 4.8
Dr was pleased with results and recommended a recheck in 3 months.
At his April check I knew he was no longer doing well because his symptoms were worse and those results were
ACTH 4/11/15
Pre values were 5.4
Post values were 19.5

I don't have today's Stim test results yet but I do have his blood work. Since I don't know how to upload the pages I will give only the abnormal findings
Value Ref range
Total protein 8.0 5.0--7.4
AST. 70. 15-66
ALT. 692. 12-118
Alk Phosphatase. 1226. 5-131
GGTP 21 1-12
Triglycerides. 571. 29-291

The ultrasound results today - consistent with chronic pancreatitis, diffusely enlarged and hyperechoic liver, and bilaterally enlarged adrenal glands (his last ultrasound was a year ago and showed one enlarged adrenal and the other was borderline normal.)

So I'm very worried about my boy. He has not shown any signs of improvement on the increased dose.
Any help or insight is appreciated.
Thanks,
Abby

[labblab]

Hi Abby, I'm so sorry your little boy is doing so poorly right now! I am going to hold off on additional comments until we see the results of this ACTH test, so please do post them as soon as they come in. But in the meantime, I just wanted you to know that I'm following what you are writing and I will try to think what I would do next if Oliver was mine.

So stay tuned...
Marianne

[AbbyZ]

Thank you Marianne! I will post them once I recieve them. I hope I get the results today. I think I forgot to mention that he is 17 pounds.
I really appreciate your input!
Thanks again,
Abby

[Harley PoMMom]

Regarding the chronic pancreatitis, I would want a spec cPL test performed to confirm. If that test does validate a diagnosis of pancreatitis then some changes in diet, etc. may be needed.

[AbbyZ]

Thank you for that info. When the vet calls I will ask about that. She did tell me to add a spoonful of canned pumpkin or Metamucil to his food in the morning or evening to help his digestion. He is currently on a low fat diet due to his liver. I feed him twice a day 1/4 cup of instinct raw kibble chicken formula mixed with 1/4 of homemade food that I make consisting of boiled chicken breast, rice, green beans, carrots and ground flax seed. I've been making that since he was diagnosed with liver disease. At 17 pound he is over weight but his belly is so swollen yet you can feel every rib (classic pot belly Cushings). He also isn't very active anymore so the reduction of exercise hasn't helped. I am anxious to speak to the vet and get his stim test results.
Thanks for the advice!
Abby

[AbbyZ]

I just got off the phone with the doctor. She indicated that she was a little disappointed to see that Oliver's stim test showed basically not much change. His post values were 19.1. She wants to bump up his Trilostane a little more aggressively to 21mg twice a day. She wants to see him back in 2 to 4 weeks after medication increase depending on what I note at home. If no symptom improvement is noted she wants to see him sooner than later. She said she is somewhat concerned about his liver specifically the ALT. She said although it can be elevated in Cushings, it is higher than she is comfortable with and given that he has known liver disease she is may want to follow up at his next visit with an aspiration(?) which she said doesn't tell her as much as she'd like but putting him through another biopsy doesn't thrill her. If his ALT values shoot up significantly higher on his next blood test she may consider it. She also said that she doesn't feel it necessary at this time to do further investigation of his pancreas unless his GI symptoms worsen again. She said he is already on a low fat diet and she feels it is the least of his problems (not to be ignored but just to watch it ). So this is where we stand. I hope things start to look up for my boy soon.

[labblab]

Hi again, Abby. I know how disappointing these test results must be, both for you and for your vet. I am going to throw a wild card out on the table, and ask whether Oliver has ever received brandname Vetoryl, or whether he has always been treated with the compounded trilostane from Diamondback. Diamondback has an excellent reputation and many of our members have used them with satisfaction through the years. But whenever I hear about dogs who are receiving unexpectedly poor or variable ACTH results while taking compounded trilostane from any source, it does make me scratch my head a bit -- especially in a situation like this, where even an increased dose of trilostane does not appear to result in any improvement in test results. Does the trilostane you are currently giving Oliver come in capsules, or instead in some other form?

Since your vet is contemplating an increase to 21 mg. twice daily, it would be possible for you to nearly duplicate that by giving two 10 mg. Vetoryl capsules twice daily. I realize that means four capsules a day, which would cost from $80-100 for just a two-week supply. But perhaps it might be worth it to give it a one-shot try, in order to see whether there is any difference in outcome. If so, there might be a more economical way to proceed with Vetoryl, even if it means splitting the twice-daily dosing unevenly (for instance, giving one 30 mg. capsule in the morning and one 10 mg. capsule at night).

It just seems puzzling to me that Oliver's cortisol has leapt out of control since January, regardless of the trilostane dose. It certainly may be the case that additional liver issues are involved. But it surely would be nice to see how his symptoms and numbers might respond if his cortisol level ever lowers back into therapeutic range.

As I say, this is just a thought. But perhaps it would be worth it to you to give the Vetoryl a try.

Marianne

[molly muffin]

You know I think I remember one of the members vet saying vetroyl is often absorbed better than trilostane so maybe Marianne is right and it is worth a shot. Just to see if that is the issue.

I'm sorry that it is so tough to get this under control along with the various issues. I do hope that things I prove.

[AbbyZ]

I'll ask my vet about it. Oliver took vetoryl at one point but when dose changed it needed to be compounded. He take capsules. I am willing to do whatever I need to to keep Oliver with me and with the best quality as long as possible. Thank you for the suggestions and for time you took to read and answer my posts.

[labblab]

You know I think I remember one of the members vet saying vetroyl is often absorbed better than trilostane so maybe Marianne is right and it is worth a shot. Just to see if that is the issue.

Hey Sharlene, maybe what you are thinking about is Dr. Audrey Cook's research study where she found that 20% of the samples of compounded trilostane (bought from unnamed pharmacies) did not meet the criteria for acceptable dissolving properties, and 40% varied significantly from the labelled dose. As I say, I know that Diamondback has a great reputation, but those are the statistics that make me nervous about compounded trilostane, in general, when dogs seem to be getting odd testing results.

Here's another off-the-wall thought, though, Abby. In reading back through your thread, it sounds as though Oliver has really always been difficult to regulate with trilostane -- you've had to make a lot of dosing changes and there has only been a rather brief time period when he was under good control. I wonder whether he might be a dog who would respond better to Lysodren, the other Cushing's drug that is in use in the U.S. Given his history of GI issues, it might not be a good option for him because GI upset can be a side effect of that medication. But it is just a thought if he really does not seem to respond well to the trilo at any dose. Maybe something else you might discuss with the internist.

Marianne

[AbbyZ]

The internist is not too keen about putting Oliver on Lysodren. She mentioned it as a last resort if Trilostane isn't effective. She said since she has room for increasing his dosage on it that Is her first preference but I will ask her about the vetoryl vs. compound to give him.

[AbbyZ]

Oliver started the higher dosing of Vetoryl yesterday. Keeping fingers crossed for some improvement. Dr. Had no problem using brand name just soooo expensive but it will be worth any price if Oliver starts doing better. He is taking two 10 mg tablets twice a day.

[labblab]

I hate it that the Vetoryl is so expensive for you! But at least you'll have this two-week test period to see whether or not it makes any difference in Oliver's symptoms and test results.

Good luck, and definitely let us know how things go!
Marianne

[molly muffin]

Crossing fingers!!!

If there is a difference, then maybe one of the online pharmacys will be a cheaper option even for brand name vetroyl.