Lots of Questions....LOTS

[weisssoccermom]

Up until the first part of December, our 14 year old (3/31/2001...then 13) was fine. She got a horrible case of fleas and since taking the flea meds she has (IMO) gone downhill. Whether this is coincidental or not we won't ever truly know. A little background on Lesley. In August 2012, we noticed a 'lump' around Lesley's ear....took her in to the vet and they operated. Salivary gland tumor...cancerous. A few months later, in February 2013, we noticed that Lesley's tummy was pooching but otherwise she was acting normally. Ultrasound showed at least one tumor (surgery found three) on her spleen....thankfully...all benign. Spleen was removed....recovery uneventful. In May of 2013, another tumor around the same place as the first salivary gland....removed, completely, with stalk intact. As you can imagine, Lesley has had her share of blood work, ultrasounds, etc. and everything has been 100% NORMAL except for 1 or 2 widely spaced bladder infections. In early September, we went on vacation, boarded Lesley and her sister and while in boarding (at the vet), Lesley became very ill....what appeared to be a bad reaction to her Piroxicam....all CHEM tests were NORMAL....her RBC was, however, extremely low. She rebounded after we discontinued the Piroxicam and all follow up testing showed everything back to normal. Everything, until the beginning of December 2014. Lesley and her fur sister came down with a TERRIBLE case of fleas (neither had ever had them). We took her in and she was bathed, given topic and oral flea medication and everything seemed fine....initially. About two weeks later, we boarded her for a long weekend and asked the vet to remove a few warts. It seemed as though Lesley was literally breaking out in them. Shortly afterwards, we started to notice that Lesley was having these head/body tremors....not seizures....just muscle twitching...something severe and sometimes very mild. We continued to give her the monthly flea medication but stopped after the March dose because of these tremors. The vet rad bloodwork at the end of December which showed elevated liver enzymes....all of which were watched closely. Other tests were, for the most part, normal. From the end of December through end of March, we watched her liver enzymes continue to climb and then slowly recede...and still continue to this day. Sometime in April, it appeared that Lesley was drinking a little more than usual, although not so much as to alarm me. She had two accidents in the house...both, though during times of excitement and frankly, when we weren't paying close attention. We also noticed that she wasn't jumping up on the couch like she had been a few months earlier and her back legs just didn't seem as though they were as strong as they once had been. In all fairness, we had stopped so many supplements, particularly her Cosequin/Dasuquin because we were worried about the liver enzyme increase (which we later learned was unfounded).

Fast forward....very worried. Repeated ultrasounds showed nothing unremarkable. Finally, a urine cortisol test was run....showed a level of 20 which apparently warranted further testing. First came the specialized ultrasound which showed mildly enlarged adrenal glands consistent with pituitary dependent Cushings. Slight liver involvement was also consistent with steroid induced liver issues consistent with Cushings. I was a little upset that based on these tests, Lesley was started on Vetoryl. Weight of 27 pounds. Initial dose was 30mg once a day. After FOUR doses, we stopped due to loose stools, vomiting and overall weakness. Waited 6 days and Lesley had a low dose dex test. Values below

Initial draw 2.4 (normal 1-5)
4 Hour test 2.1 (normal 0 - 1.4)
8 hour test 2.8 (same as above)

Consulted with internist because these results, although higher than normal, are relatively low. Internist and vet both agree that considering the few symptoms Lesley has (today was bad....lots of panting but that has also been a symptom due to her salivary gland cancer surgery) she appears to have Cushings although they classify it as a mild case. No excessive hunger, urination or drinking.
Tomorrow, we start 10 mg Vetoryl X 1/day + Flaxseed Lignan in the evening.

Liver tests from December - May 15th

AST 39, 42, 57, 34, 51, 35 (normal 15 - 66)
ALT 135, 200, 497, 346, 375, 265 (normal 12-118)
ALK PHOS 171, 239, 334, 305, 255, 176 (normal 5 - 131)
GGT 10, 8, 13, 22, 19, 12 (normal 1 - 12)

Her bilirubin, BUN, and cholesterol have always been within normal limits. Triglycerides elevated on one test....all others normal.

What are your opinions about treating Lesley with Vetoryl? She doesn't appear to have the 'normal' symptoms of Cushing's but I am very worried about her. Very lethargic and just overall 'listless'. That 'spark' is gone from her eyes.....now all of these could be attributed to 'old age' as well as many other diseases. The poor thing has undergone more than a few urine tests for bladder infections, cortisol levels, etc. in the past few months, not to mention the numerous blood tests which, except for the elevated liver enzymes, all seem to be remarkably normal. All tests done in September were perfectly fine....all well within NORMAL limits.

Blood tests don't lie....obviously something is amiss with her adrenal glands. Ultrasound can't 'definitively' rule out other reasons for enlarged adrenals such as stress or other illness. However, all other tests show nothing.

I just need to know that I am doing the right thing for my little girl. Yes, she is getting older but, as I said, she was fine up until December. She still has good days when she chases with her younger fur sister...when she plays, etc. Her appetite is good...certainly not ravenous but not picky by any means. I switched her from kibble to homemade food consisting of:
boiled chicken, brown rice, potatoes, green beans, peas/carrots

I have researched extensively to make sure she is getting all her nutritional needs and caloric intake. To make sure her blood sugar levels remain consistent (blood work is also superb in this area), she and her 'sister' get pumpkin/cottage cheese for 'lunch'. I even make sure that she gets filtered water over regular tap water.

Sorry for the long post. A few of my questions:
Is a 10 mg Vetoryl still too strong?
What type of side effects might I expect?
What, if anything, will I notice from the medication if it is 'working'?
Can any furbaby ever do well on this drug??

Any help would be very much appreciated.

[weisssoccermom]

I should also add that Lesley has been on thyroid for about 4 years now. We noticed after the wart removals in December that her fur was just not growing back. Thyroid was tested and it came back extremely low. Dosage was adjusted.....hair is now growing in normally. That condition has been remedied. In addition, with all the tests done on Lesley, she has been 'cleared' for any questions of diabetes.

[labblab]

Hello and welcome to you and Lesley! I am so sorry to be so tardy in posting a note, and especially sorry that I do not have the time to give you a thorough reply, but today is a very busy day for me. :o

I will try to get back again tomorrow, but in the meantime I did not want you to think that your thread has gone unnoticed! I am so glad you've found us, and stay tuned for some more thoughts from me...:)

Marianne

[Harley PoMMom]

Hi and welcome to you and Lesley!

I would not re-start the Vetoryl, the drugs used for Cushing's do not cure the disease. The commonly seen symptoms that are seen in a dog 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; muscle wasting; muscle weakness, especially in the hind quarters; exercise intolerant; difficulty or unable to go up steps or jump on furniture. The goal of therapy is to remedy those problematic symptoms of Cushing's, so that is why strong symptoms do play a huge role in the diagnosis for Cushing's. With no symptoms, how do you know if the treatment is effective?

I am also quite worried about Lesley's vet, to me it seems that his/her knowledge of Cushing's is lacking. Unfortunately a lot of vets are clueless when it comes to canine Cushing's and the treatment protocols. Many of us have had to fire our vet and find another one.

As far as those enlarged adrenal glands any chronic illness and/or stress can do that. This excerpt is from the blog of a renown Cushing's expert, Dr Mark Peterson,
You cannot base a diagnosis of Cushing's disease — typical or atypical — on the finding of large adrenal glands on an ultrasound exam. This dog was severely ill when the ultrasound and ACTH stimulation test were performed. One would expect a sick dog to have a "stress" response, which would include increased secretion of pituitary ACTH leading to increased cortisol section. With chronic illness and continued stress, bilateral adrenocortical hyperplasia would be an expected finding as cortisol hypersecretion continues. http://www.endocrinevet.info/2011/05/q-atypical-cushings-disease-in-11-month.html

If this were me, I would not pursue any more tests for Cushing's and just wait and see if those Cushing's symptoms do start to creep up. Cushing's is not a death sentence for a dog and it progresses at a snails pace, it takes years for the excess cortisol to do internal damage, so the wait and see approach is what I would do.

Hugs, Lori

[labblab]

OK, here I am, back again. And I'm so glad that Lori had the chance to post to you in the meantime. She has covered a lot of territory, so I'll just add a few thoughts in answer to your questions.

First, I will say that with a 14-year-old dog, comfort would be my first priority. As Lori has said, the internal systemic damage caused by Cushing's can be a slow and cumulative process. For a younger dog with many more years ahead, I would definitely wish to halt that chronic process. But for an older dog, immediate comfort would be most important to me. But also with an older dog, it is harder to unravel aging changes from a disease process. I know I'm not telling you anything here you don't already know :o, but that is still my prelude to the following.

If Lesley has Cushing's, it is possible that the trilostane might help with the hind-end weakness, panting, and lethargy. It also might help normalize her thyroid level. The muscle weakness, especially, can take time to rebound, however. So even when the drug is at therapeutic level, it will not bring an overnight change in that issue. We have seen many dogs here who have been successfully treated with trilostane, but typically the symptoms that resolve most quickly are not the symptoms that Lesley is exhibiting -- the excessive hunger, thirst and urination.

If you want to start back with the med, I think 10 mg. would be a conservative place to start. But you would be watching for the same ill effects as before: vomiting, diarrhea, loss of appetite, extreme lethargy. One thing you have not yet mentioned is ACTH blood testing. This test is used both diagnostically and also as the necessary monitoring test once treatment has begun. Has Lesley ever had an ACTH stimulation test? If you start back on the trilostane, it should be performed no later than one month into treatment (actually, preferably first at the two-week mark), and then again after any dosing change and every three months therafter once dosing is stabilized. This is not a cheap test, so you need to factor in both the expense and also the stress that repeated blood draws may bring to Lesley at her age.

I also want to add that odd tremoring episodes in Cushpups have been reported by several members through the years, both before and after treatment. My own Cushpup experienced weird shivering episodes, most often when he was resting or even asleep. We never did get an explanation, so I'm afraid I cannot offer out a cause. But I just wanted to let you know that others have also reported this odd symptom at times.

Having said all this, I think there are reasons to support your decision either way. You can start the trilo again in order to see whether Lesley seems to feel better. If so, great! But I can also support a decision to just leave things alone for the time being in order to see whether other changes occur in her behavior. Sorry not to be more help, but whatever you decide to do, we'll be anxious to hear how things are going!

Marianne

[molly muffin]

My dog too has the tremors since starting treatment for cushings that she never had before.

We started treatment due to knowing she had high cortisol, she developed high bp and kidney losing protein disease, and retinal bleeds. She never had the typical signs of cushings, but by starting low and slow, we are hopefully gaining ground on the other areas.

Comfort and quality of life though is top of the list of what is most important I think.

Welcome to the forum