Now my other dog 'might' have Cushings too

[BettyF]

Hi everyone, I posted last year about my Border Terrier Vera who was seventeen and doing fairly well with her Cushings treatment. She will be eighteen in August and despite being a very old lady with the usual elderly problems, her Cushings remains under control.

However, my other dog Graham, also a Border Terrier, has started drinking excessively. He will be sixteen next week and was diagnosed with early stage kidney failure a couple of years ago.

I took him to the vet for a blood test last week, thinking that maybe the kidney problem was getting worse, but the result was not very different from his last one in October.

So that made me start thinking that he might also have Cushings. I know it will be a massive coincidence if he also has it, but these things do happen.

This week I took a sample of his urine to the vet and asked for a cortisol/creatinine ratio test to be done, which could rule out Cushings.

The vet phoned this afternoon and said that the result was 51 nmol/l whereas the 'normal' level would be less than 30.

The vet has suggested doing an ACTH stim test next week. Is this the best test to do next, or the low dose dexamethasone one?

Because it took months to diagnose Vera three years ago, I want to make sure we are doing the right things in the right order now.

I've already mentioned that my vet does not seem overly experienced with Cushings but the good thing is that he is willing to do whatever I suggest without getting stroppy about it.

I welcome any advice and comments, thank you.

[molly muffin]

Hi Betty, welcome back and glad to hear that Vera continues to do good.

What a crap shoot, to end up with possibility 2 furbabies with cushings. It does kind of sound like that might be a possibility, especially since the kidney tests reflect the same as last test, so not that and I assume they have also ruled out diabetes?

Well the LDDS is the gold standard they say for testing for cushings. The ACTH though gives you a good idea of where their cortisol levels actually are now.
I've done both when trying to get the right diagnosis. But I'd probably start with the LDDS.

Glad to hear about Vera but very sorry about this news now of Graham maybe having cushings too.

[Harley PoMMom]

Hi and welcome to you and Graham!

Since Graham does have kidney disease this could create a false positive result from a low dose dexamethasone suppression (LDDS) test so I believe the chances of getting a more accurate result would come from an ACTH stimulation test.

Hugs, Lori

[BettyF]

Hi Betty, welcome back and glad to hear that Vera continues to do good.
I assume they have also ruled out diabetes?


Thank you for the welcome back. The vet did a urine test when I took Graham last week and it came back that there was no glucose present. I assume that means diabetes is unlikely?

[BettyF]

Hi and welcome to you and Graham!

Since Graham does have kidney disease this could create a false positive result from a low dose dexamethasone suppression (LDDS) test so I believe the chances of getting a more accurate result would come from an ACTH stimulation test.

Hugs, Lori

Thanks for the welcome back.

Thank you for putting my mind at rest about the ACTH test. I hope we can get this sorted, Vera's diagnosis took ages.

[BettyF]

Graham had the ACTH test on Thursday and the vet phoned me yesterday to say that the laboratory had lost the second blood sample! This is really annoying because Graham struggled a lot when the vet took the samples, he is not a very brave boy, and now we have to go through it all again so soon.

The result of the first sample was 19 ug/dL but I know this is meaningless without the second result.

It is his 16th birthday today, good thing he doesn't know what's in store for him.

[Squirt's Mom]

Happy 16th Birthday, Graham!

[BettyF]

Happy 16th Birthday, Graham!

Graham and I say "Thank you very much"!

[Harley PoMMom]

Happy Birthday Graham!!!

[BettyF]

Happy Birthday Graham!!!

Thank you!

[molly muffin]

A belated Happy Birthday Graham!!!!

What a pain that they lost the second blood draw. Poor little guy having to do it all over again so soon.

[BettyF]

A belated Happy Birthday Graham!!!!

What a pain that they lost the second blood draw. Poor little guy having to do it all over again so soon.

Thank you for Graham's birthday wishes. :)
I am quite upset that he has to go through it again, especially as he struggles so much when they take the blood. I think I am going to ask the vet if he would do the low dose dexamethasone test instead of repeating the ACTH. I'll let you know what he says.

[molly muffin]

How are things with Graham? Did you do another test?
How did he handle it?

[BettyF]

How are things with Graham? Did you do another test?
How did he handle it?

Thank you for asking. :)

Graham had the LDDS test yesterday and I have just had an email from the vet with the result. I've copied it below. Graham was not happy about being left at the vets all day and was quiet when he came home, but he is back to normal today.

If I am understanding the result correctly, he has adrenal dependant Cushings? (My other dog Vera has pituitary dependant) Vera is on Vetoryl, would it be the best thing for Graham too? He is 10kg.

Although I have suspected that he has Cushings for a few weeks now, I didn't expect it to be adrenal. He has exactly the same symptoms that Vera had - excessive thirst, frequent urination, panting, inability to jump up on furniture. Neither of them have an increased appetite and have not had hair loss.

I know there is an operation which could be done on the adrenal gland but at his age (16) I would not want to put him through that.

I welcome any advice, thank you.

This is the lab report,

Test Result Alert Units Reference Range
Cortisol (Basal) 95.2 nmol/L 25.0 - 125.0
Cortisol post low dose nmol/L
(4hr)
132.0
Cortisol post low dose High nmol/L
(8hr)
143.0 <=40.0
The sample order has been checked and is as labelled.
Results consistent with hyperadrenocorticism. Absence of significant suppression in response to dexamethasone is sometimes seen in pituitary dependant hyperadrenocorticism, however this pattern is more commonly seen in adrenal dependant disease.

[BettyF]

I thought the vet might have phoned me on Friday to discuss Graham's LDDS test but he didn't. Should the next step be to ask for an ultrasound?

[labblab]

Hi Betty (and Happy Belated Birthday to Graham!).

Yes, it looks as though an ultrasound would be a good next step. Even though the report says that Graham's pattern of suppression more commonly occurs in dogs with adrenal tumors, it still may be the case that his Cushing's is pituitary in origin. So an ultrasound can provide the added information you need to make that determination. However, Vetoryl can be used to treat either form of the disease. So unless surgical removal of an adrenal tumor would be an option, you may not feel the need to know which type of tumor is involved.

I am sorry to welcome you back into the Cushing's club, but we are very glad to support you in any way we can! :o :)

Marianne

[BettyF]

Hi Betty (and Happy Belated Birthday to Graham!).

Yes, it looks as though an ultrasound would be a good next step. Even though the report says that Graham's pattern of suppression more commonly occurs in dogs with adrenal tumors, it still may be the case that his Cushing's is pituitary in origin. So an ultrasound can provide the added information you need to make that determination. However, Vetoryl can be used to treat either form of the disease. So unless surgical removal of an adrenal tumor would be an option, you may not feel the need to know which type of tumor is involved.

I am sorry to welcome you back into the Cushing's club, but we are very glad to support you in any way we can! :o :)

Marianne

Thank you for your advice Marianne, and my apologies for this late reply.

I decided not to have the ultrasound done. Graham gets quite stressed at the vets and because I would not want him to have an operation if it turned out to be adrenal, there didn't seem any point.

I left a message with the vet's receptionist saying that I would like Graham to start on 10mg Vetoryl. I expected that he might contact me but he didn't. The receptionist left a message that I could pick up the Vetoryl today.

So, I've just given Graham his first one and am really worried now. I have to admit that I have never read the leaflet in the box before, but for some unknown reason, I did today. The first thing I saw was that it should not be given in cases of renal insufficiency. Graham has early stage kidney failure, diagnosed 3 years ago.

I will wait till I hear from someone before I give him another capsule and will keep a careful watch on him.

[Squirt's Mom]

I would not use the Vetoryl if my pup was already diagnosed with kidney issues. :( But that is just me - others may feel it would be alright.

[labblab]

I think the nature of the kidney issue will be the deciding factor. If Graham is showing actual elevations in the two main kidney markers in blood samples -- the creatinine (CR) and BUN (Urea) -- then the worry would be that impairment in his kidney function could negatively affect the way in which the trilostane is metabolized and excreted from the body. Adjustments might need to be made to the dose, or the drug not used at all.

If, for example, the main problem is instead that Graham is spilling protein in his urine from his kidneys, this can be caused by Cushing's itself. So it would be reason to want to treat with the trilostane in order to halt the progression of damage caused by the disease.

So I think you will want to clarify the nature of the kidney problems with your vet in order to see whether caution in using the trilostane is warranted.

Marianne

[BettyF]

I think the nature of the kidney issue will be the deciding factor. If Graham is showing actual elevations in the two main kidney markers in blood samples -- the creatinine (CR) and BUN (Urea) -- then the worry would be that impairment in his kidney function could negatively affect the way in which the trilostane is metabolized and excreted from the body. Adjustments might need to be made to the dose, or the drug not used at all.

If, for example, the main problem is instead that Graham is spilling protein in his urine from his kidneys, this can be caused by Cushing's itself. So it would be reason to want to treat with the trilostane in order to halt the progression of damage caused by the disease.

So I think you will want to clarify the nature of the kidney problems with your vet in order to see whether caution in using the trilostane is warranted.

Marianne

Thank you Marianne for such a quick reply.

Graham had blood and urine tests in May. I had taken him to the vet because I thought his excessive drinking might have been caused by his kidney problem.

In May the Creatinine was 151 (range umol/L 40 - 120) and the Urea was 19.0 (range mmol/L 1.7 - 7.4) His previous blood test last October was Creatinine 160 and Urea 14.7.

His urine test in May showed a trace of protein.

When a vet (there are three at the practice) phoned me with the May result, she said his urea was high, but did not offer any advice, or ask to see Graham again.

I will make an appointment to see the vet, but I just want to be sure of things before I speak to him.

[BettyF]

I would like to give an update on Graham, and also to ask advice.

I did go and speak to the vet about Graham's kidney problem and after he took advice from a specialist, he advised that we start the Vetoryl but keep a very careful eye on Graham. He started on 24th June with 10mg Vetoryl, once daily. All seemed to be going well and he had the first ACTH two weeks later. The result was pre 5.25 and post 8.4. The second ACTH two weeks after that showed pre 2.9 and post 8.9. About a week after this I noticed that he was not well, off his food and generally 'down'. He did not have diarrhoea and he wasn't being sick but he just wasn't right. I asked the vet to do another ACTH on 7th July and got the result the following day - pre 0.3 and post 3.4. I was shocked when I saw the pre number but the vet said he had spoken to his colleague and was told it was nothing to worry about. His Urea was up - 21.0 mmol/L (ref range 1.7 - 7.4 mmol/L) and Creatinine was 194 umol/L (ref.range 40 - 120 umol/L)

The vet did a cystocentesis to rule out any infection and this came back after a few days as negative.

After I got the ACTH result I told the vet I was not happy keeping him on the Vetoryl and he agreed that it should be stopped for a time. This was 11 days ago and Graham has not had Vetoryl at all.

This is the thing that is puzzling me - Graham is drinking much less, in fact he is drinking normally, 1oz per pound of his weight, he is not going out to pee every half an hour like he used to before starting treatment. His appetite is normal and the trembling has completely stopped. He is happy to see people when they visit, he sleeps well and is generally well for his age (16) and all of this is without being on Vetoryl.

The vet wants me to send another urine sample to him, so when I speak to him afterwards about it we will have to decide what to do.

I know it sounds crazy, but it's almost as though the few weeks he was taking Vetoryl has cured him of Cushings! I know this is not possible, but it is very strange.

Has anyone heard of anything like this before?

[molly muffin]

Well I think it is certain that the pre value of cortisol actually in his body was making him feel crappy, but keep in mind the pre can fluctuate throughout the day too and the adrenal glands where still making and storing cortisol.

I wonder if with his kidneys having lower cortisol and of course age and the aches and pains that go along with it, having the lower cortisol levels in general made him feel cruddy.

I think based on what you are seeing symptom wise that he does feel better with a higher cortisol level, but the urinating could be either from kidneys or from cortisol. At this time I'd see how he does, retest his kidneys and maybe even consider a 5mg dose rather than a 10mg.

It's always tricky with older dogs, because it comes down to quality of life and keeping them comfortable and happy for as long as possible. It's like a careful balancing act has to be maintained without tipping too far either way.

[BettyF]

Well I think it is certain that the pre value of cortisol actually in his body was making him feel crappy, but keep in mind the pre can fluctuate throughout the day too and the adrenal glands where still making and storing cortisol.

I wonder if with his kidneys having lower cortisol and of course age and the aches and pains that go along with it, having the lower cortisol levels in general made him feel cruddy.

I think based on what you are seeing symptom wise that he does feel better with a higher cortisol level, but the urinating could be either from kidneys or from cortisol. At this time I'd see how he does, retest his kidneys and maybe even consider a 5mg dose rather than a 10mg.

It's always tricky with older dogs, because it comes down to quality of life and keeping them comfortable and happy for as long as possible. It's like a careful balancing act has to be maintained without tipping too far either way.

Thank you for your reply and sorry for my late reply to it.

Graham's second urine sample showed that his specific gravity was low and there was a trace of protein.

I told the vet I would wait a bit longer before thinking about starting Vetoryl again because Graham seems quite well at the moment. He is eating well and is good for his age. His drinking is more or less normal, averaging at about 26 ounces per 24 hours.

He does not pant any more when he is resting.

I'll wait a bit longer and then have another blood test done and take it from there.

[molly muffin]

I think that is an excellent plan Betty. :)

[BettyF]

Graham has now been off Vetoryl for just over three weeks but it looks like his symptoms have returned. He is drinking more, averaging around 30 ounces in 24 hours. He needs to go outside in the night to pee and his panting during the evenings is back, but not as bad as it was before he started Vetoryl.

He has never had a brilliant appetite and rarely finished what was in his bowl but for the past week he has eaten everything I've given him, even the renal food which he wouldn't touch before.

In himself he is quite bright and lively for his age (16) but it looks like we will be heading back to the vet for another blood test to see what is going on.

If you remember, his last ACTH was pre 0.3 and post 3.4, which was the reason the Vetoryl was stopped.

Just thought I would update you on what was happening with him.

[molly muffin]

He is a tricky one isn't he. :). It's so hard some days to keep,everything in balance. Let us know what the tests show.

[BettyF]

I took Graham off his Vetoryl 6 weeks ago and he had an ACTH yesterday. The result was a bit surprising and I would love to know what others think.

6 weeks ago it was pre: 0.3 ug/dl and post: 3.4 ug/dl.

Yesterday, it was pre: 5.6 ug/dl and post: 20.5 ug/dl.

This is without him taking Vetoryl for 6 weeks.

I can't quite get my head around this, can anyone explain please?

[labblab]

Hi Betty, actually I don't find Graham's results to be too surprising given the fact he's been off the Vetoryl for six weeks. For most dogs, trilostane's active effect in the bloodstream is short-lived and there is not any significant residual activity. So now Graham is back to a cortisol level that is consistent with an untreated Cushing's dog.

What I don't really understand is why his pre-ACTH cortisol was so low last time. His post-ACTH level at that time was 3.4 which is technically just about perfect. But you say he was feeling poorly, as well, so it does seem as though the 10 mg. dose may have been a bit too high for his comfort. Dechra has started manufacturing a 5 mg. capsule which we are anxiously awaiting worldwide. During the past year, it's been our understanding that even though the 5 mg. capsule is not available for general sale in the U.K., vets can request the capsules directly from Dechra in the event that one of their patients is in need of the smaller dose. So that might be a compromise that you'd wish to try -- starting Graham back on treatment but on a lower dose than before.

Marianne

[BettyF]

Hi Betty, actually I don't find Graham's results to be too surprising given the fact he's been off the Vetoryl for six weeks. For most dogs, trilostane's active effect in the bloodstream is short-lived and there is not any significant residual activity. So now Graham is back to a cortisol level that is consistent with an untreated Cushing's dog.

What I don't really understand is why his pre-ACTH cortisol was so low last time. His post-ACTH level at that time was 3.4 which is technically just about perfect. But you say he was feeling poorly, as well, so it does seem as though the 10 mg. dose may have been a bit too high for his comfort. Dechra has started manufacturing a 5 mg. capsule which we are anxiously awaiting worldwide. During the past year, it's been our understanding that even though the 5 mg. capsule is not available for general sale in the U.K., vets can request the capsules directly from Dechra in the event that one of their patients is in need of the smaller dose. So that might be a compromise that you'd wish to try -- starting Graham back on treatment but on a lower dose than before.

Marianne

Thank you Marianne,

I will mention the 5mg Vetoryl to my vet but he seems to think that Graham should not start back on it at all. It could be because of his kidney failure that he thinks that, I'm not sure.

For his age, Graham seems quite well at the moment but I worry about what the lack of treatment is doing to his organs.