Help For Dennis

[RhondaAndDennis]

First I want to say how glad I am to find this forum. My name is Rhonda and my little guy is Dennis. He is mostly poodle and a bit ?. He is nine years old and weighs 8 pounds. In early 2015 he started to lose some hair on the back legs and both of his sides. He has always had allergies,so I was not to concerned. His hair continued to look more thin,he started to have blackheads on the underside of his belly,developed few sores and seemed to start eating more. In June I took him to our vet and was told he might have thyroid disease but would also be tested for Cushing disease. His thyroid was fine.. His test results showed Cushings. Test was a 37.4. Normal 8-17. Ultra sound showed a slightly enlarged liver and slightly enlarged adrenal glands. Blood worK was all normal except a slightly raised alkaline phosphate. Sores were polyderma. Started on 5 mg trilostane. Two weeks later,he did not improve so they put him on 10 mg. Took him back in three weeks,still no changes so was put on 15 mg. Is that to high for him. Thanks to all.

[labblab]

Hello Rhonda! Welcome to you and little Dennis :). You will see that I have moved your thread to our main "Questions and Discussion" forum. This way, our members are more likely to see your thread and offer their suggestions.

From what you have described, it sounds as though his trilostane dose has been increased too quickly. It may be the case that he ultimately requires a dose that high, but for his safety, monitoring testing must be done along the way.

The current initial dosing protocol recommended by Dechra (maker of brandname Vetoryl) as well as many clinicians worldwide, is to start at a dose no larger that 1 mg. per pound. In Dennis' case, you might have "fudged" a bit and started off at 10 mg. But a more conservative approach would have been to start at 5 mg., as your vet did. So far, so good. However, Dennis would have been better served had the initial dose been left alone for the first 30 after beginning treatment. This is because cortisol levels tend to continue to drift downward during those first weeks of treatment, even when the dose is left unchanged.

Prior to a dosing increase, Dennis ought to have had a monitoring ACTH stimulation test performed no later than 30 days after beginning treatment (and Dechra recommends testing for the first time even earlier, at the 10-14 day mark, in order to make sure that cortisol is not dropping too quickly). If, at that 30-day mark, his cortisol level was not being controlled adequately -- that is the time when an increase would be made.

If no ACTH testing has yet been performed, I do feel very concerned that his dose is already nearly twice the recommended starting dose for his weight. The thing is, the skin and coat issues that you have described can take weeks to months to improve, even when cortisol levels are optimally controlled. So you cannot judge the drug's effect based solely on outward appearance, especially in relation to things like skin/coat/muscle weakness. Many Cushdogs exhibit other symptoms that show much more rapid improvement, such as excessive thirst/urination/hunger. However, you have not described Dennis as having these types of issues. Regardless, all dogs being treated with trilostane need to have ACTH monitoring performed in order to insure that cortisol levels are within a desired therapeutic range, and are neither too high nor too low.

So it is very important for us to know whether he has had any monitoring testing done yet. Is Dennis exhibiting any symtoms of drug overdose at this time: loss of appetite, lethargy, vomiting, diarrhea, etc.? As long as he is behaving OK, if he has not yet had a monitoring ACTH test performed, if he were mine -- I would want to drop him back at least to the 10 mg. dose and then insist that ACTH testing be done after a few days at that dosing level. For his safety, I do not think he should continue with the 15 mg. until you have established that his cortisol is not dropping too low.

Marianne

[RhondaAndDennis]

Thanks labblab for setting things up for me. I forgot to add that Dennis had an acth test after being on 5mg. trilostane for 2 weeks. Pre was 6.4 and post was 14.1. After being on 10 mg. for 3 weeks Dennis pre was 4.8 and post was 8.9. He was started on the 15 mg. last Wednesday. He seems a little more tired than normal but no loss of appetite,vomiting etc. He is on a drug to clear up the sores. Also a special shampoo,omegas,demarin for his liver. Do you think I still should drop him back to 10 mg.

[Squirt's Mom]

Vets should never ever raise the dose of Vetoryl (Trilostante) during the first month of treatment because the cortisol will continue to drop on that same starting dose. In fact, one of the well-known endocrinologist who deals with Cushing's often recently wrote this drug can continue to lower the cortisol for FOUR MONTHS on the starting dose, no changes to the dose. The manufacturer recommends the med not be increased in the first 30 days. By doing so, your vet is putting your baby at higher risk of an over dose. Keep a VERY close eye on your baby for any signs the cortisol is going too low - nausea/vomiting, loose stool/diarrhea, loss of appetite, lethargy. If you see any of those things, get your baby to the vet or an ER for an ACTH asap.

Let us know how things are going!
Hugs,
Leslie and the gang

[labblab]

Hi again, Rhonda. Thanks so much for giving us those monitoring ACTH results -- now I can breathe a lot easier!!! ;)

As both Leslie and I have said, the prevailing advice is to leave an initial dose unchanged for the first 30 days of dosing. However, 5 mg. was a very conservative starting dose, and based on his first test results, I do believe I understand the rationale for going ahead and increasing to 10 mg. at the two-week mark. That's where many vets might have started in the first place, and Dennis' cortisol level was still hanging quite high.

My only question now would be whether or not it is a bit premature to bump him up by another full 5 mg. After three weeks on the 10 mg., his post-ACTH cortisol level is now already low enough that it would actually be deemed acceptable as long as his symptoms were being controlled. His cortisol can go lower and still be considered safe, but obviously you do not want it to drop too far.

Does Dennis have any of the more common symptoms at all, such as excessive thirst/urination/hunger? As I said earlier, resolution of those symptoms typically comes much faster than skin/coat healing. We have been told by some specialists that it may be necessary to lower post-ACTH levels to a range between 1.5-5.0 in order to gain control of skin problems. So that may indeed be the range your vet is shooting for. So at this point, I guess if he were mine, I would go ahead and leave his dose at 15 mg., but I would definitely watch him very closely for any signs of overdosing.

Do keep us updated, OK?
Marianne

[My sweet Ginger]

Hi,

When is Dennis scheduled for his next ACTH stim test? I hope it will be on 10day mark rather than 14day.

Marianne, here's a question for you. ;)
Let's say Dennis's post # is under 5 or around there at his 10-14 day mark on 15mg.
Then what, as he will still have two more weeks to go till his 30day mark. He can't stay on 15mg anymore so has to go back down to 10mg I think.
To me his cortisol was coming down nicely on 10mg and this 15mg just makes me nervous. This doesn't seem like going low and slow to me. Why some vets do not follow the correct protocol when dealing with such potent drug is beyond me.

[labblab]

Marianne, here's a question for you. ;)
Let's say Dennis's post # is under 5 or around there at his 10-14 day mark on 15mg.
Then what, as he will still have two more weeks to go till his 30day mark. He can't stay on 15mg anymore so has to go back down to 10mg I think.
To me his cortisol was coming down nicely on 10mg and this 15mg just makes me nervous. This doesn't seem like going low and slow to me. Why some vets do not follow the correct protocol when dealing with such potent drug is beyond me.
Hi Song! I sure wish there was a way to predict exactly how any given dose is going to any given dog -- that would make things so much easier!! :o

But since you are asking, here's my thinking about Dennis' situation. By the time of this most recent testing, Dennis had been taking trilostane for five weeks. On the initial 5 mg., he dropped from 37 ug/dl to around 14 ug/dl. That is quite a drop, so if it had been up to me, yes, I would have left that dose unchanged for another couple of weeks. But the dose was increased to 10 mg. and remained there for three more weeks. At that retest, his cortisol had dropped to a little below 9 ug/dl, so it was an additional decrease but not a massive decrease (which is what I initially would have been worried about). Would I personally have waited one more week before testing? Again, yes. But I don't know that one more week would really have made an enormous difference in the results, and especially when skin issues are involved, many vets do want to see results in that 1.5-5.0 range. So I'm not that bothered by the notion of an increase -- I just might not have increased by another full 5 mg.

But that's where we are, and as long as Dennis seems to be doing OK after taking that dose for almost a week now, I'd continue on for the time being. As far as how to handle dosing changes at this point, I think it will really just depend on the combo of his behavior and the test results. If he is tested after two weeks on this dose and his cortisol has dropped clear down to 1.5, then yes, I think you'd need to back off on the amount. If it is up around 5.0, however, I'd think you'd stay the course because that is really an ideal level in the minds of many vets and there is not necessarily an expectation that it is going to drop a whole lot further after having been on the drug for nearly two months, plus Dennis would still have some wiggle room left even it if did drop a bit more.

So as is often the case, my answer is "it all depends :o." What I'd do next all depends on how Dennis is doing outwardly, and what the next test shows. As I said above, I do think vets may be more aggressive about dosing when skin issues are involved. This may be because the skin problems can blossom and become major quality-of-life issues very quickly. With excessive thirst/urination/hunger, the problems are bothersome but for the most part, you can kind of hang in there and continue along at a slower pace. But the skin stuff can really leap out of control quickly. So I do believe there may be a bit more urgency about getting the cortisol down faster when skin lesions are involved.

Marianne

[My sweet Ginger]

Dear Marianne,

Thank you so much for your usual thorough answer. I really appreciate it and only hope that's what his vet's been trying to do for him especially re his skin lesions.

Now I feel sort of guilty taking your precious time away from you in your usual thoughtful reply when you're already too busy visiting every thread and providing such valuable guidelines to countless scared and lost us parents. :o We are all so lucky to have you and others like you around here. I'd like to take this opportunity to tell all of you that how much we appreciate your kind heart and in-depth knowledge and long standing dedication out of your own busy daily lives. Thank you very much. Song

[labblab]

Golly, Song, you're making me blush big-time! :o :o :o :o

Thank you so much for your very kind words. But it's about time you took a bow yourself, Missy. :)

I see you here, morning noon and night! Always checking on folks, and offering important information and supportive words. So I'm gonna turn the tables and thank YOU for the caring person you are and all that you contribute to our family. ;)

I wish I could say that I was always correct in the things that I write, but I'm definitely not. So it is a comfort to me to know that others are always looking over my shoulder and double-checking things that I may say, or adding their own thoughts should they be different. That's the beauty and gift of this forum -- that there are so many devoted members who throw in their thoughts and suggestions.
We are so lucky to have you with us, Song. Thank you so much for all that you do here, too!

And Rhonda, as far as Dennis, I certainly may be missing the boat entirely as far as the things I've written. The most important thing of all is just for you to closely monitor how he's doing. If he starts acting ill, then you definitely need to take him in immediately to be seen and/or retested. But we'll be keeping our fingers crossed that this will turn out to be the perfect dose for him. We'll certainly want updates all along the way.

Marianne

[My sweet Ginger]

You are so sweet Marianne and thank you for your generosity. :o:o:)

[RhondaAndDennis]

This forum is super great. Dennis will go for an acth test in 3 more weeks. He appears a little more tired than he use to. Not quite my Dennis the Menace .Unless it is the weather. I must admit I am a bit confused. Should he be on the 10mg. or 15 mg.

[My sweet Ginger]

How many days has Dennis been on 15mg?

[molly muffin]

It looks like Dennis has been on 15mg since last Wednesday, 22 July, so today would be 8 days. Since with the skin issues it is important to be under 5.0 ug and stay there, i think I probably would leave him on the 15, so as not to lose any progress that has been made, and have an acth scheduled for monday which would be 13 days and see how he is reacting. I would not increase the dosage even if he is above 5.0 which he might not be now anyway.

If you notice any vomiting or diarrhea, lethargy, then go ahead and have an acth done and don't give any more vetroyl until you know.

It's tricky, but I think it's entirely doable and tight control is more important for the dogs with the skin problems.

Hello by the way. :)

[My sweet Ginger]

I wouldn't wait another three weeks on this 15mg to have next ACTH test done which will make it 30days more or less. No, I wouldn't if that's the case. Too risky.

[molly muffin]

I would do,it this coming Monday which is 13 days and follows the protocol of 2 weeks after any dose increase. I agree with song. Too risky.

[RhondaAndDennis]

Took Dennis in for an ACTH test yesterday. Vet thought it was a bit to soon but did it. Will post results when I receive them. The puzzling thing is the polyderma or sores are worse ..

[molly muffin]

They usually get worse before they get better and it can take many months for the skin and hair follicles to cycle through. So don't let that worry you too much. See what the ACTH shows and then go from there.

[RhondaAndDennis]

Just talked to the vet. Here are the results-ACTH Pre- 4.8 Post-6.1. Polyderma and hair loss no improvement. Unexpected find--Dennis has protein in urine. Plan--raise the trilostane to 20 mg. Return in 3 weeks. Place Dennis on Benazepril. Return for bladder ultrasound. Is that normal procedure?

[molly muffin]

My molly is on benazepril for protein in urine also. She periodically has ultrasounds to check, liver/kidneys etc.

so two weeks on 15mg and going to 20mg with a retest in 3 weeks. That can be doable ,but if you notice anything off at all, don't be afraid to schedule an ACTH test earlier. The skin and hair, as I said before, will likely take many months to return to some semblance of normal.

[RhondaAndDennis]

Thanks a bunch. That gave me a bit of a scare. The ultrasound would be done to look for kidney disease. Think they also might do bloodwork. So,you do not think the increase is to much for him? .Glad your Molly is doing well.

[labblab]

Well gosh, in honesty, no I would not feel comfortable increasing him from 15 mg. to 20 mg. after seeing his cortisol drop from 8.9 to 6.1 after only two weeks on the 15 mg. You are now really close to the ideal target range of <5.0 and may well get there after another couple of weeks on the 15 mg. I think it is premature to increase his dose by yet another 30%. I understand that your vet is really, really anxious to see some improvement, but driving Dennis' cortisol too low is not going to help things any. So since you are asking for our opinions :o, I would leave his dose alone for another 2-3 weeks. If his cortisol remains higher than 5.0 at that time, that is the point at which I would consider an increase (and perhaps not even by a full 5 mg. at that time).

Anything you decide needs to be discussed with your vet, of course, so that he is aware of what you are doing. If you both feel as though you do want to proceed with an increase right now, perhaps a compromise would be to increase by 2.5 mg. rather than the full 5.0.

Marianne

[My sweet Ginger]

Many dittos to what Marianne is saying. I wouldn't increase at any dose at this time. The 15 mg is doing what it's supposed to do very nicely so far. Remember Vetoryl keeps working for 30 days and the correct protocol reads you don't increase dosage after only two wks just for that reason. I really don't get vets on this. Low and slow is how I'd go. I've read too many tragedies on the forum by not following that rule. Song

[RhondaAndDennis]

I told the vet I would like to remain on the 15 mg. and see what his results would be on his next test. He agreed. Dennis is starting to want to eat more than usual. Is that normal with trilostane use. They found a stone in his bladder. He is on Benazepril. They will recheck next week. Rhonda

[molly muffin]

Well with cushings yes they do tend to like to eat a lot. However, it often seems to depend on how their cortisol is doing, if it is down where it should be, if it is going up, sometimes it fluctuates during the day and you end up needing do do a twice a day split dose to keep things more leveled out.

[RhondaAndDennis]

Dennis had a recheck for the protein in his urine. The report stated that last time, a stone was seen in his bladder and it was not seen this time.,so it could be that the stone was what was causing his urine protein levels to be so high. Two questions-The vet wants him to remain on the Benazepril. If it was the stone,why?. And is there any way the stone would have caused a raised cortisol on an acth test ? I do not want him on medicine if he does not need it. Thank you for any information..

[Harley PoMMom]

A stone formation can cause higher levels of protein in the urine, and yes, if that stone was causing discomfort this may elevate cortisol.

I haven't read your whole thread, sorry :o was the Benazepril started for the excess protein found in the urine? Also, was this protein found with a regular free catch urine sample?

Hugs, Lori

[RhondaAndDennis]

Thank you Lori for the information. I know there are so many mommies on this site that are worried about their furbabies. I also know there is a small handful of you wonderful people that answer questions. We so thank you all. . Yes,when they saw the stone,he was put on Benazepril. Now that they no longer see the stone,they still want Dennis to stay on it. Why,as they say Cushings can also cause proteinuria and because of this,they would like to continue the Benazepril. They did a needle of the ,I guess the bladder at the vet. So now I do not know if I should continue with the Benazepril. And what about the elvated cortisol on his test. Do I keep giving him trilostane ? The vet does think he has Cushings.

[Harley PoMMom]

Benazepril is mainly used to help lower protein being lost in the urine, it is also used for hypertension. I'm not aware of it being used to deter stone formation. Identifying what the stone is made of is important in knowing how to treat those stones. If this were me, I would question the vet for the reasoning of the continued use of the Benazepril.

Forgive me for not reading your thread yet :o what symptoms does Dennie display that led you or your vet to test for Cushing's in the first place?

Hugs, Lori

[RhondaAndDennis]

Ok, I took Dennis to the vet as he had some hair loss.sores which vet said was polyderma and some blackheads on his little tummy. He has always had allergies and some blackheads. Vet did an acth test. His post was a 37. High according to my vet. A slightly raised alkaline phosphate. Nothing else on bloodwork. The ultrasound did show a slightly enlarged liver and adrenal glands. The vet wants him to stay on the Benazepril because he thinks cushings can cause proteinuria in a dog. I guess he thinks it a precaution for Dennis. I just do not want to give him anything he does not need. Thank you Lori.

[Harley PoMMom]

Many things can cause protein loss (proteinuria), such as any bladder/kidney infection, stone formations, hypertension, just to name a few. Urine samples need to be free of sediment when evaluating protein loss.

When protein loss is found from a clean urine sample generally an urine protein:creatinine (UPC) ratio test is performed. When 3 consecutive UPC tests come back with protein loss than treatment is initiated. Benazepril is one of the drugs that is used for protein loss, however it can lower blood pressure, so if Dennis' BP hasn't been checked recently I highly recommend it be done and monitored.

Here's a link to an article regarding proteinuria in dogs: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3354822/

Hugs, Lori

[Squirt's Mom]

Cushing's can also cause high blood pressure and that may be why the vet wants Dennis to remain on this drug - to help keep his BP lower. I would ask why like Lori suggested. Sometimes if we just know the reasoning behind something it helps us accept...and it could help us all learn something too. ;)

She is also correct about knowing what type stone Dennis had/has. Some stones can be and should be managed with diet while others are not in the least effect by foods. Some are *caused* by certain foods and diets; some are caused by infections; some vitamins can be a preventative for one type yet help cause another type. So "stones" is never acceptable to me - I must know what KIND of stone so I know how to help my baby. ;)

Some info on uroliths (stones) - http://veterinarymedicine.dvm360.com/stalking-stones-overview-canine-and-feline-urolithiasis

[RhondaAndDennis]

Thanks to both of you. Dennis' blood pressure is normal at this time. 146 reading. The stone was only seen that one time. There has been no others. The vet did not say what type it was. I guess they think that Benazepril somehow would benefit a cushing dog. I must admit I am a bit confused.

[molly muffin]

My dog is one of the ones with high cortisol, hypertension, protein loss in urine and is on trilostane, benazepril and amoldipine for those issues.

I can see why since there was high protein that they are thinking keeping him on the benazepril. They don't know for sure that the stones caused it (my dog too has some small stone) so better to be proactive in this case since they have seen some protein in the urine already and can't be sure of the "why" of it.

[RhondaAndDennis]

Good information Sharlene. Dennis will be going in next week for an acth test. I might be going out in strange water but I did take him off of the Benazepril and will ask the vet to retest him next week for the protein. I believe in meds but only if needed.

[molly muffin]

He can always be restarted on benazepril if he needs it. If he doesn't that is great. :)

[RhondaAndDennis]

Dennis no longer has protein in his urine. So the vets said it was ok I took him off the benazepril. Now his post was a 4.9. He is still is losing his hair so vet wants him on the 20 mg.. The skin is about the same. I am worried he might go to low. I can use a bit of advice please.

[molly muffin]

That is excellent that he is no longer showing protein in his urine. Definitely a plus.

4.9 is a good post result and I don't see why he would need to be increased to 20mg and I personally wouldn't do it. Some symptoms like skin and hair will take months to clear up, I'm talking like 6 months in theraputic range. He is at a perfect post result right now, so I wouldn't mess with that at all.

[RhondaAndDennis]

Yes Sharlene,i also that was a pretty good post. I guess they thought maybe his hair and skin would improve if they raised the trilostane. His thyroid was a .79. Normal ( 0.6 -3.) They said it was ok. How is your little girl doing ?

[molly muffin]

Well the skin and hair won't improve until it goes through all the cycles. That is what takes so long and that needs to happen while in a good range, which 4.9 is. Raising the trilostane dose to make the cortisol even lower won't change a thing when it comes to that. It's a slow process.
I know patience is not the easiest thing in the world but you have to give it a chance to see if it will improve.
Do all the other things too, keep it clean, dry and an antibiotic spray on it.

[Squirt's Mom]

No, don't raise the dose! geez....this takes time and the regrowth of hair can take a long time - some pups will lose all their hair, called "blowing a coat", then regrow a coat that is different from the one they came with. :D But you can't rush the process by overdosing the dog and that is where your vet is headed with thinking like that. ;)

[RhondaAndDennis]

Just popped in to say hi everyone. Dennis is doing well. Still has thin fur but I can live with that. Even tho I have nothing to post at this time, I still read many of the threads. I am so glad for the pups who are doing fine and so sorry for the moms who have lost their babies. Rhonda

[molly muffin]

That is wonderful news Rhonda! Great to hear that Dennis is doing well.

It just takes time with the hair and skin usually, although I have to say, molly has never really gotten that undercoat back that she use to have in her younger days. Sigh. I think it might be a thing of the past. I don't have to worry about mats as much, but do have to make sure she has a coat on or something to protect her skin in the winter when we get those cold winds blowing.

Coat time for Dennis?

[RhondaAndDennis]

Hello all, popping in to wish everyone a happy New Year. Dennis is doing fine. Yes Sharlene we took your idea and now since the cold weather is finally here, Dennis is all decked out in a coat and of course, a matching cap. My little rugrat looks adorable. Rhonda

[molly muffin]

Awww, I bet he is cute!

Molly is going through a fashion parade of coats this winter. LOL

[RhondaAndDennis]

Hi All, Dennis is doing quite well. Only thing he does not seem to have any regrowth of hair. Even looks like he is losing more. He was seen by a dermatologist who said it is fairly common for a Cushing dog never to regain a full coat. His cortisol numbers are perfect according to his vet. Last pre was 2.9 and post 7.1. The way its going he is going to be a bald little guy ! Hey Sharlene, coats and sweaters are great for winter. How about when the weather gets warm. Maybe a pair of shorts and a Tee. Hope Mollys well and her spunky little self. Thanks a bunch. Rhonda

[molly muffin]

Shorts and t-shirt eh. hahahaha Well that should be something photo worthy!

Glad he is doing so well. You never know, it can take forever for the fur to come back, some never really get it back, some get even more and in a different color.

[RhondaAndDennis]

A big hello and Happy Valentine Day to all. Dennis has been doing fairly well with the exception of no hair regrowth. For the last few weeks, his breathing has gotten somewhat loud. Especially at night when he is really sacked out. Sort of a loud snoring or rattle. . Sometimes it will even wake me up. Vet said nothing to worry about. Common in Cushing dogs. But,if anything, I have learned from this site is not to put your trust completely in your vet. Any thoughts ? Thanks a bunch. Rhonda

[molly muffin]

My dogs snoring is loud these days too. I'm pretty sure that she is very relaxed and enjoying her sleep though so I don't really worry about it. I'd be more worried if she seemed restless and not able to settle while having loud breathing while awake.

[RhondaAndDennis]

Sharlene , I guess his vet was right. But thanks for the extra input. Going out to buy a pair of ear plugs. Darn, I wish his hair would grow back. Rhonda

[molly muffin]

The hair can take a while to come back, if it does. What was the last ACTH result, pre and post? I don't know what the optimum value is for hair regrowth but I know that it needs to go through the entire cycle sometimes, which can take months and months. If it comes back, there aren't any guarantees.

My dogs hair is still thinner than it use to be and it is the undercoat that was affected. The outer coat still grows out long.

[RhondaAndDennis]

His pre was a 2.9. Post 7.1. Vet thought it was very good numbers for Dennis. Said it was only a cosmetic thing. But I still wish his hair would regrow. Thanks a bunch. Rhonda

[WeLoveAthena]

I'm very new here. Our Lab Athena was just diagnosed with Cushings. Just wanted to say that you and Dennis are in our prayers. You have found a wonderful site here. This place has been a lifesaver for our family. Wish I had more to offer but still new at this whole thing but wanted you to know you are not alone.

T~;)

[RhondaAndDennis]

Do you think that the pre and post is ok. Should it be lower for better results. He seems to be losing quite a lot of hair. Has had a couple of what the vet called polyderma sores. Thanks a bunch. Rhonda

[molly muffin]

The post is okay if his symptoms are controlled. However if symptoms are not then you could take his post down below 5.0 to see if those symptoms would resolve. So if you have concerns about those then definitely talk to your vet app out a Small increase. I wouldn't increase much those. Maybe only a couple milligram would do it.
There is. I thing wrong with those values though and they are good if you are happy with how he is doing physically and symptomatically

[RhondaAndDennis]

Hello all, Dennis is still losing lots of fur. My little man will soon be bald. Also a little more sleepy than he use to be. I did see a second vet.. He is a regular vet but uses a lot of natural products. . His thought was the Trilostane can raise the hormones and perhaps Dennis was losing hair because of the hormones. Any thoughts on that ? Thanks a bunch. Rhonda

[labblab]

Gosh, I'm sorry Dennis is still having problems with his fur. In looking back through your thread, I see that those last ACTH results were from testing sometime prior to the middle of January. When were they actually done? Before making any other changes, I believe I would repeat his ACTH. His cortisol may have increased during these intervening months, and even if not, Dechra as well as many clinicians recommend that post-ACTH results need to be lowered to a range between 2-5 in order to resolve all troublesome symptoms. So I do believe that's where I'd start first.

There is much that remains unknown about the effect of elevated hormones other than cortisol. It is true that trilostane can increase some of them, but whether or not that is a genuine issue is hard to say. Paradoxically, trilostane treatment actually helps some dogs who only have elevated hormones other than cortisol -- their cortisol is normal. So before I started worrying about the other hormones, I would want to make sure that Dennis' cortisol is actually within the proper range. I would start with a repeat ACTH.

If you didn't mind bearing some added expense, you could ask that his ACTH be analyzed by the lab at University of Tennessee in Knoxville. They are the only veterinary lab in the country that analyzes the full adrenal hormone panel for dogs, including cortisol. However, as I say, I'm not sure that those full results will guide you much differently right now.

You mention that he seems a bit sleepier now. Aside from that and the fur loss, is he otherwise acting healthy and well? How about any other Cushing's symptoms?

Marianne

[RhondaAndDennis]

Thanks a bunch Marianne, I believe the last acth test was done the very first of Jan. He is to go back in April. I asked my vet today about the hormone panel and he thinks its a big waste of money. Said even if the hormones were raised, the treatment would still be trilostane. I really would like to keep all of the things that are done at his regular vet , but I think I am going to jump on the bandwagon and go to the second vet for the hormone panel. Hoping they can do the acth test along with the panel. Besides somewhat sleepy, he Sometimes gets polyderma sores on his legs but mostly top of his head or close to his eyes. They look sort of mean. Kinda of pus or sometimes pus and blood filled. Skin is not as pink and smooth as it use to be. He does not pee a lot. Goes all night without wanting out. Does not drink excessively. He would eat if you kept feeding him. But once eating time is over, he settles down. Any advice is appreciated. Rhonda

[RhondaAndDennis]

For what I am understanding, there really is not a lot of info. on hormones in dogs and what part they play. My questions is--What would cause hormones to increase in dogs ? Is it from the disease itself ? Rhonda

[labblab]

Unfortunately, you're right that there are a lot of unknowns about all this. In honesty, I can't say whether I think the full adrenal panel is worthwhile for you to pursue right now, either. These are the two reasons why.

First, we have been told that virtually all dogs who have elevated cortisol will also exhibit elevations in at least some, if not all, of their other adrenal hormones, as well. However, it is really unknown right now as for which dogs, if any, those other elevations will create additional problems separate from the cortisol. So if you have Dennis tested, we'd expect to see other elevations, too. But do they matter? Dunno...

The other issue is that lowering cortisol is the known priority, regardless of what the status is of the other hormones. Right now, the only drugs that we know will effectively lower cortisol are trilostane and Lysodren, so Dennis is pretty much stuck with one or the other. It is true that you could try switching Dennis to Lysodren in order to see whether his skin/coat issues would be more responsive to treatment with that drug. But before switching, Dennis would have to be off either drug for approx. a month, and with no guarantee as to an improved outcome.

So long story short, I don't know that I'd bother with the full panel. I would at least repeat the ACTH of his cortisol, though, as planned. Because it remains possible that if his cortisol is brought down to a level below 5.0 ug/dL, you may see some resolution of these remaining issues.

Marianne

[RhondaAndDennis]

Thanks Marianne, for some reason this hormone thing is of interest to me. I know woman with hormone issues suffer hair and skin issues as well as sometimes strokes. . . Going to dig around a little more for info, than I will decide which way to go with Dennis. I do agree the main thing at this time is his cortisol levels. Bunches of thanks. Rhonda

[molly muffin]

I do think that elevated sex hormones can cause the hair loss, but as it is second to getting the cortisol down, you could wait on the panel. Hair loss might also be due to the cortisol being high which is known to cause hair loss too.

Then even when you get everything in range, hair follicles have to go through cycles, and that can take many months, depending on cause of damage and how long and where you are at in the current cycle.

[RhondaAndDennis]

Ok, at this time I will put the hormone issue aside and go for the acth test for Dennis. . Thanks, Rhonda

[RhondaAndDennis]

Ok, here is the acth test results. Pre - 2.9 and Post - 6.1 . Very good numbers. But the question is ,Why does Dennis have so much hair loss ? The vet thinks it is best to stay with the same dose of trilostane and not worry about the hair loss. Well, this guy is as bald as an egg. So maybe he can say that. Ok, if it has to be but its really strange that with his cortisol levels controlled, he continues to lose hair. Now and than a polyderma will pop up on his head or body. I will post any abnormal if any is seen on his bloodwork. Any suggestions much appreciated. Rhonda

[Harley PoMMom]

Those are great numbers!! Symptoms are controlled right? Improvement in the regrowing of hair can take many many months and some dogs never do grow their hair back even when their cortisol has been controlled for a long period of time. :(

[RhondaAndDennis]

Thanks a bunch for your reply. Heres the thing. Dennis has been on trilostane for 9 months. His cortisol is controlled. But he continues to lose hair. He has lost so much that only his legs and ears have hair. You can now see his skin. He looks like the breed of dog that is hairless. Very cute breed, but that is not what he is. The vet said he may never regrow hair but he is not for sure why. Dennis occasionally has polyderma sores and some blackheads. Tired at times. I am starting to feel quite frustrated. Rhonda Just a thought--I really do not think raising the trilostane would change things. I wonder if something else is going on. The only abnormal on his bloodwork was blood urea nitrogen 40 {5- 29 normal range }

[Angus2223]

Question Marianne for Rhonda: My doctor gave me Prednisolone 5mg and an injection of Dexamethasone in case of severe vomiting, diarrhea or anorexia in her loading phase of Lysodren 500mg bid, which was 7 days. If her dog becomes severely symptomatic due to, too low of levels of cortisol, couldn't she ask her doctor for these as well?

Jessica

[molly muffin]

Right now Dennis's only symptoms remaining is the extreme hair loss and blackheads on skin, some lethargy. AT 6.2ug post, she wouldn't need one of the supplements that are given in the case of too low of cortisol as he isn't too low.

Rhonda, hair follicles are like an organ, while the hair itself is dead, the follicles are alive and high cortisol levels attack the hair follicles like it would any organ.
So, lower cortisol levels over a long period of time and we are talking maybe 6 months to a year to go through a cycle of low cortisol and see if it continues to affect the follicles or not.
An interesting thing that I read while researching this is that high cortisol is actually linked in some cases to baldness in humans too. Same scenario.

My dogs hair too is well on the way with getting very thin. I've held off on taking her for a spring trim, as I'm afraid she is going to freeze once she gets her hair cut, even with a coat on outside.

I know you want to see hair regrowth and it is at best going to take quite a bit of time and as others have mentioned, might not ever come back. Or it might come back in totally different from the old hair. We've seen that happen. Hello to a smooth coat dog from a curly one or a brown coat that was white.

[Harley PoMMom]

Question Marianne for Rhonda: My doctor gave me Prednisolone 5mg and an injection of Dexamethasone in case of severe vomiting, diarrhea or anorexia in her loading phase of Lysodren 500mg bid, which was 7 days. If her dog becomes severely symptomatic due to, too low of levels of cortisol, couldn't she ask her doctor for these as well?

Jessica

Not Marianne, sorry :o but hopefully my answer will suffice. Some type of supplemental steroid, like prednisone, should be given to the pet parent to have on hand when Lysodren is the method of treatment for Cushing's, so , yes, I would ask the vet for some. just in case. ;)

Hugs, Lori

[RhondaAndDennis]

Hey guys, thanks for the replies. Sharlene, that is very interesting that high cortisol in humans can cause baldness. Maybe his vet has high cortisol. Just kidding. Well, looks like I am going to have to wait this out. Patience is not me. Maybe I will learn from this. Rhonda

[molly muffin]

Yea I think most of us can relate to the patience issue. I certainly am not a good with it either. But hair and skin, they run to their own cycles and nothing we can do will make it go faster.
I'm just guessing but it seems that the time it takes will depend on how much damage was done to the hair follicles themselves. If a lot of damage, then longer period of time and if less damage, the recover wouldn't need a full cycle or cycles perhaps to recover. Too much damage of course and it doesn't come back at all.
So it's just a waiting game at this point with the hair.

[RhondaAndDennis]

Hi, Heres a question that I do not believe has been asked before on the forum. . Last time Dennis went for his acth test and checkup, his vet noticed his teeth had quite a lot of plaque buildup. He had his teeth cleaned a little over a year ago so I was surprised.. I brush his teeth once a day and use a gel on them. He will be 10 next month and the vet really hates to put him under for cleaning. Alright, I can not believe they got so bad in a little over a year. Has anyone seen this in a cushing dog ? Vet said it could be from bacteria in a cushing dog. Thanks a bunch for any help. Rhonda

[RhondaAndDennis]

I know this is probably considered not really important. But I just was wondering if cushings disease can cause teeth to get really bad.Has anyone noticed their dogs teeth getting worse after cushings. Thanks Rhonda

[Harley PoMMom]

Rhonda,

I am so sorry we haven't gotten back to you sooner :( All questions are important ;) as this is how we learn from each other, so please do not hesitate to ask all the questions you want, ok?

So, now, I didn't know the answer to your question so I googled it and it seems when a person has Cushing's is does make them more vulnerable to dental problems...found this
Patients with Cushing’s are at increased risk to develop periodontal disease and its sequelae of tooth loss for two reasons: first, cortisol inhibits white blood cells from migrating into the space between the gum and teeth where they can fight against local bacteria; second, cortisol inhibits new bone formation which contributes to the osteoporosis of the jaw bone https://csrf.net/doctors-answers/effects-of-cushings-qa/cushings-and-dental-issues/

[RhondaAndDennis]

Hey Lori, that's ok. Thank you for looking up the info for me. I know other dogs have a lot more gone on than Dennis. That a good idea ,if information can not be found on pets,go to the effects on people. I did that with hormones and see hormones play a big part in people. I still wonder if Dennis has hormones out of whack. Hopefully his teeth will not continue to worsen. He is getting really bald and I would hate to have him both bald and toothless. Rhonda

[molly muffin]

Every dog has plenty going on that's for sure and when it's your dog well everything is crucial to know at least it is for me. :).
Now see I find this an excellent question and kudos to Lori for finding that info.
I know Mollys teeth are worst than before. we use an anti plaque enzyme spray. Can get off Amazon.

[RhondaAndDennis]

Sharlene, just want to say thank you. I brush his teeth daily and use a product from his vet. I am going to see about getting them cleaned. Vet seem to hesitate. Does dental cleaning go harder on a dog with cushings.? He is almost 10. I would not think that would be an issue. Rhonda

[molly muffin]

It's the anesthesia they are hesitant about not the actual cleaning itself. My vet won't do Molly for that reason either.

[RhondaAndDennis]

Took Dennis in for two polydermas. One on his face, close to his eye and one on the top of his head. He is on 125 cephalexin tablet twice daily .His skin had multi focal spots of pigmentation, crusting lesions and generalized alopecia over his body. This is the vets finding. Is the pigmentation and polyderma normal findings in cushings. I thought most dogs get another type of skin sores. Actually I quite tired of no results with the trilostane. Why give him this toxic drug if I see no results ?. Any suggestions ? As always, thanks a bunch. Rhonda

[molly muffin]

Polyderma is the most common bacterial infection seen in dogs and usually there is an underlying reason, such as an immune system imbalance. Any sort of lesson on the skin can become infected and be polyderma. By far most cushings direct skin issue is the dreaded calicinosis cutis (calcium deposits that come up through the skin and these often become infected)

You could try adding in some lignans and melatonin which is what is used for atypical cushings (when other sex hormones are increased) which I know you have concerns about. They are supplements and can be ordered online. This perhaps will help the hair situation, in addition to the trilostane lowering cortisol. High cortisol over time can cause organ damage, like to kidney, liver, etc. So, even having him on a moderate dose at the levels he is out now, should help with that.

[RhondaAndDennis]

Ok, thank you Sharlene. Calming down a little. I think ,my vet and myself as well got our feathers ruffled. You said what he said. He said even tho the trilostane does not seem to work on the outside, it is protecting him from organ damage, clots and strokes.Can a dog have both regular cushings and atypical cushings.? Vet said not possible and even if it was, trilostane would be the drug used. I kinda lost it. I told him maybe vets need to go back to school and learn more on cushings. Well, at this moment ,not for sure if Dennis has a vet. I do use the melatonin but will order the ligans. Rhonda .

[molly muffin]

Yes they can have both in that, they can have high cortisol (cushings) and they can have two or more other sex hormones elevated (atypical), so..technically he is correct, you either have cushings or atypical, but you can have cushings and elevated sex hormones too.

I know this for a fact, since I had testing done via the University of Tennessee on my dog and she has in fact, elevated sex hormones and high cortisol.

It is easy to have some bad days with this disease. It can be completely frustrating and drive a sane person mad. I imagine that vets feel much the same way when dealing with cushings.

[RhondaAndDennis]

Very interesting. So IF a dog has cushings and elevated sex hormones you still use trilostane and add ligians. Correct ? Rhonda

[molly muffin]

Normally to treat atypical if you have to add in something it is lysodren.

However, if you are already treating for cushings with trilostane and trying to bring down sex hormones in addition (and keep in mind, my dogs were already confirmed high) then I personally would add in the melatonin and lignans. I don't do it on a regular basis, as there are other things that are of primary importance with my dog these days, so I concentrate on that.

But you could add in and see if it made a difference. I would tell your vet though that you want to try this and see if they have any reason that you shouldn't.

[labblab]

Hi again, Rhonda. I'm so sorry that Dennis keeps on losing hair! Given his ACTH results, I would have hoped that you would be seeing some improvement by now. His cortisol is still a wee bit higher than the ideal therapeutic range for dogs for whom all Cushing's symptoms are not fully resolved (which would be between 1.45 - 5.4 ug/dL). But he's so close to that range that I do understand why your vet is not jumping on a trilostane increase at this point, and I don't know whether it would do any good.

However, in answer to your question above, no, most dogs are not put on a combination of trilostane, melatonin, and lignans. From adrenal testing that's been done in recent years, it seems likely that virtually all dogs with elevated cortisol will also have elevations in at least some other adrenal hormones as well. We know only too well that elevated cortisol causes symptoms and damage. The million dollar question is how to predict whether (or even if) those other adrenal elevations will create problems for a dog, too. There is a lot that is still unknown about the effects that may be associated with other adrenal elevations.

For the majority of dogs who suffer from elevated cortisol, though, treatment with trilostane alone remedies the symptoms, regardless of whether or not other hormones may also have been elevated. For this reason, I believe your vet is actually giving you accurate information -- most clinicians don't worry about testing the other adrenal hormones as long as a dog with elevated cortisol is responding well to trilostane (or Lysodren, the other standard treatment). However, there are some dogs for whom symptoms persist, and Dennis seems to be one of those dogs. You probably have nothing to lose by adding melatonin and lignans into the mix. But I also don't know whether or not adding those supplements will help, either. Only time will tell with that.

As I believe we discussed earlier, aside from adding the supplements, I think you've got two other options to consider. The first would be to go ahead and bump up Dennis' trilostane dose a little bit in order to get his post-ACTH level lowered below 5.4 ug/dL. The second would be to switch him from trilostane to Lysodren in order to see whether the alternative drug would offer better symptom relief. However, that is not necessarily a simple switch -- Dennis would have to be "off" the trilostane entirely for 30 days before making the switch, and Lysodren treatment involves a different type of dosing protocol. So having said all that, you may want to first give the supplements a try, or revisit the possibility of a small trilostane dosing increase with your vet.

One thing I do keep forgetting to ask, though, is whether Dennis' thyroid function has been checked recently? Dogs who suffer from Cushing's also seem to be more vulnerable to low thyroid levels. Sometimes the hypothyroidism is secondary to the Cushing's and the levels normalize once the Cushing's is treated. But for other dogs, the low thyroid level requires treatment in its own right, which is very simple -- just some daily medication. But hypothyroidism is a classic cause of skin and coat issues. So I just want to double-check and make sure that Dennis' thyroid levels are fine. On a general blood chemistry panel, the basic thyroid level will be noted as the "T4" level. If the T4 level is low, then a more thorough blood panel can be run in order to fully analyze the dog's thyroid function.

Marianne

[RhondaAndDennis]

Ok, thank you both, Sharlene and Marianne. This hormone issue is very interesting. I think I will try adding the supplements first. Read up more on lysodren treatment and talk to the vet on upping the trilostane a tiny bit. Than, I will decide the next step. His thyroid was tested last August, I believe. I think it was the Free T4. Results were ( .79 ) Normal Result ( 0.6 - 3 He was on the normal low range. Vet said it was ok. Rhonda

[RhondaAndDennis]

Do not want to seem pushy, but wondering if anyone had any thoughts on his thyroid test. Was done about 9 months ago. Vet said it was ok. . Rhonda

[Harley PoMMom]

Hi Rhonda,

You are not being pushy at all ;) if you ever have any questions please do not hesitate to ask them, ok ;)

Many dogs with Cushing's will test low on T-4 levels and it doesn't mean a dog has primary hypothyroidism. T-4 can be affected by any number of illnesses that transiently lowers T-4. This corrects itself when the underlying problem is addressed with treatment. This transient condition is called sick euthyroid syndrome. However if the Free T4 level is low and still hasn't normalized with treatment than I'd be more inclined to believe that the dog does have hypothyroidism. If I thought my dog was having a thyroid issue I would send the blood work samples to Dr. Jean Dodds. Dr Dodds is a world-renowned expert on thyroid disease in pets, more information about her and her lab can be found here: http://www.hemopet.org/veterinary-diagnostic-laboratory.html

[RhondaAndDennis]

Thanks a lot. You are very sweet. I can be pushy at times. Been told that quite a lot. Now the thing is , his vet thinks he does not have a problem with his thyroid at this time. He mentioned the free T- 4 is the best test for thyroid. And being it is in the normal low range it is not a concern at this time. Will recheck in about six months. Plus he said Dennis is not over weight which is a sign in Thyroid dogs. Maybe I keep searching for a reason for his major hair loss. Rhonda