Newly Diagnosed - Reese

[rachlynn1987]

Hi everyone - my name is Rachel and my 13 year old pomeranian mix, Reese, was just diagnosed today with cushings. Reese has always panted a lot but we noticed about 8-10 months or so ago that he was drinking a ton of water and he started urinating in the house (sometimes 2-3 times a day). I originally had talked to my vet back in February because Reese had an eye ulcer and I mentioned the growing issue. At the time he said "its probably behavioral" and shrugged it off. Since then, that veterinarian has retired and when I mentioned it to the new vet she had him blood tested. The results came in today and he has pituitary cushings. She is suggesting starting him out around 10-15mg per day. He doesn't really have other health issues other than he's getting hard of hearing and his eyes occasionally get ulcers.

I guess what I'm looking for is maybe a suggestion on where to get Vetoryl/Trilostane. I've also noticed some posts about dogs health seriously deteriorating within a year or so of diagnosis - I know cushing's isn't really a good diagnosis but are things going to get really bad really fast? Honestly, I'm just a little scared for my pup.

[deannah]

Welcome Rachel and Reese. Not an expert at all but just wanted to welcome you both to the group. Vetoryl is a prescription drug so your vet will have some say in where it is ordered. Just remember to start low and increase if needed, in small increments. My dog, Puckie, a Shih Tzu, about 17.5 lbs and is on a 10 mg daily dose.

Deanna and Puckie

[rachlynn1987]

Thanks Deanna - my vet advised that she is willing to work with whichever pharmacy I choose to go through for the medication which is why I'm looking for recommendations. She said that if I went through the Vet office directly it would be about $75/month for 30mg/day. She would prefer to see him dosed 2x per day at 8-15mg for each dose. This is why I'm kind of interested in compounding - I'm just worried about choosing a good company.

[labblab]

Hello Rachel and Reese! I'm so glad Deannah has had the chance to greet you, and I really want to "second" her recommendation to begin Reese's treatment by starting off at a low dose of medication. Dosing guidelines have changed significantly during the years since trilostane was first introduced as a treatment, and the current general worldwide consensus is to begin at a level that does not exceed a formula of 1 mg. per pound as a daily total. Even if a dog is going to be dosed twice daily, the cumulative daily total should not exceed the 1 mg. per pound amount. Many vets are still relying on previous editions of published guidelines (which is understandable). But we are trying very hard to let folks know of recent dosing changes that are being advocated even by Dechra, the company that manufactures brandname Vetoryl. Here is a link to a post on our Trilostane FAQs thread on our Resources forum that discusses these changes in greater detail.

http://www.k9cushings.com/forum/showthread.php?p=1251#post1251

I mention all this because if Reese is a Pom mix, I am guessing the lower end of your vet's suggested range will be more appropriate than the upper end. And in terms of a reliable compounding pharmacy, through the years we have had many members express their satisfaction with Diamondback Drugs, a compounding veterinary pharmacy located in Arizona. My understanding is that they will ship medication anywhere within the U.S., and also worldwide if the receiving country will allow drug importation. If you are interested in learning more about them, you can visit their website at diamondbackdrugs.com.

Being the nosy group that we are :o, we'd also love to hear more specifics about Reese's diagnostic testing. Since pituitary Cushing's was diagnosed, I am guessing the diagnostic blood test was the LDDS. Could you find out Reese's actual numerical results on that test? Also, has he exhibited any other abnormalities on standard blood or urine panels? There are certain lab results that are common with Cushpups, and can help to give further validation of the overall diagnosis.

Thanks in advance for any additional information you care to share, and once again, welcome to our family!

Marianne

[rachlynn1987]

Marianne- he did go through the LDDS testing. I don't have a copy of the results yet but plan on getting a copy from the vet tomorrow and will post the results then. We did a urine and basic blood panel first as they thought he might have diabetes. They had trouble with the urine because it was soooo diluted from excessive water consumption. I swear Reese drinks more than our basset and doxie/beagle mix combined!

I spoke with my vet about the possibility of not medicating but she seems concerned that he'll begin developing more symptoms and quality of life will decrease if we don't treat. I fear that things may get worse due to side-effects and that my choice is going to make things worse for my baby.

He's 13 and has no problem with stairs but he is not very active (unless you have food in your hand). Our initial concern had been that he kept accidentally peeing in the house. To clarify, we have a walkout basement and a doggy door into our fenced in backyard. He'll go downstairs (especially at night) to go outside but then pee in the basement. He's always been a heavy panter that I know of (I adopted him at 9 years old so I don't know much prior history) but the water consumption thing started 8-10 months ago. At first we attributed some of these things to age but now he's peeing downstairs 2-3 times a night and there have been a couple cases lately where he doesn't even make it that far.

[labblab]

We surely understand how nerve-wracking it is to contemplate treatment decisions! If it helps, though, we have had so many members through the years who have witnessed improvement in their dogs' outward symptoms once the medication was started, as well as improvement in lab results that can be associated with chronic internal damage. Yes, the drugs are powerful, but with proper dosing and monitoring, unwanted side effects can often be minimized or resolved. This is one reason, though, why we harp on starting the dosing at a lower level.

Through our experience on the forum over the course of the past decade, we have seen many dogs who ended up suffering from unnecessary side effects simply because they started out on doses of the medication that turned out to be too high for their systems to tolerate. Side effects can occur at any time and at any dose, but the likelihood of problems is exaggerated when dogs are started out at levels that are high to begin with. Even if cortisol levels are technically not oversuppressed, dogs can still feel really yucky if high levels of cortisol are suddenly reduced very quickly ("corticosteroid withdrawal syndrome"). So for several reasons, it is usually far better to start at a lower dose and work upwards if necessary, rather than vice versa.

Marianne

[molly muffin]

Hi and welcome.

Absolutely he can do well on treatment we see it all the time.
The key is start low at the 1 mg/1lb Marianne mentioned. Test in 2 weeks to see how his levels are and how is body is handling it and usually levels will continue to drop for at least 30 days on the same dose.
No one knows how a dog will react to any medicine till you start it.

But following the proper protocols and being safe he can do very well.

[rachlynn1987]

Im not sure exactly how to read or explain these results but here is the main data from the test: they took 3 samples - the first was 2.7, second was <1 an the last was 1.8.

[molly muffin]

Was this the LDDS test that he was initial tested for cushings using?

Do you have the normal range the test? They are not all usually consistent so we like to see what ranges the lab your vet uses gives.

But if the third draw is outside of the of the normal range then this might be what they are using to determine pituitary cushings. I wouldn't think he is much outside of that range though.

Did they do a culture and urinalysis to rule out a UTI at the time they where doing all the testing?

[rachlynn1987]

Here are the 3 draws with ranges: 2.7 (1.0-5.0), <1.0 (0.0-1.4), 1.8 (0.0-1.4). He had this test (it's labeled as "cortisol serial 3 (DEX)" on the paperwork. He had regular bloodwork and a urinalysis a couple of days before. Would any of those stats be useful? It included a lot of regular checks, something called a Total T4 and urinalysis data.

[molly muffin]

Okay, yes the LDDS that was used for diagnosis and yet it does point to pituitary cushings.

Only the things on any test that are abnormal, out of range.

for example.

ALKP 650ug (50 - 150ug)

[rachlynn1987]

On his original bloodwork, the following were abnormal:
Albumen - 2.3 (2.7-4.4),
A/G ratio - .7 (.8-2.0),
Alk Phosphatase - 627 (5-131),
Magnesium- 1.3 (1.5-2.5),
Cholesterol- 355 (92-324),
Triglyceride- 898 (29-291),
Platelet count - 64 (170-400), and
Monocytes- 920 (0-840).

On his urinalysis the following were off:
Specific Gravity - 1.013 (1.015-1.050),
pH - 8.5 (5.5-7.0), and
Protein - 3+ (negative).

[lulusmom]

Hi and a belated welcome to you and Reese

I just looked at the lab results you posted and have some concern with some of the abnormalities as they aren't what we are accustomed to seeing. Reese's triglycerides are very high so I'm wondering if Reese was fasted and/or if there is any mention of hemolysis or lipolysis on the blood chemistry results? Is Reese overweight? Is the glucose, lipase, amylase, BUN and creatinine all within normal range? Did your vet discuss Reese's high triglycerides with you. They are very high and the goal is to reduce that number to under 500. is a problem and it should be monitored closely. .

Aside from excess drinking and peeing, what other symptoms associated with Cushing's does Reese have. Reese is a Pom or Spitz mix and both are Northern breeds, which are known to be genetically prone to hormonal imbalances, so I'm wondering if there are any skin issues and loss or thinning of coat? Any change in skin pigmentation? Have you noticed any muscle wasting, specifically in the hindquarters? Is he begging and foraging for food like he's absolutely starving constantly?

Urinary tract infections can cause high urine PH and Reese's PH is very high. Did your vet do a urine culture to rule out a UTI? Did you collect the urine specimen at home or did the vet collect it with needle into the bladder through the abdomen? Free catch specimens left at room temp for too long can cause increase in urine PH as can a container that has not been rinsed well of detergents. It is not uncommon for dogs with cushing's to have 1+ to 2+ protein in their urine but Reese's is higher than what we usually see. Did your vet discuss Reese's PH and 3+ protein with you?

A lot of Reese's lab abnormalities are commonly found in dogs with canine tick borne diseases. Did your vet rule this out?

I'm sorry for all the questions but I am always concerned about the accuracy of a cushing's diagnosis when an LDDS test has not been validated with additional tests, such as an abdominal ultrasound or acth stimulation test, and lab abnormalities not normally consistent with cushing's are present. I'm sure your answers can fill in the blanks for me.

Glynda

[judymaggie]

Hi to you and Reese! You have already received great guidance from our in-house experts. I just wanted to add another concern to Glynda's re the lab results -- I am concerned about the very low platelet count and wonder if your vet discussed this at all.

[rachlynn1987]

Reese isn't overweight and, due to the initial visit timing, hadn't fasted before that initial bloodwork. I don't have the lab results on me right now but all of the other levels were within normal range.

I have noticed recently that he has small bare patches in his fur - nothing that is very obvious to others but I notice when looking him over regularly. He also has dry skin though it doesn't bother him - it's just kind of flaky.


He has always been a begger for food since I got him at 9yo so I'm not sure how easily I would notice him looking for even more. He has gained 2lbs since I had last weighed him back in February (less than 6 months before)which is more fluxuation than I've seen in his weight before. He has a small pot-belly but its not a huge one at this point too. He's also been sleeping more than usual - he's always been kind of chilled but I find him sleeping in his bed a lot more now.

His urine sample was a free catch done at the vet's office.

The vet did mention his platelet count and wants to keep an eye on it as he hadn't had bloodwork done very recently prior to that and she wanted to compare before declaring it an issue. She also mentioned the protein and plans on keeping an eye on those two items in particular. I'm guessing she didn't mention the triglycerides because he didn't fast? I'll have to check with her on that one.

[molly muffin]

Since he wasn't fasted for the test, that might account for the trig being high, so maybe a fasting test later to keep an eye and make sure that isn't an issue. Also a good time to take another look at the platelets and see how they are doing.

With the urine being dilute, they might need to culture it to see if there is actually a UTI or not and I see protein of +3 so as long as they are doing a urinalysis they could do a UPC (urine protein createnine ratio) to see how that is.

[rachlynn1987]

I talked with the vet yesterday to schedule his ACTH test since he's almost been on trilostane for 2 weeks now. She said she'd take some additional blood/urine to re-evaluate the protein, blood platelets, and cholesterol specifically at the same time. We'll see how it goes on Monday.

[labblab]

Hi again! I'm a little concerned hearing that your vet plans to draw blood to check cholesterol at the same time that the ACTH is going to be performed. As noted in previous conversations, you want the cholesterol to be checked after the dog has fasted. However, in order to convey accurate results, all monitoring ACTH tests must be performed 4-6 hours after the trilostane has been given along with breakfast. Trilostane is not metabolized efficiently when given on an empty stomach, so ACTH testing after fasting may give falsely higher cortisol readings.

So the bottom line is that one test should be a fasted test, while the other should not. Even though it is inconvenient, I do think the blood samples need to be obtained at different times.

Marianne

[rachlynn1987]

He's going to be at the vets office for the whole day since I can't leave work to drop off or pick up in the middle of the day. She planned on taking a final blood sample (for the cholesterol test) just before I pick him up around 4:30 and he won't be fed while he's there (he ate at 7am with his meds). Isn't that a long enough fasting time?

[labblab]

Yes, that timing should be fine, then. :)

Thanks so much for the added info, and good luck to you guys on the testing!

Marianne

[molly muffin]

Crossing fingers that the tri will be lower with no food.