Suppressed Immune System - Is this because of Trilostane or just Cushings related?

[Sofie's Mum]

My little girl Sofie was diagnosed in July. Had her LDDST, followed by an ultrasound which showed she has Pituitary Cushings. Started Trilostane syrup end July and has had her ACTH Sim Test mid August. This test showed her levels for Cortisol and Cholesterol are declining, which is fantastic news. On Monday she was at the Vet for Eye infection and a wheezing after each bark. I have read that with Cushings they can get blood clots in the lungs, so I was very concerned. After a thorough examination, her lungs were clear and she was sent home with eye ointment and antibiotics. By Wednesday she had an ear infection and Friday could hardly stand with trembles and listlessness. A trip to the Vet again, blood tests run and still her levels are good. No sign of Pancreatitis and diagnosed with Inflamation of Unknown origin. She was given an anti inflammatory and armed with a digital thermometer and my Vets mobile phone number, I have been taking her temp every few hours. The Vet feels that it is not Trilostane related but her immunity is very low right now. I'm waiting for Monday when she comes off the anti inflammatory medication and seeing if her fever returns. Hopefully she will get past this. Her temp has gone to normal levels now. Always vigilant of every health issue. You can't ignore anything. Don't know how to boost her immunity. Time I suppose but the good thing here is Trilostane is working. If all goes well here, her next ACTH Test is in 2 weeks time. Fingers and toes crossed for my little girl.

[Harley PoMMom]

Hi and welcome to you and Sofie!

First, if she is not feeling well the Trilostane should not be given, is this being withheld?

I'm so sorry your girl is having these issues and along with Cushing's to boot :( If you could tell us more about Sofie's health history that would enable us to provide you with meaningful feedback, the way we get to know your girl better is by asking a bunch of questions, ok?

Could you get your hands on copies of all tests that were done on her and post those values that are abnormal along with their reporting units and reference ranges? Also we are especially interested in the results of all diagnostic and monitoring tests (ACTH stimulating) that were performed on Sofie for the Cushing's. What symptoms led you or your vet to test for Cushing's in the first place? Does she have any underlying health issues that she is taking medications for? How much does she weigh? What is the dosage strength of Trilostane is she on, and is this given once or twice a day? It is very important that the proper treatment protocols are being followed, such as giving the Trilostane with food and that the ACTH stim tests are performed 4-6 hours after the dose of Trilostane is given, are both of these being carried out?

Ok, I believe I have asked enough questions, and will be looking forward in hearing more about sweet Sofie. Please know we will help in any way we can, and do not hesitate to ask all the questions you want.

Hugs, Lori

[molly muffin]

Lori is right, the manufacturer recommends that trilostane not be given while the dog is sick.

I hope that Sofie is doing much better by now.

Welcome to the forum.

[Sofie's Mum]

I asked my Vet today for my girls blood work results since she was diagnosed last year. I've been looking at her Annual Health Profile and discovered that her ALP levels have skyrocketed from diagnosis to commencement of Trilostane. On her initial blood work dated
22 April 2015
ALP 165
ALT 50
AST 33
Gamma GT 165

26 June 2015
ALP 301
ALT 210
AST 110
Gamma GT 29

28 August 2015
ALP 501
ALT 180
AST 40
ABS 121
Gamma GT 16

She commenced Trilostane July 2015. What I'm curious about is, why has her ALP levels jumped up to such a high level? and all others started to come down. These tests are old (August 2015) and she has only had the ACTH Stim test regularly and has shown to be in normal levels. eg her last test:

13 August 2015
Cortisol Resting 66 reference range 15-170nmol/L Normal
Cortisol 1st Post 160 nmol/L

17 September 2015
Cortisol Resting 111 reference range 15-170nmol/L Normal
Cortisol 1st Post 195 nmol/L

6 Nov 2015
Cortisol Resting 119 reference range 15-170nmol/L Normal
Cortisol 1st post 173

24 Feb 2016
Cortisol Resting 99 reference range 15-170nmol/L Normal
Costisol 1st post 118

Should she be having another blood panel done? She appears to be a happy healthy energetic girl now since she's been on her meds. No panting, licking, excessively eating. She never had a problem with polyuria. She does occasionally (once or twice a week) have front belly problems (gurgling and squeaking) she is off her food and very lethargic, but usually recovers within 6-8 hours after initially first showing signs. I know I should probably ask for another blood panel to be done and I will. It's just that I only asked for this today and have been researching the heck out of this and cannot come up with anything other than Liver Disease and normal for Cushings. Thanks in advance for your time.

[Squirt's Mom]

MODERATOR NOTE: I have merged your post with Sofie's lab results into her original thread. We like to keep all posts about each dog in their own thread. That way it is easier to look back through the history if needed. In addition, her thread will serve as sort of a record for you. Thanks!

[Harley PoMMom]

Could you add the reference ranges for these values..thanks! You can just edit your post to add them.



22 April 2015
ALP 165
ALT 50
AST 33
Gamma GT 165

26 June 2015
ALP 301
ALT 210
AST 110
Gamma GT 29

28 August 2015
ALP 501
ALT 180
AST 40
ABS 121
Gamma GT 16

[Sofie's Mum]

What symptoms led you or your vet to test for Cushing's in the first place?

I mention last year that Sofie was eating and drinking in excess and licking her feet constantly. She then ran an annual health profile. It's based on Low Normal and High. In the High range were for 22 April 2015:

Haemoglobin 218 reference range 100-206 g/L High
MCH 28 reference range 21-26 pg High
MCHC 389 reference range 310-360g/l High
Albumin 43 reference range 23-40g/L High
ALP 165 reference range 1 -150IU/L High
Cholesterol 10.1 reference range 3.5 - 9.0 mmol/L High
Everything else was in Normal range

This profile was done and followed up by a secondary blood test.


2nd Annual Health Profile 26 June 2015
UREA 12.0 reference range 2.5 - 10.0 mmol?l High
Albumin 42 reference range 240 g/L High
ALP 301 reference range 1-150 IU/L High
AST 110 reference range 18-80IU/L High
ALT210 reference range 16-90IU/L High
Cholesterol 10.7 reference range 3.5-9.0mmol/L High
Gamma GT 29 reference range 0-9IU/L High

Commenced Trilostane 17 July 2015

Annual Health Profile 28 August 2015

Reticulocyte ABS 121 reference range 10-110 x 10^9/L High
ALP 501 reference range 1-150 IU/L High
ALT 180 reference range 16-90IU/L High
Gamma GT 16 reference range 0-9IU/L High

Does she have any underlying health issues that she is taking medications for?

No. Although last September after upping her dosage of trilostane from 6.5 ml to 8.3ml (on the same night) she had problems breathing. She spend the early part of the morning in Emergency and on oxygen. The following day was transported to an Animal Referral Hospital where CT scan and more xrays were performed. She had

Increased thickness of the soft palate
Increased fluid with the nasal cavity
Nasopharyngeal collapse
Possible everted laryngeal saccules
Dynamic intra-thoracic tracheal and left Ibronchial collpse
Right cranial lung lobe atelectasiaconsolidation - could be due to bronchopneumonia, collapse during anaestethesia
Enlarged Heart - possible due to heart valve disease
After 4 days in hospital, was sent home with antibiotics: Antirobe 1.5ml twice a day for 10 days; Enrotril oral 2mls once a day 10 days; ACP 10mg tabls 6-12 hours for sedation; Bricanyl 5mls twice a day and enforced rest. She recovered and now is a different dog. Before commencing Trilostane her symptoms were being masked and once the Trilostane started to work on dropping her Cortisol level her bacterial infection took hold and brought all her health problems to the fore. She breathes normally now and no signs of any breathing difficulties. I also had her teeth cleaned under sedation in October 2015 just to be sure of no bacterial infection from dental problems. Her health seems greatly improved.

How much does she weigh?

6.5 Kilo

What is the dosage strength of Trilostane is she on, and is this given once or twice a day?

6.5 ml once a day compounded syrup.

It is very important that the proper treatment protocols are being followed, such as giving the Trilostane with food and that the ACTH stim tests are performed 4-6 hours after the dose of Trilostane is given, are both of these being carried out?

Trilostane is always given in her food at breakfast. She has her ACTH blood test done 4 hours after initial dose.

Looking at her, she looks wonderful and healthy. She walks well and plays and seems like she's coping well. I was just concerned with her liver enzymes results from August. Should I seek another Health profile just to check on her Liver.

[molly muffin]

I would yes do another blood work up. I usually do every few months when things are off.
Is she taking any kind of liver support supplement? I would introduce that if not. Something like milk thistle, sam-e for instance.

[Sofie's Mum]

I do have Milk Thistle and Sam e but do not know how much to give her. Are human Milk Thistle capsules suitable for dogs? The one I have at home is Nature's Own High Strength Milk Thistle 35000mg capsules. On the bottle is says: Each capsule contains Milk Thistle (Silybum marianum) extract equiv to dry fruit (35g) 35000mg stand to contain flavanolignans calculated as Silybin 380mg. She weighs 6.5 kilo. I did buy this will the purpose of giving it to her, but was unsure if I was doing the right thing for her. I've also had her on Kefir probiotic for 2 weeks. Just 1 tsp a day to help with her gut flora.

[Wuchi]

Found an article on the capsule/powder strength for dogs: http://www.canine-epilepsy-guardian-angels.com/milk_thistle.htm sounds like it's smaller 1/2 to 1/4 of recommended dose. Side effect of too high a dose is an upset stomach.

Since my dog is too small to take a pill I use the liquid form (purchased at Pharmica -- but available elsewhere).
With the liquid one you want to try to get alcohol free. Was giving it once a day with food (don't think that's required) -- 0.125 ml for a 4-5 lb dog.

In addition to helping the liver heal it seemed to help with her skin a lot -- my dog hadn't had hot spots up until i took her off of
Milk thistle (might be a coincidence timing wise but starting her up again on it to see if it helps calm her skin down).

[lulusmom]

Sophie's liver enzymes really weren't that high. We've seen the ALKP as high 5,000. From what I could ascertain from the information you provided, Sophie's cortisol was not effectively controlled when the blood chemistry was done in August 2015, so one would expect the see the ALKP continue to rise from April to August. I assumed Sophie's cortisol was not controlled in August as you stated that in September you increased her dosage of trilostane from 6.5 ml to 8.3ml. Milliliter (ml) is the measurement on the syringe so it would be helpful if you could look at the bottle and tell us what that actual dose is in mg? For instance if the dose is 20mg, a full 1 ml syringe would equal 20mg.

After reviewing the list of very scary differential diagnoses when Sophie was hospitalized in September, can I assume that your girl is brachycephalic (short snouted) breed like a boston terrier, pug or Shih Tzu? That list is definitely something you would see in those breeds. A lot of those conditions are not caused by cushing's but can be exacerbated by it, especially those involving respiratory issues such as collapsing trachea. Were any of those conditions ultimately diagnosed and is she taking any medications for them? Enlarged heart is definitely a sign of heart disease and I don't believe enlarged hearts return to normal size. Also, you mentioned that after starting trilostane treatment, a bacterial infection was unmasked. What type of infection was it? One of my cushdogs was a shelter rescue who appeared to have advanced disease and his long standing high cortisol was the cause of his multiple bacterial infections. The only thing that cortisol was masking for him was arthritis which became apparent after treatment.

Blood values can change over night and because the last blood chemistry was done seven months ago, it is quite possible that Sophie's liver enzymes are lower now but you won't know that until you have a new blood chemistry done. Given Sophie's history and her relatively short time on treatment, I would definitely do a complete senior screening. Her last acth stimulation test looks perfect and as long as all of her symptoms have resolved, I think you're golden.

Glynda