Bodhi - Diagnosed with Cushing's and Hypothyroid?

[Bodhi's Mom]

Hi, I'm new to all of this so it's nice to have someone to bounce things off of finally.

My 8 yr old (we think) Yorkie was recently diagnosed with Hypothyroidism and Cushing's. He is a rescue so we are not sure of his exact age. We have increased his Vetoryl dose twice and he is currently on .1 mg BID of Soloxine and 30 mg of Vetoryl SID. He is 12 pounds and the dose of Vetoryl seems high to me but his ACTH was 5.5 (pre) and 22.1 (post) on 10mg and 5 (pre) and 17.5 (post) on 20mg. His T4 is still .5 but my vet said the Cushing's may be affecting his reading so we need to wait until his Cushing's is managed and then see what his T4 says.

I guess my concern is whether that is the correct thing to do or not and is it possible that he has both all of a sudden or could his Cushing's be affecting his thyroid reading and he isn't actually hypothyroid?

[mytil]

Hi and welcome to our site.

It is possible to have both but wanted to add low thyroid function can sometimes be associated with Cushing's. Here is a good link to read through - http://www.k9cushings.com/forum/showthread.php?t=2256.

I agree with you, that does seem like a high dose for your pup's weight. Was the ACTH test performed 4-6 hours after the dosage?

Keep us posted
Terry

[Bodhi's Mom]

It was done about 4 1/2 hours post pill. Is it better to dose once a day or twice a day?

[molly muffin]

How long has her been at 30mg of vetroyl? Keep in mind a dose will usually co to ie to lower for 30 days on the same dose.
WhAt where his symptoms and as terry mentioned thyroid and Cushing symptoms can over lap.
Also hane you had regular blood work done and a urinalysis? If so could you post any abnormal values. High or low and their ranges?

This will help us to give you better feedback.

Welcome to the forum

[Bodhi's Mom]

He has only been on the 30mg dose for a few days but he was on the previous doses for 4 weeks each. His symptoms were drinking a lot, very hungry, thinning hair, weight gain, so we did a blood panel which I will have to post the exact results of when I get home tomorrow because I do not have them with me. His blood panel didn't show anything out of the ordinary, his liver values were just slightly high and his kidney values were normal so my vet decided to do a T4. The T4 results were low (.5) so we started him on Soloxine .01 mg BID, and rechecked him after 4 weeks. The results had not changed so we increased his dose to .02 in the am and .01 in the pm. After another 4 weeks his symptoms had not changed and he was getting pot bellied so the vet decided to test him for Cushing's. We did a LDDS and then a HDDS and an abdominal ultrasound, his liver was enlarged but everything else looked normal so we started meds at 10mg. The ACTH results were still high (5.5 pre 22.1 post)at next testing so we increased to 20mg, still high (5.0 pre 17.5 post) this last test 4 days ago so we increased to 30mg. I will post the numbers from his bloodwork as soon as I can.

Thanks,
Stacey

[Squirt's Mom]

Welcome Stacey to you and your baby!

Is Bodhi taking the med WITH a meal? Is the vet having you fast for the ACTH by any chance? This a fat soluble drug which means it must be taken with a full meal (even when the ACTH is going to be done) or it will not be absorbed and used in the body, it will simply slide on thru for the most part. This drug has a very specific protocol and if that is not followed the results of the monitoring ACTHs are worth nothing and the results they show are not an accurate picture of the cortisol level.

I look forward to seeing the diagnostic test results. Normal labs are not normal for a cush pup. ;) We typically see elevations in some of the liver values and CHOL to name a couple, kidney values may be off, specific gravity of the urine is off, the adrenal glands seen on the ultrasound are enlarged as is the liver. So those test results will help us give you more meaningful feedback.

I'm glad you found us and look forward to getting to know you and Bodhi!
Hugs,
Leslie and the gang

[Bodhi's Mom]

First I just want to say thanks to everyone for all of their advice and time, it's nice to have people to talk to who are familiar with my situation. He does take his Vetoryl with food he gets it with his morning meal, and no he didin't fast before his ACTH. Here are his bloodwork results.

ALP=277 5-160 U/L
ALT=398 18-121 U/L
GGT=120 0-13 U/L
PHOS=7.0 2.5-5.1 MG/DL
CHLORIDE=105 108-119 MMOL/L
ANION GAP=28 11-26 MMOL/L
MCV=77 59-76 FL
MCH=26.5 21.9-26.1 PG

Here are his LDDS results.
PRE=7.8 1.0-6.0 UG/DL
4HR=10.1 LESS THAN 1.5 UG/DL
8HR=8.3 LESS THAN 1.5 UG/DL

These are the HDDS results.
PRE=7.5 1.0-6.0 UG/DL
4HR=10.5 LESS THAN 1.5 UG/DL
8HR=6.1 LESS THAN 1.5 UG/DL

And I was mistaken about his ultrasound results, they did say that his both adrenal glands were slightly enlarged as well as his liver.

[molly muffin]

Hmm, okay so the lab work isn't normal, and my concern looking at the results is that the ALT and GGT are both Very high out of range. These two are very liver specific values.

In cushings we would expect to see the alt and ggt maybe a bit elevated, but usually it is the ALKP that is very high.

Have they done a liver specific testing such as a Bile Acid Test?

While the LDDS does support cushings, it could also be a false positive if some other chronic disease such as liver is going on? Obviously the adrenal glands are producing excess cortisol, but this would happen also with a chronic disease.

The phosphorus being elevated is a bit of a concern too. You want to watch that. I think I'd ask about the bile acid test if they haven't suggested that to you.

[Bodhi's Mom]

They haven't done any liver testing I guess because the internal medicine specialist I took him to didn't seem concerned with any of his labs. But I will check into the bile acid test. Could any of those levels be affected by his thyroid also being so low? Something else that concerns me is whether I may be giving him thyroid meds for a thyroid problem he doesn't really have. I have read that it is possible for Cushing's to affect thyroid levels.

[Squirt's Mom]

I'm with Sharlene and would want them to focus on the liver first and foremost.

We don't see the HDDS very often any more! My Squirt had one done 8+ years ago and even then people were telling me they didn't see that often! :) But it did determine which form Squirt had - PDH. Now the LDDS can do that making the HDDS obsolete. Makes me feel happily nostalgic, tho. ;)

The ultrasound results stating that both adrenals are enlarged says your baby also has the most common form - PDH.

[Bodhi's Mom]

Thanks for all the input, he is due for another ACTH next week so I am going to bring up the liver testing then. Also, I noticed a discussion on Hill's food that did not have a very high opinion of it so I was wondering what everybody feeds. I have been to the dog food advisor website but I was hoping to get some opinions here on what is best. I have always fed Science Diet because it is one of the few foods with large pieces to help keep teeth clean. Even though my baby is only 12 pounds if I feed him something that isn't large pieces he swallows it whole and doesn't chew, lol.
And what is everyone's opinion on once a day or twice a day dosing of the Vetoryl? My vet has never heard of twice a day dosing until I went to the specialist and she said that is the way she doses it. Is the compounded version just as good as the brand name? Sorry for all the questions, this is just very new to me and I am trying to gather all the info I can.

:confused: Stacey and Bodhi

[Harley PoMMom]

I'm answering some of your questions using excerpts from Dr. David Bruyette who is a member here but has not be active in some time. A little FYI about Dr. Bruyette; Dr. David Bruyette is a renown endocrine specialist, he is also a very experienced Vetoryl (Trilostane) prescriber and frequent contributor to Dechra's veterinary CE courses:




And what is everyone's opinion on once a day or twice a day dosing of the Vetoryl? My vet has never heard of twice a day dosing until I went to the specialist and she said that is the way she doses it.


...With regards to once vs twice a day dosing if we look at all the studies throughout the world you will see that about 80% of dogs do well with once daily dosing. One huge advantage of once daily dosing is owner compliance which goes up substantially when owners only have to dose once a day. While twice a day dosing may result in a lower amount of trilostane being used pre day it will require closer monitoring as the ACTH stimulation tests tend to be lower so we have to look for both hypocortisolemia and electrolyte abnormalities...

Dave Bruyette DVM DACVIM



Is the compounded version just as good as the brand name? Sorry for all the questions, this is just very new to me and I am trying to gather all the info I can.
:confused: Stacey and Bodhi


This also brings up the issues of compounding medications and not using the veterinary approved products. A couple of facts/comments that might help -

· Compounding pharmacies are not purchasing trilostane from Dechra. Dechra has an exclusive supply arrangement with the Italian company that holds the MDF (Master Drug File). This European company is the only manufacturer approved by FDA. That means the probable source of compounders bulk trilostane is an uninspected manufacturing facility in China or India.


Sources of Problems w/ Compounded Drugs

o Reformulation of any drug product into a compounded drug product alters the behavior of the finished version of the drug.
o Compounded drugs are not equivalent to generic drugs.
o Compounded drugs are not subject to external quality control measures with regard to consistency of the manufacturing process, amount/potency of drug, consistency of formulation, lack of contaminants, and evaluation of inactive ingredients or incipients.
o The stability, bioavailability and bioequivalence of compounded drugs has not been evaluated.
o Several samples of US compounded trilostane products were analyzed by Dechra and contained <90% of the labeled content.

· Key Points from the AVMA Position Statement on Compounding (Available on the AVMA website)

o Compounding is the manipulation of a drug, other than in accordance with the FDA approved label, to make a different formulation of the drug to meet the needs of a specific patient.
o Compounding may impact the absorption of a drug. The use of a compounded drug may result in drug concentrations that lead to the development of an adverse event, including therapeutic failure.
o Use of a compounded drug should be limited to those drugs for which both safety and efficacy have been demonstrated in the compounded form in the targeted species.

· According to the AVMA PLIT if a veterinarian uses a compounded drug where there is an FDA approved animal drug, their professional liability (malpractice) insurance coverage may be voided.

Dave Bruyette

Sometimes compounding is the only option because Dechra may not make a dose strength that is needed and compounding is a lot cheaper than brand name Vetoryl. When deciding to compound than one has to make sure they are getting their medication from a reputable compounding pharmacy, many of our members use Diamondback as their online pharmacy agent, here's a link to their website: http://www.diamondbackdrugs.com/

Hope this helps.

Hugs, Lori

[Bodhi's Mom]

What does everyone feed their pups? I have done some research online but I was hoping for some personal opinions. I need a food that comes in large kibble because my little guy swallows his food whole unless it is large enough that he has to chew it.

All opinions welcome and appreciated :)
Stacey and Bodhi

[Bodhi's Mom]

Hi all! I have been a member for a while but haven't posted much. (I'm more of a hang in the background kind of girl...lol.) I have a 10 year old Yorkie with Cushing's and hypothyroidism. He was diagnosed almost 2 years ago and was doing just fine on his meds this time last year but we have had trouble keeping them adjusted for about the last 6 months. He is 11 pounds (should be 10) and he is on 30mg of Vetoryl once a day and .1mg Thyro-tabs twice a day and his ACTH is high and his T4 is low. His liver values are down from this time last year. I am afraid to increase the Vetoryl because he is already on such a high dose. He has only one Cushing's symptom and that is panting I think all his other symptoms are thyroid related. Does anyone have any suggestions? My vet and the IM specialist are completely puzzled by it.

3/18/16
ACTH pre 1.0 ug/dl post 5.4
T4 3.6 ug/dl
ALP 283

9/09/16
ACTH pre 9.3 post 15.4
T4 0.7
ALP 182

[Squirt's Mom]

Hi Stacey,

I have merged your new thread about Vetoryl no longer working with Bodhi's original thread. We like to keep all info about each pup in one thread. That way it is easier for both members and you to look back thru the history if needed. I have taken the liberty of adding Bodhi's name to the thread so it is easier for you to find in the future.

I will let those more sure about Vetoryl talk with you about the high ACTH values. ;)

Thanks!

[mydogsmom]

Hi! Sharlene, is the ALKP value you refer to the same as ALP? My dog's bloodwork doesn't show ALKP. Thanks! Barbara, mom to the beautiful Miss Harriet!

[Squirt's Mom]

Hi Stacey,

I do have a couple of questions about how the Vetoryl is given and how the ACTH is performed...

Are you giving the Vetoryl with a meal, full meal? Are you giving it with a full meal before the ACTH? or is your vet telling you to fast Bodhi for the ACTH?

Is the ACTH given 2-6 hours after the dose of Vetoryl? And is the ACTH given at the same time interval every time? ie is it always given at 4 hours after the dose?

Hugs,
Leslie and the gang

[Squirt's Mom]

Hi Barbara,

Yes, ALP and ALKP represent the same liver value - Alkaline phosphatase.

Hugs,
Leslie and the gang

[Harley PoMMom]

Hi Stacey and welcome back!

Was the last ACTH stim test performed on 9/09/16 with a pre 9.3 and post 15.4? Besides the panting, what exactly are the other symptoms you are seeing? And can you clarify for me what trouble was happening with getting his meds adjusted? Sorry for all these questions but the more we know the better our feedback can be, ok?

Hugs, Lori

[Bodhi's Mom]

Yes that is correct. It was just a long process getting to the place where he was within range. We started him at 5mg twice a day and that helped slightly but not much so we went to 10mg twice a day still not much improvement. So we went to 15mg twice a day, not much better than the previous dose. We thought maybe it was because we were having it compounded, so went to the 30 mg once a day (Vetoryl) and that seemed to do the trick, his numbers were normal, his drinking was normal, his belly was gone and he was back to normal weight. Then a month or so before the ACTH in Sept I noticed he was panting again...not a lot just more than is normal for him. He only really has the panting...he has the appetite, but he has always been an "enthusiastic" eater so I can't really judge by that ;) ..He has skin issues but I think that is all related to his low thyroid because it is dry and flakey and his hair is thin. And he is back to 11.5 pounds which is about 1.5 pound over his normal weight but I think that is also because his thyroid is low again because he doesn't have the pot belly. I just have no idea what could be causing it. :confused:

[Bodhi's Mom]

Hi Leslie,

Sorry I just saw your reply. Yes I give his Vetoryl in the morning with his breakfast. I do feed him and give him his meds the morning of his ACTH and yes we always do it at the same time frame which is 4 hours after his meds.

[molly muffin]

If you haven't had an ACTH since September last year, then I would go ahead and schedule an ACTH to find out where is numbers are at now.

[Bodhi's Mom]

I will do that, a few people told me that I should have a whole adrenal panel and ACTH done by the University of Tennessee Vet School to see if there was anything else like hormones affecting his cortisol. Has anyone here had it done or have any thoughts about it?

[molly muffin]

I have had the University of Tennessee test done. It is most often used when the cortisol is normal but symptoms are persistent to see if other hormones are elevated in which case you could have atypical cushings.

I think the main thing is to find out where the cortisol is right now so you can react to it if it is low/high, with a dosage change.
Since he did react well to the previous lowering dose, this could be the case.

[Bodhi's Mom]

We have never lowered his dose. I may have misunderstood what you meant by that. It makes me very nervous to increase his dose considering how high it is already. I know some dogs need higher doses but his is already 3 times the starting dose. :eek:

[Squirt's Mom]

Some dogs need Lysodren instead of Vetoryl and vice versa. Has Bodhi had an abdominal ultrasound to make sure there is nothing going on with his organs? Do you know if he has the adrenal based or pituitary based Cushing's? ADH, adrenal based, can often take very high doses and increasing doses to keep the cortisol controlled.

[Bodhi's Mom]

He had an ultrasound about 18 months ago at the IMS when he was diagnosed. she said it appeared to be PDH because both adrenal glands were slightly enlarged as well as his liver. I am hoping it doesn't come to that because my vet knows very little about Lysodren and the closest IMS is an hour away. But if that is what we have to do we will. :)

[molly muffin]

No I'm thinking might need a dose decrease if cortisol is low

[Bodhi's Mom]

Being able to decrease would be great. I think he has too many thyroid symptoms for cortisol to be low...the last time his cortisol was normal his thyroid was normal too. I will have an ACTH done this week and post the results...hopefully they will be good. ;)

[Bodhi's Mom]

Got the results of Bodhi's ACTH back just now and they are MUCH improved! As a matter of fact I think we are going to need to lower his dose! :D

Pre 1.1
Post 1.6

Still waiting on labs for kidney and liver values.
The only thing is now I don't understand the symptoms he is having. The panting and hunger.

[molly muffin]

At 1.1 pre and 1.6 post, even though they can go that low, my thought is that the cortisol post needs to come up a bit. Say about 2.5- 3.5 and that might make a big difference in panting, and in how he is over all.

[Harley PoMMom]

Those numbers would be too low for my comfort, and one of the top animal endocrinologist, Dr. Peterson, doesn't like to see a post lower than 2.0 ug/dl on a dog being treated with Trilostane/Vetoryl.

As for the hunger and panting, has he had his thyroid levels checked recently?

Hugs, Lori

[Bodhi's Mom]

So how much should I decrease his dose? Should I just decrease by 5mg or 10mg? Help...my vet wants to leave it as is.

[Harley PoMMom]

Since he is taking 30mg of Vetoryl I would decrease to 20mg and have an ACTH stim test done in 10-14 days to see where his cortisol is at. If he would need an dosage increase, Vetoryl now comes in 5 mg strengths so you could purchase some of them to add to his 20 mg dose. Since his symptoms are panting and hunger another option would be to split that 20 mg dose and give 10 mg twice a day and see if that helps with those symptoms.

Hugs, Lori

[Bodhi's Mom]

I have not had his thyroid checked since Nov. We were trying to get his cortisol under control first in case it was affecting his thyroid. We need to do that next. However we have a new problem now. I received the rest of his labs...his ALP is back up to 310 u/l and his BUN is 42 mg/dl normal range is 9-31 mg/dl. We are going to check his urine in the morning to see what is going on but i am starting to worry...his BUN has never been high before.

[westcoastflea1]

YOU should get a complete thyroid panel done now. Have vet email you complete results not just an opinion. you should treat thyroid now if test results come back showing low numbers regardless of cortisol levels , you should see almost immediate results with thyroid meds they should take care of all problems not solved by vetoryl and when cortisol is around 4 you can have thyroid panel done again and see if numbers are normal

[molly muffin]

BUN could go up do to being a bit dehydrated when the test was done.
If the creatinine is still in range then that is good. It is when both the BUN and the CREA is high that you have to worry about the kidneys. See if the BUN remains high on the next check. Is the CREA in range still?

[labblab]

YOU should get a complete thyroid panel done now. Have vet email you complete results not just an opinion. you should treat thyroid now if test results come back showing low numbers regardless of cortisol levels , you should see almost immediate results with thyroid meds they should take care of all problems not solved by vetoryl and when cortisol is around 4 you can have thyroid panel done again and see if numbers are normal
Hi westcoastflea1,

I notice that you've been advising several folks to treat low thyroid levels in their Cushpups, regardless of whether or not the hypothyroidism is thought to be secondary to the Cushing's or instead a primary problem in its own right. I don't think that recommendation is universally held, however, and I'm going to head to your thread to talk about that a bit more.

I have no argument whatsoever with recommending that folks request full thyroid screening panels if there is a suspicion of impaired thyroid function. I think it's really helpful to explore the likelihood that hypothyroid results are a primary, or instead secondary, problem. But it's the treatment recommendation that I have questions about. So I'll see you over on your own thread. ;)

Marianne

[Bodhi's Mom]

Thanks Sharlene, that makes me feel a little better. His CREA is normal and so is his SDMA which is a marker for early kidney disease. I don't have the exact numbers (I left the copy of his labs at work. lol) but they were both in range. It's the thought of going through all of this to get him controlled just for something else to go wrong that scares me. :(

[molly muffin]

I completely understand Stacey. There seems to always be something to worry about and it can all be a balancing act. Just keep an eye on the BUN, CREA and SDMA. I use to have it checked every few months just because I too worried constantly that something else might pop up if I wasn't paying attention. That's perfectly normal to worry.

[Bodhi's Mom]

It's just nice to have people to talk to that have been down this road and have some experience dealing with it. Even though we have been fighting this battle for almost 2 years I am still learning as I go. You have to just get as much information as you can and do your best with it. Thanks for your advice and moral support!

[Bodhi's Mom]

Everything checked out ok with his urine, SG was 1.035 and the urinalysis was normal. Now to test his thyroid and see if it back to normal or not. Maybe I can breathe for a while after this. ;)

[molly muffin]

Well Yay for a good urine test! Ruling something out is important too. :)

[Bodhi's Mom]

We are going to test his thyroid in a couple of weeks when we do his ACTH for his new dose and after his neck is better. :( We have to take blood out of his neck and after doing it twice in one day it is very bruised. Is that due to Cushing's? It didn't do that before.

[molly muffin]

Molly use to bruise sometimes when blood was taken out of her neck. I don't know that it was necessarily cushings related, because I've seen other noncushing dogs have bruising on the neck too when blood is taken there.
I'd always wait or make them take it from somewhere else when her neck bruised. It didn't do it consistently which was good. The first time I saw it, it freaked me out big time.

[Bodhi's Mom]

It did me too the first time. We just have to wait until it gets better because we can't take blood out of his legs... I'm not sure if it hurts or if he is just being dramatic but he reacts badly to us trying. Have you ever had a dog react to the gel they inject for the ACTH? The last 2 times we have done it he acts like it hurts. We have been doing this for 2 years and he has never reacted before.

[molly muffin]

My dog never reacted to the gel. Luckily. Over the years I can thing of maybe a couple that have mentioned it.