Thor has passed - Diagnosed Cushings, suspect Calcinosis Cutis

[jml666]

Hi everyone, I am new to the forum (and thank my friend on Facebook for pointing me here!)

My 7.5 year old boxer, Thor, was diagnosed with early signs of Cushings earlier this summer.

We got him at 2.5 and knew he had low thyroid, so he has been on Thyroid meds. I started noticing early this summer that his fur was thinning and he was drinking a lot of water and having accidents in the house. I thought maybe he had a bladder infection and wanted to get his thyroid re-checked, so we took him and found his thyroid levels had dropped, so we increased his meds and the vet told us he had early signs of Cushings and put him on Vetoryl.

We waited and watched and he seemed to be doing better, but his fur wasn't coming back and he started to develop spots on his back last month. Without seeing him (pictures only), she said hot spots and put him on antibiotics. We were going to have him re-checked for proper treatment for Cushings anyway since it was a couple of months later.

On follow up test, the vet said his cortisol levels were still too high and we increased his meds. She didn't say anything about the spots on his back with that visit and I didn't press because I didn't know about calcinosis cutis. In the meantime, I learned from my Facebook Boxer group of others who had dogs with Cushings that also had calcinosis cutis. Thor has not been officially diagnosed with it, but from all the pictures I see online and what his back looks like, I'm convinced that it is.

Our next vet appointment with him is this Wednesday, 9/16 to check his thyroid again and cortisol levels. We will also talk to the vet about calcinosis cutis to get that treated as well.

My question for this group is this.....since I am not familiar with everything related to calcinosis cutis other than knowing that it will get worse before it gets better and it will likely spread down his back, is it common for the spots to bleed? I think yes, since the deposits are unnatural on their skin, but wanted to ask.

They started out first a bit scaly, then got pussy. We cleaned them up and now they look like pink/red irritated skin and very dark dried blood spots. In the newer areas, there are flaky spots. Nothing looks infected right now; we've been using diluted betadine to keep the areas clean.

I'm posting because they have been bleeding on and off since yesterday and I'm more concerned about that - it's a little bit alarming. I can get them to stop bleeding by cleaning them off, but it worries me.

Any help and advice would be appreciated, thanks!

[molly muffin]

Hi and welcome. I'm sorry no one got back to you yesterday. :(

Did you start vetroy but without any of the testing to see what the values are at? If so you really want to know what the cortisol value is.

To find out if these are cc (calcinosis cutis) a biopsy is needed to know for sure. They are calcium deposits that push up out of the skin and yes somtimes bleed, turn red, angry, hair loss around them. Best thing is to make sure that is what it is first, use an antibiotic spray (as any sore can become infected with yeast/baceteria) keep the sores clean and dry. If it is cc, then the cortisol needs to come down, usually to under 5ug post acth.
You don't want to start vetroyl at over 1mg/1lb. Give in the mornings or twice a day split dose (where the dose of am and pm, equal the 1mg per lb a day), give it with a meal and have the ACTH test done within 4 - 6 hours of the medication given with a meal.

Trichlor spray is an option for antibiotic spray and they have trichlor shampoo also available on amazon.

The thing with cc is that every bump, has to come through, so it does get worse before it gets better.

[labblab]

Hello and welcome to you and Thor from me, too. Like Sharlene, I'm sorry it's taken so long for you to get replies -- we've been stretched a little thin recently :o. But we do have other dogs who are actively being treated for CC, and I hope some of those members will soon be chiming in. In the meantime, here's a link to an older thread that contains a lot of treatment conversation. You may want to read through it in advance of your vet visit tomorrow. It does seem as though bleeding can commonly occur with these lesions.

http://www.k9cushings.com/forum/showthread.php?t=6093

If you can get the exact numbers for the earlier monitoring ACTH test, as well as those for tomorrow's testing when it becomes available, that will be great. It does seem as though lower cortisol levels are desirable when treating CC. So it will help us to know how Thor has been trending since beginning on the Vetoryl.

Once again, welcome to you both.
Marianne

[jml666]

Thank you both for chiming in, I appreciate your replies and no worries about not replying right away; I figured someone would chime in at some point.

@Sharlene - Yes, Thor was diagnosed with Cushings before he was put on Vetoryl. I am taking him to the vet tomorrow so I will ask for what his numbers were initially and have the vet explain to me what's normal vs not. I will ask to confirm CC tomorrow also. Thank you for all the additional info; I will be sure to take a look at the shampoo and spray.

@Marianne - I'll be sure to read the thread you included to get more info before going tomorrow.

I added an album to my profile that has pictures of Thor on 8/9, about a week before they started showing up on his back, then on 9/3 and 9/14.

I'll post after we get the test results back. Thank you both!

[labblab]

Just now had a chance to look at your photos, and yes, to my eye those lesions do look a lot like CC. :o

I also just now saw your gmail message about problems loading those photos earlier, but thankfully it looks as though the loading problem was resolved all on its own ;). We'll definitely be anxious to hear how the vet visit went today.

Marianne

[jml666]

Hi, we won't get Thor's test results back for a day or two. He is staying overnight at the vet's tonight because I talked to the Dr about possible surgery to remove the mass that is affecting his adrenal gland. She is having an ultrasound done on him tomorrow (2nd one - 1st one was back in May when we first took him to be diagnosed) and it was easier to let him stay there rather than have to bring him back tomorrow morning.

I asked the Dr for his numbers and had her explain to me what was going on with him. So here's some of the history/dates I'm putting together on his condition.

Back in January/February this year, I realized he was starting to lose his fur. I read that it could have been related to his hyperthyroidism, so I had his T4 tested in early March and it came back normal.

We continued to notice that he was continuing to lose fur and was starting to drink a lot of water and was having accidents in the house. I thought it might be a bladder infection, so we took him back to the vet in mid April (4/17 to be exact) and I asked that we figure out what was going on, and that's when the vet told us that he had early signs of Cushing's Disease. She wanted to be sure, so she LDDST test (4/20) and an ultrasound stand ACTH test (4/23) which confirmed Cushings and we put him on 30mg of Vetoryl once a day with a scheduled re-check in 3 weeks. She also found that his T4 was low, so she increased his thyroid med dosage as well.

We brought him back on 5/5 to be re-tested (ACTH) and she said then that he was still not in the right range, so she increased to another 30mg, so now it was 30mg 2xday.

Third re-test was on 5/19 when she said that his dosing was in the normal range. To save on cost, I asked if we could switch to 60mg once a day and she said that was fine (I'm wondering now if that really wasn't fine given that he's back at the vet, but it could be for any number of reasons, so I'm not going to beat myself up for this.) She also re-tested his T4 and found that it was normal. She told us he wouldn't need to come back again until his normal physical exam, which would be in May/June 2016. His pre-ACTH number was 3.7 (normal = 1 to 5) and his post was 8.6 (normal = 8-17).

I noticed that his hair was not coming back and he seemed to be losing more, then the spots started to show up on his back and I knew we needed to take him back to the vet. We went on 8/26 for another ACTH test and his pre was 6.1 and post was 11.1. The vet increased his dosage further to 60mg in the mornings and 30mg in the evenings, which is what he is on now. She said she believes the mass has probably grown which is causing him to be out of balance again.

Today, I asked the vet to provide me this info (she printed copies of the last 2 tests for me) and also asked if we wanted to consult with a specialist, so I said yes, and she gave me the name of their specialist who could potentially remove the mass if we determine that to be the best course of action. She said she didn't do all of the tests (talked to my husband, so I didn't get this info first hand) because she thought the specialist would want to order his own and she didn't want us to have to pay twice for the same tests. I also asked if she could confirm that he has CC for me and to provide a course of treatment for that as well. No word on that yet.

So that brings us to where we are now. I'll be able to pick him up tomorrow night and talk to the vet and we will go from there.

Thanks for reading!

[labblab]

Thanks so much for all this additional information! I have a couple of thoughts, one of which you may find annoying but which may actually be a blessing in disguise. And that is that, according to his monitoring ACTH results, Thor's cortisol has never really been lowered into a range that would necessarily produce therapeutic effects across the board. The desired post-ACTH range for a dog being treated with trilostane is lower than the "normal" range for a dog without the disease. Here's a monitoring decision chart published by Dechra, the makers of Vetoryl:


< 1.45 ug/dL: Stop treatment. Re-start at a decreased dose.

1.45 to 5.4 ug/dL: Continue on same dose.

> 5.4 to 9.1 ug/dL: EITHER: Continue on current dose if clinical signs are well controlled OR: Increase dose if clinical signs of hyperadrenocorticism are still evident*

> 9.1 ug/dL: Increase initial dose.

Once daily administration is recommended. However, if clinical signs are not controlled for the full day, twice daily dosing may be needed. To switch from a once daily dose to a twice daily dose, the total daily dose should be divided into 2 portions given 12 hours apart. It is not necessary for the portions to be equal. If applicable, the larger dose should be administered in the morning and the smaller dose in the evening. For example, a dog receiving 90 mg would receive 60 mg in the morning, and 30 mg in evening.


http://www.dechra-us.com/files/dechraUSA/downloads/Product%20inserts/Vetoryl.pdf

So even though the May post-ACTH result of 8.6 would be normal for a dog without Cushing's, it was still too high for a dog exhibiting unresolved symptoms while taking trilostane. By the August testing, the cortisol level was certainly too high, as you already know. However, this may or may not be the result of tumor enlargement. Over our years here, we've seen many dogs who require dosing changes over time while taking trilostane, both up and down. That's why it's very important to maintain a regular monitoring testing schedule and why Dechra recommends re-testing every three months.

So the bottom line to all of this is that Thor may simply need a higher dose of Vetoryl to keep his Cushing's symptoms under control. We've been told by several experts that dogs with calcinosis cutis especially need to be maintained on post-ACTH cortisol levels of 5 ug/dL or lower in order to get a handle on the skin condition.

As far as the tumor enlarging, has the vet discussed whether Thor's Cushing's seems to be caused by a pituitary tumor or an adrenal tumor? From what she is saying in terms of surgical removal, this implies that Thor has an adrenal tumor. But if so, you should be able to learn specific information about the tumor size and location from the original ultrasound. At this stage, if I were you, I'd request a copy of Thor's entire medical history since the original Cushing's diagnosis. The ultrasound report ought to give you specific information about the appearance of Thor's adrenal glands, and this will be important for you to know moving forward.

Marianne

[jml666]

Hi Marianne, thanks so much for your reply. We are learning more as we go. Thor is staying one more night based on what they found from his ultrasound, which is that both adrenal glands are now enlarged, not just the one on the left (original finding), which we believe now means it's pituitary related. She kept him to run further detailed tests to determine what else is going on with him. She mentioned that his ACTH test results came back saying that his cortisol levels are in the proper range, but we know he is still having issues. She mentioned possibly taking him off of trilostane (Vetoryl) and putting him lysodren instead, but wants to get the test results back before we go there. All things we can do going forward; we just have to narrow down what's really going on with him.

I understand that Thor would have to be off of trilostane for a while before he can go on lysodren - do you know how this typically is? I feel bad for him that he will be thirsty again and peeing a lot.

She also said the areas on his back are consistent with CC as well.

That's all I know for now; will be going to pick him up tomorrow morning and will be giving him lots of hugs. We miss him. Thanks for your help and comments - they are very much appreciated!

[labblab]

She mentioned that his ACTH test results came back saying that his cortisol levels are in the proper range, but we know he is still having issues.
Can you please find out exactly what Thor's ACTH results turned out to be? As I wrote earlier, prior to now, Thor's cortisol level has never been within Dechra's desired therapeutic range for a dog exhibiting ongoing symptoms and I continue to feel worried that your vet is judging outcome based upon either the "normal" range for a dog without Cushing's, or the upper limit of Dechra's range that is applicable only to dogs who are entirely symptom-free.

Before considering switching to Lysodren, if Thor were my dog, I would want to first see whether he experiences symptom resolution when taking a truly appropriate dose of Vetoryl. If you do decide to switch drugs from Vetoryl to Lysodren, some experts recommend a wash-out period as long as 4-6 weeks across-the-board. I have seen others who take a more individualistic approach and make the recommendation based upon a combination of factors including re-elevation of ACTH results and a return of obvious Cushing's symptoms. However, for whatever time period Thor goes totally untreated, I would be fearful that you would be opening the door to rapid worsening of his CC. If the switch to Lysodren is truly warranted, then "it is what it is." But as I say, I'm not yet convinced that you really have any problem other than Vetoryl dosing that has been too low. If my math is correct, he has now been on the increased dose for about 3 weeks. I will be really, really interested in finding out the exact numbers for this week's ACTH test. If the post-ACTH result is not yet at or below 5.4 ug/dL, then his cortisol is still not within the proper range for a dog that is still symptomatic. Even if it has finally fallen to 5.4, it hasn't been controlled at that level for very long, and skin/coat issues will not resolve overnight regardless of which medication a dog is taking. Unfortunately it can take weeks and even months for those problems to resolve, but the first step is to get cortisol levels down sufficiently low.

You haven't mentioned Thor's weight, but I'm guessing an average weight for a male boxer is around 60-70 pounds. If that's Thor's weight, then a daily total of 90 mg. is only a bit higher than the recommended INITIAL starting point for a dog of that size. Research studies have shown that most dogs end up being controlled on doses that range between 1-3 mg. per pound. I would never want to start a dog any higher than 1 mg. per pound, but it is not at all surprising should any individual dog end up needing a higher dose than that in order to maintain appropriate control. The point is to start low and then work upward as needed based upon the monitoring ACTH results and resolution of clinical signs. If Thor's post-ACTH result is still higher than 5.4 ug/dL, there is plenty of room to increase the dose before it would seem to be excessively high for his weight.

Marianne

[jml666]

Hi Marianne, thank you so much for your reply. I will talk to the vet about the Vetoryl and continuing to try something there first based on his recent ACTH results, but will ask her for that info before we take him off. Thor weighed in at 74 pounds on Wednesday; he was 82 before he started exhibiting symptoms and was at 77 the last time we had him tested in May.

I did some research on Lysodren and that drug scares me because of what it does. I'm inclined to stick with Vetoryl until we can get his cortisol under control. I think I also read that Vetoryl can cause the adrenal glands to swell as well, so I'm thinking that what she saw on the ultrasound may be a result of the Vetoryl, not necessarily that it's pituitary related. Thoughts?

[labblab]

Actually, Lysodren really need not be any more scary as long as it is used and monitoring appropriately. Trilostane can also result in permanent adrenal oversuppression (Addisonian condition) if a dog is overdosed. So I'd be fine with switching to Lysodren if there really turns out to be good reason to do so. I'm just not yet convinced that is the case. By the way, if you are using brandname Vetoryl, that link that I gave you with the monitoring ACTH guidelines should be the same as the product insert in every box sold in the U.S. So you can easily take that insert in with you in order to discuss therapeutic ACTH levels with your vet.

It is true that trilostane typically enlarges adrenal glands, as does the pituitary form of the disease itself. But if no tumors or masses were visualized on this ultrasound, you can feel confident that Thor has the pituitary rather than adrenal form (assuming he does truly have Cushing's). With adrenal Cushing's, typically one adrenal gland will be enlarged or mishapen due to the tumor, and the other will be small and atrophied.

Marianne

[jml666]

Thanks Marianne.

Just got home with Thor - I mussed the boy and am really glad to have him home.

This time, he pre was 4.4 and his post was 7.4, which seems better than the last, but according to what you've told me, his post is still too high. On the lab results I received, it says

Post-Trilostane - pre and post cortisol levels between 1.5-9.1 ug/dL indicate optimal control.

This implies to me that even at 7.4 on the post side is fine for him. I'm thinking your recommendation is to have it be more in the middle so that it's truly under control, yes?

[Renee]

Speaking from personal experience, both with using vetoryl and managing CC, you'll want to bring that post cortisol level down to 5 ug/dl, or lower - and keep it there long-term. CC takes approx 6 months to resolve, if you are in proper range for treatment. If you are not in range, you may slow it down, but I don't think you'll resolve it. You can read my thread to get an idea of my journey through CC and how we resolved it.

I personally would not switch to lysodren yet. From what I can tell on your thread, you have yet to reach appropriate control levels and maintain then long-term. Yes, you can be considered 'controlled' when you are in the 1.5-9.1 range, however, CC changes that. Our experience overwhelmingly on this board is that it requires a post cortisol of 5 or less.

[Squirt's Mom]

That post number of 9.1 ug/dl is ok if, and ONLY IF, all signs are controlled. With CC in play that post needs to be below 5.0 ug/dl - ideally around 3.0 ug/dl so he has a way to go yet if the CC has any hope of improvement. ;)

[jml666]

Thanks for your input. My vet and I have been emailing each other, so I will make sure she gets this info also for consideration. Will keep you posted on what comes back from the additional bloodwork she took last night.

[labblab]

On the lab results I received, it says

Post-Trilostane - pre and post cortisol levels between 1.5-9.1 ug/dL indicate optimal control.

This implies to me that even at 7.4 on the post side is fine for him. I'm thinking your recommendation is to have it be more in the middle so that it's truly under control, yes?


What you are looking at is the testing laboratory's general interpretation of monitoring ACTH results for a dog taking trilostane. However, the actual manufacturer of Vetoryl (Dechra) as well as most Cushing's specialists have more detailed guidelines that they follow when treating their patients. This is the point that I am trying to stress by providing Dechra's more specific monitoring breakdown. Here it is again, with the significant portion bolded.




1.45 to 5.4 ug/dL: Continue on same dose.

5.4 to 9.1 ug/dL: EITHER: Continue on current dose if clinical signs are well controlled OR: Increase dose if clinical signs of hyperadrenocorticism are still evident.

In terms of a dog's quality of life, CC is potentially one of the most uncomfortable effects of poorly controlled Cushing's. I will be honest with you and tell you that we have had members who have had to make the painful decision to euthanize their dogs because they could not gain control of the CC and their dog's lives were miserable. If your vet still questions the need to lower Thor's cortisol further, I really really encourage her to contact Dechra directly. Their U.S. office is located in Kansas and their technical reps are really receptive to telephone/email questions from vets re: optimal dosing and treatment protocols. Here is contact info for you to relay to your vet:

http://www.dechra-us.com/Default.aspx?ID=365

Marianne

[jml666]

Thanks, I'll be sure to point this out to her after I hear back from her - I've sent her 3 emails today already!

[molly muffin]

Hi. Goodness what a journey you have been on.

So for cc control what we have seen here on the forum is that control of the cc is not obtained usually unless the cortisol post ACTH is below 5.0ug. I don't think I've seen any that got control without it being under that. A 3.0 would probably be about right but even 4 or 5 would be better than a higher post.

It can take a very long time for cc to clear once you reach optimal control ( under 5 ug) 6 months is not unheard of. As long as the cortisol is high enough to produce calcium deposits under the skin the cc will be there and without control of that cortisol it will can and we have seen cc start to calcify within the internal organs. So this is very important.

I would personally never go that long on Cushing medication without retesting. No way no how and I don't care what a vet recommends. Their bodies continue to change and adapt to the medication and you can slip into too high or too low without much if any warning. 3 - 6 months between testing once you have everything under control would be possible I think and follows manufacturer protocols.

These are just observations that we as a group have noticed from being around cushing nonstop for years.

Thor,is your furbaby and you know him best and how he is doing and how his body is reacting so this is just what my concerns would be and what I would do.

I work currently with a vet and a internal medicine specialist and and ophamologist just to,try to keep,my dog sorted out,correctly and that is without the cc involved. It is very tricky disease for sure.

[jml666]

Thank you Sharlene. Hope to get the test results back soon and be able to consult with the vet.

[molly muffin]

Did you hear back from the vet? When do the test results come in?

[jml666]

Hi Sharlene, thanks for asking. I've been crazy busy with work the last few days I've not had time to post.

I did finally hear back from the vet today, although she has not received his test results back yet (she said it can take up to a week).

She's been consulting with an internal medicine specialist out of the vet hospital we use and they have concluded that we should increase his trilostane dosage (as we suspected). She did give me a lengthy explanation on the differences between Lysodren and trilostane and shared with me her research, which I appreciate very much.

Thor is now on 60mg in the morning and we just started 60mg (was 30mg) in the evening.

When I hear back from her next on his test results, we'll discuss next steps. At a minimum, I know I need to bring him back for a re-test in 3 weeks.

I've noticed that Thor's CC hasn't gotten worse, although it is very slow to get better. He asked to go outside on Monday and laid in the sun for a little bit (which he hasn't done since he was diagnosed), so I am encouraged that we are moving in the right direction.

Appreciate all of the info you've shared with me and your continued support! Will keep you posted on next steps!

[jml666]

Hi, we finally heard back from the vet yesterday. The last bloodwork that was done was much more comprehensive and was sent to the University of TN lab. I've attached the 2 reports she received in my album. This was based on 60mg trilostane in the morning and 30mg in the evening.

She explained that his cortisol levels were still not under control and that some other hormone levels were elevated as well (confirmed by the tests).

She said that she may want to switch him to Lysodren if after the next test, he's still not under control. She also acknowledged that he has CC and that it will take some time for it to heal.

Thor is now on 60mg both morning and night and I'll be making an appointment to have him re-tested in mid-October.

Any thoughts on next steps?

[jml666]

One more thing....for many years, we've noticed that Thor's right eye has been getting cloudier and cloudier and is now mostly white. Now that we know his Cushings is pituitary related, we're wondering if his loss of sight is also related.

I noticed today that his left eye seems to now be showing signs of getting cloudy too and that makes me really sad. He has been fine even though his eye sight has been gradually deteriorating. Our prior vet told us it was probably cataracts and nothing to worry about, but now, I'm not so sure; feeling like we should have been on top of it sooner, although I know they can't typically operate when it's pituitary related.

Thanks for your feedback.

[Squirt's Mom]

Would you do us a HUGE favor and type out those test results here in Thor's thread so that info is readily available without having to jump from this page to the photo album when trying to reply to you about them? Thanks!

EDITED TO ADD:
Have the ACTHs for Thor been done while he was fasting?

[labblab]

The main test result that I'm interested in is the cortisol level on the ACTH stimulation test, and on the UTK report, it is listed as 8.8 (pre) and 12.0 (post). But this is where I get really confused. When was the blood drawn for this set of tests? We know Thor had blood drawn two weeks ago on 9-16 (or 9-17?) and the ACTH stim results at that time were 4.4 and 7.4, at which point his trilo dose was increased. But the date on this UTK sheet is 9-28, and you say that these results have been pending for at least a week? So when was the blood drawn for the UTK tests? Was all the bloodwork drawn at the same time on 9-17, just like the sample sent to Michigan State (see below)? What lab performed the ACTH test with the 7.4 result?

Turning to Michigan State, I am very puzzled as to why your vet had them perform an endogenous ACTH test in addition to the ACTH stimulation tests performed by the other labs. I see the collection date for this MSU sample is 9-17, during the same hospitalization as the stim test/s. The endogenous ACTH is used as a diagnostic tool to try to differentiate between pituitary and adrenal Cushing's in a dog prior to the treatment phase. For a dog already taking trilostane, the test really has no value whatsoever because the trilo can affect the results, just as the lab interpretation explains. So I really don't understand why your vet requested that test, which may have been fairly expensive. I think you deserve a refund of your money paid for that test. And if you paid for two ACTH stimulation tests on blood samples collected on the same day or just one day apart, that is crazy. It's true that UTK's analysis of the full adrenal panel is more comprehensive, but then why also perform the ACTH stim test of cortisol alone? It makes me wonder whether your vet really understood what the UTK panel consisted of.

As an aside, at 60 mg. twice daily, Thor is still not at an extremely high dose for his weight. Remember, the research studies have shown that most dogs ultimately fall within a range of 1-3 mg. per pound as far as arriving at optimal control. So even increasing to 120 mg. as a daily total, he is is still taking less than 2 mg. per pound.

However, if his post-ACTH jumped from 7.4 to 12.0 within just a week or so (or even overnight??), that is indeed odd. As Leslie has asked, has the blood for all these tests been drawn under the same conditions: 4-6 hours after giving trilostane along with breakfast?

Thanks in advance for this additional info.
Marianne

[labblab]

I just want to reiterate that I believe Lysodren is an effective drug and I have no problem with making the switch if it is really warranted. But I remain uncertain as to your vet's expertise re: making this judgement, and wonder if you wouldn't be better served by consulting directly with the specialist as you discussed earlier. Your vet earlier seemed unaware of the correct therapeutic cortisol range for a dog taking trilostane, she seems very nervous about increasing the dose even when monitoring tests indicate an increase is warranted, she has now ordered an endogenous ACTH test that seems totally inappropriate for the situation, plus the timing of the ACTH stimulation tests is really confusing. I am not meaning to bash her, but vets cannot know everything about every disorder, and perhaps Cushing's is not an area of excellence for her. If a specialist is available to you, I think you'd benefit from the direct consultation.

But once you tell us more about the timing and protocol for the testing, we can talk about this all more.

[Squirt's Mom]

We learned on Facebook that the vet has been having her fast Thor for the ACTHs as well. :mad::rolleyes::(

[labblab]

Oops, that is not good. :(

Perhaps Thor was fasted for the UTK panel (12.0 post-ACTH), but not for the 9-16 test (7.4 post-ACTH)? This could account for the higher result from UTK.


With trilostane, it’s extremely important to give the morning medication with food, and then start the ACTH stimulation test 3 to 4 hours later.

Fasting these dogs on the morning in which the ACTH stimulation test is scheduled should be avoided since it invalidates the test results.

When a dog ‘s food is withheld, the absorption of trilostane from the gastrointestinal tract is decreased. This leads to low circulating levels of trilostane, resulting in little to no inhibition of adrenocortical synthesis. Therefore, serum cortisol values will higher when the drug is given in a fasted state than when it is given with food.

The higher basal or ACTH-stimulated cortisol results could prompt one to unnecessarily increase the daily trilostane dose. That misjudgment may lead to drug overdosage, with the sequelae of hypoadrenocorticism and adrenal necrosis in some dogs.

http://www.endocrinevet.info/2011/03/whats-best-protocol-for-acth.html

[labblab]

And...upon re-reading your thread, I am noticing one more thing. :o

Apparently Thor's repeat ultrasound was performed on 9-17, the same day the blood was collected to send to MSU. If that was the same day the repeat ACTH stimulation test was also done to send off to UTK, it would be a problem if the blood was collected after the ultrasound which would have stressed Thor, elevating his adrenal function. Or, as I said above, it would also be a problem if due to the ultrasound, the blood was a fasted sample or not collected within the right timeframe after trilostane dosing.

Sorry to keep throwing out so many negatives. But truly, Thor may not actually be that hard to stabilize as long as reasonable testing is performed according to appropriate protocol. For instance, if the stim result of 7.4 was performed on a fasted sample, it's possible that the result would have fallen to less than 5.0 if the trilo had been given with food. So that might have been an adequate dose, after all...

[jml666]

So let me see if I can answer all of the questions that have been asked.

The test on 9/16 was the standard ACTH test that they have done in the past. She ordered the other one that was sent to Univ of TN on 9/17 (blood drawn in the evening) to get a more comprehensive set of results to determine if there was anything else going on (not just looking at the ACTH levels). I think what she was doing was comparing results from multiple labs to get several opinions.

I believe that my vet is not experienced with treating Cushings, BUT I know that she has been consulting with a staff specialist daily and has been thorough and diligent about ruling out anything else that might be wrong with him. She has been corresponding with me regularly via email, answering all the questions I've posed to her and she is very open to feedback I've been giving her from your input both here and on the Facebook group.

We are both in agreement that he needs to go back again in a couple of weeks to get re-tested while on 60mg twice a day.

She did say that we *could* still go up to 60mg 3xper day if we absolutely needed to before we switch to Lysodren, but we're taking it a step at a time based on the results of his next test.

Question - what's the best way to keep Thor from scratching his back, opening up his CC spots and causing them to bleed? We've been keeping the area clean, applying neosporin as needed, but it can be really hard watching him bleed

[labblab]

Thanks again for this additional information. I apologize in advance for continuing to press you re: Thor's treatment and monitoring, but I believe you have come to us in the hope of receiving truthful and honest feedback. In good conscience, I cannot ignore discussing what appear to me to be mistakes that may jeopardize his health and safety. So here goes.


The test on 9/16 was the standard ACTH test that they have done in the past. She ordered the other one that was sent to Univ of TN on 9/17 (blood drawn in the evening) to get a more comprehensive set of results to determine if there was anything else going on (not just looking at the ACTH levels). I think what she was doing was comparing results from multiple labs to get several opinions.

In terms of monitoring cortisol, the test that was sent to Univ. of TN was an exact duplicate of the test performed the previous day. They were both ACTH stimulation tests. The only difference is that UTK analyzed the effect of ACTH stimulation on other adrenal hormones in addition to cortisol. We have learned that virtually all dogs with elevated cortisol will also exhibit elevations in other adrenal hormones, as well. Whether or not those other elevations are really significant is still being debated. What is important for your situation, though, is that there was absolutely no need for the 9/16 ACTH test in addition to the 9/17 test that was sent to UTK. It was a duplication of the cortisol test, a waste of your money and a stress on Thor to perform them both.


She ordered the other one that was sent to Univ of TN on 9/17 (blood drawn in the evening) to get a more comprehensive set of results

This is a huge problem in terms of the accuracy of the results. Just as is the case with any ACTH stimulation test for a dog taking trilostane, the UTK test must be performed 4-6 hours after the medication is administered along with a meal (and in as stress-free an environment as possible). If a dog is dosed twice daily in unequal doses, the test should be run after the larger dose. So in Thor's case, it should have been done after breakfast. If the dog has been fasted, or if the test is administered at a longer time after having taken the larger dose of trilostane, the results will be skewed and will report cortisol levels that are higher than they would be had the test been performed properly. This probably explains why Thor's post-ACTH cortisol on this test was so much higher than the one taken the day before. And if the one taken on 9-16 was also a fasted sample, it is also inaccurate as to the true effect that this dose of trilostane is having on Thor. It is possible that he did not really need an increase at all.


Next problem: as I wrote yesterday, the endogenous ACTH test sent to Michigan State was pointless and a waste of your money. this test is useful as a diagnostic prior to the beginning of treatment, but trilostane affects the results and renders them useless. Here is what the lab interpretation states. It advises that the ACTH stimulation test should be performed instead.


Information on this submission form indicates that this dog is receiving trilostane...Endogenous ACTH is elevated above the normal reference range. This could reflect decreased neuroendocrine cortisol feedback resulting from trlostane action rather than or in addition to aberrant ACTH release in pituitary-dependent hyperadrenocoricism. Typically cortisol values following an ACTH stimulation test or baseline cortisol are used to monitor trilostane therapy...


At this point, unless and until Thor has been given an ACTH stimulation test 4-6 hours after taking his trilostane along with breakfast (NOT fasted), you do not know the true effect of any of his trilostane doses. And if it does turn out that he needs an increase, there is no need to shift to dosing three times daily. Typically, you would simply increase the twice daily dose (if it cannot be split evenly, you add an incremental increase to the morning dose).

I am very sorry to tell you that your money is not being spent wisely, and Thor's care is being compromised in addition. I don't doubt at all that your vet has Thor's best interest at heart, but critical mistakes are being made. I repeat, if you have access to a specialist, I would go to him/her directly at this point. I have to hope that somehow the specialist's recommendations are getting confused as they are relayed to your vet, and that the specialist actually knows better him/herself.

Marianne

[Squirt's Mom]

I'm so glad to see you posting here! I was coming to FB to tell you about the replies here. :D

Since Thor has been fasted for the ACTHs - there is no way to know what is going on with his cortisol because those tests are useless, worthless, of no value whatsoever. Because your vet does not know what they are doing, they are putting your baby under stress for a test that has no value, costing you a fortune for tests that have no value, and putting Thor at extreme risk by basing the dose of this very powerful drug on invalid test results. So whoever your vet has been conferring with doesn't seem to know any more than your vet does. What Marianne had to say is critical -
Apparently Thor's repeat ultrasound was performed on 9-17, the same day the blood was collected to send to MSU. If that was the same day the repeat ACTH stimulation test was also done to send off to UTK, it would be a problem if the blood was collected after the ultrasound which would have stressed Thor, elevating his adrenal function. Or, as I said above, it would also be a problem if due to the ultrasound, the blood was a fasted sample or not collected within the right timeframe after trilostane dosing.

This is a very scary situation. It is sometimes very difficult to get a point across on Facebook when so many people are talking to you....and not all know what they are talking about. ;) So I am hoping with all my being that you WILL take mine and Marianne's words to heart - DEEP to heart - for Thor's sake. These drugs CAN and DO kill when misused....and in the hands of the vets that are directing Thor's care - they are incredibly dangerous because none of them seem to understand this disease or this drug. Please let us help you.

Hugs,
Leslie and the gang

[labblab]

So that it doesn't get lost in the shuffle, I'm copying your new question about the best way to handle the CC. I'm hoping our other folks who are also dealing with it will stop by to help out on this one.


Question - what's the best way to keep Thor from scratching his back, opening up his CC spots and causing them to bleed? We've been keeping the area clean, applying neosporin as needed, but it can be really hard watching him bleed.

[Renee]

Hi there,

Jumping in to add my voice. I sure hope you don't feel attacked, but I also must 100% agree with Leslie and Marianne. The proper protocols are not being followed by your vet, and I fear that you are not able to get consistent, accurate results with how things have been handled. It is imperative, in order to resolve the CC, that you follow all protocols.

At this point, I think we can all agree that Thor has traditional cushings, of the PDH type. Since that has been established, there is no longer ANY need to run any additional testing, except for the standard monitoring ACTH stimulation test. Any additional testing is a waste of your money and time, and a burden to Thor.

All doses of vetoryl should be given with a full meal. I have confirmed directly with Dechra myself that in order for vetoryl to be fully effective, it must be given with a meal. To do otherwise, diminishes its efficacy dramatically.

ACTH stimulation monitoring should be done 4-6 hours after the morning dose of vetoryl. I dose at 630am, and start the ACTH at 10am. I have done it this way for the last 2 years. You should choose your own protocol and stick with it.

Until you can follow these protocols exactly, you won't be able to get accurate results and therefore, will not be able to properly and safely manage both the dosing and the disease itself.

It may be difficult, but you'll need to over-ride your vet, and her specialist, in this.

As for the CC, the most important thing is keeping it dry and free of infection. If Thor is not on abx, or has not run a good course of them, then please ask the vet to start some. Do not get the sores wet or apply ointment that will keep them moist. Trizchlor spray has been used by many. I also used tea compresses to ease them. It takes months and months to heal CC. During that time, the cortisol must be below 5.0 ug/dl and kept in that range the entire time. I started seeing improvement when my girl dropped below 10 ug/dl, but it took getting it lower to get complete resolution.

I sure hope this doesn't come off as too overwhelming. CC can be one of the worse symptoms to deal with and quickly turn into a quality of life issue. I would hate to see that happen.

[jml666]

Thank you all for your feedback. If I didn't know better, it would be easy to feel overwhelmed and intimidated, but I recognize that you are looking out for my boy’s best interests and I sincerely appreciate it.

With that said, I would like to ask all of you to please keep in mind that I am fairly new to this myself, and trying to learn and get as much information as I can to do the best for Thor. Presenting information to me is one thing, but pushing as hard as you have is another and, since there is a lot of emotion involved here as well, it can be hard to digest, even with your best intentions.

Now that I have that out of the way, I do want to know if you have any recommendations for good vets who have treated dogs with Cushing’s in my area in north eastern CT or if you know of anyone who could make a recommendation. I am uncertain where to start to even search for someone with the right credentials other than asking my friends who have dogs, but they have not necessarily had dogs who have had Cushing’s.

As for Thor’s CC, he was put on antibiotics for the first 3 weeks when they showed up in late August, but has not been on them since. It doesn’t seem to be getting worse, but taking time to get better.

[My sweet Ginger]

Hi, I've just realized we live very close considering we are global here.
I was taking my pup to this IMS last year who I was very happy with.
She seems very knowledgable and very approachable. We haven't seen her this year as my pup had gotten what I'd call "stabilized".
I think she's someone you should check out. Here is her bio.

Veterinary Specialists of CT
993 North Main St.
West Hartford, CT 06117


Internal Medicine


Liz Goldman, DVM, DACVIM Dr. Goldman brings 20 years of diverse experience as a practicing veterinarian,
having worked as a general practitioner, emergency clinician, and specialist. She graduated with high honors from Cornell University’s College of Veterinary Medicine. She participated in a small animal rotating internship at Oradell Animal Hospital in NJ, as well as residencies in both Clinical Pathology at North Carolina State and Small Animal Internal Medicine at Iowa State University. At the completion of her residencies, Dr. Goldman joined a 24-hour emergency, referral and critical care hospital in Chicago as an internist, and was voted one of Chicago’s Top Veterinarians. She is a published author, has extensive teaching experience, and is board certified by the American College of Veterinary Internal Medicine. Dr. Goldman is most passionate about enhancing the acute care needs of critically ill patients. With her advanced training in pathology and small animal internal medicine, she is able to provide diagnostic services in addition to high-level interpretation of laboratory data. She joined Veterinary Specialists in 2013. Dr. Goldman’s specialty services include:
Gastroenterology
Endoscopy
Abdominal Ultrasound
Cytology
Chemotherapy

Hematology
Infectious Diseases
Endocrinology
Hepatic Diseases

[jml666]

Thank you, I will be sure to give her a call on Monday.

[molly muffin]

Oh dear, sorry that you are feeling pushed and overwhelmed. It IS overwhelming when you are first starting out and trying to learn all you can.

It is probably best to make notes of the items that have been mentioned as far as protocols go for testing, etc, so that you will know if the vet knows what they are talking about or not.

You can print out the links that have been supplied and give them to the vet if they don't follow the proper protocols. Believe me, in no time at all you will know this stuff by heart and not feel nearly as overwhelmed by it all. I think we all felt like this to begin with.

If you have a question though, don't worry about asking about it, it's better to ask first and not risk getting off track.

You'd be surprised at the number of vets who don't follow the proper set out protocols and don't even understand in some cases what the medication should do and what values are being looked for on the tests they administer. It's not really as rare as we all wish it was.

Hang in there. You are learning, each day you learn something and once learned you retain it and that is the all important knowledge that you will be armed with forever.

[Squirt's Mom]

Feeling overwhelmed is normal on this journey in the beginning. It's a bit like being dropped into a foreign country with no warning - we don't know the language, the culture, or even which fork to use....but everyone is talking to us 100mph, gesturing expansively, and staring at us expectantly. When I got here to this strange new land, I stood there staring back at them with my hair and eyes wild, drool running down my chin, blabbering and muttering incoherently, and with tears flowing down and soaking my clothes. But I kept standing there, blabbering and listening, and in time was able to learn how to give my baby the best chance with this disease. So keep standing here with us for just a bit and you will find you aren't quite as overwhelmed and are, in fact, able to help others thru what you have learned.

You're a great mom - we all know that and just want so desperately to help you and Thor have the best chance possible in living with this disease. You took a brave step that many find impossible - you contacted your vet with information you have learned in an effort to get things on the right track. That deserves a huge ATTAGIRL! :cool::cool::cool: Being proactive for our babies is the best we can do for them. They cannot speak so we must be their voice....and your voice has spoken on Thor's behalf. That is wonderful. ;)

Hugs,
Leslie and the gang

[jml666]

Thank you Leslie, you are absolutely correct with how I'm feeling!

So, I found this link this morning:

http://www.k9cushings.com/forum/showthread.php?t=198

This is what my vet was testing Thor for with the last test to the Univ of TN. Marianne, if I understand you correctly, I think you were trying to tell me that this should have been the FIRST test that was run back in April when he was diagnosed with Cushings, is that correct?

[labblab]

Before talking about the ACTH tests, I want you to know that I really regret it if the way in which I have been writing has made things feel even harder to you :o. Dealing with our dogs' illness is so upsetting and overwhelming, all by itself. So I want to join the others in telling you that you are doing such a good job of hanging in here with us, no matter what we've been slinging at you!! Also, I want to clarify that I really do not want to damage your relationship with your regular vet. It is just the case that no vet and no human doctor can possibly be an expert in every disorder. So I surely don't mean to undermine or discredit all the other care that your vet has supplied through the years (and can continue to provide in the future). I'm just hoping that y'all will be able to gain a more specialized perspective re: Cushing's.

OK, I just looked back at what I wrote and see that, once again, I can never keep anything short. I apologize in advance for how long all my replies always turn out to be! :rolleyes:

Turning to ACTH testing...The terminology here can be very confusing, because there are two entirely different types of "ACTH" tests that can be run: "endogenous ACTH" tests (like the one your vet sent to Michigan State on 9/17), and "ACTH stimulation" tests. Endogenous ACTH tests are purely diagnostic tests. There are a couple of different disorders/reasons why knowing what a dog's natural ACTH level is can be helpful. But when diagnosing Cushdogs, the test would typically be ordered if there is a question as to whether the Cushing's is caused by a pituitary or adrenal tumor (viewing the adrenals on an ultrasound is another way of getting that info). The dog's natural ACTH level can help point to the type of tumor. Once trilostane treatment for Cushing's is begun, however, this test has no value because the drug itself will skew the ACTH level. Even during the diagnostic phase, endogenous ACTH tests are not commonly performed if an ultrasound is also going to be done, since the ultrasound should give you the same information, just via a different route.

ACTH stimulation tests can also be used diagnostically, plus they are the standard blood test for monitoring trilostane treatment after it has begun. Instead of measuring the dog's own natural ACTH level, however, the stimulation test involves injecting a stimulating agent that mimics ACTH into the dog's blood stream which in turn causes the adrenal glands to dump their cortisol reserves. When used diagnostically, this test can tell you whether the dog's production of cortisol is abnormally high -- therefore "positive" for Cushing's. It cannot tell you what form of Cushing's the dog suffers from.

After treatment has begun, the test is performed in exactly the same manner for monitoring purposes, with the goal being to see how much the cortisol production is being lowered by the medication. This is why Thor has been having the subsequent monitoring ACTH tests performed.

However, the ACTH stimulation test will actually cause the adrenals to "dump" all the hormones they produce, not just cortisol. As it turns out, UTK is the only veterinary lab that analyzes the levels of other adrenal hormones in addition to cortisol. The analysis of the cortisol is identical to the ACTH testing performed by other labs -- it's just that UTK also gives you the additional info about the other adrenal hormone levels. So just like a "regular" ACTH stimulation test that analyzes cortisol alone, the UTK can be used either as an initial diagnostic test or as a subsequent monitoring test. But there is a lot of debate among researchers and clinicians as to the value of finding out the additional info about the adrenal hormone levels other than cortisol -- whether and how elevations in other hormones may also cause Cushing's symptoms (that's what you are reading about on that thread). That's a topic for another reply, though! ;)

The bottom line is that, since Thor has already started trilostane treatment, any ACTH stimulation test that is performed now (whether it be one that measures only cortisol alone, or the UTK test that measures cortisol and also other hormones), needs to be run according to proper monitoring protocol: 4-6 hours after the trilostane has been given with breakfast. WHEW! Hope this all makes at least a little sense!

Marianne

[jml666]

Hi Marianne, I appreciate the acknowledgement of being overwhelmed, which I'm over with for now and focusing on how to get Thor better, so thank you for that.

My vet and I have a great relationship and she is doing everything she can to determine what's best for him. We have agreed to consult with Dr Goldman in my area and she will be sending Thor's records over to her on Sunday evening for an appointment I have at 10:30 on Monday morning.

Thanks for your explanation of the differences with the tests, it does help.

The info that I'm missing is Thor's original diagnostic tests that confirmed his Cushings. I know they were done, but I don't have the test results in my hands.

I do have copies of the results of most of his ACTH stim tests, but I think I may be missing the first one (along with the original diagnostic test). If I don't get them when she sends them over to Dr Goldman, I will be sure to ask for them so I have the whole picture myself.

I do appreciate everyone's input; it's helping me learn and for me, information is power and helps me get through the emotional part of this better. Thanks again!

[Renee]

Hey there - I wanted to chime in and apologize for my part in making you feel overwhelmed and/or a bit on the defense with so many of us pushing.

I'll be frank with you - it's bad enough to have cushings itself, but overwhelmingly, the symptom that seems to become a quality of life issue the quickest is not the cushings itself, but the CC. I speak from personal experience here. My girl pug has CC. It's in 'remission' now, but I've been where you are. Sadly, people have had to euthanize their pets due to CC getting out of control. I NEVER want to see that happen. I think this is why we may push harder when someone on this forum shows up and their dog has CC.

If you read my thread, you'll note that I have a vet that is amazing, but totally inexperienced in treating cushings. In fact, my Tobey is her only cushings patient receiving active treatment. I learned as much as I could, as quickly as I could, and made sure that every choice made along the way was approved by me, and backed up by reputable research that I had read. Not once did she make a decision that I had not personally researched first. It's not personal. I think my vet is great. I love her. But, she's not above being wrong or making a mistake, and I refuse to take that chance with any of my pets, especially with drugs that can cause death. It's not about discrediting your vet or calling you out on following her advice. We are trying to empower you and help Thor.

Sorry, I think I'm still coming off as pushy. I am so glad you are seeing an IMS and that your regular vet is on board with you on this. You are doing an excellent job being an advocate for Thor. I am certain you are on the right path and a year from now Thor's CC will be in remission too!

[jml666]

Hi Renee, thanks for your input. Given the context of Cushings dogs with CC, I can understand your concerns. Thor's seems to be stable right now - his CC it seems to be contained and not spreading across his back, but we are certainly being cautious.

I have an appointment tomorrow with the specialist and his records have been sent over already. I'll be back to provide an update once I have more info to share.

Thanks to you and the others for sticking with me through this :)

[jml666]

Came on to give an update.

I met with Dr Goldman yesterday morning and she confirmed for me why I have been so confused by the test results. She indicated that the first set of tests done back in April/May did confirm Cushings and, at that point, all indications were that it was adrenal based.

The second set of tests done in August/September are now indicating that it's pituitary based.

Regardless if the tests results were run and/or interpreted correctly or not is irrelevant at this point; she is working with my vet and 2 other specialists to determine what the next best steps are for Thor.

She had me collect another urine sample to rule out any UTIs (last one was done when he was diagnosed initially). Since Thor was also diagnosed early in his life with hypothyroidism, she asked for his early records on that as well, which I just sent to her tonight. She said it's rare that boxers are diagnosed with hypothyroidism as such a young age, but since it runs in his bloodline, maybe that's not so unusual.

She's also asked that we do a chest x-ray to rule out anything else that may be going on with him, which I will need to schedule.

She suggested that we hold off on any more ACTH tests until we have more info, but she wants us to keep him on the vetoryl for now.

Since the records were sent to her on Saturday night and she only had a brief time on Monday morning to review them before meeting with me at 10:30am, she wanted to take more time to review and talk to my vet and the specialist that has been working with my vet and another specialist in her office.

She said she is leaning toward doing an MRI since the tests are a mixed bag and are inconsistent with telling her what the true root cause is. Since she would have him under anesthesia for that procedure, if he does well, she would do a skin biopsy to confirm CC. She indicated that boxers are also pre-disposed to other types of skin conditions and even cancer that may look similar, so we will want to get him tested for that as well.

She also said that based on the endogenous ACTH that was run, she did see that his sex hormones are high, knowing that they may be elevated due to the vetoryl, but she speculates that he may have atypical cushings in addition to adrenal or pituitary based cushings. Again, not definitive, but hard to tell based on his test results.

She's on vacation for the rest of this week, so not likely that I will hear anything back from her until next week, but I do feel a lot better after talking to her. She spent over an hour with me talking through his history and explained to me how the adrenal and pituitary types of cushings vary and how they can be treated.

I feel much better that I now have a team of 3 specialists and my regular vet consulting on him to be able to get the best care for him possible.

On another note, Thor was playing in the yard this weekend, chasing Trixie (my 4.5 month old boxer) and Twinkle (7 year old boxer) around and playing with his Jolly Ball. My husband cleaned up his back and, while I've noticed a few more smaller lumps toward the lower part of his back, the older stuff looks a lot better than it did.

Anyway, thanks again for sticking with me and being patient with me and the emotional roller coaster I've been on with this!

[jml666]

So I have a question while I'm waiting on next steps.....

I posted a picture of Thor's CC below:
http://www.k9cushings.com/forum/album.php?albumid=1038&pictureid=7923

It's been 6.5 weeks since they first showed up. Does it look like it's getting better or worse and controlled or not? Per my prior post, it seems like it's getting better, but I haven't been through this before, so defer to your feedback. Thanks!

[Budsters Mom]

Yes, many of us have been or are on that ride right now. None of us boarded willingly, yet no one rides alone.;)

Kathy


the emotional roller coaster I've been on with this!

[Squirt's Mom]

It certainly looks like the pics of CC I've seen but I am glad IMS is going to verify for sure. From the pics, to me it looks like the skin has improved marginally over the last month tho it certainly has spread from when it first showed up. The xray and MRI is also a good idea.

Vetoryl will cause the intermediate hormones to become elevated when they weren't before starting the drug. For this reason, Vetoryl is not recommended for a pup with Atypical. Lysodren is used IF NEEDED with an Atypical pup and it is not usually used to control cortisol but rather the intermediates themselves, and is only used as a maintenance dose then, no loading for Atypical pups. The catch here is that if this is CC Vetoryl is usually preferred for this condition because the dose often needs to be fairly high to keep the CC knocked down. Lysodren is very hard on the tummy so higher doses of it are hard on the pup.

It is possible, tho very rare, for a pup to have both PDH and ADH - but that is very rare. I just want you to have the info so you are shocked should that come to pass in further testing.

Those times when we see out babies acting like their old selves is so uplifting and joyous! I don't think I will ever forget seeing Squirt pick up a toy and start shaking it. She hadn't done that in ages! Sure made this old heart sing! ;)

Thanks for supplying such a detailed update! That always helps us a great deal.

[labblab]

I'm so glad you had such a good conversation with the new IMS! And I'd have to agree with Leslie in that the lesions look more widespread in the new photos but also less raw.

Now for a couple questions/comments about the results of the visit. ;)

Is the IMS talking about doing an MRI of Thor's head (to check for a pituitary tumor) or of his abdomen (to check the adrenals)?

Is she keeping him on the increased dose of 60 mg. twice daily, or are you reverting back to the 60/30 for the time being?

Also, just to clarify a bit more about those other elevated adrenal hormones. So you won't be confused if your vet talks about them further, it was the ACTH stimulation test sent to Tennessee that analyzed those hormone levels, and not the endogenous ACTH that was sent to Michigan State. If you recheck those two lab reports, you'll see the difference. Usually the term "Atypical Cushing's" is reserved for dogs who exhibit normal cortisol levels but experience Cushing's-consistent symptoms in conjunction with elevated levels of other adrenal hormones. Since Thor has elevated cortisol, most vets would say he suffers from conventional Cushing's rather than Atypical. But I am guessing the IMS is using the term as a point of reference to discuss those other elevated intermediate hormones in addition to the cortisol.

The thing is, even though UTK is dedicated to researching the area of "Atypical," not all clinicians elsewhere agree as to the meaning/significance of those other adrenal elevations. Here is an article that discusses the debate. It is pretty technical, but you may want to try to wade through it prior to meeting with the vet again. As you'll see, even though it seems as though trilostane theoretically ought to worsen symptoms for dogs with certain elevated adrenal hormones, this has not necessarily been the case at all -- in fact, trilo has improved symptoms for dogs with certain alopecias. So whether or not Thor's elevated hormones other than cortisol are actually contributing to his symptoms may remain a question mark. Probably all dogs who are treated with trilostane for high cortisol would also exhibit other elevated adrenal hormones if their blood was sent to Tennessee for analysis. But as long as their symptoms are controlled with the trilo, it really becomes a moot point. Anyway, here's the article:

http://www.2ndchance.info/cushingsbehrend2010.pdf

Definitely keep us updated as things proceed, OK?

Marianne

[jml666]

Agreed and it's good to know that this group is here to lend support and info.


Yes, many of us have been or are on that ride right now. None of us boarded willingly, yet no one rides alone.;)

Kathy

[jml666]

Squirt's Mom and Marianne, thanks so much for the additional info. The IMS also shared the same with me as well so I know there is consistent messaging.

She's talking about doing an MRI of both his head and abdomen since the results have been conflicting.

She's keeping him on the 60mg 2xday for now. I know that it will mean that I get his ACTH stim test again since we haven't done one yet at this dosage; it's been about 10 days since we increased it, so I know there is still time to do so. Thor has been definitely more like himself the last couple of days as I've read that it can take that long to really start to see a meaningful change and up to 30 days for the cortisol levels to stabilize.

I scheduled him today for his chest and abdominal xrays on 10/14 - this is prior to doing an MRI.

The urinalysis results came back as follows:
pH 6.5
USG 1.028
Protein: Trace
Blood: Neg
Ketone: Neg
Glucose: Neg
Bilirubin: 1+
Urobilinogen: Neg
RBC: None seen
WBC: None seen
Sediment: None
Appearance: Yellow with moderate turbidity
Comments: Occasional fat also seen

I think this means it was normal, but neither Dr replied on this. Pending results of the culture that they took also - still at the lab.

Both Drs are on vacation until 10/14, so I doubt I will hear anything back until both return.

Now it's just waiting for his xrays then results and culture and results to come back to determine next steps.

[jml666]

Hi everyone, I wanted to just jump on here to give a quick update on Thor.

Despite questioning the validity of his tests and knowing we still have more testing to do, since Friday, Thor has been acting more like himself than he has in YEARS.

We chalked it up to him getting older, but now I am wondering if he has been deteriorating for years and only until this year, started to really show symptoms.

Since Friday, he’s been playing with our other 2 boxers (Twinkle, 7 and Trixie, 5 months), running around, wiggle butting like crazy and being his pushy self with demanding our attention, lol. It’s been exhilarating to have him behaving like himself in so long.

He’s been on 60mg Vetoryl twice a day for about 2.5 weeks now so I know we need to go back to get an ACTH stim test done on him to check the numbers, but I feel good that he is acting like himself. I’ll take the little victory for now :)

So.....I'm now wondering if this means he's responding to Vetoryl and if that means he has adrenal based Cushings vs pituitary based - is that conclusive? I suspect no, that we need to truly validate with further tests. What are your thoughts on this? I'm interested in hearing different ideas that will prep me for when I meet with my vet and specialist next.

Oh, and I got the urinalysis and culture results back from the vet and the culture says they found Klebsiella Oxytoca, which, from what I've read, is a bacteria that needs to be treated. Both my vet and specialist are on vacation until Wednesday, but I'm thinking they will want to put him on antibiotics, correct?

And, as much as I was stressed out, I feel much better and wanted to say thank you to everyone who pushed me to really understand what was going on with him and to get him additional help. He would not be where he is now without your support, so THANK YOU!!!

[Squirt's Mom]

I am THRILLED to hear that Thor is acting like his old self! That can make a heart sing to the heavens! I would take this change in behavior to mean the Vetoryl is doing it's job and his cortisol is in a much more normal range now, making him feel much better than he was. He is due the ACTH since two weeks have passed since the dose change. Let us know what it shows when you get that done.

As for the behavior indication adrenal or pituitary, no. That is determined via the LDDS, HDDS, abdominal ultrasound and in rare cases MRI/CT scan. If both adrenals are seen and enlarged on the US, pituitary is deemed the diagnosis. If one adrenal is seen as much larger than the other, which may be even shriveled, then adrenal is the diagnosis. The HDDS has fallen out of favor since the US and LDDS can point out which form the pup has. Most pups, 85%, have PDH, the pituitary based form.

[jml666]

Thanks, Squirt's Mom :) We still don't definitively know if Thor's is adrenal or pituitary based because the first set of tests done in April/May pointed to adrenal (one bigger than the other) but this last set of tests (September) seemed to point to pituitary, hence further testing to be done. Thanks for your thoughts on it!

[Renee]

Slight to moderate differences in size of adrenals can be consistent with PDH. My pug had a CT and while both adrenals were enlarged, one was larger than the other.

I'm so glad to hear Thor is acting like his old self. I remember the first time Tobey did that. It was literally 2 minutes of play, but it was so encouraging! Go Thor, Go!

[Squirt's Mom]

There is the rare pup who has both adrenal AND pituitary tumors but Thor wouldn't dare do that. ;) :D

[labblab]

YAY, that's great that Thor is feeling so much better!! :) :) :). Fingers crossed that this will turn out to be the perfect dose for him.

Also, just wanted to note that even though, technically, Vetoryl was originally only FDA-approved to treat adrenal Cushing's, it is equally effective in treating pituitary Cushing's and that is how it is used most frequently (since the majority of Cushing's cases are pituitary based). It can be hard to fathom the ins-and-outs of FDA approval language, and why the applications were made on the basis of treating adrenal Cushing's alone, I do not know. But just as is the case with many drugs, "off-label" usage and success are very common. So I don't know whether that original FDA approval language figured into your question or not, but that's the scoop!

Really, the only reason why I would personally care to put more effort into distinguishing which type of Cushing's Thor suffers from is if I would consider surgery in the event it is an adrenal tumor. If so, then perhaps more abdominal imaging would give you useful info as to what is really going on with the adrenals.

Marianne

[labblab]

Also, it occurs to me to add that trilostane treatment, itself, can cause the adrenals to enlarge. Since Thor has now been on the medication for awhile, this could also account for differences in the appearance of the adrenals in imaging performed before and after starting treatment.

[jml666]

Thanks Marianne, I think I had read something about adrenal enlargement after use of Vetoryl too.

So, Thor has been sleeping most of today already, but that could just be because he had a big weekend....we have company over on Saturday night and he was pretty active during most of it. He slept some yesterday, but was up and about. I work from home on Mondays and Fridays, so he might just be catching up since he expended more energy this weekend. My other two boxers are slugged out too, lol.

[molly muffin]

So happy to hear that Thor is doing so good. Yay

[jml666]

Just jumping on to provide an update.

Thor had his chest x-rays yesterday morning and they came back perfect – everything in his chest looks great. Dr G wanted to check this first before doing an MRI to make sure there wasn’t cancer wide spread in his body.

I also heard back from Dr G today since she’s now has more time to review his records. She confirmed that his hypothyroidism is likely genetic since it runs in his family and the tests that were done when he was first diagnosed are in alignment with her thoughts on it.
He’s had an irregular heartbeat before, so he may be pre-disposed to cardiomyopathy, but doesn’t seem to be an issue right now.

Although Thor’s prior tests were conflicting, the fact that he’s reacting to medication is positive and she agreed that it’s time to schedule him for another ACTH stim test. My DVM agrees as well, so that’s our next step.

We have him on Clavamox right now because they found a small amount of bacteria in his urine culture.

Should we wait until he’s off the antibiotics before we get his next ACTH stim test done?

[Harley PoMMom]

We have him on Clavamox right now because they found a small amount of bacteria in his urine culture.

Should we wait until he’s off the antibiotics before we get his next ACTH stim test done?

I would definitely wait until he's done with the antibiotics AND his next urinalysis comes back clean.

Hugs, Lori

[labblab]

Can you remind us as to how long Thor has been taking the increased trilostane dose, and also tell us how many days of Clavamox he still has left to take? Thanks!

[jml666]

Thor has been on the increased dose since 9/23 and started Clavomox yesterday.

Also, below is a link to his album that shows the most recent views of his back. Generally, I think getting better....

http://www.k9cushings.com/forum/album.php?albumid=1038

[labblab]

Yep, I think the CC looks better, too! :) :)

Since next week it will be a full month since the increase in the trilo dose and Thor is just now beginning the course of Clavamox, whether or not I'd wait to test would kinda depend on how many days he'll be taking the Clavamox. I do understand Lori's concern about infection possibly skewing the ACTH results. But if he hasn't exhibited any stress or discomfort associated with a UTI and the only evidence is just microscopic, I guess I'd be more concerned about monitoring his cortisol level sooner rather than later. If he's only going to be taking a week's worth of antibiotic, for instance, I might wait until he's done with it. But if it's planned to be a longer course, I think I'd personally go ahead with the ACTH next week. But those are just my personal thoughts.

Marianne

[jml666]

Hi Marianne, thanks for your thoughts on this.

I have Thor's next stim test scheduled for 10/30. He will be done with his Clavamox tomorrow, so that should be plenty of time off of it.

I think he's still doing well. He spent quite a bit of time outside today which I haven't seen in a while. He was sniffing around the yard, being a dog, which made me happy. Tonight he also pushed Trixie out of the way when I was giving her attention so he could have me all to himself instead, lol! I definitely think he's doing better and couldn't be happier. I will be cautiously optimistic until I get the test results back from his next test, but am hopeful.

My vet has also been awesome; she's been keeping up with the specialists and their recommendations/advice and making adjustments to align with Dechra's recommendations on testing for Vetoryl, which is great.

And a shout out to My Sweet Ginger (sorry, I don't know your name) for recommending Dr Goldman to me - she has been fantastic and has totally given me peace of mind with her detailed explanations of everything and her thoroughness and deliberateness. Thank you so much for the recommendation!!

[My sweet Ginger]

I'm not really surprised you like Dr. G. Everything she was saying to me made total sense and made me feel like the thick fog that was all around us for months was being lifted in an instant when we first met.
One of her patients wrote in his review that he was going by the quote by M. Twain "The more I learn about people, the more I like my dog." until he met Dr. G so I know I wasn't the only one.
I'm so glad she was able to put your mind at ease. Hugs, Song.

[jml666]

Just jumping on to show you the latest picture of Thor's CC:

http://www.k9cushings.com/forum/album.php?albumid=1038&pictureid=7951

And to share a funny story.....

My husband made chicken wings over the weekend and shared a little bit with each of our pups. Thor wanted more and was so frustrated that hubby wouldn't give him more that when a bird flew by a little too low, Thor snapped at it, lol! The bird is fine - he didn't get it, but I'd say he's feeling better if he was doing that :)

His ACTH stim test is this Friday; will post again once we get the results back.

[molly muffin]

That does sound like he is feeling better :) and has very definite thoughts about his chicken too!!! hahahahahah

The CC looks better, like it is drying out.

[jml666]

Thanks Sharlene. I'm hopeful that his test on Friday will show that he's in the controlled range.

Btw, my vet will be doing the test without fasting him, but will give him some food before she tests. I'm grateful to the folks on this board for showing me the way (even if I was a little grumpy at first). Without you, we wouldn't quite be where we are now. Thank you!

[molly muffin]

We all came here at some point same as you. Trying to learn all we could about Cushing's. How to treat what our options are what the protocols are. Some days I was so frustrated I cried. Make that howling bawled. I was upset. Angry. Distraught. I found that the more you learned. You yourself. The better it got. The easier it was to have discussions and an exchange with vets based upon a mutual understanding which allows you to arrive at mutual goals.

I hope Thor shows good control this test too. It will always be a matter of watching and verifying, making determinations of what works best for him. As long as you have a handle or are working towards having a handle in the situation the better it goes and the smoother the journey can be. It will never be easy but some days and for months it can feel easy and that is a great stage to be in.

Cheers.

[labblab]

Thanks Sharlene. I'm hopeful that his test on Friday will show that he's in the controlled range.

Btw, my vet will be doing the test without fasting him, but will give him some food before she tests. I'm grateful to the folks on this board for showing me the way (even if I was a little grumpy at first). Without you, we wouldn't quite be where we are now. Thank you!
I just want to clarify how Thor will be fed on Friday. He needs to be given breakfast at the same time that he takes the trilostane (4-6 hours prior to testing). So for most folks, that means the feeding and dosing are done at home before the dogs are taken in to the vet's office. I'm concerned about what is meant by "giving some food before she tests." What will be the timing of the testing for Thor?

You are doing a great job of advocating for Thor, so let's make sure the timing is right. ;)

Marianne

[molly muffin]

I didn't catch that but this here is the latest published information from Dechra the manufacturer and clearly states, "ensure morning capsule was given with food"

http://www.dechra-us.com/files//dechraUSA/downloads/Client%20Literature/Treatment%20and%20Monitoring%20of%20Hyperadrenocor ticism.pdf

[jml666]

Hi Marianne and molly muffin :)

Thor did have his test done on Friday and my vet gave him his trilostane with a bit of ID (low fat dog food) and tested him per Dechra's recommendations. She gave him his meds and food so she could time it on her end; I didn't feed him or give him his meds in the morning. I feel comfortable that the test was done correctly.

She called me today to give me his test results: pre was 4.5 and post was 7.3. She also consulted with my specialist and my specialist feels that given that his fur is growing back and he is not showing symptoms of excessive thirst and peeing, and is behaving more like himself, she believes we can keep him at his current dosage and re-test him again in 3 months.

My specialist knows that 1-5 post is preferred, but since he is not showing other signs, she is less concerned (she is ok with 2-7 for the post number if they are not showing any clinical signs). Of course, we will keep an eye on him and bring him right away if he starts to show any symptoms of regression. 3 months will be end of January, so I am planning for that unless we see something that will cause us to return sooner.

I'll continue to take periodic pictures of his back and post them in my album of him in the meantime and post if anything changes with him.

[labblab]

I'm so glad to hear how things went with the testing! And yes, as long as you continue to see ongoing improvement with the CC, I'd be very content with those numbers, as well.

Definitely, please do keep us updated. We seem to have a rash of folks struggling with CC lately, so I know it will lift everyone's spirits to hear about things going well with Thor. :)

Marianne

[Squirt's Mom]

It sounds like things are finally moving in the right direction! YAY!!! Dechra, the manufacturer, says the post # can go as high as 9.1ug/dl if, and ONLY IF, all signs are controlled. At 7ug/dl and the improvements you have seen on this dose, I would also leave it as is for now. I'm not sure I would wait 3 months for another ACTH tho. With the CC in play, it is critical to keep that cortisol down and not let it start rising. So for my own peace of mind I would want another ACTH in 30 days just to see how the cortisol is doing then. If it has crept up any at all, I would want a small increase. But I am big ole worry wort sooooo.... :rolleyes::p

[jml666]

Thanks for the feedback, Squirt's Mom. I think if I didn't see as much fur growing back over on his back in a consistent manner, I'd probably still be pretty concerned too. Will definitely keep my eye out on it, but I'll admit I'm getting pretty tired of the high vet bills! We shall see, however, and, I think you know that I will bring him back in a heartbeat if I notice anything unusual :)

[jml666]

So I was reading through some of the other posts and thought of something else to ask.

I read from others that their dogs have lost weight due to Cushings. Thor has as well. He was 82 pounds when he was diagnosed in April and on Friday last week, he weighed in at 70 pounds.

He doesn't look unhealthy, in fact, I think maybe he was slightly on the heavier side before, but I'm curious what others have done to maintain weight. We are feeding him the same if not slightly more than we were before, but he consistently seems to be losing a couple of pounds each time we bring him for another test. He has no issues with eating - he gobbles all of it right up each time.

When should I start to be really concerned about this?

[Squirt's Mom]

Bear in mind, most cush pup are quite overweight by the time they start treatment and need to lose a few pounds which happens naturally as their appetites return to normal. Of course, these babies are very smart and develop habits just like humans so we do see these pups continuing to beg and wake their parents up at 3 AM for a snack even after the cortsol is back in normal range. :D) I use a body condition chart often with the rescues coming in and it does help to see exactly where they are and where they move on the chart with some nutritional adjustments. Here is a chart from the WSAVA (World Small Animal Veterinary Association) -

http://www.wsava.org/sites/default/files/Body%20condition%20score%20chart%20dogs.pdf

[jml666]

Squirt's Mom - Thanks for the info, the document is great. Thor looks perfect in the ideal range right now :)

I've added the latest pictures of Thor's back from Wednesday this week. http://www.k9cushings.com/forum/album.php?albumid=1038&pictureid=7965

It just keeps getting better and better :) I'm a happy mom :)

[molly muffin]

So glad to hear that Thor is doing so well now and that his numbers are looking good. I totally am onboard with as long as the cc is clearing up, his fur is coming back in, that there is no need to stretch for the 1 - 5 range, when up to 9 is perfectly acceptable.

Great news!

[jml666]

Updated Thor's album with more pictures. His fur is really coming in nicely and we've not noticed any increase in his symptoms. Keeping my fingers crossed that he continues down this path.

http://www.k9cushings.com/forum/album.php?albumid=1038

[Squirt's Mom]

Oh he is really looking good! I know you are thrilled to see this! WOOHOO! Way to go, Mom and Thor!

[labblab]

Great pictures and great news!! :) :)

Marianne

[jml666]

Yes, definitely happy and thankful to everyone here who helped me through this journey!

[molly muffin]

Wow, he is looking really good. The hair is definitely coming in nicely now. Yay!!!
love good news days

[jml666]

Hey everybody, just thought I'd pop in to say hello. I'm bringing Thor back to the vet for his ACTH test on Wednesday. He's continued to be stable, and had returned to being his playful self. All of his fur on his back has grown back. I'm noticing his fur is still thin in a few places, but not too worried at this point since he is behaving normally for him. Will let you know how his test comes back later this week! I'll post a current pic of him soon too to my album. Thanks for reading!

[molly muffin]

That is evcellent news! Do let us know what the ACTH is.
Hopefully his hair will come back in all areas as he continues to do so well.

[jml666]

Hi everyone, I have been absent for about 6 weeks while I was dealing with other non-canine issues (my parents were in a car accident on 2/20 - both ended up with broken ribs, mom with a cracked sternum too and partially punctured lung - they are both fine and home recovering).

Thor's ACTH test from 2/17 came back excellent: pre was 4.1, post was 4.7. His T4 was low, so we bumped him up a little with his meds. He had a spot on his back starting to form, so she prescribed an antibiotic that actually didn't really help.

Strangely enough, around the time that we got his test results back, he started drinking a ton of water, started having some accidents in the house, and had an outbreak on the back of his neck of what looks like CC (post antibiotic).

I took him back on 3/8 to get a urinalysis and get checked for diabetes, and those tests came back normal too. My vet was stumped, so we reached out to our specialist again for consultation.

I took Thor to the specialist this week on Monday, and she did a Cystocentesis and will send the sample for testing. She also took some blood to do a IDX SDMA Kidney Test and is re-testing his T4. Results to come early next week.

She did mention to me that some dogs end up with diabetes insipidus (water diabetes) instead of the regular diabetes which is tested via sugar. I'm just now starting to read up on this; been mostly focused on my parents and now just re-focusing on Thor.

Any suggestions for possible next steps?

I'm adding a picture of Thor's neck, which looks very much like CC (specialist also confirmed it) even though he's under control, which is very strange. Any tips on this too would be helpful, thanks!

http://www.k9cushings.com/forum/picture.php?albumid=1038&pictureid=8215

[molly muffin]

Oh my gosh, I'm sorry to hear about your parents accident! Glad they are both on the road to recovery.

I think you have to wait for the lab results to come back in to determine what might be going on.

CC, can have spots still come up, usually not as bad as previously, but they do pop through and erupt. Remember there might be tons of calcium deposits in his body that never came up and through and they can work their way up at any given time. Renee our resident expert with cushings, having gone through it for so long with her dog, has been known to say that her dog has had a deposit come through.

The ACTH results are really very good and exactly where he needs to be so I'm inclined to think that something else might have reared it's ugly head, something as simple as a UTI or something perhaps.

[jml666]

Thanks Sharlene.

Thor's T4 came back low, so we have to bump up his meds a little more. What are your thoughts on his T4 interfering with the Cushing's? They are both hormone related, so I was theorizing that if his T4 is treated to go back to the normal range, then maybe his Cushing's symptoms will go away?

Here's what the specialist said: "His SDMA is within normal limits - and although it does not 100% rule out kidney failure, it is not in strong support either. Also the urine specific gravity was lower this visit at 1.005 - hyposthenuria - so perhaps the kidneys can dilute somewhat which can open the differential list to include such diseases as diabetes insipidus. There was no protein registered at the lab on the evaluation of this urine this time.

The post-pill thyroid level is low out of therapeutic range at 2.4 ug/dl (2.5-6.0) so you will need to be increasing Thor's thyroid supplement again by approximately 20% to 0.6 mg by mouth twice daily and recheck a 4-6 hour post pill thyroid level again in the next 2 weeks.

The final results of the urine culture are pending." We should get these early next week.

We'll increase his thyroid meds and have him re-checked in 6 weeks unless the urine culture shows something else.

That's all I've got for now. Other thoughts?

[molly muffin]

I think that increasing the thyroid med a bit and seeing how that is, is definitely the step to take and see if that makes any difference in the urinating/drinking symptoms.

With a lower specific gravity though, as with my dog, I'm seeing way more urination, even with control of the cortisol. Thyroid for mine is okay.

[jml666]

I find it very interesting that the symptoms that have surfaced are very similar to last year when he was first diagnosed - his Thyroid was also low then, and we had to increase the meds. But we did it along side of starting him on Vetoryl, so we can't know for sure the impacts of each independently. I think we will give it some time with the increased thyroid before we do anything else even if he's drinking and peeing more for the time being.

[jml666]

Hi everyone, it's been a few months since I posted last and I'm happy to tell you that Thor is doing great. We did a full Thyroid panel on him and found that we have him under control there with up to 0.7mg twice a day dosage. His ACTH remains stable with him on 60mg Vetoryl twice a day. I've added a picture of him taken tonight, and, as you can see, his fur is growing back in everywhere! No further signs of CC either. He still drinks a lot of water and urinates a lot, but everything else is under control, so I'll take it!

http://www.k9cushings.com/forum/album.php?albumid=1038&pictureid=8493

I will take him back around his birthday to get him checked again in December just to make sure everything is on track or sooner if something changes.

Thanks to everyone here for all of your support - we wouldn't be where we are without your help and I appreciate it from the bottom of my heart.

I will post again in a few months after his check up.

[Squirt's Mom]

YAY!!!! What a great update! Thanks for letting us know our sweet Thor is doing so well! Keep up the good work, Mom!

Hugs,
Leslie and the gang

[Joan2517]

He does look great in that picture! Glad to hear he is doing well.

[Harley PoMMom]

It is wonderful to hear that Thor is doing so well!! Great job, Mom!!! On a prior post you mentioned that urine was taken for an urine culture, did it show that an UTI was present? UTI's will make a dog urinate and drink more so I was just wondering if this was ruled out.

Hugs, Lori

[Renee]

So glad you stopped by and updated! And, so very happy the CC has gone away and everything is going well. Good job mom!

[molly muffin]

Thor is looking really good. So glad that he is stable with both the thyroid and cushings. I love stable, it's one of the best words around when dealing with the multitude of issues that dogs can have.

[jml666]

Hey everyone and Happy New Year! Wanted to check in and give an update and ask some questions.

Thor has been doing fine up until recently, when we noticed he was not eating as much and seemed to still be losing weight. In the last week or so, he's become very picky about what he eats, won't drink water out of his water bowls, but loves to go outside and eat snow (so I'm not as concerned that he's not getting enough water).

Long story short, I brought him back to the vet for another ACTH stim test (and T4 for his Thyroid). His T4 is normal, but his ACTH results were not. His pre was 2.0 and post was less than 0.1. Dr Goldman is on vacation until 1/16, so we won't hear back from her until then. My regular vet consulted with another specialist and she's prescribed prednisone at 5mg twice a day until Dr Goldman has a chance to respond before we adjust his Vetoryl dosage. I am familiar with Addison's Disease as being the counter to Cushings, but he's not been diagnosed as such so I'm looking for some feedback from this group on what your thoughts are and next steps.

Appreciate your help and will keep everyone posted on his progress. Thanks again in advance!

[Harley PoMMom]

So sorry to hear this latest issue with Thor, and with a post value of <1 this is considered an Addison's crisis. When the cortisol level drops too low the electrolytes should be checked as well to make sure that no imbalances have occurred.

Starting Thor on prednisone was needed and I am relieved that this was done, however his dose seems a bit high to me as the recommended rescue dose for prednisone is 0.25mg/kg. To find Thor's weight in kg you divide his weight in pounds by 2.2, I can do this for you if you would refresh my memory on much he weighs.

Hugs, Lori

[labblab]

I support everything Lori has written above. Also, just to clarify, I am assuming (hoping!) that Thor's Vetoryl has been totally discontinued for the time being. This comment made me wonder, though:


My regular vet consulted with another specialist and she's prescribed prednisone at 5mg twice a day until Dr Goldman has a chance to respond before we adjust his Vetoryl dosage.

I just want to make sure that you're not continuing to give the Vetoryl alongside the prednisone...

Marianne

[jml666]

Yep, heard back from the vet today and she confirmed discontinuing vetoryl as well. He's lost some weight and is now 59 pounds.

I've already noticed a difference in giving him the predinsone and was wondering myself if it will be too much. I will ask my vet about it after I hear back from you guys here on what he should be getting (too tired to do the math right now, lol)!

Thanks for your help!

[Harley PoMMom]

From my calculations, for Thor's weight, the prednisone dose is 6.70 mg, so 5 mg twice a day may be a bit much.

[jml666]

OK, I will consult again with my vet and see what she says....thanks for all of your help.

The latest picture of him is here. He's pretty boney because he lost his appetite, but now it seems to be back so we are working on fattening him up again. Any suggestions on how to help him gain weight are welcomed too!

http://www.k9cushings.com/forum/album.php?albumid=1038&pictureid=8678

[molly muffin]

Oh dear. I see your concern based on that picture. Well, the thing is you don't want to over do high fat, as cushing dogs can be prone to pancreatis but some carbs would be good. So good protein would probably help him with putting on weight, but you don't want to just put it on real fast. Just as he lost it slowly by not eating, just giving him good food that he will eat, should bring his weight back up.

[jml666]

Thanks, yes we want to make sure we are being careful. Interesting that you say that because his tests also indicated that a couple of his numbers were low, which were indicative of pancreatitis, but not confirmed, so giving good quality food and having him put it back on slowly is definitely the key. We had been supplementing with canned dog food too, so wonder if that's maybe not the best thing.

We feed him nutrisca and zignature and have been adding in some cooked meat - tuna fish or turkey so far, will add in chicken soon. The canned food was nutrisca. Thoughts on if we should give him that or not? Maybe just stick to real protein?

[molly muffin]

Well you also want a balanced diet and just giving cooked protein wouldn't be balanced. Just make sure the fat content on the food given isn't too high. You are looking for a good quality food mainly, with balanced nutrition. So good protein, moderate fat, etc.

i see that nutrisca does have a good rating on dog food advisor. So that appears to be a good food.

[jml666]

So our specialist is back from vacation tomorrow so we still have not been able to consult with her, but I wanted to see what your folks advice is on this.....

We've had Thor on prednisone for a little over a week and his appetite came back for a little bit, but now all he wants to do is drink water (not on trilostane, so I can understand that his Cushings symptoms are back). He ate a little bit of tuna fish this morning, but doesn't want anything else.

Have you guys seen this behavior before and if so, what would you suggest we do? It's so difficult to watch him not want to eat when we can see his ribs, spine, and hips and not for lack of trying to fatten him up.

[Harley PoMMom]

Is Thor still taking 5 mg prednisone twice a day? If so, I'm more inclined to think that the increased drinking is due to the prednisone dose.

My experience with prednsione is that if I didn't take it with food I would get very nauseated, so if it's not being given with food I would try this and see if it makes a difference.

Some of the things I have used to entice my dog's appetite are: tripe, grated parmesan cheese, yogurt, warm meat broth, boiled potatoes. I have used baby food in the past for some of my picky eaters but make sure it doesn't contain any onion or onion powder. Also carbs are a good filler such as pasta, oatmeal, barley, and quinoa. And one more tidbit :o Dogaware has a really informative article on their website that pertains to a dog with a loss of appetite, here is the link: http://dogaware.com/articles/wdjinappetence.html

Hoping Thor's appetite picks up.

Hugs, Lori

[jml666]

Yes, Thor has still been taking prednisone 2xday at 5mg each dose. We've been giving it to him just before meals. Hmmm, if we're doing that, then maybe that's why he's not wanting to eat? Should we give it to him right after he eats?

Thanks for the tips on ways to get him to eat. One of our other boxers used to be a picky eater when she was the only boxer, so we had to get creative to get her to eat, lol. That hasn't been a problem for her since we got Thor (and now we also have Trixie - yes, 3 boxers, lol).

[Harley PoMMom]

As long as food is in his stomach giving him the prednisone right after he eats I think would be ok. Let us know if it helps and hoping it does.

[jml666]

I have and update, some good news, but still pending some test results and additional testing.

We took Thor off of prednisone to have him re-tested this week. He lost 5 more pounds in 2 weeks :( We have been really worried about him and trying everything to get him to eat.

His ACTH stim test came back this time as we would expect being off of vetoryl - pre was 7.2 and post was 8.7.
His electrolytes are generally consistent Cushings as well.
His urine did indicate microalbuminuria, but this can occur as a direct result of Cushings.
His creatinine and SDMA are within the reference range, indicating normal kidney function.

We are pending his urine culture results and have him scheduled for an ultrasound on Monday to rule out any other issues.

Today, I noticed that while he is still drinking lots of water, it's less than it has been (probably from taking him off of prednisone). Also, he was wagging his tail today a bit more than he has been :)

He's still picky about eating, but we think we figured out the trick to get him to eat with his kibble.

http://www.k9cushings.com/forum/album.php?albumid=1038&pictureid=8708

More to come next week, but I'm hopeful and will update again next week. Thanks to everyone for all of your support!

[Squirt's Mom]

Some good news with Thor! Nice to hear and I know it was so nice to be able to post!

[molly muffin]

This IS good! A wagging tail is always a good sign.

[jml666]

Hi everyone, I am away this weekend and my husband is agonizing over Thor's care. He is again not wanting to eat and he told me Thor vomited today and has some diahrea as well. Are we entering the end stage of Cushing's? We still need to bring him in for his ultrasound on Monday, so I think we may be checking him in longer term if it makes sense for us to do so. Just wanted to know what others have experienced and if we should be preparing ourselves for the inevitable. He is thin, drinking water, doesn't want to eat, but is his normal self otherwise. He's not weak or sleeping a ton; still wags his tail.

We're supposed to be going to Hawaii on 1/28 for 2 weeks and we are nervous about leaving him and have considered postponing our trip. Any helpful thoughts or comments are welcome, thanks!

[jml666]

So the latest news is that Thor has a mass in his left abdomen totally unrelated to his Cushings that is likely to be cancerous which is causing him to deny food. That's the bigger issue at hand now than his Cushings. We are working with the vet to try to help him get as comfortable as possible. Thank you for your support and guidance. At least we know what's causing the issue.

[Harley PoMMom]

Oh my goodness, I am so sorry to hear this news about Thor. :( Please know we are here for you and I'll be keeping you all in my thoughts and prayers.

Hugs, Lori

[Squirt's Mom]

Not the news any of us wanted to hear, especially you I know. Please keep us updated as you can but we understand you want to spend every moment you can with your precious boy. Know we are here any time you need to talk...and we are always at your side even tho you can't see us.

Hugs,
Leslie and the gang

[judymaggie]

My heart goes out to you -- please give Thor a gentle hug from us!

[molly muffin]

Oh dang. I'm sorry for this cruddy news. Give him some petting from me too. Not operable?

[Joan2517]

Give him some for me, too...So sorry to hear this...

[jml666]

Nope, not operable. The interesting thing is....in the last couple of days, he's wanted to eat! I think maybe having him off the Vetoryl for a couple of weeks made his appetite come back. However, so did his other symptoms of drinking a ton and peeing a ton - 18 accident clean ups yesterday alone! So I emailed my vet and specialist and we put him back on Vetoryl tonight at half his dosage (30mg 2xday vs 60mg 2xday before) to see if it would help.

His spirits are up, he still tail wags; I'm beginning to think that the mass has been there for a while and growing, but wasn't the reason for him not eating - he was on too heavy a dose of Vetoryl. Thoughts?

[Crazy Daisy]

I'm so sorry :( do you know what type of mass?

[Harley PoMMom]

Although his appetite did bounce back after being off the Trilostane, it seemed that it only lasted a short while and I think the Prednisone was the main reason for that.

Has an UTI, kidney/bladder issue or even diabetes been ruled out for the increased drinking/uriination?

Hugs, Lori

[jml666]

The vet said it is likely a mesenchymal tumor and our breeder said that in most cases that he's seen in this line, it is likely in the hemangiosarcoma family and recommended that we not do radiation or chemo as he felt Thor would not respond well (based on past experience with his other boxers).

Regarding appetite, Thor was only on prednisone for a couple of days - we had to take him off to get the bloodwork done on the 18th and didn't put him back on it. He was eating well during the earlier part of last week when we found the mass.

The vet did rule out UTI, kidney/bladder issues and diabetes. It's all Cushings/Addisons and related to the mass.

We started him on pain meds 3 days ago and that seems to be helping him.

You can see the mass in the 2 most recent pictures in his album: http://www.k9cushings.com/forum/album.php?albumid=1038

[Whiskey's Mom]

So sorry about Thor's tumor. Our Whiskey likely has a hemangiosarcoma too, so I understand. We are taking it day by day, keeping him happy and feeding him his favorite things. He has been through a lot this past year: probably misdiagnosed with Cushings. and an ACL tear, so at 14 we are greatful for every day with him. Hope you can find something that entices Thor to eat, Whiskeys tastes change a lot but we keep trying. No more dog food, I've tried countless brands. So I cook for him & he eats lots of treats. His most recent favorite is baked chicken breast -lightly seasoned & on a bed of rice, sounds crazy but it's the most excited I've seen him at meal time in awhile. Maybe Thor would like it too. All the best to you and I hope Thor is feeling better. Annie

[jml666]

Thank you. Unfortunately, it gets worse. We just noticed how swollen Thor's right "elbow" is (pictures added to his album). It's extremely sensitive to him - he flinches if you barely touch it. I emailed my vet tonight to see what we should do about that.

[Whiskey's Mom]

Oh no- Poor guy! I have no idea if dogs can get gout but it's the first thing I thought of. Hope you get some answers soon.

[Crazy Daisy]

Hmmm... is tumor on his spleen? If so, there's no way to know 100% that it's cancer unless it's sent for biopsy or there is obvious spread. Is he a golden retriever? I know they are very prone to hemangiosarcoma. We've been through spleen tumors and subsequent splenectomies twice. One was benign and one was actually osteosarcoma.

[jml666]

Thor is a boxer. He has suffered many ailments since we adopted him at 2.5 years old.

We did make a hard decision last night to bring Thor to the vet today to help him cross over the rainbow bridge. He was doing ok up until mid-day yesterday, then went down hill very fast. He is on as much pain medication that we feel comfortable giving him and we know he is still suffering. It's been a very long road with him, but we feel it's the best thing to do for him.

Thanks again to everyone who supported me in learning about Cushings, helping to treat it, and allowing us to have more time with him than we expected.

[Squirt's Mom]

We are by your side as you take this most difficult, but most loving, step with your precious baby boy. He trusts you and loves you with all his heart and knows you do this for him. My tears are falling with yours, knowing the pain you bear. We are here anytime you need to talk, to cry, to vent, whatever....you will always be part of our family and we will always be here to listen.

Hugs,
Leslie and the gang

[Joan2517]

I'm so sorry...it's such a hard decision to have to make. Sending comforting thoughts to all of you.

[labblab]

I am here, too, and sending thoughts of peace and comfort to you all. You are absolutely doing the best and right thing for Thor, but what a sad, sad day for you guys. We are right here for you, and we will remain here throughout the day and all the coming days whenever you may need us.

Fare thee well on your new journey, sweet boy. And I am sending huge hugs to you all.

Marianne

[DoxieMama]

I too am sending warm thoughts and gentle hugs for all of you from across the country.

Shana

[Whiskey's Mom]

Sending our deepest sympathy. So very sorry.

[molly muffin]

I am so very sorry. It's a hard thing to go through, losing a best friend. We'll be right here by your side.
HUGS

[jml666]

Thanks everyone. He passed quickly and peacefully today. We will miss him very much.

[Crazy Daisy]

I'm so sorry!! It's such a hard decision to make but you clearly loved him very much and were thinking only of him! ❤

[judymaggie]

My heart goes out to you -- you were a wonderful pet parent and I am sure Thor knew that for every minute of his life!

[labblab]

I am so sorry it took me until tonight to get back here to write a note. I was having some computer problems, but now I am sending my thoughts and sympathy to you from across the miles. We will always honor and remember Thor, and truly, we are always here for you should you wish to return to talk with us.

In loving memory of your brave, sweet boy.
Marianne

[jml666]

Thank you Marianne, it's been a long road and we now know he is running free of pain and is at peace.

[Harley PoMMom]

I am so very sorry for your loss and my heart goes out to you at this difficult time. Please know we are here for you, always.

With Heartfelt Sympathy, Lori

[molly muffin]

Just want to send you Big Hugs. Many, many of us know what a difficult time this and so very heart breaking. There isn't much to be said in words that will make it any better or the emptiness go away. I wish there was.
Just know that out across the world, there are people who are thinking of you and wishing you strength in this time of sorrow.

[LaurieS]

I am so very sorry for your loss of Thor, he was a beautiful boy! My boxer Charlotte is about the same age and has been having a tough time lately so I feel for everything you have gone through. You did your best for him and he knew it. They aren't with us nearly long enough but I believe we will be reunited with our furbabies one day for eternity!

Hugs to you,
Laurie & Charlotte

[Bluester]

I am so so sorry for your loss. Sending you hugs.