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Howie's Mom
10-28-2015, 03:37 AM
Hello,

My 7 yo miniature dachshund, Howie, was just diagnosed with pituitary-dependent Cushing's disease. I'm devastated by this diagnosis and am crushed that this is happening at such a young age for him as most dogs seem to be diagnosed a bit later in life.

Late last year I noticed a slight increase in Howie's water intake which I attributed to the heat wave we were experiencing at the time. However, his water intake didn't ever seem to return to baseline and a couple of months ago I noticed that it had become much worse. He is approximately 14 lbs and was drinking ~ 45 mLs of water/day. I also saw he wasn't as playful as he used to be.

I took him to the vet who noted that his heart rate was slow and steady and, based on his symptoms, felt it could be hypothyroidism. We ran blood work (CBC w/ differential, CMP, T4, ) and a urinalysis. The abnormal results are as follows:

AST: 14 IU/L (ref range 15-66) LOW
GGT: 17 IU/L (ref range 1-12) HIGH
Cholesterol: 338 mg/dL (ref range 92-324) HIGH
Amylase: 184 IU/L (ref range 290-1125) LOW
Precision PSL: 212 U/L (ref range 24-140) HIGH
Neutrophils: 12870 /uL (ref range 2060-10600) HIGH
Specific Gravity: 1.005 (ref range 1.015-1.050) LOW
Occult Blood: 1+ (ref range NEGATIVE) HIGH

I think it may be relevant to note that his T4 was 1.0 ug/dL. The vet didn't mention anything about this and the lab listed the reference range as 0.8-3.5; however, in my research I've found that 1.0-2.0 ug/dL is considered low normal and may be hypothyroid.

The vet then did a urine culture to rule out a UTI/bladder infection. The results were negative for growth (normal).

After going to the vet I began to pick apart all of the changes I was seeing in Howie. I noticed his hind legs seemed like they had lost some muscle mass. He was going up the stairs more slowly than he had before and was wanting help getting up on the couch. I was having difficulty getting him to shed the little bit of weight he had put on. Previously he would shrink right back down when I would put him on a diet and increase his exercise, but with his decreased energy level it was difficult to get him to do much exercise and dieting didn't seem to make much of a difference. He doesn't have the typical pot belly that I have seen other cushpups have in photos, but he does have a smaller one.

His appetite has also increased quite a bit. Recently he has gone so far as to steal food out of people's hands if he has the opportunity, which he never dared to do before. He has also been yelping late at night and/or early in the morning to wake me up so I will feed him. I try not to because I don't want to reward the behavior, but it is so hard when I know he's starving! I normally feed him once in the morning and once at night but lately this has not been enough for him.

Following the urine culture, his previous vet was leaning towards the diagnosis of diabetes insipidus but wasn't sure how to test for it and referred me to an internal medicine specialist. At that time I was also referred by a friend to another vet who I took him to see. This new vet did an ultrasound with the following notable findings:

Liver: isoechoic (to fat), homogenous
Gallbladder: a little debris
Pancreas: slightly hyperechoic, slightly plump
Left kidney: a little brightness but ok
Left adrenal: 0.65 cm, 0.7 cm (slightly increase normal; ie >0.6 cm)
Right adrenal: 0.7 cm, 0.4 cm
Bladder: full
GI tract: slightly hyperechoic, slightly plump

The assessment stated the following: "A few ultrasonographic signs (ie pancreas, adrenals) making early Cushing's a possibility, even though more typical signs of increased ALP are absent. Would recommend LDDST."

The vet told me that pancreatitis has recently been linked to Cushing's and that the abnormalities seen with his pancreas are consistent with what I had told her in regards to his mild case of pancreatitis that he had last October. She also said that his skin did appear to be thin when they were shaving his belly for the ultrasound.

We performed an LDDST last Friday which yielded the following results:

Cortisol pre-dose: 18.3 ug/dL (ref range 1.0-5.0 ug/dL)
Cortisol 4Hr post: 15.7 ug/dL (ref range 0.0-1.4 ug/dL)
Cortisol 8Hr post: 7.5 ug/dL (ref range 0.0-1.4 ug/dL)

Based on these results they have now diagnosed him with Cushing's disease.

I find it a little odd that his ALP is still within the normal range because I've read that it has a direct correlation with the level of cortisol. The vet told me his case is atypical and we don't see all of the same symptoms in each dog.

For treatment she suggested starting him on 5 mg of Trilostane, the lowest dose available, because dogs have responded to doses much lower than the recommended dose and his clinical symptoms are so minimal. She also proposed trying an herbal supplement. She is a Certified Veterinary Acupuncturist and said she could do a Chinese physical assessment to determine which supplements to use and that it could take up to 8 weeks to see a difference. She has only read a few case studies using herbal supplements to treat Cushing's and it's not widely known or practiced. I'm hesitant to try something that hasn't been proven to work, but seeing as how he will be on medication for the rest of his life, I think it won't hurt to try...

I'm still considering if I should take him to the internal medicine specialist the original vet referred me to. Our current vet said she has dogs on Trilostane, but after reading threads on this site that clearly emphasize the importance of finding a vet that has experience with this disease, I am feeling very anxious because I'm unsure of the extent of her experience.

Does Cushing's sound like the correct diagnosis for my pup? I was hoping to get some feedback and see if there is anything we might be missing.

Has anyone else tried natural supplements with any success?

I apologize that this message is so long-winded and thank you profusely for taking the time to read it. I appreciate your help and support immensely.

labblab
10-28-2015, 08:14 AM
Hello and welcome to you and Howie! I apologize that I have only a moment to write, but I just wanted to tell you that I'm very glad you found us. The lack of any elevation in Howie's ALKP is definitely not the norm. However, there is a small percentage of Cushpups (I've seen the number cited at around 10%) that do not exhibit this physiological response. I will try to track down some more info about this and add it later. Behaviorally, however, Howie certainly has a number of consistent symptoms and his response on the LDDS is highly elevated. So I do understand why the vet is thinking that Cushing's is the underlying issue and is recommending treatment.

The blood in the urine seems like a bit of a concern since the presence of a UTI seems to have been ruled out. Other causes could include kidney infections, kidney disease, stones, etc. However, this may have only been a spurious initial dipstick finding rather than the result of actual microscopic analysis, so it may not be all that meaningful. Has your vet said anything more about this?

We have had a few members who use or are using Chinese herbs, but I am not personally knowledgeable about them and therefore cannot recommend them myself. I am not aware of any controlled research study or testing that validates their success in lowering cortsol in the same manner as trilostane or Lysodren treatment.

So in summary, the normal ALKP is an oddity, as you already know. But I believe the majority of Howie's other abnormalities (including low-normal thyroid) are consistent with a Cushing's diagnosis. If he were my dog, I do believe I'd perhaps get an additional opinion from the specialist, but then proceed with an initial course of trilostane if that remains the recommendation. I appreciate the fact that the new vet is recommending a low initial dose because that suggests she is keeping current with the most recent research re: proper use of the drug.

Marianne

Wally P's Mom
10-29-2015, 01:13 AM
Hello and Welcome:

You have found an awesome group of people who will help you on this journey. I am glad you are seeing a different vet because diabetes can be diagnosed from a blood test. You said your dog was drinking 45mL of water. This is extremely little in quantity. My 15lb dachshund drank when he was feeling well an average of about 450mL per day. Are you measuring his intake correctly? From the data posted, how did your vets determine your pup has a pituitary dependent version of Cushings?

Marge

Howie's Mom
10-29-2015, 02:59 AM
Thank you for your replies and support. I am so grateful to have found this forum.

I am seeing his vet tomorrow regarding the herbal treatment and will be sure to ask about the blood in his urine. It was never mentioned to me during the visit so I don't know what her take on it was. Unfortunately, the report doesn't state the collection method and I'm unable to find it on the lab's website. According to the lab results and the ultrasound his kidneys are healthy though and his urine culture came back negative, so fingers crossed it is a false dipstick reading.

The last vet definitely ruled out diabetes mellitus with his initial blood test but diabetes insipidus was of concern to her. For that disease the more common tests to run are a water deprivation test (scary!) or an ADH test; however, that disease is extremely rare.

My units were definitely off in regards to his water intake! He is drinking ~ 45 oz of water a day, so approximately 1330 mL.

The vet determined that Howie has pituitary dependent Cushings because both of his adrenal glands were enlarged on the ultrasound and his cortisol level was less than half the baseline (18.3 ug/dL) at 8 hours post dex (7.5 ug/dL) during the LDDST.

From what I've read, PDH will cause both adrenal glands to be enlarged because the pituitary gland is over-stimulating both adrenal glands to produce an excessive amount of cortisol. Whereas only one of the adrenal glands would be enlarged with adrenal tumor Cushings due to the presence of an adrenal tumor on that particular gland.

This diagnosis was further supported by his results from the LDDST. The LDDST report states, "If the 8hr post dex cortisol level is > 1.4 ug/dL, the following can be used to differentiate pituitary dependent hyperadrenocorticism (PDH) from an adrenal tumor:
1. Cortisol level < 1.4 ug/dL 4hrs post-dex is consistent with PDH.
2. Cortisol level < 50% of the baseline level at either 4 or 8hrs post-dex is consistent with PDH."

Best,
Ashley

Howie's Mom
02-29-2016, 11:51 PM
Hi all,

Howie was started on Trilostane in November and has been doing much better. About 4 weeks ago we increased the dose from 10 mg/day to 10 mg 2x/day due to some persistent symptoms that weren't resolving at his initial dose (polyphagia, lack of energy, flaking skin, loss of hair, persistent loss of muscle mass, etc).

At this point I'm pretty concerned about the extent of his flaking skin. His belly began peeling quite excessively in early January. His belly is still pretty bare since his ultrasound last October, so the peeling skin was easy to spot there. His skin was coming off in large, thin flakes. Now he has dandruff everywhere; under the fur on his neck, on his back, on his sides, on his hind legs... Just everywhere. It also seems that hes starting to lose some fur where his skin is peeling. I've noticed this especially on his sides.

I've been hopeful that increasing his dose will help this, but it's been 4 weeks now and I haven't seen much of a difference. What are your thoughts? Any input would be greatly appreciated.

Thank you all! :)

molly muffin
03-01-2016, 01:13 AM
What were the last ACTH results? Is the Cushing's controlled?

You could try a supplement with vitamin e, krill oil etc for the skin.
Also just read where a vet mentioned trying Dermoscent for a dog with the same sort of problem, flaking skin. It comes in drops. You can get it on amazon.

Wuchi
03-01-2016, 10:28 AM
You can also try rubbing coconut oil on your puppy's belly (they like the belly rubs too) make sure it's Virgin coconut oil -- I think even Target carries it nowadays. You can also give them a little fish oil or coconut oil but not too much especially if your dog has had pancreatitus before. You can also use a dog shampoo with oatmeal in it to calm the skin down some.

Diet can also impact their skin/coat. Have you changed their food since the skin issues got worse? if you are feeding them kibble you can check out dogfoodadvisor.com and read the comments at the bottom of the page to see if other dogs are having their skin agrivated by the food (Cushings tends to mess their skin up a little anyway so good to know if the food is adding to that).

Howie's Mom
08-18-2017, 02:59 AM
I wanted to provide an update in hopes that it helps others in our situation.

Howie's skin continued to get worse after my post. We tried the coconut oil, fish oil, switching his food, prescription shampoo and conditioner (HyLyt), etc. to no avail. He lost hair on his ears, in patches all over his back, his chest, nose, tail... The list goes on. His skin was peeling so badly he would lay on the couch and leave behind tons of his dandruff when he got up. Poor guy.

His ACTH stim showed that his cortisol was right where we wanted it to be after the last dose increase but the dandruff persisted. They thought maybe the skin issues were a result of the adrenal glands producing other excess hormones in addition to the cortisol and they suggested I put him on oral melatonin to treat this. We tried the oral melatonin for months at different doses and frequencies, again to no avail.

My vet spoke with her colleagues and they suggested that we switch from trilostane to lysodren in hopes of having better global control of the excess hormone production. We also had a consult with a dermatologist who scraped his skin, looked at it under a microscope and saw a couple of yeast. Nothing she was concerned about or that would explain his issues. She then suggested weekly use of douxo chlorhexidine PS shampoo with the HyLyt conditioner that we already had, in addition to a melatonin implant.

The implant seemed kinda crazy, I mean we were already giving him oral melatonin and nothing had changed. I'm so glad I didn't talk myself out of it! We only used the shampoo and conditioner combo for a couple of months, but the dandruff was completely gone in less than 3 weeks of use. The implant is supposed to release the melatonin at a steady rate over 4-6 months. It took about 2-3 months for us to really start seeing the results but Oh. My. Goodness. His hair started growing back like crazy. We joke that he looks like a Pomeranian now! People that don't know him think that he's not a purebred because he has so much hair, it's crazy. Also, his implant lasted at least 8 months.

I guess they also use the melatonin implant for alopecia issues, but I know hair loss is common with Cushings and I just want to tell everyone: please try it! You and your pup won't regret it!

His treatment is otherwise going well. Currently holding drug because his levels were a little low with his last stim so we have to decrease his dose, but he has more energy than he has had since he was a puppy and he's 9 years old! His body fat redistributed and he's regained his muscle mass. I couldn't be happier. Hoping that we continue down this road for years to come!

I'm going to try to figure out how to post pictures so you can see his before and after to really appreciate the drastic change! :)

Joan2517
08-18-2017, 08:33 AM
That is wonderful news! So glad that Howie's skin issues have been resolved.

labblab
08-18-2017, 09:38 AM
Welcome back, and we really appreciate you returning to share the good news about Howie's treatment experience!!! It's especially interesting to hear that you've seen such improvement since beginning with the melatonin implant.

One question, though: did you end up switching to the Lysodren, or has Howie stayed on the trilostane?

Marianne

molly muffin
08-18-2017, 08:34 PM
That is fabulous news! Especially in regards to the melatonin implant. I've already pointed someone to your thread to read about it.

So good to hear that he is doing well. :)

Howie's Mom
08-19-2017, 12:00 AM
We switched to Lysodren in Sept-16 to try to get better "global control" of his other hormones which were thought to be the cause of his skin issues even though his cortisol was in range. Since we saw no change, we decided to try the melatonin implant in Dec-16 as suggested by the dermatologist. In Jan-17 we actually had the derm consult because we still hadn't seen improvement and that's when we used the douxo chlorhexidine shampoo and HyLyt conditioner. His dandruff resolved in ~3 weeks (but there was a drastic improvement even after the first use--that douxo shampoo is amazing) and it took a few more months for his hair to start growing back.

It's difficult to tell exactly which part of the treatment was most effective, but that was our combo and approximate timeline.

I'm now giving him the Lysodren 2x/week. It was initially tough finding the right dose because he is so atypical... We over-treated him and had to put him on steroids, but he showed NO symptoms at all when his cortisol level was non-existent. Tricky little guy always keeping me on my toes! He's been pretty stable since January, but we just did a stim that showed his levels were a little low, so we're holding the Lysodren for a couple of weeks, will repeat the stim and then restart him at a lower dose.

In case others are wondering, the melatonin implant was $99 the first time around and $140 the second time because my vet switched to a new computer system. Again, it's supposed to last between 4-6 months and his first implant lasted at least 8, so I think it's pretty reasonable. The oral melatonin is much more cost-effective, but we saw no change in his skin/coat with it at various dosages and frequencies.

I've posted more pictures so you can really see how bad his skin got and how great he looks now. Such a transformation. :)

labblab
08-19-2017, 07:49 AM
Thanks so much for this additional info and the photos. Howie looks wonderful, indeed! :)

It sounds as though everything has come together to be a great help to him. I'm a huge fan of the Douxo shampoos, too. We continue to use their chlorhexidine shampoo on our nonCush Lab who suffered from recurrent staph infections on her skin. We went through a couple of lengthy rounds of oral antibiotics that helped temporarily, but the infection always returned. Once we started bathing her religiously with the chlorhexidine shampoo, though, we finally gained control and were able to dispense with the antibiotics. We still use it as a preventative even though she's been "clear" now for a long time. We used another Douxo formula very successfully, too, on our other dog who had very dry skin. So I think very highly of their product lines.

Anyway, it's wonderful to hear how well Howie's entire combo of treatment is working. Thanks again for returning to us, and please do update us again.

Marianne