My Maltese may have Cushings

[randy]

Hi, My name is Randy. My Maltese, that I love dearly, just went for bloodwork yesterday for cushings and other things. Should hear back by tomorrow on results. From her symptoms, I'm almost positive this is her condition. It started with her biting her feet and they developed sores. Took her to Dr. and they gave her antibiotic and Pred. She's been panting, drinking H2O a lot , insane hunger, slow and a bit uncoordinated. When they gave her the test yesterday, low Dex, she came home and seemed like her old self. Playing and walking good. I know she had a good reaction to that in a good way which was short lived. I'm anxious to get the diagnosis and start her on treatment. The cortisol needs to be slowed down. I do feel like she will respond well when we get her on correct meds and dosage from seeing her react to the low Dex test yesterday. Sorry, Her name is Mimi. I've been educating myself as much as possible all week and found this forum. I feel like I may know more than my Vet now which I hope isn't correct. If they don't give concrete answers I'm going somewhere else. I need to know what she has. What type(adrenal or pituitary) Best treatment and dosage. She weighs approx 16 lbs. I saw where rule of thumb is 1mg/lb = 16 mg of Vetoryl . Curious about others feelings with this similar problem. I've read some threads and I see there are some very knowledgeable people on here. Also, experience is a great teacher. Thanks and God bless you all and your pups!!! :)

[Harley PoMMom]

Hi Randy,

Welcome to you and Mimi! Glad you found us and we will help in any way we can.

One thing that jumps right at me is that your girl is taking prednisone. Prednisone is in a class of synthetic corticosteroids that mimic the action of cortisol. So when a dog is taking prednsione they can display the same symptoms as a dog that has naturally-occurring Cushing’s. When the Cushing's is caused by steroid induced this is called Iatrogenic Cushing's, and the only treatment for Iatrogenic that is needed is to slowly taper the steroid use.

Another concern of mine is that prednisone will cause a false positive result from the low-dose dexamethasone suppression (LDDS) test, so if Mimi had this test performed when she was on prednisone than the results are skewed and will not be of any diagnostic use. Was the LDDS test done when Mimi was on prednsione?

Hugs, Lori

[randy]

Thanks for your response. I can tell you know your stuff. Mimi had cushing symptoms before I took her to vet for biting her feet. She was only on Pred for 2 days. 1 mg. She had been off Pred for 3 days before the low dose dex test. When they gave her the dex and I picked her up wednesday she was like her old self. It wore off this morning. Hope to get results tomorrow. I hope it shows whats going on. Like I said her symptoms actually go back some time. She had high liver enzymes about 2 years ago and they gave me milk thistle. I'll be mad as hockey if the 350.00 test is not correct. I just want her to get relief. I'm not sure they did the test that can tell if it's pituitary or adrenal. I'm certain she has had high cortisol levels before this foot biting episode. I don't know how long she can maintain herself in this condition. I will feel better to get it out of her system. If they treat both pituitary and adrenal with Vetoryl, why does it matter which gland it comes from? Thanks, Randy

[Squirt's Mom]

I am also concerned this was caused by external factors - the prednisone. However I am more concerned about the itching. A cush pup has high levels of cortisol running thru their system. Cortisol is a NATURAL "steroid" so your baby should not have shown signs of allergy with such high levels of a natural "treatment" for the itching. By lowering the cortisol those allergies are going to get much much worse.....IF IF IF she has Cushing's in the first place. The itching and the use of the pred give me great pause in thinking Cushing's is the direction to be looking. I think I would be looking for anything BUT Cushing's right now with that level of itching going on. ;)

[labblab]

Hi Randy,

Hmmmm...from what you've described, I'm going to take a different tack and say that I doubt the prednisone was/is an issue. If Mimi only took the pred for two days and was "off" the steroid for three days prior to the testing, it's hard for me to think it would have affected the results. We have been told that ACTH stimulation tests will be accurate after 48 hours without prednisone, so I would have to assume the same would hold true for a LDDS. Also, only two days of pred would not account for Mimi's ongoing problems, so in my own mind, I do not perceive the pred to be a testing or diagnostic issue.

A different piece of the puzzle that does confuse me, though, is the fact that she seemingly felt much better immediately after the test. I cannot think of any Cushing's-related mechanism that would account for this. The test involves injecting even more steroid -- dexamathesone -- so I don't understand why a dog who is suffering from elevated cortisol would feel better when additional steroids are injected. I really am clueless as to why she perked up after the test. In fact, it raises a tiny little question mark in my head as to whether her problem may be the reverse of Cushing's -- whether she may possibly be suffering from too little natural cortisol production rather than too much. Did she seem to feel any better at all during those couple of days that she was taking the pred?

Having said that, I will certainly be interested in the results of the LDDS since you do describe several chronic symptoms that are consistent with Cushing's. The paw-biting is indeed a question mark, though. Does Mimi itch and scratch herself elsewhere? I am wondering whether or not the biting is actually related to itching, or whether there is some other mechanism at play. For what it's worth, my own Cushpup licked his paws and our own skin incessantly for years prior to his Cushing's diagnosis and treatment. It was the weirdest thing -- once his cortisol was lowered, he completely stopped the licking. To this day, we have no clue as to what was fueling the licking, but it ended and never returned. Perhaps it was coincidental, perhaps it was not.

Anyway, going back full circle, I personally doubt that the pred will have skewed the LDDS test, so I will be very interested to learn the results.

Marianne

[randy]

Marianne, She has always licked and chewed all her feet. I think it's a response to something else bothering her. She actually seemed worse when she took the pred. She only took 2 1/2 mg twice a day on Friday 10/29. Then 2 1/2 mg once on 10/30. Then 1 1/4 mg on 10/31 and 11/1. Took her back to vet on Mon. 11/2 and they told me to stop pred. I had cut it back myself because she seemed to be a little worse. They did general bloodwork in house on that Mon. With no improvement I took her back for the Hormone Check. They told me Wed sould be clear of the Pred. I didn't think she took enough Pred to do much. maybe 10 mg total over a four day period. She walks around like a zombie dog especially in the morning. Head down amd tail down. Waiting to hear test results. Symptoms are : panting, crazy hunger, excessive thirst, pot belly, her pink skin has developed darker gray spots, lack of energy, liver enzumes have been high for a couple of years. Why she got a burst of energy after the LDDT is strange to me also. I know it's a synthetic hormone to resemble cortisol. Maybe her levels are low. If that's so, then the Pred should have helped. Isn't adding up yet. All her symptoms seem to be cushionoid. I surely don't know. Maybe I'll hear something today or tomorrow. Now I'm concerned my test won't be accurate. Thanks

[labblab]

I personally think the testing will be accurate, so let's see how it turns out.

Yes, my boy's paw (and skin) licking was really odd, too. He would lick any area of our bare skin that he could reach. After he was diagnosed with Cushing's and it stopped, I wondered whether maybe his sodium/potassium balance had been "off" somehow and he was trying to get salt from our skin. But I really dunno. The paw licking was truly obsessive, though. The skin on his "wrists" was permanently bald and pink from the constant attention. :o

[CocoPuff]

When my Coco crashed after her Lyso load I took her in and they did a baseline test for her Cortisol level which was extremely low. In order to give her a little boost in her levels (she was having and Addison's episode from the Lyso) they gave her Dex in an IV and that really helped her (I believe its the same stuff they gave her during her LDDS). I'm still fairly new at this but the pred made her feel tons better as well as the Dex when her Cortisol levels were well below normal. While on the pred she did have a huge appetite and drank tons of water but that was due to the pred.

[randy]

Ok. After pulling teeth I have some numbers from the Low dose dex test. The Dr is out of office so the new vet says test is not conclusive. Her baseline cortisol level was 8.4. Her 4 hour level dropped to 0.6. Her 8 hour level had gone up to 1.3. I think that indicates a possible Pituitary problem and an ACTH test is warranted. What do the real experts think?

[labblab]

"If" Mimi has Cushing's, then yes, the pattern of suppression would be consistent with the pituitary form of the disease. However, I have to agree with the new vet that Mimi's results are not conclusive. The diagnostic 8-hour cut-off is typically higher than 1.4 or 1.5. So Mimi's result is borderline but not confirmative. Yes, you could move forward with an ACTH if you are willing to shoulder that additional expense. As you probably already know, negative results on the LDDS are usually quite trustworthy. But a small percentage of dogs, especially those in early stages of the disease, will test negative on the LDDS even though Cushing's is genuinely in play.

Marianne

[randy]

Took Mimi to a new vet which I say may be one of the best I've ever seen. She had all her previous tests and had studied them prior. Her first observation was we may be looking more towards addisons. Her sodium/potassium numbers have been steadily dropping. Her physical symptoms more resemble cushings but blood numbers lean towards addisons. She did ACTH test and will know more tomorrow. Mimi has had a shot of Dex and it brings her back to near normal in how she feels. Which leads you to think she doesn't have enough cortisol. Her baseline numbers from low dose Dex test of 8.4 may have been a result of the Pred she had taken 3 days prior. Her liver being compromised may have slowed the process of elimination. Please hope and pray we will have definitive answers soon. Untreated, addisons can be life threatening. I'm just sharing all this in hopes it may help someone else out with unusual circumstances. She also put a tape sample of her feet she had been biting and it's a yeast infection which explains that.

[labblab]

Randy, that is so interesting that the new vet is thinking about Addison's as a possibility, too. Mimi is certainly exhibiting some paradoxical behavior that makes it harder to sort things out (improved after the dex; worse after the pred). It'll really be interesting to see how the ACTH turns out!

I'm really glad you felt comfortable with this newest vet, and I'll certainly be watching for your next update.

Marianne

[molly muffin]

I just now have had the chance to read through your thread but in your first couple posts, my thoughts went directly to Addisons too. Why because Addisons has some of the same symptoms as cushings, however, the problem is that the body is not producing Enough cortisol. Reacting to the LDDS by feeling better for a short time, is a good indicator. It might be that prednison will not be the answer but that Dex would be (and is recommended treatment for Addisons) and the sodium/potassium being low is another indicator.

I'm glad that you have found this new vet and this possibility is being looked into seriously.

[randy]

Well on this strange journey of the YO-YO my new vet has evaluated the ACTH test and her numbers clearly show cushings. She spoke to a specialist about her mixed signals with blood results and they explained it in a way that's hard to pen but basically her body and glands are creating some false numbers. She is now checking of compounding Vetoryl into 6mg to start her on a low dose and work upwards. Can any of you give me your experience with Vetoryl vs. Lysodren ? I know vetoryl is the newest and maybe the safest but more expensive. lysodren is not fda approved but most vets have worked with it a little more. I do know her dose of vetoryl is approx 1mg per pound which in her case would be 16 mg. lowest dose is 10 mg. We are leaning toward vetoryl because Mimi's liver has been over worked for some time and it's not ridding her body of drugs and toxins at a high level. Starting at a lower level and testing and working upward to correct dose is what we feel would be appropriate. So, unless we have a change(and nothing would surprise me at this point) Mimi has been diagnosed as Cushings. I'd appreciate any feedback. Thanks

[labblab]

Hi again, Randy. Well, this is indeed interesting news! Can you please get the numerical results for the ACTH and post them for us? For monitoring purposes, it will greatly help us to know what these initial diagnostic results turned out to be. I have to admit that after that baseline cortisol level of 8 on the LDDS, I was going to be surprised if Mimi was truly Addisonian. That just seemed like an awfully high baseline even considering the possibility of some residual effect from that small amount of pred given a few days previously. Anyway, it will help us to see the actual numbers.

As far as the use of trilostane vs. Lysodren, we have had many members throughout the years who have experienced both successes and problems with both meds; I honestly do not believe that either one is necessarily safer, although the effects of drug overdosing can sometimes be reversed more speedily with trilostane, simply by discontinuing use of the medication. I believe this is one reason why it is being prescribed with greater frequency. Overdosing with Lysodren can result in longer-term physiological effect on the adrenal glands. Having said that, some dogs taking trilostane have also ended up with unexplained long-term adrenal necrosis, as well, so careful monitoring is equally important with both drugs. Worldwide, more dogs are treated with trilostane than Lysodren. And I believe the scales have also tipped here in the U.S., with more dogs coming to us here with trilostane treatment. By all means, this is not to suggest that Lysodren is a bad or "worse" treatment choice. Some vets who have had experience with both drugs prefer trilostane, some prefer Lysodren. And some dogs just do better on one drug than the other. But I do believe Lysodren is being prescribed less frequently, overall, especially by younger vets who do not have previous experience with Lysodren use.

Since you are asking for opinions, here's mine: If you do proceed with trilostane treatment for Mimi, I personally would suggest starting out with brandname Vetoryl instead of a compounded product. Vetoryl is now available in 5 mg. capsules in addition to 10 mg. capsules. Given Mimi's weight of 16 pounds, I do think you could safely begin with either of those doses. If she were my own dog, I would probably ask to start at 10 mg. But if you want to go lower and are considering 6 mg. compounded, I would prefer to drop back to the 5 mg. of Vetoryl. Many of our members through the years have been quite satisfied with compounded trilostane, and in situations where cost makes Vetoryl a hardship or where an appropriate dose simply is not available, I think compounding serves an essential purpose. However, during the past few years, a couple of studies have shown a fair degree of variability in some trilostane compounds (pharmacies unnamed in the studies). Dosages have varied considerably from what was labeled, and/or effectiveness of delivery was inferior. I personally am especially wary of liquid preparations just based on the experiences of some of our members. So my own recommendation to folks is this. If you can afford the cost of brandname Vetoryl and your dog is prescribed a dose that is available, I would start with the brand product. Once your dog is stabilized, if you need to make a change due to cost, you will have a basis of comparison for the effectiveness of the compounded product. If your dog continues to do just as well, great! But if not, then you may have reason to suspect that the compounded med is not effectively replacing the Vetoryl. As I say, just my two cents worth, for you to take or leave. We do have lots of folks here who use compounded meds, and Diamondback Drugs in Arizona is one commonly used provider among our members.

Definitely let us know how things proceed.
Marianne

[randy]

Marianne, Sounds like the same as I was thinking from what I've been reading.. The fact that they do make a 5mg capsule would tend me to believe starting her on 5mg once a day then increasing to 5mg twice a day since studies have shown twice a day treatment at lower dosage seems to carry less side effects. I've called my vet but shes in surgery today to discuss this. Thanks so much for letting me know about the 5mg capsule. The Vets aren't even aware. That should make your day or scare you. lol Thanks again and I'll keep posted

[labblab]

You're welcome, Randy. The 5 mg. capsules have just recently become available, so I think a lot of folks don't yet know about them. If your vet has any questions, she can call Dechra directly. But I just now Googled "5 mg. Vetoryl" and there are already at least a couple of internet veterinary pharmacies that are offering the 5 mg. capsules for direct sale. So I don't think you should have a problem getting them if that's where you decide to start.

http://www.dechra-us.com/Files/dechraUSA/downloads/Qrtly%20Promotional%20flyer/VetorylQ4PromotionFormEditable.pdf

Marianne

[Squirt's Mom]

If she does well on the 5mg, you do not want to double that dose to go to twice a day dosing. There may be a slight increase but you never double this drug for any reason. ;)

[labblab]

Leslie makes a good point that we try to emphasize once treatment has begun. If a dog's cortisol has been effectively lowered into therapeutic range on a given once daily dose but a decision is made to switch to twice daily dosing (due to symptom rebound at night, for instance), then you would divide the once daily dose in half rather than doubling it.

In Mimi's situation, though, I don't believe that starting out with 5 mg. twice daily would be unreasonable. That daily total is still significantly less than 1 mg. per pound. So if you want to ease her into treatment with only one 5 mg. capsule for a little while, I would think it would be OK to then directly advance her to the twice daily dosing as long as she is behaving normally with no adverse symptoms (and of course, with ACTH monitoring at the prescribed intervals).

Marianne

[molly muffin]

Wow, that is interesting. I really thought it would be Addisons.

I agree vetroyl over compounded is better, although I myself use compounded trilostane. (I'm in Canada)

[randy]

I wanted to post Mimi's numbers from ACTH test. Pre was 2.5 Post was 25.1 I started Vetoryl this morning and will retest in 10-14 days. Hope things go smooth. We are starting her on 5mg once daily and see how she does.

[molly muffin]

We'll have our fingers crossed. :)

Remember the signs to watch for, vomiting, diarrhea, excessive not normal lethargy, refusing to eat.
You probably won't have any of that, but is always good to know what signs to look for too.

Let us know how it is going.

[randy]

Mimi has taken 5 mg once in am. Her test results after 14 days were Pre test 0.6 and post was 10.1. Normal range is 2-7. She seems to still have her extreme hunger and thirst and pants excessive after 6 or 7 pm. gonna keep her on 5mg and may consider twice a day. The cost would double but I think, looking at her symptoms, she may need that. Cheapest I've seen is 34.99 per 30 5mg at ValleyVet and 5.4 mg per 70 compounded at diamondback for 38.00. My vet charged 55.00 for 30 of the 5mg. She definitely is responding but probably need a little more. Now gotta see what is best route to buy Meds and if my Vet will concur.

[molly muffin]

Yes I agree that her post needs to come down a bit, at least below 9.0ug with control and if not then under 5.0ug. She has been on this dose for 2 weeks, so it could still come down more on the same dose for 30 days. Something to keep in mind.

I use trilostane but 5mg of vetroyl is probably optimal if you can get it affordably.

[randy]

I need some input for the latest on Mimi. After a stim test every 2 weeks for about two months we are currently at 10mg vetoryl twice a day. Just re-checked yesterday. She has been panting and drinking excessive and having pp accidents. We also tested her urine for UTI and found that her glucose was 480. Vet put her on twicde daily injection of .4 vetsulin to start. Just got her STIM test results also and her pre was the same at 2.5 and her post had risen from 10 to 13 which I think is odd. Take her back for curve test next week for diabetes. Vet is considering either going up to 15 mg vetoryl twice daily or changing to lysodren. So to re-cap : 1) her post number has risen eventhough we increased from 5mg to 10 mg twice daily 2) she has developed diabetes in the past month 3) she has lost a pound(which she needs too) also. from 16lbs to 15 lbs. My vet is leaning towards lysodren but I still like Vetoryl. Can I get some input on everybodies past experiences with all this information. I personally don't think we're at the right dosage level of vetoryl and her diabetes has developed as a result of the cushings. She is still esting good and walking but panting and drinking water excessively. Would like to hear opinions..... Getting very costly Thanks, Randy

[Harley PoMMom]

Hi Randy,

I would stay with the Vetoryl and for right now I wouldn't increase her Vetoryl dose. The increased drinking/urination could just be from the diabetes and once you get that under control these symptoms may subside. After her diabetes is stabilized I would then have another ACTH stimulation test done to see were her numbers are.

We have a sister site that deals with canine diabetes, here's the link:http://www.k9diabetes.com/forum/ they are a wonderful group of people that are very knowledgeable about diabetes and can help you sort that out, this way you have the best of both worlds, us and them ;)

Hugs, Lori

[molly muffin]

Yes I think it is likely that the increase in symptoms you are seeing is due to the diabetes. I'd try to get that stabilized and the cortisol might come down once that happens.

[randy]

I have diabetes myself and am on metformin. I just didn't understand how mimi developed diabetes just now. I am concerned that her post acth number went up and diabetes suddenly appeared. We are trying to treat it with .4 vetsulin twice a day and they are doing an all day curve test next Monday to get a more specific dosage of meds. Is it common for dogs to have cushings and suddenly develop diabetes. I know over 50% have both. What is the effect of one with the other ?

[molly muffin]

The basic connection between Cushing's and diabetes is this: the excess cortisol produced by the faulty adrenal gland is a signal for the body to produce new, non-sugar sourced glucose (Gluconeogenesis).

When this additional glucose reaches the bloodstream, another signal goes off; this one to the endocrine pancreas to produce more insulin to handle the glucose present in the blood.

When the insulin production ability of the pancreas can no longer keep up with the additional blood glucose which the excess cortisol from the malfunctioning adrenal gland keeps emitting, the islet cells of the endocrine pancreas are exhausted, and diabetes results[9]. In effect, the overproductive adrenal gland has the capability to "burn out" the insulin producing capability of the pancreas.

If the islet cells of the pancreas are still able to produce sufficient endogenous insulin for the body's needs, controlling the Cushing's will also control the blood glucose, meaning there would be no need for insulin injections. If the pancreas' islet cells have sustained such damage as to be unable to produce enough insulin for the body, insulin shots are necessary.



This is from the wiki on diabetes/Cushing's. http://petdiabetes.wikia.com/wiki/Cushing's_disease.

[Harley PoMMom]

Unfortunately, it's not that uncommon for dogs that having Cushing's to develop diabetes later on. We have several members that are dealing with both diseases, they post here and over at the diabetes forum, which I strongly urge you to join ;) Their link: http://www.k9diabetes.com/forum/

Hugs, Lori

[Harley PoMMom]

Acth stimulation tests...ARGH!!! They are so expensive and I was so happy to learn that there is a way to save money but only if you have a smaller dog. Most vets use a stimulating agent called Cortrosyn but we call it liquid gold because it's that little vial that dictates the cost. The vial is .25mg and instructions say to use entire vial but not all dogs need the entire vial. There have been studies done that show using just 5mcg per kg is all that's needed. If a dog weighs 37 lbs, converted to kg is 37 divided by 2.2 = 16.81 kg x 5mcg = 84.09mcg. A vet can round that off to half a vial or 125 mcg. Since there are 250mcg in one vial, the vet can get two stim tests out of one vial. This has saved members a lot of money, especially those with teeny dogs who can get five and six stims out of one vial.

Some vets are not aware of this so we always provide the url to Dr. Mark Peterson's blog which instructs vets on how to dilute and store cortrosyn for future use.

http://endocrinevet.blogspot.com/201...rosyn-for.html

Hugs, Lori