Max, 9 y/o Am Cocker with Pituitary Cushings

[AshleyC]

Hello! I'm Ashley and I'll introduce Max since he doesn't have thumbs. :D Max is a 9 1/2 y/o chocolate and tan Am. Cocker Spaniel who we adopted 6 1/2 years ago. A week ago we did the low dose Dex test which strongly indicated pituitary Cushing's. (I'll post numbers below in the interest of paragraphs.) We'd been chasing our tails thinking it was thyroid but a panel with Hemopet indicated his thyroid was low-normal at worst. At that point we decided on the Cushing's test. Max has insatiable appetite, pot belly, urinating in the house recently, hair loss, high triglycerides, high ALk Phos, lower endurance for exercise fatiguing easily, along with general restlessness and anxieties.

We've chosen to treat this with 15mg of Anipryl daily, mostly due to the monitoring requirements, its affect the pituitary gland and factors for Max. If anyone has used Anipryl I welcome any advice (or even if you're not using it). I have seen that Anipryl is a MAOI so I'm not sure if the dietary restrictions hold true for dogs like they do for humans.

Max is raw fed, fully titered/rabies vaccine exempt and also has immune mediated conjunctivitis that we treat with a cyclosporine drop daily. We also walk between 5-8 miles a week along with training games and naps. It's good to be Max.

Some Numbers:
11/2/15
Cortisol reference range for the low dose Dexamethasone test was 1-6.
Baseline cortisol (9 am) was 6.1
Cortisol suppression 4 hours after Dexamethasone (1pm)- 1.6
Cortisol suppression 8 hours after Dexamethasone (5pm)- 2.9

Other relevant numbers, run 10/16/15
Alk Phos 406 Ref: 5-131
BUN/Creatinine Ratio 38 Ref: 4-27
Cholesterol 385 Ref: 92 - 324 mg/dL
Triglyceride 871 Ref: 29 - 291 mg/dL

Thanks for a great resource!

[Harley PoMMom]

Hi Ashley,

Welcome to you and Max! I am sorry for the circumstances that brought you here but so glad you found us. And bless you for giving Max such a loving forever home.

Thank you for giving us the results from Max's tests, that helps a lot. And yep, if I thought the thyroid was the issue I would also send the sample to Hemopet, Dr Dodds is one of the leading experts on canine thyroid issues.

With respect to Anipryl, unfortunately it's efficacy is not great. It really is only effective in dogs having a pituitary tumor in the pars intermedia lobe. Only a very small percentage of dogs have a tumor in the pars intermedia and efficacy in those dogs is questionable, depending on the progression of the disease. Even the developer of the drug, Dr. David Bruyette, who was also a short time member here, limits its use to dogs with very mild symptoms or pet owners who can't afford the cost of the ACTH stimulation tests that must be done to monitor Lysodren and Vetoryl treatment. We have had members report good initial results in dogs with mild or few symptoms but improvements were short lived.

Could you expand on why Vetoryl or Lysodren is not an option, if it's the cost of those ACTH stimulation tests, we surely understand. However depending on Max's weight you can save money on your stim tests if your vet will learn how to dilute and store cortrosyn, which is the stimulating agent. That stuff is ridiculously expensive and even though the instructions on the vial say to use the entire thing, smaller dogs don't need the entire vial. I'm providing a link below to the article entitled: How to Dilute and Store Cortrosyn, which is found on Dr. Mark Peterson's blog for veterinarians. http://www.endocrinevet.info/2012/03/how-to-dilute-and-store-cortrosyn-for.html

I know how frustrating and confusing this all can be. We've all been on that roller coaster ride, some of us more than once, just know that you are in the company of people who have walked in your shoes, who will help you help Max. You're not alone on this journey.....we're here to hold your hand and help in any way we can.

Hugs, Lori

[AshleyC]

Thank you for the info. We decided to try the anipryl because work schedules are erratic and anipryl seemed to have the least chance of missing things that would lead to an overdose of lysodren. While cost of drugs and clinical monitoring was (is) a consideration it is not the main consideration. I was honestly worried we'd miss the signals that the lysodren was working and induce Addison's. Anipryl doesn't seem to carry those risks. My vet isn't terribly versed in treating Cushing's and we may find an internal med specialist if my vet isn't comfortable treating ultimately My vet also does acupuncture and herbs if we get to that point. I've also heard great things about melatonin and lignans as complementary therapy but want to do one thing at a time to measure efficacy. For now, I'm waiting for the scrip to arrive in the mail and give it a go. I do know it is not an adrenal tumor, we did the ultrasound and nothing on the gland itself.

[labblab]

Hello Ashley, and welcome to you and Max! Max looks like such a sweetie, and what a wonderful life you are providing for him. Indeed, it is good to be Max...:) :)

Lori has gotten you off to a great start, and I really hope you see some improvement with the Anipryl. But unfortunately, as she has said, we have read very few long-term success stories here. As for lignans and melatonin, they seem to offer variable assistance, as well, and largely only when trying to reduce elevated adrenal hormones other than cortisol. I think there may be a mild effect on cortisol, but generally far less than is sufficient to control symptoms in a dog with conventional Cushing's.

I am not aiming at being a downer, but I just want you to be prepared that you most likely will end up needing to take a second look at treating with either Lysodren or Vetoryl (brandname trilostane). You have only mentioned Lysodren so far -- do you know whether your vet has used trilostane with any of his patients? Both drugs are effective at lowering cortisol, but the way in which they act on the body is very different. Trilostane does not involve a "loading" phase in the same way as does Lysodren. Instead, dogs are started on a consistent daily dose which ends up being increased or lowered based upon symptom resolution and monitoring blood tests. The owner must still be very vigilant to watch for any ill effects, but the initial pressure to judge the completion of the load by focusing upon even slight behavioral changes is absent. And although there are exceptions, minor trilostane overdosing is often remedied simply by temporarily discontinuing the medication and resuming at a lower dose. So you may feel more comfortable with trilostane as a treatment option if you end up needing to make a medication change.

I do think you are wise to introduce only one new variable at a time, however. That way, you can better judge the specific effects of that drug or supplement, both for better and for worse. So we do wish you and Max good luck with the Anipryl, and we'll be anxious to see your updates.

Marianne

[AshleyC]

There was a reason the vet wasn't keen on trilostane but I don't remember what it was now. She wanted to initially go lysodren until we talked it over then decided on anipryl. Do you find it's easier to go to a specialist and then monitor with your vet or just leave it to your vet?

[molly muffin]

Hello and welcome to the forum.

Many members do use a specialist in Internal Medicine along with their vet.
I have an Internal Med specialists for the trilostane that really does most of the case management for all cushings and associated testing and a regular vet for normal vet things. They all work together, which is good

I do think I would want to around if doing a lysodren load, it is not quite as must of a worry with trilostane, but yes you do always have to be vigilant, it doesn't seem to come on as fast and leaves the body quicker. As long as protocols are followed for dosage and monitoring it isn't too bad. Everything with any drug depends on how the dog reacts to it too.

[AshleyC]

We've done the LDDS test for the initial diagnosis. Do we have to do the whole test again or could you just retest against the baseline to see if the meds are working?

[Squirt's Mom]

I'm with your vet and prefer Lysodren. ;)

[labblab]

We've done the LDDS test for the initial diagnosis. Do we have to do the whole test again or could you just retest against the baseline to see if the meds are working?
One of the attractive pieces about anipryl treatment is that the expensive monitoring testing is not relevant. Because the drug does not directly affect adrenal hormone production, there is no safety risk of a dog's hormonal production dropping too low. But as I understand it, the reverse is also true: cortisol level may still remain higher than is the case for dog's without Cushing's -- even though overt symptoms may resolve. To this day, for the life of me, I still don't exactly understand how anipryl accomplishes this for the small percentage of dogs for whom the drug works. But due to its action on the body, the best way to guage its effectiveness is simply by watching whether a dog's symptoms seem to improve.


Since Anipryl is not toxic to adrenal cells, a stringent schedule of follow-up visits for laboratory testing is not required. Response to therapy should be based on history, physical examination, and resolution of clinical signs associated with uncomplicated PDH.

While clinical signs may improve, blood cortisol levels can still remain above normal. For this reason, treatment success with Anipryl is best evaluated by improvement in clinical signs. However, because dogs with PDH usually are older dogs-and more likely to develop other medical problems-practitioners should establish appropriate schedules for followup with owners and clinic visits to monitor the'dog's general health.

During clinical trials performed when the drug was first approved for canine Cushing's, I do believe complete LDDS tests were administered to at least some research dogs throughout the study, with some improvement seen in those results. But I have never seen monitoring LDDS testing recommended to owners in "real life."

Just so you'll know, baseline cortisols are of limited assessment value even for Cushpups treated with Lysodren or trilostane. Baseline cortisols can be highly variable for all dogs, and really can be used only to try to judge whether cortisol may have dropped too low in dogs taking those drugs (which is not a worry with anipryl). Baselines are of very limited value in otherwise assessing treatment effectiveness. For dogs taking those two drugs, the ACTH stimulation test, and not the LDDS, is the monitoring test that is required throughout the course of treatment.

Marianne

[molly muffin]

How is Max doing?

Marianne is right, with anipryl you don't have to retest, just watch symptoms, but with the other too you need to do full test, the 2 hr ACTH to monitor levels.

[AshleyC]

We're seeing some benefits of the anipryl but we're seeing some undesirable behaviors too, namely persistent humping after dinner. (To be clear, I don't have a problem with humping, per se. I have a problem with being humped. We're redirecting to a pillow but it's slow going.) When i asked the vet about it, she mentioned that as the cortisol levels recede other hormones step back into closer to normal levels, which could influence behaviors. Is this a thing? Do you notice more extreme behavior changes that then taper off. It's like he's lost his brain. I should add that he was also pediatrically neutered adding insult to hormonal injury.

[labblab]

Gosh Ashley, I'm afraid I can't offer you any insight here. In all my years here, I have never heard other members speak about an increase in humping behavior in conjunction with Cushing's meds, so this is not a common response to a decline in cortisol. I've always read that humping is not necessarily sexual in nature, but can be triggered by things such as general excitement, dominance-searching, etc. But sexual or not, as to how or why this behavioral response might have suddenly changed for Max in conjunction with taking the Anipryl, I do not know.

But at least you are seeing some other improvements?

Marianne

[molly muffin]

I'm wondering about an increase in the other sex hormones. We know that vetroyl can have an affect on them, but I don't know anything about anipryl. The only way you would know for sure to have him tested. An atypical cushing test, (an acth test) sent to the University of Tennesee would show you what those levels are.