When will the shivering stop? (Mollie is suffering no more)

[JLG]

My JRT, Mollie, has been on Vetoryl since 24 Aug 2015 having just been diagnosed with Cushings. She started shivering/shaking in her legs approx 2 weeks after starting the meds. Since then she has also been diagnosed with Kidney disease due to high protein levels and also takes Fortekor.

She also pants heavily at times, but I'm inclined to think that, as it's mainly done around mealtimes or if I go out, she's gets a little stressed and has just got into a habit.

Mollie seemed fine before all these meds started, now I worry that while we may be controlling her conditions we are making her life miserable in the process.

I've read somewhere that the Vetoryl can bring on these shivering episodes while the body gets used to the reduced steroid production, but how long can it go on for? I'm so worried for her, she's a sweet little girl and an otherwise happy soul, but it's so sad to watch her shiver even when she's trying to relax.

I'd be so grateful for any advice anyone can give.

[mytil]

Hi and a belated welcome from me.

Mollie being diagnosed with kidney disease and is taking Fortekor (Benazepril)......This is an ACE inhibitor and one should use these types of drugs with caution when combined with Vetoryl. Both have the ability to lower the aldosterone levels.

Please check with your vet on this!

Regarding the shaking there are many who have experienced this but really cannot explain why and yes this is a published reaction in the manufacturer's literature. As far as her body going through the normal cortisol withdraw period, that should have passed by now given it has been several months.

What was the result of the most recent ACTH monitoring test (test used to check the cortisol levels and to make sure they are within a specific range). This test is a must when treating any dog with Cushing's.

Keep us posted
Terry

PS - please take a few moments to read through this literature on Vetoryl ---- http://www.k9cushings.com/forum/showthread.php?t=185

[JLG]

Terry, thank you so much for replying to my plea for advice.

Mollie having two conditions (like most of the pups I see spoken of on this site) is not helping the situation as her diet is affected by both and the vet has restricted her to Purina NF Renal food only. I could do with some advice on what she could have to supplement that food and make her feed times more interesting, but that's another issue.

Mollie has been having ACTH tests, Ultrasounds and Bloods taken very frequently during these last few months. It was only when I started reading through the stories on this site that I realised I should have been asking for printouts of her results. I intend to rectify this next week as I have booked an appointment with the vet to discuss various aspects. Mollie is due an ACTH, they wanted to do it today with her blood tests and cystocentesis but as I had to fast her for those (hence no Vetoryl this morning) I refused to let them do the ACTH. This will now have to be rescheduled.

I will get the ACTH results and post them here as soon as I have them. I've just heard from the vets that they want to discuss their findings with me in person regarding today's tests, which is unusual, so I'm a bit concerned now about what they may have found. I'll update this thread once I know anything.

Thanks again

[labblab]

Hello Joanne, and welcome from me, too! I will hold off on writing more until we hear what the vets are going to tell you about Mollie's test results. But I just wanted to chime in with telling you we are so very glad you've found us, and we will do our very best to help you sort through the information that you will be receiving.

I'll surely be watching for your updates,
Marianne

[JLG]

Thank you both for your concern, I realise everyone goes through a period of worry and it's nice to know that there are people out there who have been through the process and survived!

Well they called me in to tell me that Mollie, yet again, has blood in her urine; that's the 3rd time since July '15. They also want to agree how we manage the tests going forward, so that we don't have the confusion regarding the ACTH stim test that we had today. I had already made an appointment to see her normal vet next Tuesday afternoon to discuss the whole case, so we've agreed to give her more antibiotics and supply another urine sample next Tuesday. At that point I want to sort out the ACTH testing and the Cystocentesis, which didn't go ahead today because of the infection.

So, it's status-quo for now, Tuesday should give me a way forward and also, some test results that I can post here. I will update the post as soon as I can from Tuesday's meeting.

Again, thank you, I realise being in England that some of what goes on here will differ from what occurs in the US, but it's just so comforting to know that someone somewhere knows what this disease is all about and can offer advice.

[Harley PoMMom]

Hi and a belated welcome from me as well!

How was the protein loss diagnosed? Since blood was found in her urine I'm betting she has an UTI, and UTI's can cause transient protein loss. Since she has had multiple UTI's I would recommend having an urine culture and sensitivity test done so the exact bacteria is known and the correct antibiotic can be given. Regarding the kidney disease, was the protein loss the basis for this diagnosis? Are there elevations in her creatinine, potassium, phosphorus, or calcium?

Hugs, Lori

[lulusmom]

Hi Joanne and welcome to you and Mollie.

I wish there was a like button so that I could give a thumbs up to posts that I think are spot on, but since we don't have that cool feature, I'm chiming in to validate Lori and Terry's posts. They've got you off to an excellent start and you can rest assured that Marianne, who is also hugely knowledgeable, will be on the case too.

I'll be waiting with the others to hear a lot more about Mollie. The more information you can provide, the better we can put some meaningful information out there for you.

Glynda

[JLG]

Hi and a belated welcome from me as well!

How was the protein loss diagnosed? Since blood was found in her urine I'm betting she has an UTI, and UTI's can cause transient protein loss. Since she has had multiple UTI's I would recommend having an urine culture and sensitivity test done so the exact bacteria is known and the correct antibiotic can be given. Regarding the kidney disease, was the protein loss the basis for this diagnosis? Are there elevations in her creatinine, potassium, phosphorus, or calcium?

Hugs, Lori

Hi Lori. Yes they are treating her blood in urine as another infection, same as the last 2 times. She had to have a culture/sensitivity test done as the infection didn't go with the first lot of antibiotics they tried. Kesium saw the end of it then and that's what they have given her now. She then went to a specialist for a barrage of tests and during that they found another infection so gave her 1 month of Synulox, which has left her clear (I'm assuming) for approx 2 weeks.

The protein loss has been an element of her condition since approximately Aug/Sept and when she saw the specialist they put her on Benazepril 2.5mg, recently increased to 5mg as her protein levels were still increasing slightly. They have seen increases in all those you mention above.

This is all from my memory and when I get the full numbers I'm sure it will all make better sense to you than all my mutterings on. Today I was told her bloods were good, but without the cystocentesis they couldn't check the creatine etc.

[molly muffin]

I just want to say hello and welcome to the forum. Everyone has already said everything I would have and probably more. :)
My dog too has protein loss in her urine and it's been a dickens to try and get control of. We do UPC tests regularly to monitor it. Be aware that any kind of stomach upset will send the protein loss higher than it usually is. That might not be pertinent at the moment or might be with the UTI, but after about a month it usually reverts to the lower level of loss.
We too are on Benazepril/trilostane (vetroyl) and BP meds. It really is a balancing act as one thing going high, affects everything else.

[JLG]

Hi Sharlene,thanks for your advice. I think the protein issue is worse to get to grips with than the Cushing's for us at the moment.

Can I ask what you feed your little one on? Do you use a commercial dog food or prepare your own?

[molly muffin]

I feed her medi cal LP (low protein) dry food, topped with canned moderate protein. Due to her getting diarrhea if I try to just feed her that, I mix in some dry senior food or Halo chicken. Sometimes as an alternative, because she can be a hard one to get to eat, I will cook chicken/rice and add that into the dry food.

Yes the protein can be tough. We are hoovering around 2.1 - 2.7 now, with her going up to 3.1 during a gastro upset. Getting her blood pressure down and her cortisol a bit lower has helped to get the protein back down a bit too. It can be very tough to manage all of it.

[JLG]

Well hello all again. Just thought I would update you on my Mollie's progress to date.

I saw Mollie's vet, as mentioned earlier in this thread, on Tuesday this week and Mollie's latest urine sample showed that it was blood free, which was the good news. This meant she was able to have all of her outstanding tests the next day.

On Wednesday Mollie went in for her ACTH stim test and the Cystocentesis later that afternoon. The vet rang me today and advised me that the lab tests have confirmed ACTH levels are raised as are the Protein creatines and Potassium. I don't have the numbers tonight, but I will have them tomorrow, so once I have them I will post them here.

As a result of these tests Mollie has to go back to the vet's tomorrow for a blood test to confirm the potassium levels. The vet told me that the potassium may be falsely elevated if the blood wasn't tested at the lab quickly enough, I've looked it up and understand that to be something called pseudohyperkalemia. I'm hoping that's the case as should it be Hyperkalemia they are going to stop the Fortekor for the weekend and see if that helps.

The vet has also referred all of Mollie's latest results to the specialist we saw back in October, so advice from her may well change Mollie's meds.

This is so upsetting, because I had been at least hoping we had a handle on the Cushings side of her problems, but it seems even that isn't settled yet. I'm also very confused now over the conflicts her meds can have on each other and her. I DO however, trust my vet to do whatever she can to get this sorted, but it still seems at the moment that it's one step forward and two back after every test.

Just for info Mollie's meds are currently;

20mg Vetoryl (Trilostane)
5mg Fortekor (Benazepril)
0.4ml soluble Aspirin (have just read this can reduce potassium, BUT it can cause the adrenals to produce more cortisol !)

Anyway, that's it for now. I will have some figure work for those of you that understand it tomorrow and HOPEFULLY some good news on the potassium front.

Thanks for listening!

[JLG]

Morning to all my new friends, canine and human!

Mollie has had her blood test for potassium this morning, but I am yet to be given the results. However, I now have some figures from her lastest tests, regarding ACTH etc. I'll write them out as they appear on the printout, so I hope they aren't confusing.

Urine Protein/ Creatine
Urine protein: 8940.0 mg/l
Urine creatine: 4.30 mmol/l

Urine Protein : Creatine H 18.38 0.00 - 0.50

Urine Microscopy

WBC not seen
RBC not seen
Epithelial Cells +/-
Bacteria not seen
Crystals not seen
Casts not seen
Amorphous Debris +/-

Trilostane profile
Canine ACTH Stimulation Test
Cortisol basal 133.00 mmol/l 50.0 - 250.0

Cortisol Post ACTH 274.0 mmol/l 150.0 - 550.0

ALP H 184 u/l@37C 12 - 83

ALT H 103 u/l@37C 13 - 78

Urea H 12.9 mmol/l 1.7 - 7.4

Creatine H 155 umol/l 20 - 124

Sodium 149 mmol/l 139 - 154

Potassium H 5.94 mmol/l 3.60 - 5.60

Comment Sample lipaemic and haemolysed

Marked uncresed (increase ??) in UPCR here which is unlikely to be genuine, please check on a fresh sample.

They seem to be recommending an increase in the Vetoryl due to poor control. They also speak of something called Azotaemia.

"Azotaemia could be renal or prerenal and requires concurrent measurement of Urine SG to differentiate further though this may be difficult to interpret with concurrent hyperadrencorticism. Treatment with Trilostane is contraindicated if there is concurrent renal insufficiency."

Does this last comment mean that in Mollie's case we shouldn't be treating her Cushings??

Hope all of this makes sense to someone, though I must say seeing these figures, though worrying, does make it all make a tad more sense in my mind.

I look forward to your views on the above.

Thanks again.

[labblab]

Hello again, Joanne. Thanks so much for posting Mollie's lab results. I'm surely sorry that there is any reason to worry, but I think these are the issues that the vets are wondering about. There are a few different elevations that could all signal significant kidney disease, if they are indeed accurate. And if that's true, then trilostane is not a good drug to be giving Mollie because the kidney problems can negatively affect the manner in which the drug is metabolized and excreted from the body, and that could end up causing her harm.

If accurate, the highly elevated UPC ratio from her urinalysis would suggest that Mollie's kidneys are allowing an abnormal amount of protein to pass out of her bloodstream and into her urine. The elevated Urea and Creatinine levels on her blood panel (converted to U.S. units, her Creatinine is 5.6 ug/dL) would suggest that Molly has a problem that is hindering her body from properly clearing out waste products from her bloodstream (this is what is meant by "azotaemia"). In Mollie's case, the lab is suggesting that azotaemia can be caused by direct problems with the kidneys themselves, or by problems with the way in which the blood enters the kidneys. One of the diagnostics that might help figure out the source is measurement of the specific gravity (SG) of the urine. However, since Cushpups often drink and pee excessively, the specific gravity may not be as accurate a diagnostic tool as it might be for a dog without the disease.

Since the UPC was so highly elevated this time around, the lab is suggesting that there may have been a lab error, and that's why they are asking for a repeat on a fresh urine sample. Hopefully, it was indeed just an error. But all these abnormalities, taken together, are undoubtedly what are making the vets consider worsening kidney problems. And again, if this is truly the case, then trilostane is not a good drug for Mollie to be taking.

Backing up a few steps, can you tell us more about the actual symptoms that led your vets to suspect that Mollie had Cushing's in the first place? The reason why I ask is because kidney disease and Cushing's can share some of the same symptoms, and the diagnostic blood tests for Cushing's can return "false positives" when other illnesses are present.

If Mollie truly has Cushing's and we had no concerns about kidney problems, then yes, it's true that her post-ACTH cortisol level (approx. 10 ug/dL) is still a bit higher than is desired if symptoms are not being well-controlled. However, right at the moment, it seems to me as though thorough exploration of possible kidney issues is Mollie's most pressing problem, in conjunction with elevated potassium if that is present. So I doubt that increasing the trilostane is a great idea right now. In fact, your vets may end up deciding to discontinue it altogether, at least temporarily, until the severity of the kidney issues can be sorted out.

I apologize in advance if what I've written ends up worrying you even more :o. I remind you that I am not a vet, but these are the things that I think the labwork is suggesting.

Marianne

[JLG]

Marianne, thank you so so much for reinterpreting all of Mollie's stats into something even I can understand. Yes, it does sounds even more worrying, but at least now I understand what it is I'm worrying about. You may not be a vet, but your understanding of the topic is very reassuring and something I am very grateful for.

Mollie's blood test today to confirm her Potassium levels did comeback NORMAL, so that was a problem solely at the lab. I was told her reading today was 4.9, so middle of the normal range. At least that's one less thing to worry about.

My vet, new to the practice saw Mollie for the first time at her Annual Check-up in May and whilst giving her the usual examination, noted her round tummy. Mollie has always had a paunch which I don't think has ever really left her since a pup and she was also once overweight at 10.5 kg. Despite having dropped 2 kg now she still has a round tummy at times especially after feeding. The vet mentioned Cushings and suggested I keep an eye on her drinking and peeing habits and bring her back if anything changed. I really didn't see any change until July when I rushed Mollie up to the vets as I'd noticed her running around the garden trying to do lots of pees and when I checked it out there were tiny blood clots and the sample I took was pink! Obviously. it didn't need testing to see that there was blood in the pee, but she was then treated for Cystitus/Infection. At that point my vet, again raised the issue of possible Cushings syndrome and since then it's been test after test.

Mollie, as of today, is still on Trilostane, Benazepril and Aspirin, and I am now waiting for my vet to speak to the specialist before getting back to me; hopefully that will be early next week.

Mollie in herself is still a happy little girl who to anyone who doesn't know her looks very well. However, what has always bothered me is that only since she started the Trilostane has she panted heavily when stressed or desperate for food, and had what I call "the shakes". I can't shake the feeling that we've made her 'ill' by giving her all these meds. I just hope that's the worried Mum in me talking, lol!

As ever, most grateful for your time and help.

[JLG]

Hi to all who may be watching this thread and awaiting an update on Mollie's meds and progress.

Our vet in conjunction with the specialist have decided to start Mollie on another drug in an effort to reduce her protein levels. They have retained all her current drugs, so her meds cabinet now includes;

Trilostane
Benazepril
Aspirin

and now

Semintra (aka - Telmisartan) 4kg dose (Mollie weighs 8.7kg)

This is a drug currently only licensed for CATS, though I've seen studies in dogs that have shown good results, and Mollie has been prescribed a half dose when compared to that given to a cat, so they are erring on the side of caution. All of her other meds remain at their originally prescribed dosage. Her BP, today was high at 190, and they will be doing another BP check and Blood test next week to see if the drug is working

[judymaggie]

Hi, Joanne! My Abbie is currently taking amlodipine and telmisartan for high blood pressure and proteinuria (marked by a very high UPC). We tried different drug combinations and Abbie's blood pressure check this week showed a normal blood pressure. It might take a bit longer than a week to see if the telmisartan is making a difference so don't be discouraged if there is no change next week. FYI, Abbie weighs 25 lbs. and gets 5 mg. of telmisartan per day split into two doses. I have also added omega-3 fish oil to Abbie's food. She is prone to soft stools so am adding the oil in very small increments. The telmisartan is quite expensive where I live -- hopefully, it is manageable where you are. Gentle hugs to Mollie!

[JLG]

Hi Judy, so nice of you to comment. It's reassuring that there are others on this concoction of drugs. It did feel like Mollie was being treated as a guinea pig yesterday when I was told what they wanted to try. I do however feel better about it now, both for your comments and some of the research I've done today on the Web. I just hope it works and we can start to se some improvements in her protein levels.

Thanks again.

This forum is an absolute godsend.

[molly muffin]

My dog too is on trilostane, benazepril and amoldipine (for high bp) We've been on this combination for over a year and so far doing okay.

[JLG]

Dear All,

It's been a while since I posted questions on here asking for your advice on Cushing's which developed in my JRT, Mollie.

I am writing to let you know that on the 7th Sept 2016, I elected to have my sweet little girl put to rest in order to avoid any further suffering. Ironically, it wasn't the Cushings that saw her to her end, (though no doubt it contributed indirectly, we had finally got that well under control) but the ongoing Kidney disease that no matter what we tried we just couldn't get a hold on. Her blood levels went through the roof towards the end and she stopped eating. The vets tried fluids which brought her back from the brink a couple of times, but there was nothing else we could do that wouldn't have caused her even more suffering. So with much guilt and a very heavy heart I let her go.

Thank you all for your help and encouragement during what was a worrying time and I wish all of those going through similar times now the very best wishes for a good outcome.

[Budsters Mom]

So sorry to read this news Joanne.:o Thank you so much for returning to let us know. You will alway be a part of our family here.

Fly free Mollie, fly free!

Hugs,
Kathy

[molly muffin]

I am very sorry Joanne for your loss of your precious Mollie.
I too lost my Molly in September due to kidney disease not the Cushing's after going through much the same options as you.
My heart goes out to you during this truly horrible time.

[labblab]

Oh Joanne, this is such sad news, indeed! We hope it may give you a bit of comfort to know that Mollie has now been added to our special memorial thread of honor:

http://www.k9cushings.com/forum/showthread.php?t=7676

We will always remember here alongside you, and we will always be here for you, yourself, should you wish to return and share stories about your lives together or to tell us how you're doing.

Always in loving memory of your sweet little girl,
Marianne

[Burlene K]

So sorry to hear of the loss of Mollie. Losing a pup is one of the saddest events in life, but you did your best for her and gave her a great life.