My boy stopped responding to meds

[Hestie and Astro]

Good evening and thank you for this great forum.
My 10 year old min pin was diagnosed with cushings about 3 months ago. He had all the classic symptoms of eating and drinking a lot, pot belly and panting. In addition he seemed anxious and disorientated at times. He also coughed a lot! His heart was given a clean bill though. A sonar showed enlarged liver and adrenal glands and a blood test confirmed cushings. He was started on 15mg Trilostane twice a day and we saw results in a few days. We had our boy back and rejoiced. Over the course of the last two or so weeks the symtoms started coming back. (His follow up blood tests 6 weeks after treatment was started showed a decrease in levels although it was still high). But now he is worse than ever. He struggles to jump up on the couches and eats and drinks a lot again, hence the swollen abdomen returned too. And he coughs the whole time. It not the KC type of cough. He is being treated with cough syrup but to no avail. We are really worried and don't know if we should do more blood work or have scans done? Is he in pain or suffering. The vet said his heart still sounds fine. I couldn't really find anything on cushings and coughing. Any help would be greatly appreciated. Thank you so much in advance!

[Harley PoMMom]

Hi and welcome to you and your boy!

Could you get copies of all tests that were done on your boy and post those levels that are abnormal and please include the normal reference ranges and the reporting units....thanks! We are really interested in the results of all those ACTH stimulating test so could you post those too? How much does your boy weigh? Is he taking brand-name Vetoryl or is his Trilostane compounded? Are his ACTH monitoring stim test being performed 4-6 hours after his Trilostane is given? Is the Trilostane being given with food?

Increased drinking and urinating are symptoms of diabetes and/or UTI, have these been ruled out? Most dogs with Cushing's have diluted urine and a regular urinalysis may not pick up bacteria in the urine so it is recommended to have an urine culture and sensitivity test performed, this way the exact bacteria can be known so the proper antibiotic can be prescribed.

The coughing could be due to a collapsed trachea, did the vet rule this out?

I'm sorry for all these questions but the more we know about your sweet boy the better our feedback can be. I am sorry for the circumstances that brought you here but glad you found us, we will help in any way we can.

Hugs, Lori

[molly muffin]

I just want to welcome you to the forum. What are the current ACTH results? pre and post? Maybe he has gone low now?
We had another dog who for unknown reasons started coughing and after a couple months it has finally cleared up to a more manageable level. I don't think the cause was ever determined with her dog. She was on anitibiotics though.

As Lori mentioned though, things like diabetes which can come on almost over night have to be ruled out. So a blood test to check out anything that could have gone off. Also as Lori also mentioned a check on the trachea.

Are you currently seeing a internal medicine specialist? If not that might be an option for you. We see an IMS because my molly has a couple things going on plus the high cortisol. Many of do use both an IMS and a vet if that is feasible.

Also, when the cortisol goes lower, other things can be uncovered such as arthritis, luxating patellas, that the cortisol in effect masked.

[Hestie and Astro]

Dear Lori,

Thank you so much for your reply. Herewith all the info I have:
Astro weighs 7.2kg (he always used to weigh about 5.5ish).
His meds are given with food.
The trilostane are compound.
The first test done was to diagnose and results were as follows:
Date: 27/08/2015
Dexameth suppression test (0,4,8 hr)
- cortisol basal 80.80
- corisol 4hr post dex 35.30
- cortisol 8hr post dex 59.60.
Bloodglucose was normal

Treatment was started a few days later.
2nd test date: 11/09/2015
ACTH Stim test
Sample handling: lipaemic 3+

-cortisol basal 194
- Cortisol post ACTH 483
ACTH stim: trilo
This test was probably done about 3-4 hrs after meds was given.

The vet mentioned the possibility of a collapsed trachea as he is very sensitive to touch on his trachea.

I hope I covered everything. I so appreciate your effort!

[Hestie and Astro]

Dear Sharlene,

Thank you for your reply! :-)

We are not seeing a specialist. We hoped to get away without one but it seems that maybe we won't. Our vet want to do a CT scan. I don't know if it will really help much and it is very expensive. Any thoughts on this?

Today Astro coughed almost non-stop. Especially in the morning. Later this afternoon it calmed down a bit again.

He is actually still quite lively. He does lie down a lot but he also still plays with the other 3 doggies from time to time amd still LOVES to bark at anything (or nothing) ;-)

Our vet did say he has arthritis in his lower body.

We haven't done a blood test again. We are just seeing if the new batch of meds won't make a difference bit we need to make a call by tomorrow or so. Do we do a bloodtest, CT scan or do we see a specialist.

It's really sad. He has always been a healthy little doggie!

[labblab]

Treatment was started a few days later.
2nd test date: 11/09/2015
ACTH Stim test
Sample handling: lipaemic 3+

-cortisol basal 194
- Cortisol post ACTH 483
ACTH stim: trilo
This test was probably done about 3-4 hrs after meds was given.

Hello and welcome from me, too! I wish I had time right now to write a lengthier note, but unfortunately I will have to choose to focus on one main issue, and that is the result of the monitoring ACTH stimulation test. If I am interpreting things correctly, Astro began his trilostane treatment at the end of August, and then had his only monitoring ACTH test performed around ten days later (Sept. 11th as opposed to November 9th?). Has he had any subsequent ACTH testing done?

If we convert the results that you've posted for the September test into the units most commonly used in the U.S., we see a post-ACTH result of approx. 17.5 ug/dL. This is much higher than the desired therapeutic range for a dog being treated with trilostane. It is perfectly fine that your vet did not increase Astro's dose at that early stage, because the expectation is that a dog's cortisol level will continue to drift downward during the first month or so, even when the dose is left unchanged. But the test should be repeated at the 30-day mark, and if Astro's cortisol level was/is still that high, it is not at all surprising that he is exhibiting Cushing's symptoms. Unfortunatley, if his cortisol level remains that high, his disease is not being adequately controlled and a dosing increase would be warranted.

As you will see from the monitoring chart contained in the link below, a post-ACTH result as high as 250 nmol/L is acceptable as long as a dog's symptoms are being well-controlled. If not, then the desired cortisol level is even lower: it should not exceed 150 nmol/L. So as you can see, Astro's level of 483 nmol/L is really excessively high for a dog under treatment.

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

I do not have an explanation for his cough. But if his cortisol is currently running this high, there is an easy explanation for the rebound of his Cushing's symptoms and he will likely need a trilostane increase. Actually, it is not at all unusual for dosage adjustments to become necessary throughout the course of treatment. That's why the monitoring testing has to continue periodically throughout time.

Please do correct me if I am mis-stating his testing history. If not, I think your problem may be easier to solve than you are fearing.

Marianne

[Harley PoMMom]

Did the vet mention why s/he wants to do a CT scan? I'm pretty sure my Bear's collapsed trachea was diagnosed from an Xray, and he also had a honking cough, so if the coughing is due to a collapsed trachea than an Xray would be one thing I would consider having done.

I would probably have an ACTH stimulation test and have a CBC/chemistry blood panel performed too...just my 2 cents worth ;):)

Hugs, Lori

[Hestie and Astro]

Dear Lori and Marianne,

Wow thank you again for the replies. It is wonderful to be able to talk to people who are in the same boat.

Marianne you are correct in your interpretation. Our vet did tell us to have Astro tested again but as he was responding so well and all the symptoms were gone, we decided (stupidly, I realise now) not to do the test. We are from South Africa and pet medical aids are not common here as they are for example in the UK. So it was a cost-cutting decision. His current dose of 2 capsules a day is already really expensive. But I guess it pales in comparison to having a healthy boy.

The vet wants to do the CT scan to look at the pituitary gland. I read sometimes the tumors causing the disease can be removed rather effectively?

But I take your advice to heart and we will take Astro back for another test. Is there any chance that he will at some point start needing less meds? Or will the dosage just continue? I will also ask the vet to do an x-ray or whatever is needed in order to diagnose a collapsing trachea.

Warm regards :-)
Hestie

[labblab]

Hi again, Hestie! I believe you may be our first South African member, so we send out an additional very special welcome to you. ;) :)

If testing shows that Astro's cortisol is still running too high, one cost-saving measure you may discuss with your vet is to shift to once daily dosing at the time that you increase his medication. Many vets do like to dose their patients twice daily when that schedule is feasible, in order to keep cortisol levels consistently lowered throughout a 24-hour time period. However, many dogs show satisfactory symptom reduction on a single morning dose, and as you probably already saw in that link I gave you earlier, Dechra (Vetoryl manufacturer) still recommends starting all dogs with a single daily dose and only shifting to twice daily dosing if symptoms rebound again later in the day. If Astro's daily total of 30 mg. is not lowering his cortisol sufficiently, you might try increasing that dose and giving it as a single pill in the morning. For instance, I would suspect that a single 40 mg. pill would be cheaper than the two 15 mg. pills that you are giving now.

As far as dosing changes in the future, yes, it is entirely possible that his dosing will need additional tweaking throughout his lifetime, and it may be either up or down. That's why ACTH testing is recommended every three months for as long as treatment is continued.

As far as a CT of the head to view the pituitary gland, that is rather an expensive procedure here in the U.S. It is generally only done when a dog starts exhibiting neurological symptoms suggesting that the tumor may be growing excessively and thus placing pressure elsewhere on the brain. There is currently only experimental treatment here aimed at removing large pituitary tumors; more widely used laser/radiation treatment is used to temporarily reduce tumor size so as to give the dog some additional quality time. You may instead be thinking of surgery to completely remove adrenal tumors. Such surgery can be a very expensive and also risky undertaking, but does have the potential to totally cure a dog of Cushing's if his/her disease is caused by an adrenal tumor. I just checked, however, and Astro's LDDS result is consistent with the pituitary form of the disease, as was the abdominal imaging that apparently showed two enlarged adrenal glands.

So in summary, in terms of where I would put my money first, it would be the x-ray as Lori has suggested, and also a blood panel including an ACTH stimulation test. Mind you, the vet may want Astro to be fasted for the regular blood panel, but the ACTH will only be accurate if it is performed 4-6 hours after he has been given his trilostane along with breakfast (trilostane must be given with food to be absorbed properly). So the blood testing may need to be split between two different visits.

Marianne

[Harley PoMMom]

Since Astro weighs 7.2 kg (15.8 lbs) you can save money on those ACTH 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

Hugs, Lori

[Hestie and Astro]

Wow! I cannot thank you enough for your amazingly valuable inputs. We are awaiting Astro's latest stim test results. We were hoping to get it late yesterday but it seems we will have to wait until monday. I am definitely going to discuss all your suggestions with our vet.

I will keep you posted!

Ps. Thanks for the special welcome! South Africa is a beautiful country and we love our pets! But we also love networking with the rest of the world :-)

[molly muffin]

I'd go ahead and ask your vet to do an xray of the treachea and see if they can see if it has collapsed or not. If he is especially sensitive in that area, it's a real possibility.

Welcome to the forum!