Sadie has Adrenal Cushings

[LittleDog]

My 9 year old Coton de Tulear, 13.2 lb dog, started Trilostane @ 10 mg in the AM today. She is diagnosed with an adrenal tumor and is recovering from a horrible eye infection. I am conflicted about the Trilostane. Surgery to remove the tumor seems drastic to me. I don't want to cause her unnecessary suffering. I keep thinking I should have chosen Mitotane. My research indicates that without surgery, Trilostane which presumably has less serious side effects is as good a choice as Mitotane. It occurs to me that we have just begun palliative treatment for Sadie. Does anyone have experience with Trilostane with adrenal Cushings?

[labblab]

Hello and welcome to you and Sadie! Yes, we have had a number of members who have treated adrenal Cushing's in their dogs with trilostane. From clinical summaries that I have read, there may be a very small number of dogs for whom mitotane actually physically compromises the tissue of the adrenal tumor which would be a plus. However, the more common experience is that the tumor remains unaffected and larger doses of the drug may be needed to control the symptoms. In turn, this can increase the risks of unwanted side effects. For this reason, I believe trilostane has become the treatment of choice for most specialists in terms of adrenal tumors.

Can you tell us more about Sadie's overall health history? Do your vets feel that she would be a good surgical candidate if you should opt to proceed, or have you even gotten that far in your discussions? Adrenal surgery is indeed risky and expensive, but when successful offers a complete cure. We have experienced both successes and losses among our members, so we realize it is a hard choice.

Once again, welcome, and we look forward to learning more about Sadie.

Marianne

[LittleDog]

Thank you so much for responding. My veterinarian does not recommend surgery for Sadie on the basis that the surgery has a high mortality rate and that Trilostane can provide her with a potentially normal life span. Sadie, other than recent bout of frightful eye infection, is by all accounts, healthy (within the context of Cushings). As I type this, I realize that I need to ask the vet for referral for surgical consult. I admit I am fearful of a cancer diagnosis and also of the cost of surgery with poor results. It is my understanding that Sadie needs to be on medication prior to surgery so cortisol levels are normalized? It is unbelievable but Sadie was diagnosed with Cushings on the first week of December. You would not have thought that anything was wrong with her (unless you noticed the distended belly). I just thought she was fat. On 12/31 we left her along with our two other fur children, with my sister while we visited my son in San Antonio (we live in Austin). We returned the next morning and my sister greeted us alarmed with Sadie in her arms. Sadie's eyes were swollen shut and bruised as if she had been punched in the face. My sister said that she had not awoken this way but rather she noticed the change 30 minutes before our arrival. So we took her to ER vet. To make a long story short, Sadie was referred to eye specialist who diagnosed peri orbital myosotis. His educated/expert opinion is that the Cushings accounted for this condition. His recommendation was "treat the Cushings". In any case, in the span of one week, Sadie's face is thin, her eyes somewhat bulged, her facial hair sparse. Yet throughout all this she remained her ravenously hungry/thirsty but happy self. My son and I theorize that Sadie's cortisol levels must have spiked dramatically when we left her with my sister since we never have left her behind, and that this stress response provoked the eye issue. Perhaps foolish speculation. What are any of the members' experience with surgery? What if Sadie has cancer? Is the Trilostane dose reasonable? So far she is tolerating the Trilostane. I added Melatonin 3 mg twice a day. Is this okay?

[LittleDog]

By the way my name is Yolanda. I live in Austin with my husband and son, Max, age 28 along with Sadie, Tubby (9 year old schnoodle) and Kate a 3 year old miniature poodle. I am very happy to have found this forum.

[labblab]

Hello again, Yolanda. We are really glad you've joined us, too. I am not familiar with that eye condition, but how scary for all of you! I'm gonna head off and learn more about it, myself.

Yes, you are exactly correct that even if Sadie were to have surgery, she would be placed on preoperative medication to lower excessively high cortisol. Also, yes, this is a very reasonable starting dose for her.

As far as the melatonin, I personally recommend to folks that they hold off on starting any other new meds, supplements, or foods at the same time that trilostane treatment begins. Melatonin is typically rather benign, but you never know what may trigger a side effect (I'm allergic to aspirin, for instance). I think it is better to introduce new variables one at a time, so that you can accurately evaluate any side effects. Even just from a financial standpoint alone, since monitoring testing for trilostane treatment is pricey, you don't want to trigger the need for extra testing due to a side effect that is actually caused by something else instead. :o

As far as the surgical consult, you know yourself best, and I think you should take your own mindset into account. Some folks prefer to have all the info out on the table so that they know exactly what they are dealing with (likelihood that the tumor is cancerous or will grow to encroach on nearby vessels or organs, etc). For other folks, that kind of info leads them to worry excessively and is not helpful, especially if surgery is not an option for them, anyway. Since the trilostane treatment would be recommended either way, I think you are on the right track no matter what you decide about the tumor.

Do keep us updated, though!
Marianne

[LittleDog]

Sadie pictures:

http://www.themaxdose.com/sadie/Sadie_Happy.jpg <12 hours before
http://www.themaxdose.com/sadie/Sadie_12hours_after.jpg

http://www.themaxdose.com/sadie/Sadie_Today.jpg


Hi Marianne,

Thank you for your quick response and recommendations. I will stop the Melatonin. Sadie has been on Clavamox 62.5 mg twice/day along with antibiotic ointment and two kinds of eye drops (one with steroid) since the 31st. I was instructed to start Doxycycline 50 mg at night once the Clavamox was done (today) along with Pepcid 5 mg one hour before the Doxycycline dose in order to prevent stomach upset. Hearing your concerns about introducing too many variables at one time, I'm going to hold off on the Doxycycline. As you can see from the pictures I sent you, her eyes are much improved. I plan to call the vet in the morning and request more Clavamox since I am concerned about recurring eye infection (the vet wants her on an oral antibiotic until the cortisol levels are within normal range). I don't disagree. When I researched the myositis I could not find any specific reference to Cushings. The eye specialist r/o dry eye, glaucoma, abcess, teeth disease. She had no obvious eye pain or jaw pain. He informed us that when he pushed against Sadie's eyes there was no "blanching" which would have suggested neoplasms. But he did feel resistance which suggested to him an inflammation of the eye muscle behind the eyes. He stated that myositis is an immune mediated response and that the treatment is Prednisone but he told us that this treatment was out of the question for Sadie given the Cushings. He elaborated by saying that the immune system in dogs with Cushings is "all messed up." You will note that Sadie has Cherry Eye in left eye. This appeared 11/02. This was reason for the vet appointment which lead to the Cushings testing. Of note is that Sadie has inflamed lymph nodes (detected on 11/02/15). Lymph node aspiration has been done and is negative. Thyroid panel is negative. She did not have elevated glucose. CBC was normal on 11/02/15 and on 01/02/16. The eye specialist suspected that eosinophils would be elevated as this is common with immune mediated conditions. I question that if Prednisone is the treatment for these immune mediated conditions would not her elevated cortisol been protective? So, I guess the eye condition is a mystery but I worry about it. She still has to wear a cone. We bought her a soft cone so she is comfortable. We are trying to focus on the positives...no hypertension, no diabetes, no glaucoma, no systemic infection, tolerating the Trilostane, happy disposition, no urinating in the bed, no pain, no overt muscle weakness. But now we know how quickly things change. We are discussing the surgery option but deferring the decision until cortisol levels are normalized. I will forward Sadie's labwork and ultrasound results.

I appreciate the support and grateful for generously sharing your expertise,

Yolanda

[labblab]

Wow, that is a lot of new information to sort through, and I'll try to do so tomorrow. However, most importantly, if you have been told to start the doxycycline tonight, please don't withhold it on the basis of what I wrote earlier!! For that matter, don't withhold any Rx medications. My assumption was that you had decided to introduce the melatonin on your own. We often have new members who want to switch to different diets or introduce over-the-counter supplements at the same time they are beginning the Cushing's meds. That was the issue to which I was responding -- to hold off on voluntary changes until the trilostane regimen is stabilized. But if your vets have prescribed meds for Sadie, by all means, proceed with giving them as you have been instructed. You most certainly don't want to compromise her vision by not following through with the recommended treatment, OK?

Marianne

[LittleDog]

As you can see though I'm trying to remain calm, I am fretting about about everything. I want certainty when there is no such thing. Thank you for the redirection.

[molly muffin]

There never seem to be any easy answers and usually it feels like a balancing act on a high wire. At least it does to me. :)

It does look like she is better today from the pictures. I agree, getting that eye sorted out is top priority right now.

[LittleDog]

Nice to hear from you Sharlene,
This forum has helped significantly with easing worry and fears. This is day # 4 of Trilostane 10 mg a day. We've noticed decreased urination and less frequent trips to water bowl. She has not asked to go outside for three hous now. Typical for Sadie was asking to go out every 30 minutes. She ate all of her 1/2 cup of her prescription ID GI canned food plus 1/2 of Tubby's dinner but she has NOT asked for treats. I feel that it is too early to revel in these signs. Max, my son, worries that Sadie is not as active. My take is that we are not used to "subdued" Sadie but rather the Sadie that was constantly at the back door and asking for treats to the point of barking at us! Her eyes are better. I'm praying for patience and acceptance. I thank God for guiding me to this site. My prayers for all of the members and their beloved pets.

[spdd]

I just want to assure you that the people on this forum are just excellent in their knowledge of cushings. I came on here in a panic about "mah boy" and they guided me completely. I am not an expert on cushings as my story is completely different then most, but just want to welcome you to the forum and let you know that you will absolutely get the best advice possible, over and above veterinarian's care and in some cases better advice.

[Renee]

A word of caution - it may be that you are just lucky in seeing a decrease in symptoms so quickly, and I surely do not want to scare you unduly ... but, if she's responding so quickly in just 4 days, please watch very closely for signs that her cortisol is dipping too low.

Welcome to our family!

[LittleDog]

Hi Renee and Judi,
I appreciate the encouragement. I worry about cortisol dropping too low. But I am worrying about all sorts of scenarios. Right now Sadie finished her dinner and managed to grab some pizza crusts from coffee table.

We are discussing adrenal surgery. I'm having a hard time envisioning Sadie in post-operative pain. I dread the possibility of malignancy. You both have experienced these mixed bag of emotions and overcome them to share your expertise with others not to mention empathize.

Thank you so much!

Yolanda

[molly muffin]

If you are discussing adrenal surgery, we have a guide that can help you have that discussion with the surgeon.


Part I - Questions to ask when considering if surgery is an option for your dog’s adrenal tumour:
1. What type of tumour do you suspect, ?functional, ?non-functional, pheochromocytoma, benign, metastatic
2. Expected life span for my dog in a normal situation. If your dog is close to, at or past his expected lifespan for his breed is surgery going to be of any benefit?
3. Prognosis for my dog if we treated medically i.e. with Cushings medications. AND if we do not proceed with surgery how long do you think it would be before the tumour started adversely affecting his quality of life?
4. If he is miserable now, does the benefit of potentially risky surgery outweigh his current quality of life?
5. Are there any other health problems that could impact on a positive surgical outcome, for example: if your dog is overweight or has heart, BP, liver, kidney or lung conditions
6. Is there any sign of tumour spread – imaging should be done, including ultrasound and on advice of specialists either CT or MRI to check whether there is local invasion around the tumour, into blood vessels including vena cava or spread further away in the body to lungs etc
7. Surgeon recommendations – would he/she do it for their own dog?
8. Psychological impact for the owner: It is important to understand this is risky surgery, sadly current guidelines indicate 1:5 dogs do not make it, and some recommendations are not even that high. Can you accept it if your dogs dies during or in the postoperative recovery period surgery? This is where it is important to weigh up whether the benefit of your dog being fully cured is worth the risk of possibly losing him.
9. Financially – can you afford it? Find out estimate of costs.
10. Hopefully this will not happen, but if your dog collapses, e.g his heart stops either during his surgery or afterwards what emergency measures should be undertaken, do you want your dog to have CPR, how far are you (the owner) willing to go for your dog to be saved in such circumstances

Part II - Surgery has been recommended as treatment for your dogs adrenal tumour, here are a few suggestions on what questions you should ask your surgeon:
1. Are you board certified? How many operations of this type have you done? What complications have you experienced? What were the outcomes?
2. Please explain to me how you will do the surgery, which part would likely give you the most trouble? Will you be doing the actual surgery or a resident in a teaching situation? If so, is their close supervision?
3. Will there be a specialist anaesthetist available for the surgery?
4. If it hasn’t been done, do we need a CT/MRI scan to look at the tumour more closely to check for vena cava involvement or any other tumour spread?
5. What are the risks associated with this surgery, including
• Bleeding (including trauma to blood vessels or other organs during surgery)
• clots
• Blood pressure or heart problems such as arrhythmias
• pancreatitis
• pneumonia
• kidney failure
• infection
• wound problems
• bowel problems
• anaesthetic risks
• adrenal insufficiency or electrolyte abnormalities
• death (sorry but you have to ask that risk too)
6. If we proceed with surgery does my dog need preoperative treatment with Cushing’s meds, antihypertensive if high blood pressure is a problem – phenoxybenzamine recommended preoperatively for dogs with pheochromocytoma, anticoagulants or anything else?
7. How will you treat to prevent clots postoperatively?
8. What would you do if you found anything else during the surgery i.e. nodules in other organs e.g. spleen, opposite adrenal, liver, kidney. Would you remove them and what are the risks associated when doing additional abdominal surgery together with adrenalectomy
9. How long will it take and when will you contact me so I know all is OK, when can I visit after surgery?
10. How will the postoperative period go, how long would you anticipate he would need to stay in hospital? How will we manage pain?
11. What monitoring would be needed, e.g. heart monitoring, oxygen levels in the postoperative period
12. If your dog has an adrenocortical tumour affecting cortisol production will he need to be on steroids following surgery and for how long?
13. If there are problems when I take him home, who do I contact? Hopefully the surgical team until all is stable.

I'm super glad to hear that Sadie is doing so well.

[LittleDog]

Thank you for sharing these very important surgical issues with us. I most definitely will take this list with me to the surgical consult. Dr. Dunn is dissuading us from surgery but says that once her cortisol levels are normalized, and we still interested, she will refer us to a reputable surgeon. By coincidence I ran into an old acquaintance of mine who informed me that her dog died from complications of presumed Cushings (sepsis). She said that vet strongly suspected Cushings but she chose not to spend the money to make a definitive diagnosis. She explained that she simply could not afford the testing and treatment. She was very sad about the loss of her dog. I did not share Sadie's story fearing I would cause her to feel guilty for not treating her pet. I hate giving Sadie the Trilostane because I know it is a dangerous medicine, so I think surgery is a potential cure. Another voice tells me that surgery would be very expensive and that I should be "down on my knees" grateful that Trilostane exists and that we thus far can afford the treatment and all of the testing. I am grateful but struggling with not feeling foolish and impractical for wanting the best care for Sadie. What a dreadful disease and what a sorry state of affairs that many pet owners cannot afford care for their pets. I'm definitely going to get involved in raising awareness for pet insurance and raising money for dog/cat related charities.

[Trish]

Hi, just wanted to chime in that my dog had an adrenalectomy over 3 years a go now, he did not have the usual cushings type tumour but a different one, he was 11 at the time. I don't regret it for a second. I am always a little wary of GP vets putting people off surgery. My own vet told me that he has only seen a couple in his career so readily admitted we needed to see the specialists to get the best advice as he just plain did not have the experience. That being said current research shows a 20% mortality rate . I had lengthy discussions with both the IMS and surgeon before making my decision and proceeding.

[LittleDog]

Thank you!!!

[molly muffin]

Checking in to see how you and Sadie are doing :)

You're right it is awful that the treatments are so expensive that Many owners can't afford it. :( I wish there are more alternatives.

[Sadie1606]

Hi,
Our 15 year old Coton also has adrenal cushings. Our wonderful vet
Left the surgery decision completely up to us. It was a difficult one as we adore her but... The surgery is so rough we just didn't want to subject her to it. For the last year we have had the best results with trilostane. She almost immediately returned back to her old self.
We were at our wits end prior to diagnosis. We recently moved and I think the stress has aggravated something within her. She is having terrible bouts of itching. I do believe that stress can aggravate secondary symptoms in Cushing dogs.
Hope your Sadie does well on the Trilostane.