Washington newly diagnosed

[kristenv]

Hi all,

Am hoping to get some advice on managing my guy who was recently (2wks ago) diagnosed w/Cushings.
A brief history:
Washington had been at the shelter where I volunteer for months. He is a rat terrier and came in as a chunky arthritic guy (maybe 10-12 years) who could not see well. Over the months he started losing weight and developing elevated liver enzymes/enlarged liver. There was some thought that he had cancer but he was definitely failing. We decided to bring him home and within the 1st 24hrs I noticed his voracious drinking/urinating. Long and short I spoke with my vet and we tested him for Cushings (ACTH baseline draw 17 normal 1-6, 1hr draw >50). She believes this is the underlying issue with his liver as well.
We started him on Trilostane 10mg QD (he is 12.5lbs) but he had some tough reactions initially so we switched to a compounded liquid and currently he is at 4 mg BID. Big improvement in his thirst/urinating, and he will be having labs done again next week to see what his levels are.

Questions I have:
Food: I am feeding a white fish/pea based food (Blue Buffalo longevity mature) along w/ a little oatmeal or rice 4x a day. He desperately needs to gain weight but I also don't want to overtax his liver. I don't care much for the quality of the ingredients in some of the hepatic diets (corn "egg product" etc) but wonder what some of you may be using for your dogs, and what has worked well, and what are the caloric needs of a dog his size to slowly gain weight?

Medication:
While he has shown improvement thus far, I find that he gets restless at night. Sometimes he needs to potty other times he is just awake. Since he gets his last dose of Trilostane around 4:30pm I wonder if that might be a factor, or is this just part of adjusting to less Cortisol in his system?

Cognitive issues:
He had a bit of hepatic encephalopathy (pacing/staring) which has started to improve..any experience in decreasing this (aside from low ammonia diet).


Arthritis:
His little joints are painful and he struggles a bit in walking. He is on Tramadol 15mg BID, and I was considering augmenting this with Duralactin (safer for liver) but again wondered if amyone has any recomendations.

Sorry I know I have alot of questions but this has been a crash course in learning for me. He is in such a fragile state and I feel like getting this diagnosis (rather than cancer) has given us the opportunity to extend his life and get him feeling better and I want to do it all right for him.

Thanks in advance for any suggestions that you may have.

Kristen
Jenner, Alex, Samy, Dottie, BB, and Washington

[jmac]

Hi Kristen, and welcome to you and Washington!

Washington sure is lucky you took him home and were able to discover some of his issues in order to get him more help! I'm sorry Washington is having such a tough time, but you have definitely come to the right place! There are many knowledgeable people here who will be along to give you advice. We are a very caring and supportive group and we will be here to help you out however we can. I don't have much advice to offer you myself, but I was wondering if a joint supplement like Cosequin or Dasequin might help Washington along with the Tramadol. I know my vet recommends the joint supplement for older dogs in general. As I said, there will be others coming along to offer their input soon. In the meantime, there are many wonderful resources on the site you can read through to get as much information as you can.

I'm so glad you found us!

Julie & Hannah

[lulusmom]

Hi Kristen and welcome to the forum.

Wow, Washington is a lucky little guy to have you in his corner. It is apparent that you have done a great deal of research and are a great advocate for Washington. Good job, Kristen!

Part of the initiation around here is to get grilled with 20+ questions and request this and request that so let's get you started. :D It would help us a great deal if you could please post the results of the screening blood chemistry the vet did to diagnose liver problems. You need only post the abnormal values, including the normal reference ranges. Most cushdogs have very high alkaline phosphatase (ALKP) with mild to no elevation in ALT. I'm curious to know if this is the pattern with Washington. If primary liver disease was diagnosed, I would suspect that the ALT is moderately to severely elevated.

Was a bile acid test done and if so, can you please post the results? This is pretty standard for dogs suspected with primary liver disease. Dogs with cushing's usually have a slight to moderate increase but less than 50 umol/l. A minority can be a bit higher. Primary liver disease should be suspected if greater than 50 umol and most certainly higher than 75 umol/l.

Did Washington have any other symptoms besides excessive drinking and peeing? Knowing that liver disease is involved and could impact the acth stimulation test, did your vet do any other testing to validate the acth stim test? i.e. abdominal ultrasound and/or differentiation testing such as the high dose dex test or endogenous acth test to determine the type of cushing's involved? Granted 50 ug/dl is off the charts but when it comes to diagnosing cushing's, you can't be too sure about any test results so it's very important that overt clinical symptoms and validating tests are taken into consideration.

When did you start treatment? Were any acth stimulation tests done since then and if so, can you please post the results?

I'm sure sorry for the reasons that brought you here but I'm glad you found us. We're here to help you and Washington in any way we can and the best for us to do that is for you to inundate with as much information as possible.

Glynda

[marie adams]

Welcome Kristen to you and Washington!!:) You are a special person for taking in Washington and he is so lucky for you!!

I see Glynda has asked you for test results. It is a good way to help to determine if there is something else going on too.

Everyone here is so caring and helpful so you are not alone in this adventure.

Take care!!:)

[kristenv]

Hi all and thank you so much for the kind welcome!

I will try to answer the questions the best I can, I have actually not seen any of the blood work (aside from the ACTH test) as it was all done at the shelter.
From what I was told his ALT was 611 (15-110) and GGT was 177 (0-11). No one mentioned the ALKP.
I also recall that his BUN was elevated at 50 (yet his urine was clear and colorless) but his creatinine was normal. No one felt there was any kidney issues at this point.

Wash has been in treatment about 14 days and we are set for more labs (including a liver panel) on Friday. From that point on I will have more accurate numbers for him. I will also ask about the bile acid test as well.

as far as symptoms Wash really deteriorated since he first came to the shelter a combination of the stress and this disorder I am sure. He initially had a voracious appetite (although at the end of his stay he did not want to eat) and he has lost so much muscle mass and weight. Of course this made his arthritis worse, and walking difficult. When he first arrived he could walk an easy half mile..not so now. He could not see well from the start, and still doesn't but he does see movement, especially when it might be a treat..or a finger :). He is like a little crocodile.

Cognitively he became less responsive to his name and surroundings..he would do alot of staring/zoning out and paced a bit. He also would pant.
The sad thing is in the shelter setting no on really had enough consistent time with him to put it all together...and from what they saw it seemed like "old age" changes.

Also for a time in the shelter he was on Rimadyl, and I fear that may be a contributing factor in his liver issues, but that is just speculation at this point.

The ACTH test was the only one we ran, my vet did not feel the additional Cushings testing would provide any more clarity, and I think she really wanted to get him started on treatment asap. The day I drove him home I was so scared that he would make it more than a few days...and that was 17 days ago :). I wonder though would the results of additional tests alter the course of treatment?

I have found reading through the links and posts here to be so helpful, and it means so much to know other people have dealt with this problem and managed it successfully.

Thanks so much!

Kristen
Jenner, Alex, Samy, Dottie, BB, and Washington

[lulusmom]

Hi Kristen.

Based on the abnormalities you listed, I see none consistent with cushing's. Dogs with cushing's have high ALKP and mild to no elevation in ALT. It appears to me that something other than cushing's is at play. Yes, dogs with cushing's have dilute urine (clear and colorless) but so do dogs with primary liver disease. Dogs with cushing's usually don't lose their appetite unless there is another underlying condition causing the problem. Loss of appetite is very common with liver disease though. Dogs with cushing's do experience muscle wasting but it is also a symptom of liver disease. You can expect a dog with liver disease or any other nonadrenal illness that places great stress on the body to cause an increase in cortisol. It would be a surprise if a dog with severe liver disease didn't yield a false positive result on an LDDS or acth stimulation test. In my opinion, no vet experienced with primary liver disease and cushing's would pursue a cushing's diagnosis based on what you have presented here.

Additionally, no one diagnostic test for cushing's is 100% accurate so it is imperative that validating and/or differentiating tests be done before confirming a diagnosis. The shelter vet's comment about additional testing not providing any further clarity is glaring evidence that she has little experience with diagnosing or treating cushing's. If Washington's liver is so compromised as for him to suffer hepatic encephalopathy, he should not be given Vetoryl. If the vet had read up on the drug she prescribed, she would have seen this. I am a rescuer so I understand that as a shelter dog, unless you are willing to spend your own money, taking him to a specialist is out of the question. :( I deal with shelter vets a lot and every one I've dealt with would be ill equipped to treat a dog with Washington's problems and based on the information so far, I'd have to say that Washington's vet is no exception. I am not a vet but I've got two dogs with cushing's, past experience with liver disease and am a obsessive compulsive researcher. For what it's worth, if Washington were my rescue or foster, I would stop the Vetoryl immediately and focus on his liver problems.

Glynda

P.S. You mentioned Washington has serious arthritis issues. Dogs with cushing's have high circulating levels of cortisol in their blood. Cortisol is the body's natural anti-inflammatory so arthritis aches and pains are masked by the disease as an uncontrolled cushdog is self medicating. It is not until treatment has reduced cortisol levels to a therapeutic level that the arthritis becomes painful for them. What you are seeing may be weakness from the muscle wasting.

[kristenv]

Hi Glynda,

Please let me clarify..now that he is home Wash has a voracious appetite, and did as well in the shelter setting except at the end of his stay. I am actually now working with my own vet, on my own dime for his care for the very reasons you mentioned...I did not feel tht the shelter vet was well equipped to manage him, and also because I feel he is my repsonsibility now. My vet felt that his Cushings likley went untreated for a long period of time and impacted his other organs and liver..and felt that getting that under control was the first step in treating him.

Having the little information on his labs I tend to think you are correct..that something else is at play here whether the liver issue is asssociated or not is hard to say, but I am not adverse to seeking a specialist to help manage his care. I have dealt with other illnesses before in my dogs but this is a new one for me so I appreciate your perspective and will investigate asap..

Kristen
Jenner, Alex, Samy, Dottie, BB, and Washington

Thanks so much!