Atypical or Typical Cushings - Trilostane // Testing

[puuunk]

Hi Everyone!

I am so happy to have found this site and forum! I have a 14yo Jack Russell Terrier Male named Punk!

A bit of history, Punk has been on Metacam for several years for arthritis. Regularly, his liver enzyme levels would be elevated which was attributed to medication. Cushings was not discussed, they had thought he was exposed to Rocky Mountain fever a few years ago and treated with antibiotics.

2014
ALT 159 18-121
ALKP 322 5-160

2015
ALT 188 18-121
ALKP 659 5-160

In August 2015, I took him to a new vet, blood work indicated high liver enzymes, again Cushings not discussed. Treated for bladder infection for which he was given antibiotics. At the time, I did not request tests and when requested this week, realized his markers had been alarmingly high.

ALT 275
ALKP 1098
Cholesterol 371
Platelet 631
WBC 4-10

He had just started having accidents and I thought it may be due to bladder infection, behavioral, or age. In addition to pot belly, has developed skin tags, rolls around his neck but no hair loss. In the last 2 months, started drinking excessive amounts of water and having more frequent accidents. He is starving all the time, barking and begging for food and has a lot of anxiety.

January 21, 2016 went back to his regular vet for annual and several very high markers all and all symptoms pointing towards Cushings. Tests also indicated he has Lipemia.

ALT 204 18-121
ALKP 1310 5-160
Cholesterol 401 131-335
Platelet 662 143-448
WBC 9.9 4.9-17.6

Are there any other test levels I should be looking at on his blood work? Glucose is high end of range 114, also TP 7.2 and ALB 3.9

January 25, 2016 ALTC Stim done and vet said it did not indicate Cushing’s. I do not understand the very high pre-cortisol number and the Vet did not explain.
Pre 16 2-6
Post 15.4 6-18

January 29, 2016 – Ultrasound
Liver is enlarged with rounded margins and is hyperechoic
Gallbladder normal with hyperechoic sludge
Left Adrenal – enlarged with caudal pole measure 9.4mm
Right Adrenal – enlarged with caudal pole measure 7.2mm
Kidneys – normal with irregular contour and decreased cortico medullary junction
Spleen, Pancreas, Gall Bladder and Urinary Bladder Normal

When my Vet called yesterday with results, she said that it looked like he has Atypical Cushings and diagnosed 10mg Trilostane 1/day – he weighs 20 lbs. I checked the forum and saw the potential issues with Trilostane treatment for Atypical Cushings. I then called my Vet back to ask about the Trilostane and I mentioned reading about UTK Adrenal Panel. She went back on her diagnosis and said that she believed he was Pre-Cushingoid due to ACTH and results from Ultrasound, still thinks that Trilostane is the best method of treatment. She reiterated it is a low dose and requested he come back for ACTH Stim in 10 days. Insisted she would not be suggesting anything that would harm him.

Bottom Line…my Vet is wavering on diagnosis and I am nervous to start medication before additional tests are performed to indicate baseline.

Trying to figure out how to proceed in getting a second opinion or additional tests. Full disclosure, I have not been working for 7 month and have spent $1100 on testing so far and am looking at another $1000 for ACTH, LDDS, and UTK Adrenal Panel. I definitely do not want to risk my dog’s health and treatment due to finances, however I would like to have the correct testing done rather than performing multiple unnecessary tests and still not having an exact diagnosis. My instinct says not to start on Trilostane and get the Adrenal Panel done. I already ordered and started Lignans, Melatonin, Milk Thistle, Dandelion and Burdock

I am very concerned about him being misdiagnosed now and his not having been tested for Cushings the past several years, even though his liver enzymes were elevated. Has he been suffering and getting worse without treatment? He should be living out his golden years happy and healthy!

I would really appreciate any feedback or shared history in your experiences!

Licks and barks xx
Punk and Jen

[lulusmom]

Hi Jen and welcome to you and Punk.

I think the labs you posted, the symptoms you mentioned and the results of the abdominal ultrasound are all very much suggestive of cushing's and the negative acth stimulation test doesn't change my mind. None of the diagnostic tests can be trusted but the low dose dexamethasone suppression test is superior to the acth stimulation test in diagnosing a higher percentage of dogs that actually have cushing's. For instance, the acth stimulation test is more likely to yield a false negative result in dogs with adrenal tumors. If your dog has an adrenal tumor which I don't believe can be ruled out, your vet may want to consider a low dose dexemethasone suppression test (LDDS) prior to prescribing treatment. If your dog's cortisol level is normal, in my opinion, prescribing Vetoryl (Trilostane) would not be an appropriate treatment. If you have a copy of the abdominal ultrasound results, can you share the radiologist's interpretation of the adrenal abnormalities?

Glynda

[puuunk]

Hi Glynda!

Thank you so much for your quick reply! The vet said no evidence of adrenal tumor, both Adrenals are enlarged. Below is the report from Ultrasound. Is the Cortisol only tested in LDDS? I thought that is tested in ACTH which was elevated pre and slightly lower post.

History/PE findings: PU/PD, elevated ALKP, clinical suspicion for hyperadrenocorticism. Previous ACTH stim was normal
Findings:
*Liver: liver is enlarged with rounded margins and is hyperechoic. Hypoechoic nodules observed within the parenchyma
*Gallbladder: normal in size with hyperechoic sludge
*Left kidney: normal with irregular contour and decreased cortico-medullary junction
*Right kidney: similar to left
*Spleen: normal echogenicity and size
*Left adrenal gland: enlarged with caudal pole measuring 9.4mm
*Right adrenal gland: enlarged with caudal pole measuring 7.2mm
*Pancreas: normal
*GI tract: no abnormalities observed
*Urinary bladder: normal
*Abdominal lymph nodes: normal
Summary:
*Hyperechoic hepatomegaly *Bilateral adrenomegaly *Age-related renal changes
COMMENT
Based on clinical signs, laboratory findings and ultrasound findings, pituitary dependent hyperadrenocorticism is strongly suspected. Further diagnostic test such as Low-dose- dexamethasone suppression test is recommended. Although this test is an extremely helpful screening test, false negative tests are commonly seen.

Thanks so much again!
xx

[Harley PoMMom]

Hi Jen and welcome to you and Punk!

The ACTH stimulation test measures cortisol, the agent injected (usually Cortrosyn) stimulates the adrenal glands to dump cortisol in the dog's system and then it is measured. In dogs with Cushing's there is an exaggerated response.

The LDDS test uses dexamethasone to suppress the output of ACTH from the pituitary gland and therefore this decreases cortisol secretion from the adrenal glands. Cortisol levels in dogs with a normal response to the dexamethasone will decrease for a period of time (blood samples are taken at the 4 hour and 8 hour mark), cush dogs cortisol levels escape at the 4 and 8 hour mark.

The LDDS is considered the "gold standard" test for Cushing's, the one draw back is if the dog has any underlying illness the LDDS test can yield a false positive result. If Punk (love that name) doesn't have a non-adrenal illness than, as Glynda stated, I would opt to have the LDDS test performed.

Hugs, Lori

[puuunk]

Hi Lori,

Thank you for the explanation, I should probably go forward with LDDS. However, if Vet originally said that it may be Atypical Cushings, will LDDS indicate, or is that only proven by Adrenal panel? Again, concerned she prescribed Trilostane as, from what I read, this is the wrong treatment for Atypical.

I really appreciate you taking the time to reply, this is a great forum and source of information and support!

Licks and Barks xo,
Jen and Punk

[puuunk]

I am also curious any results indicate need for Pancreatic cPl test which a friend suggested.

What are improvement rates with natural remedies for Typical and Atypical? I have started him on Lignans, Melatonin, Milk Thistle, Dandelion, and Burdock. I also would like to ween him off NSAIDs as not to further stress his liver and am switching to a natural supplement to see how he does.

He has a lot of leg shaking on back legs and has long given up jumping on furniture or wanting to go on walks.

[Harley PoMMom]

The LDDS test can not diagnose Atypical Cushing's, the only test that I am aware of that is used for identifying Atypical is with the UTK adrenal panel. I am including a link from our Resource Forum that has information regarding Atypical: http://www.k9cushings.com/forum/showthread.php?t=198

My Harley's first ultrasound showed that he had prior bouts of pancreatitis, I was really shocked because he never showed any signs of pancreatitis. I don't see anything in Punk's blood work that points to him having pancreatitis, I also believe that the ultrasound would of shown an anomaly if something was wonky with his pancreas.

Has the leg shaking and hesitance to jump up just occur recently or has this been something that seems to have been going on for a while? If you think that it is arthritis some members use/have used Adequan: http://www.drugs.com/vet/adequan-canine.html

Hugs, Lori

[molly muffin]

Hello and welcome. With atypical cushings, the cortisol levels are normal and 2 or more sex hormones are elevated usually.
Melatonine and lignans are the recommended starter meds for atypical. Be aware that they can take months to actually start to work if they are going to.

NSAIDs are definitely hard on the liver. If you need a pain killer, many opt for tramadol, but that can make some dogs loopy and lethargic. You just have to adjust doses downwards if either of those show up.

[puuunk]

Thank you all!

I have scheduled the LDDS as the next step and did not put him on Trilostane. The Vet now seems to think he has more indications of typical Cushings based on blood work, ultrasound, and symptoms and was not clear as to why the ACTH came back negative.

Weaning him off the NSAIDS, he does not react well to tramadol. I am going to try daily supplements from VetriScience and give him the Metacam only as needed.

Licks and Barks xo
Jen and Punk

[puuunk]

Hi Glynda,
Did you get a chance to look at the Radiologists report I posted? Do you see anything indicated that is cause for alarm different from
the Vet or Radiologist?
Thanks,
Jen

[lulusmom]

Hi Jen. Sorry for not checking in until now. The ultrasound interpretation is what we're accustomed to seeing in a dog with "pituitary" dependent cushing's. The good news is that with the exception of the enlarged liver and bilateral enlargement of the adrenal glands, all the other organs look okay. Because Punk could be in the small minority of dogs with PDH that an acth stimulation fails to reliably diagnose the disease, I do think that the LDDS test should be the next step in confirming the diagnosis as recommended by the radiologist.

You mentioned that Punk is having accidents. Did your vet do a standard urinalysis and a culture to 1) confirm polyuria/polydipsia (PU/PD) which is the excessive drinking and peeing that is associated with cushings and 2) rule out a possible urinary tract infections? If so, can you share the results? Does punk have any loss or thinning of coat or change in skin pigmentation?

[puuunk]

Hi Glynda,

Thank you again for your reply, glad I scheduled LDDS for Feb 8th. Strange, my vet said she had not performed one for 5 years, made it seem like an out of date method for diagnosis.

He does not have apparent hair loss or thinning. His tail has had a little bald spot at the end for a while. Also, he has a small patch on his right hind leg, smaller than a dime. Again, it has been there for a few years and gotten only slightly bigger. The biggest thing I notice in his skin is several skin tags that have come up recently and they seem to grow very fast. As for skin color, his belly is dark now, almost like one big freckle, whereas previously it was pink. I guess it seems a little bit of a dark brown/gray color with pink.

Other symptoms, some of which I had mentioned. He has not had any weight loss or gain, weighs 20 lbs. His activity level is much less than before, does not jump on furniture or want to walk. His hind legs shake in resting position. He has pot belly and fat rolls on his neck. Increased water intake and pee accidents during the day. No accidents at night like I had read some dog's experience and generally he does not have to go when we are not home (guess he is just sleeping). If we are home, he has the to go every 2 hours, whereas before he went 4x/day. He has quit marking territory when outside. Halitosis has become more noticeable. Hungry all the time.

They did do Urinalysis on 1/21, results below;

Test
GLUCOSE NEGATIVE
BILIRUBIN NEGATIVE
KETONES NEGATIVE
BLOOD 1+
PH 6.0
SP GRAVITY 1.020
PROTEIN SEE NOTES
UROB NORMAL
WBC 0-2HPF Reference Range 0-5
RBC 6-10 HPF
EPI CELL 2+ (3-5) HPF
BACTERIA NONE SEEN HPF
CRYSTALS NONE SEEN HPF
CASTS NONE SEEN HPF
COLOR STRAW
CLARITY CLEAR
MUCUS NONE SEEN

RE: 900 COLLECTION METHOD FREE-CATCH
1+ (100-200 mg/dL)
Protein test is performed and confirmed by the
sulfosalicylic acid
test.

[lulusmom]

Thank you for posting the results of the urinalysis. The USG is right there at the lower end of normal so with straw colored urine and no accidents in the house, I'd have to say it's more normal than not. My two cushdogs had very low USG and were unable to hold their urine. Accidents were the norm. Their pee was diluted, clear and odorless which is normal for uncontrolled cushingoid dogs. Not all dogs have the most common symptoms associated with cushing's which can make it difficult to confirm a diagnosis if too many pieces of the puzzle are missing. I think your vet has a lot of the pieces and hopefully the LDDS will complete the puzzle.

Glynda

[puuunk]

Hi Glynda,

Thank you so much! I am so appreciative of your feedback and the information on this site! It is a frustrating not to have a definitive diagnosis. I am hopeful we will get some answers soon and get him treatment.

Licks and barks xo
Jen and Punk

[puuunk]

Hi Glynda and Lulusmom,

I received results from LDDS test and they indicate Pituitary dependent Cushing's.

Test Results
PRE-DEX 14.9 ug/dL REFERENCE RANGE 1.0 - 6.0 HIGH
4 POST-DEX 1.3 ug/dL
8 POST-DEX 2.1 ug/dL

I have not yet discussed the results or treatment options with her as she is out of the office until Thursday. However, previously she suggested Trilostane. Do you agree and think it is necessary for him to go on medication or can it be treated homeopathically with Lignans, Melatonin, and Hepati Support?

Best,

Jennifer

[lulusmom]

Thank you for posting the results of the LDDS test and yes, those results are consistent with pituitary dependent cushing's. Unfortunately, there really is no homeopathic or natural treatment that will effectively reduce cortisol so if you are at a point where Puunk's symptoms are so problematic that you need to make the decision to treat, then in my opinion, trilostane would be my first choice. However, if I had a 14 year old dog who was at or near his life expectancy and symptoms were not problematic and quality of life was still good, I'm not sure I would choose to treat at all. Melatonin and Lignans are an iffy proposition even for atypical cushing's but if I chose not to treat with trilostane, I may just give them a try. With the elevated ALKP, I would definitely keep him on liver support, which I assume is the Hepato Support you mentioned.

Up until a few years ago, the goal of treatment was to remedy problematic symptoms which are usually more problematic for the owner than the dog. However, some expert endocrinologists have come out in support of treating dogs, even in the absence of symptoms if the dog has concerning proteinuria (protein in urine) and/or hypertension.

I hope others will chime in and share their own experience and opinions.

Glynda

[molly muffin]

We started treatment with trilostane/vetroyl not because my dog had many symptoms of cushing but because she developed proteinuria (protein in urine) and hypertension (high BP) that caused retinal bleeds. This I was told can be due to uncontrolled high cortisol levels, and so we started treatment.

It is always going to be your call and when and if to start any treatment and age and quality of life is a factor. So are things like if they have arthritis or other problems that having a higher cortisol level might help with comfort.

I can say that if the quality is good now, there is nothing that says that treating high cortisol will change that and in some when the quality isn't good, it helps to improve it.

[puuunk]

Hi Glynda, Charlene and Molly Muffin,

I just spoke with my Vet and we are going to start a low dose, 10mg Trilostane to see how he does and if symptoms improve. He has been exhibiting symptoms, but not extreme. She said often times, until you start medicine, you notice an improvement in things you had just attributed to older age.

Thank you so much for your advice and support! This site has saved me!

I'll update with results.

Licks and barks,

Jen and Punk

[molly muffin]

Let us know how he does! What dose are you starting him on? No more than 1mg/1lb

[puuunk]

We are starting low on Trilostane, he weighs 20lbs and starting on 10mg/day.

xx
Jen

[lulusmom]

Hi Jen. Did your vet instruct you to give the Vetoryl with a meal and that you will need to schedule an acth stimulation test no later than 14 days after starting treatment? FYI, the morning of the stim test, you will need to make sure you get Punk to the vet's office within 3 or 4 hours after dosing. Please keep us posted. We're here to help in any way we can.

Glynda

[puuunk]

Hi Glynda,

Yes, she did advise to give the pill with his breakfast at the same time everyday and instructions for ACTH in 7-10 days. I will be sure to follow with updates and results.

Thanks again!

xx
Jen and Punk

[puuunk]

A quick update....

Sunday was day 4 of Trilostane treatment, he was not really interested in his food yesterday morning, but ate it after a few hours. He did not eat last night or this morning. He also vomited and had diarrhea this morning. I have read these are both adverse reactions to Trilostane.

I did not give him his dose this morning, he is supposed to have with food and is not eating. Can I cause further adverse reactions by stopping medication? I do not want to upset his stomach further.

I will try to speak to the vet this morning.

xx
Jen and Punk

[labblab]

Hi Jen, you are doing the right thing by not giving him the trilostane. No harm will come from missing a dose. The bigger risk with trilostane is always the risk of overdosing. So whenever a dog is unwell, it is best to stop the medication and consult with the vet, as you are doing. Even though this was a small dose given his weight, it may still be more than he can handle. Every dog metabolizes the drug differently. Please keep us updated throughout the day.

Marianne

[puuunk]

Writing to follow up on Punk's progress. He went on 10mg of Trilostane about a month ago. After 4 days, he was throwing up and had diarrhea with loss of appetite. The Vet took him off he medicine for about 5 days and he went back on a 5mg 10 day course. Did not have any adverse reaction, but have not seen any improvement in his condition. He actually had his first accident in bed this morning.

Yesterday, he went in for follow up ACTH and Blood Chemistry.
􏰤􏰫􏰣􏰶􏰞􏰕􏰢􏱎􏰜􏰕􏰡􏰫􏰢􏰠􏰼􏰡􏰟
􏰳􏰴􏱋􏰳Pre ACTH Cortisol 12.1 ug/dL (16 ug/dL on 1/25/16)
Post ACTH Cortisol 19.4 ug/dL (15.4ug/dL on 1/25/16)
Range 18-22 ug/dL 􏰣􏱇􏱈􏰗􏱗􏰰􏰮􏰥􏰖􏰜􏰽􏰰􏰱􏰚􏰶􏰞􏰕􏰢􏱎􏰜􏰮􏰰􏰭􏰚􏰗􏰱􏰰􏰖Equivocal post ACTH Cortisol
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Abnormal Blood Chemistry markers as below

ALP 1045 (1310 on 1/21/16) Range 5-160
ALT 221 (204 on 1/21/16) Range 18-121
BUN 46 (33 on 1/21/16) Range 9-31
CHOLESTEROL 385 (401 on 1/21/16) Range 131-345
NA/K Ratio 27 (27 on 1/21/16) Range 28-37
􏰤􏰫􏰣􏰶􏰞􏰕􏰢􏱎􏰜􏰕􏰡􏰫􏰢􏰠􏰼􏰡􏰟􏰤􏰫􏰣􏰶􏰞􏰕􏰢􏱎􏰜􏰕􏰡􏰫􏰢􏰠􏰼􏰡􏰟􏰤􏰫􏰣􏰶􏰞􏰕􏰢􏱎􏰜􏰕􏰡􏰫􏰢􏰠􏰼􏰡􏰟SDMA 14 (11 on 1/21/16) Range 0-14
􏰳􏰴􏱋􏰳 􏱈􏰲􏱅
The vet is going to increase the medication to 20mg (he is 20lbs) to see how he does.

I would love to hear any feedback on his results.

Best,
Jennifer



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[molly muffin]

Have you tried a bile acid test to see how his liver is doing? I'm just wondering if there is anything else that could be driving the cortisol up rather than cushings, based on his response to the 10mg. If he was that bad at 10mg then it might be like that on 20mg or worse is what I'd worry about.

If cushings is not the reason for the high cortisol and something else is, then a response to cushing meds to bring down the cortisol might be expected such as what he had.

This might be something you could discuss with your vet. Looking for other reasons for the Other values to be increase.

[Harley PoMMom]

I would definitely not raise his Trilostane dose, a dog's cortisol can drift downward during the first 30 days of treatment so the recommendation is to not increase the dosage until after the 30 day mark. And if an increase is needed I would only go up another 5 mg since Punk did have trouble with the initial 10 mg dose.

Hugs, Lori

[puuunk]

Punk was on 15mg on Trilostane for just 2 days and lost appetite again, he was only eating about half. Took him off for 4 days while his appetite slowly came back. The vet suggested we try again along with Pepcid. After his first dose back on today, he threw up and has only eaten half of both his meals.

The vet has not provided any other treatment option, only said that maybe I should consult with an Internal Medicine vet.

I am very concerned, not only the negative side effects, but it must not be good for his system to go on and off the medicine as he has for the past month.

I wanted to try the medicine to give it a chance to work, however at this time, am not planning to continue.

Any suggestions for alternate treatment options?

I am so upset and confused.

[molly muffin]

I think the internal medicine option is a good one. I use an internal medicine specialist for my dog.
I still think that they should look to see if there is an alternate reason for the cortisol to go up, based on his response to the trilostane.

See if you give cushing meds to a dog that doesn't have cushings but has high cortisol for a different reason perhaps, then they will have normally a negative reaction to the medication So that is my worry.

Liver test, ultrasound to check gall bladder, pancrease, spleen, kidneys they all need to be checked.

[puuunk]

Thank you Sharlene! I will definitely talk to his Vet regarding your suggestions and liver bile test. They have already done an ultrasound and did not mention anything abnormal besides swollen liver and adrenals, but I'll double check.

He seems to be doing better, appetite back and no more regurgitating since he is off the trilostane.

I'll keep you posted.

xx
Jen

[puuunk]

Quick Update -

Punk went to Internal Medicine specialist and he suggested giving Trilostane another try by splitting dose to 2-5mg doses morning and evening. He prescribed anti-nausea medicine in order to allow him to acclimate to the medicine. He had his first 2 doses today, so far, so good. He still has not gone back to his normal appetite after 2 weeks off the medicine, but the Vet does not see any other underlying condition.

If he is still unable to tolerate, he suggested that we try Ketoconazole or Anapryl. We also discussed Lysodren, but I am not really on board with that treatment.

I am hopeful that Punk responds positively to Trilostane. I loved the new Vet and trust his judgment and interest in Punk's case.

I will continue to update and welcome any feedback regarding treatment options and your experience in dealing with this very frustrating disease.

Licks and Barks,
Punk and Jen

[puuunk]

After only 3 days back on Trilostane, Punk is not well again. Yesterday, he did not have an appetite, so I made homemade food which he ate and gave him his morning and evening 5mg dose. In the middle of the night, he was quivering uncontrollably. This morning, he was not himself and could not get comfortable. No appetite again, but not vomiting or anything else. No medication given and he has slept most of the day.

I plan to speak to or see his vet again tomorrow. It makes me really sad that his condition is worse with the recommended treatment and I am at a loss of what to do.

[Joan2517]

I'm so sorry that Punk is still not doing well, Jen...

Joan

[Harley PoMMom]

Oh my, I am sorry too. :( I know that you aren't crazy about the Lysodren but you could put Punk on a maintenance dose of Lysodren instead of going through a loading phase.

Forgive me for not looking :o When was his last ACTH stim test done and what were those results?

[puuunk]

Thank you for your kindness and reply!

I am unsure about Lysodren as it seems to work like chemo and kills the cells in the adrenals, and effects cannot be reversed. I feel that if he was having trouble with Trilostane, it may be worse for a more intense treatment. I am going to research more but would love feedback regarding treatment with this medication.

Even though the Vets have said there does not seem to be an underlying cause, something in my gut tells me that there is more going on and I am nervous about putting too much strain on his elderly body.

His last stim was February 29th, he has not been on the medicine regularly since that time 3 - 5 days here and there due to side effects.

Pre ACTH Cortisol 12.1 ug/dL (16 ug/dL on 1/25/16)
Post ACTH Cortisol 19.4 ug/dL (15.4ug/dL on 1/25/16)
Range 18-22 ug/dL 􏰣􏱇􏱈􏰗􏱗􏰰􏰮􏰥􏰖􏰜􏰽􏰰􏰱􏰚􏰶􏰞􏰕􏰢􏱎􏰜􏰮􏰰􏰭􏰚􏰗􏰱􏰰􏰖Equivocal post ACTH Cortisol
􏰤􏰡􏰼􏰢􏰜􏰞􏰕􏰢􏱎 􏰕􏰡􏰫􏰢􏰠􏰼􏰡􏰟
Abnormal Blood Chemistry markers as below

ALP 1045 (1310 on 1/21/16) Range 5-160
ALT 221 (204 on 1/21/16) Range 18-121
BUN 46 (33 on 1/21/16) Range 9-31
CHOLESTEROL 385 (401 on 1/21/16) Range 131-345
NA/K Ratio 27 (27 on 1/21/16) Range 28-37
􏰤􏰫􏰣􏰶􏰞􏰕􏰢􏱎􏰜􏰕􏰡􏰫􏰢􏰠􏰼􏰡􏰟􏰤􏰫􏰣􏰶􏰞􏰕􏰢􏱎􏰜􏰕􏰡􏰫􏰢􏰠􏰼􏰡􏰟􏰤􏰫􏰣􏰶􏰞􏰕􏰢􏱎􏰜􏰕􏰡􏰫􏰢􏰠􏰼􏰡􏰟SDMA 14 (11 on 1/21/16) Range 0-14

[Squirt's Mom]

I am unsure about Lysodren as it seems to work like chemo and kills the cells in the adrenals, and effects cannot be reversed.

I am afraid you have been badly misinformed about Lysodren. Lyso works directly on the outer layer of the adrenal cortex, eroding a miniscule layer so the glands cannot "hear" the signals to produce and release more and more cortisol. If the dose is too high, or the load goes on too long, then too much of that cortex can be eroded resulting in an Addison's crisis BUT that layer can and does regenerate in most cases. Fact - Vetoryl (Trilostane) can and does cause this exact same thing to happen; both drugs have the same risk factors they just work differently and have different lifespans in the body. ;) That regeneration factor is why Lyso is given in two phases - 1) the loading, or induction, phase that erodes that cortex layer to the ideal depth in which the Lyso is give 2X a day, and 2) the maintenance phase to maintain that erosion, ie to keep the adrenal cortex from regenerating, in which the Lyso is given 2-4X a WEEK.

In a pup who has show themselves to be as sensitive as your baby, I would forego the loading phase altogether and go directly to the maintenance phase. That is the protocol for dogs with Atypical Cushing's in which the cortisol is normal but one or more of the intermediate hormones are elevated. Atypical pups do NOT undergo the loading phase but go directly to maintenance.

If you are willing to try the Lyso, there needs to be a washout period of 30 days to be sure all the Vetoryl is out of the system before starting the Lyso.

[molly muffin]

I am still thinking it is something other than cushings personally.

For a dog not on cushing medications, it is the pre that is high, while the post is actually not high at 19. Isn't the range for a normal dog not on medication up to 21mg? If you can check and see, that would be great.

I can't remember, are you seeing a specialist or your general vet?
If you aren't seeing a specialist then maybe a referral?

[puuunk]

Hi Ann and Sharlene,

Thank you so much for your feedback.

I, too, have been thinking it may be something other than Cushings. We are seeing an Internist, first visit was last week. I actually had to make an appointment today because he has not been eating since Sunday. Today, the little he ate, threw it up. He has not been on the meds since Saturday, but was on a 5 day course of Cerenia for upset stomach and still had no appetite and nausea. He has always had a ravenous appetite and has rarely vomited in his life.

I will discuss Lysodren with the Internist again and appreciate your detailed feedback Ann. These medications seem very hardcore and he is showing a lot of sensitivity.


Sharlene test results say that 􏰇􏱆􏰞􏰥􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰏􏰛􏰜􏰅􏰡􏰉􏰀􏰍􏰹􏰇􏰙􏰛􏰘􏰅􏰂􏰜􏰛􏰁􏰇􏰙􏰛􏰄􏰜􏰂􏰜􏰅􏰃􏰄􏰅􏰇􏰺􏰂􏰅􏱁post ACTH >19 is consistent with hydroadrenocorticism. It seems that he did not get true read on either ACTH, the LDDS on 2/8 is what definitively indicated Cushing's

PRE-DEX 14.9 ug/dL
4 POST-DEX 1.3 ug/dL
8 POST-DEX 2.1 ug/dL
􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏰇􏱁􏰷􏰨􏰃􏰘􏰐􏰪􏰘􏰃􏰄􏰛􏰙􏰛􏰘
I'll keep you updated. Thank you again!

Licks and Barks,
Jen and Punk

[Harley PoMMom]

Please forgive me for not going back and rereading your thread :o has pancreatitis been ruled out?

[puuunk]

I have really bad news....Punk was admitted to ICU today. His kidney values have more than doubled since his last blood work a few weeks ago. I don't have the exact results but BUN went from 46 to 90 and Creatine was 1.0 to 3 something. Suspected kidney disease or kidney function related to Addison's. They are giving IV therapy with fluids, antibiotics, and steroid. Urinalysis, cortisol levels and some other tests.

What tests check for Pancreatitis? He had an ultrasound on 1/29, the report listed Pancreas as normal. Kidneys were normal with irregular contour and decreased cortico-medullary junction

I am devastated. Will follow with results.

[Joan2517]

Oh no! Keeping you and Punk in my thoughts...I hope he rebounds.

Joan

[Harley PoMMom]

OMGoodness :( I know you are so worried but Punk is where he needs to be and we all are praying for you both. Hopefully this is just an acute attack on the kidneys and once the fluids and other medications are in him and have time to work his kidneys will settle down.

The test for pancreatitis is the spec cPL....keep us updated, please.

Hugs, Lori

[mytil]

Certainly keeping your sweetie pie in our thoughts. Glad to hear about the IVs and that he is where he absolutely needs to be.

Please keep us posted! I took a peek at his photo with Mr. G and I am hoping he is back home with you and Mr. G very soon.

((((hugs))))
Terry

[labblab]

I am so sorry, too! When dogs are in Addisonian crisis, their kidney values can look bad even though renal damage is not the true cause. Once the dog is rehydrated and the electrolytes are back in balance, the kidney values will renormalize. It sounds as though the ICU vets are definitely considering this, so that is good that they are recognizing this is an option. Please keep us updated as you are able!

Sending many healing hugs to you both,
Marianne

[puuunk]

Thank you Lori, Terri, Joan, and Marianne! It really means so much to have this community for support and information!!!!

I asked the vet for his blood work from today and his Lipase is very high 4400 (200-1800 range) Amylase is 1080 (500-1500 range). He said those can increase from Kidney function also and he wants to focus on treatment tonight rather than further diagnostics before receiving results from tests he has already requested.

I am praying that the treatment tonight helps improve his condition and that I can bring him home tomorrow.

xx
Jen

[molly muffin]

Forget lysodren and vetroyl and all of that right now. Lysodren isn't an option with a dog that isn't eating Very well and drinking a lot, as you need those to help tell how he is doing.

So, they think he is having an Addison crisis. That is recoverable and hopefully the kidneys will recover once the fluids are in him.

Crossed fingers here!!!

[judymaggie]

Sending healing thoughts to Punk! It sounds like the doctors are being very thorough.

[Joan2517]

Praying all goes well....

[Tina]

Hi Jen,
I'm not able to read your whole thread right now, but wanted to offer my support after reading the latest developments with Punk. My boy Jasper went through an Addisonian crisis on two occasions after he was diagnosed with Cushings and was hospitalized both times. We had initially treated with Lysodren, and he proved to be very sensitive to the medication.

Like Marianne said, the kidney values can get all out of whack during the crisis, and hopefully will stabilize with the IV fluids and other treatments. I don't see that you have mentioned anything about Punk's sodium or potassium levels. When I saw that his appetite was poor and that he had vomited, I immediately wondered about the electrolytes. I'm sure the Drs are monitoring this as they could be imbalanced as well. There is another medication that could be needed to stabilize the electrolytes, in addition to the steroids and IV therapy.

You and Punk are in my thoughts and I'm praying that he is more stable and feeling better today. I'm so sorry you both are going through this, I know it is very scary. Please update us when you can.

Hugs,
Tina

[Squirt's Mom]

Sending prayers and healing energies flying his way! Please know you are not alone - we are right by your side.

Hugs,
Leslie and the gang

[puuunk]

Thank you everyone for your kind words and support. Also, for sharing your experience. I called overnight and he was resting comfortably and vitals were stable. I asked what was ordered for his IV and they said; Fluid Therapy, Baytril, Cerenia, Protonix and Dexium.

I wanted to post full results from yesterday on the labs that were done in house. Expecting Urinalysis and culture later today. Electrolytes are being monitored, but he did not discuss any of those markers with me.

Chloride =117 mmol/L (109 -122)
CHOL = 299 mg/dL (110 -320)
PHOS = 7.7 mg/dL H (2.5 *-6.8)
Potassium = 4.7 mmol/L (3.5 *-5.8)
Sodium = 162 mmol/L H (144 *-160)
ALB/GLOB = 1.6
BUN/CREA = 29
Na/K = 35

ALB = 4.3 g/dL H (2.2 -3.9)
ALKP = 1005 U/L H (23*-212)
ALT = 218 U/L H (10*-125)
AMYL = 1080 U/L (500 -1500)
BUN/UREA = 90 mg/dL H (7*-27)
Ca = 11.3 mg/dL 0*-11 (7.9 -12.0)
CREA = 3.1 mg/dL H (0.5 -1.8)
GGT = 8 U/L (0*-11)
GLU = 110 mg/dL (70-*143)
LIPA = 4404 U/L H (200 -1800)
TBIL = 0.4 mg/dL (0.0 *-0.9)
TP= 6.9 g/dL (5.2 -8.2)
GLOB = 2.6 g/dL (2.5 * 4.5)
OSM calc = 348 mmol/kg

While I was typing this, the Vet called to give me a quick update. It is not Addison's his resting cortisol came back 11.7. Creatine has gone down to 2.4 and BUN went to 63, I don't have the rest of the results. He says indication is Kidney damage but does not know if it is acute or chronic. His primary specialist vet is calling back in about an hour to give further update and game plan. Is there anything I should request?

All testing done in the last two months, before now, had normal kidney function on the reports.

[puuunk]

It has been a rough day. Punk has to stay in the hospital another night. The vet is not seeing the improvement he would like in his Kidney values and he still is not eating. They are going to try an appetite stimulant. I visited with him for a few hours and he is so weak, his eyes say it all.

They did an ultrasound and it shows abnormal Kidneys, he said they look "old" like Punk's age and are a little irregular, does not see any indication of Tumor or Stones. His Pancreas looks normal, his Liver and Adrenal glands are inflamed and enlarged. His lymph nodes are ok.

He is not sure if the issue with his Kidney was brought on by something external or if it has been underlying and is coming up now coincidentally with Cushing's diagnosis and trilostane treatment. Addison's is not suspected as his standing cortisol is still high.

We are not discussing continued treatment of Cushing's at this time as the more urgent matter is Kidney treatment. I mentioned Pancreatitis cPL and he said the treatment is the same as what they are doing now and he would rather focus on using resources for his treatment and hospitalization.

Please continue to keep him in your thoughts, we appreciate your support.

Best,
Jen and Punk

[Joan2517]

Praying for all of you....it is awful leaving them even if it is the best thing for them.

Joan

[molly muffin]

Okay so treatment for pancreatis would be the same, so I would agree and not do the cpl test right now as you already know it is high and it could be in reaction to the kidney issue going on. Kidney could have developed due to the liver too. They are all interconnected. If the Creatinine and BUN are coming down, that is a good sign at least. I bet they want that within normal range prior to releasing him (the creatinine).

Kidney problem can cause the lack of appetite, in fact, probably does since it's not cortisol related.

If it is an acute attack, then he can recover from it and hopefully go on as normal with no other issues. If it is chronic they need to look at a treatment plan for it. (my dog has kidney problems, but hasn't had an acute attack, hers is an ongoing issue that we try to keep control of).

So, most important of all is the creatinine to come down and the electrolytes to get back into range. The fluids should help the electrolytes and hopefully the creatinine. The BUN will Should come down as the creatinine comes into range, but there are other factors that affect BUN so that isn't as much worry if the creatinine gets down where it should be.

We're waiting with you. Hoping he is feeling better soon. Bet if he gets some food in him and keeps it down he will feel a bit better.

[puuunk]

It has been a while since I wrote, the last 3 weeks have been rough!

Punk is not doing well since diagnosis with Kidney disease and hospitalized 3 weeks ago. He has changed dramatically, mostly in that he no longer is interested in eating at all. His appetite went from ravenous to non-existent. His BUN, Creatinine and Phosphorus levels are all really high.

The vet is not treating the Cushing's at this time as the issues related to Kidney disease are more pressing. I find it very odd that the Kidney disease came up after Trilostane treatment didn't work. The vet does not think it is related as his cortisol levels are still very high, but I definitely think the Trilostane had a toxic reaction to him, the coincidence is just too likely. Any experience with this reaction?

Also, if anyone has information on a great Forum like this for Kidney disease, I would love to get the link.

Thank you!

Jen and Punk

[lulusmom]

Hi Jen,

I am so sorry to hear that Punk is not doing well. I agree that continuing to treat with trilostane is not in Punk's best interest right now. I knew that trilostane is not recommended for dogs with renal disease but I also recently read in a veterinary textbook that UC Davis does not treat cushing's in dogs with kidney disease. I think concentrating on mitigating the effects of kidney disease is a wise idea. I would recommend that you join the K9Kidney Yahoo Group. I've provided the link below. Please keep us posted on your precious Punk's status. Keeping fingers and paws crossed that you can get your boy back on track.

Glynda

https://groups.yahoo.com/neo/groups/K9KIDNEYS/info

[judymaggie]

Jen -- sending lots of healing thoughts to Punk!

[puuunk]

Thank you Glynda and Judy! We will check it out....so frustrating, they are already suggesting giving him a feeding tube.

xo - licks and barks
Punk

[molly muffin]

It is very frustrating.
My dog also has kidney issues, that came after the cortisol was high. High cortisol can affect kidneys, liver, pancrease, etc, it's all tied together. We are treating her still for cushings and as long as I can get her to eat we will do so, but who knows in the long term what we will need to do.
There is a facebook kidney disease group too.
https://www.facebook.com/groups/211455130573/

[labblab]

I'm so sorry about Punk, too, and surely hope you'll soon see some improvements. Given the severity of his kidney problems, I totally understand why Cushing's treatment is off the table right now. It is so hard to know exactly what triggered this crisis. Since there were questions at the time of his diagnosis, perhaps Cushing's has never been the culprit at all, and there was some other smoldering issue that is the basis for the kidney failure. It is true that trilostane is not recommended for use in dogs whose kidneys are not filtering properly. I don't know that the drug actually hurts the kidneys further, or whether the issue is instead that the drug does not get excreted properly and therefore builds up in the body causing general overdosing issues.

At any rate, the focus right now needs to be the kidneys. There are many different causes for kidney issues, including high cortisol. As is the case for Sharlene's Molly, in that situation -- and if the doggie is not acutely ill and the kidneys are filtering sufficiently well -- then I do believe the general recommendation remains to treat the Cushing's if it is the underlying condition that is causing the problem since you want to keep things from getting worse. But if the kidneys are really failing to work properly, then they must become the center of attention.

Once again, I'm so sorry you guys are really struggling right now, and please do keep us updated.

Marianne