Help! My sweet blue heeler has Cushing's

[angelamarie22]

Hello. My girl Sophie is 8 (9 in july) and will be put thru a last test next weds to confirm her cushings dx. She has a small nodule on her adrenal gland that was found last June and monitored again in December but no size changes were noted. Recently I took her back to the vet confirming she was acting not herself. They ran a blood test and confirmed they believe it's Cushings. Anyone have experience with surgery and the adrenal gland? Sophie's is on her left side which I've read is the better of the two to have the tumor.
I appreciate your thoughts and help as I was up most of the night upset and staring at my dog :)

[Harley PoMMom]

Hi and welcome to you and Sophie!

Adrenalectomy can be a cure for a dog with the adrenal type of Cushing's, however this is very serious, very expensive surgery and should only be done by a seasoned surgeon. And yes, I do believe that tumors in the left gland are virtually always easier to remove than in the right. One of our members, Trish, has had a successful adrenalectomy performed on her furbaby, Flynn. I'm including a list of questions she prepared for others debating adrenalectomies for their dog:
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.

Could you tell us more about Sopie and share some of her medical history with us? We ask a ton of questions and then based on your answers it enables us to give you our best possible feedback, ok? So here goes some questions from me!

What symptoms did/does Sophie display that led you or the vet to test for Cushing's in the first place? Could you get copies of all tests that were done on Sophie and post those results here? With respect to the blood chemistry and CBC, you need only post the highs and lows and please include the normal reference ranges. What diagnostic tests for Cushing's are going to be or were performed on Sophie, and could you post those results too? Is Sophie taking any other herbs/supplements/medications? Does she have any other underlying illness?

Here are links to other member's threads whose dogs have an adrenal tumor or have had an adrenalectomy:

Hi-New Memeber- PHEO - Need Info and Advice Please (http://www.k9cushings.com/forum/showthread.php?t=5904)

Flynn 11 y/o Foxie Cross - Right adrenalectomy, 3rd Dec 2012 for Pheochromocytoma (http://www.k9cushings.com/forum/showthread.php?t=4242)

Amanda Update Adrenalectomy 11/4/14 (http://www.k9cushings.com/forum/showthread.php?t=7570)

Meet Kaibo :) 7 y/o toy poodle - Diabetes, adrenalectomy; now PDH and CC (http://www.k9cushings.com/forum/showthread.php?t=4648)

I am sorry for the reasons you are here but so glad you found us, and we will help in any way we can. ;)

Hugs, Lori

[molly muffin]

Hello I want to welcome you to the forum.

My dog has a nodule small on her adrenal gland too. It however, showed up after she had high cortisol, making us think that she probably has pituitary cushings (as the nodule didn't show up for quite some time after we knew she had high cortisol) So, not all nodules are secreting tumors.

Was one of the test you did or are doing an LDDS test? That might help to determine what type she has. If so can you post that result here?

[tank&kat]

A big welcome to you and your girl, Sophie.

I don't have much experience with adrenalectomy/adrenal tumors. I'll be following here to learn. What symptoms prompted you to bring her to the vet? I'm interested in seeing lab abnormalities as well. The people here are wonderful and very knowledgeable. You will get many questions answered. Looking forward to getting to know you and Sophie.

~Katherine

[angelamarie22]

Sorry I've been looking at soo many pages for answers I forgot I posted on here. Sophie is having a Low Dose test this Weds so I will post results once found. She had a blood test done last week that showed her ALP at 459. She started licking the floor a lot lately and just wouldn't stop. She has had increased thirst for awhile and started eating mulch and things in the yard. Her nodule on her gland was found last June when she was having some puking issues so we did a xray then ultrasound. She does have arthritis that she takes a supplement for every day (cosequin) but other than that her health has been good. She has had some UTI's in the last few years. I want the best for my dog. So reading on some pages about the surgery and the risk is beyond frightening. If she can be treated with meds and live a good healthy life then I'm all for it! I emailed my vet today and said hey I'm not sure but do you have experience with cushings and if not do you know a specialist? I am not far from Purdue University so I've even thought about reaching out to them.

[molly muffin]

I've heard that Purdue is a good vet school. I'm in Canada and when discussing kidney stones with my specialist she had said that Purdue does the ultrasound to break up kidney stones and is one of the few places in North America that does that procedure (as is done on humans) so I am thinking they would be a start of the art type of place to go if needed.

[angelamarie22]

My Sophie girl has her visit up at Purdue University Vet Hospital tomorrow to see a specialist. She had her low dose test last weds and her regular vet said she believes she has the Pituitary kind of Cushings even tho she has a nodule on her adrenal gland. I'm taking a cd with the 2 ultrasounds and exrays on it with me. anyone have tips or questions to ask. I want to get as much as possible out of my time with the dr while I'm up there for her initial consultation.

[angelamarie22]

Sophie has her Low Dose test on weds and it was found she has the Pituitary kind of cushings even tho she has the nodule on her adrenal gland. We are set to go to Purdue tomorrow to talk to a specialist. I don't think I will sleep all night. I have started a list of questions about treatment and meds. ugh

[labblab]

Hello again! I have only a minute to write, but I wanted to explain that I've gone ahead and merged your new thread into Sophie's original thread. This way, all your posts and replies will be consolidated in one place. I surely understand why you're nervous about the trip to Purdue tomorrow, but they have a great reputation and should be able to give you a lot of helpful information about Sophie's situation and options. If I don't have the chance to get back and post again before you leave tomorrow, I wish you both the best of luck!

Marianne

[molly muffin]

How did the trip up to Purdue go today? What did the specialist have to say?

[angelamarie22]

Met with the specialist at Purdue. They did an additional test as they weren't convinced she had pituitary cushings. They also did a urine test and culture. They called today and she does have pituitary cushings along with a possible pheochromocyroma on her rt adrenal gland. We go back this coming week for a stim test and ctscan to see what is causing the pituitary cushings and to check the adrenal gland. I'm devastated and wasn't prepared for more than just cushings.

[molly muffin]

If it is a pheo also let us know. We have a member whose dog successfully went through the surgery for removal of. Pheo.

[angelamarie22]

I'm interested in any information about that thank you! My eyes are swollen from crying. I'm so thankful that we are so close that we can take her there. My work is letting me work out of our office near campus so I can take her. It breaks my heart that she has all these issues and we didn't know.

[Harley PoMMom]

There are tests that can be used to diagnose a pheo in a dog; one is a urine test that measures the level of catecholamines; the second test measures serum inhibin concentrations. Here's a link to a study where both tests were used: http://onlinelibrary.wiley.com/doi/10.1111/jvim.12569/full

[angelamarie22]

She is back today at Purdue. They are going to do the ACTH STIM test this morning for the Cushing's. They want to start her on trilostane. They are going to do a CT scan to see if it's just cells or a tumor in her pituitary gland. Also they are going to get a better look at her adrenal gland on the left side. They suspect either cancer or a Pheo. They also are going to monitor her blood pressure and an optomologist is going to check her eyes to see if she has any dmgs from high blood pressure (signs of pheo)
The CT will also show any other nodules so they can do a needle biopsy as needed. I was up at 4:30am driving up north to the university and now I'm trying to "work" at an office here in town while I'm worried about her :(

[Joan2517]

I'm so sorry that you and Sophie are going through this. I'm praying for better news...

Thinking of you...
Joan

[molly muffin]

Crossing fingers for you and Sophie. Let us know as soon as you hear something.

[angelamarie22]

Ok quick question. Trilostane dosage. The vet wants me to give Sophie 40mg in the morning and 40 mg in evening. She weighs 36 lbs. the feedback I'm getting is that's way too much. So I haven't started her dose yet. That and she is still not 100% from the sedation yesterday.

[labblab]

How did things turn out at Purdue yesterday? I'm surely hoping that the additional imaging provided helpful information for you.

Also, a big reason why I'm asking is because I do believe the trilostane dosing may depend upon the treatment plan moving forward. If Sophie does have an adrenal tumor that requires urgent surgical intervention, then Purdue might be suggesting a higher dose of trilostane in order to quickly and significantly lower her trilostane within a very short timeframe in preparation for surgery (like within 2-3 weeks?).

However, if this is not the scenario and trilostane is instead being prescribed as long-term medical management, then 40 mg. twice a day would be double the starting dose that is currently recommended by Dechra (manufacturer of brandname Vetoryl), as well as most specialists. The currently recommended formula is to start at a daily total of 1 mg. per pound (or 2.2 mg. per kg.). So given Sophie's weight, the advisable starting dose would be either 40 mg. once daily, or 20 mg. twice daily. Here's Dechra's specific instruction re: twice daily dosing: you split the daily total rather than double it.


To switch from a once daily dose to a twice daily dose, the total daily dose should be divided into 2 portions given 12 hours apart.

I feel worried that perhaps there was some internal confusion at Purdue re: this dosing instruction. One of the big benefits of being treated at a university hospital setting is that you have a whole team involved in consultation on each patient. But the flip side is that sometimes this means communication can get confused when instructions are transmitted from one person to another to another (I learned this the hard way from human relatives being treated at medical school hospitals :o).

I have to wonder whether the actual intention is for Sophie to receive 40 mg. in total, rather than 40 mg. twice daily. This would mean 20 mg. twice daily as the correct starting dose. I would really, really want to double-check this dosing amount with the veterinarian who is actually in charge of her case. Here's a link to a post here that contains references to the 1 mg. per pound formula. If Sophie were mine, I'd contact the vet in charge and explain that you've been reading the dosing instructions published by Dechra, and you are worried about the difference between their instructions vs. the larger dose that you've been given for Sophie. Is there a specific reason why they want to give Sophie that large a starting dose? Here's the link:

http://www.k9cushings.com/forum/showthread.php?p=1251#post1251

Good luck, and please keep us updated!
Marianne

[angelamarie22]

There is no surgical intervention needed. the Adrenal nodule is benign they think and not a Pheo. She still isn't 100% after being sedated so her tummy is still not well. I put a call into my vet today to see what she thinks. I don't plan on giving her any meds until I get a 2nd opinion on the dosage. From what I gather the med will be given long term. He also didn't want to give her another STIM test until 1 month-which is different from the manufacturer information. I thought about calling them directly to confirm the dosage recommended but I cannot find a ph# for me to call.

[labblab]

YAY!!!!! That is SUPER good news that they think the nodule is benign. :) :)

I'm really hoping your regular vet can help clarify the correct dosing on your behalf. But if questions remain, you can probably just go to Purdue's website and search out contact info for the vet there. Are you to return to Purdue for follow-up, or is Sophie's care and monitoring now being transferred back to your local vet?

In general, I am not terribly surprised by the instruction to have the first monitoring ACTH performed at the 30-day mark. We are aware that other specialists are also waiting until the end of that first month before testing, I believe mainly because the consensus now is to start with lower doses and not to increase the starting dose before that time for any dog. However, if you wait a full month to monitor Sophie's cortisol, that means that starting her out on a 2 mg. per pound dose seems even more worrisome to me. From a safety standpoint, you really want to make sure that her cortisol is not dropping too low. So again, if it were me, I'd either want to start her at a lower dose or I'd want to perform a monitoring ACTH sooner -- like at the 10-14 day mark that Dechra recommends.

I want to make it clear that I am not a vet. But after years of shared experience with pet parents here, I'm just very wary of leaving higher doses of the drug unmonitored for lengthy periods of time.

Also, just to make sure -- I'm hoping the folks at Purdue instructed you to give Sophie her trilostane along with a full meal. In order to be metabolized properly, the drug must be absorbed alongside food in the stomach.

One final question: did Purdue give you Vetoryl capsule combinations to arrive at the 40 mg., or do you have compounded 40 mg. compounded capsules/tablets? If you have Vetoryl caps of 30 mg. and 10 mg. dosage strengths, you could easily still dose twice daily by giving 30 mg. in the morning and 10 mg. in the evening (Dechra says that the doses don't have to be equal, but if not, the larger dose should be given in the morning). If you instead have 40 mg. compounded capsules, then you could start out by dosing Sophie just once daily in the morning for the first month, until the result of the monitoring ACTH test is known.

Marianne

[angelamarie22]

I emailed the vet last night but haven't heard back (the one from Purdue) I also contacted my personal vet and left a message this morning. they gave me 10 mg and 30 mg caplets.

[labblab]

OK, that's great then, because you can still dose twice daily even if you cut back to the 40 mg. daily total. I truly don't see why the vets should object to starting more conservatively for the first month. Then, when you have the results of the monitoring ACTH, you can increase the dose by whatever amount seems appropriate, up to the full 40 mg. twice daily. To me, this is really a win-win situation.

And by the way, here's that full quote from Dechra about dividing twice daily doses:


To switch from a once daily dose to a twice daily dose, the total daily dose should be divided into 2 portions given 12 hours apart. It is not necessary for the portions to be equal. If applicable, the larger dose should be administered in the morning and the smaller dose in the evening.

For example, a dog receiving 90 mg would receive 60 mg in the morning, and 30 mg in evening.

[angelamarie22]

Just got off the phone with the Vet. We discussed my worries and he stated that he usually starts off higher but he stated we could do 30 mg in am and 30 mg in evening. he stated that they recommend 30 days for recheck as most owners don't want to pay for the 2 week then come back at 30 but I told him I'm in. So we will retest in 2 weeks.

[DoxieMama]

30 mg AM and PM is a total of 60 per day... for a 36 pound dog. If that's what you and your vet agreed upon, I hope it isn't too much. Be very vigilant for signs of overdose (not that you wouldn't anyway, but that is higher than the recommendations of the manufacturer and worries me).

I am glad you'll be retesting in 2 weeks! Especially at that higher starting dose.

Keeping my fingers crossed for you.

Shana

[labblab]

Yes, I'm really glad you're opting to retest in two weeks, too!

By the way, do you have the results yet for the ACTH that Purdue performed? It will be really good to have those as a baseline against which to measure Sophie's progress at the two week mark.

Marianne

[labblab]

And...I'm back again to add just one more note. :o

I know you guys have really been through the wringer, and now that you have a plan in place, I'm surely rooting for everything to go well and for this to be the perfect dose for Sophie. But also for the benefit of other folks who are reading this thread, I feel compelled to explain why I'm fearful your vet's plan may end up backfiring if his general wish is to lower testing expenses for his patients.

When high cortisol levels are lowered rapidly in dogs, they may end up feeling very yuckky even though their cortisol has not dropped low enough to constitute an Addisonian crisis. There is a technical term for this: "corticosteroid withdrawal syndrome." Outwardly, the symptoms of this withdrawl can look identical to genuinely low cortisol: listlessness, vomiting, diarrhea, etc. So the only way to differentiate between a serious condition and just an uncomfortable condition is -- you guessed it -- an ACTH stimulation test.

I cannot tell you how many dogs we've followed here who have started out on higher doses of medication, only to start vomiting or otherwise appearing ill after a few days. So not only do they NOT make it to a 14-day test, they have to be tested after those first few days. And then the dose lowered, and tested again after 14 days. And then tested again after 30 days.

In those cases, it would have been far easier on both the dog and also the owner's wallet to have started with a lower dose and allowed the cortisol to decrease more gradually. There is usually virtually nothing to be lost by allowing the cortisol to run a bit higher for the first month, plus by that time you have a much more accurate sense as to what the truly therapeutic dose needs to be.

I appreciate you letting me "highjack" Sophie's thread to explain my general thinking about this. As I say, you guys deserve a break and you've gone far beyond the norm in terms of making sure Sophie has had the best diagnostic care possible. But I did want to explain why it may seem as though we are harping on this dosing question. We are none of us vets, but whereas even specialty vets probably don't see more than 1-2 new Cushing's patient each week, we have 2+ new members joining us every day of the year. We have suffered through lots of overdoses that we wish could have been prevented.

So there you have it, and now I promise I will hush up because you will probably cringe to see my username showing up one more time on your thread today.

[angelamarie22]

I have the insert from the manufacturer and it says 1-3 mg/lb so it's within their range. He did check with the Director of the Small Animal Department at Purdue. So I feel better knowing it's within range from Dechra and she has reviewed it. Sophie will be with me 24/7 (I am lucky enough to be able to bring her to work) I think this will help me keep an eye on those signs of overdose. I do have her levels : baseline cortisol 15.3 u/dL, cortisol after simulation was 23.1

[angelamarie22]

I do appreciate all input so don't feel bad about posting :)

[molly muffin]

What you have with us, is a bunch of aunti worry warts to be honest. :)
We've seen the best and the worse when it comes to cushings and the changes that have occurred in cushings treatment in the last 10 years are nothing short of miraculous.

The first pituitary surgery on a macro, radiation treatments that started at a series of 12 and are now down to 2 or 3 depending on the facility doing it.
Trilostane dosages coming more in line for safety reasons. And even the possibility of some newer medications through trials recently or currently ongoing.

We've had really big dogs on small doses and we've had little dogs on really big doses.

One never knows for sure how any dog will react to any medication. Some it hits them like a brick truck and others it's like they just go along swimming with the flow.

I'm super glad that you can have Sophie with you at work. That makes keeping an eye on her so much easier and you know what to watch out for.

Remember, if you see those signs, let the vet know immediately.

We all have our fingers and paws crossed for you and Sophie.

[angelamarie22]

I actually emailed the manufacturer the other night ( I cannot remember if I posted that or not) I got a call back last night and had a really good conversation with them. They confirmed the 30 mg dose in am and pm is within their range of 1-3 mg per pound of animal. she confirmed with me the signs to look for and the f/u visit at 14 days for testing.
I appreciate all your support on here. Sophie is at work with me today and she had her 2nd dose this morning at 6:30am.