Milo-11 yo Maltese just diagnosed PHD

[MyMilo]

Hi all, I’ve been perusing these message boards over the last few days awaiting the results of a LDDS test for my 11yo, 16lb little man, Milo. The information I’ve found within this forum has already been so very helpful to me. I got the results yesterday and he tested positive for PHD. My vet has recommended treatment of Vetoryl 10 mg once daily but none of the recommended follow up tests that have been discussed here.

Low Dose Dex test results:

Baseline 6.2 (above reference range 1.0-6.0),
4 hours post 0.9 (which is < 50% of baseline),
8 hours post is 1.6 (which is > 1.5 and < 50% of baseline)

A little history, almost 3 years ago he was diagnosed with a heart murmur, hypothyroidism and liver disease and has been on meds to treat all 3 ever since. In Oct 2015 an abdominal & heart ultrasound was performed due to an increase in his already elevated liver enzymes. Ultrasound revealed an enlarged liver with nodules, normal spleen, gallbladder slightly distended with a large amount of sludge and severe mitral valve heart disease. Ursodiol was prescribed for the gallbladder which seemed to make him feel a lot better. Liver enzymes were checked again 1/13/2016 and there was some improvement but were still elevated. Results are below:

ALT 133 10 - 125 U/L
ALP 1,140 23 - 212 U/L
Bilirubin Total 1.9 0.0 - 0.9 mg/dL
Cholesterol 370 110 - 320 mg/dL

A few weeks ago he had his first UTI which cleared up after a round of antibiotics. The vet recommended the LDDS test due to dilute urine on the initial and follow up urinalysis as well on the Oct 2015 ultrasound it was noted that the adrenal glands were on the larger side. Urine specific gravity was 1.012 on 3/17/2016 and 1.005 on 4/5/2016.

Milo is currently on the following medications: Thyroid, Vetmedin, Denamarin and Ursodiol. Over the last 3 years he’s exhibited some of the Cushing’s symptoms, the most consistent and noticeable are excessive panting, thirst and urinating. The thirst and urinating have increased some in the last couple months but otherwise there hasn’t been too drastic of a change in symptoms/behavior.

At this point I’m sure of only one thing. That if I decide to pursue treatment for Cushing’s I will be seeking a 2nd opinion as my Vet admittedly doesn’t have too much experience treating it. With that said, I have reservations about treating the Cushing’s at all. His symptoms aren’t too severe and I’m concerned what affect the treatment will have on his other issues. Also, it seems the trips to the vet over the last few months really stress him out and it takes a couple days for him to get back to his normal self.

I know this decision is a personal one but any advice and experience that can be shared with me would be greatly appreciated.

Thanks in advance,

Beth

[DoxieMama]

Hi Beth, welcome to you and Milo. I'm relatively new here myself, having only started on treatment for my little guy's Cushing's a week ago. So my experience is limited.

It sure sounds as if you've done some great things for Milo already, treating him for his other issues and getting the testing done to confirm the Cushing's diagnosis. I'm sure someone with more experience will be along soon to provide their insight and suggestions. In the meantime, I wanted to commend you for asking for other opinions, as there are a number of experienced folks here who may be able to help you in your decision. I know the conversations that I had with people here, friends, coworkers and family were helpful for me during that process. They continue to be helpful as I navigate this new world, and I hope you find the same.

You might want to consider getting that second opinion before you make the decision to treat. I would think that an experienced vet or IMS would be able to provide the information you seek regarding possible complications from his current meds and Cushing's meds. That said, there may be others here whose dogs have the same conditions and can share their first-hand experience. I know I've seen mention of those with each of the issues Milo has, though I don't know who - or if they have just one/all three of those issues. Hopefully someone will come along that does! :)

Please know that regardless of your decision, you are welcome to participate here and share your (and Milo's!) experiences. We'll support whatever you decide, without judgment, and will walk alongside you to offer what comfort, encouragement, knowledge and compassion we can.

Hugs to you and ear scratches for Milo!
Shana

[labblab]

Hello, and welcome to you and Milo. I'm so glad Shana had a chance to greet you earlier, and I do agree with her recommendation that you seek out a consultation with an internal medicine specialist, if possible. From what you've described, it is certainly possible that Milo has Cushing's. But his LDDS result was just barely positive and that elevation could conceivably be caused by some of his other chronic problems. The LDDS is very good about not missing a "positive" result for dogs who truly have Cushing's, but unfortunately it is also vulnerable to returning "false positives" for dogs who are instead suffering from other nonadrenal ailments.

Especially given Milo's current medication profile, I would want to talk with a specialist before launching into treatment. It is possible that there is other diagnostic testing that a specialist would recommend, both in relation to Cushing's (like possibly an ACTH stimulation test which is an alternative diagnostic blood test), and also in relation to other issues with Milo's liver, heart, and gallbladder. This link may help you locate a "Internal Medicine Specialist" in your area.

http://find.vetspecialists.com/

So I apologize for not being able to offer much additional insight into Milo's overall condition, but we will certainly be anxious to hear about any additional developments re: his diagnosis and care. So please do keep us updated.

Marianne

[lulusmom]

Hi and welcome to you and Milo.

I absolutely adore Maltese and have shared my life with a number of them and have come to learn a lot about mitral valve disease and gall bladder mucocele. I am glad to hear that you are not going to entertain treatment of cushing's without a second opinion as I agree with Marianne, that this borderline result could be a false positive. I also agree with both Shana and Marianne and highly recommend that you seek out an internal medicine specialist (IMS) in your area to provide that second opinion. Even if cushing's weren't a possibility, I personally would want an IMS to reconfirm all diagnoses and provide guidance on whether Milo's current treatment regimen for both his heart disease and gall bladder issues are optimum. My two maltese also had severe mitral valve disease and were monitored closely by a friend and professor at a teaching hospital as well cardiologist on staff. Both of my boys were on a lot more than just Vetmedin. The three drugs that were static were Lasix, Enalapril & Vetmedin. I would think that if Milo has "severe" mitral valve disease, he would be on additional drugs. :confused: My boys had a heart echocardiogram at diagnosis and routine proBNP tests thereafter to monitor the progression of the disease.

Gall bladder mucoceles seem to be a condition that is no stranger to the Maltese breed. While mucoceles were not mentioned in the ultrasound interpretation you shared, I do wonder if could be a differential diagnosis as mucoceles can account for all of Milo's blood abnormalities as well as the symptoms you are seeing. The good news is that Ursodiol is the correct drug to address that problem. My first tiny Maltese was diagnosed with hepatitis and was put on a treatment regimen that saved her life but she was not on those drugs for the rest of her life. Does Milo have primary liver disease or was there something going on three years ago that impacted his liver? If he was diagnosed with primary liver disease, was a liver biopsy done to confirm the diagnosis three years ago?

I'm sorry for the reasons that brought you here but I'm glad you found us. It's not an easy road we cushparents walk and it's a lot easier when you have a hand to hold. Just know that you have a whole lot of hands to latch onto here. :) They sure kept my head above water many a time. We will all look forward to hearing a lot more about your precious Milo.

Glynda

[MyMilo]

Shana and Marianne,

Thank you both so much for your replies. This forum has been a godsend to me this past week. I was able to locate an "IMS" close to me and have an appointment next Wednesday morning. If there is one thing I'm learning though this is patience, which is something I'm usually short of ;) I'll be sure to update with new information after the seeing the new vet. Thanks again!

[MyMilo]

Hi Glynda, sorry I missed your post earlier. Again thank you so much for sharing your experience and information. You gave me a wealth of info! I have never been referred to any type of specialist for any of these on going issues. I never even thought of it, just trusted that my Vet was doing what was right. Though with that said, I've had some doubts over the last year and should have trusted my gut. Anyway, hopefully the IMS that we'll be seeing on Wednesday will be able to shed some light on all of this so my poor boy will feel better. There are other specialists in this practice too which is why I chose them so I'm hoping for the best.

Beth

[molly muffin]

Hello, I just want to welcome you to the forum and say how glad I am that you found us and are going to be able to see an IMS. Especially at a clinic with multiple areas of expertise, as I think a cardiologist as Glynda mentioned does need to see your boy.

Those results of the LDDS are really close so it could be the other things causing it to be a bit high.

Welcome!

[MyMilo]

Hello all,
This morning we had a very thorough appointment and exam with the "IMS". We have decided to start treating the Cushings with 5mg of Vetoryl twice daily. I'm a little anxious about this but will be starting tomorrow morning with his breakfast. I'm wondering what the time frame is for any of the possible side affects to appear. I plan on being with him all day tomorrow but need to return to work on Friday. Thanks so much.

[Harley PoMMom]

In healthy dogs, Trilostane reaches peak concentrations at 1.5-2 hours and within 10 - 18 hours a dog's cortisol returns to its baseline level. Adverse effects are more likely seen when a dog is started at a too high of a Trilostane dose. Milo's starting dose of 5 mg BID (10 mg total) for his weight of 16 lbs is even a bit lower that Dechra's revised starting dose recommendation of 1 mg per pound, which is good! I believe he will do just fine with his dose, I'd say ill effects are usually seen within the first few hours after the Trilostane dose is given. And if you suspect that he is acting off than you withhold his Trilostane.

Hugs, Lori

[molly muffin]

I agree with Lori at that dose, he should do okay.

Let us how how he dose.

[DoxieMama]

Hi Beth,

I asked the exact same question before I started the Trilostane, too! As Lori said, I have seen the greatest reactions about 2 hours after giving Visuddha his dose.

Do you have a follow-up ACTH test scheduled with the IMS?

Shana

[MyMilo]

Thanks for the responses Ladies. Please know that sharing your knowledge and insight has helped so much in this journey. It gave me great confidence to move forward with a 2nd opinion and to make an educated decision to start treatment.

Milo tolerated his first day very well. The IMS will be calling with the results of a full blood chemistry tomorrow and we have the ACTH test scheduled for May 2nd.

All my best,
Beth

[lulusmom]

I'm so glad to hear that Milo has seen an IMS and that you feel more confident with the diagnosis and treatment. I am also glad to hear that the IMS has prescribed a low starting dose and I'll be very interested to see the results of his first acth stimulation test. Will you be having the test done by the IMS or your gp vet?

Glynda

[MyMilo]

Hi Glynda, the ACTH stim test and ongoing treatment will be performed by the IMS. My "former" gp vet will no longer be caring for Milo or his little brother Calvin. She was a solo practitioner and as both Milo & Calvin are geting older and especially with Milo's other medical issues complicating things, I think going to a practice with multiple vets is going to be better for us over all.

[lulusmom]

I think you've made the right decision to have the IMS care for your boys. Both of my cushpups had issues other than cushing's so I shared the same concerns and made the long drive to a 24/7 specialty hospital with multiple internal medicine specialists on staff. My dogs were completely different personalities. My tiny Lulu would be scooped up in the arms of whoever was behind the front desk the moment we arrived. She spent a good deal of time being spoiled rotten before, during and after her appt. She had a few surgeries there as well and I remember one of the vet techs telling me that Lulu was demanding when left in a cage and even the surgeons would take her out and carry her around. :D My snotty old man, Jojo, was not shown the welcome wagon and stayed with me until I handed him off backwards. He would get a little testy with head on hand offs. :o The entire staff came to love both of them though as they were regulars there for many years. I miss my babies very much. :(

[MyMilo]

Hello again,
I have a few questions and was hoping to get some insight from the group. An updated full blood panel was run last week and I've requested a copy of the results so I don't have them on hand.

First, Trigylcrides were high and the IMS suggested I change to a low fat food but wouldn't give a food recommendation. Are high Trigylcrides typical with Cush dogs? Also I'm not inclined to change his food until we have a proper Vetoryl dose determined. Not to mention I just had just opened an $80 bag of dog food. :eek:He's on day 4 of Vetoryl and we have the follow up ACTH test scheduled a week from tomorrow.

Second, his first pee of the morning was typical for him than after breakfast he had a bout of staining to urinate and would have a little dribble each time. I've been home with him all day and it hasn't happened to that extent again. The on call vet was hesitant to call in a prescription without speaking with the IMS and I decided to hold off and wait to speak with her tomorrow since I didn't see any blood in the urine and he didn't seem to be uncomfortable at the time. Does this straining indicate a UTI or is it something that happens with Cushings?

Third, his ALP enzymes were higher then the last check in January. Will the Vetoryl help bring down liver enzymes?

Lastly, his calcium levels have run high for years. The IMS thinks it could be his parathyroid gland and suggested an ultrasound confirm. Though the only treatment would be surgery to remove it.

So basically, put a fork in me, I'm done. It feels like it's one thing, after another, after another, after another. I'm starting to get very overwhelmed and confused as I'm sure many can relate.

I'm trying to get my questions, concerns and head in order for when I speak with the IMS tomorrow. So any insight would be great! Thanks.

[labblab]

We surely understand how frustrating and exhausting these medical issues can feel. But try to hang in there -- you're doing such a great job of advocating for your little boy! I wish I had the time to reply in greater detail, but here's some quick answers to your questions in advance of your appointment tomorrow.

First, elevated triglycerides are a fairly common finding in Cushpups. I think your IMS's recommendation to search out a lowfat food is probably a good one, but I agree with you that I'd wait to make any feeding change until after Milo is stabilized on his trilostane dose. In the short run, trying to minimize any GI upset that can be confused with drug overdosing would be preferable. In the meantime, you can be doing some research, though, and I'll try to return tomorrow with a link to a website that provides a lot of great guidance re: evaluating lowfat foods.

Second, Cushpups are vulnerable to infections of all sorts, including UTIs. From what you're describing, I do think a UTI sounds like a plausible source of Milo's straining and dribbling.

Third, treatment can result in a lowering of liver enzymes in many Cushpups. But some dogs never return to the normal range, even after an extended period of treatment. As long as the dog is otherwise doing well, however, this does not need to signal a major issue.

And finally, I'm afraid I cannot help re: the elevated calcium. I just don't know that much about it. However, if this has been a consistent finding over a long period of time, I don't know that I'd be worrying excessively about it right now. If it was a signal of cancer or something really sinister, for instance, I would have thought that you'd have seen it turn into much bigger problem by now.

Listen, good luck with the vet visit tomorrow, and please keep us updated as to what you find out. And I hope both you and Milo are able to get a decent night's rest tonight -- you deserve it!

Marianne

[molly muffin]

In regards to the high calcium, my dog regularly bounces back and forth between high and normal calcium levels. I think some dogs do tend to bounce or run a big high. Since this has been going on for a long time and hs long as it doesn't just climb, climb, climb, then I don't know how worried I would be about it. You could do an ionized calcium to check but I'd want a couple consecutive tests showing high before I'd proceed to anything else I think.

UTI is a definitely possibility so maybe having a urinalysis/culture done would be worth while.

My dogs liver enzymes also have bounced, but never really come down, and if they did come down and I get all happy about it, the next test they have bounced back up. That can be frustrating but I know that some dogs they will never again be normal.

I think you're doing an excellent job, and I know it is sooo frustrating that all these things are going on. I usually feel like it's a balancing act and it can be one, but sometimes, having that cortisol at a good level, helps other things too.

[MyMilo]

Thanks for so much for the replies. Your encouraging words really make a world of difference for me during this journey.

[MyMilo]

Hi all,
We are on day 9 of Vetoryl and Milo appears to be responding well to treatment so far. I know it hasn't been long, but he seems to be drinking less water and appears to be more comfortable overall.

The ACTH stim test is Monday along with a bladder ultra sound. I've read that a serum biochemistry with electrolytes test is recommend as well. The IMS didn't mention doing this so I plan to bring it up on Monday.

My question is why is the updated blood work recommended? Is there something that we need to be looking at being better or worse? I want to sound somewhat educated when I ask for the test :rolleyes:

Any input is appreciated, thanks!

Beth

[Harley PoMMom]

Trilostane, which is the active ingredient in Vetoryl, has the ability to alter those chemistry values, particularly the electrolytes such as potassium, sodium, calcium, and chloride. That change could just be temporary and are monitored with the serum biochemistry panel.

Glad to hear that Milo is doing well with his treatment!

Hugs, Lori

[molly muffin]

Some dogs will actually have a drop in the cortisol that has them within the normal range, but their electrolytes (as mentioned by Lori) will be out of range and that is serious and a response to the trilostane, so would need to be addressed.
I like to have those things checked periodically especially till you know how your dog specifically will react to the medication.