Ullig, Bedlington Terrier, just diagnosed

[ulligsmam]

My lovely boy Ullig was diagnosed with Cushings this week, he is a bedlington terrier aged probably around ten years (we got him a bit over five years ago through an internet small ads page, he was supposed to be two years old but was more likely four or five, he’d been through quite a few homes so no paperwork). I groom him myself and had noticed a few months back that his coat was getting a bit thinner, but other than that he was fine so didn’t worry too much. Then he started drinking water - previously he did not drink unless given milky water - and being keen on food (bedlington terriers are odd little things, not very foody at all, we used to have to pick him up and carry him downstairs for his breakfast or dinner) - being on a facebook page about Bedlingtons I’d become aware of Cushings and the picture started to fit together, thinning coat, thirsty, tummy sagging, hungry...the vet wasn’t convinced, didn’t think he was drinking enough for Cushings. Did blood tests, no diabetes, no thyroid problems, no kidney problems, white cell count fine, AP fine, only ALT was raised (twice upper end of normal), first pee of morning test showed very dilute urine but everything else fine, I asked for a creatinine:cortisol on the morning pee sample and that showed high cortisol levels so we went to ACTH stimulation and bile acid test. Cortisol pre ACTH was 127 nmol/L, (ref range 25-125, post ACTH 839 nmol/L (ref range 125-520). Vet has prescribed Vetoryl at 20mg - Ullig weighs just over 9kg, we should be picking up the tablets tomorrow to start on Wednesday morning (should have got them Saturday but the pharmacy closed early and its a bank holiday weekend here), Vet says to give two 10mg tablets together but I'm wanting to split the dose to 10mg in the morning and 10mg in the evening just in case he has any adverse reaction. He is drinking at the upper end of normal for a dog his size, not huge amounts, his coat is thin but he has no bald patches as such (raw coconut oil has helped the general condition of his coat and skin), he is much keener on food but not ravenous, but he has had a couple of episodes of trembling. His bile acid test showed high values both before and after fatty meal - the print out has disappeared but I'll add the figures when I find it - the vet offered to do a liver biopsy but I'm not keen on that idea - no insurance and funds getting a bit stretched with the all the testing for one thing.
I have for the past week or so, since after his test, been giving flaxseed lignans, tulsi and ashwaghanda, should I stop these before starting the Vetoryl? His tummy is looking less full/droopy the last couple of days, so maybe the herbs are helping? His behaviour hasn't changed much, he's quite happy, still chases his ball around the park, in fact we can now let him off the lead because he will come back for treats which he'd never do before.
Having read up on the Vetoryl I am worried about starting it, especially as he is not very symptomatic, but I don't have enough faith in the herbal remedies to make enough difference...
Thats probably enough for now, thank you for being here :)

[Jazz]

I sure someone who actually knows what they are talking about will be along soon.
Just wanted to say Hi and that I empathise as to not knowing exactly if you should treat or not.
My girl has been having seizures that were initially suspected as being Cushings related but now they are not so sure.
Ok I'm not being much help here but as another newbie with issues I wanted to say I understand just how stressed you are.
For me it's the last thing I think of before I go to sleep and the first thing I think of in the morning. Relaxing it's not.
Hope you get a resolution and help really soon.

Jazz's Mum.

[ulligsmam]

Thank you - it sounds like there is a chance your baby doesn’t have Cushings after all, hope thats so and that whatever she does have is treatable. As you say, this takes up pretty much every waking thought. We now have the Vetoryl but I’m pretty anxious about starting him on it in case it doesn’t agree with him - our vet hasn’t offered much info and only vaguely mentioned follow up tests.

[DoxieMama]

Hello and welcome to you and Ullig. I am also rather new to this, my dog having been diagnosed only in February of this year. I wanted to comment though that it sounds like you have a very good starting dose. As Ullig is 9kg (which equates to 19.8 pounds), Dechra recommends a starting dose of 1mg/pound or 2.2mg/kg which would be 19.8mg... 20mg is perfect to start with. I'm not sure about splitting the dose morning/evening or giving the full 20mg only in the morning, as I have only dosed so far in the morning the full amount for my dog. The majority of dogs "do fine" on once per day dosing, whereas others need to have twice per day as symptoms sometimes recur in the evenings otherwise. I think that is because their cortisol does not have a chance to rise as high between doses... which suggests that perhaps it keeps the level lower overall than once per day. Does that make sense? Sorry, I am a little scattered at the moment. Hopefully one of the admins or other more knowledgeable folks will comment on your thread and provide more clear and correct information. :)

Oh! There is a subforum here with links to all kinds of information. Helpful Resources for Owners of Cushing's Dogs - here it is (http://www.k9cushings.com/forum/forumdisplay.php?f=10). You can read about diagnosis, treatment and follow-up testing there.

Hang in there!
Shana

[ulligsmam]

I’m probably worrying too much, I just don’t want to start him on too much - I know that steroids need to be withdrawn very slowly (medical secretary of many years) and as his pre ACTH stim cortisol was only a very little over normal maximum and his symptoms are quite minimal - he drinks around 500ml of water a day, or a little bit more, he is keener on food but still very polite with it, no attempts to steal from the other two dogs in the house or the cat, and though his coat has got a bit thin he has no bald patches, though I can see little dark patches of skin now that he didn’t have before. His saggy belly is improved greatly over the last few days, so I’m wondering if the herbs (flaxseed lignans, tulsi, ashwaghanda, milk thistle) are helping.
Basically, he’s my baby, even if he is a grumpy old man with only one good eye (one eye blind from cataract, maybe one of the reasons he was rehomed).

[Harley PoMMom]

Hi and welcome to you and Ullig!

It is a tough call to treat Ullig or not, he does have some of the Cushing's symptoms but they don't seem to be that strong and since the goal of treatment to control those obvious clinical symptoms I'm not sure how you will be able to judge how well his treatment is working.

The good majority of dogs, 80-90%, with Cushing's have a very elevated ALP. Other lab anomalies generally found in cushdogs are high cholesterol and triglyceride levels. They also have what is referred to as a "stress leukogram," which refers to a specific white blood cell distribution in the blood. This includes a high total white blood cell count with increased numbers of neutrophils (NEU) and monocytes (MONO) and decreased numbers of lymphocytes (LYM) and eosinophils (EOS). From what you posted I see that Ullig's blood work does not show any of these abnormalities.

So, with Ullig not showing strong symptoms and not having the usual abnormal blood work, I would be inclined in not treating him with the Vetoryl. I see no harm in continuing with the flaxseed lignans, however I'm not familiar with tulsi and ashwaghanda. If this were me I would do the "wait and see approach" and if Ullig's symptoms tend to increase than I would revisit that Cushing's diagnosis.

Hugs, Lori

[molly muffin]

Hello and welcome from me too.

I'm also not familiar with tulsi and ashwaghanda so can't comment on those, but the lignans should be fine.

If you want to wait and see how he does on these herbs and supplements for a bit and then retest the ACTH and blood work to see if they have come down any, then I would think that would be fine. I would have a discussion with your vet though, so they know what you are doing and what the plan is.

Did you buy 20mg pills? If so and you do want to start, then you could start at 20mg and then if that is the right dosage, go to 10mg/10mg next time.

Some dogs do fine on once a day and some dogs do better on twice a day dosing. It all depends on the dog. Mine is on once a day but many have what symptoms more in the evening, so twice a day makes sense to control the cortisol all day long.

[ulligsmam]

ashwagandha and tulsi (holy basil) are both in adrenal harmony gold - I’ve been taking them myself since buying them for Ullig (lots of stress, between the cushings and stuff going on at work too) and my sleep has improved at least! There seems to be a bit more science behind the flax seed lignans perhaps. I’m almost inclined to stick to the natural remedies, but then isn’t it better he start the Vetoryl sooner rather than later before he gets more damage from the cushings? The Vetoryl I’ve got is 10mg, 30 capsules, so two weeks worth and a bit, after which a blood test the vet said - she seems a bit vague about it all, I’ve been asking around looking to switch to be honest.

[Harley PoMMom]

The internal damage made by elevated cortisol takes a long time to occur.

We do have information in our Helpful Resource forum regarding the lignans and here's the link to it: http://www.vet.utk.edu/diagnostic/endocrinology/pdf/20120316-LIGNAN-Write-Up-Revision02.pdf

As far as the testing, treatment is monitored with an ACTH stimulation test which entails 2 blood draws; first a "pre" blood draw is taken, than a stimulating agent is injected and an hour later another blood draw is taken which is known as the "post" number.

We have a wealth of information regarding Cushing's in our Resource thread, which does include articles written by some of the most renown veterinarians that specialize in endocrinology such as David Bruyette, Mark Peterson, and Edward Feldman. Here's a link to our Resource thread: Helpful Resources for Owners of Cushing's Dogs (http://www.k9cushings.com/forum/forumdisplay.php?f=10) Please know we will help in any way we can, and do not hesitate to ask all the questions you want.

Hugs, Lori

[ulligsmam]

Started him with 10mg vetoryl this morning after his breakfast - just found the capsule on the floor of the conservatory, I was sure I’d got it down his throat and he'd swallowed, but he’d spat it out after! Its gone in again now in a ball of raw mince with a few biscuits and a drink to follow. Got today and tomorrow off work so I can keep a close eye on him, going to work the dose up gradually. Been having a look at photos and the difference from a year and a half ago is quite marked, he looked years younger, thick dark coat, stronger looking dog altogether. Not sure how to load photos up here, apart from avatar which I could upload from the computer..

[Harley PoMMom]

It is much easier to give the capsule in some kind of snack, and I just want to make sure you are aware that it is very important that the Vetoryl be given along with a meal.

Hugs, Lori

[molly muffin]

Most of us have run circles trying to get the pills in something they will take. I use wet food and make a ball out of it, but I've been known to also use some kind of meat or a dab of cream cheese, as what my dog likes on monday she might not care for on tuesday.

[ulligsmam]

Test results for Ullig before and after starting Vetoryl – his cortisol levels have dropped hugely, maybe even too low? Thoughts please from those who have more experience and knowledge than me would be greatly appreciated. Here are the numbers
First ACTH stim test (diagnostic) in Nmol/L
cortisol pre ACTH 127.0 reference range 25.0 – 125.0 HIGH
Cortisol post ACTH 839 reference range 125.0 – 520 HIGH
Alkp 154 U/L reference range 23 – 212
ALT 262 U/L reference range 10 – 100 HIGH
AMYL 365 U/L reference range 500 – 1500 LOW
Bile acid fasting 12.0 umol/L reference range 0.1 -10.0 HIGH
Bile acid post fatty meal 58.1umol/L reference range 0.1 – 10 HIGH

Started Vetoryl 10mg a day for three days then 20mg a day for eleven days
ACTH stim test 5 hours after 20mg Vetoryl in Nmol/L
Cortisol pre ACTH 11.6 reference range 25.0 – 125.0 LOW
Cortisol post ACTH 161.0 reference range 125.0 – 520
Alkp 37 0 c 154 U/L reference range < 130 HIGH
ALT 37 0 c 160 U/L reference range 19 – 124.0 HIGH

Not sure why the reference ranges for the ALT and ALK are different from one test to the other?
Bile acid 19.5 – this is down as a fasting sample but he’d had breakfast with his Vetoryl and quite a lot of treats (mainly fish skin so quite oily) on the walk before going to the vet, but not fasting reference range is 0.1 – 10 so still high, but maybe better than the first test? I stopped the herbal supplements (apart from the milk thistle) when he started the Vetoryl

[DoxieMama]

Converting those numbers to those I'm more familiar with:

Diagnostic ACTH: Pre 4.6, Post 30.4 ug/dL
14 days of Vetoryl: Pre 0.4, Post 5.8

Those numbers look good to me, though I'll defer to those with more experience. How are his symptoms now?

I'm curious if potassium/sodium were also tested?

[Harley PoMMom]

Yep, those are great numbers, and yep, that is a significant drop in that post number. Ullig's dose of Vetoryl is 20 mg, right? And she is stay on this dose until her next ACTH stim test in another 2 weeks?

[Aunt Jana]

I'm not an expert, just a dog mom going through this. That pre number is very low. Vetoryl insert states under 1.45 to discontinue use.

[labblab]

Here is the insert that Aunt Jana is talking about:

http://www.dechra-us.com/Admin/Public/Download.aspx?file=Files%2fFiles%2fProductDownload s%2fus%2fvetoryl-5mg-pack-insert.pdf

And she is correct about concern over a result <1.45, except for the fact that the concern is attached to the second, "post" ACTH result, which in Ullig's case is up at 5.8. As long as a dog is doing well, far less attention is paid to the baseline cortisol level. So according to Dechra's monitoring chart, you would remain on the same dose, as long as Ullig appears to be doing well. However, with a baseline cortisol that low combined with such a large overall drop in cortisol in just fourteen days, I definitely would not increase his dose, I would watch him carefully for outward signs of overdose, and I would definitely retest in another two weeks because his cortisol may continue to drop even further. You may end up needing to reduce his dose a bit if that proves to be the case.

And just to make clear -- the normal range that your lab provided for Ullig's ACTH results corresponds to the range for a dog who does not have Cushing's at all. That is the range that applies when the ACTH is being used as an initial diagnostic test. The range in that Dechra insert is the one that applies to monitoring ACTH tests when a dog is being treated with Vetoryl. ;)

Marianne

[ulligsmam]

sodium (Na) on the first test was just within normal range, one point below high, potassium (K) was mid range normal, can’t see either on the second tests though. His Haemoglobin is high on the first test too, vet didn’t say anything about that but googling suggests high sodium and high haemoglobin suggest dehydration? The vet is concerned a bit about his liver, but I don’t think he has primary liver problems (Bedlingtons are prone to copper toxicosis, but that usually shows up when they are younger) - he’s showing no clinical signs of liver problems, though the bile acid tests have all been high.
Symptomatically he’s great, not drinking nearly so much - back to asking for a bit of milky water and turning his nose up at the drinking bowls, though asking for drinks a little more often than he used to. Also he’s not snoring nearly so much as he had been recently - the vet seemed a bit mystified by that when i mentioned it.
Next test is three months.
I am thinking about dropping him to one 10mg a day of Vetoryl and adding the flax seed and herbs back in and see how he does (currently we’re out of tablets, vet didn’t have any 10mg in and I’ve got a prescription and ordered them from a local pharmacy who’ll have them by Monday - vet after much pleading gave me a repeat prescription, considering she charges £8 to write them I wasn’t keen on having to have a new one each month.) If he starts drinking loads again then will put him back to two tablets. Yesterday he had one (the last in the packet) - vet and pharmacy only keep the 30mg tablets and above in stock.

[Harley PoMMom]

The main reason in having an ACTH stimulation test performed at that 30 day mark is to make sure that the dog's cortisol hasn't drop too low.

We have seen on the forum that outwardly a dog seems to be doing fine but when an ACTH stimulation test was done the cortisol did indeed fall below the therapeutic range, for this reason I would not recommend waiting 3 months to have Ulllig's cortisol checked, I'm not a vet so this is just my opinion. Please do keep us updated.

Hugs, Lori

[ulligsmam]

Gosh, doesn't time fly - time for an update I think! Well over a year now and the boy is doing very well on Vetoryl 20mg a day with the dose split, so 10mg in the morning and 10mg in the evening, twelve hours apart (he's 10kg) No symptoms at all, coat has grown in thick and dark :)The ACTH tests upset him a lot though, whether the test itself or the stress, but he had diarrhoea for a week after, so I did a bit of Googling and came across the research being done at Glasgow university, backed by DECHRA, about testing pre-pill cortisol levels instead. We changed vets anyway as hadn't been happy with the last one (the last straw was getting him back from ACTH test with his face covered in dried vomit that they'd 'not noticed') and found one who was happy to do the pre-pill cortisol only - he even phoned Glasgow university to discuss it with them. So far all test results have been good, and I'm wondering if anyone else has looked at the Pre-pill cortisol test research? The research was published late last year and is easier to find information on now. http://www.vetpracticesupport.com/monitoring-canine-hyperadrenocorticism-using-pre-pill-cortisol-instead-of-an-acth-stimulation-test/

[molly muffin]

I recall that someone mention this study once before but I don't know anything further about it personally. I know that for a few years there was a problem getting the stimulating agent in Europe to use in ACTH tests, so vets where looking for other alternatives to monitor cortisol levels.
A pre pill test would I assume be testing just the resting cortisol level prior to a pill being given. Since cortisol Pre levels can fluctuate during the day I don't know if it would be helpful other than to know that they weren't in crisis but perhaps not as much as to whether a dosage increase is needed or not.

It is tempting to want to try it, but i think personally I'd try to do ACTH tests also at a regular interval until you know how well a pre test works for your dog.