Newly Diagnosed - Pinkie has passed

[pinkie]

My 8 1/2 year old Maltese was diagnosed with Cushing's in April. Her water intake is approximately 1 cup/day and urination does not seemed to have increased.

The LDDS test results were: pre 3 reference range 1.0 - 6.0 ug/dL; post 4-hour 2; and post 8- hour 2.

I am only listing abnormal lab test results: ALP - 408 reference range 5 - 160 U/L; cholesterol - 444 reference range 131-345 mg/dL; chloride - 99 reference range 108-119 mmol/L; sodium - 139 reference range 142-152 mmol/L; auto platelet - 723 reference range 143-448 K/uL; T4 - .9 reference range 1.0-4.0 ug/DL; Free T4 - .5 reference range 0.6-3.7 ng/dL; Free T4 - 6.4 reference range 7.7-47.6 pmol/L; UA blood - tracehigh. The vet also indicated that her urine was very diluted.

She is currently on thyroid medication and the following supplements: milk thistle, turmeric, cushex s and m.

It seems that her symptoms have become worse this past week to include panting and severe lethargy. She also feels very warm and her heart rate is very high after exercise.

I am not sure if the increased symptoms are due to worsening Cushing's. Should I stop the supplements and try medication at this point? On-line research indicates that medication can be very toxic. Also, should I schedule a HDDS test to rule out adrenal tumor?

Any information would be greatly appreciated with this confounding disease.

[DoxieMama]

Hello and welcome! Thanks for providing the abnormal test results. Do you have the reference ranges so you can add those in? You should be able to edit your post above to include them. Not all labs use the same reference ranges so it can be helpful to see exactly what they're comparing to. I'm sure others will be by to welcome you and provide feedback on the information you've provided... but don't be surprised if they ask more questions! The more details we have, the better support we can provide. ;)

Shana

[kanga]

Sorry about what happen to your baby:( I want you to know that you are always in my thought's! I know there's a lot of member here who can give you good advice and good information about the problem that you facing right now. I pray for her god is good don't loss hope.

[molly muffin]

Unfortunately cushex doesn't actually lower cortisol, it basically can help with the symptoms sometimes and usually those who try it end up on medication.

Milk thistle for the liver is fine and I've hard good things about tumeric but can't say much as I haven't tried it.

You could try vetroyl at no more than 1mg/1lb to start.

If I was going to do another test, I would probably opt for an ultrasound as it gives you a lot of bang for the buck, can tell you if there is an adrenal tumor and can also rule out sludge in the gall bladder. I've seen several maltese end up with sludge is why I mention it .

[pinkie]

Thank you for the information. I am so glad I found this forum for support and to research information.

I understand Vetroyl is very toxic and can cause more issues. I will discuss the ultrasound and Vetroyl with my vet and next steps to relieve symptoms since there is no cure.

[lulusmom]

I agree with Sharlene that an abdominal ultrasound would be a superior differentiating test and money well spent. It not only can differentiate based on the adrenal abnormalities, it can give the vet a really good look at the surrounding organs, including the gall bladder already mentioned, to make sure there are no non-adrenal problems that can be contributing to symptoms and lab abnormalities. Cushing's is one of the most misdiagnosed canine diseases so the more differential diagnoses a vet can rule out, the better.

Vetoryl is a very serious drug but if prescribed and monitored by an experienced vet who follows proper protocol, side effects can be greatly reduced and most often avoided completely. Of course, your participation in watching for signs of low cortisol is mandatory. The more you learn about the disease and the treatment, the more confident you will become in assuming an even more proactive participation in your pup's veterinary care.

In preparation for starting treatment, I highly recommend that you review Dechra's Vetoryl Diagnosing, Treating and Monitoring brochure. I've provided a link below and suggest that you make certain your vet already has this information. If s/he does not, please make sure you provide him/her with the url or printed copy. You would be surprised by how many gp vets fail to follow protocol. Speaking of which, please make sure your vet follows the latest starting dose recommendations by the manufacturer which is 1 mg per pound of body weight (2.2mg/kg) per day and always give the capsule with food.

http://www.dechrace.com/pdfs/vetoryl/VETORYLTreatmentMonitoringBrochure.pdf

I see in your first post you mentioned that your pup is now experiencing increased heart rate after exercise. It is not uncommon for the heart rate to go up when exercising but if what you are seeing is not normal for your dog, it could be that the dose of thyroid supplementation is too high. Increased heart rate is definitely a symptom of hyperthyroidism as is excessive drinking and peeing so if both of these symptoms have increased after starting thyroid supplementation, you may need to cut back on the dose. Please make sure you tell your vet about this because persistent increased heart rate can be serious. How much does your pup weigh and what dose of thyroxine is she getting?

Glynda

[pinkie]

Pinkie normally weighs 8.5 pounds, but she now weighs 8.2 pounds. She is on thyroxine 0.1 mg 1/2 tab every 12 hours.

Also, should I also schedule an ACTH test before starting Vetoryl since I recall reading that ACTH confirms Cushing's? I understand routine ACTH will be required after medication. Is ACTH necessary if LDDS is indicative of Cushing's? The ultrasound has been scheduled for next week.

Thank you everyone for your answers and support!

[Harley PoMMom]

1 cup of water is a normal amount for a 8.2 lb dog, does she have any other symptoms of Cushing's such as: ravenous appetite, skin/hair issues, pot-bellied appearance, exercise intolerance, and difficulty or unable to go up steps or jump on furniture?

An ACTH stimulation test is not required as a diagnostic test but since there isn't one test that can accurately identify Cushing's multiple tests are recommended to validate the diagnosis of Cushing's, and as the others have suggested, an ultrasound would be a very good option. ;)

Hugs, Lori

[pinkie]

Thank you for the response.

She is exhibiting the following symptoms: constant panting; severe itching around mouth area where she scratches until it bleeds; exercise intolerance; feels very warm; hesitant to go up steps; and severe lethargy. Her appetite is normal since she was always food driven from when she was a pup.

The vet said to continue normal activities, but I temporarily stopped activities that may tire her out such as walks and hospital visits.

I will wait for ultrasound results for next steps. I am encouraged to read success stories regarding Vetoryl.

[dsbailey]

Is ACTH necessary if LDDS is indicative of Cushing's?

You should get an accurate diagnosis from the ultrasound and lots of useful information to move forward with.

I'm going to approach your question from a different angle. If money wasn't an issue and my dog didn't mind getting blood drawn then I would have liked to have had an ACTH test done prior to starting meds for baseline purposes. It's not necessary but may be helpful if you start having problems finding the proper dosage. With that said and in hindsight I'd not do it because my girl has gone from enjoying her vet visits to fearing them. Getting stuck in the neck with a needle 20 ish times in the past few months would make me a little vet shy too.

On a side note if you're girl is having persistent UTI's then getting a cystocentesis (needle inserted directly into the bladder) urine culture at the same time as the ultrasound may save you time, money, and mutual stress. This is the best method for a pristine urine sample.

Darrell and Lolita

[glfprncs]

Hi Pinkie,

Just wanted to chime in regarding the use of turmeric. My boy, TC, had been on trilostane and then we switched to lysodren in order to maintain his cortisol levels. Because his cortisol was no longer excessively high, at the age of 15 1/2 (at the time), TC was showing a lot of creakiness/arthritis that had been masked previously by the elevated cortisol. I wanted to use turmeric "golden paste" as I'd heard great things about it; however, I also read somewhere online that it COULD possibly prevent absorption of the Cushing's medication.

I contacted Dr. Doug English, an Australian veterinarian who uses turmeric paste extensively in his practice (he has an incredible website), and he recommended using the turmeric golden paste at the smallest dose (and not increasing the dose which is recommended as your dog can tolerate it) so as not to interfere with his body's absorption of his cushing's medication (lysodren).

[pinkie]

Thank you for recommending the ultrasound! It has been an agonizing week waiting for the ultrasound and ACTH results.

The ultrasound results show that Pinkie has a mildly enlarged liver; immobile sediment in the gallbladder (sludge); mild intestinal wall thickening up to .5 cm (normal is usually .42 cm at jejunum and up to .47 cm at duodednum); intestines are mildly distended with fluid and gas and intestinal erosions present visualized as trapped hyperechonic gas; mildly enlarged pancreas that measures up to 1.7 cm (normal is .35 to 1.6 cm); left adrenal gland measures low normal to mildly small at .5 cm and right adrenal gland is high normal to mildly enlarged at .77 cm (normal usually up to .74 cm).

The ACTH test results were 5.7 ug/dL pre (2-6) and 24.0 ug/dL (>22).

Based on the ACTH and ultrasound results, the vet recommended monitoring rather than starting vetoryl now and redo the ultrasound in a couple of months to watch the enlarged right adrenal gland and erosion in the intestine.

Pinkie is on Keraflex 1/4 caplet twice a day (crushed in water) for 28 days and Fortiflora. I hope this is the right thing to do now since I understand elevated cortisol levels can cause more problems down the line.

[Squirt's Mom]

Hi and welcome to K9C!

From the info you posted in your first post, I need some clarification on the following statement -


She is currently on thyroid medication and the following supplements: milk thistle, turmeric, cushex s and m.

What do the "s and m" stand for?

Later when you list the signs you are seeing you say your baby has -


severe itching around mouth area where she scratches until it bleeds

A dog with Cushing's rarely exhibits itching, much less severe itching, because the cortisol acts as a sort of treatment for inflammatory conditions like allergies, arthritis, etc. So this gives me pause in thinking your baby may have Cushing's at all. However, hypothyroidism does cause itching as can allergies. If I were you, I would focus more on her thyroid and on trying to determine what, if anything, she is allergic to that would cause the severe itching around her mouth. It might be worth a trip to a dermatologist for the mouth itching. I would look at her food, what she is exposed to outside (plants, chemicals such as would be used on lawns, bugs, and other things) as well as the things she is exposed to inside such as cleaners, perhaps dyes from new carpets or furniture, etc. Anything her mouth is exposed to or comes in contact with would be suspect for causing the itching....but I would be very, very surprised if this were caused by Cushing's. ;)

Hugs,
Leslie and the gang

[lulusmom]

Thank you for updating us on Pinkie's acth stim test and ab ultrasound. For what it's worth I do follow your vet's train of thought in delaying treatment at this time. Most of the lab abnormalities you posted can be attributed to cushing's or hypothyroidism for which Pinkie is now on supplementation, plus the adrenal enlargement is minimal and the intestinal and pancreas issues could very well have been responsible for pushing Pinkie's post stimulated cortisol above 22 ug/dL, which is the threshhold that would be consistent with cushing's. While the acth stim test is less likely to yield a false positive than the LDDS, it is not uncommon. All of those things can explain your vet's decision to put cushing's on the back burner for now. When will your vet be rechecking Pinkie's Free T4?

I'll be very interested in the results of the next ultrasound in a few months so please keep us posted.

Glynda

[pinkie]

I don't know what cushex s and m stand for, but there are two different supplements produced by Pet Alive. I understand they had to split up the original cushex due to some FDA requirement.

The vet thinks Pinkie's severe itching around the mouth is contact dermatitis and I have been making a note of when the itching is worse. I have been using Microcyn AH for wound care and it seems to relieve the itching.

The vet recommended retesting for thyroid in three months which will be the end of this month.

I will post the next test results. Thank you so much for the responses. I am very comforted by the confirmation that I am doing the right thing for my furry baby.

[pinkie]

The follow-up lab results were not good and all over the place (only abnormal results are listed):

ALP current 675; previous 408 (5-160 U/L)
ALT current 162; previous 68 (18-121 U/L)
GGT current 21; previous 13 (0 -13 U/L)
Albumin current 4; previous 3.9 (2.7-3.9 g/dL)
Total Protein current 8.1; previous 7.1 (5.5-7.5 g/dL)
Globulin current 4.1; previous 3.2 (2.4-4.0 g/dL)
Cholesterol current 421; previous 444 (131-345 mg/dL) good lower!
Glucose current 122; previous 107 (63-114 mg/dL)
Phosphorus current 6.9; previous 5.1 (2.5-6.1 mg/dL)
Chloride current 106; previous 99 (108-119 mmol/L) good higher!
Auto Platelet current 816; previous 723 (143-448 K/uL
T4 current 1.5; previous 0.9 (2.1-5.4 ug/dL therapeutic)

The vet had the lab rerun the specimen, but it confirmed the results. She is recommending another follow-up blood work in three weeks. Should I request for an UA and free T4?

Pinkie definitely has more energy probably from the thyroid medication and is able to exercise a bit more; however, the vet indicated that Pinkie should be at a higher T4 level with medication. The vet also asked about Pinkie's BM and stools, but she hasn't had any problem that I have noticed.

Pinkie hasn't exhibited other symptoms, but she still panting quite a bit. She has been receiving acupuncture treatments every other week which seems to alleviate her panting, but it is only temporary.

Also, I put Pinkie on a raw food diet which I think helped her cholesterol level. I guess I need to wait for more results for next steps.

Thank you everyone for the support.

[pinkie]

Updated 8/21 lab results (only abnormal):

ALP 609 (5-160 U/L)
GGT 15 (0-13 U/L)
Albumin 4.1 (2.7-3.9 g/dL)
Cholesterol 482 (131-345 mg/dL)
Phosphorus 6.3 (2.5-6.1 mg/dL)
Potassium 5.6 (4.0-5.4 mmol/L)
Sodium 155 (142-152 mmol/L)
MCHC 31.4 (32.6-39.2 g/dL)
Auto Platelet 915 (143-448 K/uL)

Pinkie's UA was fine except Blood and RBC were high, but the vet thinks that there was blood when the UA was drawn. Her therapeutic T4 was 3.6 (2.1-5.4 ug/dL) and she definitely has increased energy. She is still panting and her water intake has decreased most likely due to cooler temperatures this past month. I guess the raw diet does not impact cholesterol levels.

We are still continuing with acupuncture and started seeing a homeopathic practitioner. I will keep you updated with her progress and lab results. Thank you.

[Squirt's Mom]

Actually based on those numbers the CHOL has gone up - ;)

8/21 - Cholesterol 482 (131-345 mg/dL)

Prior levels posted - Cholesterol current 421; previous 444 (131-345 mg/dL) good lower!

Looks like most of the other values have improved tho...the ALT is normal now I assume? Good to hear she seems to be feeling better!

[pinkie]

Yes, you are right that the cholesterol level went up. Pinkie had raw beef for the entire week before the lab test. The homeopathic practitioner recommended that I do not feed her in the evening and morning before the lab test.

The ALT result is normal for this lab test.

I am hoping to keep her at this level for as long as possible.

Thank you.

[pinkie]

Updated lab tests on 12/18 with abnormal results:

ALP 820 U/L (5 - 160)
ALT 173 U/L (18 - 121)
GGT 14 U/L (0 -13)
Cholesterol 521 mg/dL (131 - 345)
Chloride 105 mmol/L (108 - 119)
Potassium 5.7 mmol/L (4 -5.4)
MCHC 31.8 g/dL (32.6 - 39.2)
Auto Platelet 918 K/uL (143 - 448)

The ALP, ALT, cholesterol, and autoplatelet are significantly worse than her previous test on 8/21. We are still continuing to see the homeopathic practitioner and the vet is recommending an internist. I am still debating to whether to continue with the homeopathic and make an appointment with an internist.

[lulusmom]

Thank you for updating us with the latest blood labs. I am a bit concerned about the persistent increases in cholesterol. Do the test results include triglycerides? If not, you may want to ask your vet to do a lipid panel which would include cholesterol and triglycerides. You actually may want to hold off on that if you are truly considering a consult with an internal medicine vet (IMS). I personally think that is an excellent idea. Maltese is a breed that we see more than other breeds who are diagnosed with gall bladder mucoceles which can be very serious if not diagnosed and treated. You mentioned that an abdominal ultrasound interpretation stated that Pinky has a lot sludge so with the ever increasing cholesterol, that concerns me. My two cushdogs had concurrent diseases so they were under the care of an IMS until they passed away. If you can afford it, go for it because an IMS has the experience and extensive education that makes them the optimum choice of caregiver. I am sure your vet would be happy to give you a referral.

[pinkie]

Thank you for the information. I have found several local IMS under resources through the ACVIM website and will make appointments as soon as possible. Happy Holidays and good health to our furry babies.

[lulusmom]

Yay, I'm glad you used the ACVIM website and found multiple choices. We'll all be anxiously awaiting your update after the consult.

Happy Holidays and good health to you and yours too.

(Hugs)
Glynda

[pinkie]

We found an IMS that we liked and Pinkie had a dex and ultrasound on 1/12.

Dex Results:
pre: 3.3 ref range 1.0 - 5.0 ug/dL
4 hr post: 2.5 ref 0.0 - 1.4 ug/dL
8 hr post: 2.7 ref 0.0 - 1.4 ug/dL

Ultrasound: Everything normal except L adrenal at .55 cm and R adrenal at .47 cm (large according to the IMS). Interesting that the previous ultrasound on 7/15/16 showed the R adrenal at .77 cm and that .55 cm would probably be considered normal.

The dex results indicated adrenal tumor, but ultrasound indicated pituitary. I asked if it could be both and the IMS said that she had encountered a case with adrenal and pituitary tumors. A recheck of the ultrasound (no charge) and ACTH test confirmed pituitary (results will be posted as soon I receive the lab results). Pinkie is now on 5 mg vetoryl capsules daily and I split the capsules and sprinkle it on her food in the AM and PM. The IMS said this should be fine. I use gloves to split the capsules and place the contents into paper squares.

Pinkie seems to be drinking less water and not panting as much, but but it has been colder than usual. A follow-up ACTH test is scheduled for 2/2. I will keep you posted.

[labblab]

Thanks so much for this update, and generally it sounds as though you are now moving forward on a positive treatment path. :)

My one huge worry, however, is that your IMS has told you it is OK to open and split the contents of the Vetoryl capsule. Even though the printed product insert for Vetoryl explicitly warns against opening and manipulating capsule contents, we still come across vets who say it is OK to do so. Two weeks ago I spoke directly by telephone to a technical representative at Dechra, the manufacturer of Vetoryl, and asked whether they have altered this warning. She reconfirmed it is still in place, and said there is absolutely no circumstance under which they would advise either a vet or a pet owner to open and split capsule contents. There are dangers to humans if they are exposed to the powder, and there is no way to know whether the medication is being divided or metabolized properly if it is taken out of the capsule and administered in a different manner.

Even though Dechra prefers to speak directly to vets, I believe they will tell you personally about this warning if you wish to call them yourself. Or you can certainly ask your vet to call Dechra if he prefers to discuss this with them. Since a 5 mg. capsule is Dechra's smallest dose, either you need to dose only once a day with the intact capsule, or have a compounding pharmacy professionally prepare a 2.5 mg. dose.

Here is contact info for Dechra's U.S. Office:

http://www.dechra-us.com/contact/technical-support

Whatever you decide, please do keep us updated re: Pinkie's progress.

Marianne

[pinkie]

Thank you for the information. I spoke to a Dechra representative and she stated that they do not approve of capsule splitting, but if I decide to do so that I should use precaution such as gloves and hand washing to minimize exposure. I will discuss with the IMS next week when Pinkie is scheduled for the follow-up ACTH.

[labblab]

Thank you for letting us know about your conversation with Dechra, and as I say, no matter what you decide to do, we're rooting for Pinkie and we'll be anxious to hear more as the treatment proceeds.

Marianne

[Squirt's Mom]

My concern with splitting the capsules is this - most meds have fillers along with the active ingredient, in this case Trilostane. When you dump and divide that powder you can't know how much filler and how much active ingredient is in each portion. So you may give too much one time and too little the next. I would talk to a pharmacist who knows about Vetoryl, or call Dechra again, and ask if these capsules contain fillers. ;)

[labblab]

Another worry I always have about opening capsules and adding the powder to food is that I don't believe that anybody has conducted research to see whether the chemical gets metabolized the same way in the body as when it is delivered to the stomach intact within a capsule. When it gets chewed up in the mouth along with food and then swallowed, does all the powder for sure get swallowed? Does it start being absorbed first there through the tissue of the mouth, and is that a good thing instead of heading to the gastrointestinal tract? Might that actually facilitate the effect, or blunt it? I dunno and I don't think anybody else does either. So that's really my biggest worry about opening the capsules and messing with the powder.

So I have this one other comment to add for you to think about in advance of your return to the vet. I realize that, everything being equal, some clinicians do prefer to give trilostane in two daily doses. There are thought to be possible benefits to maintaining cortisol levels more consistently low throughout an entire 24-hour time period. However, experience worldwide is that many dogs still experience positive symptom resolution when dosed only once daily in the morning, and that remains Dechra's starting recommendation. If symptoms rebound later in the day even when cortisol levels seem to be optimal 4-6 hours after dosing, then Dechra recommends shifting to the twice daily regimen.

No matter what, opening and splitting Vetoryl capsules is less than ideal. So if your vet wants to stick with brandname Vetoryl instead of a compounded version of trilostane, you may want to consider starting off with the intact 5 mg. capsule in the morning. If Pinkie responds well clinically while dosing that way, your problem is pretty much solved. If her symptoms instead rebound later in the day, then you could revisit the issue of coordinating two daily doses. Just a thought for you to consider alongside your vet.

Marianne

[pinkie]

Thank you for the recommendation. I will give her the 5 mg capsule in the AM with food. Also, I called Dechra again and they will not disclose inactive ingredients due to proprietary interest.

[Squirt's Mom]

I called Dechra again and they will not disclose inactive ingredients due to proprietary interest.

But now you know for your own edification that the capsule is not pure Trilostane so dividing the powder equally between the active and inactive ingredients would be very difficult. I'm glad you called them and shared what you found with us, too. I think you are wise to pursue the 5mg tablet. There is also the option of having a dose that Dechra does not make, like 3mg or 7mg for example, compounded by a trusted compounding pharmacy.

[pinkie]

I am editing this based on the copy of the lab results of the 2 week follow-up testing on 2/2/17: 9.5 ug/dL (8-17 ug/dL) and post-trilostane between 1.5 -9.1 ug/dL indicate optimal control. The IMS recommended that I keep Pinkie on the 5 mg vetoryl if her symptoms are the same. I have noticed that her panting has decreased significantly, but I can't tell with the water intake since it has been relatively cold here.

Her 30 day post testing is scheduled for March 9th so I will post the results and any other changes.

There is a reason to get the hard paper copy since the IMS told me her result was 9.0 ug/dL.

[molly muffin]

Sometimes it is a matter of baby steps and what works best for each individual dog. Looking forward to the 30 day test results.

[pinkie]

Pinkie was diagnosed with diabetes on Friday, 2/24 most likely as a side effect from Cushing's. I took her to the IMS because it seemed that she was exhibiting side effects from trilostane with trembling back legs and lethargy. Her glucose level was 302 mg/dL (78-115 mg/dL). I was really surprised since her last glucose level in December was 99 mg/dL. I wished I started her trilostane sooner to have prevented the diabetes. She is on one unit insulin twice a day. She is scheduled for a glucose curve testing next week. Her post ACTH test was 10.6 ug/dL (8-17 ug/dL) with 1.5-9.1 ug/dL as optimal for trilostane. The IMS recommended that I continue the 5 mg dose daily.

I will keep you updated of the results. This disease is hard to control to get the right balance and you have to be really vigilant.

[judymaggie]

Hi -- I am sorry that you now have another condition to deal with but it sounds as though the IMS is knowledgeable with diabetes control. I would suggest that you consider joining our sister site, k9Diabetes:

http://www.k9diabetes.com/forum/

Hopefully, Pinkie will do well with the insulin level she is on.

[pinkie]

Thank you for the information. I joined the k9 diabetes forum since I am having a hard time capturing the urine on strips to check her general glucose levels. I have already missed twice (completely dry) even though I am kneeling on the grass and trying to make sure the strip is underneath her while she is peeing!

[molly muffin]

Oh no poor Pinkie. That is one thing, diabetes can come on practically over night in these cushing dogs or i suppose any dog. Once it goes it goes quickly it feels like.

K9 diabetes is great. I'm sure they can give you some ideas for testing/catching.

[pinkie]

K9 diabetes was great and I am using a plastic spoon dedicated to catch the urine. They also recommended that I get a blood glucose meter and have started testing her at home. It is a triple whammy for poor Pinkie with hypothyroidism, Cushing's and now diabetes. It is an endocrine mess! We need a forum for dogs with multiple endocrine problems.

[molly muffin]

Good lord isn't that the truth
It is an endocrine mess! We need a forum for dogs with multiple endocrine problems. unfortunately they all seem to go hand in hand together. High cortisol, or steroid use both can contribute to the onset of diabetes.

I remember so many times on here we have laughed about the pee catch, a ladle was often used. Now there isn't much funnier than trailing behind our dog down the sidewalk with a ladle trying to catch them when they pee.

[pinkie]

Here are the results of the BG curve: 7 AM 640, 9 AM 467, 11 AM 450 and 1 PM 546. They stopped after 1 PM since the levels were consistently high. Ideally, BG levels should be less than 200 mg/dL with insulin.

Rather than raising the insulin (2 units of vetsulin twice a day) at this time, the IMS recommended increasing vetoryl dosage from 5 mg daily to to 5 mg twice a day. The IMS believes that Pinkie's cushing is not well controlled since the last stim test was slightly elevated. This may be causing the problem with diabetes control.

I also asked about compounding and IMS said that compounded trilostane is not as effective. I am worried about the vetoryl dosage since Pinkie has lost weight and is currently at 8 pounds. She is scheduled for an ACTH test in ten days and another BG curve test. afterwards.

[labblab]

I surely hope this dosage change will stabilize things for Pinkie. Can you tell us the actual numbers for the most recent ACTH test?

I do want to let you know that twice daily dosing is indeed usually recommended as being the best dosing pattern for a diabetic dog. So I think it is good that the IMS has made that suggestion. It's also good that cortisol will be retested in ten days since the daily trilostane total is being doubled.

I am wishing you good luck with this change, and please continue to update us.

Marianne

[pinkie]

Her previous post ACTH were the following: Feb 2nd 9.5 ug/dL and Feb 24th 10.6 ug/dL. Post trilostane betweetn 1.5 - 9.1 ug/dL indicate optimal control.

Her BG yesterday was really high over 750 g/dL but came down to 591 g/dL two hours after insulin. I have a call to the IMS.

[pinkie]

I talked to the IMS and Pinkie has an ACTH test scheduled for this Friday. I will keep you posted.

[molly muffin]

oh dear, what a time of it you and Pinkie are having. Do let us know what the test shows.

[pinkie]

Some good and bad news.

Good news 3/24 ACTH sim results: pre 1.2 ug/dL and post 4.4 ug/dL (1.5 - 9.1 optimal).

Bad news BG curve is still running from 424 to 553 mg/dL so insulin has been increased to 3.3 units of vetsulin twice a day. Pinkie has ketones in her urine and is only 7.7 pounds. The IMS thinks that the cushing's is not consistently controlled throughout the day which may be contributing to her ketosis.

A follow-up BG curve and evening ACTH sim is scheduled for next week with the increased insulin dosage. I will keep you updated. It is a balancing act.

[Harley PoMMom]

Why is the IMS reluctant in having her Vetroyl being given twice a day which is strongly recommended for a diabetic dog?

[pinkie]

Pinkie is currently on 5 mg vetoryl twice a day. I was really concerned about the increased dosage since she weighs less than 8 pounds now, but it seems to be regulating the cortisol level more or less at this point. I am hoping the evening ACTH sim test will provide more information since Pinkie is panting in the evenings.

[westcoastflea1]

my 8 1/2 year old maltese was diagnosed with cushing's in april. Her water intake is approximately 1 cup/day and urination does not seemed to have increased.

The ldds test results were: Pre 3 reference range 1.0 - 6.0 ug/dl; post 4-hour 2; and post 8- hour 2.

I am only listing abnormal lab test results: Alp - 408 reference range 5 - 160 u/l; cholesterol - 444 reference range 131-345 mg/dl; chloride - 99 reference range 108-119 mmol/l; sodium - 139 reference range 142-152 mmol/l; auto platelet - 723 reference range 143-448 k/ul; t4 - .9 reference range 1.0-4.0 ug/dl; free t4 - .5 reference range 0.6-3.7 ng/dl; free t4 - 6.4 reference range 7.7-47.6 pmol/l; ua blood - tracehigh. The vet also indicated that her urine was very diluted.
She is currently on thyroid medication and the following supplements: Milk thistle, turmeric, cushex s and m.

It seems that her symptoms have become worse this past week to include panting and severe lethargy. She also feels very warm and her heart rate is very high after exercise.

I am not sure if the increased symptoms are due to worsening cushing's. Should i stop the supplements and try medication at this point? On-line research indicates that medication can be very toxic. Also, should i schedule a hdds test to rule out adrenal tumor?

Any information would be greatly appreciated with this confounding disease.aaaaaaaaaaa

[westcoastflea1]

[QUOTE=pinkie;199643]Her previous post ACTH were the following: Feb 2nd 9.5 ug/dL and Feb 24th 10.6 ug/dL. Post trilostane betweetn 1.5 - 9.1 ug/dL indicate optimal control. I WOULD TRY TO GET HER DOWN TO 5.0

Her BG yesterday was really high over 750 g/dL but came down to 591 g/dL two hours after insulin. I have a call to the IMS.

[westcoastflea1]

Look up hpa axis on internet it will give you greater understanding of how the endocrine system works knowledge is power:)

[pinkie]

Pinkie has lost her appetite and it has been difficult to make her eat. She will eat salmon snacks, so I have been giving her as much as she will eat of the snacks.

This is probably a side effect of increased vetoryl dose, but it is not good with her diabetes. I am not sure if I should stop the vetoryl now. I will call the vet tomorrow, but in the meantime, any recommendations?

[Squirt's Mom]

Yes, stop for now. It is better to be safe than sorry. ;)

[pinkie]

I will stop until I hear back from the vet. Also, I was able to make her eat a bit with adding bone stock. Thank you!

[Squirt's Mom]

Bone broth is good for us all so I am glad she accepted it! Let us know how she's doing over the next day or so but I hope you see her appetite return very soon.

[pinkie]

Pinkie ate some last night and ate more this morning with the bone broth. I talked to the vet and she recommended continuing the trilostane since the cortisol levels will affect her diabetes. It was scary since she has lost a pound and is down to 7.5 pounds. She is scheduled for another BG curve test this Thursday and PM ACTH stim test.

[molly muffin]

Is she still eating tonight? I know you are probably thinking Thursday can't get here soon enough so you can see what is going on.

[pinkie]

Pinkie will not eat the same thing twice in a row. I have resorted to letting her sniff and she will eat if she starts licking the container.

It was terrible this morning since I had to try two different meats before she ate a bit of cooked chicken. I was able to give her insulin shot to drop her off for BG curve test. The IMS just called to state that they did not feel that a PM ACTH stim was necessary, but they would do a full blood work and urine culture to determine if there is something else contributing to her low appetite and energy level. I will post the update with the results.

[pinkie]

Pinkie's BG curve 4/13 results ranged from 445 to 553 indicating that the diabetes is still not well regulated. The IMS increased the insulin dosage and recommended the first urine sample for a urine cortisol/creatinine ratio to be dropped off on Monday rather than the PM ACTH stim test since stress can result in higher cortisol levels. The IMS also prescribed cerenia to help with her appetite.

She is scheduled for a follow-up BG test curve in two weeks. Poor Pinkie is at the vet's office every two weeks.

I will post the CBC/chem/UA/T4 results as soon as I receive them.

[westcoastflea1]

make sure she is eating grain free since grains raise glucose

[molly muffin]

Oh I am sorry to hear that Pinkie's BG is still on the high side. :( That might be making her feel like not eating. I hope the increase in insulin helps. Did they switch Pinkie to a different type of insulin at one point? I seem to have in my mind that not all dogs respond to every type of insulin and that it needs to be switched sometimes.

Do you do bg checks at home too?

[Harley PoMMom]

I really do not see a benefit of doing an urine cortisol/creatinine ratio (UC:CR) test because if any kind of illness is present the chances are high that the dog's cortisol is elevated, if checking a dog's cortisol level is needed, I believe, having an full ACTH stimulation test would be the best option.

[pinkie]

She is still on vetsulin, but at an increased dose at 4 units currently. She seemed to be doing better this weekend and her appetite improved.
I only checked her fasting BG which was still high at 335 since k9 diabetes indicated that it takes at least five days for the new dosage to start working.

I will talk to the IMS about changing her insulin and another ACTH stim test. Her last stim test results were pretty good on 3/24 at pre 1.2 and post at 4.4.

[westcoastflea1]

I really do not see a benefit of doing an urine cortisol/creatinine ratio (UC:CR) test because if any kind of illness is present the chances are high that the dog's cortisol is elevated, if checking a dog's cortisol level is needed, I believe, having an full ACTH stimulation test would be the best option.

unfortunately many people dont understand that UCCR means urine cortisol creatinine ratio. the important word here is RATIO. UCCR does not just measure cortisol levels because they fluctuate if that were the reason for the test it would be called a UC, and wouldnt be used because it would be a useless test. UCCR measures cortisol levels IN RATIO to creatinine. creatinine levels do not fluctuate like cortisol so measuring ratio of CORTISOL AGAINST CREATININE is the reason why the test is so valuable. it should be the FIRST test given when cushings is suspected because while it may give false positives its negative result is rock solid. UCCR comes back as negative for cushings you KNOW your dog doesnt have it.
Most importantly this idea that dogs need constant acth tests keeps many dogs from getting the monitoring they need because of high cost. uccr is a valuable tool to use in monitoring a dog who is currently taking medication. a UCCR result will tell you your dog is non cushings or cushings. if non cushings it means meds are good if cushings increase dose. UCCR saves your dog from having cortisol levels artificially raised with acth , needle pokes, high costs and vet visits UCCR uses urine samples taken at home 1st thing over the course of 2 or 3 days kept refrigerated then mixed so urine being tested will be a 3 day period of stress free am urine.I know UCCR is accurate as a monitoring tool i had 2 tests done at once, one am catch was with no vetoryl the night before (results came back a little higher then results from am urine WITH vetoryl dose the night before. Many labs use uccr among other tests in studies of new drugs, if it wasnt accurate then it wouldnt be used

[Harley PoMMom]

I apologize for the hijack here :o



unfortunately many people dont understand that UCCR means urine cortisol creatinine ratio. the important word here is RATIO. UCCR does not just measure cortisol levels because they fluctuate if that were the reason for the test it would be called a UC, and wouldnt be used because it would be a useless test. UCCR measures cortisol levels IN RATIO to creatinine. creatinine levels do not fluctuate like cortisol so measuring ratio of CORTISOL AGAINST CREATININE is the reason why the test is so valuable. it should be the FIRST test given when cushings is suspected because while it may give false positives its negative result is rock solid. UCCR comes back as negative for cushings you KNOW your dog doesnt have it.
Most importantly this idea that dogs need constant acth tests keeps many dogs from getting the monitoring they need because of high cost. uccr is a valuable tool to use in monitoring a dog who is currently taking medication. a UCCR result will tell you your dog is non cushings or cushings. if non cushings it means meds are good if cushings increase dose. UCCR saves your dog from having cortisol levels artificially raised with acth , needle pokes, high costs and vet visits UCCR uses urine samples taken at home 1st thing over the course of 2 or 3 days kept refrigerated then mixed so urine being tested will be a 3 day period of stress free am urine.I know UCCR is accurate as a monitoring tool i had 2 tests done at once, one am catch was with no vetoryl the night before (results came back a little higher then results from am urine WITH vetoryl dose the night before. Many labs use uccr among other tests in studies of new drugs, if it wasnt accurate then it wouldnt be used

I know what the UC:CR test is AND I most certainly understand its value as a screening test in dogs that are suspected of Cushing's.

I also can cite numerous published studies that show that an UC:CR test can not be used as an replacement for the ACTH stimulation test to monitor dogs on medication for Cushing's.

If you could supply me with links to published studies that were done that came to the conclusion that the UC:CR test can replace the ACTH stimulation test in gauging if a dosage increase is needed when monitoring dogs on treatment for Cushing's, I sure would be interested in reading them. ;)

[pinkie]

I dropped off the urine sample yesterday for the cortisol:creatinine ratio. The IMS indicated that this would help evaluate Pinkie's hyperadreocorticism control. She felt that the PM ACTH stim test may not be accurate since Pinkie may be stressed from staying at the vet's all day. I will let you know the results.

Here are the results of her recent lab test:
ALP 498 (5-131)
GGT 17 (1-12)
BUN 32 (6-31)
Glucose 392 (70-138)
Sodium 136 (139-154)
Chloride 98 (102-120)
Cholesterol 401 (92-324)
Triglyceride 469 (24-291)
Precision PSL 247 (24-140) may be indicative of pancreatitis
Platelet Count 1043 (170-400)
Monocytes 981 (0-840)
UA protein 2+ (neg)
UA glucose 3+ (neg)
UA ketones 1+ (neg)
UA occult blood 1+ (neg)

The IMS indicated although there are abnormal results, she is not too concerned at this time since the results are consistent with Cushing's and diabetes not well controlled. UGH!

[pinkie]

Pinkie went blind on Saturday. I noticed that she was developing cataracts, but thought it would be gradual not all of a sudden. I asked the vet about an ophthalmology consult, but she said that surgery most likely would not be performed unless the diabetes is under control. I have posted my concern on k-9 diabetes forum.

Because Pinkie's diabetes is still not under control, the vet switched her insulin from vetsulin to Humulin-N and is currently on 5 units.

One good news - Pinkie's cortisol level is regulated. Her 5/4 ACTH test results were pre 2.2 and post 5.1 with increased trilostane of 5 mg twice a day. The UC:CR was 13 and the vet indicated that this test is not a good indicator. Not sure why she ended up recommending it.

I want Pinkie to maintain her quality of life, but weighing my options. She was having difficulty maneuvering around the house. She is still drinking lots of water and eating more (although I have to constantly change it up). She seems more upbeat today than Saturday. I feel so bad for Pinkie.

[Joan2517]

Ohhh, poor little Pinkie...she'll adjust, it just might take some time.

[molly muffin]

Poor Pinkie. I'm sure it is stressful for her and you right now.

One of our moderators had 2 little dogs that were completely blind. Dogs are grat at adapting to blindness usually as they use their other sense better than us humans do.
The key is not to move anything in the house, so they know where everything is.
There is also the halo that can be attached to a harness and it prevents them from running into anything and hurting themselves. You can google that. There is also a facebook group for blind dog owners, that you might find beneficial. Just do a search for blind dog owners on facebook and it will come up. They have some great tips.

[pinkie]

Pinkie is doing much better maneuvering around the house. I think I was more upset and probably did not help the first few days when I carried her around.

She is peeing on the carpet and not going outside since she has gone blind. I have placed wee wee pads strategically around the house, but she misses the pads. Thank goodness for spot carpet cleaners.

[Squirt's Mom]

I am sorry your sweet girl lost her sight but as mom to several blind babies I can tell you it is usually harder on us humans than it is on the dogs. These blind pups will usually teach us what they need if we will just listen. One of mine operated by touch most of all. Another by smell; another by sound. All their other senses become very very powerful when a dog loses their sight and from what I have seen one sense comes to the front as the leader in helping the pup navigate their dark world. So watch her carefully in these early days and see what she seems to use and respond to the most...then help her with that. If touch, use little rugs in the doorways that have different naps so she knows by the rug what room she is entering. If smell, use oils on the rugs or candles in each room that smell differently. In no time will be moving along just fine! (Those same tricks can be used to tell her where the peepee pads are as well.) Be sure to make no changes in furniture, water/food bowls, peepee pad locations, etc. She needs to know without question that the coffee table is exactly where it was yesterday when she came by. ;) That will build her confidence. I had one pup who I called my pin ball baby because he bounced off of everything in his haste to get where he was headed. I ended up with bubblewrap on all the furniture legs and either bubble wrap or pipe insulation on all the outside corners in the house as well as things like the fridge. Good Housekeeping did not give me their seal of approval. :p But my itty bitty man was protected and that is all that mattered.

Hope things are going well for you and Pinky!
Hugs,
Leslie and the gang

[lyswood]

If I was going to do another test, I would probably opt for an ultrasound as it gives you a lot of bang for the buck, can tell you if there is an adrenal tumor and can also rule out sludge in the gall bladder. I've seen several maltese end up with sludge is why I mention it .

I'm new to all of this, but would already second this information. My Min Pin had an ultrasound initially and then one again a couple of months ago that showed sludge, so we're working on that too.

Good luck to you and your sweet baby :)

[pinkie]

Pinkie passed away yesterday. I think her heart gave out. I was able to rush home from work and hold her until she took her last breath. She went peacefully. It was hard at home yesterday without her to fuss with food preparation and medication.

I miss her terribly! The pain is intense now, but will subside eventually. Thank you everyone for your support and assistance.

[Joan2517]

Ohhh, I am so sorry!! I'm so glad you got home to be with her...I am tormented that Lena went without me being with her. I'm so, so sorry. She looked like such a darling...

I'm crying at my desk again :(

Sending you so many hugs....

[tinybiny]

I'm really sorry to read that. I hope you heal through this.

[labblab]

Oh goodness, I too am so sorry to read this news. Thank you so much, though, for taking the time to return to let us know. Pinkie has now been added to our special memorial thread:

http://www.k9cushings.com/forum/showthread.php?t=8383

We hope it may give you a bit of comfort to know that she is surrounded by our other beloved babies, and will always be honored by her family here.

Please do come back at any time if you want to talk or share any special memories of your sweet little girl.

Sending many hugs to you on this sad day,
Marianne

[liltara]

I am so very sorry for your loss :(

Time does help, and they always have such a special place in our hearts.

May Pinkie rest in peace free of pain and suffering ...

[DoxieMama]

I am so sorry to hear of your loss.

RIP sweet girl...

[judymaggie]

My heart goes out to you during this most difficult of times. I am glad that you were able to spend Pinkie's last moments comforting her.

[Squirt's Mom]

I am so sorry to hear this but I am glad you were able to be with her. I know she is now watching over you with the same love and devotion you showed her. One day we all will be with our babies who have gone and until then they will wait for us.

Our deepest sympathies,
Leslie, Trinket, Sophie, Fox, Bud and all our angels




Rainbow Bridge
Author unknown

There is a bridge connecting Heaven and Earth.
It is called the Rainbow Bridge because of its many colors.
Just this side of the Rainbow there is a land of meadows,
hills and valleys with lush green grass.

When a beloved pet dies, the pet goes to this place.
There is always food and water and warm spring weather.
The old and frail animals are young again. Those who are maimed
are made whole again. They play all day with each other.

There is only one thing missing. They are not with their special
person who loved them on Earth. So, each day they run and play
until the day comes when one suddenly stops playing and looks up!
The nose twitches! The ears are up!
The eyes are staring! And this one suddenly runs from the group!

You have been seen, and when you and your special friend meet,
you take him or her in your arms and embrace.
Your face is kissed again and again and again, and you look
once more into the eyes of your trusting pet.

Then you cross the Bridge together
never again to be separated.

[Budsters Mom]

Fly free Pinkie, Fly free!

I am truly sorry for your loss.

Kathy

[Carole Alexander]

I'm so sorry that Pinkie died so suddenly; but I am glad that you were able to hold her and hope that you can find some comfort in helping her pass so peacefully. I am thinking of you and Pinkie.

Carole

[pinkie]

Thank you everyone for the support during my grief. I have posted additional photos on Pinkie's album which makes me smile.

[lyswood]

I am so, so sorry. :( Many hugs of comfort to you. So nice you were with her. So hard.

[molly muffin]

Oh my gosh. I am so sorry to hear about your beautiful Pinkie passing. :( I'm glad you were able to be with her. My heart just breaks for you.

My sincerest condolences.