Newbie and advise needed

[Hev3535]

Hi all my old boy has been diagnosed with cushings about two weeks ago. He has been having symptoms for a while though and the vets messed up by giving him double steroids. We only realised something was wrong when his legs gave an. After loads of bloods and scans they thought liver then did another test after the steroids were out of his system and diagnosed with cushings. He is almost 12. Very thirsty, toilet a lot, his hair hasn't grown back where they shaved it for the scan. He is so hungry too. I have been offered treatment which is so expensive and worried it won't work or will make him worse. Any advise would be great on what to do. Thanks heather and milo the dog 🐶

[DoxieMama]

Hi Heather, welcome to you and Milo! I'm sorry you're having to go through this, but you've found a great resource here. We'll help you navigate the road ahead. To do that, we'll need a bit more information about Milo.

Can you get copies of the blood tests and scans that were done to diagnose him, and post the results that are abnormal along with their reference ranges? What steroids was Milo on, and for how long... and then how long after they were "out of his system" did they do the latest diagnostic test?

Treatment is expensive, that's for sure. A large part of that expense is during the diagnostic process, then when you start treatment, due to the need for frequent monitoring via tests. After you've found the right therapeutic dose, then those tests are less frequently needed. Depending on which medication you and your vet decide to use, the cost of that may be more or less, too. We can help explain those options as well.

Hang in there!

Shana

[Hev3535]

Thanks for your reply. I've asked the vets for a copy of his results. I am finding it hard. Most nights milo is very restless and drinks all the time and then needs to go out.
He is having a down day today. He has also gone blind which seems to be really effecting him.

Heather

[LauraA]

My girl had the night time restless and would just wander up and down the hallway half the night, and of course she made sure I was awake by barking at me so I could follow her (I can laugh at it now), she also had lost all bladder control as she was just constantly emptying the water bowls. It didn't matter if she was awake or asleep she had absolutely no control. Fortunately for us the meds have given her back a great quality of life, and some 3 years later she is still doing great. She got control over her bladder quite quickly and started sleeping through the night again.

It is expensive at the beginning with the testing to find the right dose but once that part is over it does get easier. I get her meds compounded so save a fortune and we only test every 5 months now so it is much more affordable than the first 3-4 months of starting treatment and testing.

[Hev3535]

Hi,
I have the last set of results milo had done. Not sure what they mean. I have the ACTH stimulation test results are before H287.0 nmol/l 50.0-250.0 and results after stim test. H1352.0 nmol/l 150.0-550.0.
His scan on his liver showed it was enlarged and his bladder too but he had this done while still on steroids. There was about 8 weeks of no steroids before we did the cushings test.
Any other results needed?
Thanks
Heather

[DoxieMama]

Hi Heather,

Were any other tests done? UCC (urine cortisol-creatine ratio), CBC (showing BUN, ALP, ALT, etc) or anything else... If so, can you post the abnormalities and their ranges? Have they ruled out diabetes, UTI, other possibilities?

Sorry for all the questions but the more details you can provide, the better we can help!

Shana

[lulusmom]

Hi Heather and welcome to you and Milo.

If Milo was off of steroids for two months prior to the acth stimulation test, I am quite sure those results are accurate. For those of us who are used to seeing acth stim test results in ug/dL, the conversion is pre - 10.4 ug/dL and post 49 ug/dL. the post is most definitely consistent with cushing's, as is the enlarged liver. Was the scan an xray or an abdominal ultrasound? It was an xray, I highly recommend that you consider having an abdominal ultrasound done to determine if Milo has pituitary dependent disease or an adrenal tumor. Your vet should have also done a urinalysis with culture to rule out a urinary tract infection. Shana has already asked for any additional information and that would include a blood chemistry, complete blood count and a urine tests. With respect to the blood labs, we need only see the highs and lows, and please include the normal reference ranges.

You mentioned that Milo has gone blind. If he lost his sight suddenly as in days, you could be dealing with Sudden Acquired Retinal Degeneration (SARDS). It is thought that there may be a connection between SARDS and cushing's but that connection has never been established. What is known is that some of these dogs start to show signs a few months or weeks before or after the onset of blindness and a minority of dogs will ultimately be diagnosed with cushing's. Most, if not all dogs, will have some elevations in one or more of the intermediate adrenal hormones. These dogs are very likely to see a resolution of cushing-like symptoms within three or four months of blindness. This is why some vets take a wait and see approach to treatment. Did Milo's blindness happen quickly and did you have him seen by a veterinary opthamologist? These specialist are usually the only professionals who can determine by examination if a dog has SARDS. In any event, with Milo having elevated cortisol that is well above the range that is deemed consistent with cushing's, I don't believe his symptoms will resolve without treatment.

We love lots of detail so please share whatever information you have, even if you think it may not be important.

Glynda

[Hev3535]

I've had a look. There was ALP H1485 u/l@37c 12-83 and ALT H426 U/l@37c 13-78. CHOL H11.6 mmol/l 2.8-8.3. There was no ucc but creatinine? That's 44 umol/l 20-124.
It says his liver enzymes have gone down and bile production since his last test and coming off Steriods? I have a big list of what they tested.

[Hev3535]

Thanks for getting back to me. He had an x ray and an abdominal ultrasound as well. She couldn't really see his adrenal glands but did try to have a look. With regards to his blindness he has cataracts which was slowly going cloudy but suddenly went after he was gived the prednisone steroid. The Steriods were given for treatment of mange which the vet had failed to pick up after almost a year of him suffering and numerous trips to the vet. Can I attach a copy of his results? Thanks

[Hev3535]

Hi all here is a copy of milo's results.


(CSTAN) Canine Standard Profile

(VCBC) Full Blood Count

WBC 6.3x109/L 6.0 - 15.0

RBC 7.09x1012/L 5.00 - 8.50

Haemoglobin 16.2 g/dl 12.0 - 18.0

PCV 50.6% 37.0 - 55.0

MCV 71.4 fl 61.8 - 79.3

MCH 22.8 pg 20.6 - 26.3

MCHC 32.0 g/dl 30.4 - 36.4

Platelets H 583x109/L 200 - 500



Differential

Neutrophils 71 % 4.5 x109/L 3.0 - 11.5

Lymphocytes 17 % 1.1 x109/L 1.0 - 4.8

Monocytes 10 % 0.7 x109/L 0.0 - 1.3

Eosinophils 2 % 0.1 x109/L 0.1 - 1.2

Basophils 0 % 0.0 x109/L

(FILM) Film:

Film:

Fresh film examined, thank you.
Film confirms haematology analyser values.
Occasional platelet clumps in film - true count may be higher than shown
Anne Aworinde
Scientific Officer


Total Protein 68.7 g/l 50.0 - 72.0

Albumin 36.5 g/l 26.0 - 40.0

Total Globulin 32.2 g/l 19.0 - 46.0

Sodium 149 mmol/l 139 - 154

Potassium 4.74 mmol/l 3.60 - 5.60

Sodium : Potassium 31.43 25.00 - 38.00

Chloride 107 mmol/l 102 - 122

Calcium 2.83 mmol/l 2.20 - 3.00

Phosphate 1.52 mmol/l 0.60 - 1.80

Urea 5.9 mmol/l 1.7 - 7.4

Creatinine 44 umol/l 20 - 124

Total Bilirubin 2.5 umol/l 0.0 - 16.0

ALP H 1485 u/l@37C 12 - 83

ALT H 426 u/l@37C 13 - 78

Gamma GT H 17.0 u/l@37C 0.1 - 9.0

GLDH H 140.0 u/l@37C 2.0 - 6.0

Bile Acids H 12.4 umol/l 0.0 - 10.0

CK 161 u/l@37C 20 - 230

Cholesterol H 11.6 mmol/l 2.8 - 8.3

Triglycerides 1.00 mmol/l 0.34 - 1.97

Glucose H 6.1 mmol/l 3.5 - 6.0

Amylase 445 u/l@37 100 - 948

DGGR Lipase H 110 u/l@37 0 - 90

(CACTH) Canine ACTH Stimulation Test (cortisol before and after ACTH) add on

Cortisol Basal H 287.0 nmol/l 50.0 - 250.0

Cortisol Post ACTH H 1352.0 nmol/l 150.0 - 550.0

Comment

Please note: Occasionally serum left in contact with red cells may artefactually alter the glucose measurement.
Thrombocytosis is a non-specific response (e.g. to haemorrhage, inflammation, neoplasia etc) and is also a common sampling artefact.

Liver enzyme activities have reduced since the previous sample but remain above reference range. Bile acids have also reduced. How long has this dog been off steroids? Increased cholesterol may be seen with endocrine and metabolic disease, cholestasis, protein losing nephropathy and non-fasted samples.

In the presence of appropriate clinical signs, and supportive routine laboratory abnormalities, these cortisol results support a clinical diagnosis of spontaneous hyperadrenocorticism (HAC). However, please note that positive results also can be seen with the stress of significant non-adrenal illness, so interpretation will depend upon other diagnostic tests/degree of clinical suspicion.

Please feel free to call me to discuss if required.
Lucie Goodwin BVetMed DipACVIM MRCVS

END OF REPORT

[Hev3535]

Hi all,
Just wanted some advise really. My dog started 20mg of vetoryl yesterday morning. And since yesterday afternoon I've noticed he is coughing and he had some blood on his stool. He does get colitis so he is quite sensitive. Should I carry on and hope things settle down. He seems happy in himself.
Thanks
Heather

[Squirt's Mom]

MODERATOR NOTE: I have merged your post about side effects into Milo’s original thread. We like to keep all posts about each pup in a single thread as it makes it easier for members, and parents, to refer back to the pup's history when needed. Thanks!

[Squirt's Mom]

Hi Heather,

With blood in the stool I personally would stop the Trilo for now and talk to the vet about this asap. He may need to start with a very low dose and work up to the correct dose but I would talk to the vet. And some pups just cannot take one or the other of the drugs used for treatment - tho Lysodren is usually much harder on the digestive system than Vetoryl (Trilostane).

In looking back thru Milo's thread here I don't see where you have told us his weight nor his breed (which would give us an idea of his size ;) ) and that is very important information since the doses are based on weight. So if you would share his weight with us that would be wonderful! The starting dose is 1mg per lb so that info will let us know if that 20mg is within the proper range for a pup his size.

I have taken the liberty to rearrange the lab results into a format that is easier to read and have put the abnormal results in bold. I have a sick baby and a new BIG foster who insists on demanding that the hand I use the mouse with also strokes his head. :D So if you wouldn't mind, double check my edit and make sure I didn't make any mistakes. Thanks!

In going thru the lab results I am quite worried about his liver - has Milo had any further investigation into the liver before starting the Trilo? While the ACTH results do support Cushing's those results can also be caused by other problems....among them, liver disease. So I personally would really want to be absolutely sure his liver was ok before continuing treatment for Cushing's. We do know that Cushing's is hard on the liver but we don't normally see results as high nor as involved as Milo's hence my concern.

My sick baby also has Colitis and she developed a flare around 1:30AM today. So I have been up changing and washing sheet since she sleeps with me and then cleaning floors. We've started Slippery Elm Bark and she should be much better soon. She and I both have a loverly aroma about us this morning! :D So I can sympathize with Milo's issues and sensitivities.

Hugs,
Leslie and the gang

[Hev3535]

Thanks for your post and sorting out the results. The vet hadn't told me milo's liver results were still bad I just went with the fact they had gone down. What other tests can they do for his liver? He had quite a few other bloods done and the scan which said his liver was enlarged and had lumpy edges.
More info on milo he is a parsons jack Russell and weight about 11.5 kg.

[Hev3535]

Just wanted some advise. Milo has now been on vetoryl for 7 days and there is no improvement what so ever. Should I see any difference by now or is it to early to tell? Should I ask the vet to increase the dose?
Thanks
Heather

[labblab]

I know it must be very frustrating to see no improvement, but it will be important to know exactly how much the 20 mg. of Vetoryl is affecting his cortisol before thinking about increasing the dose. This is why ACTH stimulation blood tests are used as an ongoing monitoring tool. The maker of Vetoryl (Dechra) recommends that the first ACTH test be performed 10-14 days after starting treatment, then at the 30 day mark, then every 90 days thereafter. Has your vet spoken with you about scheduling Milo's first monitoring test?

Generally, Dechra does not recommend increasing a dose until after the first month has passed. This is because cortisol levels can continue to drift downward during the first month even when doses are left unchanged. However, I see that Milo's diagnostic ACTH cortisol level was quite high. So if it remains very high at the time of the first test and you still have seen no symptom relief at all, a dosing increase may be in order. You really do need to have the actual test results in hand, though, in order to know how much more medication seems appropriate.

How is he doing now in terms of the blood in his stools?

Marianne

[Hev3535]

Thanks for your reply. His stools are better now just normal. He is booked in on Friday for the ACTH test so I really hope it shows something is happening. It's really hard to tell if the drinking is easing as it's so hot and he has never been great with the heat.

Heather

[molly muffin]

I'm curious where they able to see his gallbladder on the ultrasound? Just noticed that the bile acid was also a tad high.

I too hope that you see an improvement when the next ACTH is done. Let us know what the results are!

[Hev3535]

Well I had the results from milo's ACTH test and the levels have come down a lot. He's still drinking loads though probably even more and awake most of the night. I'm exhausted. I was hoping I might see some improvement by now?

[labblab]

Heather, can you please tell us the exact numbers from Milo's ACTH? Thanks so much.

Marianne

[Hev3535]

Hi all. My dog has been taking vetoryl for almost a month. I have not seen much improvement. His appetite has gone down and he is a bit more settled but he is still drinking loads and having accidents in the house. Should things have started to improve by now?
Thanks heather

[DoxieMama]

Hi Heather,

When was Milo's last ACTH test, and what were the numerical results? It may be that he needs an adjustment in his dose.

Shana

[molly muffin]

I second what Shana said. The numbers are very important in determining how they are doing along with the symptoms and what to expect.
If you could post that it would help us to give you better feedback.

[Hev3535]

Hi all,
I need some advise. My boy milo has been put on a higher dose of vetoryl after his ACTH results came back still high. He had been on 20mg for over a month.
He has now been on the new dose for three days and today he seems very quiet legs are really shaky and really weak he can't seem to hold himself up. He is still drinking and toileting loads. Could this dose be to strong for him? Thanks heather

[Harley PoMMom]

His new dose could absolutely be too high for him and since he is acting off I would withhold the Vetoryl and see if this perks him up. How is his appetite? Any diarrhea? Could you get a copy of that ACTH stimulation test and post the results here?

[molly muffin]

Hello, what was his ACTH results before that made the vet put him on a higher dose?
It does sound like he might be going too low, which can be very serious. I wouldn't give him any more vetroyl, call the vet and talk to him.

If you can post those ACTH results then we can give you better feedback but not being able to stand is one very serious symptom of overdose.

[Hev3535]

Hi all,
Please some advise I am so worried about milo. Going to see the vet today but thought I would ask here before I go.
He has had his vetoryl medication increased to 30mg a day as his last results only had gone down 233 from 273. On the lower dose he seemed ok legs still weak and toileting a lot but was happier. Now he is even weaker and walks like he is drunk keeps falling over and can't hold himself up very well. The vet put him on metacam for his arthritis which has flared up but that seemed to make him worse and he couldn't get up on it and made him itch and restless at night. So stopped it yesterday. Is this it for milo are his legs just going to keep getting worse? I don't know what to do? Please reply I am so worried.
Thanks Heather

[labblab]

Hi Heather, I'm really sorry Milo is having such a hard time. Since he seemed to be doing better, overall, on the lower dose of Vetoryl, I'd be inclined to talk to the vet about going back to the lower dose again for the time being. This does not solve the problem of excessive thirst/urination, but right now it sounds as though his mobility is the greater issue.

Up to this point, has Milo been getting his Vetoryl all in one dose in the morning? If so -- and since you said previously that his thirst/urination is worse at night -- one thing you might ask the vet about is switching to 10 mg. with breakfast and 10 mg. at dinner. Vetoryl typically remains active in the body for less than 24 hours in all dogs, and for some dogs, the beneficial effect wears off much sooner than even 12 hours. So by splitting the total daily dose into two administrations, symptoms may be better controlled overall for those dogs. Also, some dogs end up requiring a lower overall daily total when it is split up in this way. In other words, Milo's cortisol may still end up decreasing a bit even if the total remains 20 mg. but it is given in two doses. Under these circumstances, I believe I'd want to give that a try in Milo's case.

Marianne

[Squirt's Mom]

Hi Heather,

Did you ever get those ACTH results to share with us? That would go a very long way toward helping us helping Milo. ;)

I am concerned that he seems to get worse with the increase and would want to either go back to the lower dose or stop the Vetoryl altogether and see how Milo does. Some dogs simply cannot take Vetoryl and have to switch to Lysodren; some can't handle the Lyso and have to switch to Vetoryl. So based on his reactions, if I were in your shoes I would be wondering if the Vetoryl itself may be causing his worsening behaviors.

I hope he does a bit better today!
Hugs,
Leslie and the gang

[labblab]

Hi all,
He has had his vetoryl medication increased to 30mg a day as his last results only had gone down 233 from 273.
Hey Les, here are the recent ACTH results. I am guessing they are being report in units of nmol/L. If so, they'd convert to approx. 8.4 and 10 ug/dL.

[Squirt's Mom]

geez! I need new glasses again apparently! :rolleyes::o Thanks, Marianne!

[Hev3535]

Thanks so much for your replies. Still waiting for the vet to get back to me. I supposed if the vetoryl doesn't suit milo then there isn't much else we can do. He cant have the lysodren as we just don't have the money to pay for it. Could the metacam caused him to get worse as well?
Thanks
Heather

[Squirt's Mom]

Heather, you may find the Lyso is actually cheaper to use. The med itself costs more per pill but it is not given daily once the loading is over. In addition, most pups on Lyso need fewer ACTHs because the dose isn't changed as often. So you may end up saving quite a bit on testing and the number of pills used even tho each pill costs more.

[molly muffin]

I prefer something like tramadol over metacam.

Or what about adequan injection for the arthritis? That should be fairly benign and not interact with cortisol levels.

[Hev3535]

Hi all,
Me again. I am after some more advise. Milo was doing OK after going back down to the 20mg dose and the metacam was helping. He did have a set back when the vet gave him bravecto which made him really poorly and so wish I didn't give it to him and I have now realised a lot of dogs have died from taking it. He is a lot better now but symptoms seem to be coming back. Grunting noises and drinking more and weeing more. He is due another ACTH test but was giving him a bit of a break from the vets. I feel they have let me down and can't ask them for advise. Milo doesn't seem very happy I just don't know what to do anymore.

Thanks
Heather

[Harley PoMMom]

He may have an UTI, which would cause him to drink and urinate more. How is his appetite?

Hugs, Lori

[molly muffin]

Hi Heather, I agree with Lori, a check for a UTI might be worth while even to eliminate it and also a check of cortisol levels to see where Milo is at now.
Also as I mention before, you might want to try tramadol too, as it can be easier on the liver, but some dogs are lethargic on it, so have to see what dosage Milo would respond best to.

[Hev3535]

Hi all,
I'm after some more advise. Well milo started back on 30mg vetoryl for 10 days had his ACTH levels which were 34 before stim then 150 after. He was doing well bit day 14 he went down hill sickness diarrhea and very uncomfortable panting and lethargic and stopped eating. Stopped the vetoryl for 5 days and he is alot better although he is drinking more and has just had an accident in the house. So vet said about 10mg twice a day but if 20mg once a day wasn't enough how would 10mg twice a day work? 30mg is obviously to much for him. This is such a stressful time I really thought we were going to have to say good by to our boy. Any advise please xx

[Harley PoMMom]

Once a day dosing does work for most dogs but if symptoms seem to reappear in the evening or if the dog becomes diabetic twice a day dosing is recommended.

With Milo, since the 30 mg once a day was too much and the 20 mg once a day didn't seem enough, splitting the 20 mg into 10 mg twice a day could just be what his body requires to keep his cortisol controlled throughout the day.

Was he checked for an UTI?

Hugs, Lori

[Hev3535]

Hi,
He doesn't have a UTI and he did stop weeing and drinking on the 30mg. But we have now found a tumour in his testical. Which we are trying to decide weather to remove it or now. My poor boy seems to have everything thrown at him.
Seeing my vet again tomorrow for more advise.
Heather

[Harley PoMMom]

OMGoodness poor Milo :( please let us know how the vet visit went, and in the meantime, wishing you both the best of luck.

Hugs, Lori