Introducing Sweetie - Sweetie has passed

[wftmomx2]

Hi, All. So grateful that I found this group. I have been lurking for a couple of days. I am Julie and I am owned by Sweetie, a 9.5 y.o. Wire Fox Terrier. I have only had her for a year but have suspected that something was wrong for most of that time. She is so laid back that if you did not see her, you wouldn't believe that she was a terrier. That laid back personality has gone to lethargy over the last months.

After dealing with my very conservative vet for a couple of months thinking this was hypothyroidism, I got impatient as Sweetie has gained more than 5# in a year in spite of being on a diet, has started panting and in the last 6 weeks has lost all of her undercoat. We did a senior panel a few weeks ago and her ALT and ALP were elevated which I didn't expect. Her T4 is only 0.8 (bottom of normal reference range) and TSH is high. Her cholesterol is also elevated. I decided to take Sweetie to the internist I used with my last two WFTs (who had ever disease known to man...). She looked at the records and immediately (this was yesterday), did an ultrasound which showed the liver a little enlarged (but no obvious masses seen) and both adrenal glands enlarged. After that, I left her for a low-dose dex test. Won't have the results until Monday. Internist says it's definitely indicative of Cushings, so here I am.

I've read enough to know this isn't a death sentence though sounds like it will not be an easy road. Anyway, so glad to find y'all and will appreciate info and advice if the results are positive (or even if they're not).

Julie & Sweetie

[DoxieMama]

Hi Julie,

Welcome to you and Sweetie! Do you have copies of the test results that were done? If so, would you post those results which are abnormal along with their reference ranges? When you get the results of the LDDS, post those as well. The more information we have, the better we can support you.

So glad you've joined us!
Shana

[Squirt's Mom]

Welcome to you and Sweetie!

No it's not a death sentence for the vast majority of pups and you have found the best place to land for help to make the journey as easy as possible. We will be here to help you every step of the way.

It does sound like Cushing's but the tests will give us a much better idea so I am looking forward to seeing those results. Now is the time to start the habit of asking for results every time she has a test from now on. Start a file at home so you can have records on hand should she ever need to see a different vet - for example on vacation or should you move....plus they will help you answer all our nosy questions! :D

The more you can tell us about your gorgeous girl the better - any current health issues, current meds supplements or herbs, and so on. We LOVE details so don't worry about writing a book.

I'm glad you found us and look forward to learning more as time passes.
Hugs,
Leslie and the gang

[wftmomx2]

Thanks so much for the welcome. I will post abnormal blood and LDDS results tomorrow. I get all test results always. My last two Wire Fox Terriers, both of whom passed as seniors, had many health problems so I learned early on to get test results. I am anal enough that I chart them in excel spreadsheets so I can see trends that vets don't always notice. In the last 15 years, I have dealt with acute necrotizing pancreatitis (I used to co-moderate the Dog Pancreatitis yahoo group), hypothyroidism, severe environmental allergies, Diabetes Insipidus (water diabetes), Neurogenic KCS (dry eye that also affects the nose and sometime mouth), PLN, HGE, bladder stones, etc., etc. You name it, my two dogs had it. I had to eventually let them both go after fighting Degenerative Myelopathy. One had canine cognitive dysfunction. I sure was not expecting problems with Sweetie this soon but we play the cards we're dealt. That is why I got insurance for Sweetie the minute I got her. I hope it helps. I also adopted another WFT a few weeks ago that "appears"
to be perfectly healthy.

Will try not to obsess today while waiting for test results.

Julie

[wftmomx2]

I just posted photos of Sweetie to document difference in hair coat in the 13 months that I've had her.

[judymaggie]

Julie -- I wanted to add my "welcome" to you and Sweetie! Kudos to you for educating yourself, and offering help to others. In addition to us trying to help you with Sweetie's issues, I think you will be a great asset to others here.

[wftmomx2]

Thought I'd post some of Sweetie's lab results. Do not have LDDS back yet. Not sure if there is a place to attach a spreadsheet or .pdf of labs on this site.

ALT 210 (12-118) 08/11/2016

[wftmomx2]

Sorry....still trying to figure this system out. lol

The ALT figure above was on 8/11/16. on 7/17/2015 it was 113 (ref range 18-121).

ALP on 8/11/16 was 167 (ref range 5-131). On 7/17/15 it was 37 (ref range 5-160)

BUN/Creatinine Ratio on 8/11/16 was 43 (ref range 4-27). On 7/17/2015 it was 13.3 (no ref range on lab report)

Cholesterol on 8/11/2016 was 423 (ref range 92-324). On 7/17/15 it was 265 (ref range 131-345)

Amylase on 8/11/2016 flagged low at 247 (ref range 290-1125). It was 487 on 7/17/2015 (ref range 337-1469.

Lymphocytes on 8/11/16 was flagged low at 7 (12-30). Normal last 7/17/2015

Absolute lymphocytes low on 8/11/2016 at 378 (690-4500) Normal on 7/17/2016

Monocytes 23 (3-10) on 8/11/16, normal on 7/17/2016

Absolute monocytes 1242 (0-840) on 8/11/2016, normal on 7/17/15

T4 on 8/11/2016 was 0.8 (0.8 - 3.5)
T4 on 7/17/2015 was 1.1 (1-4) (which is still low for the breed which according to Dr. Dodds should be in the middle of the ref range). It was recommended that thyroxine be started by that vet but my vet never started it (though I requested).

Urine was all good this time. Concentrating well (almost too well). pH at 7.0 (5.5-7.0).

Urine last time showed Spec. Gravity at 1.057. pH was 7.5. Trace of protein. EPI cells 1+ (1-2). Crystals 1+ ammonium mg phosphate (1-2).

Will update with LDDS results later.

Julie

[wftmomx2]

Results are in and it's definitely Cushings. I am picking up lab report this afternoon. Internist told me numbers but I was standing in the middle of downtown and couldn't write them down. Will post them later. Right now they will mean little to me. She did say this has been coming on for awhile. Starting Trilostane (sp?) tomorrow. 10mg in the am, 10mg in the pm. Praying for no bad side effects. A bit scared of this med.

Julie

[DoxieMama]

Thanks for those results. I'm sure others will be by to provide their insights and suggestions based on those. Will be watching for the LDDS results.

Shana

[Harley PoMMom]

It is really unusual for a cushdog to have concentrated urine. The elevated cortisol makes the kidneys work harder which in turn causes the dog to urinate voluminous amounts so in order to keep up with the kidneys the dog has to drink a lot more water, which causes the urine to be diluted and to have a low specific gravity.

Another anomaly with Sweetie is that her ALP is lower than the ALT. The majority of time in dogs with Cushing's that ALP level is really elevated, we have seen ALP numbers in the 1000's with the ALT only being moderately high so I am a bit puzzled, getting those LDDS test results and posting them will help us get a better picture.

Hugs, Lori

[wftmomx2]

OK, I have lab report but have no idea what the numbers mean. This is a new one for me so I need to find a better explanation than what is on the IDEXX report. I have a feeling some of you will know what they mean.

Pre Dexamethasone 3.0 (1.0-6.0)
post 4 hr 3.8
post 8 hr 4.9

Comments/insight welcome.

BTW, re: the earlier lab numbers I posted, the recent labs went to Antech; the older ones from right before I got her were sent to IDEXX (always my preference).

Julie

[dsbailey]

Hello and Welcome Julie,

I will take a stab at this but could be totally wrong. I'm sure someone more experienced will come along and correct me if I am. So don't freak out or anything until then. If this is not a false positive (Clinical Signs seem to point to this possibility) then it's inconclusive to the type of Cushings.

If
4 Hour >1.5 µg/dL and >50% of baseline
and
8 Hour >1.5 µg/dL and >50% of baseline
then

"Perform high-dose dexamethasone suppression, endogenous ACTH concentration and / or abdominal ultrasound to discriminate between PDH and ATH."

If my interpretation is correct then I would get an abdominal ultrasound done at an IMS. It will be the best value and you will get a clear picture of what's going on. I'm not sure that I would trust an internist telling me "Positive Cushings".

Hope this helps - Darrell and Lolita

[wftmomx2]

She already had the ultrasound. She had it before the LDDS which is why they did that. Her liver is enlarged, her gallbladder is enlarged and both her adrenals are enlarged. No obvious masses seen. In terms of symptoms, she is extremely lethargic; has no exercise tolerance at all. She pants in air conditioned house. She has lost all of her undercoat. She is truly obsessed with food and has gained over 5# since I got her 13 months ago. The hunger is getting worse. She is tanking up on water but not peeing that much more. Don't know why. She is having some accidents in the house and the last urinalysis was almost a month ago so I don't have really current info there. She can hold it a long time (except in the middle of the night...lol). Thyroid is very low for the breed. ALT and ALP slightly elevated. Cholesterol is elevated but I would expect that based on the weight gain. Internist wasn't surprised at positive LDDS at all.

Julie

[judymaggie]

Hi, Julie! Since the ultrasound showed both adrenal glands enlarged, this points to pitutary-dependent Cushing's (PDH). The LDDS does confirm the presence of Cushing's. How much does Sweetie weigh? Hopefully, somewhere in the range of 20 lbs. since current dosing guidelines are 1 mg. trilostane per 1 lb.

You might want to ask your vet why she is recommending twice a day dosing. This is usually reserved for dogs who have concurrent diabetes and/or high blood pressure so that those conditions are kept level for a full 24 hours. Twice a day dosing is more difficult to maintain since it requires 12 hours between doses and each dose is administered after a meal. A once a day morning dose of 20 mg. would be easier all around.

Have you talked with your vet again about trying Sweetie on thyroid medication? At this point you wouldn't want to start it until after the first month of trilostane but definitely something to discuss after that point.

Has your vet given you information about the protocol to measure Sweetie's cortisol levels after starting trilostane? Here is a link to Dechra's technical brochure where, on page 11, this protocol is described in detail:

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

It is important to keep prednisone on hand in the event of a negative reaction to the trilostane. Unless you have a 24 hour vet, this is important to discuss with your vet. An "emergency" dose is .25 mg/kg. Also, be sure to give the trilostane after a full meal and, because the trilostane is fat soluble, it is advised to give it with something fatty, i.e., rolled up inside a piece of cheese or peanut butter.

We will be right here with you as you start treatment so please ask us any questions you have. You will do fine!

[wftmomx2]

Hi, Judy Maggie. I so appreciate the support.

Sweetie is now 22.5# and is on 10 mg Trilostane in the am, 10 in the pm. I can see how much of a PITA twice a day dosing is going to be since she has to have her Denamarin on an empty stomach and I feed her 3x/day and sometimes a small snack.

Internist doesn't want to supplement her thyroid right now because she feels like it is secondary to Cushings and will normalize. We will repeat blood work in a month or two. Regular vet had her on Clavamox and Metronizadole initially when liver values showed up kinda wonky (technical term...lol) so I'm curious if there is any change since she finished them.

No mention of prednisone but I will ask. She had her first dose last night and another this morning. If she didn't have a reaction, should I assume there will be none or could it happen at any time. She did tell me that if she gets diarrhea, vomiting or stops eating, to discontinue and call her.

I hate feeding her any more fat than necessary because I have gone through so much pancreatitis with another dog but I did give her cheese this morning (she says thank you!). She is so hungry all the time and a 5+# weight gain is a lot for a dog her size. She looks like her hind legs are going to buckle when she stands. Hard to tell how much muscle mass she has loss because it was not that great when I got her. She is a former show dog that had 3 litters and until I got her, she spent her life in a kennel (albeit a very nice one as kennels go).

In terms of protocol, the only thing I know right now is that I need to bring her back in 3-4 weeks and she will be monitored with ACTH tests. I was surprised she didn't want to test at 10-14 days but I've worked with this internist enough to feel confident that what she is advising is ok. I will ask her tech though, who has become a dear friend over the years.

Thanks again for everyone's support. No one expects this kind of issue with their dogs. When I took Sweetie, I made it clear that I wanted a healthy dog. What a joke....she has had dental problems and now this.

Julie

[Harley PoMMom]

Adverse effects from the Vetoryl can happen at any time, some dogs do well when treatment starts than months go by and suddenly their cortisol can drop too low or go too high, that's the main reason for those very important ACTH stimulation tests.

A lot of information can be found in Dechra's product insert so I'm going to provide a link to it: Dechra's U.S. Product Insert (http://www.dechra-us.com/Admi /Publ/Download.aspx?file=Files%2fFiles%2fProductDownload s%2fus%2fvetoryl-5mg-pack-insert.pdf)

Also here is a link to a thread in our Helpful Resource forum with info regarding Vetoryl/Trilostane: Trilostane/Vetoryl Information and Resources (http://www.k9cushings.com/forum/showthread.php?t=185)

Please feel free to print anything out of there and if you have any questions don't hesitate to ask them.

That ravenous appetite, man, it is so strong, we have had members give their cushdogs frozen green beans and or carrots to help abate than hunger. Hopefully in a few weeks that should subside.

Hugs, Lori

[wftmomx2]

Thanks much. I have been supplementing her food with canned green beans and carrots without salt added. She doesn't seem to care much for frozen. She didn't like any kind of fruit before she became a bottomless pit. Now she loves cantaloupe and apples. Thanks for the links.

[molly muffin]

Hello and welcome to the forum. Some vets have a preference for the twice a day dosing and do start out with that. Dr. Peterson in NYC a well known specialist in cushings prefers to start there. My personal internist, likes once a day, so I think often that is a preference.
The 20mg a day is perfect starting point and hopefully will just do the trick. Give it a few days before expecting to see results as every dog is different, as you already know. 10 days hopefully you'll see some subsiding of symptoms like eating/drinking excessively.
Coat and skin are two things that take the longest to turn around usually just because of the hair cycle timeframe. Some dogs never get the under coat back. Mine never did, but her over coat grew like crazy.

[wftmomx2]

Thanks, Sharlene. I asked our internist about the once vs. twice a day dosing and she insists on twice. She did discontinue the Denamarin so at least I don't have to deal with the full vs. empty stomach. This would not be a big deal but for 6 months out of the year, I work 2 jobs and this mean I will have to dose her at 2:30pm and 1:30am.

A bad coat is not the end of the world but it is very sad. How a coat could go from thick and gorgeous to this in the course of 6 weeks is beyond me. I will just be glad if the bloating goes away. She seriously looks and feels like her belly is going to pop.

Julie

[Squirt's Mom]

....this mean I will have to dose her at 2:30pm and 1:30am.

Just FYI - the ACTH must be given 2-4 hours after the dose of Vetoryl. So with the above schedule Sweetie must have the ACTH performed before 6:30PM....unless your vet is open 24/7. ;)

[labblab]

There are indeed some vets who choose to perform the monitoring ACTH testing within the 2-4 hour post-dosing timeframe that Leslie is mentioning. However, the formal monitoring protocol recommended by Dechra (maker of Vetory) is to test 4-6 hours after the Vetoryl is given with food. So that timeframe will give you a bit more flexibility given your work schedule.

If your work schedule makes it impossible to fit exactly within that time frame, you'll just need to make it as close as you can. And then, at whatever time you pick, try to keep the testing time as consistent as possible from one test to another, so that you'll always be comparing apples-to-apples.

Marianne

[wftmomx2]

Good point. I hadn't thought about testing. I'll just have to figure it out. How hard would it be to switch to one dose a few months down the road?

Julie

[labblab]

It's not hard at all to make the switch in either direction. To go to once a day, you just double the twice daily dose. Example: instead of 10 mg. twice daily, you'd give 20 mg. once daily. Subsequent monitoring testing will tell you if you need to tweak the dose further. Some research has suggested that dogs dosed once daily may require a bit higher overall daily total to achieve the same ACTH result. So using that same example, you might have to end up giving 25 mg. once daily in order to get the same cortisol response as 10 mg. twice daily.

I do understand that, when possible, some vets always prefer to dose twice daily. But if an owner's lifestyle doesn't support that regimen, I'm puzzled as to why once daily would not be considered as an alternative, especially since the maker of Vetoryl still recommends once daily dosing as the default treatment regimen. So this is a conversation you might want to have again with your vet sooner rather than later.

Marianne

[wftmomx2]

Thanks. I'll talk to her when I go back next Monday. The 12 hour dose messes up her (and my) eating time as well. Especially while she is still hungry all the time, her meals have gone from 3 to 4, with smaller portions of same daily amount. She just looks at me like "is that all there is?" I really hope that symptom eases soon.

The good news is that her insurance paid what they were supposed to so in the long run, it will be worth the monthly premium and I won't have to take so much of a hit.

[wftmomx2]

Sweetie went for her ACTH stimulation test today (won't have results until Wednesday). In the past 2 weeks, she has gained almost (another) pound. So frustrated. Her back is starting to bow. If I press up on her belly, it straightens out. The only change I see in 2 weeks on Trilostane is that she is a little more awake/aware.

Julie

[molly muffin]

When do you get the results back? We'll be looking forward to the updates.

[wftmomx2]

Hopefully tomorrow. Just to keep things exciting around here, I gave a Vetoryl cap to my other dog this morning by mistake. Arghhhh!!!! Sweetie just looked at me with hungry eyes as if to say "where's MY cheese?"

[dsbailey]

I know this is serious business but we all make mistakes. I just recently gave my boy dog my girl dogs estrogen pill by mistake. :rolleyes:

[wftmomx2]

Sweetie's ACTH stimulation test came back. Bear with me because this is her first of this test so I'm not used to looking at this IDEXX report. Pre-ACTH cortisol was 2.2 ug/dL. Post was 2.9. Reference range is 1.5-6. Vet said this is good and to continue on 10 mg vetoryl 2x/day.

She has a little more energy. Vet says it will take time for weight to get under control. Hopefully she won't gain anymore or lose any more fur.

Supposed to go back in 3 months unless I see any problems.

Julie

[labblab]

Hi again, Julie, and yes I agree that those results are good! My only concern is the timing of the next ACTH monitoring test. Originally, I believe you told us that your vet was going to wait until 3-4 weeks had passed before testing. But now it sounds as though it has only been 2 weeks since Sweetie started trilostane treatment. If so, for safety's sake, she really ought to have another test closer to the 30-day mark rather than waiting for three full months. This is because cortisol levels are now known to continue to drift downward throughout the first month, even when the dose is left unchanged. And dogs who are dosed twice daily may be even a bit more vulnerable to low cortisol readings.

So in addition to continued visual monitoring of her behavior, I do believe I'd discuss retesting again sooner rather than later. If her cortisol level remains stable this next time around, then I'd feel comfortable shifting to the 3-month monitoring schedule.

Marianne

[wftmomx2]

Thanks, Marianne. I sent a message to her and told her Dechra's recommendation is 30 days and I'd like to do that (especially since I have insurance it won't cost much). I also want to recheck liver values and cholesterol. If I remember what I read, if the cortisol drops too much, it becomes Addison's?

Julie

p.s.......I HATE this twice a day dosing. Wouldn't be so bad if it wasn't dependent on meal timing. I will be so glad when her hunger isn't so excessive.

[molly muffin]

Those are good numbers but I'm glad that you are going to do the 30 day test too.
Yes they can go Addison's if they go too low, which includes often, they electrolytes become imbalanced too and that can be life threatening, so if you see any change such as not wanting to eat, not drinking, diarrhea, wobbly, immediately stop vetroyl and get the ACTH. Those are the warning signs of low cortisol. It may never be a factor, but good to know the signs.

I would excpect that the ravenous hunger will abadt soon with those numbers and she should have a normal hunger.

[Harley PoMMom]

If I remember what I read, if the cortisol drops too much, it becomes Addison's?

Julie


According to Dechra a post stimulated value less than 1.45 ug/dl is considered an Addison's crisis. Now, if the electrolytes become unbalanced, but the cortisol is normal, this is considered an Addison's crisis too.

Dr Peterson, who is a world-renowned veterinarian specializing in endocrinology, recommends that a dog's cortisol should not fall below 2 ug/dl.

Lori

[wftmomx2]

Thanks. IMS we can retest in the month and also do the blood work. I'm going to ask her to retest thyroid to see if there's any change since we think the low thyroid is secondary to the Cushings. Not sure how long T4 would take to rebound if that's the case but if it doesn't, we may need to supplement. Also, her triglycerides have never been checked and as much weight as she's gained, I'd like her to check that too. My "pancreatitis dog" was at this weight when he had his first acute bout that almost killed him. Pancreatitis would kill her faster than Cushings. Yes, I am overly protective.

Julie

[wftmomx2]

I posted LDDS results somewhere above. IMS did that right after ultrasound. She knew that the LDDS would come out positive just by looking at her and the ultrasound. I do think that Sweetie is regaining a little energy; not like a typical fox terrier but better than a couple weeks ago.

Thanks for the support (everyone). I really appreciate it. Hopefully I can pay it forward eventually.

Julie

[molly muffin]

Most of us are over protective :) It's normal. You are their life line.
Hopefully she is continuing to improve and sometimes it all takes awhile. Longer than we'd like of course.

Yes pancreatitis is awful and can be so deadly and painful.

[wftmomx2]

I took Sweetie for a weigh-in today (same scale) and she is still gaining. She gained another 7 ounces. She went from 18# a year ago to 23.9 today. I'm going to take her back for another ACTH stim test in another 2 weeks. The only change I see in her is slightly more energy (she can run to her food bowl). My favorite vet tech (took care of both my previous dogs) is going to talk to the IMS about the possibility of her going to "doggie boot camp", i.e., rehab. I think my insurance would cover part of it. She would not start until after the next test, otherwise I wouldn't know if it was the Vetoryl working or the rehab helping her lose weight.

Julie

[labblab]

Hmmmm...I am totally confused as to why you'd be sending Sweetie off for "rehab" to lose weight. I mean, she can only eat as much food as you give her, right? So the humans in the family are the ones who control the food intake, and not Sweetie. :confused:

Cushing's does create a ravenous appetite in many dogs, but this is not the dog's fault, if you will. It is a genuine physiological drive that is fueled by the elevated cortisol. So it sounds to me as though you are falsely hoping that somebody else can force a behavioral change by somehow "retraining" her not to beg or eat as much (hopefully not punishing her). But the hunger is a physiological drive that really requires a medical solution. Truly, once a therapeutic dose of trilostane is established for her, the hunger should abate.

Also, at this early stage in her treatment, I would really worry about you sending her outside her home to a training group. She still needs to be monitored carefully for problems such as vomiting, diarrhea, changes in energy level, etc. The stress of being sent off for training (and amidst strange dogs) could easily trigger GI and other issues that will totally muddy the picture as to how well she is tolerating the medication.

For all these reasons, I think that sending her to boot camp is really a bad idea. Normally, I am not so blunt in my comments :o, but as you can tell, I feel really strongly about this one.

Marianne

[wftmomx2]

It's not a group. It's rehab at the specialty hospital (they have their own practice there). The IMS is right there and all the techs know us. It is mostly treadmill and water therapy, neither of which I have access to anywhere else. She is eating the smallest amount I can give her without her hungry all the time. She needs exercise and it is still hot here (in central Texas) so I can't give her as much as she needs to expend the calories she is getting. Her food is low fat but I just ordered another brand that is even lower fat so I'm hoping that will help. I know it's not her fault that she is so heavy she can hardly walk but I have to get some of the weight off her, Cushings or no Cushings. She is heavier now than my (angel) pancreatitis dog was when he had his first bout and I'm not going to let her get there if I can help it.

[dsbailey]

Marianne has some very valid points and helped me tremendously in the learning process. I live in Florida and I know about the heat and trying to squeeze in a long walk / exercise before dark. Finally an hour or so before sunset it's dipping into the low 80's here.

I agree with Maryanne but also see the importance of needing this weight loss and you not being able to do this on your own. Maybe you and the vet can come to some sort of consensus and do the "Boot Camp" during the day and having them tell you Exactly what to feed proportioned out for breakfast and dinner which will take strict discipline on your part (No cheating). Maybe this can alleviate the stress involved and still accomplish the goal.

I hope this suggestion helps and by no means meant to ruffle any feathers.

Darrell and Lolita

[labblab]

It's not a group. It's rehab at the specialty hospital (they have their own practice there). The IMS is right there and all the techs know us. It is mostly treadmill and water therapy, neither of which I have access to anywhere else. She is eating the smallest amount I can give her without her hungry all the time. She needs exercise and it is still hot here (in central Texas) so I can't give her as much as she needs to expend the calories she is getting. Her food is low fat but I just ordered another brand that is even lower fat so I'm hoping that will help. I know it's not her fault that she is so heavy she can hardly walk but I have to get some of the weight off her, Cushings or no Cushings. She is heavier now than my (angel) pancreatitis dog was when he had his first bout and I'm not going to let her get there if I can help it.
I apologize for jumping to a totally erroneous conclusion re: the type of rehab you are considering :o. Usually when people talk about "boot camp," they are referring to turning their dogs over to residential training services. So that's the connection I made, but obviously totally in error.

I definitely sympathize with the activity restrictions placed on a lot of us here in the south this year due to this especially hot weather! We've had horrible mosquitoes, in addition, here in Georgia. So up until just the last couple of weeks, I'd been limited to only a single early morning walk with my dog, too.

Anyway, it sounds as though the exercise regimen you are talking about could be very helpful for Sweetie, and I am very sorry I misunderstood.

Marianne

[wftmomx2]

I guess I could have found a better way to describe it. lol

I took my heart dog to rehab at this same place when she had Degenerative Myelopathy. I knew there was really no rehab for that condition as it's just not something dogs come back from but it got her out of the house and she enjoyed it. The people that work there are wonderful. I have no idea how Sweetie would take to the water but it might be worth a try, especially since her insurance will cover 90% of it. Anyway, will discuss with the IMS when we go back on the 27th.

[wftmomx2]

Thanks. I ordered her a very low calorie food so I'm hoping that will help at least a little. She gets so little now and gets no treats at all anymore. I am a stickler about not cheating since I had a dog that had 3 bouts of acute pancreatitis. My poor dogs don't ever get anything extra, or at least nothing more exciting than green beans or carrots. They don't even expect it. And no feathers have been ruffled. I came here for info and support. Having co-moderated the pancreatitis group, I know how hard it is for moderators and group members when a member ignores good advice. :-)

[molly muffin]

I think it would be well worth a try too.

Around here (Toronto) we take them to the speciality/ER hospital for therapy like water treatments quite often too.

The good thing is that she doesn't look for other treats. :)

[wftmomx2]

Sweetie had another ACTH stim test yesterday and also a repeat T4.

Results are:

Pre -- 2.6 Ref range -- 2-6
Post -- 4.5 Ref range -- 6-18
The report also says 1.5-6 -- Desired pre- and post- ACTH cortisol on Trilostane.

This is very confusing to me. IMS said bloodwork is "great", not to change Vetoryl dosage (10mg, 2x/day) and to come back in 3 months. Can someone please decipher for me?

Her T4 is still very low normal. 1.2, reference range 1-4. This is the second vet that says low normal is "great." The same report says therapeutic ref range is 2.1 - 5.4. I have had two dogs of the same breed with hypothyroidism and we always supplemented to get them to about 2.6. Same vets. I just don't get it. I discussed this with Dr. Dodds once and she said that a Wire Fox Terrier needs to be at mid-high normal. High normal was too much for the others and it was easy to tell but low normal just didn't work.

Nothing has changed in terms of symptoms except she is slightly more "awake." She has woken me up at 4am the last two days moaning with hunger. I have changed her to a very low cal diet, supplemented by baby carrots and canned no salt added green beans. She is down 4 ounces. She is still losing undercoat. Drinking/peeing the same. IMS says it will take 4-6 months for Vetoryl to take full effect.

They were supposed to retest liver enzymes and cholesterol at this visit but they didn't. Maybe because she wasn't fasted. How do you fast a dog for blood work when you have to give them their med at 6:00am.

Guess that's all.

Thanks for your support.

Julie

[Harley PoMMom]

The reference ranges for a dog taking Trilostane/Vetoryl are 1.5 ug/dl - 5.4 ug/dl, and the post number can be as high as 9.1 ug/dl if clinical symptoms are controlled. So, those reference ranges of 2-6 and 6-18 are for a dog that is NOT on Trilostane/Vetoryl therapy.

As for the thyroid level, if this were me, I would definitely trust Dr Dodds on this as she is considered an expert in the canine thyroid field.

Hugs, Lori

[labblab]

Per your question about fasted tests, unfortunately it is sometimes necessary to postpone fasted tests until a day when a monitoring ACTH is not being performed. As you are already realizing, the dog should not be fasted for the ACTH but may need to be fasted for some other tests. If so, even though it's inconvenient, the tests must be done on alternate days.

Also, I do have one additional thought about the thyroid results. It is not uncommon for dogs to exhibit suppressed thyroid readings in conjunction with uncontrolled Cushing's. However, once the cortisol has been lowered within therapeutic range for a period of time, the T4 reading can start increasing to a higher level again, all on its own. This may be one reason why your vet is not anxious to start supplementing Sweetie's thyroid yet, especially since her T4 is still falling within normal range (even though the lower part of the range).

Low thyroid is not good, but oversupplementation is not good either, especially since it can produce some of the same symptoms as high cortisol, such as excessive thirst and urination. Sometimes more complete thyroid panels (more than just measuring the T4 alone) can indicate whether it is likely that a dog's low thyroid level is secondary to another health condition like Cushing's, or whether it is likely to be a primary issue in its own right. However, since Sweetie's T4 is still within normal range, you may want to just sit tight for the time being and wait to see whether her T4 elevates to a higher level all on its own once you get further down the road with her Cushing's treatment.

Marianne

[wftmomx2]

I have a feeling that they thyroid caused the Cushings. I don't know if that happens but her T4 has low-normal ever since I got her. She had blood work done right before I got her (July, 2015) and the vet noted that perhaps further testing would be appropriate. My vet ignored it because it was still in the normal ref. range. I am going to sit tight for awhile (we are supposed to go back in 3 months) and then ask for the full panel (my vet did what she considers a full panel but is not the same as what Dr. Dodds does). I guess I will play it by ear. She started rehab yesterday to try to get some of the weight off.

Thanks for your help and support. It is hard waiting.

Julie

[molly muffin]

Hopefully the rehab helps with the weight. Probably why she is moaning in hunger, those low cal foods don't have a lot of the fill up carbs in them. Maybe green beans or something like that when she thinks she is starving.

[wftmomx2]

Sorry for the delay in responding. Lots going on. She has been getting lots of green beans and baby carrots. She was moaning with her regular food too but it has progressed over time. She's still hungry all the time but not moaning which is good. The time change messed up meal/med times but we're slowly getting used to it.

[wftmomx2]

https://www.youtube.com/watch?v=2coJZN6aBuM

Couldn't figure out how to get a link to work but if you copy/paste this into your browser bar, hopefully it will work. I wanted to share a short clip of Sweetie on/in the water treadmill at rehab yesterday. I felt bad when I first saw it (I hate to exercise) but she HAS to take off the weight she gained. She has taken off about half a pound as of yesterday. No other symptoms have changed.

Julie

[Joan2517]

I just clicked on it and went right to it...she doesn't look like she minds the exercising. I should do that with my Gabe. I can't walk him, he's too big for me.

[molly muffin]

Doesn't look bad at all and water is easier on the joints but good for the muscles.

[wftmomx2]

Question...I know this is somewhere on this extensive, wonderful site but thought I'd ask anyway. Time challenged.

My understanding is that Cushings is not genetic. Sweetie's original owner (who has not been very nice to me) has apparently spent "hours" researching "the genetics of it" and is trying to decide whether she should say something to her breeder (she is inclined not to because if it were genetic, he wouldn't admit to it anyway which is probably true). The original owner did not want me to spay her and I am very surprised that she hasn't brought that up as a cause for the Cushings.

So am I right that it is not genetic?

BTW, Sweetie has lost approx. 1lb. 3oz and appears to be stuck at that weight. Appetite is still ravenous but her labs were good so she is not changing dosage. She doesn't have the energy of a typical terrier but she's better than she was.

Julie

[labblab]

As far as I know, no genetic basis has been established for canine Cushing's. ;)

Marianne

[wftmomx2]

Thank you, Marianne. I didn't think so.

Julie

[wftmomx2]

I have a question about skin color. Sweetie's skin is very red. It is very noticeable since grooming today but it's been red since before the Cushings diagnosis. She does not have allergies.

To update, her ACTH stim test was good and couple of weeks ago. She will continue her current dose of Vetoryl 10mg in the morning and 10mg in the evening. Her T4 went from 1.2 to 0.8 so she was FINALLY put on a thyroid supplement. I've been trying to tell my vets she needed this since I got her 18 months ago.

She has lost almost 2# of the 5 she had gained. Still going to rehab 3x/week.

Julie

[Carole Alexander]

Hi Julie,
I just read through your thread and am so impressed with your efforts to rehab Sweetie although I know it must be frustrating to not see more progress in symptom reduction since September. My dog, Skippy was diagnosed early December and immediately started Vetoryl 10/10, but he weighs 29lbs. Cortisol is still not under control and we just upped the dosage to 15/15 today. Skippy too must lose weight - at least five lbs. He refuses long walks and is still lethargic and ravenous! Questions:
1) What food are you feeding Sweetie?
2) Is the "Rehab" at a university vet clinic? A private vet?
3) Will Sweetie tolerate long walks; do you add those to her regime? I am considering trying to push Skippy further with the walking.

I'm eager/desperate to get the weight under control as I believe or at least want to believe it will help the Cushing's symptoms. Obesity can't help this disease.

Thanks much,

[Carole Alexander]

Regarding your question about skin color. Where Skippy's hair has thinned along the top of his chest and back and a little on his sides, his skin is bright red with little dark spots that are not bumps. But he has had "old dog" lumps for the past year or more and had several removed last May. Also, he's always had allergies. Likely others with more knowledge of dermatological problems related to Cushing's will respond. Best to you.

[labblab]

Hi Julie, thanks so much for this update, and I'm so glad that Sweetie generally seems to be doing well. Unfortunately, though, I have no explanation for you about the red skin. :confused:

One question for you: can you give us the exact numerical results for Sweetie's ACTH testing? Those numbers will give us an important guidepost for assessing her ongoing treatment progress.

Thanks so much!
Marianne

[tam2toys]

Welcome to to you and Sweetie!

[wftmomx2]

Resting Cortisol 2.7 ug/dl
Post Cortisol 3.1 ug/dl

Her ALP and ALT are still a little high but not high enough to concern IMS (281 and 206 respectively...don't have reference ranges with me). Triglycerides are slightly high. Everything else except the T4 was fine. Will recheck that in a month. Recheck ACTH stim 4-6 months.

[wftmomx2]

Thanks, tam2toys.

Julie :-)

[wftmomx2]

One more quick note....Sweetie's IMS says that the bright red color of Sweetie's skin is more than likely the beginning of allergies that did not show up before her Cushings treatment. I had read about this issue so I was not terribly surprised. I am lucky enough to have a wonderful skin vet that treated two of my (angel) dogs so I will zap her an email and see what she thinks. She doesn't scratch any more than any other (normal) dog so it is not an emergency. Will be interested to hear her thoughts.

Julie

[molly muffin]

That is a definite possibility. Higher cortisol levels can cover up other things, allergies, arthritis, being some of them.

Are they doing BP checks? Mollys ears would turn a red when her BP was elevated.

Hopefully the dermatologist can help determine if that is the case.

[wftmomx2]

Thought I had replied to this but don't see it. I don't know if vet does BP checks when she's there. I will ask. Her entire body is red; not just her ears.

So here is where I beat myself up even though it does no good. I forgot you are supposed to give thyroid supplement on an empty stomach (1 hr before meal or 3 hrs after) so I've been giving it to her with breakfast and Vetoryl dose. Duh! I've had 2 hypothyroid dogs so I should have known. Now the problem is, we get up at 6am and Sweetie is hungry so she is fed right away. I go to work at 7:30 and don't get home until 5-5:30. T4 rechecks need to be done 4-6 hrs after her dose of Thyro-tab or I could just give it to her when I get home and hold off her dinner and 2nd dose of Vetoryl for an hour if I could so that won't work. IMS will not bend on 2 vs. 1 dose of Vetoryl. She also thinks one dose of Thyro-tab is the way to go as opposed to many vets. My other dogs did well on 1 dose so I'm ok with that for now but can't figure out how to schedule this. She is scheduled for a T4 recheck in a couple of weeks. Should I wait for those results before I approach vet? If she did go to 1 dose of Vetoryl, it would have to be in the evening. Does that matter? Any thoughts welcome.

Thanks,

Julie

[DoxieMama]

Hi Julie,

I had a similar issue with my boy, where I was feeding him every 4 hours and had a supplement to give him that had to be given on an empty stomach. Luckily I could squeeze it in between meals in the evening as testing was not time dependent. I feel for you on this one.

But you've got the same issue with timing of the ACTH test - it must be within 4-6 hours after the Vetoryl is given. So both the Thyro-tab and the Vetoryl will have to be in the morning unless your vet is available to do the testing at night.

I do realize what I'm about to ask... but could you get up an hour earlier to give her the Thyro-tab? How critical is it to give that on an empty stomach? I have no experience with it so just curious.

Shana

[labblab]

Hi Julie,

Although this is not a cheery option for Sweetie, it seems to me that your best solution is to give her the thyroid pill at 6:00 a.m., and then wait until 7:00 to feed her breakfast and give her the Vetoryl. She may indeed be hungry and beg for food, but the reality is that she won't starve by waiting for an hour to eat. And perhaps over time she may adjust to the new regimen better than you expect.

Since the monitoring ACTH test must also be performed 4-6 hours after dosing with food, by scheduling Sweetie's breakfast and meds in this manner, you'll be OK for both tests if the first blood draw is taken at 11:00 a.m. (five hours post-thyroid pill; four hours post-Vetoryl). By the way, this is the reason why you can't switch to a once-daily dose of Vetoryl in the evening -- you can't perform the monitoring ACTH within the proper timeframe.

Unfortunately, I can't think of any other regimen that will work unless you just accept the fact that if her thyroid pill is given alongside breakfast, she'll always need a bigger dose every day than would otherwise be the case, in order to offset the loss of effectiveness by being taken on a full stomach. It would definitely be important to discuss that with your vet, so she'll know what's going on when she's interpreting the monitoring results.

Marianne

[labblab]

Also, in re-reading your earlier replies, I am concerned that your vet is advising that you wait 4-6 months before performing another ACTH. It is true that, on the face of it, this most recent result is fine. But it is important to evaluate trends as well as the numbers in isolation.

On 10-27-16, here were Sweetie's results:

Pre: 2.6
Post: 4.5

On the repeat ACTH performed a week ago:

Pre: 2.6
Post: 3.1

So while still taking the same dose, Sweetie's post-stimulated cortisol has continued to drop further during these past three months. That being the case, I would worry that she may still see an additional decline on this unchanged dose. If so, she may start dropping into a range that is truly too low. If she were my dog, I would not feel comfortable waiting any longer to test than another three months at most, in order to see whether a dosage decrease is warranted. And certainly, if she starts acting "off," I'd want to retest again even sooner.

Marianne

[wftmomx2]

Thanks, Marianne and Shana. I really appreciate your being here for me & Sweetie. Out of the last 4 days, Sweetie has slept later and not beat me to the kitchen for breakfast, barking her very shrill, insistent bark. My other Wire Fox Terrier has a much deeper bark, as did my last two (now angels.) Sweetie's bark just goes through me....instant headache. This morning, I opened her mouth at 6am, threw the thyro-tab in, she swallowed and went back to sleep. This was ideal and I hope it will work tomorrow and long term. I doubt it but a girl can hope! Usually, she will not even go out to potty until she has eaten. Her appetite is still ravenous but I think in spite of my bad timing, maybe the thyroid med will help.

I sent a note to Dr. Dodd's last night asking for a reference to reading materials on co-existing Cushings and Hypothyroidism. I was thrilled to see a reply this morning but it didn't really tell me anything I didn't already know about the medicine dosing. I haven't read it yet but did scan looking for a reference to Cushings and only saw material on Hypothyroidism. Will read complete article this afternoon.

Marianne....I have to admit that I still don't understand Cushings as well as I should. I have dealt with Hypothyroidism, Diabetes Insipidus, KCS, Neurogenic KCS, PRA, Acute Pancreatitis, perianal carcinoma, lyomyosarcoma., etc., etc. and feel like an old pro with dog disorders but I have been depending on my IMS, who has been seeing my dogs for years, to guide me and I have had a trusting relationship with her. Dr. Dodds recommends twice a day dosing on the L-Thyroxine but the IMS and several general vets I've had over the years have always said one is enough for this small dose. Don't know what to think. My other dogs did well on once a day dosing I know Dr. Dodds' reputation as an expert but I also know she is just one vet and others will have different opinions. As for the Cushings, my IMS took one look at Sweetie (visually) and knew before she did any tests that I was right about the dx. She did the ultrasound first and knew what it would show. She was very careful...maybe too careful....in diagnosing the hypothyroidism even though I knew from experience that she had it. I couldn't say for sure that it was secondary to Cushings so I went along with a longer wait for monitoring than I would have liked. I wonder if anyone ever knows for sure that they are doing the right thing for their dogs. I do have a feeling that more frequent monitoring of both disorders is probably wise since they are both hormonal disorders and my guess is that just like with humans, hormones have to balance out somehow. Just a guess. Dr. Dodds said in her email that it is not common for dogs to have both. Sigh...... I will ask IMS about all of this. Aside from the hunger, I have seen an improvement with the Vetoryl. I will be curious to see if there is much of a difference after treating for the Hypothyroidism.

Sorry this was so long. I feel kind of like I'm floundering and since there has been an improvement, I am probably over thinking this.

Julie

[wftmomx2]

It's been a long time since I've updated about Sweetie. In particular, I am looking for information on Calcinosis Cutis as it relates to Cushing's. She has not been formally diagnosed with CC but I have seen enough pictures on the web now to know what the lesions are that are rapidly increasing. I tried to get to the brochure I saw a link to (
http://www.dechrace.com/pdfs/vetoryl...alBrochure.pdf) but I can't get to it. I am hoping a general vet can diagnose it to avoid the consult with a skin vet. I think what I'm reading is that there is no cure and symptoms will just have to be managed. The internist will take a look tomorrow while she is there for rehab but probably won't want to treat this.

Newest other challenge......Sweetie's gallbladder is distended and internist says it looks like she is developing a microcele. The distension was noted on her first u/s report when she was first diagnosed with Cushing's but I guess I was in such a fog, I didn't notice. Even after losing weight, her belly is very distended so I asked for another u/s and this time there is mention of the microcele with instructions on what to look for. It may be necessary to remove her gallbladder at some point but we are hoping it resolves on its own. She will have another u/s in about a month (unless she starts showing symptoms.) I think she will have another ACTH stim test at the same time.

Her thyroid is doing well on a supplement.

Thanks,

Julie

[labblab]

Hi Julie, welcome back, although I'm very sorry that Sweetie is having these additional problems. First of all, I'm not sure which Dechra publication you were trying to link to, but take a look at the various Dechra brochures referenced in this post and see if the one you're wanting is there.

http://www.k9cushings.com/forum/showthread.php?t=185

Secondly, I'm certainly sorry to hear about the possible calcinosis cutis. Typically, though, this condition manifests when cortisol levels are elevated and not under control of medication. Is Sweetie still taking her Vetoryl, and has her cortisol level been checked recently via an ACTH stimulation test? If you can fill us in re: Sweetie's Cushing's treatment since last spring, that will be a good place for us to restart our general conversation about the path forward.

Marianne

[wftmomx2]

Is there a way to attach .pdf and .jpg? I have her most recent bloodwork (8/3/17) and letter to general vet that has last ACTH in it. She is due now for another ACTH and repeat bloodwork (and I think repeat ultrasound.

Internist does not think the lesions are CC but instead pyoderma. I don't agree and have a bad feeling. She may see one of the dermatologists on staff today....depends on whether they are going to make me pay a $270 new consult fee or not. :-(

Julie

[Joan2517]

I have been able to attach jpg very easily into the photo albums.

[wftmomx2]

Follow-up on earlier post -- Skin vet looked at her and whatever she has is bacterial so she will start a 30-day course of antibiotics and bathe with Malaseb. I am still not 100% comfortable that it is not CC, but I guess time will tell. She also has a little cyst that looks different from all the other lesions that is not an emergency but should come off and be sent to lab. She goes back for ACTH and follow-up bloodwork 1st week of October. I was a month ahead of myself when I said she was due now. Time flies when you're having fun.

In terms of Cushing's symptoms, she is doing well except still has ridiculous appetite and has gained back 1 lb (silly me...I thought I could increase her kibble by 1/4 cup and I also decreased her rehab from 3x to 2x/week.)

Julie

[wftmomx2]

Thanks. The bloodwork was scanned as a .jpg by a tech so I was able to upload it. There's a letter with other results and comments but it is a .pdf and I couldn't upload it.

[molly muffin]

Hi and welcome back.
Did they give you ursodiol for the gallbladder? I know that is often used for trying to get rid of gall bladder sludge that can cause a blockage.

Do you have the results of the last ACTH that was done? If over 5.0ug on the post, then it could be cc, but if under, then probably not as likely.

[wftmomx2]

From the internist's tech a month ago: " She said no ursodiol since it promotes gall bladder contraction and we don't want it to possibly rupture!! The milk thistle and denmarin wouldn't hurt but she still feels that they are not indicated at this time."

Last ACTH stim was June 8 and results were:

PRE 4.3 ug/Dl
POST 4.5 ug/Dl

We will repeat ACTH early next month and also more blood work (see photos section for last results.) Not sure but I suspect she will repeat ultrasound to check gallbladder again. No symptoms from that, thank goodness.

Dermatologist says the skin problem is not CC, but bacterial. She also has a few little skin masses that I will have removed when she has her next dental. I am trying to convince Trupanion to cover the skin problems but they claim it is pre-existing (she had a "grooming accident" that got infected before I signed her up.....it is not the same as all this but they are trying to say it is.) I am not going to push too hard because then they can make a case that the Cushing's was pre-existing even though I did not know she had it.

Julie

[Joan2517]

Wise decision to choose your battles, Julie~

[molly muffin]

Yep, skin tags can be removed with less cost than treating/testing for cushings for sure.

[wftmomx2]

One is a cyst, some others are small masses (look like pink cauliflower), and others are pyroderma I think she said.

[wftmomx2]

I realized that I had not let folks here know that Sweetie passed a week ago. She had a mucocele in her gallbladder which was being monitored and when it became painful, she had surgery to remove it. She came out of the anesthesia just fine and was being monitored but things went terribly wrong that night (the emergency clinic, in the same building, was monitoring her) and they couldn't save her. I want to thank everyone here for teaching me what I needed to know to deal with her Cushing's. How much of the Cushing's and gallbladder problems were related, I'll never know.

Julie

[labblab]

Oh my goodness, Julie, I am so deeply sorry to read this news. We thank you, though, for returning to let us know what has happened. This way, we can help you in honoring Sweetie always. And we hope we may offer our support to you, as well. Such a hard loss at any time, and especially at this time of the year. Please know we will always be here for you should you wish to talk more about what has happened, or to share special memories of your dear girl.

Again, I am so very sorry for your loss.
Marianne

[Squirt's Mom]

Dear Julie,

I am so sorry to hear about your sweet girl. Please know we are here anytime you need to talk, vent, cry, whatever - we DO understand the pain you feel.

My deepest sympathies,
Leslie




A Pet's Peace
by Tracy M. Johnson

I have left you now, but please don't be sad,
you gave me all the love you had.
You did so much for me in my time here
and I'll always hold those precious times near.

I know someday you'll find love again
and into your life will come a new friend.
Your heart will heal, though you'll never forget
memories like the first time we met.

Memories are wonderful, so keep them close
and remember all the good times the most.
Up in the Heaven for animals is where I'll be
and someday in the future, each other we'll see.

I am at PEACE now, so please don't be sad
You gave me all the love you had.

[DoxieMama]

I am so sorry for your loss. Run free, Sweetie.

[Joan2517]

So sorry for your loss of Sweetie...many hugs.

[molly muffin]

Oh no, I'm so sorry to see that Sweetie has passed. We all know how heart breaking that is.

My sincerest condolences.