New and seeking advice on symptom management

[BabyBear]

Hello all,

First, I just wanted to say that I'm so glad I found this forum. It has been helpful to read the posts of others going through the same thing me and my little one are going through. I wanted to post Bear's story, but I also have some questions.

Here's Bear's story: Bear is a 6 year old Australian Shepherd mix and he was diagnosed late last year after an array of testing. He presented with weight gain, increased hunger, mild depression, excessive panting, and mildly elevated ALT and ALP values. He experienced changes in his coat quality toward the end of the diagnostic process.

The initial thought was Cushings, but his LDDST was negative and his elevated liver values returned to normal with a month long course of Denamarin, so my vet and I sought out different diseases that fit his symptoms, in particular Thyroid disease (as he was only 5 and he didn't present increased thirst or coat changes at the time, and he was mildly bradycardic[not a Cushings symptom]). Bear's Thyroid Panel was within normal limits, but his Free T4 has always been on the low-normal side. We did a Urine/Cortisol Creatinine ratio test and that did turn up positive, but it's not definitive for Cushings.
After months of trial and error to treat his symptoms, I got his weight down with Hill's Metabolic diet, but I never fixed the actual hunger and I tried a few trials of anti-anxiety and pain medications to get his happy go lucky attitude back.

After awhile I was ready to see a specialist, but before I paid specialist prices (I'm a vet assistant and get a small discount at my hospital) I decided to run an ACTH Stim just to prove to myself it wasn't Cushings before I went. Sure enough, this test turned up very positive. Next we did a High Dose Dex test to find the tumor and again this test was negative. I started him on Vetoryl and took him to the specialist for a CT scan to find the tumor just incase I was able to do surgery and remove an adrenal adenoma. As it turns out, he does have the more common microadenoma on his Pituitary Gland.

I write all this out so that maybe others will see this and think that if they went the LDDST route first and it was negative, maybe it would be a good idea to talk to your vet and to do an ACTH Stim. Approx 5% of the time, dogs test negative for LDDST and this was my situation. I have been feeling so guilty for all of those months I wasted trying other things to make him comfortable. This dog is truly the love of my life and is the reason I left my old job and am currently in the veterinary field. I have a pit in my stomach from just thinking about it and to be perfectly honest I cry probably more often than anyone else would, but he is my best friend.
Bear is now controlled on Vetoryl twice a day. He gets a 30mg capsule in the morning and a 10mg in the evening. (He's about 40 lbs).



Questions: So here are my questions to those dealing with this too. I have him officially controlled on medication. He has been controlled for several months now. I still haven't seen a change in his hunger. He never had increased thirst, but he is insatiable. Are your guys and girls still starving while on Vetoryl? Did Vetoryl help this symptom at all for you? If not, what have you done to supplement them? I've added green beans and I'll be switching him to Royal Canin's Satiety diet to help, but I just hate seeing him so hungry.

What about coat quality? Bear still has a coarse coat that used to be so soft. I know that this particular symptom takes longer on Vetoryl to change, but what have you guys noticed? How long until you noticed a difference?
On Vetoryl, I have seen a decrease in his panting (it's not completely gone back to normal panting), increased energy, and his liver values are normal again after several spikes throughout the months of diagnostics. Is there anything else that you and your vets have added to your pets regimen? I just want to do everything I can for my Baby Bear.

Thank you for those that took the time to look at my post. It's hard being on the other side of vet medicine and being on the receiving end of bad news. I am so happy I have found a supportive community and I appreciate your time.

[labblab]

Hello and welcome to you and Bear! I'm sorry you were sitting in "limbo" overnight, but apparently you were not able to retrieve our confirmatory membership email. Therefore, I've now manually approved your membership and you're all set to go. :)

First of all, I hope you'll be able to be kinder to yourself re: the delay in Bear's diagnosis. Since there is no single 100% confirmatory diagnostic for Cushing's, you are in very good company in that regard :o. Many of us suffered through months of question marks and indecision, myself included. The important thing now is that Bear is receiving treatment, and that you've reached out to join our family.

Thanks very much for sharing your diagnostic experience, though, because it does illustrate the challenges in confirming this disorder. We do have other members whose dogs tested negative on the LDDS and positive on the ACTH, and also vice versa. A negative on the LDDS is usually quite reliable, but as you say, a small percentage of Cushpups don't return a positive result on that test. So just as you say, the best advice we can give folks is: if their dogs continue to exhibit classic Cushing's symptoms even though they've tested negative on one of these diagnostic blood tests, go ahead and spring for the other, just for additional validation.

Turning to Bear, when you say he is being controlled with the Vetoryl, have you been performing periodic monitoring ACTH tests in order to confirm that his current dose is truly optimal? Because that would be my first thought -- that perhaps he is in need of a dosing increase. So before going any further, I'll leave you with this question. Have you performed any monitoring ACTH tests since beginning treatment, and if so, what are the actual numerical results?

Marianne

[Squirt's Mom]

Hi and welcome to you and Baby Bear! :)

I will leave the comments on Vetoryl to those who use or have used that drug...I am a Lysodren gal. ;) I will ask some questions to get them started tho -

I don't see where you gave Bear's current weight? Do you mind sharing that with us? The new starting dose for Vetoryl is 1mg/lb (2mg/kg) - not all vets are aware of this change so I wanted to make sure you have that info.

Does Bear have any other health issues? Is he on any other meds, supplements, or herbs? If so, what for?

I assume everything else seen on the CT was normal?

You say he is controlled - do you mind sharing the actual results of the ACTHs he has had? Dechra says the post # can go as high as 9.1ug/dl if, and ONLY if, ALL signs are well controlled. Otherwise it is optimal to get that post down to 5.1ug/dl. If his post is running a bit high that may account for the continued hunger. It could also be a learned behavior - something our cush babies seem to be real pros at! :D Fresh or frozen green beans, carrots, apples, bananas are all good to help them feel full without packing on the weight like treats, etc. will do.

The coat is something that is different for each dog it seems. Some pups on Vetoryl will completely blow their original coat and regrow one that is entirety different. Have you ever seen a Boston with red, curly hair? :p I assume the skin itself is improving - thinness, bruised appearance - if they applied in the first place? No evidence of sores or raw spots?

That's all from me for now; I'm sure others will be along soon to chat. Please never hesitate to ask any questions - if we don't know we will help you find the answer if possible. We are here to listen regardless - cry, scream, vent, laugh, whatever - we are here. You and Baby Bear are now part of our little family here at K9C and this family sticks together thru thick and thin. You are never alone on this journey.

Hugs,
Leslie and the gang

[judymaggie]

Hi and welcome to you and Bear! Marianne and Leslie have the questions covered so just wanted to welcome you to our family. Don't hesitate to ask any questions you may have. I look forward to learning more about Bear.

[BabyBear]

Thank you so very much for the kind words. It means a lot to finally talk to others going through this. I know my original post was getting pretty wordy so I left out the numeric and smaller details.
I know that the LDDS is a reliable diagnostic tool, so that is another reason I went ahead to pursue a CT scan to confirm his diagnosis (and of course to locate the adenoma in case it was operable). As I'm sure you know, Vetoryl is a pretty scary drug especially for a dog that doesn't have Cushings so I wanted to be sure since he tested very negative on the LDDS.
To answer your other questions, yes I have done 3 total ACTH stims so far. I am not due for his 6 month check up just yet. The first test was his diagnosis, the second was on 30 mg of vetoryl once a day (this was not therapeutic) and the third was after he had been controlled on 30mg in the morning and 10mg at night per his specialist.
Here are the results:
September: Pre: 3.1
Post: 33.9
October: Pre: 4.0
Post: 14.0
November: Pre 1.5
Post 3.2
I was planning on doing another ACTH Stim 3 months after his last one and then every 6 months going forward. I would love to know your routines that your veterinarians have been following. Like I have said several times, I just want to do everything I possibly can for him.

-Britt

[BabyBear]

Whoops, I thought I was replying to each post individually. My previous post was for Marianne and now I know for next time.

Hello Squirt's mom!
Yes, in regards to the new starting dose my vet and I were aware of the new dosing, but thank you for the information! :) I love hearing new stuff so please feel free to send over any new things you've heard and learned. Bear is 38-39 pounds (optimally about 30-32). We initially began under dosing due to the dangers of adrenal necrosis and began at 30 mg/day. This was not therapeutic, but it was worth a try. We bumped him up to 30mg in the morning and 10mg at night for a total of 40mg per day. This gave us a therapeutic post ACTH stim value of 3.2.

Bear does not currently have any other health issues. His free T4 was 0.8 on his last blood work in December so, I'm monitoring him closely for hypothyroidism. His full thyroid panel was done in June last year when we were still in the diagnostic phase and this was normal. I get a break on blood work at my job, so I test him more frequently than most do. He has normal glucose values so we are not diabetic so far. He has had elevated ALT and ALP values but I am happy to say that after Denamarin and couple months of Vetoryl, his ALT is finally within normal limits again!! :) His ALP is still very slightly elevated but overall the bloodwork is trending in the right direction.

He is not currently taking anything other than Vetoryl. Have you heard of other herbs and supplements to try? I'm very open minded. I consulted with my specialist in regards to melatonin and lignans (I had read about these online) but she said that she had not seen this help or hurt so I didn't add it in.

The CT results were fairly normal. He has a microadenoma on the pituitary. He showed mild bilateral enlarged adrenals (no shock there). Found some funny things like he has a deviated septum and a case of tennis elbow, hahaha. But I did go ahead and do some physical therapy visits for that because he had a bit of bicipital groove remodeling and I don't want him to be too arthritic there when he's older, although I can't fix the current damage. I was hoping to prevent more in the future. In the end I'm still glad I did the CT and found some of these things that wouldn't have been noticed for a few years down the line. I also did X-rays several months before hand and he did have some rounding of the edges of his liver.

I know this is way more than you ever wanted to know about someone else's pet haha, but to finish answering your questions I know that the hunger can be learned. It's just that he was never a dog that cared about food until last year. It was actually to the point where I would beg him to eat somedays and he would just ignore his breakfast and wait for dinner. I haven't tried bananas so I'll go ahead and add some in. It's just hard to see him so ravenous when he was never like this before. 30 minutes before dinner and he will be pawing at the bowl. It's so sad. What kinds of food (kibble brand) are you feeding your pet?

As far as skin, I have seen some improvement on the thinness of his skin on his belly. He never had the bruising, rawness or sores. He did have bilateral hair thinning on his shoulders and near his hind, but that has mostly resolved. His hair is just still so coarse. I wonder if its permanent, although this is the least of my concerns. I just wanted to mention it since Vetoryl is supposed to fix it.
Thank you so much Leslie for your reply.



And to Judy, thank your for the reply. It is so nice to feel welcomed.

--Britt

[labblab]

Hello again, Britt, and thanks so much for all this additional information! That November monitoring ACTH result looks great, so unfortunately it seems as though the excessive hunger is simply taking a longer time to resolve for some reason. And has already been mentioned above, the color and consistency of a dog's coat may indeed be altered permanently after beginning treatment. The good news is that bare patches fill back in -- the startling part is that the nature of the regrown hair may be different.

As far as treatment regimens, Dechra recommends ACTH testing every three months, forever, after dosing has been stabilized. I've seen a few vets who are willing to space it out to every six months as long as a dog remains clinically well. So that is a decision you can make further down the road, depending upon your comfort level with Bear's behavior and appearance.

One more quick question: in addition to abdominal imaging, it sounds as though you must have also done a CT of his head in order to have knowledge as to the size of the pituitary tumor. Is that correct? I'm just curious about that.

Anyway, it sounds as though, overall, you guys are doing great and we'll be anxious for continuing updates.

Marianne

[DoxieMama]

Hi Britt! Welcome to you and Bear!

I have nothing to add to all that has been said already. I thought I'd posted on your thread to welcome you but apparently hadn't...

You're doing a great job!

Shana

[BabyBear]

Marianne, I had heard about the every 3 month vs every 6 month ACTH stim testing depending on the doctor. I figured I would continue with the 3 month regimen for now and if I'm not seeing large fluctuations I would continue with a 6 month plan in the future. Bear is only 6 so, fingers crossed, we have many, many more ACTH stim tests to go in his lifetime.

Speaking of lifespan, what is the general consensus after diagnosis that you've been seeing from others here on the forum? It seems all over the board for the Cushings patients at my clinic (especially depending on the initial age of diagnosis). For pets like Bear who are young and controlled, are we seeing more than a couple years? The internet is scary place to search for a number and that's typically what I've found. I really don't want to believe that. :(

And to answer your question, yes. I sprung for the full body scan. As much money I have put into Bear, another couple hundred to get the full body was worth it to me. The CT of his head specifically showed a slightly enlarged pituitary gland, thus indicating a microadenoma on the gland. It's not significantly enlarged, so it's really just a lesion but enough to confirm the diagnosis (especially with the bilaterally enlarged adrenal glands secondary to them overworking due to cushings disease).





Thanks for the welcome Shana and I appreciate the encouragement!



--Britt

[labblab]

Britt, I'm happy to tell you that throughout the years, we've seen many dogs who have essentially lived out their normal lifespans once the excessive cortisol comes under effective control. Just as you have experienced in your clinic, the prognosis for each individual dog depends upon a whole host of factors including age, overall health history, tumor growth, development and progression of secondary problems, other unrelated health issues, etc. Given all the various combinations of factors, the commonly cited two-year survival time may indeed be accurate as an average. But that discounts the extended lifespan that is possible for a younger, otherwise healthy dog who receives careful treatment and monitoring. So we'll be hoping for many more good years for Bear, just as we have celebrated with other members here!

Marianne

[Squirt's Mom]

Barring any complications, with the care, attention, and knowledge you bring to Bear's life I wouldn't worry one teeny bit about a shortened lifespan. ;)

[molly muffin]

Hello and welcome from me too.
My molly was one of the ones that also tested negative on the LDDS and positive on the ACTH. In fact, her liver enzymes where going up and they kept checking for cushing with the LDDS and every time it was negative. I think there were 4 or 5 LDDS in total over the years. So months is pretty good to be able to get to a diagnosis. I went years. During that time she did pretty good over all, with no symptoms other than the liver enzymes to go by. We too did the denamarin for the liver and she remained on that for the rest of her life.
She did fine on the vetroyl once started. Her coat did get thin and more coarse and for us, that never really rebounded.
It was kidney failure that finally got her in the end, her cortisol remained sort of bouncy, with us adjusting doses as needed based on follow up ACTH.
Once her creatinine and calcium and BUN, SDMA all started going on, that became our focus rather than the cushings.
We have had dogs on the forum be on vetroyl for a very long time. Just off the top of my head I want to say one was treated for 8 years.

Welcome again!

[BabyBear]

Thank you Squirt's mom. I'm definitely trying to do what I can.


Molly Muffin, It's so crazy when our pets won't test positive with LDDS. I wonder why that is? I need to do more research and talk with Bear's specialist.
Wow, treatment for 8 years on vetoryl? That's amazing and wonderful to hear.
And I'm so sorry about your little one. Kidney disease is so difficult to go through. Thank you for the information and your personal experience. Again, I'm so sorry for your loss.

[molly muffin]

5% of dogs with cushings will test negative on the LDDS test. I don't know if it is because of location of a pituitary tumor or what, but that is my best guess at this point.

[BabyBear]

I'm just wondering if anyone else could weigh in on my pet's case. This has been quite the battle for the last 3 years with no relief of symptoms.

Okay, I will try to keep this short. Bear is a soon to be 9 yr old, MN, Mini Australian Shepherd (30lbs). He has been symptomatic for Cushing's since he was 5yr. His symptoms include increased hunger, panting and a coarse hair coat. Bear went untreated for approx 1 year due to both a negative LDDST and high dose dex test. He was borderline hypothyroid, so we went looking for answers to his hunger in that direction. After deciding to see a specialist, we did and ACTH stim and he came up positive for cushings. We did a CT scan to confirm that the tumor was in his pituitary gland. It was mildly enlarged on the upper end of normal.

So began our 2ish year Vetoryl plan. We started at 30 mg once a day (Sept 2016) and ended up at 75mg in the morning and 50 mg in the evening (December 2018). Always needing to increase every month or two because his numbers would normalize, and then they would go up again. Only in the last 6 months of using vetoryl was his Post ACTH stim within appropriate limits (between 1.8 and 3 microgram/dl) for more than 3 months. As you can imagine, that was a lot of boxes of vetoryl a month. Over $400 plus the bloodwork. This would have been fine, but literally at no time in these 2 years were his symptoms ever controlled. Sure the numbers looked good, but he is STARVING all the time and the panting and hair never changed. It's the hunger that is so hard to watch, it's unfair. This was a dog that would skip meals before Cushing's.

So fast forward to a new plan at the local University Teaching Hospital with a different specialist for another opinion/approach. Spoke with 6 doctors who wouldn't touch mitotane and then found one who not only would touch it, but was very comfortable with it. We did a vetoryl washout and did no meds for a couple weeks. Then began induction on Mitotane. 1/2 500mg Tablet twice a day for 4 days. Recheck of 1hr Post ACTH Cortisol: 8.91. Dr has a us start maintenance at 250mg twice a day 2 times a week. Recheck in a month: 17.4. Dr. has us increase again to 250mg twice a day now 3 times a week. Recheck in 6 weeks: 16 microgram/dl.

So this is where we are. He has exceeded the max amount of mitotane he can have per week for his weight (100mg/kg) (1,300mg is the max and he takes 1,500mg) and there is no symptom change and his numbers are high again and haven't come back down. The specialist is out of the office until Monday and the other doctor didn't want to make any changes just yet without her since Bear is taking above the max he can have a week - can't blame him. I'm sure his specialist will have a plan - she basically wrote the book on mitotane. Maybe potentially do another induction phase?

I'm just so hopeless for my boy at the moment - I could cry. It's as if we give him a dose, and then he becomes resistant. Just looking for others with a similar pet experience who have any ideas, or words of wisdom or comfort. I love this dog more than anything and just want to see him comfortable.

[labblab]

Hello Britt, and welcome back to you and Bear, although I'm surely sorry the last couple of years have been so challenging for you guys :-(. As you'll see, one of our staffers has merged your newest post into your original thread about Bear, and that will be a great help to us since, at that time, you had supplied a lot of helpful explanatory details about his diagnosis and initial treatment steps. I'm going to go ahead now and address a few of your current comments and and questions. As I always tell folks, please bear in mind that I am not a vet and have had no professional training or experience. However, my observations are based on the multitude of Cushing's journeys that have been shared with us on this forum throughout the years. So here goes...


So began our 2ish year Vetoryl plan. We started at 30 mg once a day (Sept 2016) and ended up at 75mg in the morning and 50 mg in the evening (December 2018). Always needing to increase every month or two because his numbers would normalize, and then they would go up again. Only in the last 6 months of using vetoryl was his Post ACTH stim within appropriate limits (between 1.8 and 3 microgram/dl) for more than 3 months.
As you know, you ended up on a high dose of dose of Vetoryl: 125 mg. daily total for a dog weighing 30 pounds. That is a lot of Vetoryl, and if his post-ACTH result was less than 3 ug/dL, he was actually in the lower end of the desired therapeutic range. Per Dechra, Vetoryl's manufacturer, a post-ACTH as high as around 9 ug/dL is acceptable as long as symptoms are being controlled effectively. If not, the desired post-ACTH drops down to a range of 1.45 - 5.4 ug/dL. So that high dose of Vetoryl was finally effectively lowering his cortisol to the "basement" of the desired range. And yet his hunger, panting, and poor coat persisted.


So fast forward to a new plan at the local University Teaching Hospital with a different specialist for another opinion/approach. Spoke with 6 doctors who wouldn't touch mitotane and then found one who not only would touch it, but was very comfortable with it. We did a vetoryl washout and did no meds for a couple weeks. Then began induction on Mitotane. 1/2 500mg Tablet twice a day for 4 days. Recheck of 1hr Post ACTH Cortisol: 8.91. Dr has a us start maintenance at 250mg twice a day 2 times a week. Recheck in a month: 17.4. Dr. has us increase again to 250mg twice a day now 3 times a week. Recheck in 6 weeks: 16 microgram/dl.
Throughout our time here, we staffers have relied on the Lysodren treatment protocol outlined by Dr. Edward Feldman of UC Davis. Historically, it has been the classic approach that we've seen utilized by vets who prescribe Lysodren here in the U.S. Here's a link to his recommendations:

https://www.k9cushings.com/forum/showthread.php?181-Lysodren-loading-Instructions-and-related-tips

What I'm seeing is that your current specialist has departed from this classic protocol in the following ways. First, at a weight of 13.6 kg., this protocol with which we're familiar would have loaded Bear with a daily dose of approx. 680 mg. of Lysodren as opposed to only 500 mg. (following a formula of 50 mg. per kg. of weight per day). However, this difference probably only means that we might expect Bear to take a longer time to fully load than a dog taking a higher daily dose of the medication. Of greater significance is the fact that your vet switched Bear to the maintenance phase when his cortisol had only dropped to 8.91. Typically, the loading phase is not viewed as having been successfully completed until the post-ACTH drops to at least 5 ug/dL. So your vet shifted to the maintenance phase "early," but also at a higher dose than is typically used for maintenance. The Feldman protocol recommends that the weekly maintenance total generally approximates the daily dose that was required to lower the cortisol to that ideal range between 1 - 5 ug/dL, with variations based upon the speed/ease with which a dog originally loaded. Your vet's approach, however, has been to shift to maintenance early, and then give higher maintenance doses -- perhaps with the intention of still driving the cortisol down a bit further?? I really don't know. Unfortunately, that strategy has not seemed to work. So if you do reload, perhaps a different and more conventional approach would be better.

Another, not-so-cheery thought that occurs to me is that, during these past two years, Bear's pituitary tumor may have continued to enlarge into what is referred to as a macroadenoma. If so, that might explain his poor response to the medication and his lack of symptom relief. Unfortunately, that would take the expense of another CT or MRI of the head to visualize. A more benign -- and admittedly off-the-wall -- explanation might be that his excessive hunger may not be a result of Cushing's at all. If not, then lowering his cortisol to any level might not help. The reason why this even comes to my mind is because I've now owned three Labs, one of whom had Cushing's and two who have not. And in honestly, they ALL have had ravenous appetites. In terms of appetite, there truly has been no difference among the three. They will literally eat anything that is loose on the ground. Obviously that means any pieces of food that are dropped or are available to them in the house. I've tried to train them to obey the command "Gently" when a treat is offered by hand, and still my fingers often get snapped up in the process. Outside, they will gobble lawn clippings, clumps of dirt, any speck of garbage they can dart to and unearth, etc. etc. etc. So my point here, feeble as it may be, is just that if lowering Bear's cortisol clear down to <3 ug/dL did not curb his appetite, then perhaps something other than cortisol is fueling that particular issue. Of course, however, that has nothing to do with the poor coat and panting.

So these are my initial thoughts, and hopefully some other folks will soon chime in, too. But above all, we're eager to welcome you back and we'll continue to do our best to help you brain-storm about these ongoing challenges for sweet Bear.

Marianne

[Budsters Mom]

Hi, I am not very wordy, so I will just cut to the chase. You said that Bear was uncomfortable. How uncomfortable is he? What is he doing exactly to indicate this? Does he pace and have difficulty settling, particularly to sleep at night? Does he Press his head against you or other objects such as the couch? Are his back legs weak? Does he have difficulty getting up and walking from a lying down position? Do his front legs collaspe unexpectedly while running or walking? These details are hard to talk/think about, but they can be very helpful in troubleshooting.

[BabyBear]

Marianne-
Thank you for the thought out reply. I appreciate the info on the mitotane. It is a very new drug to me. I will keep this information in mind and research the UC Davis protocol and discuss it with my vet on Monday for when we come up with a new plan. Maybe this is just the change that we need.

As far as the macroadenoma, I have considered that as well. He currently doesn't have any neurological signs or vision deficits, so that's a plus. Although, it is still in the realm of possibility. I asked the neurologists on staff at the university hospital if they thought it was possible for a macroadenoma to have formed and possibly causing the insatiable hunger. Their thoughts were that if that were the case, it would also be pressing on the optic nerve and since he has no symptoms of that, we ruled it out for now. Not to say it isn't slowly growing. I'm hesitant on the CT cost until I get his cortisol back under control. When that's normal (or on the flip side and I can't get it to be normal), and if he's still symptomatic - we'll do another CT and compare it with his initial one.

As far as the hunger, I definitely understand a lab's drive for food haha. Love those babies. I discussed the possibility of the hunger becoming a learned behavior for Bear over the last couple years. The Dr said it was possible. Especially because the vetoryl 4 hour post pill ACTH stim values were very normal toward the end. However, she also mentioned that because we don't do ACTH stims at night 4 hours after the evening pill, it is possible his cortisol was unchecked at night and could have caused the continued hunger as well. So the uncertainty of his cortisol levels at night also lead me to switch to the mitotane. I would be surprised if the hunger is all a learned behavior though. I know it's been years, but I still remember a dog that I had to beg to get him to eat his dinner. To the point where I wanted to take him to the vet for inappetence a couple of times haha. And now he brings me his bowl at 2 in the afternoon after having a lunch portion at noon. I spoke with a nutritionist and she has him on a diet that allows me to give the largest amount of kibble for the calories. So he gets 3 cups a day spaced out between 3 meals. It's a lot of food for a little guy. He has even snuck into the cat food and ate an entire automatic feeders worth - that was a fun vet visit, but thank god he didn't bloat haha. So between the excessive hunger and the panting and the coat, I just wonder what else is going on, especially back when his cortisol was normal.

[BabyBear]

Buster's Mom-
He is uncomfortable mostly from the hunger. I can tell that he's never full. He licks the floor around his bowl if I don't gate off the kitchen (we're talking licking for hours if I let him), he ate an entire autofeeders worth of cat food (it was full- so several cups worth) after his lunch once which required an emergency vet visit so he wouldn't bloat, and he's just frantic when food is around. He inhales his meals so quickly that if I don't use a slow feeder, he chokes. Not that the slow feeder helps all that much. These are all behavior changes for him, he was never exceptionally food motivated before. That's one of the harder things to watch.

No pacing or difficulty settling at home. He does get a bit anxious and paces and won't settle if he goes to someone else's house, but I feel like that's just him. We don't put him in those situations very often anymore. No head pressing. No difficulty getting up yet. Front legs are completely fine.

Now his back legs are another story. I asked his specialist and she didn't know what to make of it, so maybe you might have some insight? To preface, he is on fish oil, a dechra joint supplement and gabapentin (bid). He has some muscle wasting in the hind end, more over his sacral area and hips rather than his legs themselves. So, he's an Aussie and loves to run, but over the last 6 months ish (not related to the vetoryl to mitotane change b/c it was also present prior to) his back legs begin shaking uncontrollably if he goes for too long (only talking about 5 minutes of pure running). Even walking now will cause his legs to begin to tremble maybe .25 mile in, so we don't do that anymore. I chalked it up to weak muscles from the cushings and started supplements and gabapentin. His attitude and his legs don't match up. He wants to continue running and playing, but I make him stop when his legs start trembling. He hasn't actually collapsed on his back end, but I'm pretty sure he would if I were to let him continue using them. If you have any thoughts of an underlying issue, or ideas of things to add to his meds I'd love to hear them. Thanks!