Maggie - Another Newbie, Unfortunately

[Maggie33]

Hello. My name is Jen and my dog Maggie, a 12 year old lab, was recently diagnosed with Cushing's. Background- Maggie was suffering from neck pain so she was referred to a local university's vet hospital. Diagnosis was cervical myopathy. As part of the diagnosis, blood panel was completed which showed the following abnormal results:
AST - 58 (12-40)
ALP - 2167 (15-120)
(Glucose, GGT, Bilirubin, etc. all within range)

Fast forward 6 week, neck pain is resolved. Blood panel repeated by referring vet, similar abnormal and normal results. Bile acids test performed and was within normal limits. Ultrasound showed mild decrease in liver size and small nodules throughout. Referred back to university hospital for liver biopsy. (At this time, there were no typical Cushing's symptoms.) Prior to biopsy, chest xray and clotting test performed with no issues. When Maggie was being prepped for surgery, a pyoderma was found on her belly so the biopsy was canceled. Maggie was prescribed Cephalexin for the pyoderma and was referred to internal medicine.
Low-Dex was performed a few days later with the following results:
Resting - 10.6
4 hour post - 2.6
8 hour post - 5.98
Prognosis - "Although consistent with Cushing's test results were not a textbook suppression. They were most consistent with a pituitary dependent hyperadrenocortism. At this time Maggie is not clinical and therefore we will not persue specific treatment."
Maggie is now clinical with excessive thirst/hunger and pot-bellied appearance. Also, she gets very anxious when traveling, which is totally unlike her.
I have a message out to her regular vet about starting the Trilostane soon. I have been hovering on this board for a few weeks now so I am familiar with the dosing guidelines and possible side effects but wanted to reach out to the forum members to see if I am missing anything. Thoughts everyone?
One last thing is Maggie was diagnosed with IBD 9 years ago, which is mostly well-controlled via diet (Hill's Z/D) but her stool is consistently loose so monitoring for diarrhea is more about frequency and urgency and less about consistency. TMI?

[Harley PoMMom]

Hi Jen,

Welcome to you and Maggie! You can never give us too much information, we love details, poop patrol is a topic that is commonly talked about here! ;)

UTI's can make a dog urinate and drink more, has this been ruled out?

Unfortunately I'm at work and have only a moment to post so I'll try to come back later. I'm sure our other members will be by soon to welcome you and share their thoughts as well.

I sure am sorry for the reasons that brought you here but glad you found us, and came out from the shadows to start a thread about your precious Girl!

Hugs, Lori

[labblab]

Hello to you and Maggie from me, too! As Lori says, we are sorry for your need to begin treatment, but very glad you've joined our family. It sounds as though you are basically quite well prepared to move forward with treatment, but I do have a couple of questions/thoughts. Since at the age of 12, Maggie is now a sweet "senior" Lab, I do want you to be aware that there can be trade-offs associated with treatment. Even though elevated cortisol can cause a whole range of clinical issues, it actually can have some benefits, as well. Certain inflammatory conditions such as arthritis may become "unmasked" or worsen when cortisol levels are lowered into therapeutic range by Cushing's treatment.

In Maggie's case, I am especially wondering about her cervical issue and also the IBD. Can you tell us more about the cervical issue and whether treatment was required to ease the pain? I have been Googling and find references to "cervical myelopathy," but that seems to be a different condition from what you are describing. So I'm in the dark in terms of the cause/resolution of Maggie's problem. However, if it's inflammatory in origin, her elevated cortisol may be easing the problem in the same way that supplemental steroids would.

The IBD also carries some question marks -- will lowering the cortisol help or worsen the condition? Paradoxically, elevated cortisol may ease IBD in some dogs, but it may prompt GI distress in others. We have had other folks here who have faced diagnosed IBD in their Cushpups, and have discovered that their dogs have done better, overall, when their cortisol levels have been permitted to run somewhat higher within the therapeutic range for treatment. It just may involve some trial-and-error to arrive at the "sweet spot."

I guess my main point is that, at Maggie's age, comfort and quality of life would be my main considerations. So you may end up tailoring a treatment range that is very specific to her special needs and responses. For that reason, if you do decide to begin the trilostane, I would begin at a very conservative dose and work upward, if needed. I would most certainly not begin with a dose that exceeds 1mg. per pound, and perhaps with even less than that.

I will be anxious to hear more about Maggie's cervical issue, and once again, welcome to our group!

Marianne

[DoxieMama]

Hi Jen! Lori and Marianne have covered my questions, so I just wanted to stop in and add my welcome. I look forward to learning more about your sweet Maggie.

[Maggie33]

My apologies for not being clear on Maggie's cervical issue. One morning she was wallowing on the carpet, as she used to do every morning, to try to gently remind me that it was time for breakfast. She cried out and then started showing signs of pain. X-Ray's showed a decrease in disc space width at C5-C6 and C6-C7 indicating an intervertebral disc disease. To me, the X-Ray looked like two bulging discs. Neurological symptoms were mild and treatment was 6 weeks of crate rest with Gabapentin and Deramaxx administered for the first 14 days. Ongoing, I limit stairs and jumping on/off furniture. This issue occurred in Nov 2016 with no signs of ongoing pain. The cervical myelopathy was the long-term diagnosis due to a narrowing found lower in her spine -T3-L3. Prior to this issue, she showed no signs of arthritis.

While Maggie's IBD is mild (flair-ups are rare and treated with Metronidazole) I have seen some worsening in the consistency of her stool since the excessive thirst and weight gain started. Maggie has always been a little on the thin side and now that she has that barrel look, it makes the weight gain very apparent. She seems to grunt a little when walking, especially up and down the ramp to the back yard. She also seems to sit differently, maybe her legs are further apart because her belly is in the way? (I may have that issue as well.)

I understand exactly the point you are making about her age and treatment. In fact, I am struggling with the decision about whether to start treatment or not. My goal is to allow Maggie to be as comfortable as possible. Knowing that she is constantly in a state of thirst and hunger and that her belly is causing at least a little discomfort, is it wrong to not try the Trilostane? Should I wait until more symptoms develop? Will waiting make treatment more difficult? I welcome everyone's thoughts and opinions.

The university vet hospital also mentioned repeating the low-dex test once symptoms develop and doing an MRI to confirm pituitary issues. The MRI seemed a bit exorbitant in my opinion but I am open to additional testing that may help me make an informed decision on next steps.

[labblab]

Hi again, Jen, and thanks so much for this additional info. I don't know that I'd feel compelled to do a lot more testing myself under these circumstances. But if so, probably what I'd choose would be an ACTH stimulation test and/or abdominal ultrasound. I'm not sure why the vet hospital has encouraged an MRI of the head since it's such an expensive test and Maggie's LDDS results are diagnostically consistent with the pituitary form of Cushing's (the 4-hour result is less than 50% of the baseline). If she was exhibiting neurological symptoms, the MRI could tell you if the tumor has enlarged to a size that is encroaching on other areas of her brain. But in terms of general diagnostics, I believe I'd prefer an abdominal ultrasound because it could reveal any potential contributory problems with her liver, kidneys, spleen, etc., in addition to giving you the status of her adrenal glands (pituitary Cushing's typically produces abnormal enlargement of both adrenals).

The ACTH stimulation test is an alternative diagnostic blood test for Cushing's. It is not as sensitive a test as the LDDS (meaning a significant number of Cushpups will return a "false negative" on the test). However, it is the gold standard for monitoring cortisol levels once treatment has begun. For this reason, it can be helpful to have an ACTH "baseline" against which to judge treatment results for purposes of making subsequent dosing decisions.

If Maggie was my own dog, I do believe I would give treatment a try if the excessive thirst/urination/hunger seems to be making her uncomfortable. It's possible that her loose stool may also improve if excessive cortisol is actually irritating her GI system instead of soothing it. So I don't think giving the trilostane a try is necessarily a bad idea, but again, I would definitely start with a low dose. You can always discontinue it if it seems to be creating new problems. Just be aware that you will need to take Maggie back to the vet for monitoring blood testing at fairly frequent intervals initially: after two weeks of treatment, after a month of treatment, and then after three months of treatment thereafter.

I'm sure other folks will soon be by to share their thoughts, as well. But at least here are a few ideas to begin to think over. ;)

Marianne

[Harley PoMMom]

Quality of life is the main focus with our furbabies and since it seems that Maggie's symptoms are bothersome to her than treatment would help subdue them.

With Trilostane the starting dose should not exceed 1 mg per pound of the dog's weight. How much does Maggie weigh? And in Maggie's case, since she is a senior girl there is the option of starting her out on even a lower dose so that the cortisol runs a bit higher to lessen the effects of other issues that may emerge such as arthritis.

I, also wanted to ask if the adrenal glands were visualized on that ultrasound. As Marianne mentioned when the Cushing's is pituitary based both adrenal glands will be enlarged. If a suspected adrenal tumor is functional and is the cause of clinical symptoms, an abdominal ultrasound would normally show one enlarged adrenal gland and the other gland would be much smaller or not even visualized due to atrophy as result of lack of use.

Hugs, Lori

[Maggie33]

Thank you Marianne and Lori for you thoughts, I very much appreciate you taking the time to respond. I am 99% sure that when Maggie had her liver ultrasound in December, other organs were visualized with no issues reported but I will double check when I speak with her vet this afternoon.

Maggie’s weight was 54 lbs. but it wouldn’t surprise me if she is closer to 60 now. Also, I am totally on board with the baseline ACTH test and the necessary future monitoring.

Maggie’s vet is actual a clinic so while I am currently working with one doctor in particular, there is an opportunity for consultation between the other doctors. I am fortunate that her doctor seems open to my questions/ideas and will admit when further research is needed.

Again, thank you for your responses. I will pass along any information gathered after speaking with her vet.

Jen

[Maggie33]

I spoke to Maggie's vet today about starting the Trilostane so she reached out to the Internal Medicine team at the vet hospital to make sure everyone was on the same page.

The vet hospital wants the low dex test repeated before a decision to start treatment is made. Unfortunately, I was heading to a meeting when the vet called and didn't have time for a full explanation as to why the repeat was deemed necessary. I was able to ask about the ultrasound results and there was slight asymmetry with the adrenal glands.

Obviously, I am missing a key piece or pieces of the puzzle. I am dropping Maggie off Monday morning for the low dex and an overall health evaluation. When I pick her up in the evening, I am hoping to receive a full explanation of what transpired.

Side note, Maggie who used to ignore storms and just grunt at me for allowing the thunder to wake her from her precious sleep is now terrified of storms. I guess I have something else to research now.

[labblab]

Repeating the LDDS is not necessarily a bad idea, at all. Both the LDDS and the ACTH can return "false positives" if some other illness or acute issue is going on at the time of testing. So reconfirming an abnormal result now that you're a bit further down the road is not a bad thing. For the reason I wrote above, I personally might have opted for an ACTH instead just to facilitate treatment monitoring. But the very useful thing about a repeat LDDS is that you will be directly comparing apples-to-apples. So we'll all be very interested in the results!

Marianne