Another Cushions help request (slightly complicated)

[Kal87]

Hello, I want to start off saying this forum & community is a great. I am very happy to have found you guys.

A little info about my pets history:
- Sapphire is an 11 year old Staffordshire bull-terrier. Since 12 weeks old she's had horrible skin break-outs which we managed to control after months of back n forth from vets. We found out she had allergies to everything from grass to potato. She was prescribed prednisone g daily and it was working a treat. Everything was fantastic up until she turned 9 years old and then she had signs of liver problems (fatigue, panting, always thirsty etc). After blood tests we found her liver enzymes were through the roof and then looked for other alternatives to her medication to which we were introduced to "Atopica".
So for the past 2 years she has been on Atopica & her liver enzymes stabilised although never fully returned to normal...

The last few months have been a nightmare. She very suddenly got a pot belly, tired, constantly pee'ing every hour or so etc etc.
We found out she had a UTI too. Tests. Tests. More tests. Scans. Tests. Different vets. Didn't like what we heard. Different vets. More tests...

UTI cleared up, they also did a bunch of blood / stim tests and discovered she has cushings. The brain tumour one... Please excuse my lack of medical terms.

We put her on 120mg (she's 22kg) vetoryl and began this journey. Stim tests... Reduced dose to 60mg. Daily. Stim tests... Need to increase dose. 90mg daily (60 morning 30 evening). She had terrible breakouts of calluses (again please excuse my lack of medical terms) from the excessive cortisol levels which we've been battling with sudocream and it seems to help.

The higher dose (60+30) was implemented 8 days ago and her appetite and thirst reduced, to a "normal" dogs. And I was over the moon she was finally getting better... However. In the past 24 hours she has not ate or drank anything. I've tried turn it into a game, tried give her options but no change. She was already quite weak in her rear legs and very recently diagnosed with arthritis too but within the last 24 hours she can't even stand or move about.

I couldn't handle the stress so went to the vet today who gave 4 options. Please forgive me if I can't remember fully I was practically in tears at this point:

1- leave her there for tests (he didn't recommend because she's been through so much trauma and tests already)
2- give her painkillers, however it would have to be human painkillers because of the effect it has on cushings??
3- completely stop the meds for 24 hours and we assess her again then. Hopefully once she's off the meds and feeling a little better we can decide on whether we continue treatment/adjustments of dose or maybe just let her live out the rest of her life without medication.
4- the unthinkable... I did ask if she's in pain or suffering and the vet said no. She doesn't appear to be. She is just very tired and weak.

So I reach out to you, more experienced people. I beg you give me some advice and some of your wisdom.

[Joan2517]

Hello and welcome from me. Definitely stop the Vetoryl. Others who are more knowledgeable than I am will be along shortly.

[Kal87]

Hello and welcome from me. Definitely stop the Vetoryl. Others who are more knowledgeable than I am will be along shortly.

I had already unfortunately given this mornings 60mg tab but I won't be giving anymore until I see signs of her getting better.

I just don't understand why this has happened at day 7/8 of 90mg when she was find on the initial 10day dose of 120mg. I just hope she gets better.

[DoxieMama]

Hello and welcome to you and Sapphire. First and foremost, I agree with Joan. I would stop the Vetoryl given her current reaction (not eating, not standing). Can you get in for an ACTH test today? It's quite possible that Sapphire's cortisol levels have now dropped too low. The only way to know for sure is to conduct a stim test. If you cannot get in for that right away, did your vet prescribe any prednisone to give her, "just in case"? Either way - Please call your vet ASAP!

[DoxieMama]

I was going to edit my post but I figure it's probably best to put this separately.

I have lots of questions, for which I apologize. But the more information you can provide, the better help we can offer. :)

Do you have copies of the Stim tests that were done on Sapphire? If not, can you get them? The actual numbers from those tests will help the admins and other knowledgeable folks to see how she has been responding to the Vetoryl since starting treatment.

At 22kg, the manufacturer of Vetoryl now recommends a starting dose of 1mg per pound (or 2.2mg per kg) so that should have been no more than about 50mg. It is possible that the "right" dose will be higher or lower than that, but that would have been a good start. The manufacturer used to recommend starting at twice that, so your vet was probably following that by starting at 120mg.

When an ACTH test shows that the cortisol levels are too low, the manufacturer recommends completely stopping Vetoryl until symptoms return. That's why Joan and I suggest STOPPING now. Wait until Sapphire has recovered from the low cortisol (if that's what is going on), is eating normally again and starts to show symptoms (like drinking lots of water, etc). Then you restart at a lower dose.

How long was Sapphire on the 120mg? When they said that was too high, did you take a break or did you start with 60mg right away? When increasing, you don't need to take a break... but how long was she on the 60mg before the increase? And now she's been on 90mg for 8 days. Cortisol can continue to decrease for 30 days after a dose change, which is why I ask.

I'm sure others will be along with more information, and possibly more questions.

[lulusmom]

Hi and welcome to you and your girl.

DoxieMama has done a great job asking appropriate questions and requesting test results but I would like to add my own comments and yet another request.

The symptoms you have shared with us are definitely symptoms of a Vetoryl overdose so stopping the medication immediately is called for. For future reference, even if an overdose isn't suspected, any dog who goes off of food and extremely lethargic should never be given Vetoryl until the appetite and normal activity level has returned. This is information your vet should have counseled you on and given appropriate instructions on how to proceed should you see any adverse affects. I have provided two attachments below which are the manufacturer's brochure that can help you learn more about the disease, dosing and monitoring treatment. Please review and let us know if you have any questions. You may want to share them with your vet as well. With respect to monitoring, were the acth stimulations tests after starting treatment done within 3 to 5 hours after the morning dose given with a meal?

I would be most interested in knowing which diagnostic tests were done to diagnose your girl. It would be quite helpful if you could share the results with us. These results would be the LDDS, acth stimulation test and ultrasound results, if this imaging was done to validate a PDH diagnosis.

It sounds like you are dealing with calcinosis cutis (cc), which is a not so common symptom of cushing's. Did your vet do a punch biopsy to confirm or did s/he confirm based on a visual. It's a pistol to gain the upper hand on cc and it often gets a lot worse after treatment before it gets better. The effective treatment protocol for dogs with cc is 1) twice daily dosing, which you seem to have covered. Vetoryl has a short half life with it's effects diminishing well before 18 hours. Therefore BID dosing insures that cortisol is being evenly controlled throughout the day and 2) getting the post acth stimulated cortisol well below 5 ug/dl (137 nmol). Any time you have concurrent disease or a symptom that is very much dependent on adequate control of cortisol, the usual therapeutic range for dogs treating with Vetoryl is irrelevant. Under 5 ug/dl is good but 2 to 3 is much better.

If you haven't started a medical folder containing all test results for your girl, I highly recommend that you start one now. We recommend this to all of our members. The very nature of cushing's makes cushdogs more likely than healthy dogs to have an after hours emergency and er vets love to have their patient's most recent medical history at their finger tips. I don't know about you but I tend to become addled during these times and my folders were insurance that I didn't forget to tell the vet something important. Those folders also come in handy when we start nagging you relentlessly to share results. :D:o:D I don't know where you are located but since you stated your dog's weight in kg, I assume you may be in the UK. We've had a number of members tell us that vets in the UK are not open to providing copies of test results to clients. Please give it a valiant effort because they will also help you learn to interpret the tests and learning everything you can about the disease and the treatment makes you a most excellent and very proactive advocate.

I'm glad you found us and I look forward to hearing a lot more about your precious girl.

929

930

Glynda

[Kal87]

Hi and thank you so much for the replies.
I will try to answer all questions in 1 post to not clog up the thread:

- I do not have the copies of the stim test results but I will request them and get them ASAP.
- she was on 120mg/day for 10 days before they ran stim test and said we are going to reduce it to 60mg.
- she was on 60mg/day for another 10days (no breaks in between just lowered dose and continued).
- after 10 days of 60mg, they said it's not working good enough and I should ensure she is eating properly right before the tablet and so we tried for another 10 days at 60mg ensuring age ate right before the food. (Total 20days on 60mg/day) before doing another stim test.
- after the last stim test, they recommended up'ing the dose. I was told the meds are working but not enough. I was told 60 in the morning and 30mg in the evening for another 10 days and then we will do another stim test, but on day 7/8 she became very very poorly. Didn't eat or drink, could barely stand up. I am carrying her everywhere she wants to go, bringing her water and food bowl to her and trying to turn it into a game but no matter what I try she doesn't take to it.
- she is extremely tired all the time, can barely open her eyes and if left alone just wishes to sleep all the time.
- she is a bit better today, the last time she was given meds was yesterday morning 60mg. She has started drinking water a bit and eats but very little.

- I have completely stopped meds for now.
- I have not booked another test but I am happy to do so.
- vet did not prescribe anything else for the time being, the only advice given was stop meds and see what happens.
- the tests were done exactly 4 hours after medication was given.
- in regards to CC. The vet (and I saw several), had no clue what it was. They all suspected either an infection because her immune system has gotten weak or that "cushings just plays havoc with their body this is just a side effect of cushings". But I used the Internet to find out about it. It's indee her arms, on her chest/neck and now a small patch on her back. The sudocream seams to be helping but how much, I don't know.
- I love the folder idea, unfortunately I don't have pet insurance but it could be useful to have everything on file thank you.


Thank you very much for the help. I will call my vet now and request all test results to be emailed over. Thank you!


Edit: I'm still chasing up the vet about her history

[Kal87]

I did request all the results but only given this. I'm still chasing up more results.

These results were post 60mg/day for 10 days straight after food. But she had been on 60mg/day for 20 days in total.

"Laboratory::
Cortisol 157.0 < 250 = nmol/l
Cortisol - post ACTH 233.0 < 500 = nmol/l
Comment. Both samples are lipaemic. This has been cleared by extra cen=trifugation. The post
sample is also slightly haemolysed.
These should not affect the results significantly."

I will chase up the rest of the results.

[DoxieMama]

Converting those results to ug/dl (I think I'm doing this right):

Cortisol 157.0 < 250 = nmol/l = 5.7 ug/dl
Cortisol - post ACTH 233.0 < 500 = nmol/l = 8.4 ug/dl

Given that cortisol continues to lower for 30 days, I'm very interested in what those results were after 20 days. Please let us know when you can get those!

[molly muffin]

Hello from me too. Even on the same dose cortisol can continue to drop for 30 days or so before stabalizing, so switching during this time is not usually recommended and based on the results of the 60mg test you posted, at the 10 day mark, she could have continued on that dose at best, although starting at 50mg would have been the best point as Shana mentioned.

I think she is probably too low with the bumping up and down doses and hopefully you'll be able to say she is doing much better when you next report in.

Once symptoms return you can restart at a lower dose and see then test but not plan to increase until and after 30 days if the cortisol post is still out of range.

[Kal87]

Extremely sorry for the delay.

I'm still chasing up my vet in regards to all the results. I will post as soon as I receive them.

So today is day 5 on 30mg twice say (60g daily total). Her appetite is low but still more than before, her drinking is still high but seems to be reducing.

she seems a little better in terms of fatigue. I would say she is still quite tired in general but she doesn't struggle to get up or walk as much.

Her calluses seems to be under control, we're battling it with sudocream 3-4 times a day which genuinely seems to help.

I am hopeful that this time around we will do better, and I will try to last the 30 days on the reduced dose before making any dose changes.

- thanks

[molly muffin]

Good to hear that she is doing better.

Remember though that she probably wet pretty low on the other dose, so the follow up testing will be important to show where she is at right now.

We're all thrilled to hear that she is doing better!

[Kal87]

Ok so she's on 60mg a day still split into two doses and I've been away for the whole weekend and just got back, my mothers been taking care of her. Unfortunately it looks like my baby is back to the extreme fatigue and no appetite. I'm afraid to even guess what's happening, I'm not sure what to think or do right now. My brain is melting.

[Squirt's Mom]

Do NOT give any more of the Vetoryl! Both of those things are signs of an overdose. That may not be the case but better without the drug than too much - that is life threatening. ;) An ACTH needs to be done asap to see what the cortisol level is. Are you sure your mom gave 30mg twice and not 60mg twice?

[Kal87]

Do NOT give any more of the Vetoryl! Both of those things are signs of an overdose. That may not be the case but better without the drug than too much - that is life threatening. ;) An ACTH needs to be done asap to see what the cortisol level is. Are you sure your mom gave 30mg twice and not 60mg twice?

I am certain it was 2 30mg's & yes I just got back last night. I will have her get a test done ASAP. Thank you.

Edit: are there any cushings specialist vets in or around London?

[Kal87]

They've sent me some of the blood results, I have emailed back asking for all the results as there were more.


17/02/17 - Cortisol 157.0 < 250 = nmol/l
Cortisol - post ACTH 233.0 < 500 = nmol/l
Comment. Both samples are lipaemic. This has been cleared by extra cen=trifugation. The post
sample is also slightly haemolysed.
These should not affect the results significantly.

27/01/17 - ACTH stim results: 195 pre, 250 post. Basal is still too high.

06/01/17 - 0 hours cortisol 331, 3 hours 57.8, 8 hours 155

[Squirt's Mom]

That post on 2/17 converts to 8.44 ug/dl which are the units we are most familiar with....and that is not too low. In fact, it is too high unless all the signs are well controlled. I would still withhold the Vetoryl and get an ACTH today just to make sure her cortisol is ok. It might be ok to just wait and watch but for my own peace of mind I would want to know for sure. If it is, then it could be that she is reacting very strongly to the lowered cortisol, making her feel bad. If so, that will correct as she takes it over time. Another possibility is that she needs to switch to Lysodren. But if memory serves, that drug is not used in the UK unfortunately...but I would ask just to be sure.

[Carole Alexander]

Look up the University of London Royal Veterinary College; you will need a referral from your vet. http://www.rvc.ac.uk/ They are one of the top veterinary schools in the world. Best to you.

[Kal87]

That post on 2/17 converts to 8.44 ug/dl which are the units we are most familiar with....and that is not too low. In fact, it is too high unless all the signs are well controlled. I would still withhold the Vetoryl and get an ACTH today just to make sure her cortisol is ok. It might be ok to just wait and watch but for my own peace of mind I would want to know for sure. If it is, then it could be that she is reacting very strongly to the lowered cortisol, making her feel bad. If so, that will correct as she takes it over time. Another possibility is that she needs to switch to Lysodren. But if memory serves, that drug is not used in the UK unfortunately...but I would ask just to be sure.

Yes, I agree. Unfortunately the vet himself said there's no point doing more and more tests putting her through stress. Just stop vetoryl until she gets back to normal (with obvious signs of cushings of course) then decide what to do, whether it's to start the drug again from the beginning with monitoring throughout. And to be really honest I'm unsure what to do, I feel whatever direction I turn is a dead end. I've again stopped her medication and am hoping she can get back to relatively good before going back and doing tests/drugs but please I would appreciate any input or advice.



Look up the University of London Royal Veterinary College; you will need a referral from your vet. http://www.rvc.ac.uk/ They are one of the top veterinary schools in the world. Best to you.
I have contacted them, my current vet is next door to them. I contacted them directly and they offered me a 1 hour consultation with their medicine team at £250. As much as I can't afford that I will find a way to pay, but I'm concerned whether sitting down having them repeat the same thing is worth the money. I was hoping for a vet who specialises with cushings so they can be a bit more help. I'm sorry if I sound down.

[Squirt's Mom]

Testing after a few days won't tell you low cortisol is the problem so I'm not following the vet's thinking. Maybe someone with more experience using Vetoryl can. :confused::confused::confused:

[Harley PoMMom]

How were her symptoms when the 2/17/17 ACTH stimulation test was performed? If symptoms were controlled than her post number is within the therapeutic ranges Dechra, the makers of Vetoryl, publishes which are 40 nmol/L - 250 nmol/L (as Leslie mentioned :)).

Now, regarding those ACTH stimulation ranges, they are guidelines, the way the dog is feeling is just as important if not more in deciding how treatment is progressing, so my thought is to not get hung up on those numbers and gauge treatment on how the dog is reacting. ;) Some dogs need their cortisol to run on the high side to feel their best.

Hugs, Lori

[molly muffin]

I agree with Lori, it's just as important how a dog feels and is reacting, as the numbers. Numbers can be important, when you are worrying about too high or too low, but you're actually in a good spot as long as she is acting alright.

Any time that a dog acts off and vetroyl is stopped, the best thing to do is wait for symptoms to return and then restart at a lower dose. Since the previous one was too much. So that is in line with manufactur recommendations, and is probably what I would do.

Will they not accept the test done by your vet and not redo those that don't need to be done? I wouldn't want to redo test either.