GSD with Cushing's - Kaiser has passed

[Junebugs]

Hello everyone! I am new to this forum, and am thrilled to find a place with such great support! I have a 10 year old German Shepherd (95 lbs) that recently started treatment with Vetoryl. I'm overwhelmed and confused, needing some guidance. Kaiser has had hind leg weakness issues dating back to 2012, but after imaging came back negative and pain meds did not help, I took him to a chiropractor. He had enough improvement that all seemed well for quite a while. His low back and pelvis needed adjustment. During a dental visit, his Alk Phos was found to be elevated (758), but the vet did not think it was concerning at the time. It started spiking dramatically over the past year, so tests for dilute urine were performed twice, but negative. This winter he started looking really old and slowing down. His front legs became a problem, stumbling, walking with a "hitch"... Imaging did not reveal anything, and laser therapy did not make any difference. Neither did Adequan. Then came the balding pot belly, constant panting, insomnia, ravenous appetite, thirst, hard and flaky bumps all over his back.

I scheduled the Low Dose Dexa test, and Pituitary Dependent Cushing's was confirmed. His regular vet started him on 60mg Vetoryl once a day on July 1st. I wanted to do split dose am and pm, but was told that was not protocol, and would skew test results... Well, the evening after the 4th dose, Kaiser had trouble getting up, and was like a drunken sailor... I called the vet first thing in the morning, and did not administer another dose. Was called back at the end of the day, and we decided to hold off a few days and restart 60mg every other day. That went well, except that Kaiser can no longer go for our daily walk. He stops to lay down after just a short distance. ACTH results were "good" so we agreed to do 30mg every day. Second ACTH is also good, and he has grown fur back on his belly, no longer ravenous appetite, time at the water bowl has decreased, and he finally sleeps! Vet still will not agree to twice a day dosing, and I was wondering what would be an indication for twice a day. Last night Kaiser chose to lie down in the grass to try and defecate, rather than stand. I am also worried about his exercise intolerance, and the chiropractor suggests I may need an Internal Medicine specialist.

Here are some test results:
4/18/17
Glucose 120 (63-114)
ALT 136 (18-121)
ALP 6,763 (5-160)
GGT 25 (0-13)
Cholesterol 444 (131-345)
IDEXX SDMA 12 (0-14)

6/13/17
All thyroid normal range (Total T4, T3, Free T4, Free T3, cTSH, Thyroglobulin Autoantibody, T4, T3 Autoantibody.)
LDDS
Pre Dex 5.0 (1.0 - 6.0 ug/dl)
4 hr post Dex 5.5 ug/dl
8 hr post Dex 6.9 ug/dl

7/17/17
ACTH
Pre ACTH 0.8 ug/dl (2-6)
1 hr post ACTH 2.5 ug/dl (6-18)

8/16/17
ACTH
Pre ACTH 0.6 ug/dl (2-6)
1 hr post ACTH 3.0 ug/dl (6-18)

I currently have him on dasaquin w/ MSM, milk thistle, melatonin, lignans, CBD oil. He just finished a second round of antibiotics for his skin lesions, which were crusty and open before. I spent an hour combing out skin flakes today... So much to remove! At least they are no longer open, but he is still very lumpy with countless dark spots where the bumps are. I am just so heartbroken to see him declining so much! Am I just impatient with the treatment, or do I have something totally unrelated going on with his legs? Thanks so much for any input you can offer!!

[LauraA]

Hopefully someone more experienced will come by and take a look at those results and give you some feedback. How is your boy doing today? Has the back leg weakness become more severe since starting the Vetoryl? It may be he needs the higher cortisol to help with his legs, his last test at 3 is actually pretty perfect in regards what you would want for a Stim test so you wouldn't think he was crashing. I think an specialist is actually a great idea and would be the next step I would take.

[labblab]

Hello and welcome from me, too! I am really glad Laura was able to greet you, and I totally agree with her that a consultation with a specialist would be most advisable, especially because I am concerned about several things your regular vet has told you.

First of all, the LDDS results do not establish pituitary Cushing's. The pattern of your dog's numbers (neither the 4-hour nor 8-hour result is less than 50% of the baseline) could result from either a pituitary or adrenal tumor, and is actually more common in the presence of an adrenal tumor. Vetoryl can be used to treat symptoms from a tumor in either location. However, you may want to pursue further diagnostics, such as an abdominal ultrasound, in order to determine which type of tumor is the cause. For instance, even though it is expensive and risky, surgery can actually provide a total cure for adrenal Cushing's. FYI, here's a link that explains how to properly interpret a LDDS test:

http://veterinarymedicine.dvm360.com/clinquiz-interpreting-low-dose-dexamethasone-suppression-test-results

Secondly, twice daily dosing is a perfectly reasonable and widely accepted method of dosing, and does not skew the monitoring ACTH testing at all. Some clinicians prefer that all dogs be dosed twice daily. Others, including the maker of Vetoryl, recommend that dogs first begin with one dose each morning. If subsequent monitoring testing shows that the morning cortisol level falls within the desired therapeutic range but symptoms are recurring later in the day, then the once daily dose can be divided and given in 12-hour intervals so as to keep more consistent control throughout an entire day and night.

Regardless of once or twice-daily dosing, all monitoring ACTH tests should be performed 4-6 hours after Vetoryl is given along with a full breakfast. Vetoryl must be given with food, even on testing day, to be metabolized properly. If given on an empty stomach on testing day, the cortisol level may register at a level that is higher than is normally the case on other days.

This brings me to another question/concern re: your dog's every other day treatment regimen: was the monitoring ACTH performed on the morning that he received the Vetoryl, or on the "off" day. If it was on the "off" day, his cortisol may be dropping much lower on his treatment days, leaving him feeling unwell. Also, even though his post-ACTH level is OK, his resting cortisol is awfully low. This may simply be too low much of the day for him to feel well, and he may feel better with a cortisol level that is permitted to run a bit higher.

So as you can see, I have a few concerns and would indeed recommend consulting with a vet who has more specialized training with complicated diseases such as Cushing's. In the meantime, we are very glad you've found us and will welcome any additional info you care to share.

Marianne

[Junebugs]

Thank you so much for welcoming me in and helping with Kaiser! I am working at the moment, but will post in greater length later. I did forget to mention he had an abdominal ultrasound last year, looking to see if there was anything amiss. I think only a small cyst on a testical was found, no kidney abnormalities. I did make sure we scheduled his stim tests on dosing days, and always a full meal with dose. I also made sure the test was for 4 1/2 hours after dose. Thanks so much, and I will post back later today! I feel a hundred times better already, knowing I have support and guidance!

[Junebugs]

Hopefully someone more experienced will come by and take a look at those results and give you some feedback. How is your boy doing today? Has the back leg weakness become more severe since starting the Vetoryl? It may be he needs the higher cortisol to help with his legs, his last test at 3 is actually pretty perfect in regards what you would want for a Stim test so you wouldn't think he was crashing. I think an specialist is actually a great idea and would be the next step I would take.

I do think he is having more hind leg weakness on the Vetoryl, as we have had to stop our daily walk altogether. We were walking 30 minutes daily before. Another reason that I would like to do twice a day dosing. The vet and I disagree on twice a day dosing, and it's funny that we both are referring to Dr. Peterson as our reason why. Kaiser does have sinificant muscle wasting, according to his chiropractor. This is why I wonder if I am just being impatient. His regular vet has recommended we start an NSAID. I cannot afford to take him for water therapy, but we do have lots of steps in the house, which he takes several times a day to follow me.

[labblab]

Thanks for this additional information! Just to clarify, though, are you still giving Kaiser the 30 mg. every other day? That doesn't fit either the once or twice-daily protocol, so I'm wondering why your vet has chosen this route to go...:confused:

I'm still somewhat concerned about Kaiser's very low baseline cortisol level. It's true that it's typically the post -ACTH value that is taken into consideration when making Vetoryl dosing decisions, but if my own dog was exhibiting increasing weakness while consistently showing an abnormally low baseline cortisol, I truly would wonder whether his adrenal function was being somewhat overly suppressed for his personal comfort level.

I'm assuming that at some point you will be switching to at least a once daily dose? If so, you may want to decrease from a full 30 mg. every day, because I don't believe you'd want his cortisol to drop even further which might happen once he is consistently receiving the medication on a daily basis (without the "off" day which may be allowing the cortisol to increase somewhat during each 48-hour cycle).

Marianne

[Junebugs]

Thanks Marianne for your reply! To clarify, Kaiser was on 60mg every other day until that first ACTH test on 7/17/17. We went to 30mg daily on about 7/20, and were happy with the post number of the subsequent ACTH on 8/16. The decision was made to continue the 30mg daily based on the post number and positive changes of less panting, less ravenous appetite, ability to sleep ( yay!), hair growth. He does seem to look much better, and happier. For a while his chiropractor described him as looking "tragic". I'm becoming concerned about this leg weakness possibly being degenerative myelopathy... His hind leg issues started about 4-5 years ago, and pain meds never seemed to help. Now the front legs are involved, and laser therapy and joint supplements have not helped. Sometimes I wonder if the Cushing's festered so long, and it is related to that, but I just don't know and find it all so confusing...

[labblab]

Whoops, I'm sorry about misreading what you had written about Kaiser's dosing schedule :o. So now I am perplexed, too, because aside from the low basal cortisol, I don't know of a dosing issue that would be responsible for the increasing muscle weakness. It seems unlikely to me that this particular problem would respond differently to twice vs. once-daily dosing. Under these circumstances, I do believe I'd seek a consultation with an IMS to see whether he\she has some other ideas about both the cause and a solution. I surely understand why this is so worrisome to you, and we'll be anxious to get continuing updates.

Marianne

[DoxieMama]

Hello and welcome from me, too! Has your vet mentioned calcinosis cutis at all? I'm wondering if maybe that's what those skin lesions are from. If so, then his post ACTH cortisol level is perfect for that too, though could come up a tad (it typically needs to be under 5 ug/dl to resolve CC if I remember right). I'll third the suggestion to check in with an IMS, and hope you can find answers to his muscle weakness soon!

Shana

[Junebugs]

When it rains, it pours... LOL! In addition to Kaiser's issues, my Boxer has an anal gland abscess that we are currently treating, and today I got the call that my Rottie has tested positive for Giardia. He unfortunately LOVES when he finds Coyote poop! :( Med is $140 because he weighs more than 120 lbs, and I need to have everyone re-tested to be sure it hasn't been passed along (annual testing was done in the springtime). I also adopted my brother's Puggle last month, and she has been quite a handful (but the Rottie adores her!).

Anyway, I have decided that yes, it would be best to get an opinion from an IM specialist. Kaiser's issues are just too puzzling and extensive. I have been really observing him closely the past couple of days, and he has developed a pattern where he looks really good during the day, and follows me up and down the stairs. In the evening he starts to do a weird occasional "hopping" thing with the front legs. Then he will start to go up the stairs, but balk and lie down for a bit. I started him on Tramadol last night to see if it helps at all. Curious to see how it goes tonight at bedtime...

His vet is off at the moment, so next week I will see about getting a referral to a specialist. I think we see his chiropractor on Wednesday, and hope she says she feels his muscle mass improving... On a high note, I think the crusty skin is a little less extensive than it was before. Still really crusty along the spine, but less so along the flank (I think...) and legs. Oh, and yes, the chiropractor had mentioned the possibility of Calcinosis Cutis, although she is not experienced with it. She actually mentioned it as a possible sign to look out for, before Kaiser was diagnosed, as we were trying to figure out the ALP elevation, with urine tests negative for dilute. That's when I started melatonin and lignans, but all the symptoms came on like a tidal wave, it seemed, which was quite alarming.

[molly muffin]

Hello and welcome from me too.

Oh my goodness you do have a lot of things going on with your dogs right now it sounds like.

I agree that I think I would want to see a specialist, especially about the muscle issue, which may or may not be related to high cortisol.
Since that pre is fairly low, I would think about trying him on a lower daily dose. Maybe 20 or 15 even. And see if that will keep it low, but not too low. It can be a real balancing act to find what works And what keeps them comfortable.

Again, welcome to the forum.

[Junebugs]

Hello and welcome from me too.

Oh my goodness you do have a lot of things going on with your dogs right now it sounds like.

I agree that I think I would want to see a specialist, especially about the muscle issue, which may or may not be related to high cortisol.
Since that pre is fairly low, I would think about trying him on a lower daily dose. Maybe 20 or 15 even. And see if that will keep it low, but not too low. It can be a real balancing act to find what works And what keeps them comfortable.

Again, welcome to the forum.

Hi Sharlene, and thank you for your thoughts!
I do have a question regarding Kaiser's pre stim number being low... Since he is currently on 30mg once daily, would splitting the dose 15mg twice daily have any effect on his pre stim number? I was wondering because of the effective time the dose is in his system, so wondering if a smaller dose spaced out even though same daily total would change anything.

Thanks!
Theresa

[Junebugs]

Update!
Last week I restarted Kaiser on Hyaluronic Acid. I think that was Monday... This weekend was a really good one for him, for a change, and thinking maybe it's the Hyaluronic Acid that is helping... I also started him on oral enzymes today, as I read great things about their ability to help the body heal when chronic illness is present. I nearly cried Sunday, when he picked up a squeaky ball and started playing with it briefly. Tossed it and stomped it for a minute or two, and actually looked like he was smiling! I don't remember the last time he played with a toy, so it was a joyful thing to see :)

He looks really good and seems to be walking a little better. I have started taking him up and down the little hill in our front yard a couple times a day, hoping to slowly build up some endurance. He does do lots of steps in our house when he follows me around, but I read walking up and down inclines may be better for rebuilding muscle. Hoping he will soon be able to handle going to a park nearby that has bigger hills.

I sat and combed out his fur again to remove the skin flakes, and was thrilled at how much better his skin looks. The patch that the vet's office had shaved over his shoulder due to a large open crusting, is now healed and the fur has all grown back in. The flakes I removed overall were not big clumps of shedding skin like before. I can hardly wait to see the chiropractor on Wednesday so she can see how great he looks. It is officially 2 months on Vetoryl, and 1 month since she last saw him, so I know she will notice a big change in his appearance at least. I did not take any photos when he was looking very sick and losing fur, as I could not bear to do so... I did post 2 pictures from today, as he just looked so handsome for a change! :)

Theresa

[Joan2517]

Great update, Theresa! So happy for you and Kaiser!

[labblab]

Hi Sharlene, and thank you for your thoughts!
I do have a question regarding Kaiser's pre stim number being low... Since he is currently on 30mg once daily, would splitting the dose 15mg twice daily have any effect on his pre stim number? I was wondering because of the effective time the dose is in his system, so wondering if a smaller dose spaced out even though same daily total would change anything.

Thanks!
Theresa
Wooo Hooo! That's great news to hear that Kaiser is doing better!! :) :)

Also, your question is an excellent one. However, from some of the things we've been told here, twice daily dosing actually may have a tendency to increase the risk of cortisol levels falling too low. I guess this is because the cortisol never has the opportunity to rebound very significantly at any time throughout the course of 24 hours. So, for instance, a dog who previously received 30 mg. once in the morning might need to be decreased to only 10 mg. both morning and evening if a switch is made to twice daily dosing.

I am not saying this might not be an option for Kaiser, but if you are finally seeing some good results, I don't believe I'd shake up his dosing schedule right at the moment. ;)

Marianne

[Squirt's Mom]

Oh I remember that day Squirt picked up a toy for the first time in ages! The joy and excitement that filled me instantly! I hope your sweet boy continues to improve. You might look into some glucosamine and condroiton for him, too. Both are often used in arthritic dogs.

[Junebugs]

Oh I remember that day Squirt picked up a toy for the first time in ages! The joy and excitement that filled me instantly! I hope your sweet boy continues to improve. You might look into some glucosamine and condroiton for him, too. Both are often used in arthritic dogs.

Yes, such an exciting moment!! Kaiser has been on Dasaquin with MSM for quite some time. I tried the Advanced Dasaquin that is only available from the vet's office, but did not see a difference, so switched back since the cost was much more.

[Junebugs]

Who Hooo! That's great news to hear that Kaiser is doing better!! :) :)

Also, your question is an excellent one. However, from some of the things we've been told here, twice daily dosing actually may have a tendency to increase the risk of cortisol levels falling too low. I guess this is because the cortisol never has the opportunity to rebound very significantly at any time throughout the course of 24 hours. So, for instance, a dog who previously received 30 mg. once in the morning might need to be decreased to only 10 mg. both morning and evening if a switch is made to twice daily dosing.

I am not saying this might not be an option for Kaiser, but if you are finally seeing some good results, I don't believe I'd shake up his dosing schedule right at the moment. ;)

Marianne

Thanks Marianne, I will stay the course for now, and leave any changes for the specialist when we do go see one.

[Junebugs]

Great update, Theresa! So happy for you and Kaiser!

Thank you, Joan!! Fingers crossed we can continue progressing in a forward direction now!

[molly muffin]

Hi! sorry i've been absent and didn't see your question till now, but I agree with Marianne, i would stay the course for now and since he seems to be making great improvements, I wouldn't change anything unless necessary.

[Junebugs]

Hi! sorry i've been absent and didn't see your question till now, but I agree with Marianne, i would stay the course for now and since he seems to be making great improvements, I wouldn't change anything unless necessary.

Thanks Sharlene! Yes, I will continue on with the current dosage. I was happy to see it on sale at Valley Vet Supply, as my vet's office charges over $70 for a 30 day supply...

I'm thrilled that the chiropractor says Kaiser's muscle tone is a little better along his back and hind quarters. I have to give him a pep talk to keep him moving without lying down when we walk the little hill in the yard. Slowly but surely, we will get there...!! He's being a real trooper! :)

[molly muffin]

Even a bit of the small hills can help with the muscles, tendons and ligaments.

good job!!

It is definitely worth checking out pricing online vs the vets as I always found the vets higher.

[Squirt's Mom]

Nice to hear things are improving! Keep up the good work, Mom!

[Urses]

Wishing you and Kaiser the best. Hope he is doing well.

[Junebugs]

Wishing you and Kaiser the best. Hope he is doing well.

Thanks so much! I'm hoping you find a diagnosis soon for your girl!!

[Junebugs]

Just a small update on Kaiser's progress:
We are now just over 5 months on Trilostane 30 mg per day (Kaiser weighs about 97 lbs). His skin issues seem to have nearly resolved, and his fur has all grown back in much thicker than it has ever been! I have spent the past few months working on regaining his muscle and endurance, which has been very slow and frustrating to say the least. I am happy to report that as of Sunday night, he was able to actually make it down the block to the main corner and back without laying down and refusing to walk! We did it again Monday night with success! I am feeling hopeful, as his chiropractor last month stressed the importanace of building up muscle. Of note, due to his regular vet making me get monthly re-authorizations for his Vetoryl, rather than pre- approving refills, we had run out for a few days (when they failed to respond to the Pharmacy's refill request) before he had the breakthrough on his walks. I still suspect that the Vetoryl has held him back from being able to walk any distance. Now that he is back on his regular dosage, it will be interesting to see if I am correct or not in that assumption... All the same, I am thrilled at his "breakthrough", and hope this forward momentum continues. I am planning on his next ACTH in a couple of weeks to see where the numbers are now.
Theresa

[Squirt's Mom]

What a wonderful update! YAY!! I hope the trend continues!

[molly muffin]

What a fabulous update!!! yay!

[Junebugs]

Kaiser had his next ACTH test to monitor his response to the last few months on 30mg Vetoryl once a day. Here is the result, along with his last 2 results for comparison:

12/23/17
Cortisol Pre ACTH 0.6 ug/dL
Post ACTH 1.5 ug/dL

8/17/17 Pre ACTH 0.6 ug/dL
Post ACTH 3.0 ug/dL

7/18/17 Pre ACTH 0.8 ug/dL
Post ACTH 2.5 ug/dL

The vet suggested we drop down from 30mg daily to 20mg, but wanted to consult with Dechra's IM Specialist. Once he was able to consult with her, they went over all of the results. She suggested we give a 2 week break from dosing to give his adrenals time to settle, then restart at 20mg daily split morning and evening due to his consistently low Pre ACTH numbers. We are almost at the 2 week mark now, and I do see Kaiser starting to get restless again in the night, as well as panting starting to return. I am thrilled that he can go down in dosage, although buying 2 packs of 10mg is significantly more expensive than 1 pack of 30. But I feel much better about a lower dosage, which I did not expect at all. He has been much more receptive to taking the stairs since he's been off the Vetoryl, so lowering the dosage, and splitting it sounds like maybe it will help overall...?

I do have a question: Does he need another test before restarting the Vetoryl next week, or is it ok to just start the lower dose? Also, would he need another ACTH 2 weeks after starting this lower dosage? I will be calling the vet on Friday to arrange the restart of meds.
Thanks,
Theresa

[Harley PoMMom]

Were his electrolytes checked? If not, I would want to verify that those electrolyte levels (mainly sodium and potassium) are normal because Vetoryl has the ability to lower aldosterone, the adrenal hormone that controls the balance of sodium and potassium.

I believe it is important to have an ACTH stimulation test performed before restarting the Vetoryl to confirm that the adrenal glands are producing enough cortisol. Has he been drinking and urinating more? How is his appetite, any diarrhea episodes?

[Junebugs]

Were his electrolytes checked? If not, I would want to verify that those electrolyte levels (mainly sodium and potassium) are normal because Vetoryl has the ability to lower aldosterone, the adrenal hormone that controls the balance of sodium and potassium.

I believe it is important to have an ACTH stimulation test performed before restarting the Vetoryl to confirm that the adrenal glands are producing enough cortisol. Has he been drinking and urinating more? How is his appetite, any diarrhea episodes?

I will have to ask if they tested electrolytes this time, as they did not send me that result. They did during the August test, and levels were good. He may have had one episode of diarrhea last week, as I had found his back end a bit messy one day, but seemed to be an isolated incident. In general, his stools have been slightly on the drier side. He is starting to drink more water now, and getting up in the night to do so, which he had not been doing for quite some time. I think the insomnia is starting to kick back in, too. Appetite is good, and he is returning to looking for scraps after dinner again. I find him searching under the bird cages for any seeds he can find...

[Harley PoMMom]

It makes me a bit uneasy when I see a dog's post cortisol level drop below 2 ug/dl and according to Dr. Peterson's blog, he feels the same way too:
Dosage adjustments — lowering the dose

In this report (13), trilostane treatment was continued in dogs with a post-ACTH cortisol concentration less than 1.5 μg/dl, as long as no adverse clinical signs were reported. I disagree with that regime.

When using trilostane, it has become increasing clear that we do not want the cortisol values to drop too low, because that may indicate early or mild adrenal necrosis (1,11,12). In contrast to the protocol used in this reported study, I recommend stopping the drug in all dogs that develop a ACTH-stimulated cortisol values less than 2.0 μg/dl, and repeating the ACTH stimulation test in 1- to 2-weeks in those dogs. Some of these dogs will require that the drug be restarted at a lower dosage, but others will maintain low to normal serum cortisol concentrations for prolonged periods of time. And a subset of these dogs, presumably because of mild adrenal necrosis, will never need any further trilostane treatment to control the signs of Cushing's syndrome. https://endocrinevet.blogspot.com/2012/12/low-dose-twice-daily-trilostane.html

When a dog's post cortisol level is < 2.0 ug/dl those adrenal glands may not be able to produce enough cortisol and/or an imbalance in the electrolytes could occur which can cause a dog to drink/urinate more.

[molly muffin]

I too like a post of over 2.0ug. Remember that going too low can cause the same symtoms as high cortisol (drinking, insomnia, etc) so want to watch that and I'd lower the dosage if it were me I think to bring that post up a bit.

[Junebugs]

It makes me a bit uneasy when I see a dog's post cortisol level drop below 2 ug/dl and according to Dr. Peterson's blog, he feels the same way too: https://endocrinevet.blogspot.com/2012/12/low-dose-twice-daily-trilostane.html

When a dog's post cortisol level is < 2.0 ug/dl those adrenal glands may not be able to produce enough cortisol and/or an imbalance in the electrolytes could occur which can cause a dog to drink/urinate more.

Thank you so much for this info. It has made me realize that I need to be super careful right now. The vet did mention that there would be a chance of necrosis if the levels go too low. Now I see why another stim test before restarting at even the lower dose is so important.

[Junebugs]

I too like a post of over 2.0ug. Remember that going too low can cause the same symtoms as high cortisol (drinking, insomnia, etc) so want to watch that and I'd lower the dosage if it were me I think to bring that post up a bit.

Thank you Sharlene! I did not realize that symptoms could be the same in either direction. Good to know, and not assume that his cortisol has risen, which is what I was doing.

[Junebugs]

I spoke to the vet today, and scheduled another ACTH test for Wednesday to see where Kaiser's cortisol is now that he has been off the Vetoryl for a couple of weeks. I also asked to have an electrolyte panel done as well. I will post the results once they are in, then make a decision on his treatment going forward, rather than just start him up again now at the lower dose. Thanks everyone for helping me navigate this!!

[Harley PoMMom]

I spoke to the vet today, and scheduled another ACTH test for Wednesday to see where Kaiser's cortisol is now that he has been off the Vetoryl for a couple of weeks. I also asked to have an electrolyte panel done as well. I will post the results once they are in, then make a decision on his treatment going forward, rather than just start him up again now at the lower dose. Thanks everyone for helping me navigate this!!

Crossing fingers for those electrolytes to be normal and that his cortisol has come up a bit....You're doing a great job, Theresa!!!

[Junebugs]

Kaiser's lab results are in. Just to re-cap, we temporarily stopped his Vetoryl 30mg daily due to his previous ACTH numbers. The specialist at Dechra recommended a brief holiday from dosing, with the plan to restart @ 20mg daily, with split dosing 10mg am and again in the evening.

1/25/18
Pre ACTH 4.8 ug/dL
Post ACTH 10.1 ug/dL

It's my understanding that normal ranges while off therapy are Pre 2-6 and Post 6-18. The vet and Dechra specialist think we should leave him off treatment until the clinical signs become bothersome, and then start the lower, twice daily dosing. Does this sound like a good plan for now? He has a little insomnia creeping back, along with a little panting, but not really bothersome yet. He is doing really well with being able to get around and walk longer distances since he has been off treatment, so maybe a short holiday is a good thing? I certainly don't want to wait for the balding and skin issues to come back, though.
His last numbers while on 30mg each morning were 12/23/17 Pre 0.6 and Post 1.5
We did a full blood panel, and electrolytes are normal. Glucose, which was a tiny bit high previously is now normal. IDEXX SDMA is normal @ 11 (reference value is 0-14). ALP is still way up there @ 6,896.
Theresa

[Harley PoMMom]

I'm happy to see that his cortisol has come back up, and FWIW, I agree with the plan of withholding the Trilostane until clinical symptoms reappear.

[Junebugs]

I'm happy to see that his cortisol has come back up, and FWIW, I agree with the plan of withholding the Trilostane until clinical symptoms reappear.

Thank you! I feel much better now knowing this is all going well. We go for Kaiser's chiro adjustment and acupuncture tomorrow. His doctor will be pleased, I'm sure. Maybe this weekend I can try taking him out on a short trail walk again!

[molly muffin]

Excellent that his cortisol has come up and electrolytes are normal range. Whew.
Good to have a plan, and staying off till symptoms come back is a good option, and then when and if you do restart, do so at the lower dose, as he got in trouble on the previous one.

[Junebugs]

Heading to the vet's office today... Kaiser has been struggling with soft stools and diarrhea on and off for the past 5 weeks. We did a 10 day course of metronizidole at the end of Februar. All seemed well for a couple weeks, but back to mostly pudding consistency and accidents in the house. I tried eliminating his supplements to see if one was the culprit, but no luck. His stool sample last visit was fine. He has been off the Vetoryl since the end of December, I think. His appetite is increasing, and he's getting pretty wobbly in the rear end. I'm pretty worried at this point...

[Harley PoMMom]

Poor Kaiser, 5 weeks of diarrhea has to be taxing for you both. There is a condition known as Exocrine Pancreatic Insufficiency (EPI) that can cause long bouts of diarrhea, and it seems that GSD are a breed that is predisposed for this affliction. Many vets aren't familiar with this disease or the two blood tests that are used to diagnose it, which are the cTLI and Cobalamin/Folate. EPI is the inability of the pancreas to produce and secrete the necessary enzymes needed to digest food so treatment is to replace those pancreatic enzymes, which is usually porcine "powdered" enzymes called pancreatin.

[Junebugs]

Poor Kaiser, 5 weeks of diarrhea has to be taxing for you both. There is a condition known as Exocrine Pancreatic Insufficiency (EPI) that can cause long bouts of diarrhea, and it seems that GSD are a breed that is predisposed for this affliction. Many vets aren't familiar with this disease or the two blood tests that are used to diagnose it, which are the cTLI and Cobalamin/Folate. EPI is the inability of the pancreas to produce and secrete the necessary enzymes needed to digest food so treatment is to replace those pancreatic enzymes, which is usually porcine "powdered" enzymes called pancreatin.

Thank you so much for the quick reply! I read this as I was in the waiting room, and the vet said it was a great idea to have the test run looking for this. I have been wondering if he has something off as far as digestion goes, and hopefully this will give us an answer to that. We also are running his cortisol baseline just to see if there may be a clue there, as Kaiser has been off the Vetoryl for a few months with increasing water consumption and hunger. Once the results are back we will discuss and decide what our next step will be.

[Junebugs]

Kaiser's lab results indicate pancreatitis. We did the GI panel, along with his cortisol level (not as a diagnostic, but looking for clues) since he has been off Vetoryl for 3 months now.

TLI 18.0 (5.0-35.0 ug/L)
Spec cPL 556 (0-200 ug/L)
Cobalamin 222 (284-836 ng/L)
Folate 11.2 (4.8-19.0 ug/L)
Cortisol 4.9 (2-6 ug/L)

He is back on Metronidazole, as well as B12 supplement. The vet spoke to another IM specialist, and recommends restarting the Vetoryl soon, but at 1/2 his previous dose of 30mg. He mentioned that Kaiser may need to get his cortisol down just a bit to feel better, without going to the low end like before. He would get 10mg in the morning, and 5 in the evening. I figured we would address that in the next week or two, but things have taken a turn for the worst...

I started home cooking him chicken breasts, rice, veggies, and broth. The diarrhea was bad for a few days even after starting the metro, and Immodium AD. Saturday was finally a solid stool, but soft stool and an episode of diarrhea today. The scariest issue is he suddenly is having trouble with his hind legs, especially the right one. It is all wobbly in the strangest way, and occasionally "knuckling over". I'm trying not to panic, and hoping maybe he's having issues from being off the Vetoryl. I used to feel like the Vetoryl was causing leg weakness issues, as he walked much better after stopping the drug but now that they have returned, maybe it is that he needs a specific balance between where his cortisol is now, and where it was on the 30mg dose... Also, his spine and hip bones suddenly feel much more prominent to me. Very prominent... Pot belly is larger too. His state is so concerning today, that my husband says we are making him suffer. I want to call the vet in the morning and ask if we can restart the Vetoryl right away to see if he will improve... Any thoughts would be greatly appreciated!!
I'm heartbroken seeing his declining health.

[Squirt's Mom]

Cortisol 4.9 (2-6 ug/L) Borderline high

I am confused. Why are they saying a reading right in the middle of normal is "borderline high"? To me, borderline high would be 5.8-5.9 ug/L. So I am either reading this all wrong, there has been a typo, or they have different ideas of normal and high than I. ;) Based on these readings as they are shown here I would not restart the Vetoryl at any dose because this reading is almost perfect. Are you seeing any real signs of elevated cortisol - excess peeing, excess drinking, ravenous appetite? The pot belly, panting, and hind leg weakness could be attributed to several other things besides Cushing's (elevated cortisol which these numbers do not support). One thing that comes to mind is ascites - a condition a pup here recently had to deal with. You can read about it here - https://www.petmd.com/dog/conditions/cardiovascular/c_multi_ascites

Has an abdominal ultrasound been done lately?

I am sure others will be along soon to chat with you and may feel differently than I about this cortisol reading.

Hugs
Leslie

[Junebugs]

I am confused. Why are they saying a reading right in the middle of normal is "borderline high"? To me, borderline high would be 5.8-5.9 ug/L. So I am either reading this all wrong, there has been a typo, or they have different ideas of normal and high than I. ;) Based on these readings as they are shown here I would not restart the Vetoryl at any dose because this reading is almost perfect. Are you seeing any real signs of elevated cortisol - excess peeing, excess drinking, ravenous appetite? The pot belly, panting, and hind leg weakness could be attributed to several other things besides Cushing's (elevated cortisol which these numbers do not support). One thing that comes to mind is ascites - a condition a pup here recently had to deal with. You can read about it here - https://www.petmd.com/dog/conditions/cardiovascular/c_multi_ascites

Has an abdominal ultrasound been done lately?

I am sure others will be along soon to chat with you and may feel differently than I about this cortisol reading.

Sorry, the "borderline high" was not the vets words, but my interpretation of our conversation that included the possibility that 4.9 cortisol is at the higher end of normal, and just might be too high specifically to Kaiser. He's thinking he may be sensitive to the higher range. He does have the ravenous appetite again, and will scrounge around to find something to eat off the floor, which was out of character for him previous to the Cushings. His water consumption is high, and he will down a large quantity at one time. His last ultrasound was well over a year ago, and the vet did suggest we get another to check out any changes.

[Harley PoMMom]

The Spec cPL 556 (0-200 ug/L) does indicate pancreatitis so getting that under some kind of control is important. My Harley had chronic pancreatitis and his Spec cPL results never returned to normal so don't panic if Kaiser's don't either. If this were me, I would feed him a diet of low-fat and skinless chicken breast with some very mushy rice and nothing else (meaning no veggies) for at least one week, making his meals small and spreading them throughout the day is best. Keeping him hydrated is important too as this helps in the healing of the pancreas.

The diarrhea could definitely be from his Cobalamin being low along with the pancreatitis and this may be causing the weakness in his legs. Is he scheduled for a recheck of his Cobalamin? Also, that cortisol result of 4.9 ug/dl, was that his resting or pre number?

[Junebugs]

I am totally shocked and heartbroken...
I spoke to Kaiser's vet on Monday, and explained that things were getting worse. I decided to schedule an ultrasound, but that evening things went from bad to tragic... Kaiser lost his ability to stand at all, and seemed to lose his bowel function. I stayed up all night with him, and in the morning my husband and I carried him outside to see if he could do his business. He was in total collapse, as if his back end were paralyzed. We made the agonizing decision to help free him of his suffering. We called a vet that Kaiser had previously been treated by, who now runs a very compassionate traveling euthanasia service. I carried him to his favorite spot in the house, cleaned him up with a sponge bath, and comforted him for the next 5 hours while we waited. I had to clean him up several times, and his back end never moved at all.

He enjoyed some cheese and ribeye steak as we said goodbye, and passed in such a peaceful way. We allowed the other dogs to say goodbye before my husband helped carry him out on the stretcher. I've been sobbing and wailing since Monday, trying to come to terms with having had to make that decision... He was such a special, gentle, loving member of our family. So heartbroken...

[Joan2517]

I am so, so sorry for your loss of dear, sweet Kaiser. My heart is breaking for you...many, many hugs to you and your family.

[labblab]

I, too, am so very sorry to learn this news. But thank you so much for returning to tell us what has happened. This way, we can join you in honoring Kaiser’s life and memory, and we can also do our best to offer our support to you at such a sad time. We hope it may bring you a bit of comfort to know that Kaiser has now been added to our special memorial thread of honor:

http://www.k9cushings.com/forum/showthread.php?8846-Remembering-All-Who-Have-Left-Us-(2018)

I’ll be contacting you soon in order to see whether it would please you for us to also add a photo link to Kaiser’s memorial line. In the meantime, please accept my deepest sympathy on your loss. And please know that we are always here for you, today or any time in the future, should you wish to return and share stories of your lives together or just to talk about how you’re doing.

Sending many hugs to you across the miles, always in loving memory of your sweet boy.
Marianne

[Squirt's Mom]

Oh me...I am just so sorry for your loss. Heartbroken for you. The wailing I understand and remember so very well. When I had to make The Decision for my Squirt, I think I walked around the house and yard literally screaming for days, weeks in fact. How could she not be here? So many questions and what-ifs or what-if-nots or maybes. How could she be gone when her presence was still felt so strongly that I could hear her in the next room or coming down the hall or feel her against me when I went to sleep or smell her hair tickling my nose? How could those things exist together? Because that is how deep grief works. Because even in the midst of that all-encompassing pain she was still with me and remains with me to this day....and will til it is my turn to cross over. Kaiser is still with you as well. He will keep watch over you just as you did him as long as you walk in this life. Then one day, he will be there waiting for you as you cross that Bridge. He will fly into your arms and cover your face with kisses...and you will know deep in the core of your Soul that the two of you will never be apart, that you are part of each other for all time.

Please know we are here for you anytime you need to vent, to cry, to scream, to talk. Most of us have been where you are and we understand, truly understand.

My deepest sympathies,
Leslie



Dogs Never Die

Some of you, particularly those who think they have recently lost a dog to “death”, don’t really understand this. I’ve had no desire to explain, but won’t be around forever and must.

Dogs never die. They don’t know how to. They get tired, and very old, and their bones hurt. Of course they don’t die. If they did they would not want to always go for a walk, even long after their old bones say:” No, no, not a good idea. Let’s not go for a walk.” Nope, dogs always want to go for a walk. They might get one step before their aging tendons collapse them into a heap on the floor, but that’s what dogs are. They walk.

It’s not that they dislike your company. On the contrary, a walk with you is all there is. Their boss, and the cacaphonic symphony of odor that the world is. Cat poop, another dog’s mark, a rotting chicken bone ( exultation), and you. That’s what makes their world perfect, and in a perfect world death has no place.

However, dogs get very very sleepy. That’s the thing, you see. They don’t teach you that at the fancy university where they explain about quarks, gluons, and Keynesian economics. They know so much they forget that dogs never die. It’s a shame, really. Dogs have so much to offer and people just talk a lot.

When you think your dog has died, it has just fallen asleep in your heart. And by the way, it is wagging it’s tail madly, you see, and that’s why your chest hurts so much and you cry all the time. Who would not cry with a happy dog wagging its tail in their chest. Ouch! Wap wap wap wap wap, that hurts. But they only wag when they wake up. That’s when they say: “Thanks Boss! Thanks for a warm place to sleep and always next to your heart, the best place.”

When they first fall asleep, they wake up all the time, and that’s why, of course, you cry all the time. Wap, wap, wap. After a while they sleep more. (remember, a dog while is not a human while. You take your dog for walk, it’s a day full of adventure in an hour. Then you come home and it’s a week, well one of your days, but a week, really, before the dog gets another walk. No WONDER they love walks.)

Anyway, like I was saying, they fall asleep in your heart, and when they wake up, they wag their tail. After a few dog years, they sleep for longer naps, and you would too. They were a GOOD DOG all their life, and you both know it. It gets tiring being a good dog all the time, particularly when you get old and your bones hurt and you fall on your face and don’t want to go outside to pee when it is raining but do anyway, because you are a good dog. So understand, after they have been sleeping in your heart, they will sleep longer and longer.

But don’t get fooled. They are not “dead.” There’s no such thing, really. They are sleeping in your heart, and they will wake up, usually when you’re not expecting it. It’s just who they are.

I feel sorry for people who don’t have dogs sleeping in their heart. You’ve missed so much. Excuse me, I have to go cry now.

[molly muffin]

I am so very sorry to hear of Kaisers passing and just how fast the situation turned tragic for him and you and your family.

My sincerest condolences on your loss. :(