New here, Newly diagnosed. Stewie has passed

[MichelleJVM]

Hello fellow Cushingoid dog owners!

I have one main question. But thought I'd introduce myself as well. My dog 'Stewie' is newly diagnosed with cushing's (officially confirmed yesterday). This being after a long year of blood work tests, ultrasounds, food trials, supplements, medications, etc... He tested negative for cushing's just a few months ago. We decided to retest for cushings at recommendation of the ultrasoundographer. He had his first dose of Vetoryl today, just waiting to hear back from internal medicine as to whether we will be discontinuing fortekor from his medication roster.

Anyways, back to my Question. He has had a ravenous appetite for quite some time. Just this past week he has been leaving a decent portion of his meals untouched. I am curious if any others had this at the later stages of not being diagnosed yet. And if you guys would think I should have concerns about the appetite decrease involved with Vetoryl. My dog is NOT overweight by any means, and I don't really want him to loose any. Just curious what others experiences with appetite pre treatment/post treatment.

Thanks!
Michelle

[DoxieMama]

Hello Michelle and welcome to you and Stewie! A ravenous appetite is certainly a symptom of Cushings, but I don't know that having that decrease prior to starting Vetoryl happens all that often. It could be a concern once treatment has started but... without much knowledge on the subject, I don't want to lead you astray. I'm sure one of the more knowledgeable folks will be by later today to address your concerns.

How much does Stewie weigh, and what dose of Vetoryl have you started him on today?

In the meantime, we are always interested in having the full picture. Can you share with us the result of the diagnostic tests, as well as observations on the U/S? We also like to know the actual numbers of any bloodwork that is out of range, including the range (as normal ranges vary between labs).

Once again, welcome!
Shana

[Harley PoMMom]

Hi Michelle,

Welcome to you and Stewie! I am so glad you have joined our forum but sorry for the reasons that brought you to us.
Could you get copies of all tests that were done on Stewie and post those results here? In this way we can provide you with more meaningful feedback. Regarding the CBC/chemistry blood panel you need only post those values that abnormal and please include their reference ranges...thanks!

I have some questions about Stewie's Cushing's treatment and if could provide us with answers that would help us immensely. How much does Stewie weigh and what dose of Vetoryl is he taking? Dechra, the maker of Vetoryl recommends a starting dose of 1mg per pound of a dog's weight so if Stewie is receiving more than that it could explain a sudden decrease in food consumption. When is he scheduled for his next ACTH stimulation test (which is how the cortisol level is checked)? Where his adrenal glands visualized on the ultrasound and were any anomalies found with the internal organs?

Again, I am so happy you found us and we will help in any way we can.

Lori

P.S. I see that Shana were typing at the same time so please excuse my duplicate questions. :o

[MichelleJVM]

Thank you Shana and Lori. Lori, I'm afraid you didn't read my post thoroughly. The lack of appetite started prior to starting Vetoryl, so dosage really has absolutely nothing to do with it. I was just curious if any others had this order of events prior to treatment and whether there is a concern of even more decreased appetite after starting vetoryl.

As for results and dosages, of course I am happy to share. Although I would like to be clear I am not here to replace veterinary advice. I am not looking for dosage advice. I have done my research and am working very closely with my veterinarian for treatment.

Stewie is currently 11.8lbs, he is a dachshund cross, 9 years old.

His first ultrasound showed a gallbladder mucocele, possible nodule on adrenal gland, and thickened intestinal walls. This was near the beginning of this year. His most recent ultrasound shows bilateral enlarged adrenals.

We did a low dex test in June that was negative for cushings

Our most recent tests:

11/10/17 - Urine Cortisol/creatinine Ratio
Urine Creatinine: 2,481umol/L
Urine Cortisol: 833nmol/L
Urine Cortisol/Creatinine Ratio: 335.8
>=34 : Hyperadrenocoricism is possible, stress may affect test

11/14/17: Low Dexamethasone stim test:
Cortisol - Baseline: 301nmol/L
4hr: 116nmol/L (<50% baseline and/or <41 nmol/L is consistent with pituitary-dependent hyperadrenocorticism)
8hr: 135nmol/L (>41 nmol/L is consistent with pituitary-dependent hyperadrenocorticism and/or hyperadrenocorticism)

11/16/17: ACTH Stim
Cortisol Baseline: 397nmol/L
1hr post: >1380nmol/L

Vetoryl started on 11/16/17 @ 1.7mg/lb = 20mg once a day. No medication side affects seen to date.

[labblab]

Hello Michelle, and welcome to you and Stewie. I, too, am so glad you’ve joined us, and I thank you for all this additional information. In answer to your primary question, no, it is not common for Cushpups to exhibit a sudden loss of appetite prior to beginning treatment unless a secondary condition is flaring. Since intestinal thickening has already been noted for Stewie as well as a gallbladder mucocele, perhaps he is experiencing some type of GI distress. Have his stools remained normal throughout?

The timing of the inappetance is unfortunate, because decreases in excessive thirst and appetite are commonly used as gauges in determining dose appropriateness. So if something was already affecting Stewie’s appetite prior to beginning the Vetoryl, it will be hard to know whether additional appetite changes are the result of appropriate dosing, overdosing, or a secondary condition altogether. In this situation, you will want to monitor other behavioral markers very carefully: changes in thirst, vomiting, diarrhea, increased lethargy, etc. Our hope, of course, is that Stewie will start behaving more normally after beginning the Vetoryl, and not less.

As far as dosing recommendations, indeed we are not vets and our suggestions are merely that — suggestions. However, since our sole focus for over a decade has been canine Cushing’s, we’ve had the chance to share in many experiences and to monitor changes and innovations in treatment protocol. In 2004, my own Cushpup was a pioneer and was probably the first to be treated with trilostane in the area in which we live. At that time, the initial dosage recommendations were much higher and I shudder now to realize how much medication we were giving him. Since that time, initial dosing recommendations have consistently been scaled downward. There may be an important reason why your vet thinks that the dosing formula you are using for Stewie best fits his needs. But for the benefit of all our readers, here is a post that summarizes the rationale for the more generally accepted initial formula of 1 mg. per pound. The research noted here can be a good point of departure for discussing dosing alternatives.

http://www.k9cushings.com/forum/showthread.php?185-Trilostane-Vetoryl-Information-and-Resources&p=1251#post1251

But most importantly, I surely hope that Stewie shows improvement in the coming days. We’ll be very anxious for updates, so please do let us know how things are going.
Marianne

[MichelleJVM]

Hi Marianne, thank you for sharing your thoughts. I was also wondering if it may be an underlying issue, that's a good point... His bowel movements have been normal. He has seemed to get even weaker the week or two prior to Vetoryl treatment, so that may or may not be related. I *think* he has gotten a decent amount of his appetite back, although he seems to discovered that the pills I have been giving him for the past year are not actually treats, he is turning his nose up at them now. Stewie's vet doesn't seem concerned about the lack of appetite at the moment. I am hoping that Vetoryl does the trick and gets him feeling better. I'll definitely keep you guys up to date on how he is doing. Thanks.

[labblab]

Do you guys have Stewie’s first monitoring ACTH test scheduled? You probably already know that Dechra recommends that the first test be done 10-14 days after starting treatment. Our experience here is that some vets defer the testing until around the 30-day mark, but it really should not be postponed any longer than that. Especially in Stewie’s current situation, the testing may be a better indicator of dose appropriateness than are changes in appetite and other observable behavior.

Actually, aside from hunger, can you share with us whether Stewie has exhibited any other common Cushing’s symptoms? You’ve noted the gallbladder mucocele which can indeed be associated with Cushing’s. Also, you mention that he’s been taking Fortekor: is this for high blood pressure or perhaps kidney issues? How about any observable external symptoms? I am just wondering what prompted the suspicion of Cushing’s in the first place. Thanks in advance for any additional info!

Marianne

[MichelleJVM]

We don't have the first ACTH test booked yet but I do plan to do it at the 10-14 day mark. I was trying to decipher if it mattered if it was at 10 or 14 days...

He is on ursodial for gallbladder, fortekor for protein loss, and zentonil for liver although there were no specific concerns on the ultrasound, on x-ray originally it looked slightly larger then it should be. I didn't realize gallbladder issues were associated with cushings, thanks for letting me know that!

As for symptoms, I originally brought him in knowing he needed a dental, I didn't notice at first other then him greying and not having a luscious coat, his bloodwork was off. Then I started noticing more the dry flakey skin, although he wasn't really itchy. Then the fact that he never grew hair back from the ultrasound shave or IV shave, his coat has thinned out. He has been drinking and peeing more, and in the last month or two he has had a few accidents. He has had a large appetite, I don't remember when this started or if it has just been so long it feels like its always been that way, I had him portion fed but once I knew he was loosing protein I started bumping up the food amount so he would gain some weight. His skin over the past 4-6 months has been really thin, to a point where he had 2 decently large gashes from unknown origin. He also had a few bruises also from unknown origin. Over the past 2-3 months I've noticed him tripping over his own feet more, face-planting up the back step, etc. He also licks the floor around the cats litter box like its nobodys business... (yes the litter is a safer type... I checked...)

The ultrasoundographer is the one who pushed testing for cushing's.

[MichelleJVM]

We just did Stewie's first ACTH since starting the Vetoryl. At 14 day mark. Results are as follows:

--
Cortisol - Baseline: 155 <28-120nmol/L>
Cortisol - Post ACTH: 252 <220 - 550nmol/L>

** aim for post cortisol between 60-140 for good control, alternatively, the
manufacturer suggests 250 is adequate if good clinical control
history and previous noted
--
He has not had any accidents since starting the vetoryl, although he still is drinking a fair amount. He is able to get up onto one or two things he was struggling to get onto within the previous month or so, but still has some difficulties. Appetite was wonky the week prior to vetoryl, it hasn't changed much. He still got a random bruise during vetoryl treatment. Still groans when being picked up.

His vet has opted to stay on 20mg dose for a little longer to see if it regulates with some more time.

[labblab]

Hi again, Michelle, and thanks so much for these results and the additional information. For the benefit of our U.S. readers, they convert to approximately 5.6 and 9.1 ug/dL. I totally agree with your vet’s recommendation to leave Stewie’s dose unchanged for the time being since cortisol levels often continue to drift downward during the first few weeks of treatment. By giving it a bit more time at his current dose, you’ll have a much better idea as to whether, and how much of, might be called for long term.

Continued good luck to you guys, and please keep us updated!
Marianne

[MichelleJVM]

Thank you Marianne, it is a relief to hear from someone else that we are on the right track. I haven't been seeing much changes with stewie yet and it has been making me feel like I am taking a step backwards rather then forwards with this...

Would his next testing be 30 days from the last testing or from the start of treatment? Also my vet got anxious when I told her I fed Stewie the morning of testing (with his Vetoryl), his sample was very Lipemic, just curious if you guys feed as per usual on the day of testing?

Ps. Thanks Marianne for translating his levels into numbers others are familiar with!

[Harley PoMMom]

Would his next testing be 30 days from the last testing or from the start of treatment?

Thirty days from the start of treatment is when the next ACTH stim test should be done.


Also my vet got anxious when I told her I fed Stewie the morning of testing (with his Vetoryl), his sample was very Lipemic, just curious if you guys feed as per usual on the day of testing?


Trilostane has to be given with a meal to be properly absorbed. I am including articles that state that Vetory/Trilostane must be given with a meal, this first one is the "Vetoryl Client Brochure" which Dechra publishes, (Dechra is the maker of Vetoryl):

Vetoryl Client Brochure (http://www.animalhealthinternational.com/animalhealthinternational.com/media/Animal-Health-International/Training/Dechra/VetorylClientBrochureSpreads4_20HighRes.pdf)

On page 6 of that brochure:


How do I give VETORYL Capsules to my dog?

Give VETORYL Capsules with a meal in the morning so they can be effectively absorbed. Administration in the morning is critical so your veterinarian can perform the monitoring test at the appropriate time after dosing.

This second excerpt is from an article on Dr. Mark Peterson's blog (Dr. Peterson frequently contributes to Dechra's online continuing education for veterinarians) and is titled: What's the Best Protocol for ACTH Stimulation Testing in Dogs and Cats?


Remember that the ACTH stimulation test is the most useful test for monitoring dogs being treated with trilostane (Vetoryl) or mitotane (Lysodren) see my blog entitled, Diagnosing Cushing's disease: Should the ACTH stimulation test ever be used? Both medications are fat-soluble drugs and must be given at time of meals, or the drugs will not be well absorbed.

With trilostane, it’s extremely important to give the morning medication with food, and then start the ACTH stimulation test 3 to 4 hours later.

Fasting these dogs on the morning in which the ACTH stimulation test is scheduled should be avoided since it invalidates the test results.

http://www.endocrinevet.info/2011/03/whats-best-protocol-for-acth.html

Lori

[MichelleJVM]

Day 30 ACTH Stim Test + electrolytes

Cortisol - Baseline: 112 <28-120nmol/L>
Cortisol - Post ACTH: 210 <220 - 550nmol/L>

Calcium: 2.15 <2.20-2.80mmol/L>
Chloride: 101 <108-118mmol/L>
Hemolysis: +++
Lipemia: ++++

They say the Calcium is due to hemolysis and artifact, Chloride supports loss, Stim still supports marginal control and that the Post should be less then 100nmol/L for good control.

We have bumped up his dose to 30mg SID

And we are back to day 1 ... Woot!
_____________
Ps. Thank you Lori for the info!

[labblab]

Hey Les, I think you must have been looking at Stewie’s chloride result instead of the post-ACTH ;-). The post-ACTH was 210, which converts to about 7.6 ug/dL. So Michelle, that is indeed a bit higher than Dechra’s prime therapeutic range of 1.45 - 5.4 ug/dL (or 40 - 150 nmol/L), and therefore is apparently triggering this dosage increase. This makes sense, but Leslie’s warning about continuing to monitor Stewie carefully still holds. Any time a dose is increased, we want to be especially alert to any behavioral changes that might herald a cortisol level that is dropping too low.

In that vein — behavioral changes — are you seeing any improvements yet?

Marianne

[Squirt's Mom]

You are absolutely correct, Marianne! :o So I have deleted that post, Michelle....if you have already read it, please disregard. :o

[MichelleJVM]

Hi Les, I did see your original message, but I saw it in conjunction with Marianne's. So not to worry. I appreciate your concern, and its nice to know that if I did veer off the track that you guys would be there to back me up and get me back on the right path again. So far his transition to the new dose has gone pretty smoothly, he did have 1 bout of soft stool but it went back to normal the next day.

Still no big changes. The main change has been the lack of accidents in the house. As for eating and drinking, there is no significant noteworthy changes. His food intake is still a little wonky since prior to starting vetoryl. I think he must of bit into an ursodial capsule and doesn't trust any meds/food anymore... I'm not convinced it is strictly appetite related. As for behavioral, is there anything specific I should be looking for? I can't say he is any more playful. He definitely does not want to walk to the vet, can't say I blame him though. He was a rescue and was never friendly with other people, except maybe if it came to food. If anything maybe he's crawling into my lap a little more then usual?!

I'll keep you guys up to date as things progress.

Thanks again for the support and advice.

[MichelleJVM]

I'm curious if you guys know how soon Urine Protein Creatinine improves after starting Vetoryl. We haven't seen any Changes for the better since starting a month and a half ago. Just wondering if improvement is expected this soon in the game or if it is one of those things that takes time?! The vet seems concerned that we aren't seeing more improvements by now.

[Harley PoMMom]

With some dogs, even with treatment, their proteinuria never resolves, I know we've seen this to be true on the forum. Here's an excerpt from Dr. Peterson's blog:


About half of dogs with untreated Cushing's syndrome have proteinuria, defined as a urine protein:creatinine ratio (UPC ratio) >0.5-1.0, in the absence of UTI (1-4). Although such a protein-losing glomerulopathy is common in dogs with Cushing’s syndrome, the severity of proteinuria is generally less than that typically seen in dogs with hypoalbuminemia or hypoproteinemia. Hypertension and proteinuria are common in dogs with Cushing’s syndrome, and they may represent a “cause-and-effect” relationship.

Results of this study also confirm that proteinuria is common in canine Cushing's disease, with high pretreatment UPC ratios found in 68% of dogs of this study (9). However, as with hypertension, proteinuria sometimes fails to completely resolve despite treatment of Cushing's disease (1-4). In agreement with that, results of the present study found that the median levels of proteinuria decreased after treatment, but proteinuria persisted in 5 of 13 (38%) dogs after 12 months of treatment.
https://endocrinevet.blogspot.com/2012/06/hypertension-and-proteinuria-frequent.html

[MichelleJVM]

Hmmm that is interesting. Thank you for sharing the article. I secretly wish some of these articles were more recent, but the studies apply all the same. I suppose it will just be something we will monitor over time. Stewie may just end up being in the percentage that does not resolve.

[molly muffin]

He might never resolve the protein loss but as long as his kidney values, BUN and creatinine stay good ranges or not too far out, then that is main thing. I'd just monitor kidneys along with everything else and stay on top of it.

[MichelleJVM]

Day 28 ACTH Stim Test + electrolytes (since increasing dose to 30mg once a day)

Cortisol - Baseline: 41 <28-120nmol/L> ((1.49ug/dl))
Cortisol - Post ACTH: 121 <220 - 550nmol/L> ((4.39ug/dl))

Chloride: 107 <108-118mmol/L>
Hemolysis: ++
Lipemia: ++

** aim for post cortisol between 60-140 for good control, alternatively, the
manufacturer suggests 250 is adequate if good clinical control
history and previous noted

Drinking + Urinating has decreased. Appetite still on and off, getting very picky! Has had a few soft bowel movements. Still moans and groans occasionally (especially when being picked up). Still seems weak.

[Harley PoMMom]

Did the ultrasound that was done reveal anything regarding the pancreas? Some of his symptoms fit pancreatitis such as the on-off-again appetite, soft stools, and that moan when he is picked up could be from the tenderness of his stomach.

Looks like the 30 mg of Vetoryl is doing the job as those are great stim numbers!

[molly muffin]

As Lori said, those are very good numbers and I think you have control with this dosage.

I agree with her that pancreatitis could be an issue. If so try feeding, really low fat, small meals several times a day. Mushy rice and boiled chicken is a good option. I would do that with my dog when she would start to show signs of being sensitive in her stomach.

She loved it and thought it was a treat. :)

[MichelleJVM]

Thanks guys. That is a great point, that is one test we have not run. I got my clinic to run the CPL (pancreas test) yesterday and it did come back normal. I'm glad I can rule it out for now. The ultrasounds in the past have not shown any indication of pancreas issues either.

My vet and I are thinking it may be his meds causing the food aversion. I am changing up my feeding/medication schedule a bit by giving his meds after eating. Hopefully that way he doesn't have a bitter taste in his mouth while he is eating. We will see how that works and go from there.

Thanks again for the ideas.

[Harley PoMMom]

I'm glad to see that his pancreas is not the problem, that is one fickle organ! Keeping my fingers crossed that his appetite picks up. I wonder if Pepcid AC would help?

[molly muffin]

Yay, always good to eliminate that possibility with the pancrease. As Lori said, it's fickle!

We've seen before where some dogs do become picky eaters with the lower cortisol. I'm not really sure why that is. Mine was always picky and lowering the cortisol made her even more so.

Maybe topping with something tasty would help?

[MichelleJVM]

I am very glad it is not pancreatitis!

As for his pickiness, it continues. I have tried toppings, he has become talented with picking them off the food, if it is mixed in he won't touch it at all. He still wants treats, so its not like his appetite is all together gone... But its just so odd to see him not gulp everything down in less then 5 minutes like he always has. If I'm lucky he will eat his whole meal or a decent portion of it within an hours time. But there are also times where he will take a bite and walk away.

My previous attempts at switching up his food gave him the runs, that was prior to his diagnosis, but it still makes me nervous to do any major switching... I tried to switch to a vet food because we had suspected allergy/IBD/Kidney issues before, he didn't have firm stool for the whole 1-2 months he was on it.

Maybe I'll get some probiotics again and see if that helps settle his stomach a little.

[molly muffin]

I used Foriflora probiotic. My molly loved it. I sprinkled it on her food.

[MichelleJVM]

So, Stewie is currently off of Vetoryl as per veterinarian advice. He had not been eating well, loosing weight. Although his bloodwork results were looking fine at his last testing; he was not really improving much. I had brought him into the vet to discuss the plan because I was it happy with how things were going, I was thinking more along the lines of something to settle his stomach and anti-nausea meds, his stool was very loose if not diarrhea... Anyways the day I brought him in the ultrasonographer was there, we had him do a quick check to see if there were any concerns. He noticed that the liver and pancreas weren't looking too happy, he is assuming that vetoryl is not agreeing with him.... So We have taken him off vetoryl, the plan is for 2 weeks and to slowly reintroduce. He is eating normally again, it has been a week since we took him off.

My main question is, is there anyone who has tried alternative treatments then Vetoryl? My vet briefly mentioned a Chinese herbal medicine, she still had to look in to it. But it would be good to know if any others have successfully treated with alternative medicine?!

[molly muffin]

I've heard several mention that they gave chinese herbal medicine but I don't know what the success was long term with just using that. However, I understand that the weight loss and not eating are a concern and a break to let the liver and pancrease settle down could be helpful. I'd try it anyhow.

[molly muffin]

Try a break from meds I meant to say. :)

[MichelleJVM]

Is it more common that one needs to take breaks from vetoryl since it is so tough on the system?? I'm not sure if I'm a big fan of that... If it is doing that much harm on the system you'd think you'd have to stop and find an alternative treatment rather then continuing...

[molly muffin]

No I wouldn’t say it is common to need a break from vetroyl and many dogs never need a break and are on it for years. That being said though for your specific case the liver and pancreas are showing some need for tender care. Whether this is from the vetroyl I couldn’t say but in general my personal opinion is to not give Cushing med to an animal that isn’t well. With the not eating and the US showing it might need to recuperate. It could be that a mild case of pancreatis occurred or it could be that it is on the verge of becoming. In which case I would stop meds and go with a low fat chicken and mushy rice diet. Smalll meals several times a day until better.

[MichelleJVM]

I'm getting very frustrated with the inappetence Stewie has been having.

Not too long ago we decided to take Stewie off Vetoryl due to inappetence, the vet and ultrasonographer felt it was negatively affecting him. He started eating a bit better since taking him off. We then decided to put him on a smaller dose two weeks after so that we could at least partially control his symptoms. We also have started him on Chinese herbal medicine Ophiopogon.

We have taken Stewie off Vetoryl again. It has been two and a half weeks since he has really eaten much of a meal, he'd eat a third of his meal (tops) on occasion. Although the last two evenings he has eaten most of his dinner...

I did realize about a week ago that he has an abscess in his mouth that may be partially to blame. He is on antibiotics now. We want to do a dental on him and remove any teeth that may be causing the problem, but at the same time he is not a very good anesthetic patient. His dental last year he was pretty light under anesthetic, he woke up part way through. The vet wants to send him to a specialist but says they may not accept him due to his bloodwork.

At what point do you guys think it's not fair for them to go on like this?? I'm curious where others have drawn the line. I know it's a hard topic, and may bring up some bad memories. I just don't know anymore. I partly feel like this isn't fair for him, but I also don't feel like it's time yet.

I've also been concidering going to internal medicine to see if they have any more insight. But the dental abscess kind of threw a wrench in that plan, I think it would be best to deal with that first if anything...

Sorry for being all over the place...
Here is one of my previous forums if you want to refer back for some reason. I thought Id start fresh with a new one... http://www.k9cushings.com/forum/showthread.php?8793-New-here-Newly-diagnosed-Question-about-appetite

[Budsters Mom]

For me, it's all about quality of life. Is Stewie still happy? Is he able to do what he loves most, at least some of the time. Does he have unmanaged pain? I knew when my Buddy had enough. I could see it in his eyes. I knew that he would hold on for me. That wouldn't have been fair to him. You know Stewie best. This is the toughest question any pet parent EVER has to answer. I am so sorry.

[MichelleJVM]

I feel like Stewie is still happy, he still has life left in him. I feel like there could be some unmanaged pain, but I don't know for sure. He is definitely weaker then he used to be, and has lost weight due to the inappetence.

I'm don't necessarily think its quite time for him but I feel like I need to keep it in the back of my mind because I don't want him to suffer.

[Squirt's Mom]

I have merged your latest post concerning frustration over Stewie's appetite into his original thread. We like to keep all posts about each pup in their own thread. That way it is easier to keep up with the history for us and for you. ;)

I wouldn't give up just yet. Finding the abscess in his mouth may account for a lot of his disinterest in food. Once that is healed he may feel much more like eating. Wouldn't it be nice to learn this has been his issue all along! :)

As for the question of when is the right time, that is a very personal thing and we all approach it differently but I always go to what one of our members said years ago - they deserve a dog-worthy life and as long as they can enjoy a dog-worthy life then it is not yet time. What is a "dog-worthy life"? That is a life in which the dog still enjoys things like sniffing as they walk along or in new areas, barking at the mailman or the dog next door when it comes out, chasing that cat who comes by every now and then, interacting with their people and other animals in the home, enjoying their food, wanting attention like ear and belly rubs and so on. You know your baby best of all and you know the things Stewie has always enjoyed doing. As he starts to lose interest in things, and they all do as they age, then you need to decide what things make Stewie's life dog-worthy. Another member here said she listed I think 5 things her baby liked and when her baby no longer enjoyed those 5 things, it was time. Another member believes it is flat out wrong to release them; she believes we leave it up to them unless they are in obvious pain...and her baby remained with her even tho he could no longer walk, void, drink or eat on his own. So the most important thing in this decision is your knowledge of Stewie. YOU will know when he has had enough because YOU know him best of all. ;) But for today, I would put this all on the back burner and see if getting his mouth taken care of puts him back on track.

Hugs,
Leslie

[MichelleJVM]

I was curious about when people may make a decision more specifically geared toward Cushings patients. If there was some sort of pattern most Cushings dogs go through near the end. I know it is my decision, I have my own thoughts on this. I just don't know what further things lay down the road. He's obviously not going to improve if we take him off Vetoryl. I can't exactly let him eat nothing for multiple months on end, that doesn't seem right or fair (let's just assume we go through the dental and appetite doesn't improve... For the sake of argument).

[labblab]

My guess would be that if the inappetence does not resolve after the dental procedure, it may become a deciding factor for you. Clearly, something shifted for Stewie back last fall when his ravenous appetite took a 180 degree shift. Diagnostically, I know you have tried hard to sort it out, but to no avail. One possibility that we’ve not yet discussed is an enlarging pituitary tumor that is placing pressure on the part of his brain that controls appetite. A large pituitary tumor could account for both his other Cushing’s symptoms as well as his appetite drop-off. I believe there were some adrenal nodules noted on his ultrasound, but I don’t think an actual adrenal tumor has been identified? If not, then we’d have to suspect that it’s a pituitary tumor that is causing his Cushing’s, and appetite problems can result from that. Unfortunately, continuing to give trilostane to ease the other Cushing’s symptoms may result in greater brain inflammation since cortisol acts as a natural anti-inflammatory. For dogs with suspected pituitary macrotumors, the recommendation is often to stop the trilostane, and sometimes even to additionally give supplemental prednisone. Of the competing issues, not eating is more immediately critical than are most conventional Cushing’s symptoms.

My own Cushpup developed symptoms consistent with an enlarging pituitary tumor, including loss of appetite, lethargy, pacing, loss of coordination, etc. Rather suddenly, he completely lost the desire/ability to eat or drink at all, and rather than supplementally sustain him, my husband and I decided the most compassionate thing was to release him since without dramatic intervention he would not be able sustain any semblance of a normal life. If an enlarging tumor was the cause, he would not improve in the absence of extensive radiation treatment which we did not choose to pursue. I know many people do not feel as though it’s the right thing to do to intervene to end a companion’s life through euthanasia. But I feel as though it’s as much of an intervention to prolong an animal’s life beyond the point that he or she could survive in the natural world. As long as there’s quality of life, the action seems justified to me. But if the animal is mainly just “existing,” then not so much.

At this point, we don’t know what is causing Stewie’s inappetence. But if it persists and worsens, it seems inevitable that he will suffer increasingly severe consequences from the malnutrition. And at that juncture, you’d have to decide whether there’s any intervention you’d want to consider vs. releasing him.

I really, really hope this dental procedure will turn things around! But if not, I don’t know how many diagnostic stones are left for you to turn over. A dog with no appetite is not a healthy dog. But how long Stewie can continue in this manner remains a big question mark. He may continue on a gradual downward slide, or like my own dog, a crisis may force a decision. I’m so sorry that I can’t offer you a more definitive answer.

Marianne

[MichelleJVM]

Thank you Marianne, that was very well written and helpful.

Just an update: Stewie has been very weak this past week, he has been for a while- but more so now. I took him for a walk with my friend last week Monday, he was very slow, which wasn't unusual at the time. Since then its been harder and harder for him to get up the stairs, and on the couch (even with a step stool). The last two days especially he has been noticeably limping. Last night he was extremely restless, whimpering and in pain. I contacted his vet and they said to up his pain meds and do it three times a day instead of two times. He has not been restless or whining since. But he definitely doesn't want to move or do much.

The plan is to do a bunch of x-rays on Wednesday, possibly take the tooth out that is still infected- under local block (since he isn't stable enough for anesthesia). The vet has always been convinced that something more is going on then cushing's. We don't think this limping is from injury but it will be ruled out on Wednesday. Until then he will be under my constant supervision...

[Squirt's Mom]

Bless his little heart. I hope he finds some relief with the dose change that holds til he has the tests done. I also hope that his vets can find the problem and offer a viable solution soon.

Hugs and belly rubs,
Leslie

[MichelleJVM]

Thank you Leslie.

I brought stewie to the vet today, a different vet (same clinic) then before. We ran some bloodwork. A lot of values are out of whack, Potassium is extremely low which explains the weakness, values show kidney and liver damage. We will have him on fluids for 3 days and see if there is improvement. Before the bloodwork there was talk of doing a joint tap to test for immune mediated polyarthritis, but I think that will be on hold until he is stabilized.

[molly muffin]

Oh poor little guy, well no wonder he is weak and not hungry. Hopefully he improves with the fluids.

[MichelleJVM]

Thank you for all your advice and support. We had to put stewie down tonight. As of this morning he was no longer walking, he was crying out in pain. The pain meds didn't help. We reached a point where we knew there was no improvement ahead and no more quality of life. The doctor noticed Stewie's front legs were ridged and said that supports the theory that he has a brain-stem tumor, whether that be a pituitary tumor or otherwise.

RIP Stewie

[Joan2517]

I'm so sorry for the loss of your darling boy. Rest in peace, Stewie.

[labblab]

Oh Michelle, I’m so sorry, too. You tried so hard for so long. What a brave, sweet little boy — I know you will miss him dearly. We hope it will be a comfort to know that Stewie has now been added to our special memorial list of honor:

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

I will contact you shortly to see whether you’d like us to also add a photo link to his memorial line. In the meantime, please know his family here will always honor him, and we’ll always welcome you back to talk more, or to share memories of your lives together.

Sending big hugs across the miles, in loving memory of sweet Stewie.
Marianne

[Squirt's Mom]

Dear Michelle,

I am so so sorry to hear about sweet Stewie. You did all you could to make his life the best possible and when you saw no more could be done you did the brave and loving thing - you freed him from a failing vessel. There is no doubt that he left this life with gratitude for that act, for that decision that meant you let him be pain-free while you take on the intense pain of grieving. That is true love and Stewie will carry that love in his heart until you meet again....and one day you will hold your precious boy once again while he covers your face with kisses.

Fly free, sweet Stewie, fly free.

My deepest sympathies,
Leslie



I'm Still Here

Friend, please don't mourn for me
I'm still here, though you don't see.
I'm right by your side each night and day
and within your heart I long to stay.

My body is gone but I'm always near.
I'm everything you feel, see or hear.
My spirit is free, but I'll never depart
as long as you keep me alive in your heart.

I'll never wander out of your sight-
I'm the brightest star on a summer night.
I'll never be beyond your reach-
I'm the warm moist sand when you're at the beach.

I'm the colorful leaves when fall comes around
and the pure white snow that blankets the ground.
I'm the beautiful flowers of which you're so fond,
The clear cool water in a quiet pond.

I'm the first bright blossom you'll see in the spring,
The first warm raindrop that April will bring.
I'm the first ray of light when the sun starts to shine,
and you'll see that the face in the moon is mine.

When you start thinking there's no one to love you,
you can talk to me through the Lord above you.
I'll whisper my answer through the leaves on the trees,
and you'll feel my presence in the soft summer breeze.

I'm the hot salty tears that flow when you weep
and the beautiful dreams that come while you sleep.
I'm the smile you see on a baby's face.
Just look for me, friend, I'm everyplace!

Author Unknown

[MichelleJVM]

Thank you for the condolences. It has been a rough week, I miss him a lot. Sometimes I second guess my decision but then I remember how he was on his last day and I know there was no turning back from that, he was never going to be back to himself again... Still trying to get used to his absence. I still guard my food from him, then realize he is not there to stick his nose in my food anymore. Getting up in the morning and not having to take him outside is also very strange, and also at night... lots of little things.

[Joan2517]

Yep, the little things...they are so much a part of our lives that the little things don't seem so little when they are no longer there. I still reach out in bed at night to touch Lena and make sure she's not too close to the edge of the bed. I still miss the sound of her moving the food around in her dish. None of the others do that. It's Spring and I miss watching her explore the garden with Doree following behind, the two of them trotting along and smelling every new flower. Doree is the leader now with Sibbie following...looks so different.

Hugs....

[Squirt's Mom]

My Squirt has been gone four years this past Wed, the 9th. When I was in the grocery store yesterday they had turkey breast on sale and I put one in my basket. I walked thru several aisles before I remembered I no longer needed to buy turkey because I was no longer cooking her food. Four years and I forgot, four years and that habit remains strong. It takes time but I'm not sure how much time. What I do know is that those deep-seated habits that are so hard to let go of are balanced by the times when I hear her coming down the hall or making her bed in my closet because I know then she is still with me and always will be. Your sweet boy will let you know in his own way that he is still by your side too. So grieve as long as you need and know you always have a safe place here.

Hugs,
Leslie

[molly muffin]

Oh no.. I'm so sorry to see that Stewie has passed. :( My heart goes out to you.