Shirley and me

[poomama]

Hello and thank you in advance for any information and support. Shirley is an almost seven year old shih tzu that was recently diagnosed with Cushing's. In a span of a couple of months, it has amazed me how much this disease has ravaged my dog. Treatment with Trilostane started on Nov. 4th with a loading dose of 15mg twice a day. Prior to Trilostane, she was given an LDDS test and that number came back >50. Her ultrasound showed a slightly enlarged liver but her adrenal glands looked normal. A CT scan of her head didn't show a large pituitary tumor. Since her adrenals glands looked normal, it was determined that she has a small pituitary tumor. On 11/20, Shirley had an ACTH stimulation test and the value for that came back at 18. That's better but a number of 5 is what is desirable, so her vet upped the dosage of Trilostane to 20 mg twice a day. The caveat to all this is her liver enzymes. Her total bilirubin is back to normal, but her ALP is ridiculously high. A fine needle aspiration was done of her liver and the pathologist didn't see any sign of cancer there. I will get all of her reports from the specialist after the holiday, so maybe I can get some help here.

What my REAL question is: what are the chances that Shirley will ever be normal again? She is still drinking and urinating frequently, she has significant hair loss and very obvious muscle weakness, particularly in her back legs. Will this ever go away?

[Harley PoMMom]

Hi and welcome to you and Shirley!

Definitely getting the results from all tests that were done on Shirley and posting them here will help us to provide you with more meaningful feedback so thanks in advance for that. Regarding the LDDS test, there are 3 blood draws performed so you'll have 3 numbers to post for that one. For her CBC/chemistry blood panel we need only to see those values that are marked abnormal with their reference ranges. And to put your mind to a somewhat ease over the ALP, it is very common for dog's with Cushing's to have an elevated level, on the forum we have seen numbers in the 1000's. In fact, 80% to 90% of dogs have a steroid induced isoenzyme of alkaline phosphatase (ALP) so if one of those dogs has Cushing's, you are gonna see anywhere from a mild to severe increase in ALP.

Can you tell us how much Shirely weighs? The recommended starting dose of Vetoryl is 1mg per pound of a dog's weight so if she was on 15 twice a day that's 30mg which means that she weighs 30lb or more. What symptoms was she displaying that led her to be tested for Cushing's? The increased urination/drinking she has usually lessens within two weeks of treatment, however for some dogs this may never improve that much. The muscle/hair loss generally takes a while to see any improvements so patience is needed for that, I know that's hard to do when your precious pup is going through all of this. I do what you to know that with treatment dogs with Cushing's can have a good quality of life.

With Vetoryl there are two very important rules to follow: The dose of Vetroyl has to be given with a meal and those monitoring ACTH stimulation tests have to be done 4-6 hours after the Vetoryl was given with a meal. Is the vet using this protocol with Shirely?

I am sorry for the circumstances that brought you here but so glad you found us and we will help in any way we can.

Lori

[poomama]

Hi Lori,

When this journey first started for Shirley and I (and my husband), I thought for sure we were seeing symptoms of diabetes. She was drinking frequently and peeing a lot, especially indoors. So, I made an appointment for blood work. I think the vet was suspicious of a UTI, but I asked him to do a full small animal panel so we would have some baseline values that might be useful for the future. She had also gained a lot of weight and I had noticed she had lost some hair, particularly her tail. When we got the results, her AST, ALP and GGT were all elevated and her T4 was slightly lowered. He gave us some thyroxine and some SamE and we made an appointment for six weeks. Within four weeks, there was enough deterioration that I became alarmed so we went back and had more blood work. This time, the ALP and GGT were so high that there machines couldn't measure it and they had suggested an ultrasound of her belly. I had been doing some research about Shirley's symptoms and was reasonably sure I was looking at a Cushing's dog. The vet didn't want to listen and so we were referred to a specialist in another state.

Right now, Shirley weights 14 pounds so it would seem that she is getting too much Trilostane, but she seems to be tolerating the added medication well....no vomiting or diarrhea and I am keeping a close eye on her. I haven't noticed a significant decrease in drinking and urination so perhaps she will be one of those pups where that never goes away.

Once I have all her lab and imagine reports I will post them here and maybe get some feedback on where this is all going. In the meantime, Shirley seems content. Three weeks ago, we thought she was going to die and I think the vet did, too. She spent a week in the hospital and they managed to to pull her back from the ledge. I am grateful.

Jo-Ann

[Harley PoMMom]

Three weeks ago, we thought she was going to die and I think the vet did, too. She spent a week in the hospital and they managed to to pull her back from the ledge. I am grateful.

Jo-Ann

Oh my, a whole week in the hospital, I know how worried you must have been. :( Can you share what they were treating her for?

[poomama]

It ended up to be Cushing's disease, but we did not have a definitive diagnosis when we brought her in. She had had her first LDDS test, which came back abnormal, and they were waiting for the result of an endogenous ACTH test before starting treatment. In the meantime, Shirley stopped eating and was very lethargic. Her electrolytes were not good either and her liver enzymes were sky high. It wasn't pretty. They did some more imaging of her belly and also a CT scan of her brain and I think their reasoning was that there might be a huge pituitary tumor there. As it turned out, there wasn't. Another thing, too, was that even though she was drinking and peeing a lot, she wasn't well hydrated, so she was on IV fluids. After four days, she started eating again. Anyhow, as I mentioned before, I will get a copy of all the testing that was done and post it here.
Shirley is doing much better, thank God!

[poomama]

Here are results from Shirley's blood work from 11/20/17

PRE-ACTH CORTISOL 18.4 ug/dL
POST ACTH
CORTISOL 19.0 1 ug/dL


ALT: 780
GGT: 463
ALKP: 7618
K: 3.4

She is currently taking 20mg of Trilostane 2xday plus Denamarin and Ursodiol for liver support. She is scheduled to have another ACTH stim test on 12/7.

[Harley PoMMom]

Treatment with Trilostane started on Nov. 4th with a loading dose of 15mg twice a day. Prior to Trilostane, she was given an LDDS test and that number came back >50.


Please correct me if I am wrong :eek: instead of a LSSD test did she have an ACTH stimulation done which the post value was >50 ug/dl?


Here are results from Shirley's blood work from 11/20/17

PRE-ACTH CORTISOL 18.4 ug/dL
POST ACTH
CORTISOL 19.0 1 ug/dL

Although the pre value really isn't looked at when a monitoring ACTH test is performed Shirley's pre number (18.4 ug/dl) is high. Did she seem to be really stressed when this ACTH test was done?

Also, if in fact that result of >50 ug/dl was a post level before Trilostane was started the drop to 19. ug/dl was significant, so I'm a bit concerned, because a dog's cortisol can continue to drift downward for the first month of treatment. If she would begin to show signs of her cortisol dipping too low an ACTH stimulation test should be performed. Symptoms of low cortisol can be one of the following; a loss of appetite, lethargy, vomiting, diarrhea, or Shirley just not acting her usual self.


ALT: 780
GGT: 463
ALKP: 7618
K: 3.4

She is currently taking 20mg of Trilostane 2xday plus Denamarin and Ursodiol for liver support. She is scheduled to have another ACTH stim test on 12/7.

We've seen some pretty elevated ALP levels on the forum but not ALT or the GGT. Those two are considerably higher than what we are used to seeing.

Even though the aspiration that was done on her liver showed no cancer those elevations in her ALT and GGT are concerning. A bile acid test is commonly run to see how the liver is functioning and the vet would know if this test could be beneficial in Shirley's case.

Keep us posted.

Lori

[molly muffin]

Hello,

Did Shirley have a monitoring ACTH test on the 7th Dec? Just wanted to see how she is doing, how she is tolerating the dosage of trilostane and if those liver numbers have started to come down.