Is it cushings or not with our blue - Blue has passed

[Larinda]

New to forum...so here's our story...our 5 year old Australian Shepard lab mix (100 lbs)went from energetic puppy to old man seeming overnight. Last January we noticed his symptoms...lethargic, mopey, sad, tired, not wanting to run and play or engage, no longer jumping on bed, hungry constantly to the point of stealing off counter, garbage (which he never did) drooling, thirsty drinking constantly , peeing alot, snoring, pot belly...we went to the vet as nervous parents with the complaint of "he just ain't right". Everything checked out fine with regard to bones hips knees etc. Xrays showed nothing amiss. Urine tests (first catch in am) showed diluted urine. Bloodwork (they had him for the whole day) showed positive for cushings but they said the adrenal type. We had never heard of that before. We had ultrasound in June from prominent vet specialist who found nothing. We chalked it up as false positive results. His hair has never grown back on his belly and now I see what I suspect as that cutaneous calcinosis -scaly bumps on top of his back almost like dandruff. My question is this...if we go back to vet what next steps should I expect? If I do nothing what should I expect? We are torn not knowing and realize each situation is different. I wish there was a clear cut answer. Will meds help or hurt? Will doing nothing help or hurt? Any advice would help thanks .

[labblab]

Hello, and welcome to you and Blue — we’re so glad you’ve joined us! First of all, it’s unusual for severe Cushing’s symptoms to come on overnight; usually it’s a process of symptoms steadily worsening over time. However, having said that, Blue certainly does exhibit a number of the most common outward symptoms. So, combined with a “positive” blood test, Cushing’s has to be suspected. I am guessing the diagnostic blood test was the 8-hour LDDS test? If so, however, this is one clarification. Depending upon the results of that test, Cushing’s in general can be diagnosed. Also, if the results turn out in a certain pattern, they point to a pituitary tumor as the cause. However, they can also turn out in such a way that either a pituitary or adrenal tumor could be the cause. I suspect that’s what happened for Blue, and the goal of the ultrasound was to see if an adrenal tumor was indeed present. Based on the ultrasound report, it sounds as though no tumor was seen. Therefore, if Blue has Cushing’s, it must instead be caused by a pituitary tumor. In that event, you’d expect to see both adrenal glands to be enlarged to some extent (because they’re being “overworked” by churning out excess cortisol, as it were). However, a minority of cases do not show adrenal enlargement, especially early on in the disease process.

So here are some questions for you. Can you find out the exact results of Blue’s diagnostic blood test, as well as any other blood panel abnormalities? Cushpups typically display elevated liver numbers, especially the ALKP (or sometimes listed ALP). Often they also have high cholesterol and also some abnormalities in white blood cell counts. Finally, did the ultrasound note anything abnormal at all about any internal organs? In addition to adrenal enlargement, Cushpups often exhibit liver abnormalities as well.

Once we see this additional info, that will help us chart the path forward. As I say, Blue certainly does sound as though he is suffering from Cushing’s symptoms that are affecting the quality of his life. And if cutaneous calcinosis is emerging, you really do want to nip that in the bud because it can make a dog’s life miserable. In fact, if a biopsy confirmed CC, that would pretty much confirm the overall Cushing’s diagnosis in and of itself. And if Blue were mine that would definitely prompt treatment. But we can talk more about that in another reply.

Once again, welcome to you both!
Marianne

[Larinda]

Thanks for replying...yes from January to June it was clear something was wrong. In fact we kept looking back to try to figure out when it might have started. I'll see if I can get the blood test results but you are right thats just what happened. When they saw nothing in ultrasound they said could be false test results or early onset? We went home with no treatment happy that they were "wrong" . Well now it's February and well...I will call vet today then to have his skin tested but I bet you're right if its that cc then I bet we pretty much know for sure. Will the vet order more tests again then like bloodwork again ? Or another ultrasound? I've heard it said if they don't have it and you give them meds it could hurt them but if we can't confirm diagnosis then how do we know what to do? It's scary because I worry about meds and dosage and side effects ...ugh... thanks for your advice...

[Squirt's Mom]

Hi Larinda and welcome to you and Blue! :)

CC can be caused by other things but 99% of the time it is caused by Cushing's. If Blue has not been exposed to any steroids and does have CC then the odds are really good he has Cushing's. Just for my peace of mind, tho, I would want an ACTH performed and probably another ultrasound just to be sure there is no sign of a tumor on one or both of the adrenal glands. You want to be sure the US is performed on a high resolution machine so they can see the most possible.

Giving Vetoryl (Trilostane) to a pup who does not have Cushing's is dangerous but Lysodren (Mitotane) works differently and does not seem to have any effect on dogs who don't have the disease. HOWEVER, we want to be as sure as can be that the pup actually does have the disease before starting treatment with either drug. ;) So pursue the CC diagnosis then follow up testing as recommended by the vet(s) and let us know what you learn.

The most important thing I can tell you today is that you and Blue are now part of our family here at K9C. You will never be alone again. We are here to listen, to guide, to support anytime you need us.

Hugs,
Leslie

[Larinda]

so I got some numbers for you if you know what they mean...in july 2017 the dexamethasone suppression test : cortisol - 4 hour post dex 4.6 ug/dL and cortisol 8 hour post dex 4.4 ug/dL .
does that make any sense?
now hematology from july shows ALP 259 5-160 u/l
cholesterol 433 131-345 mg/dL
the ultrasound showed everything normal. our vet called in a specialist to perform the test for accuracy so we trusted his judgement.
seemed a mystery but fast forward to today...February...he's the same or slightly worse, and now the skin disorder. looking back we had him tested for allergies in 2016. nothing major there. he had skin disorder then and we changed his diet and it settled down. so I guess I should have them test for this CC. see what they want to do next?
thanks .

[labblab]

Hi again, and thanks for this additional information. Everything you’ve shared thus far is consistent with Cushing’s except for the normally-appearing adrenal glands. And as I wrote earlier, not every dog with a pituitary tumor exhibits adrenal enlargement especially in the early stages of the disease.

As far as the LDDS, there should actually be three numbers: the resting (baseline) cortisol level, and then two more readings taken at the 4-hour and 8-hour mark. You’ve given us the last two readings; it would be interesting to know the first baseline reading, too. However, unless the baseline was over 8, I understand why an adrenal tumor needed to be ruled out. The quick explanation for this is that dogs with pituitary tumors generally show significant suppression of their cortisol levels after the low-dose dexamethasone injections have been given. Dogs with adrenal tumors do not. But a percentage of dogs with pituitary tumors don’t, either. Hence, the ultrasound to check.

At this stage, if your vet thinks the skin issue could be calcinosis cutis and proceeds with a biopsy, I’m banking on Cushing’s as the correct diagnosis. Without a CC diagnosis, I suppose you could repeat the ultrasound. But even without the definitive CC biopsy, I still think Cushing’s is likely given all the symptoms and lab abnormalities. Let’s first see what your vet thinks about the skin condition, though.

Marianne

[Larinda]

Vet wants to examine and possibly repeat the day long blood tests on Wednesday. Would that sound right? I guess we shall see.thanks so much. I have a copy of the original tests i wish I could send it to you somehow as it's hard for me to understand. I'll keep you posted thanks

[Larinda]

7/27/17 7:35 AM (Last Updated)
TEST RESULT REFERENCE VALUE
Cortisol - 4 hr
Post Dex
4.6 ug/dL
Cortisol - 8 hr
Post Dex
b 4.4 ug/dL
b Low-Dose Dexamethasone Diagnostic Intervals (Canine)
4 hours 8 hours Interpretation
----------------------------------------------------------------------
<1 <1 Normal
1.0-1.5 1.0-1.5 Inconclusive
>1.5 and >50% >1.5 and >50% Consistent with hyperadrenocorticism
of baseline of baseline Further testing required to
differentiate adrenal tumor from
pituitary-dependent
hyperadrenocorticism (PDH)
<1.5 or <50% >1.5 and >50% Consistent with pituitary-dependent
of baseline of baseline hyperadrenocorticism (PDH)
<1.5 or <50% >1.5 and <50% Consistent with pituitary-dependent
of baseline of baseline hyperadrenocorticism (PDH)
>1.5 or >50% >1.5 and <50% Consistent with pituitary-dependent
of baseline of baseline hyperadrenocorticism (PDH)
High-Dose Dexamethasone Diagnostic Intervals (Canine)
4 hour 8 hour Interpretation
----------------------------------------------------------------------
<1.5 or <50% >1.5 and >50% Consistent with pituitary-dependent
of baseline of baseline hyperadrenocorticism (PDH)
>1.5 and >50% <1.5 or <50% Consistent with pituitary-dependent
of baseline of baseline hyperadrenocorticism (PDH)
<1.5 or <50% <1.5 or <50% Consistent with pituitary-dependent
of baseline of baseline hyperadrenocorticism (PDH)
>1.5 and >50% >1.5 and >50% Further testing required to
of baseline of baseline differentiate PDH from adrenal
tumor.
Hyperadrenocorticism is a clinical disorder with clinical signs. If
the animal has no clinical signs, we do not recommend treatment.
Approximately 5% of dogs with hyperadrenocorticism will have normal
low dose dexamethasone suppression results. Conversely, some animals
with significant nonadrenal disease may fail to adequately suppress on
this test.


does this help at all? I copied it from his test results page.
thanks
larinda

[labblab]

Gosh, how good of you to lay out the entire test interpretation guidelines. However, the one value that remains missing is the first of the three blood draws: the baseline (or resting) cortisol reading. It’s so odd that it’s not listed on the lab sheet. Maybe it’s printed somewhere else on the lab results along with some other testing.

The reason why it’s an important value to know is because all the “<50% or >50%” interpretations refer to comparing the 4 and 8-hour values to the original baseline cortisol reading. In Blue’s case, we know the LDDS was consistent with a Cushing’s diagnosis in general, because the 8-hour reading was greater than 1.5. However, in order to know whether either the 4-hour or 8-hour reading is greater or less than 50% of the baseline reading — we need to know what the baseline reading actually was.

I am making the assumption that Blue’s baseline reading was not greater than 8. If that was true, this is the interpretive line that fits his results (with my clarification in brackets):


[4-hour reading] >1.5 and >50% [of baseline]; [8-reading] >1.5 and >50% [of baseline]: Further testing required to differentiate PDH from adrenal tumor.

When you return to the vet, I’d ask him/her to point out where the result is for Blue’s baseline cortisol on the LDDS. That way, we’ll know for certain how to interpret his test. As far as repeating the LDDS, I suppose you could do so. But since it’s already turned out positive once, perhaps the money would be better put towards some alternative diagnostics, such as a skin biopsy, or an ACTH stimulation test as Leslie suggested earlier. This is a second diagnostic blood test for Cushing’s, and is also used for monitoring treatment progress after medication has been started. It can be helpful to know how high cortisol levels are on this test prior to beginning treatment. One drawback to this test is that it has a higher percentage of “false negatives” than does the LDDS. Also, it cannot distinguish between the pituitary or adrenal form of the disease (the Endogenous ACTH, a different test, does that). Still, in Blue’s situation, an ACTH stimulation test might be useful corroborative info to consider.

Marianne

[molly muffin]

Hello and welcome from me too. You could also have the ACTH done to find out what his cortisol results are for within the adrenal gland, how much is it making. That is only 2 draws, a pre and a post.

It does appear that your vet said the LDDS was positive for cushings, so I am thinking that yes the stuff on the back is probably cc and to get rid of that you need to get the cortisol levels down.

Since he was positive, it doesn't matter which type you of medication you would use, vetroyl or lysodren and most vets opt to go with the medication they are most familiar with using. So that would be a discussion to have with your vet about treatment.

[Larinda]

so to summarize Blue's visit with the doctor....he was diagnosed with cushings.
He had substantial weight gain since oct 2017 at 98 lbs -he's close to 110 lbs now. His appetite is so ravenous, polyphagia, excessive thirst and urination, polyuria/polydipsia, he hasn't grown his hair back from his ultrasound last summer, alopecia, and now the scabbing, thickening calluses on his elbows, and skin bumps on his back, calcinosis cutis. (not to mention his "mopey, sad, lazy, crotchety, old man " mood/behavior as I like to call it.)
His lddst test run last summer was indicative of Cushings, and I did ask about his baseline and she said "4" so ...but...the ultrasound ruled out adrenal tumors, making it more likely pituitary dependent cushings.
She would like to start him on Vetoryl, but is awaiting results of his thyroid function test and serum chemistry and urinalysis to determine the best treatment plan.
so...i'll keep you posted, thanks so much. I sincerely hope its smooth sailing on this medication. after a month, they said they will blood test him to see how he's doing on it. do you think that would sound about right then? thanks!

[Squirt's Mom]

There is a strict protocol to follow with Vetoryl and based on that protocol the first test is 2 weeks after starting treatment. You also need to make sure his vet knows that the new starting dose is 1mg/lb NOT 3mg/lb as it was when Vetoryl was first released in the US. You can find all this info and much more here (and I would share this with his vet just to make sure they know how to handle this very powerful drug) - http://www.k9cushings.com/forum/showthread.php?185-Trilostane-Vetoryl-Information-and-Resources

btw - that link is from our Helpful Resource section where you will find a great deal of beneficial info. ;)

It is also important that you know in order to get the CC under control his post ACTH after starting treatment must be at optimal range - around 2.5-3.5 ug/dl. The CC will get worse before it gets better even with treatment so don't get discourage. You can read about a successful journey with CC on Tobey's thread. Sadly, she has passed but her story continues to help babies with CC like Blue.

http://www.k9cushings.com/forum/showthread.php?5908-My-girl-pug-(confirmed-Cushings-amp-confirmed-calcinosis-cutis)-Tobey-has-passed&highlight=Renee%2C+Tobey

[Larinda]

hello again...so the vet called last night, and had a change in plans. she is taking baby steps, and doesn't want to start the vetoryl just yet. she is prescribing thyro tabs .8 mg - she said his liver tests were high (she said should be 100's and is in upper 600's?) and his cholesterol is way high. she is still awaiting the urinalysis results. she will email me the numbers but...she is thinking perhaps he can benefit from thyroid meds. in a month she will do blood work to see how he's responding. so I guess I need a crash course in thyroid disorders? I know its probably still cushings, but...and I was thinking back and realized a couple years ago he wasn't making tears, and was put on some eye drops. I wonder if that had anything to do with this at all. or if it was a symptom of cushings we didn't realize? oh and the CC's on his elbows and back are being treated with medicated shampoo and mousse. so he gets a spa treatment at home a couple times a week now! :) hope it works! thanks-I'll keep you posted.

[labblab]

It is not uncommon for dogs with Cushing’s to register low thyroid results. Sometimes dogs suffer from both conditions truly independently — Cushing’s and “primary” hypothyroidism. However, low thyroid readings can often be secondary to Cushing’s and end up resolving all by themselves once the Cushing’s itself is treated.

I am guessing your vet may be basing the decision to start thyroid supplementation based on a low T4 reading on the general lab panel. The thing is, more specialized thyroid testing can help interpret whether low T4 readings are likely to be secondary to another condition, such as Cushing’s. If so, it’s very unlikely that thyroid supplementation alone will solve the problems.

Based on my personal experience with my own Cushpup, I would ask your vet to first draw blood to be sent off for a complete thyroid panel prior to starting the thyroid meds. This is because any thyroid test result will be skewed once the meds are in the system. My own dog was diagnosed as being hypothyroid in conjunction with a low T4, but in the presence of many Cushing’s symptoms. We gave him thyroid supplementation for several months but his condition steadily worsened. When we finally tested for Cushing’s, his cortisol level was highly elevated and it became clear that he had Cushing’s that needed to be treated. We had lost a lot of time and a lot of his strength in the process.

I may be missing the boat and your vet may have included more involved thyroid testing in the panel that was already performed. But I would want to explicitly know if that was the case. If it wasn’t done, waiting a couple of months more to start Cushing’s treatment, if appropriate, is not a big issue for many dogs. But CC can be the huge game-changer. If it starts to worsen during the interim, I would rapidly advance to Cushing’s treatment. We have seen the condition explode here, and sadly, some dogs have even needed to be euthanized because of the massive discomfort. I don’t mean to tell you this to scare you, but I do want you to be aware of the big picture when CC is genuinely present.

Marianne

[labblab]

I’m back with some quotations from the diagnostic test lab at Michigan State’s vet school. They are nationally known for their thyroid analysis, and blood can be sent to them for performance of a complete thyroid profile.

https://animalhealth.msu.edu/sections/endocrinology/Thyroid_Canine.php


How do I interpret MSU's thyroid profile?

In addition to testing for serum levels of total thyroxine (TT4), total tri-iodothyronine (TT3), free thyroxine (FT4), and free tri-iodothyronine (FT3), this profile tests for T4 antibodies (T4AA), T3 antibodies (T3AA), canine thyrotropin (cTSH; thyroid stimulating hormone), and thyroglobulin antibodies (TgAA). The cTSH test provides much needed information in any attempt to diagnose hypothyroidism. Many non-thyroidal factors can cause decreases of TT4, TT3, FT4, and FT3 into the hypothyroid range in a dog with normal thyroid function making it difficult to differentiate sick-but-euthyroid animals from those with hypothyroidism. When thyroid hormone levels are low due to primary hypothyroidism, most (around 85%) animals will have abnormally high cTSH levels...

Non-thyroidal illness (sick euthyroid). It is well known that thyroid hormone concentrations can decrease as part of a metabolic response to non-thyroidal illness. This decrease occurs in part from changes in thyroid hormone production, characteristics of serum binding, and metabolism of thyroid hormones. In these circumstances, measurement of free T4 in the direct-serum analog assay (standard profile) may underestimate the true circulating concentration of free T4 and give a falsely low result. Free T4 by equilibrium dialysis gives a more accurate result and so will more correctly identify normal free T4 concentrations in sick animals, allowing for better identification of animals that are not hypothyroid...

My patient has low thyroid hormone concentrations, but thyroid stimulating hormone is not elevated. What does this mean?

Depending on the clinical presentation, one of two main possibilities is likely.

The more common explanation is that T4 values often decline in animals with non-thyroidal illness and in animals receiving certain drug therapies (some glucocorticoids or anticonvulsants). Non-thyroidal illness may suppress TSH release from the pituitary via glucocorticoid-mediated inhibition or lower T4 concentrations by altering serum protein binding affinities...

With this pattern of test results, a trial with T4 supplementation is suggested only if there is a strong clinical presentation consistent with hypothyroidism and if no non-thyroidal illness can be detected. An objective case review should be conducted after 6-8 weeks of therapy for evidence of clinical improvement. Thyroid supplementation can be discontinued if no improvement has occurred in that time, and the diagnosis reconsidered. A therapeutic monitoring sample taken during treatment should help confirm whether adequate amounts of thyroid medication were being absorbed. Even when there is clinical improvement, strictly speaking, therapy should be discontinued to see if the original clinical signs return in the absence of medication. Admittedly, this latter protocol is rarely followed in clinical practice.

While the administration of thyroid hormone to animals which do not have hypothyroidism is generally considered to have minimal risk, large scale studies in human medicine have shown detrimental effects of such treatment in patients that have decreases in serum thyroid hormone concentrations due to non thyroidal illness. (Brent GA and Hershman JM. Thyroxine therapy in patients with severe non-thyroidal illness and low serum thyroxine concentrations. J Clin Endocrinology and Metabolism. 1986, 63:1)

And here’s why blood for complete thyroid testing must be drawn prior to beginning supplementation:


Once an animal is receiving thyroid hormone medication, thyroid testing can only tell if that medication appears to be well absorbed. No comment can be made about the patient’s endogenous thyroid functional status. Because of the suppressive effects of thyroid medication on the endogenous thyroid in normal dogs, a withdrawal period of 6-weeks is recommended before a diagnostic sample can be taken with which the dogs' endogenous thyroid status can be assessed free from interference by the thyroid medication.

[Larinda]

Thanks...blues urinalysis wasn't what she wanted to see, a bad thing I guess so the vet ordered a different urine test to measure creatine, cortisol? She will call me tomorrow.

[labblab]

I wonder if the test your vet is ordering is instead a UPC (Urine Protein to Creatinine Ratio). Performing a UC:CR (Urine Cortisol to Creatinine Ratio) wouldn’t seem to make a whole lot of sense at this late date, since it is typically an initial “gateway” test which, if elevated, would lead you to a specialized diagnostic Cushing’s blood test such as the LDDS, which has already been performed for Blue.

The UPC is ordered if a dog’s general urine test indicates that an excessive amount of protein is present in the urine sample that was collected. There can be several different causes for excessive protein in the urine, but one cause can be abnormal kidney funtion. Going one step further — and this can be significant in Blue’s case — untreated Cushing’s is a disorder that can cause the type of kidney changes that result in proteinuria. We’ve had a number of dogs here who have exhibited excessive protein loss secondary to their Cushing’s. Depending upon the persistence and severity of the loss (you want to perform multiple UPC tests over time to make the disgnosis) there are specific treatment measures that may be recommended such as moderate restriction of dietary protein along with medication. But if Cushing’s is the underlying culprit, it is also necessary to lower the excessive cortisol production that is leading to the kidney impairment in the first place. So this may end up being the trigger to start the Vetoryl, after all.

After having written all of this, if your vet is instead planning to perform a UC:CR test, I confess I will be pretty much baffled and very interested to find out why.

Marianne

[molly muffin]

To diagnose urine protein loss you need to have 3 consecutive blood draws showing protein loss, and I'm trying to remember, but needs to I believe be at least 2 - 3 weeks apart. I went through that with my dog who had cushings and kidney issues.

I do agree that I would want a complete thyroid panel before starting the thyroid meds to see if it is primary or secondary. As Marianne mentioned, it isn't uncommon to have a thyroid be out of range if there is cushings involved also.

Spa days are great days. :) My dog always pranced a bit after her spa days.

[Larinda]

thanks guys...this is all so confusing. I'm trying to grasp how this all works. its seems so complicated. so the vet replied today from the urinalysis completion, urine cortisol:creatine ratio test...Blue's urine cortisol creatinine is highly elevated, which indicates clinical Cushing's disease is still on the list of differential diagnoses. (the test results are hard for me to understand really, but would urine cortisol result of 15.9 ug/dl and urine creatine 48.9 mg/dl and cortisol;creatinine ratio 101 mean anything?) This means they will run the proposed ACTH stim test in a month when he is scheduled for his T4 check . This test does not require fasting and we will need Blue for two consecutive blood samples one hour apart. For the thyroid aspect of the testing we need to ensure that blood sample is taken 6 - 8 hours after he takes his thyroid medications.
so I guess we will keep doing the thyroid meds am and pm until then. so far so good with that. he's doing ok. it just baffles me the timeline and tests. she must have her reasons? lets hope the month goes well. I just worry. watching him like a hawk. not knowing what to expect. or what might happen. when I hear liver, kidney, I get scared. should I be worried? do you think the vet is wanting to confirm for sure before she starts cushings meds? I know its hard to confirm at times. and I know the meds can help or hurt. ugh. what do you do.

[Harley PoMMom]

so the vet replied today from the urinalysis completion, urine cortisol:creatine ratio test...Blue's urine cortisol creatinine is highly elevated, which indicates clinical Cushing's disease is still on the list of differential diagnoses. (the test results are hard for me to understand really, but would urine cortisol result of 15.9 ug/dl and urine creatine 48.9 mg/dl and cortisol;creatinine ratio 101 mean anything?) This means they will run the proposed ACTH stim test in a month when he is scheduled for his T4 check .

I am still so puzzled as to why the UC:CR test was done when Blue already had the LDDS test performed which we're assuming was positive (we do really need to see that baseline draw for the LDDS test to make an accurate interpretation), the UC:CR is only a screening test as it can not aid in the diagnosis for Cushing's. If this were me, I would have a biopsy done on those skin bumps to see if it is calcinosis cutaneous and if the result is positive I would start treatment for Cushing's.

Lori

[Larinda]

I did ask about the baseline from his blood test last summer and she said 4. and I believe the results were 4.6 ug/dl at the 4 hour mark and 4.4 ug/dl at the 8 hour mark. would that make sense or help at all? I have no clue.

[labblab]

I truly don’t understand why your vet ran the UC:CR. All it can tell you is whether excess cortisol is being produced, and any illness or stress can cause elevated cortisol. In that vein, I must ask how the urine sample for the UC:CR was obtained. In order to accurately reflect a dog’s typical cortisol production, the urine sample should be obtained at home when the dog is not stressed, preferably the first pee of the morning. And actually, some specialists prefer that a pooled urine sample from three successive mornings be used for the test in order to average out the results. If your vet performed the test on a sample that was obtained there at the office, any stress that Blue was under could have skewed the results upwards. We all naturally manufacture more cortisol when we are scared or excited.

If your vet is still searching for confirmation of the Cushing’s, I don’t understand why she didn’t go ahead with the ACTH right now instead of doing the UC:CR. The ACTH is a diagnostic test that is specific to Cushing’s; the UC:CR is not. Why wait now for another month before proceeding with the ACTH?

I regret sounding so confused by your vet’s gameplan. I know it must feel very worrisome to you for me to be constantly second-guessing her. But in good conscience, I feel as though I need to continue to raise these questions. For whatever reason, she seems really hesitant to try to confirm the Cushing’s, either via the ACTH or skin biopsy or more complete diagnostic thyroid testing. As long as Blue remains stable through this month, then I guess all you are losing is time. But at the risk of sounding like a broken record, if his skin worsens, I would not wait to press for some quicker action on the Cushing’s front. By any chance, would you want to try to upload some photos of his skin bumps to your photo album here? If so, we could at least take a look at them and compare them to other known cases of CC among our members here.

Marianne

Edited to add: I just saw your note about Blue’s resting (baseline) cortisol level being around 4. If so, then he truly did not show any suppression during the LDDS test. As discussed earlier, that type of result is most often consistent with an adrenal tumor. That’s why the ultrasound was performed. In the absence of any adrenal tumor or mass showing up on his ultrasound, though, it seems as though it is a pituitary tumor that is causing his Cushing’s should he truly suffer from the disease.

[Larinda]

thanks my sentiments too! no... the urine sample was taken by us at home first thing Friday morning and dropped off to vet first thing. she called Saturday morning saying he had elevated levels, and she wanted to do additional urine test for cortisol based on the initial findings from Friday, but she was going to use that sample i had given her Friday. so today...she said that additional test showed elevated cortisol/creatinine but she will do additional blood testings in a month. so im not sure now what to think. should I be worried that a month is going by or should I be hoping the thyroid meds we started on Friday will be enough. how would I know? would he take a sudden turn? what should I be expecting? I half worried when I heard liver, kidney, creatinine, words, I got nervous. as for his bumps, sure I could try to get a photo tonight. see how they are looking. I honestly don't know what it should look like, and was hoping for a biopsy to determine but she felt at office visit that that's what it was (CC).

[Squirt's Mom]

Here is a google link showing images of calcinosis cutis in dogs. WARNING - some of the pics are graphic.

https://www.google.com/search?q=calcinosis+cutis+dog&client=firefox-b-1&tbm=isch&tbo=u&source=univ&sa=X&ved=0ahUKEwix_teX57fZAhWj6oMKHQ5LC5MQsAQIXA&biw=1366&bih=603

[labblab]

... the urine sample was taken by us at home first thing Friday morning and dropped off to vet first thing. she called Saturday morning saying he had elevated levels and she wanted to do additional urine test for cortisol based on the initial findings from Friday...
Do you remember what elevated levels in the urine your vet was worried about on Friday?


...should I be worried that a month is going by or should I be hoping the thyroid meds we started on Friday will be enough. how would I know? would he take a sudden turn? what should I be expecting? I half worried when I heard liver, kidney, creatinine, words, I got nervous. as for his bumps, sure I could try to get a photo tonight. see how they are looking. I honestly don't know what it should look like, and was hoping for a biopsy to determine but she felt at office visit that that's what it was (CC).
If your vet believes the bumps are truly CC, then the thyroid meds will be of no help no matter how long Blue takes them. Low thyroid does not cause CC. The thyroid meds will not lower elevated cortisol levels, either. So I honestly don’t know why your vet is waiting for a month to perform the ACTH and/or to confirm the CC diagnosis.

If Blue does have Cushing’s, you’d expect any symptoms caused by elevated cortisol to continue to worsen over time in the absence of treatment. Most symptoms might only worsen gradually. The one I’d be most concerned about is CC, because it can worsen and spread very rapidly.

Marianne

[Larinda]

i tried to get some photos...I think I created an album. blue's bare belly from last july ultrasound (hair never grew back) and his elbow, which bleeds at times, and the top of his back, when you pull away the hair, you see flakes and bumps, sores like, and clumps of hair fall out with the flakes. sounds gross I know. we are doing a once a week medicated bath and two times a week medicated mousse but im not seeing any improvement in a weeks time. we have to be vigilant in checking him as his hair is so black and thick, you have to feel to find these spots. as far as I remember...liver and cholesterol levels were high. then after the additional urine test, cortisol and creatinine levels high. I wish I understood more about these tests. so now she wants to do the acth in a month. and a t4 check.

[labblab]

Thanks so much for setting up your album. Blue looks like SUCH A SWEETHEART!!!!! No wonder you love him so!

The fourth picture of him comes out clearly for me, but unfortunately, the photos of the bumps are blurry when I click on them to enlarge them. I’m looking at them from my iPad, though, and maybe other folks can see them more clearly. But I can’t see them well enough to really evaluate his skin.

Have you clicked on the link that Leslie gave you of the Google photos of CC? Do any of them look similar to what you’re seeing on Blue?

Marianne

[Larinda]

I got a closer photo but im having trouble uploading it into my album. not sure why. not sure how to add it to this post . sorry I cant be more helpful. any suggestions?

[labblab]

Larinda, you can try emailing the photo to us at our administrative mailbox: k9cushings@gmail.com. If it comes through clearly, maybe we can problem-solve the uploading issue. We recently upgraded our forum software, and are still working out some glitches. Unfortunately, uploading photos doesn't always seem to work as smoothly as before. But we can see what we can do.

In the meantime, though, I'm still wondering whether you've had the chance to look at the CC photos in the link that Leslie gave you. Do they look anything like Blue?

Marianne

[Larinda]

ok i'll try that thanks. its the strangest thing.(kinda gross really-sorry.) but the yellow you see in the photos that i emailed is flakes of skin, with hair clumps attached, that fall off, and red spots like bumps. we have to pet him to feel for them, and pull his hair away on his back to find these bumps, as his hair is so black. I did look at the photos Leslie shared with me and some look like him and others not so much. gosh, maybe we should force the issue of a biopsy. but then again, would that be a mute point? I certainly don't want him flaring up any worse! but he's no better just yet with the medicated shampoo. the vet did think it was CC's, but did not biopsy it. I guess I was hoping you all would know and be able to tell me yes or no. maybe we are in early stages? because some of those photos looked really bad and I don't want poor blue getting to that place? I guess that's why im worrying about it so much. but what else could it be right? We are only on thyroid meds now, and Our next vet apt is in a month (march 28th) and they will do those blood tests, T4 and ACTH, but I bet we are going to be looking at that vetroyl aren't we. unless you think I should call the vet now and force the issue? awe thanks guys for putting up with me being such a pain. you're the best for taking the time to talk to me. thanks! im in unchartered waters here. I just want whats best for blue.

[Squirt's Mom]

If his skin looks like any of those pics I would do what I could to get him tested asap. OR I would take him to a dermatology vet if there is one in your area. They will know pretty quick if it is CC or not. CC will get worse before it gets better. The excess calcium is deposited under the skin and will have to work its way out before the condition clears. So what starts out not looking so bad does get worse - but that is how it is supposed to work as the condition is healed. ;) So the MOST important thing right now is to get a confirmed diagnosis one way or the other - time is not your friend with CC; it needs to be diagnosed and treatment started asap to prevent widespread problems. If I were you, I would look for a derm vet in your area if his current GP vet won't get the testing started asap.

[labblab]

Hey Larinda, your pictures did make it through to our email box. Later on, I’ll try to transfer them here. Bear in mind that I’ve never seen or dealt with CC personally. But at first glance, your pictures look more like a staph infection that my current nonCush Lab suffered from a couple of years ago. She’d have round areas of yellow crust/goop the size of a dime which pulled out along with a small clump of hair. It left a raised angry red welt behind. It got really bad with multiple lesions all over her back and flanks, but over time we were able to get rid of it with medicated baths.

Both hypothyroidism and Cushing’s can leave the skin vulnerable to infection. So if it’s infection rather than CC, either disease could be the root cause. But as I say, for sure I’m not a skin expert, and so I’m not able to say for certain that it’s not CC. Like Leslie says, a consult with a derm vet would be ideal. If Blue was mine, I might be willing to wait another week in order to see if you get any improvement from the baths. If Blue is no better, I believe I’d contact your vet to see about a derm consult or to move up the ACTH. As I said above, hypothyroidism does not elevate cortisol. So if Blue tests positive on the ACTH as well as the LDDS — combined with all his symptoms that are consistent with Cushing’s — I don’t see any value in waiting to start Cushing’s treatment regardless of the status of his thyroid. Again, this is just what I’d do with my own dog. But I’d sure hate to see Blue’s skin get any worse if Cushing’s is the cause.

Marianne

[Joan2517]

My Gable gets those a lot, too. The vet told us they are bacterial infections and that they are seasonal. He gets a round of antibiotics and they go away. Gable is hypothyroid and on medication for that.

[k9cushings]

OK, I was able to upload one of the photos you sent, Larinda, but not the other. Dunno what the difference was — I’m afraid I’m not very photo savvy myself :-(. But anyway, here’s one of the two pix. It’s in an album created by “k9cushings.”

http://www.k9cushings.com/forum/album.php?albumid=1223

Marianne

[Larinda]

thanks so much guys. so heres a new twist...blood in stool? he seems fine. regular and all. we've noticed it before but didn't think much of it. is that a symptom of cushings as well? I'm taking a sample to the vet for a check but I'm assuming its going to be fine. who knows. gosh.

[Squirt's Mom]

I had a pup who had colitis and she would have bloody stools but there was also mucous and diarrhea. This is not typically a cush sign tho.

[Larinda]

just checking in...its been 4 weeks since blue started his thyroid meds. no change really. he just mopes around. well actually i should clarify, he's claimed the rocker recliner, the only thing he can get up on anymore, so he's officially the old man of the house. its priceless how he leans back on it and looks out the window, and watches the world go by. his skin is no better even though he gets his weekly spa treatment of medicated shampoo and mousse. it may be a wee bit worse, we are noticing more areas effected than before. he is scheduled march 28th for the blood tests. so we are waiting it out but shouldn't we be seeing any improvement by now would you think? how long would it take for thyroid meds to kick in? all of his cushings symptoms are still as pronounced as ever. seems like he has all of them. (although he hasn't become incontenant in the house yet thank god) its just shocking to see him change so much from last month, last fall, last summer, last winter...its crazy how when you are with them daily, you make excuses and deny whats going on, but then you realize what he "used" to do and what he "cant or doesn't" do now. and its quite scary. reality hits you in the face. how will I know if hes "suffering" ? whats going on in that head of his? I mean, physically, I know if he can no longer get around, i'll see that, or physically sick, say organ failure and all, but otherwise...when he mopes in his chair, my heart just aches for him. whats he thinking? hows he really feeling? ugh...

[labblab]

I don’t see any value in waiting longer to perform the ACTH. Given his positive LDDS and all his consistent symptoms, it seems very likely to me that Blue has Cushing’s. If so, he will continue to degenerate without Cushing’s treatment. So why wait any longer to find out? Thyroid supplementation alone will do nothing to halt symptom progression caused by Cushing’s.

Given Blue’s young age, you may actually see significant improvement quite rapidly once appropriate treatment is initiated should he indeed have Cushing’s.

Marianne

[molly muffin]

Yep, I agree with Marianne. I'd do the ACTH and based on age, look at starting medication if that test is positive. If vetroyl/trilostane, start at 1mg/1lb to be on the safe side and go from there. I do think there is a good chance you could see some improvement sooner too.

Now the skin, if that is cc, then it takes quite a while to clear up and you want to get the cortisol down into a specific range. But skin/hair has a cycle growth, and all that nasty calcium deposit has to push up and out, without more building up. Then you get the skin and hair regrowth. It can take months, but if he is feeling better, then it is more bearable to deal with that than if he is feeling awful.

[Larinda]

the vet agreed to do the testing tomorrow. wish us luck. hopefully we will get some answers and help for blue.

[Squirt's Mom]

We will be with you! Give Blue a belly rub from me and tell him things might be getting much better soon!

[Larinda]

We got the blood test results vet said it's through the roof...baseline of 3 and test results at 28 post. Is this bad? It sounds bad. She is starting him on trilostane i have to order it. I have to get the directions yet but I think she said 120mg. I'll know more later today. And antibiotic for his skin issues. I pray this will work and he will get better. I don't know what to expect or how this will go. Thanks for any insight or advice.

[labblab]

I’m so glad you went ahead with the testing. A post-ACTH of 28 is indeed consistent with Cushing’s, but it is far from the highest result we’ve seen here. I think my own boy had a post of 35 before we started treatment. So try not to worry unduly about that level, and now we’re all gonna focus on getting him better! I’m guessing and hoping that you’ll see some fairly rapid improvement in some of his symptoms.

Here’s a big tip about ordering his medication, though. I see that Blue is a big boy, weighing about 100 pounds. So a starting dose of 120 mg. is only a little bit higher than the recommended formula of 1 mg. per pound and may turn out to be fine. However, our experience on the forum is that larger dogs often end up needing only a comparatively smaller dose of trilostane compared to their weight. So if you’re going to be ordering brandname Vetoryl, I’d encourage you to ask your vet to write the prescription for 60 mg. capsules rather than 120 mg. capsules. This will be more expensive to begin with, but you may save money in the long run. You can always change the capsule size once you know for certain what dose Blue ends up stabilizing on. But while you can always give him two of the smaller capsules (or make different combinations with even smaller capsules), you cannot split the 120 mg. capsule. So if 120 mg. is too much for him, all those capsules will go to waste. You might even want to start with only 60 mg. for the first few days in order to help his body adjust to lowering his cortisol more gradually. Dogs tend to have fewer side effects from the trilostane if they start on a lower dose and work upwards, rather than vice versa.

I strongly encourage you to make this dosing suggestion to your vet. Over the years, we’ve really seen this sort of plan work out better, both clinically and financially. And definitely continue to keep us updated, OK? I’m really hoping you’ll see Blue starting to normalize again before long!

Marianne

[molly muffin]

Did you start him on medication yet? How is it going if you did?

[Larinda]

hello! We ordered the meds and it came on Saturday. so I need to be aware of that I guess when it comes time to refill...allow for shipping? We gave him his first dose, 120mg of trilostane yesterday. we are planning on giving it to him in the evening with his dinner, and watch him closely. they said once a day. they also scheduled the next blood tests for april 4th. we are scared to death, but realize he really needs this so we are hoping for the best. his skin condition is getting worse, but doesn't look infected. he is on antibiotics, but hes flaking with scaly bumps on his back, hair falling out in small clumps. i'll keep you posted on our progress. thanks so much for thinking of us.

[labblab]

When dosing once daily, the manufacturers of Vetoryl and also specialized clinicians tell you to dose in the morning with breakfast rather than in the evening. There are a couple of important reasons. First, if your vet is planning to monitor via ACTH stimulation blood testing, the blood should be drawn no later than 4-6 hours after dosing. For most folks, this rules out getting the medication only once in the evening.

Secondly, trilostane remains optimally effective in the body only for about twelve hours. So if you’re dosing once in the evening, the medication is most effective when the dog is asleep, and is already wearing off by the time the dog awakens and is active the next day. As a result, you may be disappointed by a lack of symptom improvement during the waking hours. So unless it is difficult to dose Blue along with breakfast, that’s the better way to go.

Also, I’m now able to supply you and your vet with a link to a research study that highlights the warning I wrote about earlier — that larger dogs often need/tolerate smaller doses of trilostane, per pound, than the general, 1mg. per pound formula. So I continue to caution you to watch Blue very closely for signs of overdose since he is starting out with 120 mg. We’re you able to order 60 mg. capsules, or do you only have 120 mg. capsules on hand?

Here’s the link: http://www.k9cushings.com/forum/attachment.php?attachmentid=8272&d=1522092380

Marianne

[Larinda]

oh good to know. you are so right! gosh I didn't think that through. how do I switch him over? skip tonight and give it in the morning? thanks so much! and also, yes they only approved the 120 mg tabs for 30 days supply. should I just order a lower dose now? I will definitely talk to the vet about my next order for sure. but for now I only have the 120mg tabs.

[labblab]

Yes, that’s what I’d do — skip tonight and start fresh tomorrow. Also, I think we were typing at the same time, so be sure and look at the info I added to my last reply about larger dogs needing smaller doses.

[labblab]

oh good to know. you are so right! gosh I didn't think that through. how do I switch him over? skip tonight and give it in the morning? thanks so much! and also, yes they only approved the 120 mg tabs for 30 days supply. should I just order a lower dose now? I will definitely talk to the vet about my next order for sure. but for now I only have the 120mg tabs.
Since you’ll be seeing the vet on April 4th for monitoring, you can probably hold off on a decision about placing a different order until then. However, this is assuming you don’t see any adverse effects before then. If so, I’d stop the medication and immediately let your vet know. If the 120 mg. turns out to be too high, you can take a break if necessary and await a lower dose to arrive. But if it were me, no matter what, I’d request that the next order be placed in smaller capsules so you’ll have more flexibility to make changes down the line.

Also, here’s one more helpful link for you. It’s an excellent sheet of trilostane dosing guidelines put together by a couple of our staffers:

http://www.k9cushings.com/forum/attachment.php?attachmentid=8273&d=1522092871

[Larinda]

4 days in with 120mg vetoryl in the morning with his breakfast, and so far so good. I may see slight improvement, but certainly not any worse than he was prior to the meds. No adverse reactions thus far. Here's hoping to a great weekend with positive improvement daily! His blood test is Thursday April 5th. Praying this works!

[Larinda]

Blues acth came back 3.5 pre and 3.5 post. (At the bottom of the results the lab stated an extra lavender tube was submitted and would be held for 48 hours). So I'm hoping they did the tests right. Ever see it perfect like that? The same? Last month prior to vetroyl it was 3.0 pre and 28 post. Doctor said keep him on 120mg daily and unless anything changes with him they would test again in 6 months. He weighed in at 95lbs. Last month he was 106lbs. T4 is 1.7 . I asked the doctor about the dosage and how the guidelines from drug maker may have changed to lesser mg per lb recommendations but the doctor stated he was on correct dosage. I also told him I was new to cushings and I am trying to educate myself and I thought I had read where testing should be 30 days rather than 6 months? He felt if blue is doing well then keep doing what we are doing. If he loses weight or gets sick like vomiting diarrhea let them know. I admit I should be jumping for joy I suppose but I also feel this nervous speculation. I guess I'll take one day at a time and hope for the best. Blue is doing better with his symptoms somewhat. Certainly no worse. His skin is looking better and they gave him 3 more weeks of antibiotic and still prescribing thyroid pill as well.

[molly muffin]

Blue is on 120mg and went from 28 post cortisol to 3.5 pre and post? in 30 days on 120. And blue weighs 95lbs, so my concern here is that the dosage is too much, that is alot very quickly. 3.5 pre and post means that no additional cortisol was released from the adrenal gland after the ACTH injection.

So, here is what I would do if in your shoes. Based on a the way testing is now being done in Europe and which is actually considered to be a more accurate method of determining how a dog is reacting on the medication. They are testing cortisol levels, with a simple blood draw prior to the trilostane being given to see what the level is. It cost less and is accurate.

This was posted to another member

Just within the last couple of weeks, those of us in the U.S. have learned that many vets in the U.K. and Europe have shifted away from using ACTH stimulation tests to monitor trilostane treatment unless there is a worry that a dog’s cortisol may have dropped too low. Instead, they are simply measuring resting cortisol right before the next dose of trilostane is due to be given. New research supports the notion that this actually gives better guidance re: the need for dosing increases, and it’s certainly a heck of a lot cheaper. Take a look at this link and the monitoring flowchart that’s included. Your vet may be very interested in this info, as well, and might be willing to investigate it further on your behalf.

http://www.k9cushings.com/forum/show...=1252#post1252

So I'd print that out, take it to the vet and say just to ease my mind, can we please just check the cortisol before she gets her med one day in a week or two. :)

[labblab]

In reading back, I see that Blue started taking the Trilo on 3-25, so he dropped clear from 28 to 3.5 in only two weeks. That is a big, big drop in a short time, and it sounds as though your vet is unaware that cortisol typically continues to drop even further clear through the 30 day mark when treatment is initiated. I agree with Sharlene 100%. I would insist that testing of one sort or the other take place at that time — either a full ACTH or a pre-pill cortisol level. If Blue’s cortisol does remain stable and the dose is unchanged, then I would insist on retesting at the three month mark. Your vet is not following the testing protocol recommended by the drug manufacturer, researchers, and clinicians alike. I do not know why. But as Blue’s advocate, I think you need to insist on the proper monitoring yourself.

Marianne

[Larinda]

I had a random question...its 3 weeks today Blue is on Trilostane 120mg daily. He seems to be doing ok. he does look like he's lost some more weight but its hard to weigh him at home. he went from 106lbs march 15th to 95lbs - on april 6. i should probably try to get him weighed again somehow. He had a couple good days this weekend. his eyes looked good. (last weekend his eyes looked dilated or something- it seemed kind of weird). But...I do notice sometimes he breathes kind of different when he's sitting in his chair, and it seems like his heart is beating right out of his chest sometimes. my friend noticed it also this past weekend when he was sitting beside him. why is that? should I be worried or is it just some random thing. I thought I'd see if you've ever encountered anything like that. In the meantime, I did email my vet(she was out on vacation when blue had his last ACTH test april 6) to ask her to review the last ACTH test, as it seemed so "perfect" and I also asked about a 30 day testing rather than 6 months as her associate vet told us. perhaps she will enlighten me more when she returns from vacation. thanks for any insight.

[Harley PoMMom]

Like Marianne and Sharlene mentioned, there was a huge drop in Blue's cortisol in only 2 weeks so an Addison's crisis could be a possibility. When the cortisol drops too low and/or an imbalance in the electrolytes has occurred many symptoms will present themselves, one of them being a change in breathing and heart-rate so having his cortisol tested is what I recommend.

[Larinda]

We spoke with blue's vet today and we are doing another month of 120mg trilostane. (he started this medication a month ago) She then wants to go to 60mg and schedule acth test 10-14 days after the change in dosage. We'll see how he does. So far so good. His skin is looking much better too, and his antibiotics are almost finished. (6 weeks worth). Thanks to all of you who are helping me to better educate myself on this crazy cushings. I know what to be looking for. One day at a time I suppose.

[labblab]

If he is doing well on 120 mg., why would she want to cut the dose in half a month down the road? Has she scheduled another monitoring ACTH test now that a full month has passed? If not, I’m doubly baffled by her dosing plan. If she doesn’t know how the 120 mg. has effected his cortisol level at this point, how does she know it’s safe to continue for a full month as is? And if it is indeed a safe and therapeutic dose, why would she then want to arbitrarily cut the dose in half. I am totally baffled. Can you share her rationale with us?

Marianne

[Larinda]

she said....and here goes....
" In regards to the ACTH stim testing: equivocal results pre and post within the reference range are excellent. It means the adrenal glands cannot be stimulated excessively and are producing adequate levels of cortison.
If symptoms are well controlled that easily I usually back off testing for a while as well. Nevertheless I do agree that with the weight loss and the additional research coming out of UC Davis, it is a good idea to try a lower dose of Trilostane.

Let’s go with 60 mg after your next box is finished and monitor his response. If his symptoms return, we will increase his dosage to 90 mg. If he is stable, happy and healthy with no excessive drinking and urinating, normal appetite and energy levels, I still want a repeat ACTH stim test after about 10 days to be able to compare apples to apples.

There are different opinions out about doing resting cortisol levels only, as there can be unexpected fluctuation present on a daily and circadian basis, which in return may lead to us switching his Trilostane dose erratically. The most important factor for us is his quality of life and control of symptoms.
he is currently doing well, tolerating his medicine well and improving. My goal is to see if the lower dose will suffice to help him just as much. I don’t anticipate him having negative effects from staying on 120 mg for 4 more weeks and then switching. So go ahead and finish that box of 120 mg and follow up with 60 mg, thus setting his next ACTH stim test in 6 weeks."

so...I guess that's good news then?

[labblab]

Hi again, Larinda. Thanks for supplying us with your vet’s email. Unfortunately, I still have remaining concerns about your vet’s dosing/monitoring recommendations. Here are my worries.


she said....and here goes....
" In regards to the ACTH stim testing: equivocal results pre and post within the reference range are excellent. It means the adrenal glands cannot be stimulated excessively and are producing adequate levels of cortison.
If symptoms are well controlled that easily I usually back off testing for a while as well.
Your vet hasn’t offered any explanation as to why she thinks it’s OK to back off from testing other than the fact that Blue’s symptoms are well controlled. The problem is that we can expect that Blue’s cortisol level continued to drop even lower after that first two-week testing mark. Outwardly, he may still be looking OK, but inwardly, he may be verging on a cortisol level that may end up being unhealthy for him. Virtually all specialized clinicians recommend that cortisol testing be done at the 30-day mark after beginning treatment. Here’s what Dechra, the manufacturer of Vetoryl has to say: “Given that there is so much emphasis placed on using the control of the clinical signs to monitor Vetoryl, why bother with Cortisol testing? This sounds like a good idea but there is no way of detecting too little cortisol in an otherwise well dog until it becomes unwell – and hypocortisolism can be dangerous.”


Nevertheless I do agree that with the weight loss and the additional research coming out of UC Davis, it is a good idea to try a lower dose of Trilostane.

Let’s go with 60 mg after your next box is finished and monitor his response. If his symptoms return, we will increase his dosage to 90 mg. If he is stable, happy and healthy with no excessive drinking and urinating, normal appetite and energy levels, I still want a repeat ACTH stim test after about 10 days to be able to compare apples to apples.

Again, if Blue’s symptoms are well-controlled and his cortisol level does remain within the desired therapeutic range on the 120 mg., I don’t understand why your vet would arbitrarily cut the dose in half. Broken record here, I would want to know where his cortisol level has stabilized after a month on the 120 mg. before continuing for another full month on that dose, or before making any dosing change.


There are different opinions out about doing resting cortisol levels only, as there can be unexpected fluctuation present on a daily and circadian basis, which in return may lead to us switching his Trilostane dose erratically. The most important factor for us is his quality of life and control of symptoms.
he is currently doing well, tolerating his medicine well and improving. My goal is to see if the lower dose will suffice to help him just as much. I don’t anticipate him having negative effects from staying on 120 mg for 4 more weeks and then switching. So go ahead and finish that box of 120 mg and follow up with 60 mg, thus setting his next ACTH stim test in 6 weeks."

In regards to testing resting cortisol levels alone, your vet is correct that some research done several years ago on testing baseline cortisol several hours after giving trilostane yielded equivocal results. However, she may not be aware of very recent research that has revolutionized trilostane monitoring in the UK and Europe. It utilizes baseline cortisol testing right before the daily dose of trilostane is given (“Pre-Pill” testing). This is now the monitoring testing protocol that is formally recommended by Dechra in the U.K. and Europe. I would give your vet this link so that she can read about the newest monitoring advances. After doing so, I’m hoping she will rethink her decision to delay retesting Blue, whether via ACTH testing or pre-pill resting cortisol level.

https://www.dechra.co.uk/therapy-areas/companion-animal/endocrinology/canine-hyperadrenocorticism/vetoryl-monitoring-1?utm_source=directmailing&utm_medium=link&utm_campaign=PreVetorylCortisolSuperPage

As owners who know our dogs best, we are always responsible for watching them closely and reporting any observable changes to our vets. Unfortunately, though, your vet is placing an extra burden on you personally. By neglecting to test Blue’s cortisol before continuing with the 120 mg., the first warning that you would have of low cortisol is him actually becoming sick, and overdosing can be life-threatening. So you will need to make note of any changes at all that you see, and report them immediately. I have to trust that your vet will know how to respond appropriately by testing cortisol level and if called for, stopping the Vetoryl and giving supplemental steroids as needed.

Marianne

[Larinda]

ok good to know thank you so much. I'm a nervous wreck but I watch him closely. i'll keep you posted. thanks for all your advice.

[Squirt's Mom]

I just want to reinforce something Marianne posted -


...hypocortisolism can be dangerous

By "dangerous" that means up to and including death. High cortisol (hypercortisolism or Cushing's) is rarely life threatening. Low cortisol (hypocortisolism or Addison's) IS life threatening. If you see any of the following you cannot wait - you must stop the med and call the vet asap. If it is after hours, contact the closest ER.

loss of appetite
nausea / vomiting
loose stool / diarrhea
lethargy

If you see any of the above you must act quickly. So do keep a very close eye on him especially over the next few weeks since he is out in wild waters with his vet's approach to treatment.

Hugs,
Leslie

[molly muffin]

If you see the first sign, stop the meds and go get an ACTH okay? We are going to worry ourselves silly until we know everything is fine long term. :) I know, mother hens, its just what we do . hahaha

[Larinda]

quick check in...Blue had his test and the results are looking good.
cortisol pre acth 2 and cortisol post 3.7
that's good right?
thank goodness we are in a good place right now...with him....hope it continues!!! his weight has stayed at 90 lbs.
hes one expensive pup though! We are doing 60mg trilostane twice a day, as well as his thyroid pill twice a day.

[labblab]

Yes, those results are great as long as Blue is looking and behaving well :-). How long has he been taking the 60 mg. twice a day?

Marianne

[Larinda]

A couple of weeks

[labblab]

OK, thanks for the info. If Blue has only been taking this dose for two weeks, do be aware that his cortisol level may continue to drift downward during the first month on any given dose. So you’ll want to remain very watchful for any signs that his cortisol is dropping too low. But we join you in hoping this works out your be the perfect dose for him.

Marianne

[Larinda]

hello! hope you are well! I had a quick question. Blue has a dry cough...hack....not constant. started last night. and this morning, and still this afternoon. I initially thought he ate his food too fast. warm dry nose. laying around. but he does that all the time. we are on a wait and see basis, thinking it will get better or worse, right? then we can call the vet if it continues? has anyone had this happen or is it an unrelated issue? thanks for the advice.

[labblab]

Welcome back! Yes, if this continues, I’d contact your vet. I doubt that the cough is Cushing’s-related, but could instead be a symptom of a virus or illness such as canine flu or kennel cough. If so, no special treatment may be required. But I always like to be safe rather than sorry, especially with a weekend coming up.

How’s Blue been doing in terms of his Cushing’s symptoms?

Marianne

[Squirt's Mom]

If Canine Influenza is present in your area I would get Blue in for testing asap.

[Larinda]

He has been doing well. Even his hair grew back on his belly. His next test is next week. It's been 6 months. We did leave him for a few days as my son got married in tampa Nov 17. Had a babysitter come stay with him at our house so he wouldn't get so stressed out. He's been a little off since but maybe it's the adjustment of that? We even wonder if he's getting forgetful ? forgets we just fed him ha. Usually a cookie helps. And I can always tell in his eyes when something isn't right. they get glossy and blank stare. Now the cough. So maybe I'm worrying too much. At least I know his test is soon to ease my mind. I'll keep an eye on his cough. Thanks!

[Larinda]

just wanted to check in....we got blue's test results...doing good! total T4- 2.2 - the cortisol-pre ACTH was 1.3 and the Cortisol-Post ACTH 2.1 . his ALP was 642 six months ago and now it is 281. we were happy about that! the Anion GAP number was 29 which was high. should I be worried about that? anyhow...we are winning I suppose. his cough stopped also so maybe he had a bug. thanks for listening.

[labblab]

Thanks so much for updating us! In general, it sounds as though things are looking good. However, depending upon how far out of range the Anion Gap is, that could indeed be a problem. That’s a lab result with which I am largely unfamiliar, but after Googling it just now, I see that there can be a variety of causes for elevation including diabetes, pancreatitis, kidney problems, Addison’s disease, GI problems, etc. Some of these issues can be serious, so what has your vet told you about Blue’s result? Is the result very far out of range?

Marianne

[Larinda]

hello! blue's urinalysis came back and I think we are doing good.
the vet stated: Blue's urinalysis results are as expected showing a very dilute urine (caused by Cushing's disease), without protein or blood in the urine. One commonly finds bacteria in free catch urine and without evidence of an active sediment (white and red blood cells), this is considered not clinically significant.

[Harley PoMMom]

When urine is dilute a regular urinalysis may not pick up bacteria so an urine culture and sensitivity test is recommended.

Lori

[Larinda]

Blues eyes are dilated we went to vet his pupils aren't working she thinks sards we are referring to opthomologist. She did test for diabetes and high blood pressure all good there. Ugh.

[Harley PoMMom]

I am so sorry to hear this, please let us know what you find out...keeping you all in my thoughts and prayers.

Lori

[Larinda]

So eye doctor said his eyes are healthy so vet thinks it's neurological in his brain. A stim test showed normal cushing s controlled no overdose on vetryol. We are treating conservatively symptomatic so he's started on low dose steroid last night to maybe reduce swelling his brain. This morning he's peeing in my house. Ugh

[Joan2517]

Ugh...I'm so sorry.

[Larinda]

Blue has passed. We believe it was brain tumor that caused him to shut down. He became totally lethargic didn't engage seemed confused didn't seem to know us had strange distant cloudy look in his eyes didn't want to eat incontinent in house. vet agreed it was time. We are devastated. Thank you all for so much support and guidance. we couldn't have got through all this without you. You were such a great help to us in taking care of blue.

[labblab]

Dear Larinda, I’m so deeply sorry to read your news this morning. Having lost my own Cushpup to what we assume was an expanding macrotumor, my heart goes out to you doubly. We witnessed the same symptom progression, and it was tragic to witness our boy leaving us, step-by-step, right before our eyes. Blue is now released from any more confusion or suffering, but I know the hole in your own heart is enormous. We hope it’ll give you a bit of comfort to know that Blue is now listed on our memorial thread of honor:

https://www.k9cushings.com/forum/showthread.php?9161-Remembering-All-Who-Have-Left-Us-(2019)

If you will tell us the day he passed, we can add that to his line. We can also add a photo link at any time. You can send any photo of your choice to us at k9cushings@gmail.com.

In the meantime, please accept my deep sympathy on your loss. And please know that we’ll welcome you back at any time to tell us how you’re doing, or to share memories of your sweet boy.

Sending many hugs to you from across the miles,
Marianne

[Joan2517]

I'm so sorry, Larinda. Losing them is one of the hardest things that life throws our way. Many, many hugs to you and your family.
Joan

[Squirt's Mom]

Dear Larinda,

I am so sorry to hear about our sweet Blue. I know your heart is broken. My tears fall with yours in empathy and sympathy over this loss. You are a great mom and I have no doubt he left this life filled with the love you gave him over the years. He will carry that love with him always and one day you will meet again.

My deepest sympathy,
Leslie


A Bridge Called Love

It takes us back to brighter years,
to happier sunlit days
and to precious moments
that will be with us always.
And these fond recollections
are treasured in the heart
to bring us always close to those
from whom we had to part.

There is a bridge of memories
from earth to Heaven above...
It keeps our dear ones near us

It's the bridge that we call love.

Author Unknown

[spdd]

Just wanted you to know I have been following your thread. I am so very sorry to hear about Blue. Many hugs to you.