New cushings diagnosis

[Lovebird2005]

My sweet dog chuie was diagnosed with cushings this last Tuesday. He is 13. He was given Vetoryl 30 mg. I asked the vet if I should continue temarl p since it contains prednisone. He said give it as needed. He has been on it for 2 years 1 tablet a day. My concern is everything I read says to wean him off. What should i do now?

[lulusmom]

Welcome to you and your precious pup, Chuie.

I have manually approved your membership so there is no need to respond to the email you received from us asking you to validate.

Long term administration of Temaril P can cause symptoms of cushing's. This is called iatrogenic cushing's and conventional treatment is not necessary as symptoms will resolve by weaning a dog off of the drug. I am therefore concerned about the accuracy of a cushing's diagnosis given that Chuie has been on this drug for two years. I have an even greater concern that if Chuie has iatrogenic cushing's, giving him Vetoryl could be very, very risky. Can you tell us why Chuie is receiving Temaril P and what symptoms he has that lead your vet to suspect he had naturally occurring cushing's as opposed to iatrogenic cushing's caused by Temaril P? What tests were done to diagnose him and can you share the results of those tests? To answer your question, regardless if Chuie has iatrogenic cushing's or naturally occurring cushing's, he should be weaned off of Temaril P and placed on an alternative treatment if necessary. Your vet's comment about giving Temaril P as needed makes me wonder if he is aware that you have been giving him the drug every day. I apologize for so many questions but we can offer more meaningful and appropriate feedback if we have a much clearer picture of Chuie's medical history. Please share as much information as you can.

I'm sorry for the reasons that brought you here but I'm very glad you found us. We'll do our very best to help you in any way we can.

Glynda

[labblab]

Hello and welcome to you and Chuie! On the face of it, you’re entirely correct — it makes no sense to treat a dog for Cushing’s at the same time that Temaril-P is being given. Since Chuie has been taking the Temaril for two years, that may very well be the cause of any Cushing’s symptoms and the recommended treatment would be to gradually wean him off the medication in order to see.

Also, the testing for Cushing’s may be inaccurate if steroids were given on the days leading up to the test. A LDDS test should not be given unless a dog has been steroid-free for 2-4 weeks. A highly elevated result on an ACTH after 1-2 days without pred may genuinely point to naturally-occurring Cushing’s since there’s rather a low dose of prednisolone in the Temaril-P. But I’d want somebody really knowledgeable making that determination. Here’s a link to an article that discusses the testing issues in more detail:

https://endocrinevet.blogspot.com/2011/04/q-prednisone-and-cushings-syndrome.html

Either way, it makes no sense to me to treat with Vetoryl while still continuing an oral steroid since the effects of the two medications are totally contradictory — one lowers circulating steroids while the other increases them. I’m assuming Chuie is taking the Teraril due to allergies of some sort? Can you tell us more about the symptoms that resulted in both the Temaril treatment and also the Cushing’s testing? The actual numerical results for the testing will be very helpful. Also, how much does Chuie weigh? If Chuie were my own dog, I would not start giving him the Vetoryl until these questions are fully sorted out.

Once again, welcome, and I’m really glad you’ve found us.
Marianne

P.S. I see I was composing my note simultaneously with Glynda, so please forgive my overlapping info and questions!

[Lovebird2005]

They did an X-ray and it showed enlarged liver, they did blood test and it showed elevated liver enzymes, they did ultrasound and it showed no cancer, only some deposits in right kidney. His symptoms are extended belly, constant skin infections, hair loss , crackly breathing , extreme hunger.

[Lovebird2005]

His ultrasound also shows left adrenal moderate enlargement 1.03CM/ 2.11CM with hyperechoic parenchyma

[labblab]

Naturally-occurring Cushing’s cannot be diagnosed solely on the basis of abnormalities in liver enzymes and appearance. Long-term use of oral prednisone can cause liver changes in the same way as Cushing’s; I assume the same may be true of prednisolone. So specialized blood testing would be required to differentiate between naturally-occurring Cushing’s vs. Cushing’s symptoms caused by supplemental steroids.

I’m back to questioning the reason/s why Chuie has been taking the Temaril-P for so long. Again, it makes no sense to start Vetoryl while he is still taking Temaril. Why did Chuie start taking the Temaril-P? Has he always taken it daily?

Marianne

[labblab]

His ultrasound also shows left adrenal moderate enlargement 1.03CM/ 2.11CM with hyperechoic parenchyma

I just now saw this additional comment. Does the vet suspect that Chuie has a tumor in his left adrenal gland? If so, that does change the situation.

[Lovebird2005]

I just now saw this additional comment. Does the vet suspect that Chuie has a tumor in his left adrenal gland? If so, that does change the situation.

Yes he does

[Lovebird2005]

He has been taking temaril p for constant skin infections

[labblab]

Hmmm...if the vet thinks Chuie has an adrenal tumor that is producing elevated amounts of cortisol, then I can see no reason for the continued use of the Temaril-P. Elevated levels of steroids can lower the body’s immune system and leave a dog more vulnerable to infections of all kinds. I would think you’d want to treat the infections with antibiotics and not continued steroids. I would think you’d want to taper Chuie off the Temaril rather than continue giving it.

Not all adrenal tumors produce excessive amounts of cortisol, though. Before beginning Vetoryl, your vet ought to have performed a specialized blood test in order to measure Chuie’s cortisol production. Since Chuie has been taking the Temaril daily, I’m assuming an ACTH stimulation test was performed rather than a LDDS. The ACTH involves two blood draws taken one hour apart. Can you get a copy of these recent blood tests? That will help us a lot.

[Lovebird2005]

Can you send a private link to communicate with you ?

[Lovebird2005]

I sent you a private message. Thank you

[labblab]

I just checked and I’m afraid I’ve not received your message. Maybe try again?

[Lovebird2005]

I got the copy of the blood test. What info should I send you?
Or should take a picture ?

[labblab]

You can try taking a picture, and uploading it to a photo album that you create on your profile page:

http://www.k9cushings.com/forum/faq.php?faq=vb3_user_profile#faq_vb3_albums

Or within a reply here, you can just type out any results that are higher or lower than normal, along with the normal range that’s given on the lab sheet.

I still haven’t received a PM, but if you were wanting to share test results, it’s really better to do it one of these two ways. This way, all our members can join in with their feedback.

Marianne

[lulusmom]

Marianne, she sent the message to me. She said:


I will pick up the copy of the blood test today. I'm sure
It was one test though. I am going for a second opinion on
Monday. I started chuie on 1/2 pill per day since wedsnesday, and he
Started vitoryl Wednesday

I am very concerned that the vet has started Chuie on Vetoryl while still on Temaril P so I am happy to hear that Chuie will be seeing another vet for a second opinion. Hopefully the new vet is experienced with cushing's. I personally would feel much better if the second opinion was going to be solicited from an internal medicine specialist. Lovebird2005, can you please share the abdominal ultrasound interpretation as well as the results of the other labs?

[Lovebird2005]

I uploaded a photo in my album. Can you see it ?

[molly muffin]

Hello,

No I don't see a photo album available for viewing. Can you check your settings and make sure that you have checked option for photo album to be publicly viewed.

[labblab]

Hi again, I see you’ve created a couple of albums now, but unfortunately no photos are showing up in them.

If it’s only one blood test, though, maybe the easier thing is just to type the results into a reply here.

[Lovebird2005]

The album covers are the photos I guess

[Lovebird2005]

The settings are set for everyone to view

[molly muffin]

i see them set to view, what i don't see, is any photos uploaded to the albums.
You should be able to click on your album and that will open it.
At the top on the right side of the album, you will see this: Upload Photos, Add to Group, Edit Album, Edit Photos, Upload Photos, Add to Group, Edit Album, Edit Photos

click upload photos, this will open a separate tab called Manage Attachments. On the right you will see it will say add files. Click this, choose a photo from your computer and upload. You can also choose what photo you want to be the album cover.

[labblab]

The album covers are the photos I guess

No, your photos have not loaded into your albums at all yet. I tell you what, try emailing the photo to us at k9cushings@gmail.com. That way we staffers can take a look at it and see if we can figure out a posting solution.

[Lovebird2005]

ALK phosphatase 1344 (5-131 is normal )

GGT 27 (1-12 is normal)

[labblab]

OK, they just came through to our gmailbox. Let me take a look at them and see what I can do!

[labblab]

ALK phosphatase 1344 (5-131 is normal )

GGT 27 (1-12 is normal)

OK, in addition to these liver abnormalities, the only other abnormal lab readings are a mild elevation in the PrecisionPSL (a marker for pancreatitis if a dog also exhibits clinical symptoms of pancreatitis), and an elevation in platelets:

PrecisionPSL 198 (24-140 is normal)

Platelets 625 (170-400 is normal)

You’ve already given us the complete ultrasound readout on the left adrenal gland; the right adrenal was normal.

Your vet has written “Cushing’s Disease, Hyperadrenocorticism” across the lab report. And it’s true that these lab abnormalities are often found in dogs with Cushing’s. However, they don’t diagnose naturally occurring Cushing’s in and of themselves. I think there are still several missing puzzle pieces in play here, perhaps most importantly a specific test of Chuie’s actual cortisol production. Given Chuie’s history of Temaril-P and the apparent lack of specific Cushing’s testing, I think it’s very important to seek a second opinion, and if he starts behaving abnormally I would stop the Vetoryl immediately until you can see another vet about all this.

How much does he weigh? For a dog who truly has naturally occurring Cushing’s, the recommended starting dose of Vetoryl shouldn’t exceed 1 mg. per pound.

[Lovebird2005]

OK, in addition to these liver abnormalities, the only other abnormal lab readings are a mild elevation in the PrecisionPSL (a marker for pancreatitis if a dog also exhibits clinical symptoms of pancreatitis), and an elevation in platelets:

PrecisionPSL 198 (24-140 is normal)

Platelets 625 (170-400 is normal)

You’ve already given us the complete ultrasound readout on the left adrenal gland; the right adrenal was normal.

Your vet has written “Cushing’s Disease, Hyperadrenocorticism” across the lab report. And it’s true that these lab abnormalities are often found in dogs with Cushing’s. However, they don’t diagnose naturally occurring Cushing’s in and of themselves. I think there are still several missing puzzle pieces in play here, perhaps most importantly a specific test of Chuie’s actual cortisol production. Given Chuie’s history of Temaril-P and the apparent lack of specific Cushing’s testing, I think it’s very important to seek a second opinion, and if he starts behaving abnormally I would stop the Vetoryl immediately until you can see another vet about all this.

How much does he weigh? For a dog who truly has naturally occurring Cushing’s, the recommended starting dose of Vetoryl shouldn’t exceed 1 mg. per pound.


He weighs 13 1/2 lbs

[Lovebird2005]

Should I continue tapering off temeril p?

[labblab]

It is very, very unusual for me to advise people to *not* follow their vet’s recommendation. I am not a vet myself, so you need to take that into account. But if your vet has not done any recent testing other than what you’ve just shared, this is what I would do if Chuie was my own dog. I would stop the Vetoryl and return to your original Temaril dosing until you can see the new vet next week. I would want somebody with specialized Cushing’s experience to oversee the Temaril weaning and evaluate the appropriateness of Cushing’s treatment. If Chuie’s natural cortisol production has not been tested, I think it can be extremely dangerous to give such a large dose of Vetoryl to a 13-pound dog. Waiting a few days to restart treatment, if warranted, has less potential to harm Chuie than does continuing to give the Vetoryl if he isn’t actually overproducing cortisol.

I hope other folks here may also chime in with additional thoughts and opinions.

Marianne

[Lovebird2005]

I just emailed a dosing chart for Vetoryl to the k9 email.

[labblab]

Unfortunately, the information on that chart is outdated. Please read through this link:

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

One of the resources in the link includes the following statement published by Dechra (maker of Vetoryl) in 2014:


Dechra Veterinary Products has announced a change to the Summary of Product Characteristics (SPCs) for its Vetoryl (trilostane) Hard Capsules for Dogs.

The new lower recommended starting dose for Vetoryl – a treatment for dogs with Cushing’s syndrome – follows the publication of research and studies into the effects of reducing the initial dose rate.

Brand manager Craig Sankey explained: “Since Vetoryl capsules were first launched more than ten years ago, vets have accumulated a considerable amount of practical experience in using the product to transform the lives of dogs with Cushing’s syndrome.

“Several leading veterinary teaching establishments have carried out studies investigating the effects of reducing the initial dose rate and the published literature indicates that lower starting doses are efficacious and may reduce the risk of side effects.

The new, lower recommended starting dose is 2 mg/kg [1 mg/lb] once daily, and the 10 mg capsules can now be used as a starting dose. Further guidance is also given for switching to twice daily dosing.

“Our new dosing recommendations are in line with current thinking from veterinary specialists in endocrinology and internal medicine, ensuring that Vetoryl evolves with the times and continues to restore vitality to Cushingoid dogs.”

[Lovebird2005]

Unfortunately, the information on that chart is outdated. Please read through this link:

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

One of the resources in the link includes the following statement published by Dechra (maker of Vetoryl) in 2014:


Thank you so much for your guidance. I will definitely make the new vet
is aware of this update. Our appt is this Monday at 3 pm. I am so unbelievably thankful
to this support group. I will post as soon as I'm able to.

[emmagirl]

Thank you so much for your guidance. I will definitely make the new vet
is aware of this update. Our appt is this Monday at 3 pm. I am so unbelievably thankful
to this support group. I will post as soon as I'm able to.

Hi. I am a new member to this forum and the owner of a cushpup - her name is Emma. She was diagnosed in December of 2017 and I did a lot of research following her diagnosis, but I learned very valuable information from this board - it helped me make decisions for Emma I could not have made from research alone!

I am hoping and praying that you did get a second opinion today at 3pm, because after reading all of your posts I am very nervous for Chuie.

I am not a vet but I do know some cushings disease basics, and one of them is making certain that Chuie does indeed have hyperadrenocorticism, or an increase in cortisol levels, before he is treated with Vetoryl. It's a very strong medication and dogs should be given the lowest possible dose when first taking it. Emma is 20lbs and is taking one 10mg a day. You said your Chuie is 13lbs, and he is on 30mg? That and a few other things make me very concerned for Chuie.

Please share with us as soon as you can after Chuie's vet visit today. I hope you can get him on the right track! Much luck to you and to Chuie. Hope to hear that a new plan has been put into action for him.

Sharon - Emma's Mom

[Lovebird2005]

Hi. I am a new member to this forum and the owner of a cushpup - her name is Emma. She was diagnosed in December of 2017 and I did a lot of research following her diagnosis, but I learned very valuable information from this board - it helped me make decisions for Emma I could not have made from research alone!

I am hoping and praying that you did get a second opinion today at 3pm, because after reading all of your posts I am very nervous for Chuie.

I am not a vet but I do know some cushings disease basics, and one of them is making certain that Chuie does indeed have hyperadrenocorticism, or an increase in cortisol levels, before he is treated with Vetoryl. It's a very strong medication and dogs should be given the lowest possible dose when first taking it. Emma is 20lbs and is taking one 10mg a day. You said your Chuie is 13lbs, and he is on 30mg? That and a few other things make me very concerned for Chuie.

Please share with us as soon as you can after Chuie's vet visit today. I hope you can get him on the right track! Much luck to you and to Chuie. Hope to hear that a new plan has been put into action for him.

Sharon - Emma's Mom


Thank you so much for your kind words. We went to the vet and they are concerned and puzzled.
As of yesterday the recommendation is to discontinue vetoryl, and wean off temaril p. She gave an
injection of
Cytopoint to help with his skin allergies. Some fecal samples and urine samples were taken to rule out
Other possible suspicions. I can elaborate once those results come back. At the moment I feel we are in
Good hands and he seems to be comfortable. I will say that we should always go with our gut feeling when given a diagnosis. I thank God That I did! I will post as soon as I'm able. Today is chuie's birthday! My lovely boy turns 13!

[labblab]

I’m so relieved to read your post, because I think stopping the Vetoryl and weaning off the Temaril is exactly the right course of action right now! Definitely keep us updated, and Happy Happy Happy Birthday to your sweet baby boy!!!!

[emmagirl]

That sounds like the right thing to do for now. I'm glad you got someone different to look at Chuie and reassess his problems. I hope his skin allergies clear up soon; he will feel so much better, and I know you will too.

Feeling like your in good hands is a welcome relief. I started off with a vet that was not the right fit for Emma, and her actions puzzled me then worried me. I'm glad I found a vet that I feel comfortable with, and wants to do everything she can for her. I will check back for updates.

Happy birthday to Chuie!

Sharon

[lulusmom]

I too am relieved that you have found a vet who appears to understand how to address Chuie's issues. I think stopping the trilostane and weaning Chuie off of Temaril P is the way to do that.

HAPPY 13TH BIRTHDAY, CHUIE!

[Harley PoMMom]

Happy 13th Birthday, Chuie!!!

[Squirt's Mom]

Happy 13th Birthday, Chuie!!!

[molly muffin]

I'm late to the party, but Happy Birthday Chuie!!!

and congratulations on finding a vet who "gets it"