Daisy: 10-year-old Pit Bull/Boxer Mix with Cushing's; questions about Vetoryl dosage

[Daisybaby]

Hi everyone,

I'm newly registered to this site, but I've been following it for a few months now, as all of you dispense such wonderful, helpful advice!

I have a 10-year-old, 45-lb petite pit bull/Boxer mix named Daisy (aka, best friend ever--haha). I have two vets for her: a holistic practitioner and a "conventional" vet, where I take her for all of her testing. My conventional vet suspected Cushing's in late 2015, after a pre-dental blood test revealed a high ALP (500). Daisy was also showing increased thirst and fur loss. They later ran an ACTH stim test (her reading was 35), and I started her on flax lignans and melatonin. After months on that natural protocol, Daisy was only losing more fur, drinking more water, and even presenting with flaky, bumpy skin problems--so I took her to a specialist for further testing, including an ultrasound. Their recommendation was: "treat with next level of medication for pituitary dependent hyperadrenocorticism." At that point, even my holistic vet suggested I put her on Vetoryl, and so our journey with Cushing's meds began....

I think I've done a pretty good job of following the testing recommendations, and I've kept a running diary of Daisy's ACTH stim test results. Here are the latest:

*7/11/17: Pre: 1.5; post: 6
*10/10/17: Pre: 1.6; post: 4.5
*1/31/18: Pre: 1.4; post: 3.7
*5/16/18: Pre: .8; post: 2.7

So her post numbers have been steadily declining...and after researching various threads on this site, I found others expressing concern that these numbers might keep dropping into unsafe levels. After this last testing, my vet and I decided to temporarily discontinue the 30mg once-daily Vetoryl that Daisy's been on for a year now, wait about a week, and restart her on a lower dose. My question is: Would the seasoned members on this site suggest I restart her at 20 mg, then wait 10-14 and retest her?

I tend to panic...but I am trying to keep my head about me, as Daisy is seemingly OK, for the most part. Since starting Vetoryl, her fur and skin have completely rebounded, and she's drinking a bit less water. Just recently, though, this generally VERY ACTIVE, BOISTEROUS girl had a couple funny moments. She usually bounces up from a seated/down position, but she seemed to have a little trouble getting up recently, and even seemed to have a little back leg weakness walking up the stairs. Looking back at past threads, I've taken notice of others posting similar episodes and wondering if cortisol dropping too low has something to do with it.... Thoughts?

One more question, for now: Even though her cortisol levels are now on the low side, her ALP level has stayed high. On this latest testing, all readings came back good except for two: CK, which has trended very high for a while now (436) and ALP (1200). Why would ALP not be coming down?

I'd greatly appreciate any insights, and thanks in advance!

Daisy's Mom

[Harley PoMMom]

Hi and welcome to you and Daisy!

Even though her ACTH numbers are great I think it was definitely a good idea to stop the Vetoryl because of the cortisol continuing to drop. If this were me, I would restart the Vetoryl at 10 mg once a day instead of 20 mg with a retest in 2 weeks and see how it goes. You say that her drinking is a bit less, so I'm assuming this never returned to normal so my next recommendation would be if symptoms seem to rebound than I would give the 10 mg twice a day so that the cortisol can be controlled on a more even keel.

Is Daisy getting her Vetoryl with a meal and are those ACTH stimulation tests being performed 4-6 hours post pill?

Regarding the ALP, sometimes that level never returns to a normal range and if the other liver enzymes (ALT, GGT, AST) are within normal limits I wouldn't worry too much about that ALP.

Rear leg weakness may be a symptom of too low cortisol especially if the onset is suddenly, however the other more common signs of Hypocorticism that are seen are: vomiting, inappetence, diarrhea, increased drinking/urinating. Is Daisy showing any of those symptoms?

One quick question, what did the ultrasound show?

Lori

PS...Great job in keeping a diary of her ACTH test results!!!

[Daisybaby]

Hi Lori,

Thanks for the quick and thorough response.

Oh good, I'm glad to hear that I'm likely on the right track, and I appreciate your suggestions. Suddenly stopping the Vetoryl felt kind of funny...but I now know from other posts that you can stop and start again fairly easily with this med. You're right: Her drinking probably hasn't returned to normal, but it's hard to tell. I take her on long walks (you should see how nicely she jogs along, even uphill), and she comes back wanting water but isn't out of breath. She does drink a fair amount during the day, too, but it doesn't seem crazy excessive like before. I wish I could remember how much she used to drink before Cushing's started... Another thing I have noticed recently (besides her sudden trouble getting up sometimes) is her panting. She's definitely doing that more frequently.

Yes, Daisy gets her med every morning around 7am, right after a meal. I also feed her on testing days and won't even walk her into the vet's waiting room until 11am, just to be sure they don't test her early! As for symptoms of hypocorticism: She has occasional soft stool and has had bouts of diarrhea before (mostly when I was attempting to transition her to a raw diet, which the vet eventually said might just be too "rich" for her system). We're back to high-quality dry food and canned food, a bit of canned pumpkin, and ground turkey--that's a typical meal for her.

The ultrasound showed:
Liver: Mild diffuse, hyperechoic hepatomegaly
Gallbladder: Normal
Spleen: Normal size and echostructure
Adrenals: Bilateral enlargement, no masses
Pancreas: Normal
Peritoneal cavity: Normal omentum. No effusion, no lymphadenopathy
GI tract: Stomach filled with food material
Urinary Bladder: Normal wall and luminal echostructure
Retroperitoneal cavity: Normal
Kidneys: Mild, hyperechoic renomegaly with mild increased cortical echogenicity and increased corticomedullary ratio.

Differential diagnosis: Mild steroid hepatopathy, bilateral adrenal hypertrophy with no masses, supportive of pituitary dependent hyperadrenocorticism

That's a mouthful, huh?

Anyway, thanks for the advice so far!
Heather

[Daisybaby]

One more thing for now: I'm curious as to what other members' experiences are like with once-daily Vetoryl dosing vs. twice-daily dosing...

[Harley PoMMom]

The normal amount of water for a dog with out Cushing's drinks is approximately 1 ounce per pound of the dog's weight. Is she drinking a lot more than that?

Panting is a common symptom with Cushing's. In cushdogs, it is believed to be caused by a combination of muscle wasting, redistribution of fat to the thoracic area and a general sensitivity to heat.

Glad to see that the adrenal glands were visualized on the ultrasound, and yep, both of them being enlarged is indicative to PDH. The mild steroid hepatopathy is something else that is generally found with cushdogs, it means that they have a fatty liver due to Cushing's. Is she taking any kind of liver supplementation? If not, you may want to ask your vets about giving her milk thistle.


Yes, Daisy gets her med every morning around 7am, right after a meal. I also feed her on testing days and won't even walk her into the vet's waiting room until 11am, just to be sure they don't test her early! WOW, you are on top of things! GREAT job!!!!!!

Lori

[Daisybaby]

I don't believe she is currently drinking more than that--but I will measure it out for a couple days.

Wow, you are very good at interpreting those ultrasound results. Funny you mention milk thistle: I actually asked my holistic vet about that, but he didn't think it was necessary. I'll have to ask him again WHY because I also thought that would be a good supp for her. As for other supplements she's on: Crananidin cranberry tabs (she had a UTI last year), Dr. Mercola Complete Probiotics for Pets, and Dr. Mercola Digestive Enzymes. The vet also has her on a couple Chinese herbs, as he's experienced in that realm. I'm not sure if they truly help her, but they don't appear to harm her in any way.

Also, thank you--I'm definitely trying to stay on top of things because, as others have said, we're their only voice! While I don't always do a very good job of standing up for myself, I try my hardest when it comes to Daisy. :) This website has certainly helped me learn so much about Cushing's, too.

[molly muffin]

I just want to say hello and welcome. You are doing an awesome job and I wouldn't do anything different. I would add in a liver support supplement too, just because cushings is always hard on the liver. Another one to think about going forward might be a joint support supplement. You can get these in dog treat format, so that's a possibility.

You're dong such a great job with the cushings medicating. That can be a tough one, but you are very on top of it.

[Daisybaby]

Thanks so much, Sharlene! I appreciate your comments. It's very comforting to know I'm on the right track, and I'll definitely check into liver support and even joint support. You're right; navigating the meds is a toughie for sure. And although putting Daisy through so much testing is THE WORST, I know close monitoring is very important.

[Daisybaby]

Hi everyone,

I haven't posted in nearly a year, as Daisy has been doing pretty well. She's currently on 20 mg Vetoryl daily, and her latest ACTH came back with a post of 8.4. I'm hoping she'll test out a bit lower on the next one, but I am hesitant to go toward a higher mg (as you can see from previous messages in this thread) if she doesn't. Anyhow...Daisy still has rear leg weakness and appears very stiff at times. She jogs along very nicely on a walk, but is stiff before and after. Per some of your suggestions, she's been on a supp for joints (Cosequin DS plus MSM) and a liver support supp (Dr. Mercola Liver and Kidney support, containing milk thistle) for months now. My vet recently recommended I also try her on Rimadyl, but I'm very concerned about doing that, as I know Cushing's is so hard on the liver. At the same time, the Cosequin--even at a higher dose than suggested for her weight--doesn't seem to be making much of a difference.

I'd love to hear your thoughts on this!
Daisy's Mom

[labblab]

Welcome back to you and Daisy! I'm so glad to hear that, for the most part, she's remained stable. Given her age, I do believe that daily quality of life really takes a front seat, so if she were mine, I wouldn't be averse to being more aggressive with pain relief measures at this time. The risks associated with NSAIDS are especially heightened when cortisol levels are high and uncontrolled. Since Daisy has been managed well for this length of time on the Vetoryl, I'd probably be willing to try adding in an NSAID. However, I believe there are newer NSAID options that are generally considered to be somewhat safer than Rimadyl. For instance, my epileptic nonCushpup suffered from worsening orthopedic pain but was also at higher risk for liver damage to her phenobarb. We opted to treat her with Previcox which is a newer NSAID, and I believe there are additional, even newer, possibilities on the veterinary market now. So if you want to move forward, I'd ask your vet whether or not there might be a better option for chronic pain than Rimadyl.

Another pain relief option is Tramadol. It is not an NSAID, so it doesn't offer anti-inflammatory benefit. But it is a straight pain-killer with perhaps a "safer" profile in certain ways. So that might be an option to discuss further with your vet, as well, to see if there are advantages or disadvantages that might be in play for Daisy. As I understand it, Tramadol and an NSAID can even be given at the same time since they represent two different classes of medication.

Good luck to you both, and please do keep us updated, OK?
Marianne

[Daisybaby]

Thanks for the wonderful information, Marianne. I'm definitely going to follow up with my vet about new NSAIDs on the market and go from there.

Yes, she has remained stable, for the most part. She did have a scary episode in December, and I'm still unsure whether it's related to Cushing's. All of a sudden, she was exhibiting trouble eating and drinking--like she couldn't manipulate her tongue normally or open her mouth as wide. She wound up spending the weekend at the vet on IV fluids/Benedryl and she improved greatly, but they recommended following up with a neurologist. I made that appt., and my options were 1) Pop her on 2 antibiotics to see if they would knock out a possible infection; 2) Put her under for an MRI and muscle biopsy; or 3) Put her on Pred. I chose the 1st option--didn't seem to make a difference after 2 weeks--and I was unwilling to put her under anesthesia, and Pred didn't seem like an option because of the Cushing's. As of now, she's much better but does still have some restricted mouth opening. Perhaps any inflammation in that area could be mitigated by one of the NSAIDs you mentioned as an added benefit?

[labblab]

Has Daisy seemed to have a problem with a lack of appetite, or has the issue solely seemed to be mechanical?

Marianne

[Daisybaby]

Her appetite is GREAT. I've actually never seen more of a chow hound--from the moment I adopted her (at about 1-2 years of age) until now (she's about 11, could be older). It seems she has some inflammation in the jaw/upper neck area that maybe makes it difficult or painful for her to open her mouth very wide. She's seemed to adapt to it and eats and drinks without issue, but I wonder how bothersome it is to her otherwise.

[LauraA]

Hi Daisy. Galliprant is one of the newer NSAID meds and there have been many Cush pups using it with success, and it is kinder to the liver and kidney than the older types. Well worth discussing with your vet.

[Daisybaby]

Thanks for your thoughts, Laura. I DID ask my vet about Galliprant, and she said in her experience, it's not been as effective as Rimadyl...but it might be worth a try. I gave Daisy her first dose this morning. Starting very low at 20 mg/day (Daisy weighs about 43lbs) to hopefully avoid upsetting her stomach. We'll see how it goes!

[Daisybaby]

Hi everyone! First, I just want to express how much this forum has helped me over the last couple of years. I was lurking a while on the site before posting...and whether I'm reading other threads or seeking answers to my own questions, I'm always learning SO MUCH. You are all truly incredible, compassionate people.

Secondly, I wanted to provide an update after trying Daisy on Galliprant for over a month. Daisy weighs about 43 pounds. Initially, I started her at 20 mg/day, increased to 30 mg in a few days, then increased to 40 mg and kept her on that for about a month. Unfortunately, I didn't notice much improvement, so I stopped and will investigate something else. But I won't try Rimadyl--and my third reason for writing today is why!

I took Daisy for her latest ACTH test six days ago, and here are the results: pre was 1.3, post was 4.3. Great, right? My vet said let's keep her on the dose (20 mg/day, which she's been on for about 6 months after we had to take a break last year when cortisol was progressively dipping), but as of this morning, I stopped. When I took her in for the test, I reported that Daisy's been having some loose stools. It's not terribly uncommon for her, but they've definitely been looser recently, and I haven't altered her diet. She's also had terrible gas recently. I've read so many times on here that you shouldn't continue dosing Vetoryl if something seems off, so I'm thinking she might need another break.

ALSO, the vet ran a urinalysis and checked SDMA, and here are the results:
*Urine Creatinine: 32.3 mg/dl (no range provided)
*Urine Protein: 62.3 (no range provided)
*Urine Protein: Creatinine Ratio: 1.9
*Specific Gravity: 1.010 (no range provided)
*Urine Protein: 2+ (no range provided)
*IDEXX SDMA Result: 15 (range: 0-14 ug/dl); in May 2018, the result was 4
*Creatinine: 1.0 (range: 0.5-1.5 mg/dl)
*BUN: 28 (9-31 mg/dl)
*Phosphorus, Calcium, Sodium, Potassium, all squarely in range

As for other chemistry, ALP remains pretty high, and other values are out of range (not new):
*ALT: 134 (range: 18-121 u/l)
*ALP: 1649 (range: 5-160 u/l)
*GGT: 16 (range: 0-13 u/l)
*Lipase: 947 (range: 138-755 u/l)
*Creatine Kinase: 489 (range: 10-200 u/l)
*Lymphocytes: 0.683 (range: 1.06-4.95 k/ul)
*Eosinophils: 0.068 (range: 0.07-1.49 k/ul)
*Platelets: 489 (range: 143-448 k/ul)

My vet said I should bring in another urine sample in two weeks and we'll reassess the situation at that time. Could it be that Vetoryl is also causing these funky kidney values and damaging her overall organ function? What are your thoughts on my deciding to discontinue Vetoryl for now until I figure out her loose stool and now these kidney values (which seem like the priorities over Cushing's at this time)?

[labblab]

Hello, and welcome back! I’m sorry, though, about these new worries about Daisy’s kidneys. However, as far as your question re: the Vetoryl, if it was me, I’d probably not be stopping her Vetoryl right now. Those ACTH results were indeed great, and although there is an explicit warning against using Vetoryl in dogs who have compromised kidney function, I don’t think this is because the kidneys themselves are at great risk of being directly damaged. Rather, if the kidneys are not functioning properly, the drug will not be excreted properly and can build up to dangerous levels in the body in terms of general overdose. Since Daisy’s Creatinine and BUN are still within normal limits, it would seem as though her kidneys are still providing a proper job of excreting fluids and toxins, as well as the medication. However, I’m far from an expert about this, and you can certainly discuss it further with your vet who, in turn, can contact Dechra to see what they’d recommend in this situation.

I do think your vet is doing the right thing by retesting Daisy’s urine. It is not uncommon for Cushing’s itself to cause a particular type of kidney damage that results in protein being released from the kidneys into the urine. This is called “proteinuria” and that’s what that 2+ protein reading means. Before getting too excited about it, you want to see whether it was an isolated reading or whether it is a persistent issue. If so, then your vet may well add some additional medications for Daisy to take in order to better protect the kidneys from further damage as the result of that protein leakage. Vetoryl alone does not necessarily halt that progression in all Cushpups. I do see that her SDMA has leapt a lot higher in a year’s time, so I think it’s good that your vet is continuing to monitor her urine in order to see whether additional treatment decisions are in order.

As far as the GI issues, did your vet take a stool sample to check for parasites or infection? Also, I notice that her lipase is elevated. Has it consistently been this high? Lipase is a pancreatic marker, and we do see a fair number of Cushpups who are afflicted with pancreatitis. This can take the form of an acute episode or instead a chronic, “smoldering” type of issue. Given her new GI complaints in conjunction with the elevated lipase, one thing you might discuss with your vet is running a specialized blood test, the cPLI, that checks for pancreatitis.

OK, that’s all I can think of for now. But it’s good to have you back, even though I’m sorry about your new worries.

Marianne

[Daisybaby]

Hi Marianne,

Thanks for the thoughtful response. You made some good points about the Vetoryl and my continuing it for now. I’ll definitely follow up with my vet, as you suggested.

Yes! I neglected to mention that I did bring a stool sample to last week’s testing, and it was negative for hookworm, whipworm, and roundworm. The report also states: No ova or parasites seen. Cyniclomyces guttulatus, also known as Saccharomycopsis guttulatus (non-pathogenic yeast), present. I researched that a bit and what I’ve found on it seems fairly benign, but I wonder if it could explain her loose stool (which is even looser this a.m.). Also, I’ve had her on a bland diet of boiled chicken/white rice, supported by my vet, since Friday and her stool quality hasn’t improved. She’s already a very skinny little girl, since weight has redistributed to her belly, so I don’t want to continue that for long. Maybe it’s not even necessary?

As for lipase: It was 659 (138-755 u/l) in May 2018, but a whopping 2,983 on 1/12/19!!! Daisy was at the vet’s 1/12-14, as on 1/11, she had an episode where she wasn’t able to open her mouth wide enough or manipulate her tongue in the right way to eat/drink. She spent the weekend at the vet’s on fluids and I had followed up with a neurologist who put her on 2 antibiotics to wipe out a possible infection…but I still don’t know what caused that. Even now, she can’t open her mouth very wide but can eat/drink without issue. Perhaps her muscles have atrophied? I think your suggestion to have her tested for pancreatitis is warranted. I’ll talk to my vet.

My follow-up questions for you all right now are: Do you think I should also talk to my vet about adding Tylan powder (which I’ve read pretty good things about on this forum) or Flagyl to try to firm up her stool? Also, when I collect the urine sample for the next urinalysis with UPC/pancreatitis blood test, should I fast her that morning? I hate to fast her, since I always give Vetoryl in the a.m. with a good meal.

[labblab]

Oh, I’d forgotten about that scary episode over the winter! That was weird, for sure :-(.

I definitely think it’s worth asking your vet about the Tylan and/or Flagyl. I don’t have any personal experience with Tylan, but as you’ve probably already seen, we’ve had some folks here who have reported good results. As for the Flagyl, I’ve used it a bunch over the years with my dogs. I’ve always had Labs, and they’ve periodically had loose stools for reasons unknown to me (probably often related to eating something nasty in the yard, but not always). Flagyl has often been helpful for us in those situations.

Lots of people swear by giving a spoonful or so of canned pure pumpkin to help firm up stools. That has never seemed to help around my house, but it might be worth a try? If you do try that, make sure it’s the pure pumpkin and not pumpkin pie filling, and you can check the internet for specific amounts to give depending on the size of the dog.

As for the blood test, you’ll want to get specific instructions from your vet as to whether fasting is necessary. I don’t know what the requirements are for that test, but he’ll have the lab’s instructions. It might require fasting since the pancreas is involved in the digestive process. If so, though, maybe you could give her early breakfast and then wait 6-8 hours or so before having the blood drawn. That might satisfy the fasting requirement, but your vet should know for sure.

Good luck with everything!

[Daisybaby]

Great, I'll ask my vet about Tylan and Flagyl. I've also had luck with Flagyl over the years but have never tried the Tylan powder. And, canned pure pumpkin is actually a part of her normal diet, and I just now mixed it in with her bland diet lunch. I'm not sure it really helps her, though (and I see you can relate). Anyway... I'll keep you posted on what happens in the next few days! Thanks so much for the advice.

[Daisybaby]

Just wanted to post a quick update! Daisy is currently on Flagyl (day 6) and her stool is back to normal. :-)

[Harley PoMMom]

That's great!!

[labblab]

Great news, for sure! Thanks so much for letting us know.

Marianne