New diagnosis of Cushings

[Nlcope]

We have a 13 1/2 year old male, neutered dachshund. Cooper. Has had very few health issues in his life. Went for annual in April. Some lab results raised question of Cushings. No clinical signs. Did high dose suppression. Not indicative of Cushings. Did urine cortisol test. Not indicative of Cushings except for somewhat dilute urine. Did low dose suppression test. Cortisol 30, so diagnosed with Cushings last week. By then, Cooper was urinating in the house and had a tremendous appetite. Started Vetoryl 4 days ago. 30 mg. for a 23 pound dog. Cooper is not tolerating it. Projectile vomiting, mild lethargy. Waiting for weekend to be over to get back to Vet. Feeling unsure of whether treatment is worse than the disease. Please advise.

[Harley PoMMom]

Hi and welcome to you and Cooper!

Veterinary specialist that are versed in Cushing's agree that if the urine cortisol/creatinine ratio test is within normal limits than Cushing's is ruled out. I see that you mentioned that a low dose suppression test (LDDS) was also performed, could you get those results and post them here, there will be 3 numbers associated with the LDDS so I'm not exactly sure what test that Cortisol 30 is from unless it was an ACTH stimulation test. Also could you post the abnormal values from his Chemistry/CBC blood panel and please include the reference ranges...thanks!

Have you stopped the Vetoryl? If not, please do so as it is stated in Dechra's (makers of Vetroyl) product insert that an unwell dog should not be given Vetoryl.

As for treatment of Cushing's, we have many members who are treating their dog for Cushing's using either Vetoryl or Lysodren and are experiencing success, so hang in there and we will try to get things figured out.

Lori

[Nlcope]

Im so excited for your input! I have taken snapshots of the tests you would like to see. Is there a way to upload them?

[Squirt's Mom]

PLEASE tell us you stopped the Vetory yesterday!!!! What you are describing is an overdose where the cortisol drops too low. This is a life-threatening situation and the vet should have told you what to do if you saw those signs - vomiting, lethargy as well as loss of appetite and loose stools/diarrhea. By failing to do so this vet put your baby's life at risk. ANY time you see any of these things you should stop giving the medication and call the vet asap. Your baby should have an ACTH immediately and have the electrolytes checked at the same time to see if any medications like prednisone are needed to help him get thru the crisis.

You can find some excellent information on the drug your baby is using (Vetoryl/Trilostane) here: http://www.k9cushings.com/forum/showthread.php?185-Trilostane-Vetoryl-Information-and-Resources

Also there are some new dosing and monitoring protocols just coming out in EU and slowly making their way to the US. Share this info with his vet - it can save you money and bring less stress for your Cooper. Here is that info: http://www.k9cushings.com/forum/showthread.php?8925-GENERAL-GUIDELINES-for-Dosing-and-Monitoring-Treatment-with-Vetoryl-(trilostane)

Oh! and welcome to you and Cooper! I am very worried about your baby boy based on what you said yesterday so I hope to hear soon that he is much better today.

Hugs,
Leslie

[Nlcope]

We did discontinue the Vetyrol, but our vet wanted us to start back today. So far, so good. We’re trying to digest what was a contradictory succession of diagnostic results so that we aren’t treating him for Cushings if he doesn’t have it. At his annual in April, among the many things tested for in the blood work, Cooper had elevated liver enzymes, elevated cholesterol, and had gained two pounds (results below). That put up the flag to our Vet that Cushings might be a possibility, although at that time, there were zero clinical signs. We did a LDDST (results below). We were told it was inconclusive for Cushings. Next was a urine cortisol/creatinine ratio result that included a note that Cushings was highly unlikely. Next was an ACTH test (results below). That test signaled our Vet to begin treatment. During the course of testing, Cooper did develop a ravenous appetite and began having urinary accidents in the house, further convincing him it was Cushings.

ALT-486
AST-77
ALP-3,074

Cholesterol-394

LDDST:
baseline-3.2
4 hour post-1.8
8 hour post-1.3

Urine cortisol/creatinine ratio-133

ACTH-30

[Harley PoMMom]

Could you do me a favor and recheck the results for that urine cortisol/creatinine ratio (UC:CR) test as the reference range is usually <13 so I'm thinking that the 133 may be the measurement of the creatinine and not the ratio result.

I'm a bit worried that Cooper has restarted the Vetoryl without knowing what his cortisol and electrolytes levels are at. As Leslie mentioned if Cooper has indeed developed Addison's than he needs medicine to supplement for this. How is his appetite? Has he had anymore vomiting episodes? Any diarrhea?

[labblab]

Hello and welcome from me, too! I’m also feeling worried that your vet has restarted Cooper on the 30 mg. dose of Vetoryl after the ill effects you witnessed over the weekend. Even if we assume that the Cushing’s diagnosis is accurate, the 30 mg. dose is larger than would now generally be recommended for a dog of Cooper’s weight. When Vetoryl was first introduced, dosing protocols were higher. But experience over time has led most clinicians — as well as the maker of Vetoryl — to recommend starting with a dose that doesn’t exceed 1 mg. per pound.

I am going to give you a link to a reply on our Resources forum that discusses this dosing formula. You may even want to print it out and show it to your vet. However, the bottom line is that experience has shown that dogs tend to experience less worrisome side effects if they are started on lower doses and then later increased, if need be, rather than vice versa. Here’s the link:

http://www.k9cushings.com/forum/showthread.php?p=1251#post1251

If it does turn out to be safe to resume dosing, I would encourage you to talk with your vet about shifting to a lower dose. Vetoryl is sold in 10 mg. capsules, for instance, so you could cut back to either 10 or 20 mg. as a starting dose. For a dog of Cooper’s age, you are indeed wanting to balance the benefits of treatment vs. unwanted side effects. So starting “low and slow” can be both a safer and gentler route to go when beginning this medication.

Marianne

[Nlcope]

I rechecked the urine test.
Cortisol-30.8 (14.2 last year)
Creatinine-72.2 (201.7 last year)
Ratio-a133

Reference norm=< or >34


I do see the new recommendations for Vetyrol dosage that you sent me. Thank you for that. But all of the literature is very confusing. Some sites say 1mg/kg. Others say 1 mg/lb. Those are diversely different dosages. Cooper weighs 23 lbs.
In kilograms, that would be approximately 10 mg. of Vetyrol. In pounds, it’s closer to 20. Can you clear that up for me? I can’t imagine that a company would wait so long to correct their packaging insert for such a crucial piece of information.

[Squirt's Mom]

How are his kidneys? That creatinine is frightening even tho you haven't provided any normal ranges for reference. Has an SDMA been run on him? This is a fairly new test that will show kidney damage LONG before the old tests could. It used to be that we had no idea anything was wrong with the kidneys until something like 75% of function was already lost. The SDMA let us know very early there is a problem. ;)

As for the dosing info...this has been typical of this drug since it's release. The manufacturer has made several changes, this is just the most recent. This is not uncommon with drugs that are new on the market and this drug was only released in the US about a decade ago and had been in use in EU for a couple of years prior to that. A 10 yr old drug that is not heavily used can go thru many changes as it is used more and more. Such is the case with Vetoryl (Trilostane).

The current starting dose is 1mg/lb or 2mg/kg. Be VERY careful where you are getting your info as much you will find on the web, in forums, groups, lists, magazines, etc is incorrect. Stick to trusted info such as can be found here on our site. If you haven't check out the Helpful Resource section and start your education there. If you find or hear anything elsewhere that is contradictory to what you have learned here ask us about it! We may all learn something new! :)

[Nlcope]

That’s disturbing. The reference range is less than or greater than 34. Is 133 even possible? He still asks to go out to urinate most of the time. Other times, he just stands and pees on his feet like he doesn’t even know he does it. No squatting or lifting a leg.

His blood creatinine is 0.8.

A big question here is whether he should not be taking Vetyrol if his kidneys are already compromised. What do you suggest I do next? Ask for a SDMA? We see our vet on July 5th for a cortisol check. Is the Vetyrol safe till then?

I have looked for reference ranges on the urine cortisol/creatinine ratio. Can’t find one. What are the norms?

Thank you for all of the time you are giving me!

[labblab]

I agree that 133 seems high for the UC:CR ratio, but I honestly don’t know exactly how the mathematical calculation takes place. I see you’ve typed in the letter “a” before the 133 — does that “a” correspond with some other notation on the labsheet, or is that maybe just a typo?

I do think I can ease your mind about the urine creatinine value, though, especially in light of what looks to be a normal blood creatinine value. In a UC:CR, the creatinine level is valuable solely as an indicator of how concentrated the urine sample is. The concentration of the urine affects the interpretation of the cortisol level, so the creatinine level acts as a kind of “control” or calculation aid. On its own, the creatinine level in that one small urine sample is not diagnostically meaningful in terms of kidney function. If kidney problems are suspected, a 24-hour total urine collection can be analyzed in terms of creatinine levels. And as noted above, blood creatinine levels are diagnostically significant. But in Cooper’s case, the blood creatinine appears to be normal and thus we have no reason to believe he’s suffering from kidney dysfunction.

As far as the dosing issues, I totally agree that it’s very frustrating to have such a variation in the printed materials. But once approved by the FDA in the first place, it is a lengthy process to have revisions submitted and formally OK’d. That’s why human doctors and vets alike sometimes give “off-label” instructions to their patients when clinical experience leads them to believe that alternative protocols may be safer or more effective.

As far as continuing to give Cooper the Vetoryl, at this point — if he were mine — it would depend on whether or not he develops any ill effects once again. If so, I would stop it immediately and only restart in the future on a dose that’s no greater than 20 mg., and perhaps even smaller.

Marianne

[Nlcope]

Yes, the “a” was a notation symbol, referring to a note saying the result was indicative of Cushings and we should proceed with ACTH, which we did.

Do you know what number would be a norm or even a high norm on the UCCR?

Cooper has, in three weeks, gone from a dog who would never pee in the house to just peeing copious amounts with no warning. He doesn’t squat or lift his leg. He just looks at you and pees rivers all over his own feet. Is that extreme normal? It’s as though he has no control at all. This morning, in two and a half hours, he has peed nine times. Is he losing electrolytes?
So worried about the little guy. He seems bright enough most of the day, others listless.

[labblab]

The only normal reference range for Cooper’s UC:CR is that “magic” number of 34: a normal ratio is below 34 and an abnormal ratio is above 34. Since Cooper’s ratio was 133, it was significantly elevated and provided the rationale to move on to the more Cushing’s-specific ACTH testing. I honestly don’t know whether 133 is actually unusually high for a dog with Cushing’s. But it was certainly high enough to warrant additional testing. As far as the individual numbers for the urinary cortisol and the creatinine, there really are no meaningful norms because the two readings must be evaluated in tandem, in the form of that ratio. So the ratio is the only number you really care about in this situation.

I’m so sorry to hear that Cooper is doing so poorly right now. It’s kind of unusual for such excessive urination to come on overnight — usually Cushing’s results in worsening symptoms over time. I do wonder whether Cooper may be suffering from a urinary tract infection. Cushpups are especially vulnerable to UTIs, and they can cause sudden increases in thirst and urination. I’d let your vet know about this sudden change, especially considering that Cooper has started back on the Vetoryl and that ought to be helping symptoms rather than worsening them. Your vet may want to check a urine sample for infection, and yes, also check Cooper’s electrolytes to make sure they’ve not gone out-of-whack. Poor little boy, and poor you :-(((((.

Marianne

[Harley PoMMom]

You may want to check for diabetes as this can come on suddenly.

[labblab]

You may want to check for diabetes as this can come on suddenly.

Oh, that is an excellent point! Just a simple test of blood glucose level can check that. It would be part of the same blood chemistry panel as the electrolytes.

[Nlcope]

Such good information, Marianne. We actually wondered about a UTI a couple of weeks ago because he started looking like he had the urge but couldn’t pee. Our vet kind of glossed over it. We go back on July 2 for our first cortisol check since beginning the Vetyrol. We will address these things. The vet today thought it sounded like we were okay till then. We watch Cooper like a hawk, so we’ll be alert to any potential problem.

I can’t tell you how helpful and comforting it is to talk to someone so knowledgeable and compassionate. Cooper means the world to us. Thank you!!!