New to the Forum but Lurking for a While

[Bearscreek]

Hi, I have been lurking occasionally for a couple of years, but this is my first post. I’m sure what I have to say or ask is not new, but I have seemed to have trouble with the search function on this iPad in the past. I decided to post in order to see if anyone has experienced a similar situation to mine. I’ll try to be brief (but may not be successful).

My dog Katie was diagnosed with Cushing’s over 2 years ago. She had a sebaceous cyst at the base of her tail and had been given some Dermalone for that. The vet wasn’t thinking about that and tested her for Cushing’s because of an elevated alk phos, basically at my partial suggestion, and then she had to be tested again in a few days because of the possible influence of the Dermalone. I don’t remember the numbers, but I know the test results weren’t that high. I really don’t remember the vet saying anything about her being borderline, but apparently she was (maybe about a 21 or 22). The vet recently said we had discussed her being borderline, but I know I wasn’t given a choice to hold off on treatment, because I know I would have. I’m hoping she saw in the records that the first test may have been tainted by the Dermalone. I didn’t really think about that when she called recently. When Katie had the test about 2 months ago, my vet was out sick, and I kept wondering why none of the others had called me with the results, especially after I had been very patient, but had called there twice to try to find out something. I’m now wondering if they really just didn’t want to get involved with a dog who was misdiagnosed.

She ended up on 60 mg of trilostane and did great for 2 years. She is now 12 and behaves much younger than 12, I’d say. This past early April, she was suddenly not feeeling well, vomiting and not eating. The vet did abdominal x-rays and fluids, etc., and when I reminded her that my dog was a tad overdue for her ACTH stim, she decided to do that. The numbers were very low, like maybe 1 or 2. My dog stayed off meds for 2 weeks and got retested and was closer to normal. Again, sorry I can’t remember the exact number. We waited another 2 months and tested again, and she has now tested at about a 10 or 11 and is appearing to not have ever had Cushing’s in the first place.

On the one hand, I’m ecstatic if she doesn’t have Cushing’s but on the other hand I’m not happy about the testing and medicine (and expense that comes along with it) that were apparently unnecessary. I’m wondering how common this is and is there anything I should look out for. Is it likely that she will continue to not have Cushing’s? Could the lab values be playing dirty tricks on me, lol? Any insight would be greatly appreciated.

[labblab]

Hello, and welcome to you and your girl! I’m really glad to hear that she’s doing well right now, but it does sound as though there are some question marks surrounding her diagnosis and treatment. Just because she has needed a break from the trilostane in order to allow her cortisol to rebound doesn’t necessarily mean she didn’t/doesn’t have Cushing’s. Dogs who are overdosed on the medication can experience adrenal oversuppression that requires varying times from which to rebound. Some need to quickly resume dosing — a few never return to taking the medication.

However, there are other questions surrounding Katie’s diagnosis. Aside from the elevated ALKP, did she originally exhibit any other lab abnormalities or any observable symptoms of Cushing’s? Several conditions can lead to elevated ALKP, and most clinicians warn against assuming that Cushing’s is the culprit unless the lab abnormality is accompanied by bona fide observable symptoms. Both of the diagnostic tests for Cushing’s, the ACTH and the LDDS, can return “false positives” if a dog is severely stressed or suffers from a different, nonadrenal disease. That’s why symptom assessment is such an important part of the diagnostic process.

For younger dogs who truly suffer from Cushing’s, you do want to halt progressive long-term damage that the disease can cause. But for older dogs, the main goal is really to provide symptom relief and improve quality of life. So in the absence of observable symptoms or evidence of certain specific internal problems, treatment may not even be recommended.

Can you tell us how much Katie weighs? Did she always take 60 mg., or did that dose change over time? How many monitoring ACTH tests did she having during that two-year time period, and were the results within the desired therapeutic range? I am very, very concerned that your vet didn’t immediately order an ACTH when your dog became ill. Her symptoms were classic for trilostane overdose, and it’s a bit shocking that you had to be the one to request the testing. That doesn’t inspire a lot of confidence in your vet’s experience with using the medication!

If you can, please do get the exact numbers for any monitoring testing. Also, again, we need to know whether there were originally symptoms or abnormal tests aside from the ALKP. But I think the bottom line is that only time will tell as to whether or not there will be reason to restart the trilostane. Given her age, if your girl remains symptom-free, then I think you’re done with treatment regardless of whether or not Cushing’s was the correct diagnosis. However, if her cortisol continues to rise along with the start of traditional symptoms (excessive thirst/urination/hunger, pot belly, hair loss, hindend muscle wasting, panting, heat intolerance, etc.), then resuming the trilostane may be the correct thing to do, although at a lower dose than before. We’ll just have to see.

Marianne

[Bearscreek]

Thank you for the welcome and the comments. Yes, I thought about it later last night and knew I should have said what Katie's weight and breed are. Katie weighed about 29-1/2 pounds early last year and weighs about 26-1/2 pounds now. It surprised me when I saw the weight loss, but she has actually been overweight for several years now and needed to lose weight. It worried me a bit, but I suspect it's simply due to the fact that her other parent was out of state more often than not last year due to a sick parent, meaning that the constant snacks didn't happen, lol.

Katie had been on 60 mg for a long time, probably well over a year and had tested with normal range steadily for a long time. She was tested at least every 6 months, I think, with the exception of this last one, which was closer to 7+ months, and she looked fine. I know some would say she should have been tested more often, but she really never seemed sick and her levels were always fine, so I stretched the time interval out a bit. I know things can always go downhill fast with a 12-year-old, but she eats, drinks, plays and seems to feel great for her age. I honestly haven't ever been 100% convinced that her symptoms were that strong for Cushing's. She does have a voracious appetite, but that has been going on for a long time. She pants quite a bit, but it's hot in Southern Tennessee, and I am cold natured and keep the thermostat higher than most, I'd say. I don't have all her blood test values from the past.

This vet who has been treating Katie is in a clinic that is affiliated with the vet I had been seeing for years, but when Katie had the cyst and then was diagnosed with Cushing's, I just stayed with this one because they are only 1-1/2 miles from home (versus 10+ for the other one), and it's so much easier for the stim tests, taking her there and picking her up later, etc. I'm definitely going to go back to the other vet I had followed to the other clinic many years ago, though. I'm not really a happy camper right now.

Katie had had an elevated alk phos on a senior blood panel a few years ago, so when I had them do the blood work at the time she had the cyst and mentioned that she had had an elevated alk phos and it showed as elevated again, I guess the vet just assumed things. I'm also very concerned that my vet didn't immediately want a stim test when Katie became so ill out of nowhere. That's a good reason to return to the 10+ mile drive for the other vet, not that anybody is perfect, and not that humans don't all make mistakes, but gosh. I also really wasn't happy that this vet had done a stim test in the beginning without realizing she had just given Katie the Dermalone and that it could possibly affect the results, but at least she didn't charge me for the second one. I have to say, though, that she didn't know Katie's past history, not that there was much, and had never seen Katie until this started. Like I think I said before, when she said that Katie's test was borderline at first, I'm not sure if she was looking at the "Dermalone" test or the second one.

I really don't remember any abnormal lab values at any time besides the elevated alk phos. Once many years ago, Katie had a UTI and an x-ray had shown a small, irregularly shaped liver. Those are the only abnormalities I can think of right now. I guess maybe the vet's suggestion of testing in about a year might be a bit too long an interval, but if she doesn't develop symptoms, maybe it would be okay. Of course, she's been totally off the trilostane for 3 months now and seems fine. Again, I don't know for sure that I can blame her panting on Cushing's.

Thanks again for the warm welcome.

Edited to add that Katie is a Mini Schnauzer/Yorkie mix, as far as I know, basically a rescue. I know her weight is high for those breeds, lol.

[Bearscreek]

If you can, please do get the exact numbers for any monitoring testing.

Marianne

This is just a quick update and brief lab summary, in case anyone has this problem in the future. I finally called the vet and got Katie's ACTH test results. Basically, she had started out at about 5.0 mcg/dL pre and 9.0 mcg/dL post ACTH stim (while on trilostane) in the summer of 2016 and had then had 3.2 and 4.4 in late summer (possibly when her dosage was changed from 45 mg to 60 mg), 1.2 and 2.4 in January of 2017, but the one that really caught my eye was that she had 1.1 and 1.5 in the summer of 2017, with normals for pre and post (with trilostane treatment) on the sheet from the lab showing as 1.5-9.1 indicating optimal control. That looks like she was starting to be too low, for sure, at that point. By spring of this year, she had plummeted to 1.0 and 0.6, which is when she was so sick.

Katie still seems to be feeling and acting fine, especially for a 12-year-old, so I guess I'll just have to play it by ear for now. Thanks for listening. Venting is always a good thing.

[labblab]

Thanks so much for your continuing updates. Katie looks like such a sweetie, and I’m so glad to hear that she’s still doing well! It may simply be the case that she never needs to return to taking the trilostane. Even assuming that she was correctly diagnosed with Cushing’s, the adrenal oversuppression that occurred when her cortisol dropped so low this spring may never rebound to a level of overproduction again. This doesn’t happen often with trilostane, but it is possible. So for the time being, I’m hoping you girls continue to remain stable and happy :-))))

Best wishes to you both!
Marianne