New to this Forum-with Ollie a Cushings Dog, False Positive Cushings

[alleng8304]

My rescue dog, Ollie, a 9 year old Norfork Terrier dx with Cushings in April 2018 by LDDS and started on low dose Trilosane 5 mg. He also has a dx of diabetes. His clinical signs were always hungry, bloat belly, hair loss, drink a lot of water, elevated liver enzymes. He is not a real active dog so it was hard to determine if he was lethargic. He reiceives 4.5 units of Vetsulin q12 and a prescription dog food to help maintain his glucose levels.

My concern is that diabetes could also generate a false positive Cushings. Although he has all the clinical signs of Cushings -how would one know if there was a false positive? Hw will be due for another ACTH stim soon. Thanks you

[Harley PoMMom]

Hi and welcome to you and Ollie!

Yep, those tests for Cushing's can yield false positive results when a non-adrenal illness is present and unfortunately the LDDS is one that is more likely to do that. The symptoms that Cushing's produce overlap with the same ones of diabetes so the recommendation is when diabetes is in the mix and Cushing's is suspected the first thing to do is to get the diabetes under control before performing any tests for Cushing's. However, since Ollie is already on treatment for Cushing's we've got to move ahead and look at the overall picture. How hard was it to get his blood sugar regulated? And how are his symptoms now? Could you post the results of all the tests that were done on Ollie, you need to only post those values that are abnormal with the reference ranges and units of measurement. Also, could you post the results of any monitoring ACTH stimulation tests he has had done? Is Ollie taking brand-name Vetoryl or is his Trilostane compounded? And is he getting his Trilostane with a meal?

We have a sister forum that deals with canine diabetes so I do urge you to join there also, in this way we will have the best of both worlds...here's their link: http://www.k9diabetes.com/ Please know we will help in any way we can and if you have any questions do not hesitate to ask them.

Lori

[alleng8304]

Lori- Thank you so much. Ollie has been a difficult case. He was dx with diabetes in January. We started him on 4 units of Vetsulin daily and went up until we hit 15 units. Results were erratic where we would get Urine strips of negative to 500. We now do Vetsulin q12 4.5 units and use a Glyco balance meal like Royal Cannine. I do blood sticks 3x per week and urine strips 3x a day. He has been staying in the 150-250 range. Since we just started this, same dose of insulin at each dose, my plan is to let the insulin/meal settle in for 2 weeks. I would not say that he is under control but getting there.

Yes we have done LDDS and Acth stim and I will get those values back to you tomorrow. I have had 3 dogs (poodle mixes) with Cushings-one lived 12 years and one 14 years. I asked the vet if Cushings is in my walls or something. I live in a rural town and the vet I love and has helped me in tough spots but he is no specialist. I have a PhD in medicine and I never thought that it would be that hard to get Ollie under a good control. I am also on the sister site. Again, many thanks

[Harley PoMMom]

One important thing I wanted to mention is that diabetic dogs should have their Trilostane twice a day as this helps to keep a tighter control of the cortisol.

[alleng8304]

Lori-

Going to vet Wednesday. I will ask the vet why he thought my muti-poo (Opie) had Cushings- may have been an altered chem profile. He has no symptoms- period. Off Trilosane since June 20th and no ill effect

As for Ollie- 9 yro Norfork Terrier
I finally got is diabetes under control-took 6 mo. He get 4.5 units of Vetsulin q12 and meals q12 with a Royal Cannie Gylobalance in an effort to prevent sugar shock. For the last two weeks his urine and bld glucose stays under 200 and usually in the range of 120-150. My plan was to do a Fructosamine which should tell me if he is in good control or not. for past 2-3 weeks. Numbers should be between 265-280. I was going to do a 12 hour curve but his veins in the ear are very embedded. I will also ask vet about his hair falling out (on back) and cataracts. His right eye seems worst (mature)- cannot see close vision only further away. I was thinking of trying Lomax eye drops (has good reviews)

In April 2017-LDDS done cortisol ug/dl 9:30 am=7.5, 1:30 pm=5.3, 5pm=5. In May ACTH Stim 10:45=9.2, 11:45=9.6

Thats it Thanks Ollie

[Harley PoMMom]

Hey Allen, I just wanted to make sure you saw this post of mine. :)


One important thing I wanted to mention is that diabetic dogs should have their Trilostane twice a day as this helps to keep a tighter control of the cortisol.

[alleng8304]

I did Thanks

[alleng8304]

Ollie went to vet this morning. His meds include Vetsulin 4.5 u q12, Denamarin alternate 1 tab & 2tab daily, Ocu-glow daily, trilostane 5 mg daily. Food is Royal Cannin Glycobalance. Labs today- Glucose=61, I finally think he is under control. Glucose runs between 61-121. All under 200. I may cut back to 4 U q12.

ALP=181, ALT=183 both high but lower than June which was 2356 and 439 respectively -Denamarin? BUN went up to 41 was 37 in June.? Drew blood for Fructosamine- will have results on Friday- looking for a number below 265. Left eye mature cataract-only has peripheral vision. Immature in right-better vision. Considering a trial of Lanomax drops in left eye only. Test for Glaucoma good- 20 in both eyes

Ok clinicians, what are your thoughts. Many Thanks-Allen and Ollie

[Harley PoMMom]

Everything looks pretty good to me. If his blood sugar would ever start to get out of control you may want to look into giving his Trilostane twice a day to get a tighter rein on the cortisol, I do see from his last ACTH stim in May that his cortisol levels were in the high therapeutic ranges for a dog on Trilostane but if it works why rock the boat...Great job, Allen!!

[alleng8304]

Update: Ollie's Fructosamine was 250 reference range of 150-350. So good control. I read somewhere that ACTH stim should be performed 2-4 hours after Trliostane administered? is there a reference for that? Thanks Allen & Ollie

[Squirt's Mom]

Check out these links from our Helpful Resource section:

This first link gives general information on Vetoryl (Trilostane) and the original method of testing:
http://www.k9cushings.com/forum/showthread.php?185-Trilostane-Vetoryl-Information-and-Resources

There is now a new testing protocol in EU that vets in the USA are just learning about. That info is here. Feel free to share with Olli's vet.
http://www.k9cushings.com/forum/showthread.php?8925-GENERAL-GUIDELINES-for-Dosing-and-Monitoring-Treatment-with-Vetoryl-(trilostane)

[Harley PoMMom]

Dechra, the makers of Vetoryl, state that the ACTH stimulation test should be performed 4-6 hours after the Vetoryl has been given with a meal. Some veterinarians are now administering the ACTH stimulation test (for monitoring purposes) in shorter times. Dr. Mark Peterson, who is a renown veterinarian that specializes in endocrinology, recommends doing the test 3-4 hours post pill, here's an excerpt from his blog:
With trilostane, it’s extremely important to give the morning medication with food, and then start the ACTH stimulation test 3 to 4 hours later. https://endocrinevet.blogspot.com/2011/03/whats-best-protocol-for-acth.html

The important thing is to do the test at the same time frame so as to be consistent, so if the vet does the test 4-6 hours after the Vetoryl/Trilostane was given than it should always be done in that time frame if possible.

Lori

[alleng8304]

Ollie my 9yr old, Terrier has diabetes and Cushings. He weighs 15 ibs. His diabetes is under control @ 4 units q12 of Vetsulin . His bld glucose now runs between 60-100 most times and always under 200. On Friday, 7/27 he had a ACTH stim. His results were 0.9 and 0.7. Reference range 1-5- Trilostane dose of 5 mg. The 0.9 and 0.7 numbers tell me his adrenals are NOT working and vet suggested to stop Trilostane for one week and then restart @ 1.25 mg. q12. I am concerned that if he gets stressed we could go into a full blown Addison's. He is also partially blind from the diabetes but still seems to get around OK. We were going to have cataracts removed, but now will have to wait awhile. The vets seems to think that his adrenals will bounce back?? Any thoughts and Thank you. It has been a long battle with these two diseases.

[labblab]

Welcome back, Allen! You’ll see I’ve merged your new question about Ollie into your original thread. This way, we’ll have his complete history consolidated all in one place. Your vets are correct in saying that cortisol levels will rebound in most dogs subsequent to temporary discontinuation of the trilostane. However, our experience here is that the time period can be highly variable. Some dogs quickly begin making excessive amounts of cortisol, while the effects of adrenal oversuppression can linger for others. For a few dogs, adrenal function remains permanently suppressed.

I realize you’ve been working hard to coordinate both the insulin and trilostane doses for Ollie. Therefore, you have added pressure not to leave him off the trilostane any longer than is necessary. But I personally wouldn’t feel comfortable restarting it so quickly in the absence of repeating the cortisol testing in some form. If not a complete ACTH, then at least a resting cortisol level. As is, restarting in a week at that specific lowered dose seems like a shot in the dark to me. As I say, I’d want some concrete evidence that Ollie’s adrenal function has sufficiently normalized before resuming the medication.

Marianne

[alleng8304]

Marianne-

Thank you and I agree. Without knowing if the Adrenals are functioning I will not restart the Trilostane. I think that a month may be a more reasonable time period. To do another ACTH stim @ $232 in one week seems like a waste of money. I understand the reason for moving the post to the older threads so it gives complete info. But I am a little concerned that the this last post may not be seen since there are so many. But you saw it? It has been a long hard road in the last 6 mo with Ollie

[Squirt's Mom]

All your posts are being seen...we just may not have anything to offer other than "I see your post" so we don't comment. Keeping all info in one place helps not only the staff and members but also you. This tread will serve as a sort of diary or journal for the Cushing's journey. You can come here anytime and look back to see if there is a pattern, to remind yourself of when events happened or tests were given, etc. But rest assured, your posts are seen even when no comment is offered.

Hugs
Leslie

[alleng8304]

Marianne-
In speaking to the vet further this afternoon, Ollie's resting cortisol would be the first Number which was 0.9-close to normal but when down to 0.7 (suppression). He is getting a protocol from Merck and I will share it with the group. Thanks. We agreed to watch sugar levels and not repeat ACTH for several weeks with Ollie off Trilosane.

[labblab]

Yes, before restarting, you would probably want to see a resting cortisol back up to around 2.0 or higher if you were to try to rely on that alone. However, in a situation like this, it’s always better to perform a full ACTH to make sure that sufficient cortisol reserves are available. And per Dechra, the manufacturer of brandname Vetoryl, this is what you’d be looking for:


If the ACTH stimulation test is < 1.45 μg/dL (< 40 nmol/L) and/or if electrolyte imbalances characteristic of hypoadrenocorticism (hyperkalemia and hyponatremia) are found, VETORYL Capsules should be temporarily discontinued until recurrence of clinical signs consistent with hyperadrenocorticism and ACTH stimulation test results return to normal (1.45-9.1 μg/dL or 40-250 nmol/L). VETORYL Capsules may then be re-introduced at a lower dose.

https://www.dechra-us.com/Admin/Public/Download.aspx?file=Files%2fFiles%2fProductDownload s%2fus%2fvetoryl-5mg-pack-insert.pdf

Marianne

[alleng8304]

many thanks

[alleng8304]

Ollie-9yro diabetic and Cushings- not new to this forum. We stopped his Trilostane 5 mg daily (7/31) since his last ACTH stim was terrible-0.9 resting and 0.7 rebound. His glucose levels were staying in the 60-120 range but now going up. Last night- 1hr after evening meal and 4 u of insulin-bld glucose was 236. This morning 1 hr after meal and 4 u-his bld glucose was 231.

Does this make sense-His need for insulin will be greater with Ollie off Trilostane and sugar will go up. Vet seems to think that we should leave his insulin dose as is for now and I will recheck blood later today when insulin peaks. I also believe that his Adrenals are not burned out since his glucose went up. I think the plan should be to do a resting Cortisol next week and if in normal range- start back on Trilostane at very low dose-perhaps 2.5 mg. Any thoughts. Thank you!

[Harley PoMMom]

I would recommend having a full ACTH stimulation test performed before restarting the Trilostane, this is the only true way to know if his adrenal glands are properly producing enough cortisol.

[Eve]

My vet never raised the possibility of a false positive Cushing's diagnosis. My dog was on trilostane for a few months and suffered GI problems. And now he has been diagnosed with hyperparathyroidism, a condition that can look like Cushing's. So, he's off the medicine now and I'm told it's difficult to determine whether he has Cushing's until the hyperparathyroidism is treated.

All to say, you're ahead in being cautious about false positives. I've already spent mega-money on Cushing's tests and meds, plus a hospitalization for my dog's bad reaction to trilostane. It's still possible he may have Cushing's but I regret his premature treatment for it. Vet should have done the parathyroid test first since he had high calcium, a strong clue. I've been educated after the fact upon finding this forum.

[labblab]

Hi again from me. Yes, it does make sense to me that Ollie’s glucose level will start to rise again if his cortisol level is also increasing due to the withdrawal of the trilostane. As Lori has said, the ACTH is definitely the preferred way to assess his adrenal rebound. But if you see steadily increasing glucose as well as the return of other Cushing’s symptoms, then I’m guessing you’re correct that Ollie is bouncing back again. In that scenario, the ACTH remains the best monitoring test, but I do believe a resting cortisol would be better than no test of cortisol at all. And also yes, when/if you do resume the trilostane, I’d do so at a reduced dose.

Marianne

[alleng8304]

Thank you and I agree-glucose running in 200's again-was in 60-120-do I increase insulin?

[labblab]

I’m afraid I have no expertise re: the diabetic side of things. I’d have to rely on the advice you’re getting from your vet and the folks at K9diabetes. My uninformed guess would be that a lot depends on the trajectory of starting back on the trilostane. If that’s not going to happen for awhile, then Ollie’s insulin needs may need to be increased. If it’s safe to resume the trilo soon, then temporarily leaving the insulin as is may be the best route. That way, you’ll only be adjusting the dose of one med at a time. But once again, this is just a guess on my part.

Marianne

[alleng8304]

sounds logical