Mia-4 year old poodle recently diagnosed

[joalgopa]

Hi everyone. I'm glad that I found this forum to share our stories and support each other. My name is Jonathan and I live in El Salvador, a small country in Central America (you know south of Mexico, neighbors with Guatemala and Honduras).
This is my story:

I have 2 poodles, one is a 11 year old male named Clean and the other is a 3 years old female named Mia. Mia will be 4 years old in september and has been recently diagnosed with Cushing. Mia always had thin hair since she was a puppy and she always was hyperactive, she panted more than normal and always seemed to be anxious, but aside from that she didn't have more Cushing symptoms, I don't know if she had the disease since she was a little puppy and it developed gradually. Mia and Clean had a litter of 3 puppies when she was 2 years old but she got spayed after that.

Earlier this year I noticed that Mia was drinking a lot more water than usual, she gained some weight, started peeing frequently and had a couple of indoor "accidents" and that caught my attention, she also had a few almost bald patches and couldn't jump into the bed and couches anymore, so I took her to the vet and they made a few generic tests and found normal sugar, hemoglobin and other blood levels so the vet said there were no abnormal signs and that the behaviour of Mia could be normal for spayed female dogs.

After that and in a matter of weeks Mia was hungrier than normal and she even ate things that were not normal for dogs to eat like mint candies and raw tomatoes, she developed a pot belly and a curved back and she lost more hair in her face and stomach, so I searched for those symptoms in the Internet and it was almost obvious that she had Cushing disease. I took her to another vet and told the new vet that I suspected it was Cushing, she said that it was a very rare disease especially in young dogs and that she never had a patient with Cushing that wasn't related to steroid drugs, so the vet made a lot of tests and ruled out diabetes, kidney failure and thyroid issues, the alcaline phosphatase and bilirubin were higher than normal though. After that they made an abdominal ultrasound and found that one of her adrenal glands was smaller than normal and the other one was bigger than normal although no tumors were evident and the other organs were normal. With those tests the vet diagnosed Cushing but unfortunately no labs in my country do the ACTH test for dogs, and we only did total cortisol in blood in a human lab that accepted the sample, indeed the cortisol was higher than normal but I understand it is not the right test.

Now that we are almost sure it is Cushing, we still don't know if it is pituitary or adrenal in origin and we don't have the technology to know it with certainty though we had started with the treatment, unfortunately in my country there is no Mitotane or Trilostane, so the vet prescribed ketoconazol, the first week 50 mg every 12 hours and now 100 mg every 12 hours. Mia has been 2 weeks now with ketoconazol but her symtomps have not improved yet. I will travel to Mexico in october and I can buy Vetoryl there, so meanwhile we will be using ketoconazol. I also bought lignans online as a complement to the treatment but I still have not received them.

I wanted to share this with you to know your opinions, do you think we have done the right decisions? any advice on the treatment and caring of Mia?

[Joan2517]

Hello and welcome to you and Mia. Could you post the results of the bloodwork, just the highs and lows, with the reference ranges? Also how much does Mia weigh? Others more knowledgeable than I will want to see those numbers.

I am on my second dog with Cushing's. Lena, my teacup poodle had adrenal and it looks like Gable, my lab mix has pituitary, although we did not do an ultrasound on him.

You've come to the right place. This forum has been a godsend for me.

[joalgopa]

Thank you Joan2517.

Mia's most recent weight is 19 pounds.
Her results were:

Blood chemistry
Glucose 118 mg/dL (normal range 60-117)
Alkaline phosphatase 441 U/l (normal range 10-100)
SGPT 306 mg/dL (normal range 10-94)
SGOT 104 U/L (normal range 10-62)
Total cholesterol 342 mg/dl (normal range 116-317)
Total bilirubin 8.7 mg/dl (normal range 0.1-0.6)
Anyway, the sample was hemolyzed so we have to take them again to see if there was some interference.

Urine test
Density 1.006 (normal range 1.008-1.012)
ph 8 (normal 7)
Few oxalate crystals observed.

Ultrasound
Left adrenal gland 0.29 cm (normal 0.54 cm)
Right adrenal gland 0.76 cm (normal 0.54 cm)

Cortisol 17 ug/dL (normal range 0.5-5.5)

[labblab]

Hello and welcome to you and little Mia from me, too! I do have some thoughts that I want to share with you, but unfortunately I don’t have the time to do so right now. But I’ll return tomorrow and write in more detail. In the meantime, though, I want you to know that we’re very glad you’ve found us, and we’ll do our best to help you figure out the best path forward for your little girl.

Marianne

[labblab]

OK, I’ve finally made it back again, and here are some of my thoughts about Mia’s situation. Certainly, many of her symptoms are consistent with Cushing’s, but there are also some things that raise additional questions. The first is her age: it’s not unheard of, but far less common for dogs to develop Cushing’s when they are very young. Secondly, the fact that her SGPT, SGOT and bilirubin are all elevated make me worry about actual liver damage of some type. We regularly see elevated ALKP levels in Cushpups, but not these other three indicators all together. Why this is additionally worrisome is because I believe ketoconazole can be very hard on the liver. So if Mia already has pre-existing liver damage of some sort, I don’t know that ketoconazole is safe for her to take. Did the ultrasound show anything abnormal about Mia’s liver?

Also regarding the ultrasound, the appearance of the two adrenal glands does raise questions. As I think you already know, one large and one small adrenal gland is typically associated with an adrenal tumor that is causing overproduction of hormones. And yet, the ultrasound didn’t show the presence of any masses. If there is not a tumor present, I just don’t know what would account for the abnormalities in size. So that is another oddity.

In terms of Cushing’s diagnostics, there is an alternative blood test to the ACTH. It is the LDDS, or Low Dose Dexamethasone Suppression test. We’ve had some other Central/South American members who have been able to have this test done, so that might be an option for you. One advantage to this test is that, depending on the pattern of the results, we can sometimes determine whether pituitary Cushing’s seems to be the likely diagnosis, as opposed to adrenal Cushing’s. However, a drawback to this test is that it is vulnerable to returning “false positives” in the presence of other nonadrenal illnesses. So I’m back to worrying about the possibility of a primary liver problem, and what effect that might have on the testing.

You do mention that Mia’s blood sample was hemolyzed, and I don’t know off-hand whether that causes false elevation in those liver values. If so, then I’d definitely want to repeat the testing in order to see whether there are genuine abnormalities present or not. If so, I think those would be one of your primary concerns right now. If not, then Cushing’s is again the main question. If Mia indeed has Cushing’s, then it might be possible for you to obtain some trilostane (the active ingredient in Vetoryl) from a compounding pharmacy here in the U.S. so long as you have a valid prescription. You will know best whether your country allows medications to be imported. If so, you might want to contact this U.S. pharmacy to see whether they could ship the medication to you:

https://www.diamondbackdrugs.com/

Also, we are just now learning of a new treatment monitoring plan for trilostane/Vetoryl that involves only testing resting cortisol levels rather than ACTH tests. So that could be a big help to you. We can tell you more about that later on depending on when you may be able to obtain the medication.

I will close for now, but again, I’m most worried about those liver values. So if you can tell us more about the testing, the ultrasound, and your vet’s thinking about this — that will be very helpful.

Marianne

[labblab]

P.S. OK, I just checked and see that hemolysis can cause noticeable/significant elevations in SGOT and SGPT levels. So hopefully those elevations are not really present. However, the reverse is true for bilirubin — hemolysis decreases the actual value. So I’m still worried about that high bilirubin, and still wondering about further liver or gallbladder diagnostics. And also worried about the ketoconazole...

[joalgopa]

P.S. OK, I just checked and see that hemolysis can cause noticeable/significant elevations in SGOT and SGPT levels. So hopefully those elevations are not really present. However, the reverse is true for bilirubin — hemolysis decreases the actual value. So I’m still worried about that high bilirubin, and still wondering about further liver or gallbladder diagnostics. And also worried about the ketoconazole...

Thanks for your reply!

The ultrasound shows that liver is normal but the vet was worried because of those levels too, meanwhile she prescribed Trihepat (which I've just found is milk thistle) to help protecting the liver, I'm not very fond on natural remedies but I hope it helps someway. Mia doesn't show any other signs of liver damage like jaundice, vomiting, diarrhea or loss of appetite, so that's kind of a relief for now. I will let you know what the new tests show as soon as we take them.

Thanks for the pharmacy recommendation, I will try to buy it from there if i don't find it in Mexico. I also found a few canadian pharmacies where I can buy it online and ships to my country.

[joalgopa]

Hi! I want to give you a quick update on Mia's case.

We finally get Vetoryl thanks to a cousin that traveled to Spain and a friend that went to Mexico and both of them bought the Vetoryl for me.
I'm planning to start the treatment this weekend but Mia has been 3 weeks on ketoconazole and the vet said we should wait just 24 hours to change meds but I know that changing from Vetoryl to Lysodren requires a few weeks without any medication, so that made me wonder if I should wait more to change from Ketoconazole to Vetoryl?

Yesterday I got HMR lignans that I bought on ebay a few weeks ago, I know they are more useful with atypical Cushing's but can I give it to Mia as a complementary medication? do you think it could help?

By the way, ketoconazol helped her to drink less water though she still drinks more than normal but the other symptoms still persist, I know it has been only a few weeks but hopefully Vetoryl will be more effective.

[Harley PoMMom]

I don't know of any interactions between ketoconazole and Trilostane so waiting only 24 hrs sounds ok to me. What dosage strength is the Vetoryl? With Mia weighing 19 lbs you really don't want to start her at a dose larger than 20 mg and 10 mg would be best especially since the ACTH stimulation test isn't a option in El Salvador.

As for the HMR lignans, I'd hold off on giving them for right now because if you would start them at the same time and Mia would have a bad reaction it would be tough to judge just what was causing it. Now, down the road when she has been on Vetoryl for a while you could begin them.

Lori

[joalgopa]

I don't know of any interactions between ketoconazole and Trilostane so waiting only 24 hrs sounds ok to me. What dosage strength is the Vetoryl? With Mia weighing 19 lbs you really don't want to start her at a dose larger than 20 mg and 10 mg would be best especially since the ACTH stimulation test isn't a option in El Salvador.

As for the HMR lignans, I'd hold off on giving them for right now because if you would start them at the same time and Mia would have a bad reaction it would be tough to judge just what was causing it. Now, down the road when she has been on Vetoryl for a while you could begin them.

Lori

The vet wants to start with 5 mg twice a day, at least for the first 7 days. From what I've read it may be too little but the vet wants to be sure that Mia will tolerate the low dose before increasing it.

And you're right about the lignans, I should better wait until the Vetoryl dose is adjusted.

Thanks for your advice!

[Harley PoMMom]

The vet's suggestion of 5 mg twice a day sounds perfect. Keep us updated, please!

Lori

[joalgopa]

Mia started on Vetoryl yesterday and fortunately I have not seen any side effects yet.

This week she developed a nail bed infection and one of her toes is very red and swollen, the vet prescribed a topical cream with Gentamicin-Betamethasone-Clotrimazole but I'm not sure to use it because betamethasone is a corticosteroid and I'm worried it could elevate more cortisol levels, am I right?

[Harley PoMMom]

Yes, any steroid whether it be given orally, topically, or by drops can raise cortisol levels. How long is Mia supposed to take this medication? If only for a few days than I think it would be ok as you do want that inflammation to go down but any longer could be an issue. If she needs to take it longer, you could ask the vet to prescribe something without a steroid in it as she definitely needs medication for that sore toe.

[joalgopa]

She will take it for 7 days, we have an appointment with the vet this week so I will ask her about other options.

[joalgopa]

Mia's toe had an abscess that opened up on Monday and drained a lot of pus but since then it had been draining less each day, I've been cleaning it with chlorhexidine 3 times a day and then I put the ointment on it.

She also developed a very bad sore on one of her elbows that we clean everyday and put an ointment with neomicine and acexamic acid that always work well with her skin sores but this time she licked it a lot, so we put a bandage on it to stop her licking as I didn't want to use the e-collar, unforunatley my cousin wrapped the bandage to tight around her leg and it became very swollen and the skin turned dark, it really scared me when I noticed it and I took Mia straight to the vet, she said there was no damage to her leg and that the dark skin will fade in a few days though the swelling is already gone. We are not using bandages anymore, so Mia is using an e collar now until her elbow and toe are better.

[joalgopa]

Also, we are just now learning of a new treatment monitoring plan for trilostane/Vetoryl that involves only testing resting cortisol levels rather than ACTH tests. So that could be a big help to you. We can tell you more about that later on depending on when you may be able to obtain the medication.

Marianne

Hi Marianne. Could you tell me more about that cortisol test, please?

Mia has been 6 days on Vetoryl now, and tomorrow the vet will revise the dose as we started with only 5 mg twice a day.

[labblab]

Hi again! Here’s a link to a post that describes this new monitoring system in greater detail. Take a look, and then let us know if you have additional questions, OK?

http://www.k9cushings.com/forum/showthread.php?185-Trilostane-Vetoryl-Information-and-Resources&p=1252#post1252

Marianne

[Harley PoMMom]

How are her symptoms? If they seem to be subsiding than you may want to wait until she has been on the 5mg Vetoryl dose for a month. Also, since her medication has a steroid in it she would need to be off of that for at least a couple days before checking her cortisol levels.

[joalgopa]

Hi again! Here’s a link to a post that describes this new monitoring system in greater detail. Take a look, and then let us know if you have additional questions, OK?

http://www.k9cushings.com/forum/showthread.php?185-Trilostane-Vetoryl-Information-and-Resources&p=1252#post1252

Marianne

Thank you very much:D I think I understand well but I will send the files to the vet so we can discuss them and decide when to make the test.

[joalgopa]

How are her symptoms? If they seem to be subsiding than you may want to wait until she has been on the 5mg Vetoryl dose for a month. Also, since her medication has a steroid in it she would need to be off of that for at least a couple days before checking her cortisol levels.She's drinking a little less water, but the other symtoms persist: she's too hungry all the time, polyuria, skin issues and pot belly.
The good thing is that she keeps her good mood all the time, she loves to play with the ball and is always running around the house.
I will see the vet today to decide if we give her an oral non-steroid antibiotic to help with Mia's toe infection and I will tell her about the cortisol tests.

[Harley PoMMom]

Any steroid, whether it be drops, oral, or topical can cause and/or exacerbate Cushing's symptoms so please keep that in mind.

[joalgopa]

Hi! Mia has been doing well, at least she's drinking less water, the nailbed infection is gone and her elbow sore is slowly getting better. She still has the rest of Cushing signs though, I know 2 weeks is not enough time to see more results.

Yesterday I took Mia to the vet to take the tests and after 2 weeks with Vetoryl (and 3 weeks with ketoconozale before that) there have been some improvements in some levels and not so much in others. These are the results:

Weight is 18.6 pounds.

Glucose 133.5 mg/dL (normal range 60-117) Last time 118
Alkaline phosphatase 460 u/L (normal range 10-100) Last time 441
SGPT 168 mg/dL (normal range 10-94) Last time 306
SGOT 109 U/L (normal range 10-62) Last time 104
Total cholesterol 334 mg/dl (normal range 116-317) Last time 342
Pre Vetoryl Cortisol 10.8 ug/dL or 298 nmol/L Last time 17 ug/dL

After this the vet decided to increase Vetoryl dose from 5 mg twice a day to 15 mg only once a day.
And now I ask for your opinion as usual, do you think it's good to change from twice to just once a day? Is the increase in the dose OK?
Let me know what you think and I will discuss it with the vet, I have told her about this forum and that you guys know a lot about Cushing, so she's kind of open to any advice I get from here.

Thanks.

[labblab]

Normally the recommendation is to leave a starting dose of Vetoryl unchanged during the first month of treatment because cortisol levels tend to continue to drift downward even when a dose is left unchanged. However, given the fact that you started Mia at a dose that was well below the typical starting formula of 1 mg. per pound — and additionally, her pre-pill resting cortisol is still really high at almost 11 ug/dL, I’d think you could safely increase now to the 15 mg. daily total. As to whether or not you want to stick with twice daily dosing vs. consolidated once daily dosing, I really have no strong opinion about that. Once daily dosing is typically an easier regimen for an owner to follow, so if a dog responds favorably to once daily dosing, I’d tend to go with that. If you do want to stick with an unequal divided dose, though, Dechra recommends giving the larger dose in the morning (that is to say, give 10 mg. in the morning and 5 mg. in the evening).

Marianne

[Harley PoMMom]

Is she still getting the medication with the steroid in it?

[joalgopa]

Ok, thank you labblab.
I think I will divide the dose, I feel safer that way.

[joalgopa]

Is she still getting the medication with the steroid in it?

Yesterday was the last day with that medication.

[joalgopa]

Hi everyone!

I'm back with an update. Mia has been 1 month on a daily Vetoryl dose of 15 mg. She's drinking less water (about 30% less than before Vetoryl), her skin has improved and there have not been any infections, her coat is still thin but new hair is growing back in some bald spots like her elbows and face and she still has a great energy and is very playful, she even has been able to jump on beds with some difficulty but a few months ago it was impossible for her. Some symptms that remain are excessive hunger, pot belly, excessive panting (especially at nights before the 2nd dose of Vetoryl) and a few indoor accidents.

We went to the vet last weekend to do the medical tests and most of the results were very good except for resting cortisol which contradictory went very high again.

Weight: 21.3 pounds, last time 18.6 pounds

Blood chemistry
Alkaline phosphatase 80 u/L (normal range 10-100) Last time 460
SGPT 60 mg/dL (normal range 10-94) Last time 168
SGOT 51 U/L (normal range 10-62) Last time 109
Creatinine 0.4 mg/dL (normal range 0.5-1.4) Last time 0.5

Pre Vetoryl Cortisol 17 ug/dL or 469 nmol/L, last time 10.8 ug/dL or 298 nmol/L

Urine test
Density 1.012 (normal range 1.008-1.012), last time 1.006
ph 8 (normal 7)
No crystals were seen.

The vet suggested we should increase the daily dose to 20 mg because she has increased her weight to 21 pounds but I'm reluctant to do it and I want to see if she starts to eat less and her weight stabilizes. I'm giving her a little less food, this last month she has been eating 1 1/2 cups of food daily, now I'm giving her 1 1/4 daily.

Your opinions are very welcomed as always.
By the way, today's Mia's 4th birthday and I'm planning to celebrate it next weekend, I wil try to share some pics here.

[Harley PoMMom]

Happy 4th Birthday, Mia!!!

Since she is still symptomatic and her resting cortisol is high you could increase her evening dose by 5 mg so that would be 10 mg in the morning and 10 mg in the evening. Man oh man, look at the drop in her liver enzyme levels in chemistry panel, that is great!!!

PS...I changed her thread title to reflect her new age, hope that was ok.

[Joan2517]

Happy Birthday, Mia!

Gable's belly took a while to disappear. He started the Vetoryl in May and I don't think we noticed the belly gone until around the end of August or beginning of September.

[Squirt's Mom]

Happy 4th Birthday, Mia!

And many more!

[joalgopa]

Since she is still symptomatic and her resting cortisol is high you could increase her evening dose by 5 mg so that would be 10 mg in the morning and 10 mg in the evening. Man oh man, look at the drop in her liver enzyme levels in chemistry panel, that is great!!!

PS...I changed her thread title to reflect her new age, hope that was ok.

Yes, the liver enzymes have dropped a lot! that was a very nive surprise, I wasn't expecting such a big change that quick.
And, thanks for changing the title!

[joalgopa]

Thank you for your wishes Joan and Squirt'sMom!

[joalgopa]

Hi! Here are some pictures from Mia's birthday.

https://i.imgur.com/ruvLz9g.jpg

https://i.imgur.com/wmkh18l.jpg

https://i.imgur.com/CNVyHKJ.jpg

The one on the left is Clean, Mia is in the middle, and their son Terry is on the right.

[Joan2517]

Adorable pictures!

[labblab]

Awwwwww, yes, they sure are!!!!!

Happy Belated Birthday, little Mia :-))))))))))))))))

Marianne

[Squirt's Mom]

Oh they are all adorable!!

[Harley PoMMom]

OMGoodness, they are all so gorgeous, and that grin Mia has is adorable!!!!

[joalgopa]

Hi everyone! I have an update on Mia's case.

Her hair has copletly grown back on her legs and face, but her torso still has thin hair. She's still hungry all the time but her thirst is almost back to normal. The pot belly has reduced a bit. Her skin and nails are better but she has some kind of dandruff and small red lesions appear every now and then.

I took her to the vet for her medical tests on november 6, most of the levels are stable and close to normal but glucose and cholesterol are a little high and creatinine has increased a bit too, the good news is that cortisol is at the lowest level since she was diagnosed wit Cushing. These were the results:

Blood chemistry
Alkaline phosphatase 39 u/L (normal range 10-100) Last time 80
SGPT 63 mg/dL (normal range 10-94) Last time 60
SGOT 74 U/L (normal range 10-62) Last time 51
Creatinine 1 mg/dL (normal range 0.5-1.4) Last time 0.4
Glucose 159 mg/dL (normal range 53-117) Last time 134
Cholesterol 392 mg/dL (normal range 116-317) Last time 334

Pre Vetoryl Cortisol 6.46 ug/dL or 178 nmol/L, last time 17.4 ug/dL or 480 nmol/L

The next medical exams will be until February and we're still keeping the 15 mg daily dose of Trilostane.

[lulusmom]

Thank you for the update. It sounds like you are on the right track but because you are still seeing symptoms and the pre Vetoryl cortisol is higher than it should be, a dosing increase may be a very good idea. I have provided a link below to the monitoring flow chart for assessing the pre Vetoryl cortisol and if you look at the left side of he chart, you will see that a dose increase would be appropriate for your dog based on persistent symptoms and high pre Vetoryl cortisol. Top of the range is 5.0 u/dl plus 15% which would be 5.75 u/dL. You may want to share this flow chart with your vet and discuss a possible dose increase.

8521

Glynda

[joalgopa]

Hi guys! I have an update on Mia. Phisically she's still playful and with lots of energy but she has severe skin problems (a persistent staph infection) that we have not been able to control, we will be starting a new treatment with new creams, spray and shampoo combo next week.

Today, I got the results from her most recent tests and they are not what I would like to see, here they are compared to February tests:

Weight: 19.8 pounds Last time: 22 pounds
Alkaline phosphatase 259 u/L (normal range 23-212) Last time 131
SGPT 110 mg/dL (normal range 10-94) Last time 91
SGOT 0.66 U/L (normal range 10-62) Last time 42
Creatinine 1.08 mg/dL (normal range 0.5-1.4) Last time 0.88
Pre Vetoryl Cortisol 8.75 ug/dL or 241 nmol/L, last time 8.46 ug/dL or 233 nmol/L

Based on those results, the vet thinks that liver damage has already begun. The dose has been 20 mg daily since February but it seems like we have to increase it even more.
We will be doing an ultrasound on Mia next week to see how her adrenal glands and other organs are doing.

[labblab]

Thanks so much for this update on sweet Mia! I’m sorry to hear about the skin problems. We experienced a lengthy battle with a skin staph infection in our non-Cushing’s lab, and it took a lot of frequent medicated baths to finally get it under control! But we finally did, and I hope the same will be true for Mia.

I’d agree that an increase in her Vetoryl dose is likely in order. And scheduling that ultrasound also sounds like a very good idea. Please do let us know how the results turn out, OK? And in the meantime, please give her a big hug from her family here!

Marianne

[joalgopa]

Hi everyone!
Thanks for your kind words labblab.
I have an update on Mia's case.

We made the ultrasound on July and the results were good, not great but it could have been worse. The test revelead:
Kidneys The left kidney increased its size in 0.07 inches and the right kidney reduced its size in 0.31 inches. They look normal.
Venae cavae and aorta They are normal but they grew 0.05 inches larger.
Stomach Gastritis was evident.
Left adrenal gland Larger than normal 0.35x0.36 inches, last year it was actually smaller than normal with 0.11x0.10 inches
Right adrenal gland Larger than normal 0.57x0.49 inches, last year it was also larger than normal with 0.30x0.27 inches
Liver Larger than normal. Last year it was normal.

The good news is that no tumors, nodules or abnormal masses were observed in any of the organs.

The bad news is that the liver, kidneys, stomach and adrenal glands have grown larger.

Te weird news is that now both glands are bigger than normal which would be a sign of pituitary Cushing, and not the Adrenal Cushing that was diagnosed last year.

And about her skin, it's improving little by little, at least the lesions doesn't bleed like they did before.

[Squirt's Mom]

Thanks for the update! Is Mia still on the Vetoryl? What dose is she taking now? Did the vet make any comments about the change in the adrenals? That is odd to me as well and I would be curious to know what they thought about that.

Great news that no tumors or other issues were found so rejoice in that! And I am glad to hear the skin is improving. With CC that is wonderful news; it can take such a long time for it to clear up so any improvement means steps toward the end of that condition.

Hugs,
Leslie