Potential Cushings diagnosis

[Doggy_David]

Hi,
I found this forum while looking up info on Cushings in dogs, and am hoping you all can help. My dog Bella is looking at a potential Cushings diagnosis, and am wondering A) if her combination of symptoms sounds familiar to anyone, and B) What are the risks of treatment vs waiting, since right now she doesn't have very much in the way out of outward symptoms.

To back up a bit, Bella is a ~50 lb Husky/Samoyed/northern breed mix. We rescued her 5 years ago, and the vet estimates her current age is around 8-10. she was diagnosed with hypothyroidism about 2 years ago about 6 months after a severe bout of acute Pancreatitis, Gall bladder infection, UTI, and a blood clot (all at the same time). For the 6 months after that her energy level was low, losing fur, skin turning black, etc, recurrent diarrhea, plus another UTI. I asked our vet to perform a thyroid test, and her T4 levels came back very low (<50). After starting the thyroid supplement, it was like she was a new dog, fur grew back, energy back up, stomach problems went away. Since then she's been doing great except for another gall bladder infection about a year ago and 2 additional UTIs within the past year. She's also had 2 blood clots to go along with the gall bladder infection.

Fast forward to now, and a month ago we took her to get her first dental cleaning in about 3 years, and when they did the pre-anesthesia blood work her ALKP levels came back high (432 vs 212 max normal range). They were elevated on her previous blood work as well but not as high, although the ref max was different for that test (275 vs 131 max normal range) All other liver enzymes and other blood test levels came back normal. Our vet recommended a followup to a specialist given her history of gall bladder disease. We went to her internal medicine specialist who did an ultrasound. Ultrasound showed no issues with her liver or gall bladder (other than some stones that were pre-existing but not obstructing anything) but did show another blood clot. To try to determine the source of the recurring blood clots, the doctor did a urine cortisol/creatanine test (sample collected in the morning about 5 days after the initial visit). I just got back the results, which showed an high level of cortisol (22 vs <13). Based on this, the recurring blood clots, and the elevated ALKP levels, the Dr is thinking it may be Cushings and wants to do the LDDS test next Monday. Other than the internal readings, she's not showing a ton else in the way of symptoms. Her appetite is completely normal, although she has been drinking slightly more water over the last month or so, but we had just chalked that up to summertime heat. She doesn't drink a lot of water normally, so its not a huge total amount of water she's drinking, but it has been maybe a 25% increase from her usual. She's also been panting a lot more over the past several weeks(waking up panting during the night occasionally), but has seemed better the past few days, so not sure if that's just the heat as well. She's not peeing more frequently (she has always "marked" like a boy dog on walks, but otherwise only needs to go out once or twice in addition to her two daily walks). She has been having intermittent incontinence issues for the past few months. We put her on Incurin for a bit, but she got ALL of the side effects, so now we're just doing a tiny (.5mg) does once a week (vs 1 mg/day dose she was on that caused side effects), and that seems to be enough to limit those issues for the most part, but no side effects. Her energy levels seem pretty normal (active bursts around morning and evening walk and then dinner time, pretty relaxed and chill most of the rest of the time).

Hoping I can get some advice on whether this might actually be Cushing's or just some weird coincidences and false positives. Given her complex medical history, its hard to tell what's causing what, and I definitely don't want to have her end up on any drugs that she doesn't need (already taking enough drugs as is!). Sorry for the huge info dump, and thanks for any help. Also definitely don't want to put her through more tests than necessary, so understanding what's worth doing and what isn't would be helpful.


-David

[Squirt's Mom]

Hi David,

Welcome to you and your sweet girl, Bella!

Some of what you describe is consistent with Cushing's - the pancreatitis, reoccurring UTIs, and blood clots are found with uncontrolled elevations of cortisol. But with all Bella has going on I would expect her cortisol to run higher than normal. Cortisol is one of the fight or flight hormones and any time stress is present, external or internal, the cortisol rises in response as it is supposed to do. My Squirt was also first suspected of Cushing's from pre-dental testing and in subsequent Cushing's tests - LDDS, HDDS, ACTH, and UTK panel - she tested positive for Cushing's. HOWEVER, when we did the abdominal ultrasound a tumor was found on her spleen. Once that tumor and half her spleen were removed, her cortisol returned to normal levels. The cortisol was high due to the tumor and caused false-positives on ALL her testing. So I am always very cautious when a pup presents with many issues and Cushing's is suspected. :)

It would seem the thyroid was responsible for many of the other signs of Cushing's - hair loss and dark skin. Diarrhea is not typically a sign of Cushing's. The ALP, or ALKP, readings we see are MUCH higher than what Bella is showing - we see those values in the 1000's, not just a 100 or so points above normal. We typically also see changes in other liver values as well as kidney values, the triglycerides, cholesterol, neutrophils, monocytes, very dilute urine, and an abnormal UC:CR, which compares cortisol to creatinine. An abnormal UC:CR does *not* mean Cushing's however - it simply means SOMETHING is off and further testing is needed. On the ultrasound we expect to see one or both adrenal glands enlarged OR one enlarged and one very small, even atrophied. Normal adrenal glands are a rarity. Signs in Cushing's are just as important as the test numbers partially because those lab results can indicate many thing other than Cushing's. So without obvious signs such as a ravenous appetite 24/7, loss of house training *without* the presence of an UTI, heat intolerance, hair loss, pot belly, panting for no discernible reason, exercise/jumping intolerance, to name a few, I am again suspicious that something other than Cushing's could easily be in play. The LDDS is particularly known for returning false-positives when any non-adrenal condition is present....like UTIs.

So that is *my* take - that something OTHER than Cushing's is responsible for what you are seeing and that that something may well cause false-positives on the cush testing. Bear in mind tho - I am coming from my own experiences...which include a second dog diagnosed with Cushing's when she had COPD, anal gland disease, and many other conditions she was battling. A necropsy (autopsy for animals) revealed that she did NOT have Cushing's after all. So my advice, proceed with an open mind and a willingness to strongly question any diagnosis of Cushing's unless her signs become much stronger and her labs reveal more consistency with Cushing's.

I am glad you found us and look forward to hearing more about your sweet girl. Regardless of her final diagnosis, you are both family here now and we will want to know how she is doing.
Hugs,
Leslie

[Doggy_David]

Hi Leslie,
Thanks for your thoughts. I too am a little skeptical that we're seeing false positives, although I'm also not sure what else might be the issue, unless her existing blood clot is causing all the problems, although the vet didn't seem to think so. She has been panting a lot more over the past few months (and again today, even though its not that hot out here). She's also had multiple abdominal ultrasounds over the past year, and no abnormal growths or anything detected. Do you think it's still worth proceeding with the LDDS test? I guess if its negative that'll rule things out, but somehow given her medical history I doubt it'll end up being that simple.

Thanks,
David

[Doggy_David]

What is the sensitivity of the LDDS test to external stressors? There's a decent chance of thunderstorms tomorrow, and Bella tends to freak out a bit when she hears thunder. I'm worried that if she does the LDDS test tomorrow and hears thunder, it'll artificially bump up her cortisol levels.

[Squirt's Mom]

I'm not sure the LDDS is sensitive to that sort of short term stress however the ACTH is. A dog who gets stressed simply going to the vet can return a high reading on the ACTH. As for proceeding with the LDDS, personally I wouldn't right now. The normal ultrasounds is another red flag about a Cushing's diagnosis. The adrenal glands would show as abnormal in a cush pup due to the extreme work they are doing producing cortisol. They change in one of two ways - both enlarged which indicates the pituitary form, or one enlarged and the other very small or atrophied which indicates the adrenal form. I wouldn't expect a normal LDDS in a dog with as much going on as Bella has so I'm not sure it will tell you anything valuable. But again, that is what I would do in your shoes. She is your baby and you must do what you feel is right for her. And we will be right here with you all the way.

Hugs
Leslie

[Squirt's Mom]

David, I've asked, Lori (Harley PoMMom) to come take a look at Bella's story. She is one of our Admins and may well have a different outlook to present.

[Harley PoMMom]

Hi David, and a belated welcome to you and Bella!

Due to the absence of strong clinical symptoms I'm inclined to believe that Bella doesn't have Cushing's. Two diseases that Bella does have, hypothyroidism and pancreatitis, have the ability to cause blood clots and will elevate the ALP levels. Has Bella been tested for heartworms? Heartworms are another health issue that can cause abnormal blood clotting. Where was the blood clot located that showed up on the ultrasound?

Lori

[Doggy_David]

Thanks all for the ideas, it's very much appreciated. Just as an update, I put off the LDDS test, but am reconsidering and planning to try it next week. She hasn't been tested specifically for heart worms (unless its done as part of a regular exam and I just don't know), but she's consistently been on heart worm preventative since we adopted her, and her symptoms don't seem to line up with heart worms. Her blood clot is in the abdominal part of the aorta, it's blocking about 50% of the aorta, although she's had a similar/worse one in the past and also showed no symptoms from it.

Also, just to clarify, her pancreatitis and gall bladder infections were 2.5 and 1 yr ago, respectively. Since then, she's been quite healthy except for what seems like a yearly UTI that she gets and her recurring blood clots, (not full blockage, just partial), although the blood clots don't really present any symptoms that I can tell.

I've also noticed that her coat is starting to thin again. The skin on her tail is very visible now, and it wasn't a few months ago. It's also easier to see the skin on her back, which I also couldn't do 6 months ago. It's nowhere near as bad as before her thyroid diagnosis, but definitely different over the last few months than the 2 years between then and her hypothyroidism diagnosis. Her T4 levels are still good, so I don't think the issue is with her thyroid supplement. I'm wondering if she may just have a fairly early, very slow moving version of Cushing's. The adrenal glands were both small on ultrasound, although the Dr did say one was slightly larger than the other. Maybe with them starting smaller than normal she may be producing excess cortisol now, but not as much as a dog who started with normal size adrenal glands? I've been doing a bunch of research, and even though she's not showing some of the typical signs (excessive thirst, potbelly, etc), I can't find anything else that would explain the increased ALP, increased Cortisol ratio, history of blood clots and infections/UTIs, excessive panting, worsening incontinence, and now hair thinning in an otherwise (behavior/energy-wise) seemingly healthy dog. (panting and hair thinning have only been over the last ~3ish or so months, and her energy level is down slightly, but she's still goes on walks and actively jumps and runs for food and treats, something she did not do for the few months prior to her hypothyroidism diagnosis). If anyone has ideas of other possibilities, I'm definitely all ears. She likes to give us a challenge by always having the obscure symptoms or side effects from things so figuring out what's going on can definitely be a challenge (i.e., she is almost completely asymptomatic for blood clots and UTIs, but got ALL of the rare hypothyroidism effects, and has had rare side effects to various medications she's been on previously like incurin and chloramphenicol).

My current plan is to go to her regular vet and check to make sure her thyroid (T4) levels are still good and that she's UTI-free (since sometimes its hard to tell). Assuming it's neither of those issues, I was going to go for the LDDS test. I'll follow up afterward, and would definitely love to hear any other thoughts on alternative diagnoses.

[Harley PoMMom]

According to Dr. David Bruyette, who is a veterinary endocrinology expert, monitoring thyroid supplementation using the T4 post pill isn't as accurate as once thought:
Once canine hypothyroidism has been diagnosed, what are Dr. Bruyette’s recommendations for laboratory monitoring? He says that many veterinarians, including those attending this CVC session, were taught that they should draw blood for T4 testing from four to six hours after the thyroid hormone pill was administered. Dr. Bruyette says, “The percentage of T4 that is absorbed from the gut varies from 13% to 87% in a given dog from day to day. So, on Monday, the dog may absorb 13% of the dose; on Tuesday, it may absorb 87% of the dose. The post-pill test is severely affected by the intrinsic ‘weirdness’ of the T4 bioavailability. Therefore, the post-pill test is probably physiologically meaningless.”

So, is there a way to confirm a dog is euthyroid when it is receiving thyroid hormone supplementation? There are two options: thyroid-stimulating hormone (TSH) measurements or free T4 by equilibrium dialysis (fT4 by EqD). If the TSH is normal, the dog is euthyroid. If the TSH is high, it needs more thyroid hormone; if it’s low, the dog is getting too much of the hormone.

But if you read the companion article “Canine hypothyroidism: Shield your patients from overdiagnosis,” you may have already spotted the problem with this option. In that article, we stated that with the TSH assay, 25% of hypothyroid dogs have a normal TSH concentration to start with (because the assay does not work well). Therefore, to use TSH assays to monitor a dog on hormone replacement therapy, you must have had a pre-treatment TSH result that was high. Without that, you simply can’t interpret what the TSH concentration means now.

The other option is to measure fT4. After two weeks of thyroid hormone supplementation, fT4 concentrations over a 24-hour period are constant. With the fT4 by EqD test, it doesn’t matter what time of day or when in relation to the pill administration you collect the blood sample, because the concentrations don’t fluctuate.

http://veterinarymedicine.dvm360.com/canine-hypothyroidism-supplementation-and-monitoring-updates?pageID=2

[Doggy_David]

Hi,
Wanted to revive this, since I have some more updates on Bella and wanted to get some thoughts, since we're getting ready to start Veotryl treatment. Shortly after previous posting, performed a LDDS test, which came back negative. However, over the next 2 months, her symptoms grew worse, particularly after she built up a tolerance to the Incurin we were using to treat her incontinence. When we stopped the incurin and switched to Proin, her incontinence improved, but she became very PU/PD (drinking about 300-400% her normal water intake, lots of pee). Our vet performed a complete set of bloodwork, urinalysis, CBC, etc. Everything came back normal (no signs of infection, no kidney issues, etc), with the exception that her ALKP values had increased again up to 790 (previously 490). We repeated the LDDS test (now that her PU/PD was worse and off the influence of the incurin) and this time it came back positive (3.9 initial, 2.0 at 4 hrs, 1.8 at 8 hrs, reference range is <1.4). We also rechecked her T4 and free T4 levels, and those were seen to be well controlled (also her typical first sign of hypothyroidism is diarrhea, which she doesn't have).

With that info, plus all the other cushing's signs she's been showing (hair loss on tail/along spine, heat intolerance, increased panting, decreased energy levels), the vet diagnosed cushings. We are starting a very low dose of Veotryl (.5 mg/kg), but I wanted to know what to expect with starting this treatment. We don't start until next week (they had to order the right dosage of the medicine), and we already have schedule an electrolytes check at 1 week and an ACTH stim test at 2 weeks. However, any experience with this drug and risks/concerns/issues/etc to be aware of would be helpful.

[Doggy_David]

Also, if anyone out there has any experience with HAC and incurin, I'd be interested in knowing if you've seen similar effects. there's not a lot of info out there, but my theory is that since estriol is a form of estrogen (which is also produced by the adrenal glands), somehow this gives a similar effect to dexamethasone, essentially suppressing (some) of the effects of HAC, assuming its pituitary-caused. I'm no expert, but that makes sense to me, given what I've seen, but I'm curious if anyone else has a similar experience.

[Squirt's Mom]

It's good to hear from you again and to hear that Bella is doing well for the most part. However anytime I see that someone is using Proin it scares the crap outta me because of what that drug did to my Sweet Bebe, Squirt. Not only does it cause side effects that are the same as some of the signs for Cushing's I have no doubt it caused her stroke which changed her for the remainder of her life. You can read our experiences at the following link to her thread. It starts at post #532 where she is prescribed Proin. One of the links to the FDA report no longer works but you can search the FDA website using the word "Phenylpropanolamine". You will find several articles concerning the dangers of this drug, the FDA's efforts to remove it from the market, and their success in removing it from all human drugs. Sadly it remains in veterinary use. You can also google "Proin death", "Proin side effects", "Proin dangers" and learn more. Here is Squirt's thread to get you started - (post #532 starts the conversations on Proin in her life) -

https://www.k9cushings.com/forum/sho...-Bridge/page54

[Harley PoMMom]

Are you getting the Trilostane (active ingredient in Vetoryl) compounded? And is your vet testing the cortisol using the pre pill method or the regular full ACTH stimulation test? Also, it is very important to give the Trilostane with a meal as it needs food to be properly absorbed. Here are a couple links to information from our Resource Thread that I believe you'll find useful: Cost Savings for Owners of Cushingoid Dogs (https://www.k9cushings.com/forum/showthread.php?9066-Cost-Savings-for-Owners-of-Cushingoid-Dogs) AND Trilostane/Vetoryl Information and Resources (https://www.k9cushings.com/forum/showthread.php?185-Trilostane-Vetoryl-Information-and-Resources)

Please keep us updated!

Lori

[Doggy_David]

No, we're getting Vetoryl at one of the existing dosages (she's a ~22 kg dog, so at .5 mg/kg, they want to start her on a 10 mg dose 1x/day). For checking the cortisol, the plan is to do a full ACTH stim test is my understanding. They are going to do an addition electrolytes check at the 1 week mark which is just a blood draw, but I think the 2 week check is a full ACTH stim.

SquirtsMom,
So sorry to hear about your awful experience with Proin, and thanks for the warning. So far Bella is tolerating it very well (no real side effects), and the vet is monitoring her blood pressure regularly. Part of the reason I'm interested in trying to start the Cushings treatment is I'm hoping that will improve some of her incontinence/PU/PD issues, since without the Proin she is leaking urine about 5-10+ times/day, and it was making her miserable, not to mention the toll it was taking on us trying to keep her and our house clean. The cushings symptoms all pre-date her starting Proin, so I'm hoping once we get that under control we won't need to have her on so many incontinence meds.

[Harley PoMMom]

Hi David,

Has Bella started the Vetoryl?

[Doggy_David]

Yes!
She's been on it for about 20 days now. She had an electrolytes check at 7 days (everything normal) and an ACTH Stim test at 14 days. The ACTH test came back with values of 3.9 (pre) and 9.7 (post). Our vet called today about the results (just came in over the weekend) and said it all looked good, keep the current dose. I'm a little confused by this, since while her PU/PD has improved slightly, it's definitely still not normal, and overall behavior is mostly unchanged. She's only on .5 mg/kg dose right now, and according to the flowchart that came with the Vetoryl, over 5.4 and symptoms not controlled means the dosing should be increased. Am I misreading this? I understand we're supposed to wait a full 30 days before any dosing changes, which makes sense, but I was going to make an appointment to talk to the vet about upping the dose when I need to buy more vetoryl (which will be at 30 days, she's taking 10mg doses right now).

[Doggy_David]

Also, just as information, the ACTH stim was done 4 hours after her morning meal and pill.

[Harley PoMMom]

Yes!
She's been on it for about 20 days now. She had an electrolytes check at 7 days (everything normal) and an ACTH Stim test at 14 days. The ACTH test came back with values of 3.9 (pre) and 9.7 (post).

Very happy to hear that her electrolytes were checked and they were normal. As for her ACTH stim test results, for right now I think those are good too...GREAT job!!!


Our vet called today about the results (just came in over the weekend) and said it all looked good, keep the current dose. I'm a little confused by this, since while her PU/PD has improved slightly, it's definitely still not normal, and overall behavior is mostly unchanged. She's only on .5 mg/kg dose right now, and according to the flowchart that came with the Vetoryl, over 5.4 and symptoms not controlled means the dosing should be increased. Am I misreading this? I understand we're supposed to wait a full 30 days before any dosing changes, which makes sense, but I was going to make an appointment to talk to the vet about upping the dose when I need to buy more vetoryl (which will be at 30 days, she's taking 10mg doses right now).

Nope, you not misreading it, however, cortisol can continue to drift downward during the first 30 days of treatment so a dosage increase is not recommended at this time. Will you be getting another full ACTH stimulation test performed at the 30 day mark? If so, and her cortisol is still over 5.4 ug/dl and she is still exhibiting symptoms a dosage increase would be justified but I wouldn't increase it more than 5 mg. Vetoryl does come in 5 mg capsules so if this were me, I would purchase 5 mg capsules in addition to the 10 mg capsules so that dosage adjustments could be made in 5 mg increments.

Lori

[Doggy_David]

Thanks. Glad to know I'm not misreading. I think I need to have a talk with the vet closer to the 30 day mark. Not sure if the plan is to do another ACTH test at 30 days or not. The big thing for me is the clinical signs haven't improved. It seemed like they were improving slightly for a bit (drinking less, spending more time hanging out with us versus sleeping on the cold tile all day, etc), but since the ACTH test things seem to have regressed back to before we started the vetoryl in terms of the PU/PD levels and the activity levels. Is this normal?

[Harley PoMMom]

The PU/PD shouldn't be getting worse, however, it could be that an UTI is brewing as cushdogs are notorious for getting them, since their urine is so dilute the best way to check for an UTI is to have an urine culture and sensitivity test done.

[Doggy_David]

Hi,
Just wanted to check in with an update. After several dose increase, we've seen some noticeable improvements in her PU/PD (PU is pretty much gone, PD is slightly elevated still but much better). We're randomly panting less (although still has some occasional bits of panting), and overall she's been much more sociable and less irritable. Still waiting for the fur to grow back, but I expect that will take some time. Her incontinence has also improved somewhat. She still seems to have some bits where her cortisol levels seem high, seems kind of episodic, but overall she's having more good days than bad days. Is this the right dosage now, or should I expect all the symptoms to be gone? I've kind of been waiting to see if her fur starts growing back to confirm we're at the appropriate dose, since her ACTH tests don't seem to show much effect after various dose changes. Any thoughts? She's currently at 30 mg twice a day (she's a 23 kg dog). Overall I'm pretty happy with her current dose, but am curious about the meaning of her ACTH tests (results are below). Thanks!

ACTH Results (vetoryl dose, pre-values, post-values)
10 mg 1x/day 3.9. 9.7
20 mg 1x/day 5.0 7.7
20 mg 2x/day. 4.0. 10.2
30 mg 2x/day. 1.6 9.5

[Harley PoMMom]

Improvements usually aren't seen in their fur until at least 6 months of treatment has occurred, and sometimes their fur may look/feel different (curlier, different color. etc.). A few questions regarding her ACTH stimulation tests, is she getting the Vetoryl with a meal? And the timing of the tests, are they being done 4-6 hours after the Vetoryl has been given with a meal and are they being performed around the same time? What I mean about the time, as an example: if her first ACTH test was done at 11 am, were all other tests performed close to that time?

Lori

[Doggy_David]

Thanks! I'll hold off on looking for the fur improvements for a little bit then. She does always get the vetoryl with a full meal, although I'm not very confident that the vet is performing the ACTH testing at a consistent time (or even precisely within the 4-6 hr window).

[Harley PoMMom]

I firmly believe that ACTH numbers are not the sole guide of how a dog is doing on Vetoryl. The goal of treatment is to control the clinical symptoms of Cushing's, so since Bella's symptoms have improved, if this were me, I wouldn't get so stressed about those ACTH stim results, I realize that may be hard to do and we're here for you.

[labblab]

Thanks! I'll hold off on looking for the fur improvements for a little bit then. She does always get the vetoryl with a full meal, although I'm not very confident that the vet is performing the ACTH testing at a consistent time (or even precisely within the 4-6 hr window).
Hi David,

I do agree with Lori that a dog’s clinical appearance is generally equally as important as test results. But given those ACTH results, I encourage you to confirm with your vet the exact testing protocol that is being followed. Those test results are really weird — I just don’t know any other way to say it. It is very strange to me that the post-ACTH numbers show very few changes whatsoever after increasing the Vetoryl dose from 10 mg. to 60 mg. as a daily total. That’s a *big* dosing increase, and I really can’t fathom why you’d see virtually no effect on the post-ACTH cortisol level. The resting cortisol level is lower on this final test, and actually you don’t want it to drop much lower. But the post-ACTH results are really puzzling.

Something about this doesn’t seem right, and if you have doubts as to whether your vet is performing the test properly, that’s the first place I’d start. Has your vet commented at all on the apparent lack of testing response to the dosing increases? Are you still using brand name Vetoryl at this point?

Marianne

[Doggy_David]

Thanks for the comments. I've been less worried since the clinical signs are *mostly* improved, but those results have also been very puzzling. Bella's primary vet at the practice doesn't really seem to have much experience with Cushing's (one of the other doctors seems to have more experience, but has been out the past two months). They are still basically viewing the ACTH test results through the lab provided "good" ranges, not taking into account that modified test ranges for dogs on vetoryl, so they have basically viewed almost all of the results as being acceptable. We've been using brand-name vetoryl the whole time (either combinations of the 10mg pills or now the 30 mg pills). I am planning a follow-up with Bella's internal medicine specialist, so I will see what they say about the results history. When last I saw them they recommended the switch to 2x/day vs 1x/day.

Overall, the only concern is that her cortisol still seems to flare up periodically. She'll be doing great for a week (minimal panting, no incontinence, etc), then have several days where she's panting more, leaking more urine again, etc. Overall its still definitely much improved and she's acting much happier, but I do get concerned when she still has these "down" patches.

[Doggy_David]

Hi all,
Following up with an update and a question. Bella's been on a 40mg 2x/day dose of Vetoryl for the past 6-7 months and has been doing great. Her fur has grown back in, her energy level and personality are back, it's been a dramatic turnaround from the pre-Cushings treatment days. The only catch is that she has started having some recurring diarrhea issues over the last few weeks. Diarrhea starts up, we get her seen, her electrolytes look fine so they put her on metronidazole, the diarrhea clears up, but a few days to a week after ending the metro, the diarrhea returns. This has happened 3 times now. I know that diarrhea is a common side effect of too large a dose of vetoryl, but she'd been stable on the current dose for many months. Anyone else have experience with issues occurring after long periods at the same dose?

If it occurs again we're doing an early ACTH stim test (had her last 3-4 months ago, it was 1.2 and 2.3, which according the vetoryl documentation is ok), but trying to get a grip on whether this is the likely culprit. She has no other symptoms other than the diarrhea when this occurs (no fever, etc). Would've done the ACTH sooner, but electrolytes and behavior were fine and the test is just so expensive. After talking with vet we did lower her dose of vetoryl to 30mg 2x/day with so far no return of the incontinence/panting/extra water intake that are her initial high cortisol level symptoms.

[labblab]

Welcome back to you and Bella. It’s great to hear that, overall, she’s been doing so well. However, I think it’s safest if you repeat the ACTH right away if the diarrhea occurs. Back when you posted in April, this had been the ACTH monitoring history up until that point in time:


ACTH Results (vetoryl dose, pre-values, post-values)
10 mg 1x/day 3.9. 9.7
20 mg 1x/day 5.0 7.7
20 mg 2x/day. 4.0. 10.2
30 mg 2x/day. 1.6 9.5
Now her most recent test 3-4 months ago had dropped clear down to 1.2 and 2.3. That is a significant drop from all those previous readings, without much wiggle room to go even lower. Trilostane doses frequently do need to be modified over time, both up and down, and that’s why the manufacturers of Vetoryl recommend that cortisol testing be performed every 3 months throughout the lifetime of treatment.

You had mentioned earlier that you had doubts as to whether or not your vet had been conducting the ACTH testing within a proper and consistent timeframe. This time around, I encourage you to confirm beforehand that the test will be run 4-6 hours after the morning dose of trilostane is given along with a full breakfast. Good luck, and we’ll be anxious to hear the results!

Marianne

[Squirt's Mom]

In addition to what Marianne said about the testing....it should also be done around the same time every time. So if Bella had the firs test at 10AM then all the ACTHs following need to be done as close to 10AM as possible. This way the cortisol is tested at around the same level in the body every time since Vetoryl has such a short life. Varying testing times means the cortisol level is varied making it hard to get a true picture of how well the drug is working.