Breathing difficulties

[77sammy]

Hello, I'm new to the forum. I have a 14-year-old rescue dog who was diagnosed with Cushing's about 13 months ago. He's a large mixed breed dog.

He started vetoryl in July Â’17, gradually increased dose, now on 100mg daily, weight is 35kg. Coat has improved (except tail) but still very hungry and very thirsty. He is also restless. Alkaline phosphatase reading is around 1500, this has come down a little since last year.

My question is regarding his respiratory rate. It is consistently high, often around 60, even at rest, and he pants a lot, again, even at rest. The panting is raspy and sometimes he wheezes. I keep him cool at all times. I understand there are several reasons for panting and breathing difficulties in CushingÂ’s dogs - enlarged liver, which he has, deterioration of laryngeal muscles (and possibly chest muscles), possible calcifications in lungs etc.

Does anyone have experience of this and, if so, are there any ways to keep your dog more comfortable? My vet did prescribe tramadol - I have only given him this a couple of times, it helps a little with the restlessness but, of course, doesnÂ’t help his breathing.

Any thoughts or advice gratefully received.

[Harley PoMMom]

Hi and welcome to you and your sweet boy! I've only a moment to post but do have a couple questions. Could you post his ACTH stimulation monitoring test results? What symptom did your boy display that led to test him for Cushing's in the first place? Is he getting the Vetoryl with a meal?

I have seen respiratory issues brought up by other members and I do believe that it is listed as a side effect of Vetoryl.

Please know we will help in any way we can, and we are here for you both.

Lori

[77sammy]

Hi and welcome to you and your sweet boy! I've only a moment to post but do have a couple questions. Could you post his ACTH stimulation monitoring test results? What symptom did your boy display that led to test him for Cushing's in the first place? Is he getting the Vetoryl with a meal?

I have seen respiratory issues brought up by other members and I do believe that it is listed as a side effect of Vetoryl.

Please know we will help in any way we can, and we are here for you both.

Lori

Hello,

He had two ACTH tests.

June ’17 Post 0.25mg synacthen - 469
Sept ’17 Post 0.25mg synacthen – 505

Both of these were inconclusive (<600) but he was displaying more signs of Cushing’s by August/September ’17. And his ALP had been elevated from the outset.
The first symptom I noticed was an elevated respiratory rate (May ’17) and his breathing has been a constant issue since then. He didn’t start the vetoryl until Sept ’17 so it would appear to be unrelated. He has the vetoryl with his meals (2 x daily).

Good to know you are there!

[Squirt's Mom]

Welcome to you and your sweet baby boy!

Does anyone in the home smoke around your dog? I ask because I used to smoke and one of my dogs ended up with COPD as a result. I had been concerned about the smoke and asked several vets about it - they all told me it was very unlikey to cause them any problems because of their superb filtering system in the nose (with the exception of smush faced dogs like Pugs, Pekinese, etc.). I no longer believe that - smoking DOES harm our companion pets that are exposed. I would want a chest xray to see if there is any fluid in the lungs or around the heart and/or lungs and I would want that asap. Pneumonia is another consideration. Panting IS a sign of Cushing's but it could also mean other things completely unrelated to Cushing's and that is where I would start looking - outside Cushing's.

Hugs,
Leslie

[77sammy]

Hi Leslie,

Thanks for the post and your thoughts.

Absolutely no smoke in my home. I am extremely careful about all possible irritations - I use a fragrance free natural laundry liquid, never use any scented products or sprays and my boy even has an AirFree air purifier and filter by his bed.

He has had a chest X-ray, a bronchoscopy with lavage and a CT. This has shown that he has a few small areas of consolidation in his lungs as well as an interstitial pattern. He has been under the care of another veterinary team (who did the more in-depth investigations) and they, and my own vet, think that the former would not affect his breathing significantly. However, the diagnosis was a chronic lower airway condition for which there is no specific treatment. It seems likely that this would be adding to the breathing issues. It’s frustrating not being able to do anything about it – my vet tried various antibiotics in the first instance but they had no effect.

Obviously the combination of Cushing’s and the lower airway condition means that his breathing is compromised but he is doing amazingly well as he was diagnosed with Cushing’s almost a year ago.

[77sammy]

For Harley PoMMom/Lori,

I should clarify that the ACTH results I posted were nmol/L.

These convert to µg/dL as follows:

469 nmol/L = 16.99 µg/dL
505 nmol/L = 18.30 µg/dL

[Harley PoMMom]

Thank you so much for converting those ACTH test results, and I gather they were for diagnostic purposes, correct? Have there been any monitoring ACTH stimulation tests performed, and if so, could you post those?

The most common symptoms of Cushing's in a dog are increased drinking/urination, ravenous appetite, intolerance to exercise, seeking cool places, reluctance to jump up on furniture or go up steps, hair and skin thinning, and pot-bellied appearance. Did your boy have any of those symptoms? Cush dogs normally have elevations in the ALP, and other chemistry anomalies usually seen are increases in the cholesterol, glucose, and triglycerides. Were/are any of those levels high with your boy? Were any abnormal values found in his CBC blood work?

Lori

[77sammy]

Hi Lori,

No additional ACTH tests, he has been having regular blood tests.

He didn’t present with the classic symptoms early on but, as time has progressed, all of these behaviours and signs have become apparent. I should say that his coat has improved dramatically since starting the vetoryl, only his tail still looks a little ragged!

My vet indicated that the only findings that were elevated were his ALP and ALT (the latter to a lesser extent). I don’t have the print out for the other values but I will try and get this information from the vet.

I’ll be back in touch.

[77sammy]

To confirm, yes, those two ACTH results were for diagnostic purposes.

I have had a look at the last couple of blood tests – his glucose is slightly elevated, just outside the normal range in June and back within range, albeit at the higher end, in July. There doesn’t appear to have been a cholesterol test so I will check with my vet on our next visit.

All other biochemistry and haematology results were within the normal range.

Look forward to hearing your thoughts.

[Harley PoMMom]

I am really concerned about his cortisol levels, the vet should of performed at least 3 monitoring ACTH stimulation tests since the start of Vetoryl in July 2017. The monitoring ACTH stimulation tests are done to check the cortisol to make sure that it hasn't dropped too low. If this were me, getting his cortisol levels checked would be my first priority because if cortisol is too low, known as Addison's, this can be life threatening. Some common symptoms of Addsion's are: increased respiratory rate, panting, loss of appetite, lethargy, pale and/or tacky gums, diarrhea. Is your boy drinking and urinating normally?

Lori

[77sammy]

I have been keeping a close watch for Addison’s symptoms and I have some prednidale (steroid) tablets at home, provided by my vet, in case his cortisol is too low.

He does still have increased thirst and does need to go to the toilet more frequently, and of course has the breathing issues, but he has a voracious appetite and is not lethargic. I always keep an eye on his bowel movements, these tend to be soft as he has IBS but he hasn’t had diarrhoea.

However, I take your point about regular ACTH testing. We will be having another test in the next couple of weeks.

He has always been a quiet dog and likes to keep himself to himself – he came from Eastern Europe and was shut down when I first got him, clearly he’d had a difficult life and was very nervous of people. He’s absolutely wonderful with all other animals though – including cats. He was a street dog, likely put out on the streets when he got older and was no longer required as a ‘guard dog’.

He doesn’t covet attention, I think he has never had any love so he’s a little unsure about why I want to give him a cuddle or scratch his ear. I try not to impose but he has these beautiful, soulful eyes so it’s difficult!

Like everyone else on the forum, I want to do everything I can for my boy. It can be so difficult to know what to do when the same symptoms have different causes. I really wish I could do something to help his breathing – it’s so distressing to see. However, the next step should be another ACTH test.

Thanks for your support and please let me know if you think of anything else that might help with the breathing.

[Harley PoMMom]

Have the vet suggested to try any bronchodilators, such as Terbutaline or Albuterol, to help with the breathing?

[77sammy]

Yes, he was on theophylline for about 3/4 weeks in July 2017. It did not appear to make any difference so it was stopped.

The vet hasn't suggested any inhalers.

[77sammy]

Does anyone know if there is a recommended safe upper limit for daily dosage of Vetoryl? If so, what is it per lb (or kg)?

[labblab]

Welcome back! You’ll see that I’ve merged your new question into your original thread about your dog. This way, all the info about your boy’s treatment journey will be consolidated in one place, and that helps provide better context for any subsequent questions.

In answer to your question about dosing, specific parameters usually are given only when dogs first begin treatment. Initial daily dosing totals are commonly 1 mg. per pound, or 2.2 mg. per kg. After that, the size of the dose that’s required is based upon symptom improvement and subsequent monitoring blood tests. Dogs can metabolize the medication very differently, and thus, dogs of the very same weight may end up requiring very different doses. I’m not aware of any given upper dosing limit — it all depends on each individual dog’s physiological response to the medication.

Can you tell us what dose your boy is currently taking, and how he’s doing these days? We’d love to get an update!

Marianne

[77sammy]

Hello Marianne, thanks for moving the post.

I know that the Dechra recommended starting dose is 1-3 mg/lb (2.2-6.7 mg/kg). My boy is now on 300mg (2 x 150mg). He weighs 37kg. The dose has been increased gradually from 100mg in September. He has been on vetoryl since Oct '17 (starting dose 20mg per day).

Every time the dose is put up his symptoms improve for 3-7 days but then the hunger, thirst and panting resume. It's difficult to know what to do as, obviously, I want to keep him on the minimum possible dose but his symptoms are not being controlled by the 300mg. Also, it seems to me that a daily increase of 200mg in 3 months is a lot.
He tolerates the drug well although his stools tend to be quite loose for a day or two after the increase.

It could be that he has a fast growing tumour (I'm not sure if it is adrenal or pituitary) but this is just speculation. He is nearly 15 and I don't want to put him through a lot of tests as I think the stress would outweigh any benefits. I am thinking about contacting a veterinary endocrine specialist to have a chat. He was diagnosed in summer ’17.

Any thoughts would be welcome.

Thanks for your help.

[randomguy]

Deleted disregard

[labblab]

I am very worried if you are continuing to increase your boy’s Vetoryl dose without the benefit of testing his cortisol. Truly, this is very, very dangerous! You may not have a lot of outward warning signs prior to experiencing a life-threatening internal Addisonian crash. For this reason, it is not safe to continue giving the medication — let alone significantly increasing the dose — without checking the effect on your boy’s adrenal function and cortisol production. In honesty, I am dismayed that your vet is continuing to prescribe ever increasing doses without the benefit of the necessary monitoring testing.

300 mg. daily is a lot of Vetoryl, and works out to a bit over 3 mg. per pound for your boy. Even though published therapeutic dosing ranges fall between 1-3 mg. per pound, I don’t believe I’m aware of many dogs on this forum who have been dosed with that large an amount. My own 60-lb. Lab was initially dosed with a total of 240 mg. daily when he started treatment fifteen years ago when general dosage guidelines were much higher than they are now. His cortisol never dropped too low, but we did monitor his cortisol closely and ultimately significantly lowered his dose. Rarely since then have I seen doses that approached that level.

Once again, if I knew you were checking your boy’s cortisol after each of these increases, my anxiety would be relieved. But in the absence of testing, I’m really, really worried about the path you’re following. Given your boy’s apparent lack of response to these ever-increasing doses, it makes me wonder whether Cushing’s is even the correct diagnosis. Looking back, I’m reminded that your dog’s diagnostic ACTH results did not fall within the range that is consistent with the disease. So this makes me even more nervous.

Please, please, please make arrangements to have your dog’s monitoring cortisol testing scheduled ASAP!

Marianne

[77sammy]

Thanks Marianne. I really appreciate this. I am very worried about it as well.

Would you recommend just the ACTH and blood tests or is there something else I should be getting done?

[lulusmom]

I share Marianne's great concern that your dog has been steadily increased to such a jaw dropping high dose without the benefit of an acth stimulation test to justify those increases. I am dismayed that your vet has allowed this to go on for so long without testing and believe you are very lucky that your dog has not gone into crisis. I think your idea of getting a consult with an internal medicine specialist is an excellent one. I personally would do just that as soon as possible and would let the specialist direct treatment and any testing s/he feels is appropriate.

[labblab]

Monitoring cortisol production and basic blood chemistries (most notably potassium and sodium levels) are the most important tools. Historically, ACTH stimulation testing has been the preferred method for monitoring cortisol and it is still the most common method in the U.S. However, an alternative method has recently been introduced and is growing in favor, especially in the U.K. and Europe. It involves testing the baseline cortisol alone, right before a dose of trilostane is scheduled to be given. I think either monitoring method is fine — it’s just important to do one or the other in order to check adrenal function. Here’s a post that describes the newer “pre-pill” method in greater detail:

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

The importance of also monitoring potassium and sodium is because trilostane has the potential to lower the production of another adrenal hormone, aldosterone, as well as cortisol. Aldosterone controls the proper balance of potassium and sodium in the body, and it’s the other “half” of concern over an Addisonian condition. If either cortisol or aldosterone — or both — drop too low, an Addison’s crisis can be induced. But any basic blood chemistry panel ought to include potassium and sodium levels.

I truly believe that you are seeking only the best for your boy, especially after the rough life he led before you rescued him. You saved his life then, and you are trying your hardest to give him the best quality of life now. We are all grateful to you for what you are doing for him. In that vein, if the trilostane is not really helping him, even if his cortisol level is OK, you might want to give him a trial period to see whether he’s better or worse without it at all. I agree with you that at his age, comfort is the most important thing. So if the trilostane isn’t making him feel any better, you might want to just forget about it. That way, you wouldn’t have to worry about any negative side effects or the need for the monitoring blood draws. Just a thought. But who knows, maybe the cortisol testing will show that his cortisol is actually remaining too high to expect good symptom control. As you say, it’s possible that he may have an aggressive adrenal tumor that is really ramping up the cortisol production. When used diagnostically, the ACTH stimulation test frequently doesn’t return a “positive” result in the face of adrenal (vs. pituitary) tumors. So that might explain his original equivocal test result. All in all, we’ll surely be anxious to hear what the current testing shows!

Marianne

[Joan2517]

I have used the new resting cortisol testing and it is much less stressful on my boy (and me). Simple blood draw and home we go.

[77sammy]

My vet has been using the pre-pill blood test. Following two ACTH tests at the end of last year, my boy has had three of these tests. Just before the dose was raised from 180mg to 240mg, the vet was going to do another blood test but decided just to go ahead with the increase based on his symptoms.

Reading the post on the blood test, I was interested to read the following:
Very importantly, the resting cortisol level is evaluated in conjunction with the dog’s appearance and symptoms.
My vet has been very diligent in checking my boy and taking note of his symptoms and general behaviour as recorded by me. We see the vet every month, sometimes twice a month.

As I mentioned, I was anxious about giving him such a high dose of vetoryl and after careful thought, and receiving your posts, I decided to lower the dose over the weekend. I called my vet on Friday to check on this but he had already left the surgery.

Result, my boy has been absolutely fine. If anything, he is slightly perkier although it is sometimes hard to tell as he is such a quiet, gentle dog. He is still drinking more than normal and still hungrier than normal but not excessively.

Incidentally, he was only on 240mg for two weeks, then 300mg for two weeks (dose prior to that was 180mg). Granted that is four weeks too long and I am giving myself a hard time over this but we all do what we think is best at any given moment. I did keep a close eye out for any Addison’s symptoms but I take the point that this can happen with minimal outward warning signs. I am anxious about possible necrosis but, hopefully, that has not happened (would welcome your thoughts on this).

My plan now is to have another blood test done immediately and I have already asked for a referral for the endocrine clinic.

Thank you so much for the information and support, it’s good to know you are all out there.

[labblab]

That’s very reassuring that your vet was performing the pre-pill cortisol tests, so that’s a protocol we know that he’s familiar with and can be resumed once again. From what you’ve described, I doubt that any actual or lasting damage has been caused by the period of time that your boy was taking the higher dose. And who knows, it may turn out that the higher doses are appropriate for him. But we’ll all be relieved to know that further increases will also be monitored by actual testing.

Do let us know how things progress, especially if you do proceed with the specialty consultation.

Continued best wishes to you and your boy!
Marianne

[77sammy]

The blood test results were, in the main, good. ALP and ALT were both high, ALP in particular (1800). It was just under 1000 when he was given the Cushing's diagnosis just over a year ago and I am concerned about the increase. However, everything else is within the normal range including sodium and potassium.

Unfortunately, his cortisol level came back at 156 pre-vetoryl (normal range 40 - 138) so obviously the Cushing's is not being controlled. I'd reduced the dose from 300mg and he did really well for about 4 days but he's back on 240mg per day at the moment.

Some days are fine and others, like today, are not so good (agitated, ravenous and a lot of panting). I don't want to give him more vetoryl but I do want him to be comfortable. I have booked an appointment with the endocrine clinic so, hopefully, they'll be able to point me in the right direction.

Trying to stay calm!

[Harley PoMMom]

T I have booked an appointment with the endocrine clinic so, hopefully, they'll be able to point me in the right direction.

Trying to stay calm!

Has he had his visit at the endocrine clinic? And how are you both doing?