Cushing's and muscle wasting.

[Wolfchan]

Hello all!

My boy Jasper is a 13 year old 25lb Jack Russell mix who was diagnosed with Cushing's in December. He's been hypothyroid for 3 years. He has been well managed on 45mg of trilostane daily along with his thyroid meds, dasuquin for his joints, and 5mg of amlodipine daily for his blood pressure. He has an adrenal tumor which was located via ultrasound just after diagnosis. His kidneys were affected enough that I've got him eating Hill's K/D now but he hasn't required any other management for his kidneys.

Recently I noticed lameness in his left front leg. It comes and goes. He's also struggling to get on and off the furniture and sometimes falls just running around the house. My husband took him in for and exam and radiographs this week and we've been told that he's not all that arthritic he just has quite a bit of muscle wasting. We've added injectable meloxicam daily (He was prone to hemorrhagic gastroenteritis in his youth so I avoid oral NSAIDs if possible) as well as adequan and gabapentin 100mg twice daily.

The new meds were started on 9/9 and I don't feel like I'm seeing much improvement yet. I know the adequan injections can take awhile to build up in the system and I'm trying to be patient but it hurts me to see him so uncomfortable.

I'm wondering how people here have managed their dogs' comfort once muscle wasting starts really affecting them. I'm a registered veterinary technician but I work in shelter medicine where we don't treat cushingoid dogs, so this is very new to me. I was feeling pretty good about his quality of life until the limping started, everyone who knew him was commenting on how he seemed years younger once we found the right medication regime and I was hoping he would remain stable for a long time, now I'm afraid I won't be able to give him a good quality of life anymore. :(

Here's my boy having a cuddle with our kitty.
https://ibb.co/b9ymS9

[labblab]

Hello, and welcome to you and Jasper! I’m surely sorry that this new issue has emerged for you after your initial treatment success. And to be honest, it is a bit puzzling. Once excessive cortisol levels have been stabilized with treatment, muscle wasting in Cushing’s dogs typically improves rather than worsening. I’m assuming that Jasper has had monitoring blood tests of his cortisol level since beginning his trilostane treatment. If so, it’ll help us to find out exactly what those numbers have been since my first thought would be that perhaps his cortisol is still running too high.

My second thought would be that he may be suffering from too severe of a dietary protein restriction. Can you tell us more about his kidney issues? My impression is that attitudes about kidney disease and protein restriction have shifted in recent years such that severe protein restriction is reserved for dogs who are uremic — exhibiting genuine and persistent elevations in creatinine and BUN that are making the dog overtly ill. Protein loss into the urine is fairly common among Cushpups, and may indeed warrant a moderate degree of protein restriction. But unless actual kidney function has been compromised to the extent that the creatinine/BUN are elevated, severe dietary protein restriction may not be beneficial (even harmful), and I would wonder if muscle wasting might be a consequence. Take a look at this article:

http://dogaware.com/health/kidneydiet.html


There are several prescription renal diets available that are not as low in protein as k/d, which is designed for dogs with advanced kidney disease and is not appropriate for dogs with early-stage kidney problems. There are also some senior diets that have low enough phosphorus levels to be used for dogs with early stage kidney disease (see Non-Prescription Commercial Foods).

The Hill’s K/D may indeed be suitable for Jasper, but as stated above, I believe that there are prescription dog foods with varying degrees of protein restriction and a different food might be less restrictive (for instance, Hill’s G/D). Or, per the article, you may find that there is a regular commercial food available that fits a nutritional profile that would be suitable for Jasper. But once again, we can better judge the situation once we know more specifics about his actual kidney problems.

So those are my two first thoughts. Once again, welcome, and we look forward to learning more about your sweet boy!

Marianne

[Joan2517]

Hello and welcome to you and Jasper. That is a great picture, he sure is a cutie! My last Cushing's dog, Lena, had a lot of muscle wasting before we got the Cushing's diagnosis. She couldn't go up and down the stairs anymore by herself, but it didn't seem to bother her at all. We just picked her up and put her down wherever she wanted to be. She slipped a lot, but she was so tiny she didn't have far to go. She was happy, and we all just adjusted to it. I don't think it affected her quality of life at all.

My big guy, Gable, who also has Cushing's, had stopped getting on the couch and running around playing with our other dog. He's been on Vetoryl since May and there has been a drastic improvement. He's playing again, sitting on the couch with us. Sometimes when he's running through the house, he does slip and fall, but he gets right back up and continues.

I think that if they don't notice or show signs that it is bothering them, then they still have a good quality of life. Checking on his levels would be a good start and if they are good, changing the food might be a good idea.

Gable had loose stools for the longest time before his diagnosis. I had them all on Wellness Original. They'd been eating it for years, and it never occurred to me that it just wasn't good for him. Finally my vet suggested Hills w/d and the very next day he had a solid poop! And has had them since. So it could just be a matter of changing his food...you never know.

[FoxFire]

I've noticed this too with my boy Kobe. He's always been a lean muscular dog, so much so that people would comment on how sturdy he was. But since his Cushing's set in (assuming that's what it is, so far all the test indicate it but he hasn't had his ultrasound yet), his muscles have definitely seemed weaker. He's put on weight, but not that much more since the days when he would literally jump up into the air to kiss any person that refused to get down to his level to get their requisite kiss from him. He was a very bouncy dog, and when he stopped being so bouncy I just chalked it up to his getting to middle-age.

His back haunches were particularly muscular. But now there is, what I perceive, a noticeable loss of muscle mass. Of course I wondered if it is just a perception thing, since he's gained weight and so his larger body may make his legs seem less bulky. But given his exercise intolerance, his no longer jumping up, and his reluctance to go up stairs (though he still does, he really has to be motivated), and the fact that Cushing's is known to do this to muscles, my suspicion is that's what it is causing it.

I'm hopeful that once Kobe starts and is on Vetoryl for awhile that this will reverse itself. Though it sounds to me like maybe in some dogs it does not. :confused: if your pup has only gotten worse.

Please keep us posted on how he does with his new medications, and if the dietary changes Joan and Marianne suggested help out.

Best of luck with adorable Jasper.

[Wolfchan]

I don't have the ACTH stim results handy, but his last test was within normal limits. His vet feels that this is old muscle wasting that has been exacerbated recent events (we replaced all the carpet in the house with vinyl plank, and we have been doing some traveling and Jasper's pet sitter has a pack of five dogs and several children in her home.) We've put up a baby gate so he can't go up and down the stairs at home anymore, as he was falling down the stairs regularly. The vet wants me to restrict his access to the sofas, but he has been allowed on them for 13 years and he's not going to stop using them. He refuses to use the carpeted stairs I've put next to the couch, but maybe someday he'll change his mind.

K/D is actually formulated to help maintain muscle mass since renal patients are so prone to muscle wasting. Jasper's last chem panel showed a SDMA of 17 combined with 2+ proteinuria. He does get high protein treats but I will ask his vet about mixing in a higher protein food. She (and I) feel pretty strongly about controlling his phoshporus and sodium intake.

Overall I do feel pretty lucky...instead of hair loss he has grown an undercoat and his fur has gotten all soft and plush. (He was always a single-coated wiry boy before!) He's more playful then he has been in the last year. Even his potbelly has gone down significantly, as his liver was quite inflamed when we started treatment and is now back to a normal size.

Thanks to everyone for the advice and well wishes! We'll keep you posted.

[labblab]

Thanks so much for this additional info! As far as the ACTH results, I’d encourage you to get the actual numerical results in hand. I always get a bit nervous when we’re told that that the monitoring results are “normal,” because the desired therapeutic range for dogs being treated with trilostane is actually significantly lower than the listed normal range for dogs who do not have Cushing’s. That difference can have a big effect on treatment expectation and outcome.

For what it’s worth, we have recently learned that many vets in the U.K. and Europe have now adopted a revised trilostane monitoring protocol that involves pre-pill testing of a resting cortisol level alone, as opposed to a full ACTH stimulation test. This protocol is endorsed by Dechra U.K., the maker of brandname Vetoryl. It is hoped/believed that this new protocol may aid in even better management of Cushing’s symptoms, and I am especially mentioning it to owners of dogs who are experiencing persistent symptoms even when ACTH results imply that they should be well-controlled. Here’s a link to a post with more info:

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

As far as the renal issues, I am definitely far from being an expert in any way. I tried to gain more knowledge a couple of years ago when my non-Cushpup Lab girl exhibited both a moderate degree of proteinuria and also an increasing SDMA, but I still have a lot to learn. In my nonprofessional opinion, though, I think you’re right on the mark as far as controlling phosphorus, and also some degree of protein restriction. I’m just concerned that you may be restricting too severely right now. Given both the SDMA that corresponds with early kidney disease and also the proteinuria, you don’t want to be overloading Jasper’s kidneys with protein. But the flip side is that he’s already losing protein in his urine, so you don’t want to restrict so severely that he’s malnourished. Here’s a quote from a round table discussion on proteinuria that is old enough that it predates SDMA testing. But I think the recommendations are still accurate.


Sanderson: Yes, there are some indications for renal diets in the nonazotemic proteinuric patient. If you have a choice between early-stage renal diets, which tend to have a little more protein, and advanced-stage diets, go with the early-stage diet in the beginning. The benefits are the omega-3 fatty acids and the protein itself. You want to keep up with what they’re losing, but you don’t want to give them so much that more and more protein is leaked into the kidneys and causes damage. Mild dietary protein restriction is warranted in those cases. Renal diets are indicated in both chronic renal failure and glomerular disease.

http://www.idexx.de/pdf/de_de/smallanimal/education/proteinuria-round-table.pdf

So, bottom line, I remain interested to see the actual numerical results for the ACTH testing. If Jasper’s cortisol level can be safely lowered further, that might help with both the muscle wasting and also the proteinuria. And in the meantime, I’d definitely continue to control his dietary phosphorus but, as said earlier, maybe be somewhat less restrictive of his protein intake than the K/D food.

Marianne