Corgi diagnosed today w Cushing's - Sadie has passed

[Alsarve]

Hello all. First time here, referred from a Reddit post. My 12 yr old, 13 in Jan, Corgi was just diagnosed today w Cushing's. Our vet is recommending a liquid medicine for Sadie because it's the "cheapest" option and easier to change the dosage. Still reeling a little from the cost. $250 for a 2 month supply and $241 everytime she gets the blood work done. Thankfully I have the Care Credit card that I can use to help spread out the cost. Hopefully by Saturday morning I will have the meds to start her on. Hoping to see some improvement in her heavy pot belly and panting.
Any recommendations on a dog food for dogs w this disease or not really an issue? She is on Rachael Ray Zero Grain chicken for the last 5 years. She doesn't have any of the skin issues. Mostly the pot belly, panting and lethargy. Pretty bummed, hoping we can afford to treat her til the end! Love that bratty fur baby! ❤

[Harley PoMMom]

Hi and welcome to you and Sadie!

I've got only a moment to post but have a few questions. How much does Sadie weigh? What is the medicine that she was prescribed, maybe Trilostane? What is the dosage (mg per ml) and is she supposed to take this once or twice a day? Could you post all test results for us?

I'm sorry that this post is short and I'll try to get back later on. Please know we are here for you both and will help in any way we can.

Hugs, Lori

Please read this material: -Cost-Savings-for-Owners-of-Cushingoid-Dogs (https://www.k9cushings.com/forum/showthread.php?9066)

[Alsarve]

I am hoping to get her meds on Tuesday morning now, they seem to have been delayed in shipping. She said she will have to have it twice a day but I am not sure of brand name or dosage yet. I hope it will start to make a difference. I worry about her labored breathing and panting. She had an episode this morning before I came home from work. She was coming up the ramp we made for them off the porch. Emily said she got halfway up and then she got a faraway look in her eyes and her back end gave out on her. I dont know if it was too much of a strain to come up the ramp or what? I am not going to use that yard anymore, she can go out front w just one step down. I worry I waited too long to get her diagnosed and that the medication won't help. Really worried about my good girl!

[Joan2517]

Hello and welcome. It would help if you posted answers to Lori's questions. You should be able to get the dosage amount from your vet, even before the meds get there, which you can post here. It would be difficult to answer your questions without answers to Lori's.

[Squirt's Mom]

Hi and welcome to you and Sadie! :)

Until we see test results from the LDDS and/or ACTH (and hopefully an abdominal ultrasound) used to diagnose Sadie's Cushing's plus have the info on the medicine prescribed along with the dose we really can't tell you anything specific to Sadie's Cushing's case. Monday if you can get those test results to share here, tell us the mg per ml in the liquid med prescribed and which drug, Vetoryl (Trilostane) or Lysodren (Mitotane) then post all the info here we will be able to offer more meaningful feedback. Today tho can you tell us how much she weighs?

However I can talk with you about diet today. For a cush pup the critical factor is the fat content. Our cush babies are prone to pancreatitis and fats can bring that condition to the forefront so it is important to keep our cush babies on a LOW fat diet. Moderate proteins are next unless she is a working or agility dog. Beyond that - whatever works best for her is the best diet for her. Other than the fats, diet has no impact on Cushing's, does not have any bearing on the cortisol or hormones running rampant in their little bodies so don't fall for anything that tells you she MUST eat raw, grain free, __________. Not true; ONLY low fat content matters. ;)

The incident on the ramp is not unexpected in an untreated cush pup. The cortisol causes the muscles in the hind quarters to weaken so they lose the ability to jump and move like they used to. Torn tendons like the ACL are also common so I would keep her from doing anything too strenuous until the cortisol is back to a more normal level. With treatment they typically regain that muscle mass in time. Their livers are typically enlarged as they are working much harder than normal with untreated Cushing's as well and that causes the diaphragm to be squashed making it harder for them to breath - hence the panting. This, too, will improve with treatment and usually pretty quickly. Because their livers are working so hard we avoid anti-inflammatories because those drugs are particularly hard on the liver. Talk to your vet about something easy on the liver if Sadie needs some assistance in this area but the cortisol is a natural anti-inflammatory and we don't usually see inflammatory conditions like arthritis, allergies, etc. until AFTER the cortisol has been brought back to a more normal level...then those things may make an appearance.

Are seeing any hair loss/failure to regrow hair, loss of house training, excess urination, excess drinking, HUGE appetite? The drinking, peeing, and eating are hallmark signs of Cushing's and if you are not seeing these I am concerned about the diagnosis. If you are seeing more drinking and peeing do NOT restrict the water. Our cush babies don't pee so much because they are drinking so much. It is just the opposite - they must drink excessively to keep hydrated because they are peeing excessively due to the effect of the disease on the kidneys. They WILL pee a lot regardless of how much water they get so we must keep water available at all time or they will quickly become dehydrated which is dangerous.

I'm glad you found us and look forward to seeing those test results plus other info as soon as you have them to share. If you have any questions don't hesitate to ask!

Hugs,
Leslie

[Alsarve]

Ok, finally got Sadie's medicine from the vet. They are going to email her test results hopefully today, if not, I will call and remind them tomorrow. Right now I am kind of worried about her because she can't stop panting long enough to drink. So then she is drinking, panting, coughing, choking. Afraid she's going to choke or end up w fluid in her lungs. Ughhhhh...
Ok, here is any info I have so far. Sadie is 38 lbs, almost 13 yr old corgi. Vet prescribed her Trilostane 40 mg/ml, .5 ml 2xday, liquid. She said it was adrenal not pituitary. I gave Sadie her 1st dose of medicine this morning. Should I always give it with food? And when she goes back Jan 3rd for her next blood test, should I feed her that morning, her appt is at 8:30am. And I dont give her the Trilostane that morning right? Aagghh! A lot to remember right now.
Thank you everyone!! Its still a lot for me to wrap my head around. Will post test results as soon as I get that email.
Almost forgot. No hair or skin issues that I have found. Appetite has gone down, water consumption up just a little. Pants pretty much non stop unless sleeping. Pot belly. Gets worn out super easy, just from walking.

[Alsarve]

Leslie, you said you are concerned about the diagnosis if Dadie doesn't have the huge appetite, increased drinking/peeing. I honestly dont see that. She will only eat for me now, not my mom or anyone else. Normally she gulps down her food as soon as she gets it. But shouldn't the results she got from the 8 hr blood testing show Cushing's? I know you guys need those numbers, haven't got anything yet. I'm sorry for the questions without the test results. Thank you!

[Alsarve]

Got the results in an email but am too computer dumb to figure out how to post it on here. Could I forward it to someone? Have to get some sleep tho. 2 PM and I am a night shifter that's been up since 9pm yesterday. Thanks again everyone! Amanda & Sadie

[labblab]

Hello from me, too! Thanks so much for updating us with this additional info. As far as test results, probably the best thing for you to do (after you’ve gotten some sleep ;-) is just to type the significant results into a reply here. In terms of regular bloodwork, you only need to type in values that are either abnormally high or low (usually marked with an H or an L), followed by the normal reference range for that value. I’m assuming Sadie also had one or more specialized blood tests for Cushing’s — either an ACTH stimulation test, or a Low Dose Dexamethasone Suppression Test (LDDS). Both of these tests will report the results in terms of cortisol levels. The ACTH will have two different cortisol readings taken one hour apart, The LDDS will have three cortisol readings: a baseline reading, then one taken four hours later, and the third taken eight hours later. So if you can give us that information, that will be a good start.



Ok, here is any info I have so far. Sadie is 38 lbs, almost 13 yr old corgi. Vet prescribed her Trilostane 40 mg/ml, .5 ml 2xday, liquid. She said it was adrenal not pituitary. I gave Sadie her 1st dose of medicine this morning. Should I always give it with food? And when she goes back Jan 3rd for her next blood test, should I feed her that morning, her appt is at 8:30am. And I dont give her the Trilostane that morning right? Aagghh! A lot to remember right now.


Based on what you’ve told us, Sadie will be getting 20 mg. of trilostane twice daily, for a total of 40 mg. This is an appropriate starting dose for a dog weighing 38 pounds, so that is good. In answer to your question about food, yes, trilostane should always be given along with a meal in order to be absorbed properly.

In terms of her monitoring test in January, it’ll be very important to find out what type of test will be given. Traditionally, the trilostane monitoring test has been an ACTH stimulation test performed 4-6 hours after the dog is given her morning dose of trilostane along with breakfast, just like every other morning. A newly introduced monitoring method is to test the resting cortisol level right before the morning dose of trilostane is given. Since Sadie’s test is scheduled for 8:30 a.m., I’m wondering whether your vet is planning to test using this newer method. As I say, you’ll want to clarify which testing method is being used before the day arrives for the test itself, because the feeding and dosing schedules are very different.

One other question: usually a vet can’t know for certain that a dog is suffering from an adrenal vs. pituitary tumor unless an abdominal ultrasound has been performed to actually view the adrenal glands, or some additional specialized diagnostic bloodwork is done. Do you know the basis by which your vet has diagnosed an adrenal tumor for Sadie? Trilostane can be used to treat either form of Cushing’s, but there can be some issues that are different if an adrenal tumor is definitely known to be present.

OK, I think I’ve rattled on long enough for now! In closing, though, I’ll give you a link that will explain trilostane treatment and monitoring protocols in greater detail. I think this info will be a help to you.

https://www.k9cushings.com/forum/showthread.php?8925-GENERAL-GUIDELINES-for-Dosing-and-Monitoring-Treatment-with-Vetoryl-(trilostane)

Marianne

[Squirt's Mom]

It's best to type in the results. From the test that shows things like ALP (or ALKP), BUN, CHOL, etc we only need to see those values that are too high or too low. Enter the little letters that follow along with the normal range so it looks something like this -

ALP 1600 ug/dl 150-300
BUN 12 mnol/L 9-13

For the ACTH we will need to see all the numbers given. There will be either 2 or 3 depending on if you are in the US or not. There will be a pre and post number and maybe a middle one.

For the LDDS we will also need to see all the numbers given - there will be 3 of those.

For the ultrasound, any comments other than "unremarkable" or "normal" we will want to know all of those comments on each organ mentioned. It may say something about the kidney wall being thickened for example.

The appetite falling off is a bit concerning to me but we have seen cush babies who don't show the ravenous appetite that is normal for a cush pup tho is it unusual. Since you have been told it is adrenal and not pituitary there is another consideration - a type of adrenal tumor called a pheochromocytoma which is not a cortisol producing tumor but can cause some of the same signs seen in Cushing's and can cause false-positives on the cush testing. But seeing the lab result will help us. The appetite change is what made me think of a pheo. Here is some info on the pheo just in case -

https://www.addl.purdue.edu/newsletters/2007/Spring/CP.htm

https://www.petmd.com/dog/conditions/cancer/c_dg_pheochromocytoma

http://vetnetinfo.com/tudasbazis/files/2016/02/Pheochromocytoma-2006.pdf

Hugs,
Leslie

[Alsarve]

Ok, gonna try some numbers. Got a 2 hr nap, please excuse my sleep deprived brain. Sadie is finally sleeping comfortably in her favorite spot, the cold hard bathroom floor.
HEMATOLOGY
L Hemoglobin 13 (13.4-20.7)
H Reticulocyte 133 (10-110) comment: appropriateness of regenerative response should be evaluated due to degree of anemia and reticulocytosis.
H Neutrophils 13439 (2940-12670)
H Platelets 531 (143-448) comment: platelets clumped on blood film
Polychromasia & Anisocytosis are both "slight"
Slide reviewed microscopically, no parasites found.

[labblab]

Great, that’s an excellent start! These first results relate to blood cell counts (often labeled as “CBC” summaries). You should also have a page of blood chemistries (“Chem” panels), and also any specialized Cushing’s tests. But you’ve typed these cell counts just as we need to see them. Good job ;-).

Marianne

[Alsarve]

H Glucose 126 (53-114)mg/dL
H ALT 208 (18-121) U/L
H ALP 3539 (5-160) U/L
H GGT 23 (0-13) U/L

Sorry for so many posts. Have to post stuff before I fall asleep and erase stuff ��

[Alsarve]

Ok, looks like everything was normal in the urinalysis. Last thing on this paperwork is her cortisol.
H Cortisol 14.3 (2-6) ug/dl
Total T4 1 (1-4) ug/do

Remarks at the end of this bloodwork, which was done 11/14/18.
Both SDMA and Creatinine are within reference levels which indicate kidney function is likely good.

Her test for cushings, cant remember the initials, was the 8 hr test, done on 11/28/18. Sent into Michigan State and interpreted by Kent Refsal, DVM PhD, Professor Endocrinology.

Cortisol Baseline 135 (15-110) nmol/L
Cortisol low dose dex 4h 90 (0-30) nmol/L
" " " dex 8h 67 (0-30) nmol/L

Interpretation: There is incomplete cortisol suppression in response to administration of dexamethasone. These results support a diagnosis of hyperadrenocorticism, provided that the clinical signs and other test abnormalities are consistent. The extent of suppression of cortisol at 8h suggests this is more likely to be pituitary dependent hyperadrenocorticism. There is recognition of false positive adrenal function test results as a stress response to non-adrenal illness. Are there clinical features that do not fit well with hyperadrenocorticism?

[Alsarve]

I also had bloodwork run on her Aug 28th at another vet because she was vomiting and off her food, just not right. Here are some of the numbers to compare, from Aug to Nov 2018.

Glucose 121 mg/dl 70-143
ALT 144 U/L 10-125. HIGH
ALKP >2000 U/L 23-212 HIGH
This bloodwork wasnt quite as thorough. At this Sadie was panting but not all the time. And just started to show the muscle weakness a little more. Evidently I was wrong about the adrenal or pituitary part. Ok time for another quick snooze before Sadie's dose at 9pm. Thanks ladies! ❤

[labblab]

Okey Dokey, thanks so much for typing in all this info. Sadie does indeed exhibit some lab abnormalities that are consistent with Cushing’s: elevated neutrophils and platelets in terms of cell counts, and elevated liver markers on her chemistry panel. Her glucose is slightly elevated and her thyroid is low-normal, both of which can be associated with the high cortisol of Cushing’s. Her 8-hour LDDS test is indeed consistent with the pituitary form of Cushing’s. However, please note this important part of the LDDS interpretation:


These results support a diagnosis of hyperadrenocorticism, provided that the clinical signs and other test abnormalities are consistent... There is recognition of false positive adrenal function test results as a stress response to non-adrenal illness. Are there clinical features that do not fit well with hyperadrenocorticism?

What this is saying is that this test may show elevated cortisol readings when something other than Cushing’s is the true cause. The body can produce high amounts of circulating cortisol in response to the stress of other illnesses or injuries, as well. That’s why you want to make sure that actual observable symptoms of Cushing’s are also present, in conjunction with the elevated cortisol. And that’s where I worry a bit about Sadie’s diagnosis. This is what you’ve told us about her symptoms.


Almost forgot. No hair or skin issues that I have found. Appetite has gone down, water consumption up just a little. Pants pretty much non stop unless sleeping. Pot belly. Gets worn out super easy, just from walking.

Most all Cushpups exhibit excessive thirst/urination that translates into abnormally dilute urine with a low specific gravity, yet apparently Sadie’s urinalysis was normal. Her lack of appetite is also worrisome, and contrary to the norm for Cushing’s. The fact that all three of her liver markers are elevated can be associated with Cushing’s, but it might also indicate a problem that is more specific to the liver. So I’m not wanting to raise unnecessary questions in your mind about the diagnosis, but I do think some questions are there. If you don’t see improvement while taking the trilostane, and especially if things worsen, I’d stop the medication and rethink things. Although it would mean extra cost, an abdominal ultrasound might give you the most bang for your buck in terms of additional diagnostics. The imaging would allow you to see whether there are problems with Sadie’s liver or other internal organs that could account for her illness, aside from or in addition to Cushing’s.

So bottom line, please do keep us updated as to how she’s doing!
Marianne

[Alsarve]

The vet also did a radiographic of her abdomen (I know that's not the same as an ultrasound just forgot to add it in with the other info).
It says radiographic shows markedly enlarged liver and inflammation in the upper GI tract (duodenum and pancreas). Distended cranial abdomen and tenderness on cranial abdomen palpation.
My vet said it doesn't matter if I give Sadie her Trilostane with a meal or not. Does anyone think maybe my vet doesn't have enough experience w Cushing's?
Sadie didnt want to eat this morning, so I cooked her up a little venison burger so she would have something to have her meds with. Any thoughts guys?

[Alsarve]

Thank you guys. Sadie passed in my arms about 20 mins ago. :( glad she had some yummy meat before she crossed over that rainbow bridge.

[Squirt's Mom]

Trilostane MUST be given with a meal, not snack, meal. It is a fat soluble drug and without food the body will not absorb and use it. However, with Sadie not wanting to eat I would not be giving the Vetoryl. I continue to find the diagnosis suspicious especially in light of the liver enzymes. In your shoes I would ask for an abdominal ultrasound and liver testing. But that is me. My first cush pup came back with false-positives on ALL her testing because of a tumor on her spleen. When the tumor was removed her cortisol returned to normal. She did eventually develop conventional Cushing's. My second dog diagnosed with Cushing's had many pre-existing conditions and a necropsy (autopsy in animals) following her death proved she never had Cushing's. So I am highly cautious when the dog does not present as a typical cush pup and Sadie does not. I wouldn't rush into treating Cushing's right now but would want further, in depth, testing myself.

[labblab]

Sadie’s lack of appetite is a real concern to me. If she were my dog, I would not feel comfortable continuing to give her the trilostrane under these circumstances. For one thing, I wonder whether she might be suffering from pancreatitis — that could account for the lack of appetite and also pain (panting). Or a primary liver/gallbladder issue could be a problem.

As far as the food, your vet is incorrect that it’s OK to give trilostane on an empty stomach. The manufacturer is very specific that food is required for the medication to be properly absorbed. Plus, giving on an empty stomach could increase the likelihood of tummy upset.

Bear in mind that I am not a vet, but I don’t feel good about your vet’s advice right now. I’m sorry about the expense involved, but if Sadie was my own dog, I’d ask for a referral for a consultation with a specialist in internal medicine. I’d simply say that Sadie’s lack of appetite is a real worry for you, and you want to make sure there’s nothing else going on before continuing treatment. In reality, I simply don’t think it’s safe to give trilostane to a dog while it’s not eating and the source of apparent pain is unknown.

Marianne

[labblab]

Thank you guys. Sadie passed in my arms about 20 mins ago. :( glad she had some yummy meat before she crossed over that rainbow bridge.

Oh my goodness, I was busy typing my own reply while you posted this news. I am so, so sorry!!!!!!

I have to wonder whether Sadie actually had a tumor or some type of internal bleed that was causing her the pain and the bloating. Again, I’m so deeply sorry, but I know you’re so grateful that she was there in your loving arms. And please know we’ll always be here for you if you want to talk more about what’s happened. What a shock :-((((((((

Sending huge hugs flying across the miles to you!

[Squirt's Mom]

Oh no! I am so so sorry to hear this and cannot imagine how you must be feeling. But I am sure she was where she most wanted to be - in your loving arms and that she flew from this life on the wings of love. Please know we are here to listen any time.

My deepest sympathies
Leslie

[Joan2517]

How sad....I have been following and hoping things would improve. Sadie died knowing she was loved. I am so sorry for your loss.

[Alsarve]

Having terrible amounts of guilt right now thinking I should have taken Sadie back to the vet days before she passed. Sick to think she was in pain and I passed it off as Cushing's symptoms. Miss her...

[labblab]

Everyone here surely understands, and we remain so sorry for your pain. I think it’s impossible not to feel guilty in the face of such a sudden loss. After the passage of nearly 15 years, I still have moments of guilt and regret over the death of my own Cushpup. And questions. So many unanswered questions that really can never be answered.

Since our beloved companions can’t talk, we can never know for certain whether or not they’re OK. We can only guess as to what they’re feeling and as to what is really going on inside. But you did the very best you could for Sadie, armed with the information you had in hand. Most importantly, you loved her. And the decisions you made for her were based on that love.

I know we can’t make your grief or guilt or questions go away. But we do understand since many of us have suffered in the same way. So please know we’re always here to talk, and to share our hearts and also memories of better days, as well.

Tons more hugs flying your way, always in loving memory of your sweet girl.
Marianne

[Squirt's Mom]

Oh that guilt can destroy us if we let it and sometimes it is so so very hard to let it go. I still carry an immense amount of guilt over my little Trinket who suffered horribly her last week of life while I continued to believe she wanted to live and fought so hard to give her that chance. The necropsy showed me how very wrong I had been in that belief, how badly she had been misdiagnosed which I trusted for the most part and it is so hard for me to put that away even tho she has been gone 1 1/2 years now. It has changed me forever.

Our little beloved Souls are so so stoic when they are in pain. They hide it well and no matter how intune with them we may be it is all too often easy for us, and vets, to miss what is actually going on with them. And I believe they truly do know how much we want them with us so they fight all the harder to keep their suffering to themselves. They are noble creatures with whom we are blessed to share life. Once they leave this life the battle to survive anguish becomes ours. We have to remind ourselves constantly of the good times, the times that are the true treasures of our relationship with them, and do our best to forgive ourselves even tho we did not, never would have, caused their suffering on purpose. We did all we did from a place of deep, deep love.

You and I will continue to grieve as we need as we learn to accept what was and what never could have been...and that in spite of the voices in our heads work to remember we were and are good moms, that we did everything we did or didn't do because we loved them so very very much. Our babies know what is in our hearts, now and then, and they don't harbor any harsh feelings but still love us as much as we do them.

You are not alone. My tears and the tears of others here who feel the same as you and I are with you.
Hugs,
Leslie

[Joan2517]

The guilt...always wondering if I did the right thing.

Towards the end, she wouldn't look at me. It was like she didn't want me to see how she was feeling, like she knew I would know...and I did. She just didn't seem right, even though her blood work was good and the vets kept saying how great she looked for her age. She, who would eat anything, refused any food that I put the Vetoryl in, like she was telling me enough. I should have left her alone and enjoyed the time she had left. Instead, I medicated her, ran to the vet at any sign I perceived of something being wrong, watched her like a hawk, took her every couple of weeks for the ACTH test.

The guilt...I live with it every day. My little Lena, my angel, dog of my heart.

We all know how you feel and what you're going through, but we can only do as much as we can with the knowledge we have at the time. We love them and they know it. They love us and we know it.

[Alsarve]

Thank you everyone....❤