Dog Diagnosed and feeling unsure about diagnosis and treatment

[Winston's Mom]

Hello,

My dog, Winston, a 12 yr (almost 13yr) old pit/chow/boxer mix was diagnosed with Cushing's last week. I had actually suspected it for close to 3 years now but each time I asked any general vet if that's possible they seem to be convinced his problems were due to a GI issue or disease. Two weeks ago my dog became listless and I took him to the ER where they took his vitals. He had a high respiratory rate and was running a fever. When I finally met with an ER doctor she asked me his acute symptoms (one bout of diarrhea earlier that afternoon but really nothing else other than feeling too weak to walk and the fever and refused to eat). I then went over his changes and symptoms historically and she said, "He looks like a Cushing's dog" then told me she suggested they do full lab work (CBC, Urinalysis and Culture in case it was a UTI) and an ultrasound. Well bloodwork showed show abnormal numbers and ultrasound found that his small intestine was thickened (has been for a while), his bladder was partially distended, liver was inflamed and both adrenal glands were enlarged. His last ultrasound prior to this was back in March 2018 that showed normal adrenal size and everything else was normal except for the thickened small intestine.

Anyway, long story short, he was given fluids, pain medication because his abdomen hurt upon palpation and I decided to take him home rather than hospitalize him. They also gave me Metrodizanole (?) to take home. The following morning his poop was completely normal and thereafter so I did not give him the metrodizanole. A few days later I had an appointment with an Internist at a vet speciality hospital. The internist seemed young (think she just completed her residency this past year) and immediately wanted to test for Cushing's disease. She didn't mention any other possibilities. Just immediately went off on the whiteboard and explaining cushion's and the two tests. Her recommendation was the ACTH stem test and a cPL (?) test for pancreatitis. She explained why she preferred ACTH over LDDS, but I can't remember why that is now. So they took him and the following day the results came back and she confirmed his diagnosis as positive for Cushing's.

Here's where I'm beginning to question the diagnosis now, even though I suspected it for years. She told me it was a complex disease to diagnose. So the fact that I literally got a diagnosis based on just the ACTH stim test has me questioning everything and maybe feel like she's not begin thorough enough to find out what is really wrong with him. So I asked her why she was so confident just from that test and she said it's also because of his clinical signs and symptoms, his ultrasound showing two enlarged adrenal glands combined with the ACTH stim test which was positive and when all those are combined there is high confidence of Cushing's. Am I being paranoid now? Now I'm worried there are actually other problems and maybe it's not Cushing's. Sometimes I wonder whether he is simply just Hypothyroid? His symptoms are:

-Ravenous Appetite (3 years now)
-Distended Abdomen (3 years now)
-Loss of hair on his tail, around his neck and around shoulders where his harness sits, a bit on the underside of his belly and underside of his thighs (gradual loss of -hair over the last 3 years)
-The hair all along spine to where the tail meets is very rough in texture (just started this summer)
-Increased thirst (just started this summer - vet blamed it to UTI)
-He is NOT incontinent, no house accidents, can hold it in up to 8 hours
-A hell of a lot of muscle mass loss. He's gotten very bony, can see and feel his ribs. The vet gave his body score a 3...but his appetite is through the roof and we feed him the same amount as he always had before, maybe if not more and have had a hard time getting him to put on weight. His spine has been sticking out severely for a couple of years now. It was one of the first symptoms along with the slow loss of hair on his tail.
-His skin used to be pink/whitish and now has varying degrees of black spots (3 years now)
-Oily dandruff (1 year now)
-Strange clusters of tiny black scabs developing under the arm pits (just this summer)
-weird skin nodules across his body (popped up over the last 3 years)
-He DOES not pant but his breathing, always closed mouth and through his nose, sounds labored (started a year ago) when he's sleeping at night and snores now.
-Sleeps all day long, lost interest in long walks, does not hang with his people anymore, stays in the bedroom, only shows excitement when treats or food is involved. (for a while now)

Should I be questioning my dog's diagnosis?? Does this sound familiar? Does it seem odd that after just one visit and one test with the Internist that the diagnosis is confirmed??

Thanks everyone.

[labblab]

Here's where I'm beginning to question the diagnosis now, even though I suspected it for years. She told me it was a complex disease to diagnose. So the fact that I literally got a diagnosis based on just the ACTH stim test has me questioning everything and maybe feel like she's not begin thorough enough to find out what is really wrong with him. So I asked her why she was so confident just from that test and she said it's also because of his clinical signs and symptoms, his ultrasound showing two enlarged adrenal glands...
Hello, and welcome to you and Winston! We’re really glad you’ve found us. In honesty, what your specialist has told you sounds accurate to me. Unfortunately, there is no way to know with certainty that Cushing’s is the “correct” diagnosis for any dog. Different puzzle pieces have to be considered, and if enough indicators point to Cushing’s, then confidence in the diagnosis increases. Winston does seem to check off a lot of the Cushing’s “boxes,” with the ACTH stimulation test being the final puzzle piece. There are only two lab tests that are specifically diagnostic for Cushing’s: the ACTH and the LDDS. And the ACTH is actually the more “specific” of those two tests, meaning it is less likely to return a “false positive” in the event that some other illness or injury is actually at play instead of Cushing’s. Perhaps that’s why the specialist preferred it in Winston’s circumstance.

So short of also performing an LDDS, there really is no other specialized testing available at this point. Having said that, we can review a few aspects of Winson’s previous testing in order to see how the puzzle pieces fit. When you took him to the ER, you mention that he exhibited certain lab abnormalities. Can you tell us more about them? Cushpups typically have elevated levels of ALKP — sometimes huge elevations — as well as higher levels of other liver markers, as well. Cholesterol, triglycerides, and platelets may also be high, and irregularities in certain white blood cell counts can occur. Urine is typically dilute, with low specific gravity. And you mention hypothyroidism — is Winston’s thyroid level within normal range? Low thyroid readings can be secondary to Cushing’s and rebound once cortisol levels are well-controlled, or hypothyroidism can be a genuine problem in its own right. It’s true that hypothyroidism could be responsible for some of Winston’s issues, so knowing more about his thyroid status will be helpful to us.

Once we know more about any of these other possible clinical abnormalities, we can better judge the likelihood that Cushing’s is at play. However, given the ultrasound results in addition to the other testing and symptoms that we already know about, I’m guessing your specialist is giving you an accurate assessment thus far of the diagnostic challenges/realities associated with Cushing’s. Have you discussed treatment options yet, should you decide to proceed with that?

Marianne

[Harley PoMMom]

Hi and welcome to you and Winston from me as well!

One question I have is; was pancreatitis confirmed, and if so, what were the results of that specific test?

Lori

[Winston's Mom]

So happy to have found this forum! Here are my dog's lab results. FYI, the labs results that they emailed me from the ER (CBC and UA) look totally different format wise from what I'm used to seeing from my regular vet's office. Those typically include more footnotes and information. Also, I don't see any thyroid value in any of these tests.

CBC Panel I'm posting what was outside normal range - or results I'm unsure of..

ALT 154
10-125 U/L
ALKP 330
23-212 U/L
CHOL 510
110-320 mg/dL
Cl 108
109-122 mmol/L
MCV 60.1
61.6-73.5 fL
MCH 21.1
21.2-25.9 pg
WBC * 19.09 5.05-16.76 K/μL
NEU * 16.74 2.95-11.64 K/μL

There was no range for these...I don't really understand what this means or what it is?
%NEU * 87.6 - %
%LYM * 9.0 - %
%MONO * 3.1 - %
%EOS * 0.2 - %
%BASO * 0.1 - %

EOS * 0.03 0.06-1.23

Urinalysis
(there were no normal ranges for reference..so i don't know what this all means? but specific gravity and PH had a green line marker on some scale - i guess that's good?)
COLLECTION METHOD CYSTOCENTESIS -
COLOR YELLOW -
CLARITY CLEAR -
SPECIFIC GRAVITY 1.025 -
GLUCOSE NEGATIVE -
BILIRUBIN NEGATIVE -
KETONES NEGATIVE -
BLOOD 2+ -
PH 8.0 -
PROTEIN 2+ -
UROBILINOGEN NORMAL -
WBC 2-5 0-5 HPF
RBC 20-30 - HPF
BACTERIA NONE SEEN -
EPI CELL RARE (0-1) -
MUCUS NONE SEEN -
CASTS NONE SEEN -
CRYSTALS NONE SEEN -
SOURCE URINE_CYSTO -

ACTH STIM RESULTS:

Time 1 PRE CORTISOL SAMPLE 1
5.4 (HIGH) 1.0-5.0 ug/dL

Time 2 POST CORTISOL SAMPLE 2
21.7 (HIGH) 8.0-17.0 ug/dL

HYPERADRENOCORTICISM (HAC): Post ACTH results greater than 20 ug/dL
(dog) and greater than 15 ug/dL (cat) are consistent with HAC.

NOTE: ACTH results should always be interpreted in light of clinical
signs. False positive results may occur with stress or non-adrenal
illness. In addition, exogenous steroids may be measured by the assay
and result in falsely elevated cortisol levels. Because of wide
variability, resting (basal) cortisol should not be used to rule-out
or diagnose HAC.

IATROGENIC HYPERADRENOCORTICISM: Resting cortisol is usually between
1-5 ug/dL with little to no increase in the post-ACTH cortisol level.

HYPOADRENOCORTICISM (HOC): Resting cortisol is usually subnormal
(less than 1 ug/dL) or low normal with no increase after ACTH.

POST-LYSODREN: Pre & post cortisol levels after Lysodren loading or
while on maintenance Lysodren should be between 1-5 ug/dL.

POST-TRILOSTANE: Pre & post cortisol levels between 1.5-9.1 ug/dL
indicate optimal control.

cPL
Chemistry
12/4/18 (Order Received)
12/4/18 7:35 AM (Last Updated)

Spec cPL 264
0 - 200 ug/L H

Serum Spec cPL concentration is increased and pancreatic inflammation is
possible. Consider additional diagnostics and/or treatment if clinical signs
or other evidence of disease exist. Recheck cPL in 2-3 weeks.

[Winston's Mom]

Hi and welcome to you and Winston from me as well!

One question I have is; was pancreatitis confirmed, and if so, what were the results of that specific test?

Lori
The specialist confirmed Pancreatitis. I asked her if it was just an acute episode or chronic and she said "chronic". I'm puzzled as to where she came to that conclusion.
Results:
cPL
Chemistry
12/4/18 (Order Received)
12/4/18 7:35 AM (Last Updated)

Spec cPL 264 0 - 200 ug/L H

Serum Spec cPL concentration is increased and pancreatic inflammation is
possible. Consider additional diagnostics and/or treatment if clinical signs
or other evidence of disease exist. Recheck cPL in 2-3 weeks.

[Winston's Mom]

Additionally, the specialist also just days later diagnosed him with Pneumonia. Also a bit puzzled...I did mention that there was one afternoon we were in the car and we heard him have 3 small coughs in a row. We weren't even sure if they were coughs or sneezes honestly. Just a random thing that happened. A few days later he sneezed when we walked out of our unit to go for our morning walk. After his sneeze I saw cloudy discharge from one nostril. I also described his breathing sometimes sounded wet at times, like he had boogers in his nose even though he had a runny nose for a while but it was clear except for that one time he sneezed. So I brought him in for a chest x-ray. She came back into the room and immediately said, "he has a little pneumonia" and immediately put him on Baytril. A few days later when I received an email with a summary of the visit and radiology report of the chest X-ray it mentioned "wet cough" which I never said and it said the X-ray was consistent with a case of Pneumonia, but then it also mentioned about considering PTE since the dog is Cushing's? My dog has had no other symptoms since then - now I'm questioning the Pneumonia diagnosis. I never know how much faith and confidence I should be putting into vets now ever since I spent the last 3 years of several vets telling me Winston could have this or could have that, or not looking further into abnormal lab work. *sigh*

[labblab]

Yeah, I sure do understand why you have a lot of reservations and questions about the whole diagnostic process. I tend to question most everything I’m told, myself (needless to say, that makes me not-the-most-popular patient and pet-parent on the block...;-). But definitely keeping in mind that I am not a vet myself, here’s some observations.

Several lab abnormalities are consistent with Cushing’s: elevated ALT, ALKP, cholesterol, overall white blood cell count, and neutrophils; low eosinophils. At 1.025, the specific gravity of Winston’s urine would probably be considered only moderately concentrated and somewhat below a preferred range. The presence of both blood and protein in his urine can also be associated with Cushing’s-related changes in his kidneys. Also, I’m guessing the possibility of the PTE was mentioned because there seems to be a higher risk of blood clots forming in Cushing’s patients. Cushpups are also more vulnerable to infections, in general, and that could account for the vet’s decision to treat any possible pneumonia or respiratory infection with an antibiotic. Last but not least, Winston’s cPL was a little bit elevated, but I don’t know whether the vet didn’t feel as though his clinical symptoms warranted additional concern in that regard.

And actually, that’s not quite the last thing — given Winston’s symptom profile, I’d be quite surprised if nobody has checked his thyroid status. It would appear as a “T4” reading on a blood chemistry panel. If the T4 level is out of range, then more involved blood testing can be done in order to better clarify whether a genuine thyroid issue exists. If his thyroid function truly hasn’t been evaluated at all yet, that’s one thing that I’d want to pursue further. As I said before, hypothyroidism doesn’t explain all his abnormalities, but it could play a role.

So, bottom line, Winston really does check an awful lot of those Cushing’s “boxes.” At this stage, it does sound to me as though it’s a likely diagnosis and I would be considering treatment if he were my own dog and I felt as though the symptoms of the disease were really diminishing the quality of his life.

Marianne

[Winston's Mom]

Yeah, I sure do understand why you have a lot of reservations and questions about the whole diagnostic process. I tend to question most everything IÂ’m told, myself (needless to say, that makes me not-the-most-popular patient and pet-parent on the block...;-). But definitely keeping in mind that I am not a vet myself, hereÂ’s some observations.

Several lab abnormalities are consistent with CushingÂ’s: elevated ALT, ALKP, cholesterol, overall white blood cell count, and neutrophils; low eosinophils. At 1.025, the specific gravity of WinstonÂ’s urine would probably be considered only moderately concentrated and somewhat below a preferred range. The presence of both blood and protein in his urine can also be associated with CushingÂ’s-related changes in his kidneys. Also, IÂ’m guessing the possibility of the PTE was mentioned because there seems to be a higher risk of blood clots forming in CushingÂ’s patients. Cushpups are also more vulnerable to infections, in general, and that could account for the vetÂ’s decision to treat any possible pneumonia or respiratory infection with an antibiotic. Last but not least, WinstonÂ’s cPL was a little bit elevated, but I donÂ’t know whether the vet didnÂ’t feel as though his clinical symptoms warranted additional concern in that regard.

And actually, that’s not quite the last thing — given Winston’s symptom profile, I’d be quite surprised if nobody has checked his thyroid status. It would appear as a “T4” reading on a blood chemistry panel. If the T4 level is out of range, then more involved blood testing can be done in order to better clarify whether a genuine thyroid issue exists. If his thyroid function truly hasn’t been evaluated at all yet, that’s one thing that I’d want to pursue further. As I said before, hypothyroidism doesn’t explain all his abnormalities, but it could play a role.

So, bottom line, Winston really does check an awful lot of those Cushing’s “boxes.” At this stage, it does sound to me as though it’s a likely diagnosis and I would be considering treatment if he were my own dog and I felt as though the symptoms of the disease were really diminishing the quality of his life.

Marianne

Marianne

Glad I'm not the only one who scrutinizes a bit! In my mind, there are lots of little telltale signs that dog may not show when we are actually at the vet, behavior wise as well, and often times I'm not the best at always describing things. Additionally, I have this perception that because the vets see tons of dogs day in and day out that after a while the are just trying to move patients in and out throughout the day and do not spend as much time really talking things out with me. That being said, I want to believe the Cushing's Diagnosis but I also want to feel like other possibilities are being explored just to rule anything else out. I think the specialists very quick diagnosis was a surprise to me!

I checked the the last CBC again and there isn't a T4 level there. I'm guessing because he came in sick so they assumed it would likely be low anyway but all three of his last CBC panels showed low T4 level. Each were with different vets. Two vets said it could be temp. caused by him being unwell. One of those vets did do some further testing on thyroid. Results were as follows:

Total T4 0.7
1 - 4 μg/dL L
Free T4 0.4
0.6 - 3.7 ng/dL L
Free T4 (pmol/L) 5.1
7.7 - 47.6 pmol/L L

cTSH 0.11
0.05 - 0.42 ng/mL

She said because his TSH level was normal that he was not Hypothyroid. I also just found another test result during that same testing. It is Cortisol level. I don't know if it's in the blood or urine. Is this the Urine:Cortisol ratio that is initially used to rule out Cushing's??
Endocrinology
3/14/18 (Order Received)
3/16/18 5:14 PM (Last Updated)
TEST RESULT REFERENCE VALUE
Cortisol 4
2 - 6 μg/dL

Aside from Cushing's and Hypothyrodism concern, I'm now beginning to become considered about his Kidneys. Could he have early Kidney disease? Over the summer there was bacteria in his urine. It was a free catch and a culture was made with the free catch urine. His only UTI-like symptom was drinking more (which has not resolved since then). I'm wondering if the bacteria was already present in the pan from doing the free-catch and he was placed on unneccessary antibiotics and whether this all points to early-onset Kidney disease - most recently his back legs have gotten extremely weak.

My overall hesitation and stress over the last week since his diagnosis has been treating him with Trilostane. I've heard that the adverse effects could be worse than the disease itself and the damage it can do would be irreversible. I'm having incredible anxiety over this, yet at the same time I want to improve the quality of my dog's life - the major symptoms that are most important to me on improving is bring his appetite back to normal, his energy level back to where it used to be and improving his muscle tone. I've looked into alternative methods, but I don't know how much affect they will truly have. My biggest fear is poisoning my dog with drugs and possibly affecting his own body's response to stress and illness if his cortisol is suppressed.

The specialist recommended I switch his raw diet to a cooke one and that I only give him low fat food now, in addition to treat the Cushing's with Trilostane at a dose of 30mg 2x/day. He is currently 43lbs (19.7kg). I asked the vet if that dose was too high and she said it was a very low dose for him.

My other hesitation with starting him right away is that in 5 days we will be traveling back to the east coast for the holidays. This means that we won't be here with the specialist to do the initial ACTH stim test after starting treatment with Trilostane. So a part of me wants to wait until we are back home after the New Year but now I'm wondering if my dog's situation is grave and whether or not me waiting another 3 weeks to begin could mean further deterioration in my dog's health. I should note that Winston will be traveling back with us and we could possibly do the ACTH stim test in New York but I don't know if that is wise or not?

Should I call my regular vet and ask to do a proper Hypothyroid panel? I had read somewhere that there is a very specific test for this other than what my vet had done earlier in the year.

Thanks for all your advice. I'm so new to this.
-Olivia

[Joan2517]

Hi Olivia and welcome to you and Winston. 30mgs twice a day is a high dose for a 43lb dog. The recommended dose is 1mg per pound, so I would not go over 30 mgs to start. It is always better to start low as you can increase. You check it in 14 days, don't increase until the 30 day mark. Sometimes it takes a while to get it right.

[labblab]

Hi again, Olivia. I agree 100% with what Joan has written. The dosing recommendation is really the first disagreement that I have with your specialist, and I’ll return to that in a minute.

First, the thyroid result that you posted is consistent with a dog who is exhibiting low T4 readings secondary to some other illness, of which Cushing’s is a prime suspect due to the elevated level of circulating glucocorticoid in the body. If that’s the case, then the thyroid level may also normalize all on its own once the primary, underlying trigger is satisfactorily controlled. Here’s a related “blurb” from Michigan State’s veterinary thyroid FAQs. As you’ll see, Winston fits best into the first, most common explanation.


My patient has low thyroid hormone concentrations, but thyroid stimulating hormone is not elevated. What does this mean?

Depending on the clinical presentation, one of two main possibilities is likely.

The more common explanation is that T4 values often decline in animals with non-thyroidal illness and in animals receiving certain drug therapies (some glucocorticoids or anticonvulsants). Non-thyroidal illness may suppress TSH release from the pituitary via glucocorticoid-mediated inhibition or lower T4 concentrations by altering serum protein binding affinities.

The second possibility (if clinical evidence for hypothyroidism is strong and there is no illness or interfering medication identified) is that the animal truly has hypothyroidism but it is one of approximately 15% of cases in which TSH is not found to be elevated. If clinical signs are not suggestive of hypothyroidism, this picture could also be consistent with advancing age or normal breed differences (esp. sighthounds - see below). It is not clear why as many as 15% of hypothyroid dogs can have a normal TSH concentration, but suggested explanations include: rare cases of secondary hypothyroidism (where the pituitary gland is unable to secrete adequate TSH), the presence of TSH-suppressing concurrent significant non-thyroidal illness, and structural differences in the TSH molecule that interfere with its detection.

Additionally, it is common for Cushpups to suffer from persistent or recurrent UTIs. I suspect the earlier urine culture was probably accurate, and even though no bacteria were noted on this most recent analysis, there may still have been some present that were missed because they are more difficult to detect in more dilute urine.

Lastly, the cortisol reading appears to be a resting reading taken from a blood sample. It falls within normal range for a resting, or baseline, cortisol level. But resting cortisol levels are highly variable for all dogs and cannot be used alone as a diagnostic indicator for Cushing’s. I suspect a vet may have ordered that level just out of curiosity, though, to see whether it was elevated once Cushing’s became a possible consideration.

So all in all, I think we have added reason to believe that Cushing’s is likely the underlying problem that is the source for a number, if not all, of Winston’s symptoms and abnormalities, including changes in the kidneys. If the elevated cortisol production is curtailed, we’d hope to see the resolution of many outward symptoms and also a halt to the progression of any internal damage. Having said that, though, I’d see no reason why you can’t postpone the start of treatment until you’re back home again. All of these issues that we’re talking about are the result of slow, chronic changes in the body. So waiting another three weeks shouldn’t be a big deal, and it will likely be much easier to monitor any changes or medication side effects once you’re back again into your normal, daily routine.

In closing, though, I do want to return to the dosing issue. Initial dosing recommendations have lowered dramatically in recent years, and unfortunately the published labeling that accompanies boxes of Vetoryl don’t really reflect this change so your vet may not be aware of it. Take a look at this post, though, and what Joan and I are saying will make much more sense. You may even want to print off the info to have in hand when you talk to the vet. Vetoryl (trilostane) is indeed a powerful medication, but any ill effects can be greatly reduced so long as proper dosing and monitoring procedures are followed.

https://www.k9cushings.com/forum/showthread.php?185-Trilostane-Vetoryl-Information-and-Resources&p=1251#post1251

All in all, though, I hope you’ll be able to take enough of a “time out” from your worries to enjoy the holidays. Regardless of whether or not you feel comfortable with beginning treatment at that time, we’ll still be right here to continue our discussions when you get back!

Marianne

[Winston's Mom]

Hello and Happy New Year! Winston and I are back home in California after a trip back to our family in New York during the holidays. We got the chance to go and visit Winston's trusted vet while we were back on the east coast. During the same time as the Cushing's diagnosis, Winston was also believed to have a pneumonia due to what looks like fluid in the lung. He was put on antibiotics, and is still on them, since we did a recheck with his vet back in New York. He's due for another X-ray since he's been on antibiotics for a month now and the specialist here said that if his chest X-ray hasn't changed that we'll stop the antibiotics and it could be something else, like PTE which is common in Cushing's dogs. Is this something anyone here has experienced or heard of?

When we visited with his vet while in New York our vet agreed that 60mg per day was far too high for Winston. So he wrote us a prescription for 40mg per day. The thing I also liked is that he wrote a prescip for 10mg capsules which allows us to continue to use the capsules if we have to reduce the dosage eventually. He also mentioned that there many people who do not want to medicate their dogs put their Cushing's dogs on melatonin and lignin's which was researched by vets at the University of Tennessee. Has anyone heard of this?

The pharmacy we dropped the prescription off has to order the vetoryl so it we won't be able to start Winston on it until this Thursday. I'm more comfortable with our long time vet's dosing, but I'm still extremely nervous about the risk that my decision to medicate with Vetoryl will do Winston more harm than good...very scary at bringing levels too low. When we returned home and I emailed the specialist an update and our vet's lower does of 40mg per day, she mentioned giving him 40mg once a day and doing the ACTH stim test 2 weeks later (her original 60mg per day was broken into 2x doses of 30mg) Meanwhile, my vet in New York said to split the 40mg dose into 2x/20mg per day. Is there a reason why one vet recommends 1x a day and the other 2x a day?

[Squirt's Mom]

I am very glad this vet lowered the Vetoryl dose for Winston! The comment about melatonin and lignans however is not correct. That combination is the treatment for a form of Cushing's called Atypical in which the cortisol is NORMAL but two or more of the intermediate, or sex, hormones are elevated. The combination will do next to nothing for elevated cortisol. So I wouldn't worry about trying that with Winston. The only place that does testing for Atypical is the University of TENN in Knoxville who did the initial research on this form. However Vetoryl causes elevations in the intermediate hormones so having that test done now would not be valid nor would I waste my money since the diagnostic ACTH showed elevated cortisol. So for now, just use the lower Vetoryl and let us know how that works for him.

As for PTE, that means blood clots in the lungs which is very serious so I am surprised no further testing was recommended. Our cush pups are prone to blood clots and Cushing's is one of the causes of PTE. Here is a link about PTE in dogs for you to read - https://www.petmd.com/dog/conditions/respiratory/c_multi_pulmonary_thromboembolism

[Harley PoMMom]

Regarding the once or twice a day dosing, if a dog has diabetes it is strongly recommended that the Vetoryl be given twice a day to help keep the cortisol on a more even level which is needed to control the diabetes.

Now for dogs without diabetes, once a day dosing is generally tried first but if it seems that symptoms rebound in the evening than twice a day dosing can be done.

Lori

[Winston's Mom]

Squirt's Mom - we haven't had the 3rd chest x-ray performed yet. He's going in this Thursday for the chest X-ray and that will determine whether or not to continue the antibiotics course. The specialist had only mentioned that if they find that there are no change to the lung on Thursday when they perform a new x-ray then we will stop the antibiotics and that it *could* be something like PTE, so I'm not sure what the next steps from there would be.

[Winston's Mom]

Lori - thank you for clearing that up!

I guess we'll go with once a day to start based on the specialist recommendation. Today I read a PDF of all the fine print information (ALL OF IT) for Vetoryl describing how to dose, testing stages, etc. and adverse effects including information regarding the studies that were done on the dogs and how many died and suffered from various adverse effects. Reading that gave me anxiety and continued worry. My dog's biggest obvious symptom is a ravenous appetite and lethargy which is pretty bad right now. That being said, one of the adverse effects is decreased activity and decreased appetite and if that happens to my dog how will I know that it's not a serious side effect and I need to stop the medication or if it means it's working?

Also curious if anyone can tell me from experience when I can expect to see improvement of his current symptoms like depression, large loss of muscle mass and increased appetite?

Very nervous about how he will react to Vetoryl - Winston is my entire life, we don't have kids, so he is even more so truly my baby - the thought of him getting worse or losing him due to the medication pains me beyond belief.

[Harley PoMMom]

Kudos to you for reading up on Vetoryl! I know it's scary starting your furbaby on treatment but we are here and will help in any way we can, we are the best hand holders!

Adverse effects are usually only seen when the dog is started out at a too high a dose. Diarrhea, inappetence, lethargy are some ill side effects so if you should see any one of those symptoms the Vetoryl needs to be stopped, also, if Winston would start acting not like his "ole" self than you would need to stop the Vetoryl, remember you know Winston best so if he would act off in any way cease the Vetoryl.

Muscle mass takes a long time to improve, that ravenous appetite should calm down within 2 weeks of treatment.

Lori

[Winston's Mom]

I am so so thankful that this group exists and that there is such a vast knowledge and first hand experience of Cushing's from actual dog owners and I think that is pure gold. I am very scared for my senior puppy but feel a bit better knowing you and everyone here is able to support me through this journey!

Olivia

[Harley PoMMom]

We are definitely here for you both! And remember, if in doubt don't give the Vetoryl as missing a dose will not harm him in any way....oh another thing, remember to breathe :)

Hugs, Lori

[Winston's Mom]

So, I've been having increasing anxiety about medicating, even though I feel like I should give it a shot. To be honest, the dosing is what has been bothering me the most even though it was decided to start with 40mg a day. Took my boy in this morning for a recheck on his chest to see if the lung has cleared up or not. Won't have results until tonight, but while I was there I spoke with the Internist who diagnosed him and the stress that starting him on Trilostane has been consuming me.

Surprisingly, she told me she didn't want me to do anything I wasn't comfortable with and even told me that I won't hurt her feelings if I wanted to go to UC Davis for other treatment options or another Internist at the same clinic that is familiar with other ways of treating Cushing's aside from the usual meds. Well, I still felt like I should give the Trilostane a shot at least and since I already paid for and picked up the Vetoryl from Costco yesterday. Luckily, they are 10mg capsules so I suggested starting with .5mg per lb/ a day and she said that's totally fine. So I'm going to start him on 10mg 2x a day. She also scheduled me in for an ACTH stem test this Monday, just a few days after starting treatment so we can check his levels to be sure they aren't too low. Feeling a little better about this now...but I am still so afraid. The anxiety is really starting to consume me. I have this fear I'm going to make my dog so sick. Does it matter if I begin the first capsule for his dinner tonight or wait until tomorrow AM?

Thanks in advance!
A very nervous me.

[Harley PoMMom]

Since you are dosing twice a day than its fine to start this evening, just make sure that he gets it with a meal. I'm sure he'll do fine, and remember to try to stay calm as possible because our furbabies can pick up on our stress...breathe!!!

Hugs, Lori

[Squirt's Mom]

Also, remember that Vetoryl (Trilostane) has a very short life in the body - leaving the system in 2-12 hours. So even if there were issues, simply stopping the med and giving Winston a few hours should set thing right again. This is the good thing about Trilo. Short life, easy to stop and restart if needed. So try to take a deep breath and believe in you. You are doing a great job of educating yourself and that is half the battle in canine Cushing's!

Hugs,
Leslie

[jrepac]

Lori - thank you for clearing that up!

I guess we'll go with once a day to start based on the specialist recommendation. Today I read a PDF of all the fine print information (ALL OF IT) for Vetoryl describing how to dose, testing stages, etc. and adverse effects including information regarding the studies that were done on the dogs and how many died and suffered from various adverse effects. Reading that gave me anxiety and continued worry. My dog's biggest obvious symptom is a ravenous appetite and lethargy which is pretty bad right now. That being said, one of the adverse effects is decreased activity and decreased appetite and if that happens to my dog how will I know that it's not a serious side effect and I need to stop the medication or if it means it's working?

Also curious if anyone can tell me from experience when I can expect to see improvement of his current symptoms like depression, large loss of muscle mass and increased appetite?

Very nervous about how he will react to Vetoryl - Winston is my entire life, we don't have kids, so he is even more so truly my baby - the thought of him getting worse or losing him due to the medication pains me beyond belief.

By most accounts, and from other pet owners I have spoken to, Vetoryl is a very good drug and safer than many/most of the older Cushings treatments. Just observe him carefully during the first week or so. Any adverse events/behaviors, you would stop dosing and contact your vet. good luck!

[Squirt's Mom]

Vetoryl is actually no safer than Lysodren. It simply has a shorter life in the body so if there is an issues it leaves the system much sooner than Lyso. Both have the exact same side effects up to and including death. Both require an experienced vet and an educated, diligent pet parent. ;) Neither one is safe but both are life savers WHEN used correctly.

[Winston's Mom]

Update on Winston

Yesterday we had Winston's first ACTH test since starting Vetoryl 12 days ago. Vet left a voicemail and said his pre level was 1.4 and his post was just over 2. She didn't email me the lab results yet but she said he's in normal range for excellent control of Cushing's. Well I'm a little perplexed that the levels are that low after only 11 days. Is this normal, especially since his dosage is very low for his weight. He's 45 lbs and takes 10mg 2x a day. If his levels continue to go down within the first 30 days should I be worried about them going too low before the 30 days is up and now I'm beginning to wonder if he's even Cushing's and simply just hypothyroid?? When he had the initial ACTH test to diagnose the disease his post level was just shy over the borderline that is considered likely to be Cushing's.

[Harley PoMMom]

Although those ACTH results are within the therapeutic ranges they do make me a bit uneasy too, because, as you mentioned, that it has been only 12 days since treatment began and cortisol can continue to drift downward during the first 30 days of treatment. I'd really keep an eagle eye on him, look for any signs that his cortisol is dropping too low such as diarrhea, lethargy, inappetence, or Winston simply just not acting himself, if any one of those symptoms are observed stop the Vetoryl. Since Vetoryl has such a short half-life ceasing the Vetoryl should be enough, however, if those ill effects would last an ACTH stimulation test is required.

[Winston's Mom]

I am home most of the time so I've been very eagle eye on him. So far since starting trilostane he had one bout of diarrhea several days ago and it was a one-time occurrence. I attribute that to trying out a new brand of food on him. His bowel has been normal after that. His appetite is still very good but honestly, he is lethargic even before starting treatment and that is actually his biggest symptom other than hunger so it's a little hard to gauge him based on energy level unfortunately. Considering his low level of cortisol I haven't really seen much improvement in his clinical signs so far.