11 yr old with CRCL injury—is surgery safe in a dog with Cushings?

[Sophiebearsmom]

Hi. I’m new to this forum and am hoping for some guidance. My 11 yr old Shih Tzu mix was diagnosed with Cushings and hypothyroidism when she was five. She has had great success with Vetoryl and Thyroid-Tabs. Last summer, Sophie injured her right leg and the vet suspected an ACL tear. She told me that she did not recommend surgery because dogs with Cushings have difficulty healing after surgery. We rested the leg and she seemed to recover but she does have quite a bit of arthritis.

Two months ago, Sophie began limping on her left leg after a fall down the stairs. My vet examined her, took x-rays and said it was a soft tissue injury. She was prescribed rest and Gabapentin.

Sophie seemed to get better, and then much worse. My vet recommended she be seen by a surgeon who has recommended TPLO surgery. My concern is that Sophie will be in extreme pain because the pain meds are limited for dogs with Cushings. It is also very expensive ($4300 plus $1000 in pre op testing). I remember being told that recovery from surgery is tough on dogs with Cushings because they don’t heal quickly. A normal healthy dog has four months of required restrictions for healing from the TPLO surgery.

Has anyone else had their dog in this situation? I want to do what is best for Sophie and don’t want her to have a permanent limp, but don’t want her to be in pain if the surgery isn’t necessary or best. I have read about Conservative Management restrictions without surgery but there is no guarantee that she will ever completely heal.

Any suggestions or advice? Thank you!

[Squirt's Mom]

Hi and welcome to you and Sophie,

Yes, it's true that our cush babies can take longer to heal however my own cush dog had surgery on her leg after being diagnosed and she did just fine. She had patella surgery when very young and had to have one knee redone when one of the pins started coming out. If I were you I would find a surgeon you trust to do the surgery and ask them what they would do if Sophie was their baby. The surgeon, not the GP vet, is the one who will be best able to tell you if this is a good idea for your baby or not.

We would love to hear more about Sophie and her journey with Cushing's - how she was diagnosed, what the most recent ACTHs have shown, what if any signs you are still seeing, her weight and dose of Vetoryl (Trilostane), and so on. The more you can share the more meaningful our feedback can be.

I'm glad you found us and look forward to learning more about your sweet girl in the future!
Hugs,
Leslie

[labblab]

Hello, and welcome to you and sweet Sophie! I’m wondering if you’ve had the chance to talk with the surgeon about your concerns re: the healing and the painkillers. If not, I’d encourage you to do so. It’s true that the high circulating levels of cortisol in an uncontrolled Cushpup can create these types of problems. In terms of painkillers, I believe it’s the combo of steroids and NSAID painkillers that is the chief worry. However, if your girl has been successfully treated with Vetoryl for such a long time, then I would think that some of these worries would be negated. In other words, if her cortisol level has been kept under therapeutic control all these years by the use of the Vetoryl, then she may not actually be subject to any greater current surgical/medication risk than any other dog. In the alternative, there may be other painkillers that would not hold the same risk for a Cushing’s dog as do NSAIDS. For instance, I know that tramadol is a painkiller that can be safely used in instances where NSAIDS are contraindicated. So if you’ve not done so already, I’d ask your surgeon what he thinks about Sophie’s specific situation. At that point, you’d then be in a better position to decide whether you’d want to consider going forward with surgery vs. trying a more conservative medical approach.

I’m surely sorry about these mobility issues, but also glad to hear that she’s done so well with her Cushing’s and thyroid meds. Does she still exhibit any outward Cushing’s symptoms, or has the medication largely resolved them all? How about her cortisol level — has it indeed remained well-controlled?

Once again, welcome to you both, and we look forward to learning more about you little girl.
Marianne

[Sophiebearsmom]

Hello, and welcome to you and sweet Sophie! IÂ’m wondering if youÂ’ve had the chance to talk with the surgeon about your concerns re: the healing and the painkillers. If not, IÂ’d encourage you to do so. ItÂ’s true that the high circulating levels of cortisol in an uncontrolled Cushpup can create these types of problems. In terms of painkillers, I believe itÂ’s the combo of steroids and NSAID painkillers that is the chief worry. However, if your girl has been successfully treated with Vetoryl for such a long time, then I would think that some of these worries would be negated. In other words, if her cortisol level has been kept under therapeutic control all these years by the use of the Vetoryl, then she may not actually be subject to any greater current surgical/medication risk than any other dog. In the alternative, there may be other painkillers that would not hold the same risk for a CushingÂ’s dog as do NSAIDS. For instance, I know that tramadol is a painkiller that can be safely used in instances where NSAIDS are contraindicated. So if youÂ’ve not done so already, IÂ’d ask your surgeon what he thinks about SophieÂ’s specific situation. At that point, youÂ’d then be in a better position to decide whether youÂ’d want to consider going forward with surgery vs. trying a more conservative medical approach.

I’m surely sorry about these mobility issues, but also glad to hear that she’s done so well with her Cushing’s and thyroid meds. Does she still exhibit any outward Cushing’s symptoms, or has the medication largely resolved them all? How about her cortisol level — has it indeed remained well-controlled?

Once again, welcome to you both, and we look forward to learning more about you little girl.
Marianne

Thanks so much for your quick reply! The surgeon seems very confident and the group was recommended by my vet. The surgeon believes that Sophie would be ok on a few days of stronger drugs. I guess I’m just a very nervous momma and read too much negative reporting on the internet.

When Sophie was four yrs old, I voiced my concerns to her vet because of her constant thirst, sudden peeing in the house, and her weight gain. She was always hungry. The vet I was using was new to the field and kept treating her for a UTI.

A friend recommended a groomer who was located in a local vet’s office. The groomer mentioned that Sophie had a large mass on her chest. The vet where she was being groomed looked at it and said he would like to discuss his concerns. I was upset that my original vet had not noticed this mass and switched her to the groomer’s vet. He removed the large mass (benign) and she has had several small wart-type masses removed since then. Is that a symptom of Cushings?

During her surgery follow up exam, we talked about Sophie’s weight, thirst, heavy panting, thin hair, and the fact that the skin around her eye used to be pink but was turning black. I thought her pot belly was simply because she had gained weight but he said she had quite a few symptoms of Cushings. She had several rounds of bloodwork and an ultrasound to confirm the diagnosis. I recall that the ultrasound technician mentioned that she had an enlarged spleen.

I honestly didn’t realize there were so many possible bad side effects of Vetoryl when she first started. I had blind faith that the vet knew what he was doing and started her on the meds. If I had researched the drug prior to starting it, I would have been very nervous. In the beginning her meds fluctuated a bit but her dosage has remained the same for the past three years. She has the cortisol bloodwork twice a year. She takes one 10 mg capsule in the morning. I can pull her most recent bloodwork and report if you tell me what to look for.

I noticed in the first two months on Vetoryl that her panting had decreased and the accidents in the house stopped. She still has thin hair in spots and we are constantly battling skin issues. She gets little black flakes in her hair that looks like flea poo. We have worked hard on helping her lose some weight after she injured her right knee last summer. She has lost almost seven lbs during the past 18 months on prescription Science Diet canned food. She is sitting at 23.6 lbs and the goal weight is below 20 lbs. She will still try to sneak and eat her brother’s food so she still battles the hunger bug.

I am constantly worrying about how much time I have left with her, which is probably why I’m so stressed over the knee injury. A few years ago, her vet told me to expect Sophie to get to 12 yrs of age. That’s not too far away and I hate the thought that her last year of life may be spent in significant pain.

[LauraA]

My Cush girl has had Patella Surgery in 2016 and last year she had ACL surgery as well (she is 15 1/2 years young :) and has had Cushings for 5 1/2 years) The Patella Surgery was way more painful than the ACL surgery which she pretty much sailed through without any problems. Both times we gave her strong painkillers/anti inflammatories for a few days and then went with tramadol as needed. She loves her walks and is still doing her 2 walks a day even at her elderly age. The pre bloods were important and we were told if there was any irregularities that showed up in the pre blood work they would not go ahead. She had ACL surgery when she was about 4-5 years on her other leg (chasing a Kangaroo), and this time around the recovery was so much different. Instead of keeping her crated for months we had her up and walking around the 2-3 week mark, she was allowed 5 minutes a day which we divided up. And we also had to give physio therapy to her twice a day - which was pretty much stretching and contracting her leg. Luckily she is only a small dog and weighs 6 1/2 kilos so it was much easier to carry her and for her to recover. Hoping your surgery is just as successful as my crazy old girls was.

[labblab]

In the beginning her meds fluctuated a bit but her dosage has remained the same for the past three years. She has the cortisol bloodwork twice a year. She takes one 10 mg capsule in the morning. I can pull her most recent bloodwork and report if you tell me what to look for.
That’ll be great if you’d like to discuss her labwork further. If there are any results on the standard panels that are abnormally high or low, you can just type those individual numbers in a reply, along with the corresponding normal range that’s listed for that result.

I’m assuming the monitoring cortisol testing has been in the form of ACTH stimulation tests. In the U.S., those results will be listed as two cortisol levels, taken one hour apart. In Canada, there may be three levels listed. So again, you can just type those results in a reply, and then we can discuss things further.

Marianne

[Sophiebearsmom]

That’ll be great if you’d like to discuss her labwork further. If there are any results on the standard panels that are abnormally high or low, you can just type those individual numbers in a reply, along with the corresponding normal range that’s listed for that result.

I’m assuming the monitoring cortisol testing has been in the form of ACTH stimulation tests. In the U.S., those results will be listed as two cortisol levels, taken one hour apart. In Canada, there may be three levels listed. So again, you can just type those results in a reply, and then we can discuss things further.

Marianne

Bloodwork results on 9/1/18
ACTH
Test 1: Cortisol 1.1 - normal: 1.0-5.0
Test 2: cortisol 3.1 Low - normal 8.0-17.0
Alkaline phosphatase: 699 High - normal 5-131

T4 post pill 2.3 Low - normal 2.5-6.0

GGT 122 High - normal 1-12
Bun/creatinine ratio 30 High - normal 4-27
Monocytes 2 Low - normal 3-10

[randomguy]

Are NSAIDs not recommended for cushings dogs? I didn't know that.

[Squirt's Mom]

NSAIDS are very hard on healthy livers and the livers of our cush babies are already working overtime so drugs in that class simply add to the strain on that organ and can increase the risk of damage so we do our utmost to avoid them.

[labblab]

Are NSAIDs not recommended for cushings dogs? I didn't know that.
In addition to being hard on the liver, the combination of NSAIDS and steroids in any form really elevates the risk for serious GI irritation and related internal bleeding. The same risk holds true regardless of whether the steroid is in the form of medications such as prednisone, or whether it is in the form of elevated circulating cortisol. In the case of Cushing’s, I would think this particular risk is minimized once cortisol levels come under therapeutic control with treatment. But this risk is one of the big reasons why NSAIDS should be used cautiously with Cushpups.

Marianne

[labblab]

Bloodwork results on 9/1/18
ACTH
Test 1: Cortisol 1.1 - normal: 1.0-5.0
Test 2: cortisol 3.1 Low - normal 8.0-17.0
Alkaline phosphatase: 699 High - normal 5-131

T4 post pill 2.3 Low - normal 2.5-6.0

GGT 122 High - normal 1-12
Bun/creatinine ratio 30 High - normal 4-27
Monocytes 2 Low - normal 3-10
Thanks so much for posting these numbers. Sophie’s cortisol levels on her ACTH stimulation look great and under excellent control! So I would think that would be a “positive” no matter what you decide to do. I see that her thyroid was just a tad low, but not far out of range. It’s not surprising that her Alkaline phosphatase remains elevated — high ALKP is a classic Cushing’s effect and the level often never returns to normal even following treatment. The high GGT may reflect the same effect.

I’m surely hoping that all goes well for you and Sophie, regardless what path you choose. We’ll be anxious for an update whenever you’re able to return to us.

Marianne