Cushings Meds and Senior Dog

[BillyD]

Baxter is an 11 yr old Beagle. He takes Phenabarbital/Potassium Bromide, Thyroid medicine, Pancreved tabs, milk Thistle. History of seizures (5 yrs seizure free), Hypothyroidism, Pancreatitis.

Diagnosed with Cushings this week. He has been prescribed Lysodren, but has not started.

In a senior dog, does starting Lysodren for Cushings outweigh the possible side effects? I have read some positive results with Holistic drops. He lets us know when he needs to go out and is making it through the night w out accidents. He is still going on His regular walks. Trying to get as much info as I can to make the right decision for him. Concerned starting Cushings meds could negatively impact his quality of life, and then again i know he has a condition needing treatment. Considering Pet Wellbeing Gold Harmony drops.
Thankful to have found k9cushings.

[Harley PoMMom]

Hi and welcome to you and Baxter!

Could you get copies of all tests that were done and post any results that are abnormal with the reference ranges and units of measurement? Also, we are really interested in the results of all tests that were done that confirmed the Cushing's.

Vetoryl is another medication used for Cushing's, did the vet mention why they prefer Lysodren over Vetoryl? And what symptoms is Baxter displaying that led the vet to test for Cushing's in the first place? Does Baxter have the pituitary or adrenal form of Cushing's? Sorry for all these questions but the more we know the better our feedback can be.

Again, welcome to our family and know we will help in any way we can.

Lori

[Squirt's Mom]

Hi! Welcome to you and Baxter! :)

YAY! A vet that prescribes Lysodren! I used Lyso with my cush dogs and that will be the drug I always choose to use as long as the dog tolerates it. Some dogs can't tolerate Lyso and some can't tolerate Vetoryl - in US we are lucky that we have the option to choose the other drug; not all countries have that choice sadly and are stuck with Vetoryl...or nothing. For me and my dogs, I will always prefer Lysodren until a better option comes along. ;)

As for side effects - both drugs have the exact same side effects. The main difference as far as side effects go is that the Vetoryl has a much shorter life in the body, leaving the system in 2-12 hours while Lyso stays in the system for several days. So if there is a problem the Vetoryl is out of the body quicker. It is up to a cush savvy vet to decide which drug they are most comfortable using AND to follow the protocols for that drug closely AND up to us to be educated as to what to look for that would indicate the cortisol has gone too low, which is a life-threatening situation. Once you start treatment we will help you learn all we can about this disease and the drug you are using...IF you choose to treat.

I have not used seizure meds but others here have and I hope they will be along soon to talk to you about them and how they can impact Cushing's. I am a bit concerned about the Pancreved - does Baxter have EPI? or has he had several bouts of pancreatitis that prompted the use of this med?

As for the drops you mention - they might help with some of the signs and they might make them worse. But they will do nothing for Cushing's unfortunately. IF those things worked none of us would use Lysodren or Vetoryl and forums like this wouldn't exist. We would simply buy an over the counter supplement and carry on because that is all the dog would need. And you can't imagine how often I have wished those things did work. ;)

I'm glad you found us and look forward to learning more about your sweet boy soon!
Hugs,
Leslie

[labblab]

Hello, and welcome from me, too! I see that Lori and Leslie have already gotten you off to a great start. Having had a non-Cushpup that was successfully treated with phenobarb for seizure disorder, I just have a couple of extra thoughts to throw in concerning the phenobarb “angle.” First, phenobarb itself can cause several side effects that mimic Cushing’s, such as excessive thirst/urination/hunger and lethargy. So I’m also interested in learning more about the specific symptoms that led to the Cushing’s testing, and to find out how recently they’ve surfaced. Also, how recently has Baxter’s phenobarb level been checked to ensure that he’s not suffering from a dose that’s too high?

Secondly, I’m wondering about the specific test results that led to Baxter’s diagnosis. In many cases, the LDDS is considered to be the most sensitive blood test for Cushing’s. However, phenobarb can skew the LDDS, resulting in “false positives.” So for dogs taking phenobarb, the ACTH stimulation test would likely be the preferred diagnostic blood test.


Phb treatment can alter thyroid and low dose dexamethasone suppression (LDDS) tests. Phb is associated with decreased total serum T4 and Free T4, but normal T3 and normal or increased TSH concentrations...Phb also enhances the clearance of dexamethasone, which may lead to a false positive (escape from suppression) on LDDS testing. However, Phb does not affect the cortisol response to ACTH stimulation or endogenous ACTH concentrations. Therefore, when testing for Cushing’s disease in dogs receiving Phb, the ACTH stimulation rather than LDDS test should be used. Dogs receiving mitotane (Lysodren) as well as Phb may require higher loading and maintenance doses of mitotane as PB increases its elimination.

http://www.canine-epilepsy-guardian-angels.com/antech.htm

Also, from experience with my own dog, I discovered that phenobarb interacts with a whole bunch of other drugs! It can be a real pain, sometimes, to find alternatives that don't interfere or compete with it. Importantly, as noted in the quote above, phenobarb is known to interact with Lysodren such that higher doses of Lysodren may be needed. This is something you’d definitely want to clarify with your vet prior to beginning treatment. As of a few years ago, phenobarb was not listed as actively interacting with the alternative medication, trilostane (Vetoryl), but apparently some dosing alterations may be recommended along the way with trilostane, as well. Here's a related reply that I posted to another member quite some time ago. There may be newer info available re: the combo of trilostane and phenobarb — for that, I’d encourage your vet to contact Dechra, the manufacturer of brand name Vetoryl.


OK, I just spoke with one of Dechra's technical reps, and what he told me pretty much coincides with what you were already thinking. Even though there is no documented interaction between trilostane and phenobarb (he is unaware of any clinical trials that specifically addressed that drug combination), dogs who are being treated with both drugs need to be monotored very diligently both in terms of liver function and also trilostane efficacy. He is aware of dogs that are currently being treated with both drugs, and no particular problems have surfaced thus far. But theoretically, phenobarb's effect on the liver could alter the way in which trilostane is metabolized by any given dog, leading to the potential for trilostane overdosing in the absence of appropriate dosing adjustments.

I don't know that there is a perfect answer in terms of drug preferability in conjunction with phenobarb, but I wanted to at least mention these considerations to keep in mind.

Marianne

[BillyD]

Thank you so very much for the info. Mr Baxter did the Urine Cortisol Creatine Ratio. Result was 273. Also, LDDST and I was told confirmed Cushings. Requested test results today and hope to get soon to share results. Thanks so much.

[labblab]

Given the interaction of phenobarb and LDDS testing, I do feel a bit wary about a “positive” result on Baxter’s test. So it will indeed be good to discuss the specific results, as well as the symptoms that led to the testing.

Marianne

[labblab]

Hi again! I’m still thinking about you and Baxter, and hoping we can find out more about his symptoms that have prompted the Cushing’s testing. In your first post, you write that he is still going for regular walks, makes it through the nights with no accidents, and lets you know when he needs to go out. So I’m wondering what his symptoms are that are pressing you to consider treatment right now.

Aside from the surgical removal of adrenal tumors, Cushing’s is not a disease that is “curable” in dogs — instead, the treatment goal is to control symptoms that are making a dog unhealthy or uncomfortable. Over time, Cushing’s can result in chronic internal damage in addition to observable outward symptoms. For this reason, owners of younger dogs often choose to be more aggressive about pursuing treatment, in order to lessen risks of long term damage in addition to easing observable problems. However, for older dogs, immediate quality of life may “trump” concern over slow chronic damage that might take months or years to accumulate. If symptoms are not that severe or worrisome in an older dog, then the monitoring and financial burdens associated with treatment may not be worth it either for the dog or the owner.

For this reason, it will really help us to find out exactly why Baxter has been tested. Once we know the answer, we can help you compile some helpful questions for your vet. You may indeed choose to move forward with the Lysodren treatment. But it shouldn’t be a problem for you to take some time to better understand your options. As stated above, Cushing’s is typically a slowly evolving disease. In most cases, there is no need to leap into treatment. So taking a few more days now to better understand Baxter’s options will most likely help him rather than harm him ;-).

Looking forward to learning more about your sweet boy,
Marianne

[labblab]

I have written post the past couple days and for some reason unsuccessful.

Wanted to share some test results of Baxter.

Urine Cortisol/Creatinine Ratio
>13 consistent with Cushings, Baxter result was 270

LDDST
Cortisol Sample 1 8.6 Range 1.0-5.0
Cortisol Sample 2 Dex 8.3 Range 0.0-1.4
Cortisol Sample 3 Dex 8.1 Range 0.0-1.4

From lab work, his ALP was 2072 range (20-150)
ALT 636 range (10-118)

Baxter was prescribed Trilostane 2/7/19 After much research, we decided with advice of Veterinarians to to with Trilostane instead of Lysodren.

His Urination has reduced. His bowel habits have changed. He has lost a great deal of muscle mass. His back legs are getting weaker each day. November he had his thyroid checked, was in normal range, but going to get that checked Monday.

Does Cushings cause the rapid muscle loss. We are now thinking he seemed to feel better not on any Cushings meds, then again if we were not treating Cushings we would probably question that also. Mr Baxter is having a tough time. He is a strong and tough dog.

We greatly appreciate the knowledge we have received here at K9cushings and the kind words of support and encouragement. Thanks so much.
Hi again. I’ve copied and pasted this private message that you sent me. I’m sorry you’re having trouble posting on your thread. You can send me another message and tell me exactly what is happening when you post and I can try to help you. In the meantime, though, I wanted to let everyone see your questions so that you can get feedback from other folks as well as from me.

Here are my thoughts/worries, however. Baxter’s LDDS is abnormally high. But as I’ve written before, the LDDS is not a reliable test for Cushing’s when a dog is also taking phenobarb. The preferred diagnostic blood test is the ACTH stimulation test. So in my own mind, I don’t think we can yet conclude whether Baxter has Cushing’s or not. I’m also wondering about the symptoms you’ve described. Loss of muscle mass is indeed a symptom of Cushing’s, but less urination is decidedly not. Cushpups drink and urinate excessively. Do you mean that Baxter is urinating less in these couple of days since he started taking the trilostane, or has this been going on for a while?

Secondly, Cushing’s dogs do often have very high ALKP levels, as does Baxter. However, his ALT, a specific liver market is also very, very high. Higher, perhaps, then we’d expect from Cushing’s alone. Phenobarb can be very hard on the liver, so I am worried that perhaps Baxter is having liver damage from the phenobarb that may be worsened by the trilostane, even if he does have Cushing’s.

I’ve asked this question before, but now it’s really crucial. When was the last time that Baxter’s phenobarb level was checked? If he is taking too much phenobarb, that can damage his liver and also cause many of the same symptoms as Cushing’s. If you are taking him in tomorrow to have his thyroid level checked, you need to ask about his phenobarb level, as well. This is very, very mportant.

Last but not least, how much does he weigh and how much trilostane is he taking? Although, to be honest, until these other diagnostic questions are resolved, I would not yet be giving him the trilostane at all. I’m not yet sure he has Cushing’s, and even if so, whether his liver can handle the combo of phenobarb and trilostane.

Marianne

[labblab]

Thanks for your response and posting. Baxter started having frequent urination the end of November. The urination frequency declined after starting Trilostane.

November 30th his weight was 44 lbs and is now around 34 lbs.

The dosage of Trilostane is 120 mg each morning. I am thinking to hold off on morning Trilostane until further discussion with his vets. The vet is planning to do ACTH after 10 to 14 days on Trilostane.

We have been concerned for years about the adverse affects of Phenobarbital on his liver. He has taken Milk Thistle for years in hopes to help his liver.

Will check with vet to get Phenobarbital levels, ACTH test, and then Thyroid levels.

Baxter did not feel so well yesterday, I sat up with him most of the night. He is having a much better day today, more active.

Thanks so much.
I’ve again copied your private message. Please try clicking on the “Reply to thread” button at the lower left at the bottom of this post. That should open up a new window for you to type into. If that does not work for you, please let me know.

Please do not give any more trilostane right now — 120 mg. is MUCH too high a dose for a dog weighing 34 pounds!!!! Initial dosing recommendations used to be higher, but current recommendations are not to exceed a formula of 1 mg. per pound. You are risking severe overdosing of Baxter even if he truly does have Cushing’s! Here is a link that will explain the importance of lower doses:

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

You can print this information to share with your vet tomorrow. But you have been giving Baxter four times the recommended starting dose for his weight, and that is very dangerous. I am really worried about your vet’s experience, or lack of experience, with Cushing’s. I am worried about the diagnostic testing, and now I am especially worried about the trilostane. Since your vet initially discussed Lysodren, I’m wondering whether Baxter is his/her first trilostane patient. I encourage you to encourage him/her to contact Dechra, the manufacturer of brandame Vetoryl, in order to get more guidance re: diagnostic testing, dosing, and possible liver issues associated with dogs taking phenobarb. I would not give Baxter any more trilostane in any dose until this all gets sorted out!!

https://www.dechra-us.com/contact/technical-support

Marianne

[Squirt's Mom]

I cannot second Marianne's plea for NO MORE TRILOSTANE strongly enough. The dose is way out of bounds even for a 44 lb dog and, I'll be very blunt, could easily kill your precious boy. Your vet is obviously out of touch with current protocol for this drug. My guess is they are more comfortable with Lysodren, have used Lysodren more, and simply do not know how to work with Vetoryl (Trilostane). For Baxter's sake tho you cannot give him any more Trilostane. In fact, if I were you I would not treat for Cushing's at all right now. There are simply too many questions concerning the Cushing's diagnosis for my comfort.

Please stay in touch and let us know how your sweet boy is doing.
Hugs,
Leslie

[BillyD]

Thank you for the feedback and support!

No more 120 mg. Will continue with 30 mg Trilostane per day.

Is hunger a typical symptom of Cushings?

[Joan2517]

Do not give Baxter any more Vetoryl until you do an ACTH test to see where levels are!

[Squirt's Mom]

Yes, extreme hunger is a hallmark sign of Cushing's. Our cush babies feel as if they are starving 24/7 - literally. They will wolf down a bowl of food then immediately start begging and hunting for more. They will counter surf if large enough, start getting into the trash when they never did before, and eat a host of weird, frightening things trying to stop that feeling of starving. It goes WAY beyond normal hunger to a exhibition of being ravenous constantly.

[BillyD]

Baxter is taking 30 mg Trilostane. He has been doing really well until tonight. His left hind leg is troubling him. He at times is not weight bearing that leg. Is hind legs weakness common in Cushings? Hopefully this is short term.

[labblab]

Muscle loss can cause hind-end weakness in Cushing’s dogs, such that they have difficulty climbing stairs or jumping. High levels of circulating steroids can also cause ligament damage. However, these problems typically appear when cortisol levels are uncontrolled, prior to starting treatment.

Since Baxter’s problem is only now showing up, it’s possible that lowering his cortisol level is now “unmasking” an arthritic issue that higher levels of cortisol were actually easing. This can be one of the “Catch-22s” of Cushing’s treatment in older dogs. There can be some quality of life trade-offs. If the problem continues, you may need to discuss pain control options with your vet.

I’m glad to hear that, otherwise, Baxter is responding well to the trilostane. As you know, I’ve had concerns about his diagnostic process and the idea of starting treatment while several question marks remain. So I’m relieved to hear that, basically, he is doing OK.

Marianne

[BillyD]

Thank you for that information. Next will seek solutions for his left hind leg and inquire about getting ACTH test sooner.
As far as his diagnostic process; his long time vet did urine and LDDT tests. We were advised to start Lysodren based on tests results, but concerned over possible drug side effects. Then consulted with a veterinarian in my home state. I then connected with a Veterinarian at a Vet school who has extensive experience with Cushings. Also a family member consulted with their vets regarding Baxter. I then found the tremendous resource of K9cushings. Then went to a second vet who treated Baxter years ago. This vet favored Ventoryl and started treatment. Then gained knowledge of his dose being higher than it should so that was changed. Our treating vet now has him on 30 mg Vetoryl. We are doing everything possible to help Mr Baxter. I will forever be grateful that he had K9cushings, 4 veterinarians, and an expert veterinarian/professor guiding us in his care.

[labblab]

I have tried to make this point several times now, but I’ll try one last time. LDDS results can be screwed up by phenobarbital. The LDDS should not be used or relied upon as a test of Cushing’s for a dog taking phenobarbital. The ACTH should instead be used as the diagnostic test for a dog taking phenobarbital. As a diagnostic, the ACTH should be run before any treatment drugs are started (it is also used as the monitoring test after treatment has started).

Your vet is relying on the LDDS to diagnose Cushing’s in Baxter, and that test may be wrong. Baxter may not have Cushing’s at all. That is why I’m relieved he is doing OK on the 30 mg. — because I don’t believe a genuine diagnosis has yet been made.

Marianne

[labblab]

I have tried to make this point several times now, but I’ll try one last time. LDDS results can be screwed up by phenobarbital. The LDDS should not be used or relied upon as a test of Cushing’s for a dog taking phenobarbital. The ACTH should instead be used as the diagnostic test for a dog taking phenobarbital. As a diagnostic, the ACTH should be run before any treatment drugs are started (it is also used as the monitoring test after treatment has started).

Your vet is relying on the LDDS to diagnose Cushing’s in Baxter, and that test may be wrong. Baxter may not have Cushing’s at all. That is why I’m relieved he is doing OK on the 30 mg. — because I don’t believe a genuine diagnosis has yet been made.

Marianne
Welp, I want to correct what appears to be misinformation that I have repeated here multiple times. I’m very sorry if I’ve confused you in the process!

Numerous publications state that phenobarbital has the potential to skew LDDS results in dogs. However, this morning I finally decided to dig deeper. And this is what I found. Phenobarb DOES affect LDDS testing in humans, and that’s undoubtedly why authors have included cautionary warnings across the board. However, I found two 2000 studies that were limited to specifically studying the effects in dogs alone, and apparently both the UC:CR and the LDDS are NOT affected by phenobarb in dogs. So again, I apologize for causing you to question Baxter’s LDDS result based on his phenobarb use. And I’m really glad that he generally seems to be doing well on the 30 mg. dose! I do want to note, though, that phenobarb does significantly skew thyroid test results in dogs, as the second article below describes.

https://www.ncbi.nlm.nih.gov/pubmed/10736678

https://www.ncbi.nlm.nih.gov/pubmed/10772487

Marianne

[BillyD]

You have been tremendous in trying to help Baxter. We appreciate your going above and beyond in finding that information.

Sitting with Mr B now. He and his brother Bucky say thank you Marianne.

[labblab]

Thank you for your most gracious reply in the face of my previous misinformation. You are very kind.

Best wishes, as always, to you and Mr. Baxter (and Bucky, too)!

[BillyD]

Wanted to give an update on Baxter He has healed from back left paw issue. His Cushings symptoms are being managed well. Urination, thirst, and panting all improved. For further diagnostic testing, he is having an Abdominal Ultrasound next week.

[Joan2517]

Nice update, thanks for letting us know.