Pookie - Dog not eating and has Cushing's

[fkhan]

Hello,

My baby Pookie, which is a 15 ½ year old Pekingese has been suffering from Cushing’s for a year. The vet advised not to treat until the water and food intake excessively increased. She started of with panting and has had acth, low & high dose dex. The vet feels it’s pituitary based. Recently, I took her in because I wanted to start Trilostane with her, but her Kidney values were high after the Vet did another ACTCH test. They also found a minor UTI, which I’m hoping her Kidneys were high. After this test, my Pookie was excessively panting and listless/lethargic. Brought her to the ER for IV’s and antibiotics and her Kidneys got normal again. Now the main concern is her weakness and her lack of appetite. She doesn’t eat much at all and I’ve been feeding her Gerber baby food by syringe. Before the recent ACTH test, Pookie was doing pretty good. I had her on melatonin, lignans, ginkgo, adrenal harmony, fish oil, and denamarin advanced for her liver. Now I’m extremely worried about her and hate Cushing’s. I just started to give her the supplements she has been used to, because she has been off of them for 10 days. Maybe these supplements were helping her all this time, but I want to do everything I can for her. Her right eye is red too, which has got me worried. The vet gave antibiotics for the eye, but it didn’t change anything. Luckily, I have been on vacation this week and have been able to help my Pookie get by. She was running before the ACTH test and after that, Pookie went downhill. I don’t know if it was Adrenal fatigue, Macroadenoma possibility (loss of appetite and red eye), or her being off her supplements. She has been through so much the past 10 days and was going to have an MRI done, but held off to give her a break. Any clues, suggestions, or feedback would be appreciative. Pookie has a half sister who is older and is doing just fine. Pookie sleeps well, but her weakness and loss of appetite has me very concerned. I know she is old, but her blood tests are pretty good given the circumstances. She has always been a strong girl, and still carries herself outside to pee, but it’s challenging for her. I know that day may come for me to put her down, but if it’s Cushing’s that’s causing this or Old Age, I don’t want to put her down if something can help her. Sorry for all this info,
FK

[Harley PoMMom]

Hi and welcome to you and Pookie!

I am so sorry your precious girl is not feeling well, and I understand how worried you must be about her. Getting her to eat, I believe, is the most important thing right now. Baby food is good as long as it doesn't contain any onion or onion powder. Another thing you may try is boneless, skinless chicken breast (baked, boiled) mixed with some very mushy rice, if she doesn't like the chicken you could give her lean hamburger instead.

Could you post the results of all tests that were performed on Pookie? We need only see those values that are marked abnormal with their reference ranges and units of measurement...as an example ALT 150 (5-50 U/L)...thanks! Has the vet mentioned about performing a SDMA test for the kidneys? If not, I do recommend having this test done.

Please know we will help in any way we can, and if you have any questions don't hesitate to ask them.

Lori

PS...Here's a link to a thread regarding inappetence in dogs: https://www.k9cushings.com/forum/showthread.php?8565-Inappetence-in-dogs

[fkhan]

Just got back from the vet and her blood looks good, but they think it's a Macroadenoma. I'm preparing for the end, but don't want to. Her ACTH base was 181 and post was 494

[fkhan]

I also have tried cooked chicken, ground beef, baked salmon, hot dogs, honey nut cheerios. She ate a little hot dog one day and never again. She at the cheerios one day and never again. She did it the bacon I made, but only about 1 strip worth. I'm afraid her days are coming to an end and am extremely sad about it. Her sister who is older is running around the house while Pookie is lying on the floor.

[fkhan]

My poor little Pookie may have a Macroadenoma. Does anyone know of a Dr. on the East Coast that removes these types of tumors? I really want to take care of her and am holding off putting her down. I don't mind maxing out my credit card for my baby...

Thank you,

[Harley PoMMom]

Just got back from the vet and her blood looks good, but they think it's a Macroadenoma.

I am so sorry that Pookie may have a macrotumor and my heart breaks for you both. I'm including this reply from one of our Administrators, Marianne, to a member whose dog was diagnosed with a macro because I believe it has information you may be interested in:



I am not surprised to hear this news about the tumor, but also very sorry that yet another major challenge - and major decision - may now be facing you. Through the years, we've had members who have undergone a variety of treatments for enlarging macrotumors. Initially the only option here in the U.S. was the prospect of over a dozen traditional radiation treatments over the span of a month, with general anesthesia required for each procedure. Over time, more specialized options have been introduced in some centers, including cyberknife-type treatment that only requires a very few sessions, and also actual surgery. Returning to Dr. Bruyette, he helped pioneer successful canine surgery as a joint effort between UCLA and Cedars-Sinai Hospital in L.A. One of our very own members, Lucy, was his first patient in that pilot program, and I believe surgeries are still bring done there on select patients. Here are some write-ups:

http://dogaware.com/articles/newscushingssurgery.html

https://www.cedars-sinai.edu/Research/Research-Areas/Endocrinology/Mans-Best-Friend.aspx

We've also had members who have received advanced treatment at UC Davis and Washington, among other centers. I think Florida may also offer advanced options, as well. As you might expect, results have been variable. Some dogs have had very good responses and remained neurologically improved for an extended period of time. Some have not. Some have had an extended respite from Cushing's treatment. Others have had to continue with Cushing's treatment even though the tumor size was reduced enough to relieve neurological symptoms. I think a lot will depend on the actual location and dimension of the encroachment, as well as the vets' assessment of Yogi's overall viability as a treatment candidate.

Age may be a factor in his candidacy and also your decision. I'm guessing he may now be eleven. I've not had either of my two retrievers (Labs) reach twelve, with or without Cushing's. So one consideration may be the length of his expected lifespan, even with successful treatment. In other words, would he really have enough quality time left to gain from an invasive intervention. However, on the flip side, if he could benefit substantially from 2-3 cyberknife sessions and affordability was not an issue for you, then maybe that would be a worthwhile option.

I'd say, let's see how the actual MRI report reads, and then see what your vet recommends. And then we'll be here to talk over all your options.

Marianne

We also have a thread dedicated to macroadenomes so I'll include a link to it too: https://www.k9cushings.com/forum/showthread.php?3567-Macroadenomas&highlight=macrotumors


Her ACTH base was 181 and post was 494

Was this Pookie's initial ACTH stimulation test used to diagnose her Cushing's? Also, could you post the abnormal lab values from her Chemistry and CBC blood work test results?

Hugs, Lori

[Harley PoMMom]

I don't know of any veterinary hospitals on the east coast that perform pituitary removals, I did find a hospital in Fairfax VA that specializes in Oncology and Neurology, their website: https://vcahospitals.com/southpaws?utm_source=maps&utm_medium=organic&utm_campaign=VCA_SouthPaws_Veterinary_Specialists_&_Emergency_Center

[Squirt's Mom]

Hi FK,

First I want to welcome you and your baby, Pookie. No matter what is going on with her we are by your side all the way. Please never hesitate to ask any questions or to just talk when you need. We understand what you are going thru because we have walked in your shoes. You and Pookie are part of our little family here at K9C now.

And I wanted to let you know that I have merged the two threads you started. We like to keep all info about each dog in one thread. That way it is easier to look back thru the history. Plus this thread will serve as a sort of diary for Pookie's cush journey. Any time you need to post something just come to this thread titled Dog not eating and has Cushing's.

Hugs
Leslie

[fkhan]

Thank you all for your replies. I brought Pookie in for an MRI yesterday. I was concerned to have this done, but needed to confirm what a Specialist said that the cushings was from a pituitary tumor. It has been diagnosed as this earlier this year, but this is not the case. The Cushing's is coming from her left adrenal gland and her pituitary gland is fine. A little dissapointed in my vets and specialist, but I know Cushing's is difficult to diagnose without an MRI. The ultrasound showed calcification on the left adrenal months ago, but given both adrenal glands were close to the same size, they thought it was pituitary based. They thought Pookie was one of the small percentages that failed to suppress on a high dose dex test. Poor little Pookie has been through so much. She is trying to recover from the anethesia now. I have loaded my credit card with 8k in debt now. Not good news and may take me a year to pay it off if I'm lucky. I have to plane for another 6k in credit card debt, because I think I'm going to have an adrenalectomy on her to cure her of this nasty disease. She is 15 1/2 and am worried about the surgery. Before I even do surgery, I have to get her eating again. She had bloody diarrhea during anesthesia and as suffering from it afterwards. The neurologist thinks she has an infection causing her not to eat. I had fecal samples tested prior and they were negative. Going to try a course of antibiotics on poor little Pookie to see if the blood goes away and she starts eating again. I may have to start looking for a higher paying job soon, because my Pookie is worth every penny to me. I think I must be in love with these dogs, because I get more joy and comfort from them than going anywhere on vacation. Haven't had a vacation in over a decade. I think these little rascals are my vacation....

[fkhan]

Pookie had an ACTH Stim last year and didn't show she was cushinoid. The low dose dex did, but did not show from where. I pushed for a high dose dex to find answers, but still no answers were found. She failed to suppress on the high dose test. Given all the costs, it may be wise for new cushings owners to have both an ultrasound and MRI done if the dog is a candidate for anesthesia. If I had to do it over, I would have gone this route, because the truth will set you free. Not knowing is stressful in itself and just treating clinical signs and lab work is treating on probability and not the truth. Just my opinion from everything Pookie and I have been through. Also, I worry that when a dogs has cushings and we inject more sterioids into them for these tests, it has to hurt them in some way, because if they are already stressed and in that Fight of Flight moment, why do we want to add to that... An ultrasound and MRI could alleviate all that stress.

[labblab]

Hello to you and little Pookie. I’m sorry I have only a moment to write this morning, but I wanted to explain that we have merged your two threads together so as to create one single, unified thread about Pookie’s diagnosis and treatment decisions. This way, with all of her history consolidated, it’ll be easier for our members to follow along with any new developments.

I know you have some big decisions facing you right now, so I’m really glad you’ve found us!

Marianne

[fkhan]

I also wanted to add that the MRI that was done on Pookie reflected a stroke. After doing some research, it appears that dogs with Cushings could have strokes. I don't know when she had it, but I feel she must have had it between the time of her cushings clinical signs and now. Just for you future cushing's pet owners. The sooner you get cushing's under control, the better. I also read that adrenal tumor based cushings reflect less clinical signs than pituitary based cushing's regarding water intake and peeing.

[fkhan]

Can anyone recommend a Great Doctor for this surgery?

Thank you,

[Squirt's Mom]

Hi,

Your latest post referred to "this surgery" but as a stand alone post (not in this thread) no one has any idea what surgery you are referring to and cannot give you any meaningful input. So I have once again merged that post into Pookie's orginal thread. Please try to find Pookie's thread when you wish to talk or to ask any questions. It will be of benefit to Pookie if you will because everyone can refer back to her history. Thanks!

Now about an adrenalectomy. This is not just a difficult surgery it is one of the riskiest surgeries a dog can have. IF IF IF they are a candidate and they survive the surgery they still have to face a very rough recovery. That is for a young dog in good health otherwise. For a 15 yr old it would be doubly risky, both surgery and recovery. I am not saying for you not to do it but I want your eyes to be fully open. Here is a link to a list of questions that one of our former members created. It has several for you to answer to yourself and several for you to ask the surgeon(s) you talk to:

https://www.k9cushings.com/forum/showthread.php?8555-Questions-for-dog-owners-considering-adrenalectomy


And here is a link to help you find a doctor:

https://www.k9cushings.com/forum/showthread.php?182-Finding-an-Internal-Medicine-Specialist-Vet-(ACVIM)-(N-America-and-other-countries)

Please read those questions carefully and fully consider the ones you are to ask yourself, especially the one about being prepared to loose your baby girl. That is a very real risk that you must be prepared for.

Hugs,
Leslie

[fkhan]

Sorry for the confusion. New to forums.

[Squirt's Mom]

I understand. It's especially confusing if you are in many Facebook groups where just about every post is a new deal every time! LOL

[fkhan]

Poor little Pookie's Kidney values are up again. She has been on metrondiazole for the past 5 days. Here is her history. We are going to try iv's for 2-3 days and my vet doesn't think the cushings is causing the kidney values to rise; BUN, Creatinine, and Phoshourus. CPL showed a slight positive for Pancreatitis. I hope I don't have to put my baby down and am dropping her off tonight for IV therapy.
Progression or History:
Pookie has a medical history of suspected cushings disease (diagnosed 2018) and has been mangaged with a home made diet and herbal supplements. She also has a history recurrent UTIs which has been resolved with antibotics, chronic increased liver enzymes treated with Denamarin, and intermittent anroxeia.
1.1.19 - Presented to VVC for evaluation of being painful due to excessive panting and vocalizing after attempting to use the stairs. Exam findings note a tense but not overtly painful and pendulous abdomen with subjective cranial organomegaly, stiffened gait, and pain elcited upon extension of right hip and spine. Recommendations were made for spinal radiographs but were declined. DVM discussed different causes for back pain such as IVDD, infectious/inflammatory diseases, and neoplasia. Medical management was elected by owner and Codenie was prescribed. Exercise restrictions were advised.
~Feburary 2019 - Pookie developed some intermittent ataxia and difficulty using the stairs. No veterinary attention was sought out.
6.5.19 - Presented to VVSA for evaluation of possible adrenal dependent hyeradrencorticism. Exam findings note a pendulous abdomen with cranial organomegaly but no discrete mass was felt or pain elicited on palpation. Recommendations were made for evaluation of size of left adrenal gland via ultrasound, MRI, or CT but were declined at this time.
7.31.19 - Presented to RRAH around ~3am for evaluation of not drinking and lethargy. Exam findings were unremarkable. DVM discussed difficulty in assessing etiology of azotemia in cushings patients. Owner expressed concerns for Pookie possibly having renal failure due to her decrease water intake and wanted to be proactive. DVM offered 48hr hospitalization but owner declined and elected to continue plan outline by BBAH yesterday.
Presented to RRAH as a transfer for overnight hospitalization and fluid therapies after being briefly evaluated by BAAH. Exam findings were unchanged from previous visit. Pookie was hospitalized, started on IVF therapies (LRS at 38 ml/hr) and administered Ampicillin (22mg/kg IV) every 8 hours.
8.1.19 - Pookie did well overnight while hospitalized. She was eating well, urinating adequately, vitals were normal, and her renal values improved. She was discharged from RRAH to the owners care. Clavamox was advised to be discontinued and Cefpodoxime was prescribed.
8.2.19- Presented to BAAH for evaluation of falling over and difficulty walking. Buprenex was prescribed.
8.3.19 - Presented to RRAH for evaluation of anorexia, restlessness, and red eyes. Exam findings notes lenticular opacity OU, sluggish PLRs, sclearal hyperema OD>OS, and mild epiphovalmucoid discharged. Recommendations were made for sedation due to Pookie's stressful tempermant to obtain diagnostics (bloodwork, urinalysis, eye staning, and tear test) but were declined. A urine collection kit was also provided to owner. Zofran, Entyce, and NeoPolyBac were prescribed along with Trazadone, which is to be given prior to veterinary visits. Recommendations were made for a recheck tomorrow if Pookie is still not eating and to consider an opthamology consult.
8.4.19 - Presented to RRAH evaluation of anorexia and diarrhea. Exam findings notes mild pL (pelvic limb) ataxic/arthritic gait. Bloodwork was performed. Recommendations were made to continue Entyce, Zofran, Buprenex, Triple Antibiotic Onitment, and daily SQ fluids as previously prescribed. DVM advised to syringe feed every 6 hours with 1 90cal jar of baby food and trying probiotics. Metrondiazole was prescribed.
8.7.19 - Owner contacted BAAH to relay that Pookie is still not interested in eating and expressed concerns for her to have Addisons and is considering starting Triolstane. Entyce, Metronidazole, and Buprenex have been finished for several days now. Owner elected to give Pookie an additional 24 hours to see if her appetite improves.
8.8.19- Owner contacted BAAH and reported that Pookie ate some this morning and owner is interested in pursuing an MRI.
8.9.19 - Presented to BAAH for evaluation of anorexia and no improvements with eye redness. Exam findings include mild conjunctive enlargement, OD- tiny white plaques in center of cornea. Fluorescein stain, urinalysis, and bloodwork (CREA, BUN, PHOS) were performed. Mirtazipine was prescribed.
8.10.19 - Presented to BVNS for neurological examination. Owner express concerns for Pookie's continued lethargy, progressive weakness, and anroexia.
Pookie is up-to-date on vaccines. She has not had any coughing, sneezing, vomiting, but suffered from diarrhea about 1 week ago but has improved. She has not been eating and drinking normally over the past week and has been syringe fed with baby food. Her regular diet is Hills Science Diet K/D. She does not travel out of the area.
Past Diagnostics:
8.9.19 - BAAH
Fluorescein stain- Slight uptake
Chemistry- Values within normal limits
Urinalysis- See report
8.4.19 - RRAH
Complete Blood Count- MCV 60.1 fL (l), MCH 20.9 pg (l), RETIC-HGB 22.2 pg (L), NEU 13.66 K/uL (H), LYM 0.63 K/uL (H), LYM 0.63 K/uL (L), PLT 493 K/uL (H), MPV 13.6 fL (H), PCT 0.67 % (H), otherwise within normal limits.
Chemistry 17 & Electrolytes- ALT 368 U/L (H), ALKP 1815 U/L (H), GGT 13 U/L (H), otherwise within normal limits.
Urinalysis (Free Catch)- See report
8.1.19 - RRAH
PCV- 44%
TS- 7.0 g/dL
Chem 8- tCO *26 mmol/L (H), all other values within normal limits.
7.31.19 - RRAH
Chem 8- All values within normal limits
7.31.19 - Michigan State Univeristy
Endocrine Test- Cortisol Basline= 181 nmol/L (H), Cortisol 1hr post ACTH= 494 nmol/L (WNL).
7.29.19 - BAAH
Urinalysis- See Report
7.4.19 - BAAH
Complete Blood Count-MCH 21.3 pg (L), MCHC 31.6 g/dL (L), RETIC 128 K/uL (H), NEU 12876 /uL (H), all other values within normal limits. Chemistry & Electrolytes- BUN 50 mg/dL (H), Cl 105 mmol/L (L), AGAP 29 mmol/L (H), ALT 169 U/L (H), ALP 1378 U/L (H), GGT 19 U/L (H), CHOL 397 mg/dL (H), all other values within normal limits.
5.4.19 - Michigan State Univeristy
Endocrine Test- Cortisol Baseline= 102 nmol/L, Cortisol; High Dose Dex 4hr= 125 nmol/L (H), High Dose Dex 8hr= 130 nmol/L (H).
4.11.19 - BAAH
Chemistry- ALB 4.1 g/dL (H), ALT ~unable to read value (H), ALKP 1748 U/L (H), GGT 20U/L (H).
2.13.19 - BAAH
Abdominal Ultrasound- Left adrenal gland about the same size and calicified.
913.18 - BAAH
Dexamethasone Suppression Test- Cortisol; Pre Dex= 1.9 ug/dL, Cortisol; 4hr Post Dex= 2.1 ug/dL, Cortisol; 8hr Post Dex= 1.8 ug/dL
9.10.18 - BAAH
Abdominal Ultrasound- Liver enlarged- hyperechoic. Lots of gas present in stomach. Left adrenal gland calcified and irregularly shaped.
Current Medications:
Adrenyl Harmony, given as directed once daily.
Advanced Denamarin (unsure of dose), 1/2 tablet given once daily.
Fish Oil, given as directed twice daily.
Ginko Biloba, 50mg given once daily.
Lignan, 20mg given twice daily.
Melatonin, 3mg given twice daily.
Objective
Vitals: 9:41am 8/10/19 Wt: 8.2 kg. T: 101.8 F. HR: 136 RR: Pant CRT: <2 Other: MM: Pink By: AEB
EENT: Eyes: ___, Ears: no redness or exudate observed
Oral Cavity: Teeth are dirty for free from excessive tartar; gums are pink and moist; no gingivitis present
Lymph nodes: Lymph nodes all normal size
Heart and Lungs: No murmur detected; lungs ascultate clear
Gastrointestinal: Normal eliminations; abdomen palpates normally
Musculoskeletal: Orthopedically sound
Dermatologic: Skin flaky and hyperpigmented in areas; dorsal alopecia
Urogenital: Owner reports normal eliminations; external genitalia appears normal; bladder palpates normally
Body Condition Score: 6/9
Pain Score: 0/4
Mentation: Quiet, alert, and responsive. Appropriate.
Posture of Head and Body: Normal posture of head and body
Gait: No paresis or ataxia noted
Postural Reactions: Normal paw replacement and hopping in all 4 limbs
Thoracic Limb Reflexes: Normal withdrawal reflexes bilaterally
Pelvic Limb Reflexes: Normal patellar and withdrawal reflexes bilaterally
Cutaneous Trunci: Present bilaterally at L5 (normal)
Perineal Reflex: Normal
Muscle Tone: Normal tone
Cranial Nerve Function: intermittently delayed menace response OU (possibly ophthalmic in origin) Retinal Exam: Normal fundic exam OU
Hyperesthesia: No pain elicited on spinal palpation or cervical manipulation
MRI Report
BODY REGION & SEQUENCES
August 9, 2019
HEAD– Localizers, Sagittal T2W, T1W post-contrast, Transverse T2W, FLAIR, GRE, T1W pre- and post-contrast, DWI/ADC maps, and Dorsal T1W post-contrast images are available for review.
ABDOMEN–localizers, sagittal T2-weighted, dorsal T2-weighted fat-sat, T1-weighted postcontrast fat-sat images are available for review.
FINDINGS
There is mild periventricular T2-weighted/FLAIR hyperintensity with no evidence of contrast enhancement consistent with leukoaraiosis. The subarachnoid space within the sella tursica is prominent. However, a small pituitary gland is present with T1W hyperintensity of the neurophysins as well as subtle contrast enhancement. There is a small pucntate, lesions within the dorsomedial aspect of the left thalamus that is hyperintense on the T2W, hypointense on the T1W, FLAIR with no evidence of contrast enhancement. Best seen on the sagittal T2-weighted images, there are subtle dilation of the caudal cerebellar vermian sulci with prominent visualization of the overlying subarachnoid space. The masticatory muscles show subtle T2-weighted heterogeneous hyperintensity in varying degrees of contrast enhancement. The medial retropharyngeal and mandibular lymph nodes are within normal limits of size, signal, and contrast enhancement. The salivary glands are within normal limits. There are small condylar cysts within the temporomandibular joints. The visible oral cavity is within normal limits. The visible aspect of the nasal cavity and frontal sinuses are within normal limits. The tympanic bullae and ear canals are within normal limits. The orbits are within normal limits. There are multifocal small dorsal cutaneous nodules.
The right adrenal gland is enlarged measuring 1.6 cm diameter. The cranial pole of the left adrenal gland is enlarged measuring 1.8 cm diameter with mineralization the lateral aspect. There is a small contrast enhancing nodule within the dorsal extremity of the spleen measuring 6 mm diameter.
There is variable loss of normal T2-weighted hyperintensity of the intervertebral discs consistent with dehydration. There is protrusion of the T12–T13 intervertebral disc space with no spinal cord compression. There is protrusion of the T13-L1 intervertebral disc with mild spinal cord compression.
CONCLUSIONS
1) Focal dilation of the caudal cerebellar vermian subarachnoid space may represent mild hydrocephalus ex vacuo secondary to atrophyfrom a historical ischemic infarct. The subtle lesions within the dorsomedial aspect of the left thalamus likely also represents a historical ischemic infarct. Both lesions are thought to be quiesscent on the current study.
2) Mild periventricular leukoaraiosis may be seen secondary to edema vs. gliotic changes.
3) Incidental partial empty sella syndrome. This may be seen in canine patients with no associated endocrinopathy (VRUS 2008;49(4):339342). There is no evidence of a pituitary mass, however, a functional pituitary microadenoma cannot be ruled out.
4) Bilateral adrenal gland enlargement with mineralization of the left. This may be secondary to pituitary dependent
hyperadrenocorticism. The left sided adrenal gland mineralization may be seen 50:50 in benign and malignant etiologies (VRUS
1997;38(6): 448-455)
5) Signal changes to the masticatory musculature may be secondary to chronic hyperadrenocorticism. Chronic bilateral masticatorymyositis is considered much less likely.
6) Protrusion of the T13-L1 intervertebral disc causing mild spinal cord compression.
7) Splenic nodule may represent benign (ie. nodular hyperplasia, extramedullary hematopoiesis, hemosiderin deposition) vs. earlyneoplasia (ie. round cell, sarcoma, others).
8) Incidental temporomandibular joint condylar cysts.
FEATURED DIAGNOSTIC IMAGE / SUPPLEMENTAL INFORMATION
Thank you for this referral. We are always interested in hearing any feedback on cases. If you have any questions or follow-up regarding this case, please do not hesitate to contact us at Radiology@SynergyVIP.com or to the specific radiologist's email in the upper right hand of the report. (This contact information is for veterinarian use only, please). Thank you.

[fkhan]

I'm waiting to hear back from my vet, but I was thinking if we get those kidney's flushed, that we need to address cushings asap with something that doesn't hurt the kidneys or pancreas. What do you think? Her time may have come.........Sorry for all of you that have to deal with Cushing's.

[Harley PoMMom]

Definitely addressing the kidney issue and getting her to eat on her own are the top priorities right now. The Cushing's should be put on the back burner as it is a slow progressing disease and it takes a long time before any internal damage occurs. Exactly what medications is Pookie taking right now? And has an urine culture been performed to be sure that the UTI is completely gone?

Sending hugs, Lori

[Squirt's Mom]

I second what Lori said - forget about Cushing's. When my Squirt reached the age of 15 she had developed several other conditions and I made the choice to stop treatment for Cushing's even tho none of her conditions dictated that was necessary. I simply wanted her last days to be as normal as possible without the constant vet visits, pokes, and prods. It was more important to me that she and I be able to enjoy those days instead of worrying about pills and tests. She lived to be a couple of months beyond 16 and I am grateful for every single second of that time we had.

Hugs,
Leslie

[Joan2517]

I also second and third that. I wish I had let Lena spend her last few months without all the testing and vet visits. Instead we ran back and forth to the vet every time we changed her dosage and even though she never fussed, I think we both would have been much happier just enjoying our time together.

[fkhan]

Definitely addressing the kidney issue and getting her to eat on her own are the top priorities right now. The Cushing's should be put on the back burner as it is a slow progressing disease and it takes a long time before any internal damage occurs. Exactly what medications is Pookie taking right now? And has an urine culture been performed to be sure that the UTI is completely gone?

Sending hugs, Lori

Thanks for the advice. Pookie is in the ER getting IV's. She had a CPL test done that showed a light positive on her pancreas. They don't suspect pancreatitus or cancer, but it's not 100% ruled out. I'll double check on the urine they took yesterday to verify the UTI can be ruled out. The strange this as she has been going through all of this is that her clinical signs for cushings have diminished. No panting and her calcinosis cutis has smoothed out. I screamed addisons, but nobody thinks it's that. Right now they want me to keep her on IV's and will check her kidneys tonight. They also want me to see an internal medicine doctor, which I'm working on scheduling. She still didn't eat for the ER and have been syringe feeding her the past 2 weeks. She did however eat the tuna steak I made for her a couple of days ago. Docs have hinted that we never know the answer and I too want her home to be comfortable with me and her sister Peaches. Pookie has also been off her supplements for 2 weeks and don't know if that's impacting her or not. Melatonin, Adrenal Harmony Gold, HMR lignans, Ginkgo, Tumeric, and was just starting to look at four marvels. Thank you.

[fkhan]

Pookie is at home now and her kidney values are normal again after IV therapy. I hate putting her through all the tests as well, but nobody knows what is going on with her and why she will not eat. Doctors have said we may never know. I have a scheduled appointment with internal medicine next week on Wed at 10:30. She has been off her supplements for over 2 weeks and am not sure that has anything to do with it or if she is just slowly fading way. I have almost maxed out my credit card of 9k and am running out of options. I'm going to give internal medicine a try, because she shows signs of joy and signs of sadness. It use to be more joy than sadness, but is leaning more towards sadness and that time may come, but I have not given up on her and do not want her to suffer. It's very difficult to let her go when she still shows signs that she wants to stick around. It has been a battle the last couple of weeks and has taken a huge toll on me financially, physically, and mentally, but my baby is worth that and more...........

[fkhan]

Pookie is at home now and her kidney values are normal again after IV therapy. I hate putting her through all the tests as well, but nobody knows what is going on with her and why she will not eat. Doctors have said we may never know. I have a scheduled appointment with internal medicine next week on Wed at 10:30. She has been off her supplements for over 2 weeks and am not sure that has anything to do with it or if she is just slowly fading way. I have almost maxed out my credit card of 9k and am running out of options. I'm going to give internal medicine a try, because she shows signs of joy and signs of sadness. It use to be more joy than sadness, but is leaning more towards sadness and that time may come, but I have not given up on her and do not want her to suffer. It's very difficult to let her go when she still shows signs that she wants to stick around. It has been a battle the last couple of weeks and has taken a huge toll on me financially, physically, and mentally, but my baby is worth that and more...........

I have a bit of joy right now. I ran out this morning after having Pookie home for 4 hours resting and came home seeing her lick the leftover chicken that her sister didn't finish last night. I picked up some prescription Recovery canned food and tried to feed it to her, but all she did was scoot her nose at it. I walked in the kitchen and warmed up my leftovers from last night, bec I made tuna steaks to bring to her in the ER last night. She didn't eat it last night in the ER, but she came in the kitchen from the smell from the microwave. I couldn't give her my tuna, bec it was seasoned, but I did have some baby carrots with my meal and offered her some. She ate the little chops up pretty good. I had 1/4to 1/2" sections that I would put on the floor intermittently and she crunched them down. She probably had about 2-3 baby carrots in total, which is really great to see her eat again. She is now back snoring in the Den. She is still really weak, but still walks to go out and pee on her own. Crossing my fingers I get my baby back to a good quality of life.

[Squirt's Mom]

That sounds great! Let her eat what she will for the next few days to gain as much strength as possible! Thanks for that lovely update.
Hugs and belly rubs!

[fkhan]

Last night we cooked chicken for Pookie, but she didn't eat it. I gave her a little baby food by Gerber and started her melatonin and HMR lignans again last night, because she has been off of those for 2 weeks. I can see her walk better this morning when she went out to pee. I also chopped up 3 baby carrots again and she ate those this morning. I'm wondering if she is afraid of eating meat, because it might be causing something. Will try some scrambled eggs this morning for her. Given her rise of kidneys twice in the past month, I ordered Kidney Support Gold on Amazon and will start giving that to her when it comes it today. Prime shipping is wonderful. I don't want to start daily SubQ fluids unless I have to, but I want to set the priority of her Kidneys over Cushings, but they may be related. I'm also wondering what I can give her to help her immune system since Cushings suppresses that. Any ideas for immune support in old dogs with Cushing's?

[fkhan]

I also am interested in blood clots in dogs with Cushing's. When Pookie had her MRI, the neurologist said she had a stroke at some time. I read that Cushinoid dogs are prone to blood clots and was wondering if she needs blood thinners or something else to keep this in check. Her blood pressure is not great, not good, and not bad. Systolic I think is in 180's, which is a bit high. Not sure what to do with this information going forward. I know I'm looking at a lot right now. I should probably wait on all this other stuff and just address her eating and make sure her Kidneys are ok. Sorry, just worried, but glad to have her home.

[Squirt's Mom]

I think your last thought is spot on - focus on her kidneys right now. Remember hydration is crucial for any sort of kidney problem so if she needs subQ fluids then don't hesitate to provide them. That makes sure her body is well hydrated. When we feel bad, and malfunctioning kidneys make you feel really bad, we tend to forget about little things like drinking. You can also help the hydration by adding water to her food. Make a carrot puree using water if she like carrots, or green bean puree, etc. Try everything with water added when you feed her...any meats or veggies can be mushed and made soupy. She may find that easier to eat as well. In human years she's around 75-77 yrs old so keep that in mind when considering food. Also as dogs age their sense of smell fades so they just don't find foods as appealing as they used to. We can help there by adding stinky things like water from tuna (plus some tuna!), Parmesan cheese, canned tripe (unless you make your own), and so on. Things that will appeal to her nose...but maybe not yours. :D

[fkhan]

Thanks for the tip. I just gave her 100ml of SubQ's. I have an appt with internal medicine on Wed. I tried to had parmesan and water to her recovery food, but she didn't like it. She didn't eat the chicken last night, but will try ground beef and rice tonight. For some reason she is still eating the baby carrots.

[fkhan]

Just found out the brown rice is higher in phosphorous than white. Don't have any white rice, but pasta and a little butter appears to be ok. Will try that soon.

[fkhan]

Good news for now. Pookie ate the lean hamburger minced with angel hair pasta cut up and a little butter. I'm going to give her more in about an hour. She really hasn't eaten much since all of this has started. She use to weigh 19.2.lbs and now weighs 17.6lbs. The odds are against her being 15 3/4 years old, has had Cushing's for a year with elevated liver enzymes, and now in the past month has been to the ER twice for IV therapy, which gets her values back to normal. I was initially thinking the UTI caused the first one, but now I'm thinking she may have CKD given her age and everything else. Just to stay proactive, I'm giving her filtered water from now on, I'm going to brush her teeth tonight, I ordered Pet Well Being Kidney Support Gold, which should be here tonight with Prime. I'm also going to check with my vet tomorrow about phosphate binders. She walks good sometimes and sometimes she has Ataxia drunken sailor walk, which really alarms me, because my little Maria cat had that before her Kidneys went and the vet tried IV's with no success. I don't know if I can own another dog after all of this. It's very difficult emotionally, physically, and financially... I have lost close to 20lbs with all the stress and my blood pressure has dropped to 96/67, which I guess is good for some and maybe good for me, because I haven't been eating junk or drinking to deal with this stress. I have been a fined tuned machine with all senses on alert for my Pookie. I don't want to miss anything and staying focused has probably kept her alive through all of this. I just hope she pulls through and am doing everything I can to give her some more time with a good quality of life. It's hard to just put her down if she shows promise, but I feel bad that she is suffering right now, but I don't know if she can pull through or not without trying. I wish dogs could speak to me and us not to rely on clinical signs. When I'm sick, I'm miserable to, but that doesn't mean I'm ready to check out for good.

[fkhan]

I also read that fish is high in phosphorous and not good for the Kidneys. Will stay away from that. I also read that acidity is not good for the kidneys either. Will give Pookie a half tablet of pepcid too tonight.

[fkhan]

Pookie ate again!! Pasta, ground cooked leaned beef with a little butter on the angel hair pasta. Administered her with the Kidney Gold, Vitamin C, Omega 3 fishoil, and HMR lignans tonight. Held off on melatonin and gave her 1/2 pepcid. Crossing fingers. She did have a good poop too. It was so nice to see her eat with her sister again side by side. Hoping for the best..

[Harley PoMMom]

That's great to hear that Pookie ate again!!!! This Dogaware web site, that I'm including a link to, has a lot of information regarding canine kidney disease, I hope you find it helpful: http://dogaware.com/health/kidneydiet.html

Hugs, Lori

[Squirt's Mom]

How is Pookie doing today?

[fkhan]

She is doing ok, but not great. Went to Internal Medicine yesterday and waited for 45mins to be seen and then 2 emergencies came in. Left the vet and am following up with Pookie's primary tomorrow to check her kidney values. She is still eating her baby carrots and pasta and hamburg. I just started adding Azodyl to her diet per her primarys recommendation. If she has CKD on top of cushings, it is going to be a struggle, but am doing everything I can for her. I'm also concerned over her right eye that is red and now appears to be getting mucus buildup that I'm starting to notice. Thank you.

[fkhan]

Hello,

Followed up with Pookie's primary yesterday and her BUN is high, but Creatitine, Phosphorous, and Urine were ok to normal. Vet recommended 100mg of SubQ's 3 times a week and another Blood check next Friday. Vet also recommended to stay on Azodyl, 1/2 tablet of Pepcid. Tried Dr. Harvey's food last night and added protein to it, but Pookie didn't care for it. Her sister seemed to like it. Pookie doesn't appear to like chicken anymore. She might associate chicken with making her sick or maybe it really does. The vet seems to think Pookie had Pancreatitis, but it's hard to say given her age and her Cushings. I'm also adding Fish Oil to Pookie's diet in the evening. In the morning, I will give her some baby carrots, Azodyl, Kidney Harmony Gold, and Advanced Denamarin. I stopped the melatonin for her Cushings and cut back on her HMR lignans. She is a complicated case and I just wish I knew exactly what she needs. She likes carrots and broccoli, but she has to have protein. I guess the highest protein is eggs, but she didn't like them boiled. May try some scrambled eggs this morning for her without the yolk. She also liked english muffins, but I don't know if those are good for her or not. She use to weigh 19.2, but now weighs 16.7 and appears much better than she has been since all this started. I don't know if Cushings caused this or something else. Regarding her kidney's, I'll have to ask if Lepto, Tick virus, and other bacteria have been ruled out. I guess they, but I can't say for sure. It is exhausting, but am staying strong for her. The SubQ's are not easy to do with her now that she is feeling better. When she was sick, it was easy. She is the sweetest little dog and has such a good personality....

[fkhan]

Even though Pookie is eating the pasta and beef, she doesn't eat that much. Had to try something else. She appears to like the Nutro Ultra Duck and Lamb mix. Today is the first day in a week she ate enough food. My concern is the store bought food and her BUN levels. Should I worry too much, or just be glad she is eating again? Also, do you think it's time to try Trilostane? My gut tells me Cushing's is causing her problems, but I'm concerned about Addisons too. The scary thing with Cushing's is it cause back leg weakness, but Kidney disease can cause Ataxia, which kind of look the same. I'm keeping her on Azodyl, but not doing 2 tabs in the morning, bec she is new to it. I'm also continuing with the SubQ's, fish oil, vitC, Pepcid, and kidney gold. Do you think it's ok to keep feeding her the Nutro?

[Squirt's Mom]

I am glad she is eating something :cool: and that would be my goal for right now - getting her to eat, period. If she will eat the Nutro then let her have it. Odds are she will lose her taste for that in a bit, too. In my experience that is pretty common in older dogs, even those without kidney problems -they just lose taste for things so the food is constantly being rotated. Did you talk to the vet about a phosphorus binder? Phosphorus is a bigger enemy of dysfunctional kidneys than protein. I was very glad to see they had tested that level and found it to be normal. The subQ is probably helping there. I would try to keep the protein levels low but the focus would be the phosphorus.

As for the Vetoryl, that would be off the books if Pookie were mine. I would forget about treating the Cushing's and focus on her kidneys and comfort from here on out.

Thanks for the updates! We love hearing how she is doing!
Hugs,
Leslie

[fkhan]

I asked the Vet about Phosphorus binders last week, but the vet didn't recommend that yet since her Phosphorus levels were fine. I have an appointment this Friday to have Pookie's blood checked again. My only concern with not treating Cushing's is that it may be causing all these issues. I am still not sure what happened with Pookie. We know her Kidneys were elevated, but don't know if it was from CKD, Pancreatitis, Ulcer, UTI, or something else. It's stressful not knowing for sure. Pookie has back leg weakness and her skin pigmentation and hair loss is not good. She is not excessively eating, drinking, and having accidents in the house. Some people say to start treatment and some say not too. Cushing's is very stressful....

[fkhan]

Pookie has not gone for a walk outside in over 3 weeks. Last night she showed some spunk when I came home, and sure enough, Pookie went for a walk last night. Experiencing that was priceless. Still not out of the woods, but it felt amazing to have her do that again.

[Maggiemoo1]

How’s she doing today?

[fkhan]

Pookie is doing much better. It has been an exhausting stressful month. Her kidneys are back to normal and she is eating good again. I'm waiting on a thyroid test to come back and am considering Trilostane, but haven't made a decision on it yet. Pookie lost 10% of her body weight through this ordeal and they think it was Pancreatitis. All the tests and mixed opinions of not knowing was an expensive, stressful ordeal. Currently, Pookie is on Azodyl, HMR lignans, Pepcid, VitC, Kidney Gold, SubQ's 3 times a week, FishOil, and Denamarin Advanced. Thank you,

[Squirt's Mom]

FYI - if you are giving the lignans in the hope they will help with Cushing's they won't by themselves. In Atypical Cushing's, in which the cortisol is NORMAL but 2 or more of the intermediates are elevated, a combination of lignans plus melatonin is used to correct the intermediates. It takes at least 4 months for that combination to work...if it is going to. The University of Tennessee in Knoxville (their vet school) has done the research on this form and devised this treatment. My Squirt started off Atypical and we used the combination treatment; it helped her. Just wanted you to know that the lignans alone will have no effect at all on the intermediate hormones or cortisol. The combination does not effect cortisol - only the intermediate hormones involved in Atypical.

I am VERY glad she is doing better! I still would hold off on treatment until she is back on her feet and strong again if she were mine tho. Give her a chance to recoup then look at starting treatment.

[fkhan]

Before this past month, I was using Adrenal Harmony, Melatonin, HMR Lignans, Ginkgo Biloba, and some Tumeric. Also, before Pookie crashed, she had 2 doses of 4 marvels, because I heard that might be good for her. Now that she is getting better, I'm afraid to give her supplments, because I don't know if they caused it or not. I could try and go back to natural treatments for cushings, but her kidneys became my first concern. I read that melatonin and trilostane are not good for the kidneys, which has me somewhat lost in space for treatment plans. I still don't know if her kidneys were from something acute, or maybe she now has CKD. I guess I just have to wait and see. The vet recommended she stay on SubQ's, which is what I'm doing, but don't know for sure if she needs it.

[Harley PoMMom]

If feasible, I'd recommend having a SDMA test performed to gauge the function of the kidneys.

Lori

[fkhan]

Can someone clarify what these numbers mean, or if Trilostane should be started? Here are Pookie's numbers for her Cushing's tests and dates:

913.18 - BAAH
Dexamethasone Suppression Test- Cortisol; Pre Dex= 1.9 ug/dL, Cortisol; 4hr Post Dex= 2.1 ug/dL, Cortisol; 8hr Post Dex= 1.8 ug/dL

5.4.19 - Michigan State Univeristy
Endocrine Test- Cortisol Baseline= 102 nmol/L, Cortisol; High Dose Dex 4hr= 125 nmol/L (H), High Dose Dex 8hr= 130 nmol/L (H).

7.31.19 - Michigan State Univeristy
Endocrine Test- Cortisol Basline= 181 nmol/L (H), Cortisol 1hr post ACTH= 494 nmol/L (WNL

[Harley PoMMom]

Can someone clarify what these numbers mean, or if Trilostane should be started? Here are Pookie's numbers for her Cushing's tests and dates:

913.18 - BAAH
Dexamethasone Suppression Test- Cortisol; Pre Dex= 1.9 ug/dL, Cortisol; 4hr Post Dex= 2.1 ug/dL, Cortisol; 8hr Post Dex= 1.8 ug/dL

These results look like they are from a low dose dexamethasone suppression (LDDS) test, when interpreting this type of test the 8 hour post number is looked at first, if this number is over the cut-off value (which is usually 1.0 or 1.4) than the dog may have Cushing's. In Pookie's case her 8 hour result is over the usual cut-off value which indicates Cushing's but her results do not differentiate between the adrenal or pituitary form of Cushing's. With this test, and unfortunately, all tests for Cushing's, any non-adrenal illness and even stress can yield a false positive result.


5.4.19 - Michigan State Univeristy
Endocrine Test- Cortisol Baseline= 102 nmol/L, Cortisol; High Dose Dex 4hr= 125 nmol/L (H), High Dose Dex 8hr= 130 nmol/L (H).

This is a high dose dexamethasone suppression (HDDS), interpretation results are the same as LDDS.


7.31.19 - Michigan State Univeristy
Endocrine Test- Cortisol Basline= 181 nmol/L (H), Cortisol 1hr post ACTH= 494 nmol/L (WNL

These results are from an ACTH stimulation test and show that her post stimulation is within normal limits (WNL), which indicates that she doesn't have Cushing's.

Given the fact that Pookie doesn't display the most common Cushing's symptoms such as a ravenous appetite and increased drinking/urinating along with the issues with her kidneys I would not pursue treatment. I would focus on getting her to eat normally and keeping those kidneys functioning well.

Lori

[fkhan]

These results look like they are from a low dose dexamethasone suppression (LDDS) test, when interpreting this type of test the 8 hour post number is looked at first, if this number is over the cut-off value (which is usually 1.0 or 1.4) than the dog may have Cushing's. In Pookie's case her 8 hour result is over the usual cut-off value which indicates Cushing's but her results do not differentiate between the adrenal or pituitary form of Cushing's. With this test, and unfortunately, all tests for Cushing's, any non-adrenal illness and even stress can yield a false positive result.



This is a high dose dexamethasone suppression (HDDS), interpretation results are the same as LDDS.



These results are from an ACTH stimulation test and show that her post stimulation is within normal limits (WNL), which indicates that she doesn't have Cushing's.

Given the fact that Pookie doesn't display the most common Cushing's symptoms such as a ravenous appetite and increased drinking/urinating along with the issues with her kidneys I would not pursue treatment. I would focus on getting her to eat normally and keeping those kidneys functioning well.

Lori
Thank you for your feedback. I'm just concerned that an untreated dog with Cushing's is more prone to all sorts of problems, which can be fatal. I'm also concerned with treatment, because that could be fatal as well. The interesting thing is if she was taking Trilostane, according to table 2 here: https://www.drugs.com/pro/vetoryl.html, she would need an increase in her dose. Her hair loss and skin changes seem to be screaming for treatment, as well as her back leg weakness, but her panting, appetitie, and thirst appear to be normal, but she use to pant alot. I'm waiting on her T4 test to come back for her Thyroid results. Thanks again.

[fkhan]

I'm still waiting on her Thyroid test to come back, which was over a week ago. Given the immune suppression of cortisol in our dogs, I'm supplementing Pookie with Vit C twice a day. Since Cushing's has effected her liver and her kidneys were failing last month, I have her on Azodyl, SubQ's, Denamarin Advanced, and Vit B12 shots once a week. I also give Pookie fishoil, Pepcid, HMR lignans, Kidney Gold, and just started alternating Kidney Gold and Adrenal Harmony, and a little Ginkgo Biloba again. Since my vet hasn't recommended Trilostane, I have to be my own vet and see what works and doesn't work for Pookie. It's dangerous to experiment with our own dogs, but I feel leaving Cushing's untreated is not a good idea. At the least, I think VitC is needed if their immune system is being suppressed. Since Pookie is suspected of have been dealing with Pancreatitis, her CLP still shows a light positive, but the Vet said it could take time for that to resolve.

[fkhan]

I'm still waiting on her Thyroid test to come back, which was over a week ago. Given the immune suppression of cortisol in our dogs, I'm supplementing Pookie with Vit C twice a day. Since Cushing's has effected her liver and her kidneys were failing last month, I have her on Azodyl, SubQ's, Denamarin Advanced, and Vit B12 shots once a week. I also give Pookie fishoil, Pepcid, HMR lignans, Kidney Gold, and just started alternating Kidney Gold and Adrenal Harmony, and a little Ginkgo Biloba again. Since my vet hasn't recommended Trilostane, I have to be my own vet and see what works and doesn't work for Pookie. It's dangerous to experiment with our own dogs, but I feel leaving Cushing's untreated is not a good idea. At the least, I think VitC is needed if their immune system is being suppressed. Since Pookie is suspected of have been dealing with Pancreatitis, her CLP still shows a light positive, but the Vet said it could take time for that to resolve.

Pookie is doing pretty good given the circumstances and her age. Since I'm still waiting on the Thyroid test and my vet doesn't know yet if we should start the Trilostane, I started adding back the Adrenal Harmony and Ginkgo Biloba at night. She was on this stuff for months before her episode of possibly Pancreatitis and elevated kidney values. Pookie gets SubQ's/3week, VitB12shot/1week, FishOil at night, Kidney Gold in day, Azodyl/day&night, Denamarin Advanced/morning, VitC/day and night, HMR Lignans/day&night, and Pepcid at night. Given her issues, I have to try and suppress that cortisol, but be careful about her kidneys and liver. I'm watching her clinical signs like a hawk when I can and will stop these supplements if I notice something out of the ordinary. I think the VitC is important, bec her immune system is being suppressed. Pookie could die any day now or live a year or longer. I really despise Cushing's. The strange thing is that one of her clinical signs for almost a year have been panting. She doesn't pant like she use to and that clinical sign is gone. I can take Pookie for walks again, but not far. She doesn't like chicken anymore, so ground beef made at home works as well as the Nutro Lamb and Duck trays. She eats baby carrots sometimes and she gets some peas, green beens, and brocolli sometimes too.

[fkhan]

Just an update. Pookie is eating kibble again after a month. Not sure what to make of this, but kibble is not good for her Cushing's, but this isn't her main dish in the day, just a snack that's left out.

[Harley PoMMom]

... but kibble is not good for her Cushing's, ...


Why is her kibble bad for the Cushing's?

[fkhan]

I thought kibble was bad, because it's not fresh. I could be wrong. Do you think it's ok for Cushing's dogs to eat kibble?

[Harley PoMMom]

Yes, kibble is fine. We do recommend that a high quality protein be listed as the first ingredient, however, if a dog is doing well on a certain dog food than it really doesn't have to be changed.

[fkhan]

Just got a call from my vet and said her base cortisol level is now under the normal range at 1.7. Pookie was given a trazadone the day her blood was drawn. I don't know if Trazadone could be the cause or not. Now that her cortisol is low, we were thinking of waiting to start Vetoryl. Her clinical sign of Cushings for the past year have been panting and hair loss/skin pigmentation, increased appetite with a little thirst increase. Now after Pookie crashed/Pancreatitis over a month ago, her only clinical sign is hair loss/skin pigmentation. We decided to wait a week or two and run another ACTH stim test. I'm concerned now, because her cortisol level is low. All tests in the past year have shown High cortisol and the vet said it could just be a fluctuation that occured. Pookie has had consistent high levels over 3-4 tests and now low, which has me putting on the brakes.

[labblab]

Hello again from me! I’m sorry it’s been such a long time since I last wrote on your thread, but I’ve been traveling and am just now having the chance to catch up again on the forum. After reviewing your recent posts, I agree with your decision to hold off on starting the Vetoryl at this time. Truly, I think there are too many question marks as to whether or not Pookie would benefit from the medication, even assuming that she truly has Cushing’s.

A first cautionary note is that resting cortisol levels alone have no Cushing’s diagnostic value at all. They are simply too variable. For instance, stress itself can elevate a baseline cortisol level in even a healthy dog. Conversely, I would guess that a medication with sedating properties such as trazadone could artificially lower a baseline reading in a dog who otherwise might routinely run higher levels. For this reason, Cushing’s diagnostics require a more complete picture gained from either a LDDS test or an ACTH test, both of which you’ve had done in the past. Pookie did return a mildly elevated result on her LDDS, but that test is particularly vulnerable to “false positives” in the presence of other illnesses or systemic stress, of which it sounds as though Pookie has had quite a few medical issues going on. The ACTH is less vulnerable to false positives, and Pookie’s cortisol level fell within normal range on that test. If her repeat ACTH is still negative next week — coupled with the recent drop-off of the observable symptoms that prompted you to suspect Cushing’s in the first place — I would really question whether she actually suffers from the effects of elevated cortisol at all.

Even if so, I do think you need to carefully weigh the advisability of giving Vetoryl to a dog with a history of serious renal dysfunction. If the kidneys are not working properly, the danger of a trilostane overdose is increased because the body is not capable of optimally flushing the drug out of the system. This can create a very dangerous, even life-threatening, situation.

I know you are trying so hard to give Pookie the best quality of life that’s possible. I’m just fearful that given her age and medical history, the testing and risks associated with starting Vetoryl may make things harder for you both rather than easier. Her appetite may be depressed even further, she’ll require ongoing blood draws and vet visits, and her risk of overdosing may be heightened. If you do decide to proceed with treatment, we’ll do our very best to support and guide you. But in honesty, if Pookie were my own dog, I’d likely forego starting a potentially risky treatment requiring such rigorous follow up as Vetoryl, and instead try to keep her life as stressfree as possible with the foods, supplements, and homecare that brings her the greatest comfort. Either way, though, we’ll surely be anxious to know how things are going for you both.

Marianne

[fkhan]

Hello again from me! I’m sorry it’s been such a long time since I last wrote on your thread, but I’ve been traveling and am just now having the chance to catch up again on the forum. After reviewing your recent posts, I agree with your decision to hold off on starting the Vetoryl at this time. Truly, I think there are too many question marks as to whether or not Pookie would benefit from the medication, even assuming that she truly has Cushing’s.

A first cautionary note is that resting cortisol levels alone have no Cushing’s diagnostic value at all. They are simply too variable. For instance, stress itself can elevate a baseline cortisol level in even a healthy dog. Conversely, I would guess that a medication with sedating properties such as trazadone could artificially lower a baseline reading in a dog who otherwise might routinely run higher levels. For this reason, Cushing’s diagnostics require a more complete picture gained from either a LDDS test or an ACTH test, both of which you’ve had done in the past. Pookie did return a mildly elevated result on her LDDS, but that test is particularly vulnerable to “false positives” in the presence of other illnesses or systemic stress, of which it sounds as though Pookie has had quite a few medical issues going on. The ACTH is less vulnerable to false positives, and Pookie’s cortisol level fell within normal range on that test. If her repeat ACTH is still negative next week — coupled with the recent drop-off of the observable symptoms that prompted you to suspect Cushing’s in the first place — I would really question whether she actually suffers from the effects of elevated cortisol at all.

Even if so, I do think you need to carefully weigh the advisability of giving Vetoryl to a dog with a history of serious renal dysfunction. If the kidneys are not working properly, the danger of a trilostane overdose is increased because the body is not capable of optimally flushing the drug out of the system. This can create a very dangerous, even life-threatening, situation.

I know you are trying so hard to give Pookie the best quality of life that’s possible. I’m just fearful that given her age and medical history, the testing and risks associated with starting Vetoryl may make things harder for you both rather than easier. Her appetite may be depressed even further, she’ll require ongoing blood draws and vet visits, and her risk of overdosing may be heightened. If you do decide to proceed with treatment, we’ll do our very best to support and guide you. But in honesty, if Pookie were my own dog, I’d likely forego starting a potentially risky treatment requiring such rigorous follow up as Vetoryl, and instead try to keep her life as stressfree as possible with the foods, supplements, and homecare that brings her the greatest comfort. Either way, though, we’ll surely be anxious to know how things are going for you both.

Marianne

Hi Marianne,

Thank you for your feedback. My vet also suggest that if it were her dog, she wouldn't treat, but she said it was up to me. I am just worried about not treating and encountering another episode; pancreatitis, blood clots, etc if left untreated. I was told by my vet that even if we treat a cushpup, that they still have an increase in these types of episodes. This leads me not to treat. I will probably do another acth without trazodone in a week or two and see what it looks like. Thanks again!

[Maggiemoo1]

Hi Marianne,

Thank you for your feedback. My vet also suggest that if it were her dog, she wouldn't treat, but she said it was up to me. I am just worried about not treating and encountering another episode; pancreatitis, blood clots, etc if left untreated. I was told by my vet that even if we treat a cushpup, that they still have an increase in these types of episodes. This leads me not to treat. I will probably do another acth without trazodone in a week or two and see what it looks like. Thanks again!

How’s pookie?

[fkhan]

How’s pookie?

I'm crossing my fingers she stays where she is at, because Pookie is in a good place right now. I had to email the vet yesterday, because Pookie is now screaming when I give her SubQ's. I'm thinking she is feeling much better or the area around her shoulder blades has gotten really sensitive. I had asked for smaller needles to try and am waiting for a response from my vet. Her last panel showed BUN still high. My azodyl could be rancid and not even know. In the meantime, I have cut back on how much protein she eats as well. I have also started trying Dr. Harvey's food and add protein to it. One of the things that brings me the most joy is that she can take longer walks now (20-40yards extra), she doesn't pant anymore(still shocked as to why not), her hair appears to be growing back(not sure if cushings is reduced somehow or the antiseptic shampoo helped), and that she gets up on the couch with Peaches and I to cuddle. Love that!!

Thank you,

[fkhan]

Hello,

Just wondering if anyone suggest using Plavix for blood clots. My little Pookie has had at least one stroke, and possibly another a few weeks ago. It was either an acute vestibular incident or blood clot in the brain. Internal medicine stated they would stop the plavix for risk of a brain bleed, but if infarcts are noted on the mri, wouldn't blood clot medication be the treatment?

[Squirt's Mom]

Your latest individual thread has also been moved to Pookie's original thread. We keep all posts about each dog in one single thread. It makes it easier for everyone to look back thru the history plus gives you a good record of her journey all in one place VS spread out across the board with individual threads getting lost. So if you need to bookmark this page so you can find her thread from now on, please do. I am also going to add her name to the thread title to make it easier for you to find.
Thanks!

As for the Plavix...I haven't used it with any of my dogs. BUT blood clots VS brain bleeds are very different things. The clots are thickened blood needing thinners such as Plavix but drugs like Plavix would make bleeds anywhere much much worse. I would listen to the IMS on this one if any bleed is present. Of course if you are dealing with both a bleed and clots then things get difficult unfortunately.

Hugs,
Leslie

[labblab]

I’m so sorry Pookie is having this added problem, but I think Leslie’s comments are 100% spot-on. I really have nothing to add about the Plavix, but I surely hope that things will improve for Pookie. Please do let us know.

Marianne