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[vanay126]

Hello all! My name is Vanessa and my oldest furkid Cheyenne (10yr, Boxer) was diagnosed with Cushing’s October 2019. I’ll try to keep our experience so far here as short as I can, but it’s a lot so please bear with me.

Early 2018 at a biannual comprehensive exam (done out of state at the closest Banfield), we noticed elevated liver enzymes in Cheyenne’s bloodwork. Her vet suggested an abdominal ultrasound. When we got back we found a vet in town to do it and the results were negative.

January 2019, she is developing a skin condition. Cheyenne has had skin infections in the past and usually cleared up but this time she couldn’t recover from it. Saw the in town vet multiple times to be sent home with a special shampoo and antibiotics. She started losing hair in places on her torso dorsally and the spots became calcified and dark.

Around this time she started to get abscesses in her elbows (first one on one of her back hind joints) that would cause the leg below the joint to swell up. It was diagnosed as that, an abscess, and was lanced. We went to another vet in town for a second opinion when another abscess popped up, this time on her front leg. It was lanced, and this second vet expressed concern over Cheyenne’s skin and started talking to us about Cushing’s disease. She was eventually tested using the low dose Dexamethasone suppression, I believe. She developed another abscess on her opposite front leg that we kept an eye on. Antibiotics made the swelling go away but now it’s a hardened lump that has flattened and gotten smaller.

As of now Cheyenne has taken one month’s supply of Vetoryl 60mg. After she ran out, the vet did the ACTH test. She wants to keep her on the Vetoryl 60mg for six months, then follow up with her again to see how she’s doing with the medication.
I should also mention Cheyenne weighed 64 lbs in 2018 and is now at 50lbs.

I am hesitant to give her Vetoryl again as I have read of the negative side effects associated with it. I know all dogs respond differently and she may very well thrive on it. It may be too early to tell since she was only on it for a month but my husband reassures me Cheyenne is more energetic and her skin seems to be looking better and I can’t really argue with that.

So this is where we are now. I’m awaiting her prescription to come in so she has been off of it for about a week. Does anyone have positive experiences with Vetoryl? What are your thoughts on Cheyenne’s ailments? I’m particularly curious if anyone else has dealt with abscesses in the joints as well, although I think it may be something unrelated to Cushing’s. Lay your thoughts on me, my heart hurts for her so much. Thanks in advance!

[labblab]

Hello, and welcome to you and Vanessa! Thanks so much for all your introductory information; I just have a few more questions to ask. Cushing’s can be a very difficult disease to diagnose, and that’s why a combination of observable symptoms and laboratory results are important puzzle pieces. You mention the elevated liver enzymes that were first noted early in 2018. Have those elevations persisted, or did they normalize on their own prior to starting the Vetoryl? Also, aside from the skin issues, does Vanessa exhibit any other common overt symptoms such as excessive thirst/urination/hunger, pot belly, panting, hind-end muscle weakness, or searching out cool places when resting?

Unfortunately, there is no single blood test that can definitively diagnose Cushing’s. Both of the common tests (ACTH stimulation test and/or LDDS) can return “false positives” in the presence of other nonadrenal illnesses or bodily stresses. For that reason, the presence of observable symptoms builds confidence in the accuracy of the diagnosis. So if Vanessa exhibits no symptoms other than the infections/abscesses and her blood chemistries returned to normal on their own, I do worry about the diagnosis. One huge exception, however, is if her skin issues turn out to be a particular disorder known as “Calcinosis Cutis.” With this disorder, internal calcium deposits can work their way upward until they erupt through the skin. This process can result in very angry weeping lesions that ultimately resolve into hardened plaques. CC can only be definitively diagnosed via a skin biopsy. But if it’s present, it’s almost a sure guarantee that Cushing’s is the underlying cause, and our experience here is that boxers with Cushing’s seem to be especially vulnerable to developing this condition. If CC is present, then prescription medication such as Vetoryl aimed at lowering cortisol levels is indeed a very important part of ongoing treatment. If those lesions are allowed to expand and spread, a dog’s quality of life can be miserable. So we’d definitely like to find out more specifics about Vanessa’s skin issues and abscesses.

If Cushing’s is indeed her proper diagnosis, then Vetoryl is one of the two effective drug treatments. Vetoryl is a powerful medication with risks of side effects, but we’ve seen many success stories here over the years with dogs whose symptoms were safely and effectively controlled. From what you’ve told us, I do have another worry, however.


As of now Cheyenne has taken one month’s supply of Vetoryl 60mg. After she ran out, the vet did the ACTH test.
How long after Vanessa’s last dose of Vetoryl was the test performed? Proper Vetoryl monitoring requires the ACTH to be run 4-6 hours after the morning dose of Vetoryl is given along with breakfast. If the test is performed later than that, the medication’s effect has already started to lessen, and therefore you get an inaccurate picture of the Vetoryl’s effect on suppressing cortisol production. From the standpoint of safety, you want to know where the cortisol level is at its lowest point: 4-6 hours after dosing with a meal. If the test is delayed by hours, or certainly by days, you may falsely conclude that a given dosage level is OK, when actually it is too high a dose for safety. So we’d really appreciate learning the exact timing of the monitoring ACTH, as well as the actual numerical test results.

I’ll go ahead and close for now. But thanks in advance for any additional info. And once again, we’re really glad you’ve found us!

Marianne

[vanay126]

Hi Marianne!

Thank you so much for responding! Here is some more information regarding my dog, Cheyenne.

The liver enzymes continue to climb. Each time Cheyenne gets a comprehensive exam, it is checked. She hasn’t had them drawn since she started the Vetoryl but when we go in April it will be done again.

Here are her results from last year:

4/20/19
ALKP: 417 U/L
ALT: 248 U/L

10/26/19
ALKP: 1305 U/L
ALT: 302 U/L

Yes, my dog does present with other symptoms. The ones I’ve noticed are excessive thirst, pot belly appearance, and hind-end muscle weakness/loss.
I also did look into Calcinosis Cutis recently and it does look similar to what Cheyenne has. I will ask the vet's office in town about getting a biopsy to confirm this for sure. I recall that Dr. Wolf did mention herself that she thought her lesions looked calcified.

Now to when Cheyenne ran out of Vetoryl. We gave it to her consistently every night with her food. She did go almost a week without it when she did run out. It was right before New Years Day and we were busy with work and family around that time. When we called the vet in town to let them know she would need to be tested there was a bit of confusion but the techs ended up getting back to us when Dr Wolf was in town again. The thing about this office is you don’t talk to the vet directly. She’s a very busy person, and we only see or talk to her when we go to her office (which is an hour away from us). They got back to us on a Friday and said we could schedule Cheyenne's test for that Monday and to come get enough pills to get her through the weekend. We went in and got three pills and she took them every night up until that Monday (three doses). I am not sure why my husband and I had first decided to give them to her at night but it sounds like it does indeed make a difference when it comes time to test.
Here are her results from the first and second test Cheyenne has had done.

LDDS from 10/22/19:
Pre LDD and ACTH: 4.52
Post 2hr ACTH: 30.00
Post 4hr LDD: 5.52
Post 8hr LDD: 5.96

ACTH results from 1/7/20:
Pre ACTH: 5.54
Post 2 hr ACTH: 13.40

I am thinking since Cheyenne went almost a week without it towards the end of the month that it would be best to retest her ACTH after 30 days of taking Vetoryl again, while making sure to have enough medication on hand before testing. I will also start giving her the medicine with her AM feeding. I definitely want to ensure that she is not getting too much of a dose.

Thank you for your reply and I look forward to hearing from you again!

-Vanessa

[Squirt's Mom]

Hi Vanessa and welcome to you and Cheyenne!

Thank you for sharing that information on the LDDS, ACTH, and labs for the liver values. Were there any other abnormal results, too high or too low, from the test that shows those liver values? I think once the correct way to dose and monitor is going on you will see that post, or second, number come down which is what we want. We would like to see that post number somewhere around 3.5ug/dl. At that level you should start to see this skin issue changing IF it is CC.

I want to add something to what Marianne has shared. Recent studies have shown that most larger dogs need to start with a much lower dose than what is stated in the literature about Vetoryl. They need to start at a 0.5 mg/lb. So a 60 lb dogs needs a 30mg starting dose according to the most recent research. Dechra, the manufacturer, is aware of this but refuses to change their literature at the moment so vets continue to give starting doses that are often much too high. In light of this, please keep a very close eye on Cheyenne for the following signs -

loss of appetite
loose stool/diarrhea
nausea/vomiting
lethargy

If you see any of these signs, stop the med and call the vet for an ACTH immediately. Some dogs do ok on the old dosing of 1mg per lb but some do not so I just wanted you to know what to look for in case Cheyenne is one of the ones who needs the lower dose. In light of this, I would not pay for 6 months worth of medication if they ask you to do so. Not only is that not the correct way to monitor, she may need a lower dose and you would be stuck with meds she couldn't use and out money you didn't need to spend. ;) Here are some links to those studies you can share with her vet -

https://www.ncbi.nlm.nih.gov/pubmed/22708554

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1939-1676.2012.00956.x

Most vets don't have the time or take the time to try to stay on top of all the research going on with Canine Cushing's...but some of our members are just the opposite and spend a great deal of their time learning all they can about things going on in the cush world that impact our babies in diagnosing the disease, treating the disease, monitoring treatment for the disease, and living with this disease. It is all they focus on VS the myriad things a vet has to focus on. So often we are ahead of vets in knowing the newest info concerning Cushing's. It's not a judgement call on the vets at all...it's just what we do because this is our sole focus. :)

I am glad you found us and look forward to learning more as time passes. We are here to help any way we can so never hesitate to ask questions....we will do our best to help you understand.

Hugs,
Leslie

[vanay126]

Hi Leslie!

Thank you for your reply and the links to the studies. Next time I speak to the vet I will definitely bring it to her attention. When Cheyenne resumes her meds I will monitor her for the signs you mentioned.
We are also going to request another ACTH 30 days on Vetoryl since Cheyenne went almost a week without it right before her last test.

I haven't noticed any other abnormal numbers in her labwork besides her lymphocytes at 0.53 and her GGT at 55 U/L. They were both back in April 2019.

I was so overwhelmed by her diagnosis in the beginning it was starting to make me pessimistic. But I am so happy I found this forum. I appreciate you guys helping me to understand Cushing's a little more. It is inspiring and most of all, if it helps Cheyenne in any way, I'm here for it! I'll do my best to keep you updated.

-Vanessa :)

[labblab]

Hi again, Vanessa. Thanks so much for all this additional information. Based on Cheyenne’s complete history, I do agree that Cushing’s is the likely diagnosis for her. And given the suspicion of Calcinosis Cutis, I would be opting to go forward with treatment if she was my own dog. I’m really glad that Leslie has given you this updated dosing information, though. Since it seems as though Cheyenne didn’t suffer any ill effects during the first month that she was taking 60 mg. daily, that may indeed turn out to be an appropriate dose for her. But it will be good to keep close watch on her.

I do feel compelled to note a couple of concerns about Cheyenne’s testing and vet care, though. I don’t wish to undermine your confidence in your vet, but since you’ve come to us asking our feedback, I wouldn’t feel right if I didn’t point out my concerns. In your first post, you said that your vet wanted to keep Cheyenne on the 60 mg. for six months before testing again. Recommended monitoring protocol is to retest every three months even after a dog appears to be stable (and more often if the dose is changed). This is because cortisol levels can end up changing over time, even when the dose itself is left unchanged. Given the irregularities around Cheyenne’s first monitoring, I’m really glad you’re going to request another test after another month of consistent dosing. But your vet really ought to have been the one to recommend this, herself.

Secondly, when you started treatment, you should have been given clear instructions about when and how to give the Vetoryl, both daily and also in advance of a monitoring ACTH test. If your vet is going to rely on her techs in terms of communicating with pet parents, it’s her responsibility to make sure that they are communicating accurate information.

Lastly, I have been puzzling over Cheyenne’s initial diagnostic testing results:


LDDS from 10/22/19:
Pre LDD and ACTH: 4.52
Post 2hr ACTH: 30.00
Post 4hr LDD: 5.52
Post 8hr LDD: 5.96

It is possible, but uncommon, to perform a combined ACTH and Dexamethasone test. Usually the tests are run separately, but once in awhile we see them performed on the same day. However, when done so, my understanding is that the Dexamethasone portion is typically performed first, rather than vice versa, as seemed to have been done with Cheyenne. I am no lab expert, but it seems to me that if the ACTH was performed first — injecting the stimulating agent first — you’d end up skewing the subsequent suppression results upwards, as well. I just checked the published protocols from two labs that run a combined test, and these are their instructions. The first is from Univ. Of Tennesse; the second is from Michigan State. Both of these labs are performing High Dose Dex tests in conjunction with the ACTH, though, instead of Low Dose tests. So maybe the protocols are different. And maybe the Dex part was actually finished before the ACTH for Cheyenne — the way the results were posted for her may just be confusing.


Cortisol-Dex Supp/ACTH Stim Test – DOG:

a. Collect baseline serum sample (1.0 ml). Administer dexamethasone at 0.1 mg/kg (IV).
b. Take a post-Dex serum sample 4 hrs later.
c. Following the Post-Dex collection, perform the Cortisol-ACTH Stim Test as above.



Combined Dexamethasone Suppression Test /ACTH Response Test:

For Dogs or Cats. Collect baseline sample, administer 0.1 mg dex/kg IV. Obtain second sample 2 - 4 hr later. Then follow ACTH Response Test protocol.

Anyway, I’d be curious to find out more about Cheyenne’s test — which laboratory ran the test and printed out the results? Why does this matter, you may ask. It’s because Cheyenne’s LDDS test, as reported, could result from Cushing’s caused by either a pituitary or adrenal tumor. Her ACTH results are definitely consistent with Cushing’s, in general, and there’s no reason to think they aren’t accurate. If the LDDS results are also accurate, then you may want to proceed with some additional diagnostics, such as an abdominal ultrasound, to determine whether an adrenal tumor is the cause of the Cushing’s. Pituitary tumors are far more common. But if Cheyenne instead has an adrenal tumor, this may affect her treatment and prognosis. Surgery offers a complete cure for adrenal Cushing’s, but it is very expensive and quite risky. So it’s not an option for lots of dogs. But even without surgery, knowledge about the type and location of an adrenal tumor may guide your expectations about Cheyenne’s care moving forward.

I see that I’ve written a book here, so will close for now. Once again, I am no expert about laboratory tests, so my concern about Cheyenne’s test may be totally off base due to my misinterpretation of the way in which the results have been presented. But still, I’d be interested in getting a few more specifics about that test, itself. Thanks again, in advance.

Marianne

[Squirt's Mom]

I'm glad Marianne address her concerns because they are some I share whole heartedly. In my first post I felt I was perhaps overwhelming you so I stopped with my primary concern - the research on lower doses for larger dogs. So I am very glad Marianne was able to get back to you on the other issues.

How are things going now?