Not convinced my dog doesn’t have Cushings! (Cesar has passed)

[Ryles]

Hi everyone

New to this forum and hoping to get some advice about my dog. I have a rescued 7 year old male cane Corso. We rescued him in 2018 from Romania. The first year was great. Healthy, loved his walks, happy dog! Then in October 2019 I noticed he’d become quite greedy then started drinking lots of water. A few weeks later he stopped running, jumping up and just generally lethargic not wanting to exercise etc also he keeps staring at the floor. Took him to the vet where they did blood tests expecting Cushings. Results came back and showed high liver enzymes (70) and high cholesterol. However didn’t show Cushings as usually it would be a much, much higher result. So tested him for hypothyroidism. His results came back low thyroid but TSH normal. As his symptoms got worse my vet done a trial on thyroxine but this made no difference so we took him of it. He has had 2 lots of scans and xrays which all came back completely normal. I’ve swapped him to a raw food diet as he has put on so much weight through not exercising. However I’m still seeing little difference in his symptoms. I’ve even changed vets for a second opinion but they still don’t think he has Cushings. I’ve seen little improvement in his symptoms. He has every symptom apart from panting and hair loss although weirdly he has stopped moulting completely since all this started. The vet thinks it’s all behaviour related I.e the excessive water drinking etc. Personally I don’t. He is like a totally different dog. Any advice? What would you do? Specialist next possibly? Thank you!

[labblab]

Hello and welcome to you and your boy! You’ll see that I’ve moved your thread to our main Questions and Discussion forum — this way, our members are more likely to see your thread and join in the conversation.

My first question is whether or not your dog has been given an actual diagnostic blood test for Cushing’s. It sounds as though your vet ruled out Cushing’s based on general blood chemistries — that the elevation in the liver marker didn’t seem high enough. However, given your dog’s observable symptoms as well as a low thyroid result that is most likely secondary to another condition (like Cushing’s), I agree that Cushing’s remains a likely candidate.

The two diagnostic tests are the ACTH stimulation test, and the Low Dose Dexamethasone Suppression test. For a dog with no other known illnesses, the LDDS is the preferred test because it is less likely to register a “false negative” in a dog who truly has the disease. Here in the U.S, the LDDS is an 8-hour blood test. In Europe, I believe it is sometimes conducted as a urine test over a 3-day time period. Both the ACTH and the LDDS can be skewed by the stress of other physical conditions if they are present. But they remain the two tests that are most specific to making a Cushing’s diagnosis. So if neither of those tests has been performed on your boy, that’s what I’d be requesting right now. If one of those tests has been done, it’ll be great if you can give us the results.

And once again, welcome!
Marianne

[Ryles]

Hello and welcome to you and your boy! You’ll see that I’ve moved your thread to our main Questions and Discussion forum — this way, our members are more likely to see your thread and join in the conversation.

My first question is whether or not your dog has been given an actual diagnostic blood test for Cushing’s. It sounds as though your vet ruled out Cushing’s based on general blood chemistries — that the elevation in the liver marker didn’t seem high enough. However, given your dog’s observable symptoms as well as a low thyroid result that is most likely secondary to another condition (like Cushing’s), I agree that Cushing’s remains a likely candidate.

The two diagnostic tests are the ACTH stimulation test, and the Low Dose Dexamethasone Suppression test. For a dog with no other known illnesses, the LDDS is the preferred test because it is less likely to register a “false negative” in a dog who truly has the disease. Here in the U.S, the LDDS is an 8-hour blood test. In Europe, I believe it is sometimes conducted as a urine test over a 3-day time period. Both the ACTH and the LDDS can be skewed by the stress of other physical conditions if they are present. But they remain the two tests that are most specific to making a Cushing’s diagnosis. So if neither of those tests has been performed on your boy, that’s what I’d be requesting right now. If one of those tests has been done, it’ll be great if you can give us the results.

And once again, welcome!
Marianne

Thank you so much for the response Marianne!
You are correct both vets ruled out doing the specific tests for Cushings as his blood chemistry seemed to rule it out. However I’m not sure if maybe he had a false reading? I know my boy isn’t well, I just know! But at the same time I don’t like telling my vet that I think they’re are wrong. They are the professionals at the end of the day what do I know! He did say that his recent scans did not show he had Cushings as both glands looked normal and so did his liver. But his symptoms just haven’t improved if anything they have got worse. His whole body has changed shape. His belly hangs and his back really dips down which I’m assuming is due to muscle wastage? His lost all of his muscle in his back legs. I think I’m just going to ask for the LDDS test and if that comes back negative then I agree I could most likely rule Cushings out.

[labblab]

Hi again! There is one other alternative “gateway” test that you could consider. It’s called the UC:CR, or urine cortisol to creatinine ratio. We’ve been told that the best method by which to conduct this test is for the owner to collect a urine sample at home on three successive mornings, pool the samples together, and then take them to the vet for analysis. The samples should be collected with the least amount of stress involved as possible. This is why they should be collected at home and *not* at the vet’s office. If the ratio comes back within the normal range, Cushing’s can pretty much be ruled out definitively. If it shows an elevated proportion of cortisol, then Cushing’s is a possibility, but not proven, and you’d then still have to advance to either the LDDS or ACTH. However, I did want to offer this test to you as an additional possibility. It’s likely much less expensive than the LDDS if it rules out Cushing’s, but it would be an added expense if you have to move on to the LDDS in addition.

However, it’s just a thought, and here’s a link that explains it in more detail. One note: the link only references collecting a single urine sample for analysis. As mentioned above, we’ve been told by experts that a pooled sample from three mornings is more accurate.

https://vcahospitals.com/know-your-pet/urine-cortisol

Marianne

[Ryles]

Hi again! There is one other alternative “gateway” test that you could consider. It’s called the UC:CR, or urine cortisol to creatinine ratio. We’ve been told that the best method by which to conduct this test is for the owner to collect a urine sample at home on three successive mornings, pool the samples together, and then take them to the vet for analysis. The samples should be collected with the least amount of stress involved as possible. This is why they should be collected at home and *not* at the vet’s office. If the ratio comes back within the normal range, Cushing’s can pretty much be ruled out definitively. If it shows an elevated proportion of cortisol, then Cushing’s is a possibility, but not proven, and you’d then still have to advance to either the LDDS or ACTH. However, I did want to offer this test to you as an additional possibility. It’s likely much less expensive than the LDDS if it rules out Cushing’s, but it would be an added expense if you have to move on to the LDDS in addition.

However, it’s just a thought, and here’s a link that explains it in more detail. One note: the link only references collecting a single urine sample for analysis. As mentioned above, we’ve been told by experts that a pooled sample from three mornings is more accurate.

https://vcahospitals.com/know-your-pet/urine-cortisol

Marianne

So back to the vet today as my boy has gone really downhill over the last 2 weeks. Done more blood tests. These are the chemistry’s that came back high:
Albumin 41.0
A:G Ratio 1.8
ALP 366
ALT 356
Gamma GT 25.0
Cholesterol 9.2

He is so depressed and has absolutely no energy. The vet still doesn’t want to test him for Cushings so is going for full thyroid profile including antibodies.

I honestly think we are running out of time. It’s almost like he is giving up. What does anyone think? I’m thinking of getting him referred to a specialist now as we are going around in circles and getting no answers. 😔

[labblab]

If I were you, I’d indeed go ahead and request a referral to a specialist. Obviously something serious is going on, and given all his symptoms, I do think that Cushing’s remains a possibility for your boy. At this point, you really have nothing to lose by having a specialist take a look at things, and you may have a lot to gain. Please let us know how things develop, OK?

Marianne

[Squirt's Mom]

Definitely see an IMS - Internal Medicine Specialist! And if you are in the US you have the right to tell the vet what tests to run. This is YOUR dog and YOU will live with the results of what the vet does or does not do on his behalf. If this vet won't do as you as, find a new GP vet asap along with that IMS.

[Ryles]

So after 6 months we finally have a diagnosis of Cushings. Unfortunately he also has hypothyroidism as well and has been on treatment for 4 weeks at the moment for that. He has started vetoryl today. His dosage is 90mg and his weight is about 44kg. Does this sound about right? Thank you

[Budsters Mom]

44kg = about 97 lbs. The suggested starting dosage for Vetoryl is 1mg. per pound of weight. Since he weighs 44kg/97 lbs. , 90 mg. would be a reasonable starting dose.

[Harley PoMMom]

Kathy is right, however, there is a published study that has found that larger dogs require less of the recommended dose of Trilostane to control cortisol, so if this were me I wouldn't start out any higher than 40 mg of Trilostane. Here's a link to that study:https://onlinelibrary.wiley.com/doi/full/10.1111/j.1939-1676.2012.00956.x

Lori

[Joan2517]

I started my Gable, who weighed about 75lbs ,at 40mg at Lori's suggestion and he did well for about six months, then we had to lower it. He is on 5mg now, so I would do as Lori suggests and start at 40. You can always go up if needed. It's better than having the cortisol drop too low, which could be dangerous.

[labblab]

I agree with the advisability of starting out at a lower dose. Since you say that he’s already begun 90 mg. daily, I’m assuming you have either only 30 mg. capsules on hand, or a combo of 60 mg. and 30 mg. capsules. If that’s the case, I would definitely decrease at least as far as giving only 60 mg. for the first 10-14 days, until you can monitor the effect of that dose on his cortisol level. Or you could be even more conservative and just start out with 30 mg., knowing that you can always increase the dose easily should he need a higher dose of the medication, after all. At this stage and after the six month diagnostic delay, giving him a bit more time to build up slowly from a lower dose should not be a problem and may allow his body to adjust more easily to a gradual lowering of his cortisol, regardless of whether or not the dose is increased later on.

Also bear in mind that his low thyroid reading may have been secondary to the uncontrolled Cushing’s. Once his cortisol has been effectively lowered into therapeutic range for a period of time, his thyroid level may naturally rebound, too. That being a possibility, you’ll want to make sure to also monitor his thyroid level on a regular basis to make sure that he doesn’t end up with too *much* thyroid supplementation.

Marianne

[Ryles]

Kathy is right, however, there is a published study that has found that larger dogs require less of the recommended dose of Trilostane to control cortisol, so if this were me I wouldn't start out any higher than 40 mg of Trilostane. Here's a link to that study:https://onlinelibrary.wiley.com/doi/full/10.1111/j.1939-1676.2012.00956.x

Lori

Thank you! I’m really not sure what to do? I only gave him 60mg this morning as I was so worried after reading this. I was also on a support group on Facebook but my god they were scary so I came off it! Pretty much told me I was killing him by giving him that dosage. I’m just so confused a vet is meant to be a professional who I pay a hell of a lot of money to and he doesn’t even know what to dose him? Does it make a difference if he has had Cushings for a long time? Does that mean a bigger dose? My dog has been sick for nearly 7 months now. Thank you for any help....I’m an absolute wreck at the moment. To make it even worse he has a respiratory infection that we just can’t get rid of and is in the vets every few days as he has trouble breathing. I’m so worried for my boy.

[Ryles]

I agree with the advisability of starting out at a lower dose. Since you say that he’s already begun 90 mg. daily, I’m assuming you have either only 30 mg. capsules on hand, or a combo of 60 mg. and 30 mg. capsules. If that’s the case, I would definitely decrease at least as far as giving only 60 mg. for the first 10-14 days, until you can monitor the effect of that dose on his cortisol level. Or you could be even more conservative and just start out with 30 mg., knowing that you can always increase the dose easily should he need a higher dose of the medication, after all. At this stage and after the six month diagnostic delay, giving him a bit more time to build up slowly from a lower dose should not be a problem and may allow his body to adjust more easily to a gradual lowering of his cortisol, regardless of whether or not the dose is increased later on.

Also bear in mind that his low thyroid reading may have been secondary to the uncontrolled Cushing’s. Once his cortisol has been effectively lowered into therapeutic range for a period of time, his thyroid level may naturally rebound, too. That being a possibility, you’ll want to make sure to also monitor his thyroid level on a regular basis to make sure that he doesn’t end up with too *much* thyroid supplementation.

Marianne

Hi Marianne, so yes I have 60mg and 30mg. I gave him 60mg this morning and will carry on with that until he is back at the vets in 10 days. I’m so worried about him at the moment! He is so unwell. We had his thyroid levels checked on Wednesday and they look good so at least that’s one good thing. Thanks for your help x

[labblab]

Welp, I actually give your vet kudos for not recommending an initial dose that exceeds 1 mg. per pound. Many vets are still prescribing doses much higher than that, even though the 1 mg./lb. recommendation has become become more widely known. One huge problem relates to the FDA-approved printed literature that accompanies boxes of Vetoryl. The language dates from the time when Vetoryl was first approved for use in the U.S. back in 2009 when dosage levels were much higher. Subsequent studies and real-life experience have led to subsequent revisions among clinicians who commonly use the medication. The first big shift was to the 1 mg./lb. recommendation, and now — as you see — even smaller initial doses are recommended by some clinicians for larger dogs. However, none of this is reflected in the formal FDA-approved labeling, which is beyond frustrating and irritating. So even though I’d like to think that every vet (and every human doctor, for that matter!) is entirely up-to-date re: all details about the meds they prescribe, I realize that’s unlikely in the real world, and I’m willing to cut some slack when the drug’s own labeling is out-of-date. But how I *do* judge a vet’s reaction is the manner in which they respond when they are informed about new, important information. So I would hope that your vet will welcome the info contained in the link that Lori provided, and integrate the new info in his approach to treatment of dogs going forward.

And nope, the length of time or severity of the disease prior to beginning treatment does not play a role in initial dosing. The recommendations have always been, and still remain, based on weight alone. Subsequent dosing changes are then based on observable clinical response as well as monitoring blood testing. Dogs of the same weight can end up needing widely varying doses after treatment has actually been underway.

Marianne

[Ryles]

Welp, I actually give your vet kudos for not recommending an initial dose that exceeds 1 mg. per pound. Many vets are still prescribing doses much higher than that, even though the 1 mg./lb. recommendation has become become more widely known. One huge problem relates to the FDA-approved printed literature that accompanies boxes of Vetoryl. The language dates from the time when Vetoryl was first approved for use in the U.S. back in 2009 when dosage levels were much higher. Subsequent studies and real-life experience have led to subsequent revisions among clinicians who commonly use the medication. The first big shift was to the 1 mg./lb. recommendation, and now — as you see — even smaller initial doses are recommended by some clinicians for larger dogs. However, none of this is reflected in the formal FDA-approved labeling, which is beyond frustrating and irritating. So even though I’d like to think that every vet (and every human doctor, for that matter!) is entirely up-to-date re: all details about the meds they prescribe, I realize that’s unlikely in the real world, and I’m willing to cut some slack when the drug’s own labeling is out-of-date. But how I *do* judge a vet’s reaction is the manner in which they respond when they are informed about new, important information. So I would hope that your vet will welcome the info contained in the link that Lori provided, and integrate the new info in his approach to treatment of dogs going forward.

And nope, the length of time or severity of the disease prior to beginning treatment does not play a role in initial dosing. The recommendations have always been, and still remain, based on weight alone. Subsequent dosing changes are then based on observable clinical response as well as monitoring blood testing. Dogs of the same weight can end up needing widely varying doses after treatment has actually been underway.

Marianne
Thank you Marianne, you are so knowledgable and I appreciate your advice so much x

[Ryles]

So Cesar has now been taking vetoryl for nearly 7 days. I dropped his dose to 60mg and he seems to be doing fine. We have noticed a large improvement already in his excessive drinking and urinating. However there hasn’t been any improvement in his lethargy. Still just sleeping all day. How long does this usually take to improve? Thank you x

[Squirt's Mom]

60mg is still too high based on the latest studies which say large dogs, over 66lbs (30kg), should start at no more than 0.5mg per lb. I would have wanted a starting dose no higher than 40mg, 30mg preferably. ;) Since you don't mention any other signs of overdose other than lethargy hopefully he is not being adversely affected by the 60mg. But do be aware that lethargy is one of the signs that the cortisol is too low so keep a close eye out for loose stools/diarrhea, nausea/vomiting, and loss of appetite.

As for when this will go away....I can't say because of the high dose. Lethargy is not typically a sign of elevated cortisol but the opposite - cortisol that is too low. Some dogs simply feel bad when the cortisol is lowered tho. If you have ever been on prednisone then you can relate to a small degree. While on the pred you feel pretty good, no pains, more energy but when the course of pred is over all that reverses. Some pups experience a period of just being off once the cortisol starts to lower. This may be what is happening with Cesar. Just keep an eye on him as you have been and hopefully he will be feeling more like himself soon.

Hugs,
Leslie

[labblab]

Hi again. Leslie is definitely right that lethargy can be caused by low cortisol. However, in looking back through your thread, I see that Cesar was acting this way prior to beginning the Vetoryl. So I’m suspecting it’s not a new problem, but instead an issue that has not yet shown improvement with treatment. It may take a while, though. My own Cushpup also acted tired and lethargic prior to treating, and even though the excessive thirst and urination improved quite rapidly, it took a longer time to see improvement in his energy level and his muscle tone. He especially had grown very weak in his rear end while his cortisol was uncontrolled, and he did a lot of laying around.

Of course, you do want to keep watch for any of the other symptoms of low cortisol that Leslie has listed. And we’ll all definitely be interested in the result of his first monitoring blood test in order to see where Cesar’s cortisol level actually is.

Marianne

[Ryles]

So we made the incredibly hard decision to get Cesar put to sleep today. I felt so relieved after finally getting his diagnosis 10 days ago but unfortunately that was very short lived. Over the past 5 days he just went downhill so quickly. Confused, crying, hasn’t eaten since Saturday, diarrhoea then constipation. The vet done and ultrasound on his liver last night and said it was very enlarged and tender to touch. He was so weak that we felt like we couldn’t put him through anything else. He was also still battling a respiratory infection that just wouldn’t go away despite 5 weeks of antibiotics. I want to thank you all for your help and advise, quite frankly your knowledge on here is superior to any vet I’ve seen. If I’d gone with my gut 8 months ago instead of listening to the vets he may still be here now. I’m beyond devastated. Good luck to everyone else and your fur babies xxx

[labblab]

I am so deeply sorry to read this news, but I do understand about your decision and how incredibly painful this day must be for you. In the midst of your own shock and sorrow, thank you so much for taking the time to come back and tell us what has happened. We hope it may offer a tiny bit of comfort to know that Cesar has now been added to our special memorial thread where he will always be honored:

https://www.k9cushings.com/forum/showthread.php?9294-Remembering-All-Who-Have-Left-Us-(2020)

As hard as it is to lose him, I hope you’ll also find comfort in knowing that you rescued him twice now. You rescued him physically back in 2018 when you gave him a wonderful life and home; now you’ve rescued his spirit by releasing it from his ailing body. He was so lucky that his forever home turned out to be yours.

One other thing I want to mention is the possibility that Cesar’s Cushing’s may have been caused by a pituitary tumor that was enlarging and placing pressure on the parts of his brain that control his appetite and behavior. I worried about that a bit when I first read your description of his lethargy and staring at the floor beginning back last fall. That’s what I suspect caused me to lose my own Cushpup, and it also was a possible issue for another recent member, little Stella. Her parents lost Stella just last week, so I had also been writing on her thread about the ill effects of such a macrotumor. Diagnostics and treatment of a macrotumor are very expensive and must be performed at specialty centers. My own boy was in such ill health and had already put up with so much testing that I did not feel as though I could ask any more of him, either. So I truly do understand the push-and-pull of praying for answers, but also not wanting to poke and prod our furbabies any further. Sometimes the greatest gift is truly to give them peace.

But all of us here also understand how much your own heart must be hurting today. So please know that we’ll always welcome you back here at any time if you want to talk or vent or just share stories of your lives together. In the meantime, I’m sending many hugs to you from across the miles.

Always in loving memory of your dear boy,
Marianne

[Joan2517]

How sad, I am so sorry for your loss of dear Cesar. Losing them is just so hard. Many hugs to you during this heartbreaking time.

Joan

[Squirt's Mom]

Dear Ryles,

I am so sorry to hear about the passing of your sweet Cesar. :( No matter what is going on, we are never ready to face this day when they must leave us for a while. Yes, for a while. I firmly believe we will all see our precious babies again one day when we cross that Valley from this life to the next. Cesar will be waiting for you then and from that time on you will never be parted again. Til then, he will be watching over you with the same love and care with which you watched over him for so long.

Grieve as long as you need in any way that you need. There is only one rule to grieving...do no harm. So don't let guilt take hold. It is part of the grieving process but let it be a passing phase as it should be. To hold on to it is harmful. You did all you could to help your precious baby boy and he knows that so don't beat yourself up.

Please know we are here if you need to talk, cry, scream, vent, whatever. We DO understand.

My deepest sympathies,
Leslie



Tribute to a Best Friend

By Unknown Author

Sunlight streams through window pane onto a spot on the floor…
then I remember,
it’s where you used to lie, but now you are no more.

Our feet walk down a hall of carpet, and muted echoes sound…
then I remember,
it’s where your paws would joyously abound.

A voice is heard along the road, and up beyond the hill,
then I remember,
it can’t be yours — your golden voice is still.

But I’ll take that vacant spot of floor and empty muted hall,
and lay them with the absent voice and unused dish along the wall.

I’ll wrap these treasured memories in a blanket of my love,
and keep them for my best friend until we meet above.

[Ryles]

Hi Marriane, thank you for your kind words. My vet also said he feels it could be a macrotumour. He really went downhill so much over the past week. He didn’t really even look like my Cesar anymore and lost so much weight in such a short space of time. My heart is absolutely aching for him today. I will miss him so much. X

[Ryles]

How sad, I am so sorry for your loss of dear Cesar. Losing them is just so hard. Many hugs to you during this heartbreaking time.

Joan
Thank you Joan

[Ryles]

Dear Ryles,

I am so sorry to hear about the passing of your sweet Cesar. :( No matter what is going on, we are never ready to face this day when they must leave us for a while. Yes, for a while. I firmly believe we will all see our precious babies again one day when we cross that Valley from this life to the next. Cesar will be waiting for you then and from that time on you will never be parted again. Til then, he will be watching over you with the same love and care with which you watched over him for so long.

Grieve as long as you need in any way that you need. There is only one rule to grieving...do no harm. So don't let guilt take hold. It is part of the grieving process but let it be a passing phase as it should be. To hold on to it is harmful. You did all you could to help your precious baby boy and he knows that so don't beat yourself up.

Please know we are here if you need to talk, cry, scream, vent, whatever. We DO understand.

My deepest sympathies,
Leslie



Tribute to a Best Friend

By Unknown Author

Sunlight streams through window pane onto a spot on the floor…
then I remember,
it’s where you used to lie, but now you are no more.

Our feet walk down a hall of carpet, and muted echoes sound…
then I remember,
it’s where your paws would joyously abound.

A voice is heard along the road, and up beyond the hill,
then I remember,
it can’t be yours — your golden voice is still.

But I’ll take that vacant spot of floor and empty muted hall,
and lay them with the absent voice and unused dish along the wall.

I’ll wrap these treasured memories in a blanket of my love,
and keep them for my best friend until we meet above.

Thank you Leslie, such lovely words. Yep the guilt has already set in. Just wish I’d pushed for the Cushings test so much earlier instead of listening to the vet. He’d had it for 8 months and most probably suffered a bit. That makes me feel so bad. But I know he knows I loved him more than anything. He was my best boy. I’ll never forget him.

[StellaHealing!]

Hi Ryles,

This is Adele, Stella's mom who Marianne referenced on the 16th. My husband Chris and I are touched by your story and can relate to your feelings. We too had more than one vet downplay the possibility (then the severity) of Stella's Cushing's. So very sorry to hear about sweet Cesar. I'm sure he knew how much he was loved and that you did what you thought was best at the time. We all put faith in the 'experts' and often they are correct, but perhaps our recent experiences are also pointing us to trust our own intuitions as well.

Thank you for sharing about Cesar and for being such a big hearted pet papa. I hope you give a lucky dog another home when the time is right. I'm sure Cesar will be putting the word out on the streets... ;)

One of the things someone shared that has helped me the most is that the love these precious animals gave while they were here and left once they departed continues to GROW. It's as if a seed was planted and their magic will appear throughout your life, especially if you look.

Wishing you all the best,
Adele