Skylar - loving ten year old rescue (Skylar has now passed)

[gvlinds]

Hi new forum friends!

I am a relatively new Cushing's dog mom - I rescued an ~10 year old 16lb yorkie 9 weeks ago. When I got him, he'd been picked up from a shelter into a rescue, they'd done an initial senior blood panel and had some concerns about his heart. His kidney levels at that point I believe were slightly high. He was diagnosed first with mitral valve degeneration and we spent a few weeks getting his heart meds right.

As I got to know him, his excessive thirst stood out to me, and the corresponding need to pee! He'd pant frequently, and had a hard time with being very restless at night (and we'd have to go out to pee a few times). His temperament was sweet, but he was quite docile and lazy (wouldn't walk far at all). I kept up with the vet, and we agreed to test him for Cushings and he was diagnosed on June 24th.

For two weeks he was on 5mg of Vetoryl in the AM and PM. I saw no improvement in symptoms.... he went in for his first ACTH check, and they increased to 10mg in the morning, 5mg at night this past Friday (July 10th). They did say that the numbers looked great (though I dont have the results, will ask today) and that it was now more about symptom management. Well, his activity level since the 10mg morning dose change has skyrocketed! It's adorable, he runs and runs and runs. I didn't even know this was possible for him! It's pretty great to see such a happy go lucky dog. I did read on here not to change dosage that quickly, but I am hoping that these are good signs and we'll leave him on this for at least a month. We are getting re-checked 11 days from the increase in the meantime (July 20th). I will try to find the actual test results to share as a follow up (his initial and the ACTH follow up #1)

Was curious if anyone else gives the Vetoryl twice a day? a lot of the threads I was reading administered only in the morning? What time of day?

I have been doing 9am/9pm, and the full of beans activity starts as early as 6am! After I feel like we are on the right dosage for the long haul I may play with timing. Obviously still new 'results' but he's still up to pee during the night, so it's more the first thing in the morning change I am most noticing currently. I think he may be drinking less water during the day! But still drinks a lot of water when he's up to pee during the night.

My other pressing question for the group, however, is eye related! Since June 6th, we've had three eye issues. First, a corneal ulcer which I suspected at the time was from dust after a very windy day. He completed 10days of meds, was re-checked at day 5 and all signs pointed to clearing up. He was then fine for about a week.... then had a green gunky eye discharge. Back to vet, clear of ulcer but with an infection. Treated with different eye drop antibiotics, cleared up quickly.... completed the 10 day course treatment. Again, a week of all good. Now here we are with discharge/eye irritation (this time more white discharge). Waiting to call the vet this morning. Is this Cushing's related? Unrelated? He has some cataracts, and I think it's time to see an ophthalmologist, was just curious if anyone else has experienced anything similar. I just feel bad for his gunky winky eye!

Look forward to being a part of this community, glad I found it
Lindsay & Skylar

[labblab]

Hello Lindsay and Skylar! I’m sorry that I have only a moment to post right now, but I definitely want to welcome you two and to thank you for all the great information that you’ve supplied in your introduction. Unfortunately, things have been a little slow on the forum lately, but I’m sure that others will be by to greet you as well. And I’ll be back, myself, later today or tomorrow, in order to write more. But in the meantime, please know that we’re really glad you’ve found us!

Marianne

[labblab]

Hello once again! Gosh, it took me longer to get back to you than I had planned :-(. But hopefully, “late” is truly better than “never,” as they say!

First of all, bless you for taking in this little guy, knowing that he has these health challenges to overcome. As far as the Cushing’s treatment, it sounds as though your vet is proceeding very appropriately. You’re right that the general recommendation is to leave an initial dose unchanged for the first month. But Skylar started off at quite a conservative dose, and this intermediate increase is really just bringing him up to the accepted starting formula of 1 mg. per pound. In other words, this is the dose that he could even have been started off at. So as long as his labwork and behavior show no signs of overdose, I think this increase is fine.

Also, both once- and twice-daily dosing regimens have been researched, and are recommended as satisfactory options. Some clinicians believe that twice-daily dosing affords the most consistent control of cortisol levels, and it is definitely recommended for diabetic dogs or for dogs whose symptoms seem to rebound as the day wears on. However, that schedule is not the easiest for many parents to maintain, especially since every dose of Vetoryl should be given with a full meal in order to be metabolized properly. So if satisfactory symptom resolution can be achieved by dosing just once daily with breakfast, then that can be a much easier schedule for many folks to follow.

In terms of arriving at the best dosing schedule for you and Skylar, I want to stress the importance of giving each dose with food. Above anything else, that may help determine which time of day works best for you.

As far as his eye problems, it is generally the case that dogs with uncontrolled elevated cortisol levels seem to be more vulnerable to infections (and slow healing) across the board. But I’m not aware of any particular link between Cushing’s and eye problems. Hopefully Skylar’s new Cushing’s treatment regimen will end up improving his immune system, overall.

Guess that’s all I can think of for now. But once again, welcome to you both. It sounds as though you’re on the right track!

Marianne

[gvlinds]

Thanks Marianne!

Appreciate the support, and the info! I've been doing dinner in sort of two parts, some at 7pm and then the rest at 8pm with his pills. He takes his heart meds at the same time.... so with a good amount of meal (dry and wet). But great point as we settle in to consider.

His eye is still the corneal ulcer they believe slow healing, so I think you're right about general immune system...

Still peeing 1-2x a night, so hopeful eventually we will reduce that some when he gets settled :).

Thanks for the support! Will share more of our journey.

Lindsay and Skylar

[Squirt's Mom]

Hi Lindsay,

Welcome to you and Skylar!

I have a concern about the timing of the medication. You said -
I've been doing dinner in sort of two parts, some at 7pm and then the rest at 8pm with his pills. He takes his heart meds at the same time.... so with a good amount of meal (dry and wet).

I am reading this to mean that you give the Vetoryl at night and only putting one hour between the two doses. When Vetoryl is given twice a day it should be given AM and PM - with breakfast and with the night meal, dinner or supper depending on what term you use. ;) Vetoryl has a short life in the body and giving it 12 hours apart allows the drug to maintain a better level throughout out the 24 hour period. So spacing the two doses out only by one hour is defeating the purpose of twice a day dosing and putting a much higher dose in the body all at once.

In addition, another reason for an AM dosing are the testing requirements to monitor the drug. If the vet is using the ACTH then this test must be done 4-6 hours after the dog has had a meal and the Vetoryl. If the vet is using the newer PVC, or pre-Vetoryl, test then the test must be done within 3 hours of the time the dog would normally be given the drug. So unless the vet is open and able to do the monitoring test at night, giving the drug in the PM will not work, making the test given the next day invalid. I will post a couple of links below that detail the ACTH first and PVC second.

ACTH monitoring protocol:
https://drive.google.com/file/d/0B5RToo4GC5HPSlBUemlDZ09oejQ/view

PVC monitoring protocol:
https://www.dechra.co.uk/therapy-areas/companion-animal/endocrinology/canine-hyperadrenocorticism/vetoryl-monitoring-1

I may be misreading your comment but wanted to share this info just in case.
Hugs,
Leslie

[gvlinds]

Hi!

Oops, sorry for the confusion. I had been doing Vetoryl doses 9am and 9pm, but just switched to 8am and 8pm with meals.

For a few days I was giving him half his dinner (food no meds) at 7pm and then the rest with the PM meds at 9pm but he seems OK to just have meals now at 8am and 8pm with the medications. That's what I referred to below but didn't clarify. Apologies! But appreciate the reminder and info :D

We just checked his levels again after the increase to 15mg.... the vet wants to get more aggressive and go to 15mg in the AM, and 10mg in the evening to try to get the excessive thirst and peeing under control. I know this is more 'in the middle' of the recommended dosing of 1-3mg per pound.... he's been at the 15mg (10mg am & 5mg pm) for two weeks.... I am thinking of keeping that level for another two weeks before increasing based on reading on here. Not sure I want to increase within 30 days? Anyone have thoughts?

I was also reading about Cushex and some natural milk thistle supplements that can be tried along with Vetoryl..... thinking about all our options!



[QUOTE=Squirt's Mom;212292]Hi Lindsay,

Welcome to you and Skylar!

I have a concern about the timing of the medication. You said -

[Squirt's Mom]

Oh ~~whew~~ so glad for the clarification. I feel better about that now.

It is during the first 30 days of treatment that you don't want to increase the drug because the cortisol can continue to drop during that period on the same dose. After that period has passed then increases are based on both the test results and the signs. If the recent test results are good, within optimal range, then I would be hesitant to increase just yet myself in spite of the continued excess urination/drinking. However, if those test results were still higher than desired an increase would be the best option. Sooooo it all depends on what those test results are. Did you get copies of the tests?

As for Cushex....I wouldn't waste my money. It will have no bearing on the cortisol, which is the enemy in Cushing's. As for Milk Thistle...it can help with the liver if needed. But I would want to wait until all the cush signs were controlled and the cortisol within optimal range before looking at adding that. The elevated cortisol will cause the liver to work extra hard, elevating many of the values associate with that organ. But once the cortisol is better controlled those values often return to a more normal level because the liver isn't working as hard as it was. Milk Thistle can cause some digestive upsets in some dogs, mine was one of them, which can cloud the picture by mimicking signs of an overdose/cortisol going too low. So I would hold off on the MT for now....and just forget about the Cushex.

Thanks for the quick reply and setting my old mind at ease!
Hugs,
Leslie

[gvlinds]

I am hoping you guys are better than I am at figuring out what all of this means! As a reminder, he's currently on 10mg in the AM and 5mg in the evening, starting July 8th. The vet wants to increase to 15mg in AM and 10mg in evening based on the July 21st test results and on-going excessive thirst/peeing & check his ACTH & chemistry at next appt. Thoughts & any help understanding below would be greatly appreciated

JUNE 22nd
PRE-DEX
4 POST-DEX
8 POST-DEX

Result Reference Range
3.5 ug/dL 1.0 - 6.0
0.4 ug/dL
2.1 ug/dL

July 6th (after being on 5mg AM & 5mg PM dosage of vetoryl, after this result increased to 10mg AM & 5mg PM)

Cortisol Sample 1
results 1.9
ref range 1 - 5
unit ug/dL

Cortisol Sample 2
result 6.2
ref range 8 - 17
unit ug/dL

JULY 20th

Cortisol Sample 1
result 2.5
ref range 1 - 5
unit ug/dL

Cortisol Sample 2
result 7.1
ref range 8 - 17
unit ug/dL

and here's results from his chemistry check on July 7th

Superchem
Total Protein 7.5 (ref range 5 - 7.4 g/dL)
Albumin 4.5 2.7 - (ref range 4.4 g/dL)
Globulin 3.0 1.6 - (ref range 3.6 g/dL)
Alb/Glob ratio 1.5 (ref range 0.8 - 2)
AST (SGOT) 25 (ref range 15 - 66 IU/L)
ALT 88 (ref range 12 - 118 IU/L)
ALP 493 (ref range 5 - 131 IU/L)
GGTP 2 (ref range 1 - 12 IU/L)
Total bilirubin 0.1 (ref range 0.1 - 0.3 mg/dL)
Urea Nitrogen 44 (ref range 6 - 31 mg/dL)
Creatinine 1.0 (ref range 0.5 - 1.6 mg/dL)
BUN/Creat ratio 44 (ref range 4 - 27)
Phosphorus 6.2 (ref range 2.5 - 6 mg/dL)
Glucose 113 (ref range 70 - 138 mg/dL)
Calcium 11.4 (ref range 8.9 - 11.4 mg/dL)
Magnesium 2.4 (ref range 1.5 - 2.5 mEq/L)
Sodium 147 (ref range 139 - 154 mEq/L)
Potassium 5.1 (ref range 3.6 - 5.5 mEq/L)
Na/K ratio 29 (ref range 27 - 38)
Chloride 108 (ref range 102 - 120 mEq/L)
Cholesterol 202 (ref range 92 - 324 mg/dL)
Triglycerides 419 (ref range 29 - 291 mg/dL)
Amylase 601 (ref range 290 - 1125 IU/L)
PrecisionPSL 225 (ref range 24 - 140 U/L)
CPK 133 (ref range 59 - 895 IU/L)

Comment Albumin may be falsely elevated due to a Hemolysis 2+, Lipemia 2+ and could be in the Normal Range.

[labblab]

Hello again, and I’m sorry to have been delayed in getting back to you. By now, you may have gone ahead with the dosing increase, and if so, I hope that all is well. However, I have to say that I think your vet is being overly aggressive with the dosing increases. Please know that I’m not a vet myself, but over my years on the forum, we’ve consistently witnessed fewer episodes of overdose or ill effects when dosage increases are instituted more gradually.

Starting with the original diagnostic LDDS test, Skylar’s results are indeed consistent with pituitary Cushing’s. Elevated ALP and triglycerides are also common with Cushpups. So I understand why the Vetoryl treatment was started. However, given a post-ACTH result of 6.2 after only two weeks of dosing, I honestly wouldn’t have endorsed an increase at that time. I understand that he was (is) still exhibiting observable symptoms, but the most commonly accepted dosing recommendations are to leave the initial dose in place for the first 30 days, in order to allow the cortisol level to stabilize before deciding how much, or if, to change the dose. Since apparently Skylar didn’t have an ACTH performed prior to starting treatment, we don’t know how much of a decline is represented by that initial drop to 6.2. But that level is already well within the desired therapeutic range as long as symptoms end up under control. So no, I would not have increased already at the two-week mark.

However, your vet *did* increase, and here’s the perplexing part: two weeks later, the post-ACTH is actually a bit *higher* at 7.1, and apparently you’ve still seen no improvement in his symptoms. The increased ACTH on the higher dose is definitely odd. I have no explanation for that. However, I don’t know that I’d feel comfortable with another significant dosing increases after just two weeks at that previous level. If it were me, I believe I’d prefer to leave things alone for that full month, and then reassess again. As I say, you may have already started the higher dose and if so, I hope all is well. But if not, I’d advocate for just leaving things status quo for a while longer. Because if you do end up seeing symptom improvement at the current cortisol level, you’re within the desired therapeutic range and there would be no need to increase at all. On the other hand, if his cortisol level is still increasing at that point, you may want to reassess whether other systemic stresses are affecting his endocrine system. For instance, how’s his eye doing at this point? He’s not receiving any eye medication that contains steroids, is he?

Marianne

[gvlinds]

No worries on time to reply!

Sigh, this was all my suspicion after reading. I have not gone ahead with the increase yet.... I've ordered more meds to have on hand (since it's really just adding 10 or 5mg which he takes now). They arrive next week, and I think I will delay increasing at least for the 30 days on this.

I was curious, and the vet didn't mention anything around his ACTH being higher the 2nd time. He is on Oflocacin for his eye, which is an antibiotic not a steroid I believe. Along with his heart meds (Vetmedin/Benazipril) which are not steroids either.

His eye is... not "better" but has improved. No more squinting/excessive tearing but it's not 100%. We're going to an ophthalmologist, but our appointment isnt for three more weeks! GRRR. :D

Thanks for the advice,
Lindsay & Skylar

[gvlinds]

Hi!

Wanted to provide an update here. Skylar has been on his 15mg a day dose (10mg in the AM / 5 mg in the evening) for about 5 weeks. We just ran a fresh stim test yesterday, i'll update here later today when we have the results.

If he still is in the 6-7 range, we are going to try to increase to 15mg AM and 10mg in PM to see if that helps with the excessive thirst/urination we're still seeing. I feel comfortable with this, but would love thoughts! Glad we didnt do it at 2 weeks post dosage.

Update on his eye - he still has a corneal ulcer, we finally say an ophthalmologist. He's having a small procedure to remove some mineral deposits on his eye that's preventing it from healing! She thinks he's closer to 14 than 10 years old..... having this next Wednesday, and hope it will clear up his chronic eye! And he can live his life without a cone on again :)

Won't be increasing his Vetoryl dosage until post recovery, as he'll be given a sedative and likely pain meds for the procedure.

test results this afternoon!
Lindsay and Skylar

[Squirt's Mom]

I hope Skylar's procedure goes well tomorrow and the eye will heal with this behind him. I know he will be so very glad to be cone free! :)

I agree completely with waiting until after this procedure and plenty of recovery time before increasing the dose. In fact, I would want another ACTH before the increase just in case it has been the stress from the eye situation that has been keeping his cortisol a bit higher than optimal. Once his eye is healed and the cone is gone it is feasible that his cortisol will drop a bit just from those things no longer being an issue for him. So watch his signs as well as checking the numbers. Of course if you start seeing the cush signs coming back pretty strong after his eye has healed that is a fair indication the cortisol is rising due to Cushing's and not stress. ;)

Please let us know about his test results and certainly how Skylar's procedure on his eye goes.

Hugs,
Leslie

[gvlinds]

Leslie-

Thank you so much for the feedback!

His procedure is a week from today, I wish it was today! We had to get off a steroid eye drop for some time first so he wouldn't be pre-disposed to infection at time of procedure. I will update as to how it goes for sure.

His latest stim was 7.4, and my vet said the same thing - that the stress & introduction of a myriad of meds for the eye are likely making an impact here for now.

Will overcome this eye hurdle, and then re-assess clinical signs and maybe even do another ACTH before the increase.

Lindsay

[Squirt's Mom]

How did Skylar's vet visit and procedure go?

[gvlinds]

thanks for checking!! We are both so relieved the procedure is over with, but he was a champ. In a cone for 2-3 weeks until our check up and hopefully all clear. His eye seems to be healing well, his eyesight is already much improved. Looking forward to putting this chapter behind us and then seeing how his Cushing's symptoms are :)

[labblab]

This is great news! Thanks so much for the update :-).

Marianne

[Squirt's Mom]

Oh good news! I hope he is fully healed very soon and up to antics in no time!
Hugs,
Leslie

[gvlinds]

Hi friends
I wanted to post an update that my loving Skylar went over the rainbow bridge on September 29th. A few days before he woke up paralyzed on one side, from a suspected stroke.... his heart condition made everyone concerned about the risk of anesthesia and MRIs, so we hoped to see some improvement with NSAIDS and pain management but he was really suffering.

I miss him so much, but know I got to give him a fantastic last chapter of his life. I am so grateful to have found this blog and become an informed advocate for him through his cushing's diagnosis.

<3

Lindsay
in loving memory of Skylar

[labblab]

Dear Lindsay,

I am so sorry for your loss, but so grateful that you’ve come back to let us know. What a gift you gave little Skylar by taking him in during his final days, and I know he fully returned that gift with his sweet love. I so wish that you two could have had yet more time together, but his body needed the same peace that you had already given to his heart and spirit. Although all our time together was short, we’re so glad that you’ve shared Skylar with us, and you’ll both always remain a part of our family here. Skylar has now joined our other Rainbow Bridge babies on our special memorial thread of honor:

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

If you should ever wish to have a photo link added to his name there, you can email a picture at any time to k9cushing@gmail.com. We’ll take care of everything from there.

In the meantime, do take good care of yourself. We’ll welcome you back at any time should you wish to share more stories about Skylar, or to let us know how you’re doing. Once again, I’m so sorry for your loss and I send you my best wishes always.

Forever in loving memory of your sweet little boy,
Marianne

[Joan2517]

Gosh, I'm so sorry, Lindsay...he sounded like a sweet little boy :(

[Squirt's Mom]

Oh Lindsay,

I am just so sorry to hear about our sweet Skylar and know your heart is shattered. You were a great mom and advocate for him and I know he carries the love the two of you shared in heart til you meet again. And, yes, I fully believe you will meet again when your job here on Earth is done. Until that joyous day, your baby boy will be watching over you just as you watched over him.

Thank you so much for letting us know. That is such a painful step to take and we so appreciate it.

My deepest sympathies,
Leslie



I have not gone

You think I’ve gone, that I am dead, and life has lost its will,
But look around, I am right there, living with you still
I watch your tears, I feel your pain – I see the things you do
I weep as well, each time you cry, my soul, it lives with you


It gives such joy to hear you laugh, and do the things you do
And when you smile o’er by gone days, I smile right with you too
For we’re still one, just you and me, one mind, one soul, one being
Walking forward into life, though only you are seen


And in the stillness of the night, when the pain it really starts
Stretch out a little with your mind and draw me to your heart
For I am always right in there, always by your side
For you have been, all my life’s days, my joy, my love my pride.


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