My 13 yr old baby has Cushings

[eliz]

Hi,

My pup, Chi, was recently diagnosed with pituitary Cushings via a 2-hour ACTH stimulation test. She has been exhibiting symptoms consistent with Cushings for around 6 months -- excessive hunger and peeing with increasing panting, and also has the pot belly. The vet recommends putting her on 10mg Vetroyl (currently weights 17 lbs - normally weighs 14). I'm a bit nervous because of the potential side effects and would like to get your opinion. Also, should I be requesting prednisone from the vet? Thank you in advance for your help!

P.S I wanted to attach Chi's bloodwork etc as a PDF but I couldn't figure out how to do it??

[labblab]

Hello, and welcome to you and Chi — we’re so glad you’ve found us! I’m sorry you aren’t able to upload your PDF, but for site security reasons, members currently aren’t permitted to do so. We’ve suffered from some devastating forum hacks over the years, and we’ve been advised that limiting member uploads is one safety step that we can take. Members *are* permitted to create albums and upload photos, however. So if you want to add a photo of any lab reports, that’s one option. However, in honesty, we’re generally only interested in knowing diagnostic Cushing’s test results such as the ACTH, and also any other lab results that are abnormally high or low, along with the printed reference ranges for those values. So even though it’s a bit of a pain, the easiest thing for you to do may be to just type out those specific values in a reply.

For right now, given Chi’s outward signs of Cushing’s and assuming that her lab results are also consistent with the disease, let’s go ahead and talk about treatment. The Vetoryl dose that your vet is recommending seems very reasonable. For dogs the size of Chi, the most widely accepted current initial dosing protocol is to give a daily total that doesn’t exceed 1 mg. per pound. The starting dose is just a guess for any dog, since there can be wide variation in how each individual dog metabolizes the medication. After beginning treatment, subsequent dosing adjustments are based upon observed symptom resolution as well as monitoring bloodwork. But we’ve learned over the years that it’s much safer for a dog to start at a lower dose and work upward if necessary, rather than vice versa. Hopefully, this strategy also minimizes unwanted side effects. So returning to Chi, the starting dose of 10 mg. seems reasonable to me, and a dosage that I would feel comfortable giving to my own dog.

As far as the need for keeping prednisone on hand, I think a lot depends on your access to emergency vet care. If a dog is exhibiting acute symptoms of overdose, it’s always preferable to head to a vet ASAP so that they can make the determination as to what is really going on. I never kept prednisone on hand, myself, because I live in a large urban area and both my regular vet and several ER vets are within easy driving distance. However, for pet parents who don’t have easy access to vet care — especially overnight or on weekends — then I think it’s reasonable to keep a small supply of prednisone on hand for use in an emergency. It’s unlikely that you’ll ever actually need it, but it can give you some extra peace of mind if you can’t easily get your dog to a vet in a crisis.

OK, I’ll go ahead and quit for now. But I’ll leave you with links to a couple of threads on our “Resources” forum that offer a lot of helpful info about treatment with Vetoryl. Once again, welcome, and don’t hesitate to ask further questions.

https://www.k9cushings.com/forum/showthread.php?8925-GENERAL-GUIDELINES-for-Vetoryl-(trilostane)-Dosing-amp-Monitoring-with-ACTH-Stimulation

https://www.k9cushings.com/forum/showthread.php?9066-Cost-Savings-for-Owners-of-Cushingoid-Dogs

Marianne

[eliz]

Hi Marianne,

Thank you so much for your reply. You're a calming voice in a stormy ocean! Question: before Chi had the ACTH test, she was ravenous pretty much all the time. Since then, I must coax her into eating. Is that a reaction to the test or just a coincidence? I'm now really worried about how she will react to the Vetroyl. I'm enclosing below a list of Chi's bloodwork that came back in the red zone. Also, including the Reference Value number & her separate ACTH test numbers.

1. BUN 47 ------Reference Value: 9-31 mg/dL
2. Phosphorus 6.4 ------Reference Value 2.5-6.1
3. Calcium 12.1 ----Reference Value - 8.4 -11.8
4. Potassium 5.6 ---4.0 -5.4
5. Na: K Ratio 26 ---28 - 37
6. Total Protein 7.8 ---5.5 - 7.5
7. Albumin 4.0 ----2.7 - 3.9
8. ALT 267 ---18- 121 U/L
9. ALP 855 ---5-160 U/L
10. Cholesterol 391 ---131 - 345 mg/dL
11. Lipase 342 ----0- 250
12. MCH 26.2 ----21.9 - 26.1pg
12. Platelets 739 ---- 143 - 448
13. Creatine Kinase 263 ---10 - 200 U/L

Below is the results from the ACTH stimulation test:

pre -
Cortrosyn 250 mcg/ml 0.1 ml IV RCV @ 3:36
post (1-hour)

In summary, to say that Chi hates going to the vet is an understatement! She panics. But I just want her to have the best life possible for whatever time she has left. FYI -She still has a good life. She hikes every day with me— just not as much a badass as she used to be. Lol. Not sure what I'm really asking except maybe just your thoughts on if moving forward with the Vetroyl is the right thing to do after reviewing the above results and knowing a bit of Chi's history.

With infinite gratitude,

Elizabeth

[labblab]

Hello again! I’m afraid it will still be later today before I’m able to return and add a more thorough reply. But I wanted to assure you that you’re not being forgotten in the meantime. It’s been a busy couple of days for me, but I will talk to you soon!

[eliz]

Thanks for getting back.

I messed up on the ACTH results. See the correct numbers below.

Cortisol - Pre = Result 4.0 ug/dL
Cortisol - Post = Result 28.2 ug/dL

Look forward to hearing your thoughts.

[labblab]

OK, I’m finally back — Whew! Thanks again for all this additional info, including Chi’s ACTH results. The ACTH test is definitely elevated, and yes, that’s certainly consistent with Cushing’s when viewed alongside her outward observable symptoms.

Before commenting on her other lab values, though, let me state that I’m not a vet myself and have no professional training. However, based on my experience following the Cushpups on this forum, here are my thoughts. Certain of her lab abnormalities are also consistent with Cushing’s: elevated liver enzymes (ALP and ALT), cholesterol, and platelets. Some of her other values are only slightly out of range, and I don’t have any specific knowledge that they would be a concern. The three values that I *do* wonder about are the elevated BUN, phosphorus, and potassium. The latter two are only mildly out of range, and I believe BUN can be elevated on testing simply due to dehydration. However, elevations in all three can be caused by kidney dysfunction, and so the combination of these three abnormalities — alongside Chi’s new inappetance — would prompt me to question your vet as to whether or not they pose any concern about the current status of her kidneys. You don’t list her creatinine (CR) as being high, and that’s another important kidney marker. So that’s good. Also, there’s an additional blood test directly related to kidney function that already may have been included in her testing: the SDMA. If that’s normal, that is also reassuring. But if that test hasn’t yet been run, that could give you important info about the status of her kidneys.

We have been told by other parents that their dogs have temporarily felt “off” after the ACTH stimulation test, but I wouldn’t expect there to be a lasting effect. So if Chi’s appetite doesn’t pick up, I’d definitely report that to your vet, and I personally would hesitate to start the Vetoryl until she’s back to normal in that regard. Cushing’s is a slowly developing disease, and there’s no harm in holding off on treatment until you’re sure there’s nothing else going on with her. Especially if there’s any newly developing problem with her kidneys, you’d need to be cautious about starting Vetoryl treatment. Since the kidneys are involved in proper metabolization and excretion of the drug, there are specific warnings about using the medication in dogs with genuine kidney impairment.

And if and when you do start up, I’d want to make sure your vet checks her basic blood chemistries alongside her cortisol when monitoring blood testing is performed. In addition to lowering cortisol, Vetoryl can also lower the production of another adrenal hormone, aldosterone. Aldosterone helps control the balance of potassium and sodium in the body, and I see that Chi’s “Na:K ratio” is already a bit off. So you’d want to make sure that the medication doesn’t create further problems in that regard.

So in summary, I don’t mean to worry you unnecessarily about those three abnormalities. They may not mean anything. But if Chi were my own dog, I wouldn’t start treatment until I reported her inappetance to the vet, and asked him/her if any further kidney diagnostics might be warranted.

Marianne

[eliz]

Hi Marianne,

Thank you so much for your detailed response. You're a Godsend!

Chi has a vet appointment on Thursday to have the SDMA test run. In addition our vet wants to run a Spec cPL to check her pancreas since she has a decrease in her appetite.

I'll report back after I get the test results.

Thanks again!

[labblab]

I'm relieved to hear that the SDMA is being done, and I think the Spec cPL is also an excellent idea. I wasn't sure whether the elevation in Chi's lipase was enough to warrant concern, but for sure, pancreatitis will affect the appetite. One of my non-Cushing's dogs suffered from a couple of acute pancreatitis attacks during her lifetime and she was definitely ill during those times. So I'm very glad your vet is checking on that further, too.

You told us how much Chi hates going in to the vet, so I know these visits have to be very stressful for you, too :-(((( Good luck to you both, and we'll surely be anxious to learn the results!

Marianne

[eliz]

Hi Marianne,

See below from our vet. It seems like Chi does have pancreatitis. Her Spec cPL was elevated at 425 (normal range (0-200). Awaiting our internists response to the below from our vet.

I'd love to hear your thoughts. I don't know how we can put her on Trilostane at this point. She's having issues eating. OY. I think this approach will change once our internist reviews.


Follow up - I did receive your note about Chi's pancreas being more prominent on the U/S and her appetite being so so -- so with the elevated spec cPL active pancreatitis is now suspected. Let's await Dr Yau's thoughts on how to proceed.

Thank you,
Dr Hsu

On Sat, Oct 22, 2022 at 3:33 PM <results@vetconnectplus.com> wrote:
Hello,
Please find Chi's results from her lab blood test. Her SDMA returned within normal limits after she was fasted - so no active kidney changes are noted.

Her Spec cPL was elevated at 425 (normal range (0-200). I reviewed her previous labwork and did not find any other spec cPL results to compare this value with. Some of our pets have elevated pancreas enzymes due to chronic inflammation to the pancreas without active clinical illness. I understand that you asked to have her pancreas value checked, so unless Chi's appetite has been poor or she has been vomiting, we can keep this value to monitor and recheck this value in 1-2 months to see if there are changes once she starts on her Trilostane.

Per Dr Yau and from Chi's latest blood panel - Chi can be started on Trilostane 10mg by mouth once a day in the AM. Recheck blood work (ACTH stim test) should be completed in 2-3 weeks (with the blood draw taken 2 hours after the morning dose).

Take some time to review these results and let us know how you would like to proceed and if you need the Trilostane filled with AMH or you will be getting this from Veterinary Specialty Group of Glendora. We will forward these results to Dr Yau for her records.

Thank you,

Dr. Andrea Hsu
hello@amhpasadena.com
(626) 796-3019

[labblab]

I’m so glad to know Chi’s SDMA came back within normal range so we can eliminate kidney issues from our worries! And like you, I’ll be anxious to see what Dr. Yau’s recommendation is at this point. I really do defer to your specialist in terms of the trilostane. Through the years that I’ve been on the forum, we’ve had multiple members whose dogs have experienced pancreatitis both before and during treatment, and a possible relationship between Cushing’s and pancreatitis has been talked about but not necessarily well understood. However, newer research of which I’m unaware may be offering clearer direction in that regard. Normally, a general rule is to hold off on giving trilostane to a dog who is not eating and is observably unwell. However, if elevated cortisol is fueling the pancreatic inflammation, then perhaps it’s advisable to go forward with treatment.

Inappetence does present problems. The medication is not metabolized as efficiently if not given alongside a meal. And since inappetence can be a symptom of overdosing, your ability to monitor the effects of the dose becomes more limited. However, as I say, your specialist may feel that the possible benefits would outweigh the negatives. Whenever you do begin, the written treatment instructions you’ve been given are just what we would be expecting. I would just add one note: on the morning of the monitoring ACTH test, Chi should be fed breakfast alongside her dose of trilostane, just like any other day. (And hopefully, she’ll want to eat her breakfast by then!)

So please let us know what Dr. Yau suggests. This will be a learning experience for me, as well, and I’ll appreciate the information moving forward.

Marianne

[eliz]

Hi Marianne,

Hope all is well. See below email answer from Dr. Yau. Chi is still having issues eating so I guess we're going to wait to start the trilostane. We have her on a low fat diet. Also, how much should a ACTH cost?

Thank you so much!



Dear Elizabeth and Danielle,

I will recommend low fat diet for Chi at this point. Pancreas does not like fatty food.

I will not treat her Cushing's until her appetite is back.

Diet recommendation

Royal Canin GI low fat
Hill's i/d low fat
Purina EN low fat

Lipase can be elevated from hydration status. It is not a reliable test for pancreatitis.

Sincerely
Vivian

On Wed, Oct 26, 2022 at 12:21 PM Elizabeth Daro <elizabethdaro@eliasentertainment.net> wrote:

Hi Dr. Yau,

Hope all is well with you.

Sorry we missed your call yesterday. I’d like to get your thoughts on Chi starting Trilostane in light of her Spec CPL levels. Also, as I mentioned before, Chi has become a picky eater which is very unusual for her. I’m assuming that’s caused by the pancreatitis. I noticed back in March her Lipase were at 1564 and now they’ve dropped to 342. Has she had pancreatitis since then? Is there anything we can do to help her out? She’s not her old peppy self. ☹

[labblab]

As always, thanks so much for this update. I certainly can’t argue with holding off on starting the trilostane until Chi is eating normally once again. Hopefully the low-fat diet and a bit of time will turn things around for her.

As far as ACTH costs, it’s been years since I personally paid for one, myself. We do have a survey posted here to which members have had the chance to respond over the years. Unfortunately, there have not been many recent responses, and costs are probably higher now than ever before. Historically, it looks as though the average was in the $200-250 range. But as you’ll see, there was also a lot of variation around those numbers. For what it’s worth, here are those historical survey results:

https://www.k9cushings.com/forum/showthread.php?1148-What-do-you-pay-for-an-ACTH-stimulation-test-U-S-Dollars

Marianne

[eliz]

Hi Marianne,

Thank you so much for your response re: ACTH costs.

I'll keep you posted on Chi's progress.

[eliz]

My 13-year-old chihuahua (Chi) has Cushing and now has to have another tooth extracted. I’ve read that general anesthesia should not be administered and that Cushing dogs require a different drug administered by a specialist. Has anyone dealt with this issue?

[labblab]

Elizabeth, welcome back to you and Chi. You’ll see that I’ve merged your new question into Chi’s original thread. This way we can remind ourselves of her past history and also keep any new discussion consolidated in one place. As for your question about general anesthesia for a Cushpup, I’ve personally not heard of a blanket contraindication. However, anesthetic agents can be hard on both the liver and also the kidneys. So any dog who’s suffering from compromised liver or kidney function can be at an increased risk. Since liver abnormalities are often associated with Cushing’s, I’m guessing that’s where the concern may arise, depending on any given dog’s individual situation. In terms of an anesthetic alternative for a tooth extraction, though, I’m afraid I’m unfamiliar with what that may be.

How’s Chi generally doing these days? Did she ever start taking the trilostane? Once again, we’re glad to have you back, but sorry about the need for the extraction!

Marianne

[Harley PoMMom]

When my boy, Harley, had 3 teeth extracted, it was performed at one sitting, and this was when his Cushing's was not controlled, he sailed right through this surgery with flying colors, no complications at all. Harley's vet did state that they would be doing things a bit different with him since the Cushing's was not controlled: like pushing more fluids before, during, and after surgery; using a different kind of anesthetic that's not as hard on a dog with some type of illness, I believe it was Propofol.

Hugs, Lori