To treat or not to treat?

[inheriteddog]

My Kobe is a beagle, turns ten next month. He shows signs of Cushing's: pot belly, drinks and pees a lot, wants to eat much of the time, has had bouts with skin infections and hair loss, pants sometimes... Lab work done in July indicates high cholesterol, elevated blood sugar, one liver enzyme high. Vet is pushing me to test for Cushing's and if indicated get him on trilostane right away. Says it's for "quality of life." The thing is, I don't see Kobe as being that bad at this point. He's been developing the pot belly for years (vets in past have said he was just "overweight") and while it is clumsy, he still gets around. Panting was bad during summer heat wave but right now is mild when he walks a bit much, so I limit his exertion. His drinking was bad in summer but is down right now and he controls his peeing and pooping for outdoors, no issue of accidents. Cholesterol was 439 at test, glucose 128, taken in afternoon when he had eaten a couple of hours before. ALP was 350, the other 3 liver enzymes were ALT 115, AST 17, GGT 6. Radiology shows "mild to moderate" liver enlargement. He also has two hard lumps on back, oval shaped about 3 inches by 2; aspiration of one a couple of years ago brought only blood and the vet suggested possible cancer (she doesn't seem to worry much about it now).
His quality of life right now does not look bad to me. He likes going for walks in morning and evening. He eats and poops well, has not gained weight in years despite the larger belly. He gets excited if a cat intrudes in the yard or he sees squirrels in the park. Is happy to meet other (friendly) dogs, barks to protect the yard, generally seems normal for a dog his age. Uses a step to get into car. Major problems are infections between toes and occasional large hot spots which have been treated successfully with Cytopoint and/or antibiotics. He did have breathing problems during the summer heat wave but not now. I would like to have him evaluated by a good vet (I'm not confident about my current pushy vet) but all the doctors in my area seem questionable. ACVIM website has no referral in San Diego at all. Short story, I think I can just wait and see how Kobe does before acting. He may, after all, have issues besides Cushing's. And my finances are limited (retired on social security). I want to do right by him, but sometimes doing right is to not rush to judgment.
Any thoughts?

[labblab]

Welcome to you and to Kobe! After reading what you’ve written about Kobe, I can’t say that I disagree with your decision to hold off on further diagnostics/treatment for the time being. At age 10, we’ll be hoping that Kobe has several quality years ahead of him. But still, he’s approaching the “senior” category, and as such, my personal opinion is that it makes sense to weigh several factors when making a decision like this. So as to save some time, I’m going to paste in some comments that I’ve already posted elsewhere here on the forum.


In my own mind, the decision whether or not to treat any dog depends on a number of factors: age of the dog, apparent discomfort, severity of symptoms (both external and internal), etc. Cushing's is typically a slowly developing syndrome, and the decision to actively treat may come sooner or later in the process. The primary goals of treament are to control the troublesome observable symptoms (things like excessive thirst, urination, hunger, panting, muscle wasting), and also to halt/delay silent internal damage. Untreated Cushing's can make dogs more vulnerable to things like high blood pressure, high cholesterol, protein-losing kidney disease, blindness (as a result of high blood pressure), pancreatitis, ligament damage and slow healing, chronic infections and skin issues, GI disturbance, etc. Not every dog will suffer from all or even many of these issues, but the disease can make them happen. For a younger dog, I would want to provide as many quality years of life that I could, and that would mean putting a stop to the development of the internal systemic damage as well as relieving the uncomfortable outward problems.

However, since the damage usually occurs over time, my own opinion is that I don't worry so much about the "silent" damage in a dog who is already elderly. Instead, my biggest concern for a senior dog is immediate quality of life. So if the overt symptoms are making the senior dog uncomfortable, I would treat. Otherwise, I might choose not to treat, especially if my senior dog suffers from inflammatory conditions like arthritis that may actually be soothed by the elevated cortisol level of Cushing's. Treatment also involves frequent vet visits and blood draws, especially at the beginning. So again, if vet visits are really stressful for a senior dog, I'd also factor that into my treatment decision.

From your description of Kobe’s past history and current situation, I’d be especially watchful about two issues. The first is elevated glucose. Uncontrolled high cortisol, on its own, can elevate glucose to unhealthy levels. Also, it is not super-uncommon to see dogs exhibiting actual diabetes as well as Cushing’s. Regardless of whether elevated glucose is a temporary or permanent condition, it can quickly become life-threatening. So if Cushing’s is indeed involved and continues to raise Kobe’s glucose upward, that would be a reason to press onward with diagnosis/treatment in my opinion.

Secondly, given the fact that he has suffered from skin conditions in the past, I’d be especially watchful for the development of a skin condition called Calcinosis Cutis. If you Google the disorder as it appears in dogs, you’ll see photos and more information. The emergence of CC in dogs is almost always due to uncontrolled Cushing’s. It can quickly worsen, and has the potential to ruin a dog’s quality of life unless treatment is undertaken to lower cortisol levels.

I don’t mention either of these two things to worry you unnecessarily. But as I say, the presence or absence of either of these issues would affect my own treatment decisions if Kobe was mine. In the meantime, though, as I say — I can’t fault your decision to hold off on things for the time being. I also understand why you’d welcome the input from a specialist, and I’m so surprised that there are no internists listed in San Diego. That *really* surprises me. But I’ve just now checked the online database and have come up empty, too. You may already have seen this, too, but the ACVIM does list a toll-free number: 800-245-9081. Maybe if you talk to them directly, they can give you more info about specialists in the area. Anyway, we’re still really glad you’ve found us, and please feel free to ask any more questions.

Marianne

[inheriteddog]

Thank you for your comments and advice. A neighbor recommended another vet and I have an appointment scheduled for next week. I'd like a fresh evaluation, possibly alternative measures for the time being. But we'll see.

[Squirt's Mom]

Hi and welcome to you and Kobe!

IU agree with Marianne's comments 100% but did want to add some info on the liver enzymes.

You wrote - "ALP was 350, the other 3 liver enzymes were ALT 115, AST 17, GGT 6."

The ALP is typically very elevated in a cush pup...this elevation is very mild UNLESS the top of the normal range is something like 2. :) It is not uncommon to see this value in 1000's - I have seen it over 10,000 and it returned to more normal levels. According to an IMS (Internal Medicine Specialist) I used in the past, the ALP is telling you how hard the liver is working....these are LIVING cells.

The ALT and AST are very liver specific and do indicate dying cells according to that IMS. The ALT is usually indicative of liver injury via medication, accident, or disease process.

The GGT is associated with the bile ducts and often the functioning of the gall bladder.

Here is a good link for solid info on the liver values.
https://www.dvm360.com/view/canine-liver-enzymes-so-many-questions


Beagles are among the breeds we see quite often with Cushing's but based on what you have shared so far, I wouldn't rush into testing just yet. I would be more inclined to make sure the liver and gall bladder are functioning correctly. Just FYI....Cushing's is one of, if not THE, most difficult canine disease to correctly diagnose because it shares signs with so many other conditions, including liver and kidney disease. Also other health issues can and do cause false positives on any and all blood tests for Cushing's - the LDDS and ACTH. So diagnosing this disease is as much about ruling all other possibilities out first.

I'm glad you found us and hope to learn more soon about you and your sweet boy!
Hugs,
Leslie

[inheriteddog]

Thank you. Appreciate the extra information. We will be seeing a new vet tomorrow. I hope to get a clean evaulation.

[Harley PoMMom]

Looking forward to hearing what the vet says, good luck!

Lori

[inheriteddog]

The vet visit was done. After physical exam, the doctor recommended testing for Cushing's. He was unconvinced by my suggestion that Kobe's symptoms are not yet serious enough to warrant treatment, that he is an older dog, etc. For the doctor, the possibility of metabolic distress is enough. They did blood work and there were some changes. The ALP was still high but lower than six months ago. The AST was low. Cholesterold and triglycerides high, glucose high. However, the protein and albumin counts are low, and this offers a new concern, possibly issues with kidneys or liver, not related to Cushing's. He's advising tests to look into this, which may include abdominal ultrasound. So I'm going around with new things to be concerned about. Not to mention the finances. Not what I expected.

[Harley PoMMom]

Was Kobe fasted for the blood work? And if so, could you post the actual results?

[Squirt's Mom]

I would definitely want the abdominal ultrasound done. That can go a long way toward diagnosing Cushing's AND it can find things going on with the organs that could cause false positives if the cush testing were done. So this is a great diagnostic tool for Cushing's. My first cush pup tested positive on the ACTH, LDDS, HDDS, and UTK panel but the ultrasound found a tumor on her spleen and once that was removed all those tests returned to normal. It was the stress of the tumor causing the cortisol to rise in a NATURAL response. If the US had not been done I would have started treatment for a disease she did not have at the time. She did develop it later but at that time she did not have Cushing's. I highly recommend the US. ;) I would agree to this test asap. Then go from there. Be sure to ask for copies of the comments made from the US if you decide to have this done.

With the glucose high that is also a concern depending on how high. So seeing those test results will help us help you better. You don't have to type the normal results but please do list all the abnormal along with the normal ranges and little letters that show. It will look something like this:

CHOL 300 H 150- 250 mnol/L
BUN 21 L 25-35 ug/dl

You aren't alone on this journey tho I know at times it sure can feel that way. Just holler at us here if you need to talk. We will be more than happy to help if we can....and we can always listen.

Hugs,
Leslie

[inheriteddog]

OK, here are the abnormal blood counts. I am giving two results, the first from July 2022, the second from this week, 6 months difference, followed by "normal" range. For comparison I am including all four liver enzymes even if they are within normal range. Blood was drawn maybe three hours after Kobe last ate.

Reticulocytes 77 115 10-110
Eosinophyls 0.042 0.042 0.07-1.49
Platelets 487 668 143-448
Glucose 128 153 63-114
Creatinine 0.3 0.5 0.5-1.5
Protein Total 5.7 5.1 5.5-7.5
Albumin 2.6 2.0 2.7-3.9

ALT 115 72 18-121
AST 17 10 16-55
ALP 350 318 5-160
GGT 6 11 0-13

Cholesterol 439 462 131-345
Triglycerides - 314 20-150

[Harley PoMMom]

To get an accurate result for the glucose, triglycerides, and cholesterol it should be drawn from a 12 hour fast. So, if this were me, I'd have that done.

[Squirt's Mom]

I put the abnormal results in bold so they will stand out. ;)

[inheriteddog]

Urinalysis was performed on Tuesday, including protein:creatinine. Protein in urine was high, likely the cause of the low albumin in the blood. Vet considers this probably due to Cushing's, not a separate kidney problem. Ultrasound was conducted yesterday. Prelim results show both adrenals affected, suggestive of pituitary based Cushing's. Also liver enlarged. I am planning to ask a few questions on tests, but for discussion's sake this is how they stand so far.

Vet wants BP test performed at home. One was tried at office but Kobe was unable to calm down enough. Then vet wants to do the LDDST and go on to treatment for Cushing's, assuming a positive result.

Kobe needs a break (several vet visits in just 10 days and yesterday's ultrasound took 6 hours). Meanwhile, I have to look at finances. So far have spent about $1200 on tests and not finished yet. I estimate low-dose Vetoryl (as suggested by Vet if Cushing's is confirmed) will be around $100/month. And that's just to start. All this is not really workable on fixed low income. (And my home heating bill tripled this month.) Doctors don't seem to factor in cost to client when they recommend this test and that.

Back to my original question: will all this be worth it? Kobe gets along pretty well on day to day basis. Although drinking is heavy, volume of intake is inconsistent, as are panting and skin issues. He appears in good mood, sleeps well, gets excited when smells that a cat has visited the yard. I don't know how concerned I should be about metabolic issues like diabetes and BP at this stage. The low protein in blood does concern me, but I don't know how it is affecting Kobe right now. In cooler weather Kobe's panting has not been too bad, but come summer there might be problems. I need time t clear my head. Any thoughts are appreciated.

[Harley PoMMom]

Here are my thoughts, however, I want you to know that I am not a vet or do I have any veterinary experience so on that note! If Kobe were my furbaby and if symptoms were not bothersome to Kobe or me than I would probably not treat. The elevations in the glucose, triglycerides, and cholesterol could be because the test wasn't done while fasting. Although he does have elevations in the liver enzymes, a dog with Cushing's generally has much higher numbers, usually in the 1000's. This is just my opinion and hopefully the others will be along to share theirs.

If at some time you do wish to go through with treatment, there are ways to keep cost down and we will be happy to share them with you.

Hugs, Lori

[Squirt's Mom]

First, I agree with Lori on the test results and fasting. Now, three things stand out to me. One has to do with your decision ahead on treating, the second on the dosing, and the the last on the vet's comment.

We rarely see the ALP go down in an untreated cush pup. It typically rises and rises and rises well into numbers much much higher than Kobe's...I've seen the ALP in the 10,000's. So the fact that Kobe's ALP has gone down is enough to give me pause on the suspicion of Cushing's and certainly treating.

The vet said he would use "low dosing"...that is rather open-ended. Just so you know, for dogs under 40 lbs the correct starting dose is 1mg per pound per day. So let's say Kobe weighs 30 lbs - the maximum dose to start him on would be 30mg per day. Dechra says to start at the lowest possible dose and that is 1mg per lb. I have seen vets who think a low starting dose is 3mg per pound and the majority of the dogs get sick starting so high. So stick to your guns IF you decide to treat and accept no more than 1mg per pound per day IF he weights under 40 lbs. I have skimmed thru this thread and didn't see his weight so just in case I will tell you about larger dogs. Dogs over 40 lbs should start at no more than 0.5mg per lb per day....lower than the dogs who weigh less. This is because over the years since Vetoryl/Trilostane hit the market it has been observed that larger dogs are often much more sensitive to this drug. Studies have supported this observation and lower dosing protocol. Many vets are not aware of these studies and use out-dated guidelines from Dechra. Dechra does know about the studies, about the dogs getting sick (and worse) on the current dosing literature and they simply do not care. They refuse to change their literature leaving vets handicapped and putting dogs at risk. Here is a write-up from one of our Admins on this topic you can share with Kobe's vet.

https://drive.google.com/file/d/155aj2gOey6_fypWyihlhenygpCjmRdUz/view

Now what the vet said. You wrote: "Then vet wants to do the LDDST and go on to treatment for Cushing's, assuming a positive result". Treating based on an assumption is a great way to make Kobe extremely ill if not worse. You NEVER EVER start treatment without at least one positive blood test and a solid sign profile. So this has made me very nervous. Do NOT allow this vet to convince you this will be ok...it could be very very bad for Kobe and you, not to mention the pocketbook. These are very powerful drugs and should never be used based on an assumption.

Now a disclaimer if you will. I have had 2 dogs "diagnosed" with Cushing's. BOTH were misdiagnosed by different vets. So I am hyper-alert when it comes to any possibility a dog has been or could be misdiagnosed. I never ever advocate rushing into treatment for this reason. Take your time and be sure. Treating a dog for Cushing's who doesn't have the disease or starting a dog on a dose that is too high is much worse than not treating at all. So it is paramount to me to be as sure as possible that the diagnosis is correct and that the starting dose is correct. We are here to help you in any way we can but I did want you to know that much of my input is based on my own experiences as well as what I have observed in these forums/groups.

Hugs,
Leslie

[labblab]

Both you and Kobe have been through a lot during these past ten days, so I absolutely endorse you taking a bit of time to catch your breath and consider your options. You both deserve a break! I'm so glad that Lori and Leslie have given you their thoughts about all this, and I'll go ahead and add mine for your consideration as well.

I've already written to you earlier regarding my general thinking about the decision to treat in older dogs, and my initial reaction re: Kobe was that I probably would not be rushing into treatment. And that may still be your decision. However, these new test results do skew my thinking a bit as far as tipping the balance towards treatment. Here's why. At this point, I personally think the Cushing's diagnosis is likely accurate. As Leslie says, it's definitely true that ALP levels typically continue to trend upward in untreated dogs -- often to much higher levels than Kobe's. So that is one oddity in his bloodwork. But aside from that, basically all the other lab abnormalities are consistent with Cushing's including the new addition of elevated platelets, low eosinophyls, and urinary protein loss. I agree with Lori that a fasted sample would be preferred for glucose, cholesterol and triglycerides, but I think that 153 is somewhat high for even a random glucose sample in a dog. And of those three blood chemistries, the glucose is the one I'd be most focused on right now.

The ultrasound is also exactly what you would expect to see in a dog with pituitary Cushing's. So thus far, I think your vet has proceeded appropriately with the testing, and the LDDS is indeed the logical final step in the diagnostic process. I'm guessing that what you were intending to tell us is not that your vet is just assuming that the LDDS will turn out positive. But instead, that in the event the LDDS *is* positive, at that point he'd recommend starting treatment. If so, I think that would be an appropriate recommendation. So I'm guessing Cushing's is your culprit; the question is whether or not you decide to start treatment if the LDDS indeed turns out to be positive.

I absolutely appreciate the financial burden on you, as well as the stress on Kobe associated with ongoing vet visits and testing. So what might tip me over into treatment? The new discovery of protein in the urine, now being added to the risks of elevating glucose and history of skin problems. I think it's very good that the vet wants you to try to take Kobe's blood pressure at home, because if he is suffering from high blood pressure in addition to the proteinuria, I believe he is at an even higher risk of developing worsening kidney disease. Ongoing high blood pressure can also increase the risk of blindness and other systemic problems. In the past, I made note of comments by a leading veterinary endocrinologist that the presence of hypertension and proteinuria would be symptoms that would lead him to recommend treatment for a Cushpup who otherwise was not exhibiting bothersome external symptoms of the disease. I'm assuming this is because those two problems have the potential to lead to serious systemic damage. Would that necessarily be the case for Kobe? I don't know. And even if so, how quickly? Also a big question mark. However, since you're asking for our thoughts about treatment, these would be factors that I'd put on the scale.

Having said that, I still think you have -- and should take -- whatever time you need to fully consider things. One good thing is that, aside from the LDDS, the big expense of the diagnostics is now behind you regardless of what you decide to do. The cost of medication and monitoring testing is not minimal, by any means. But at least from now on, it would be spread out on a monthly basis as opposed to all coming due at once. Also, it is preferable to slow or halt the progression of systemic damage because, once it occurs, some or all of it may be irreversible. However, I'm not knowledgeable as far as the normal lifespan of a beagle. In other words, at his age, would we expect Kobe to soon be vulnerable to increasing health problems regardless of the progression of untreated Cushing's? How much additional quality time might we expect the treatment to grant him?

I hope I haven't muddied the waters even further! But these are the factors that I would be taking into consideration if Kobe were my own. Please continue to let us know what you're thinking, yourself.

Marianne

[inheriteddog]

As always, I appreciate the comments. I've read so many articles that it just gets overwhelming. Especially when they don't seem to address my specific questions. That's why I sought out a forum, to hear from people who have been there, done that.

For the record, Kobe's last weight measured 34.4 lbs. He has been consistent in that regard for the last few years, that is around 33-34. He is a relatively small beagle, which suits me because when he gets on the scent he can really pull hard on the leash. The pot belly has made it hard for him to climb in the car, even with the step I built for him, but he still manages. It is surprising to me how quickly he jumps up from a lying position when he smells food. He also gets up on his hind legs to sniff the table. He makes short runs when he senses an intruder and paces quickly around the yard sniffing for cats or other critters. He still goes on walks in the morning and evening and gets plenty of rest during the day.

In terms of the vet "assuming" a positive test, I did mean it to be "in the event that the LDDST is positive", not that he assumes it will be so. This doctor has been very careful to emphasize that he is only making recommendations when a diagnosis is confirmed and only a test can do that. I asked him about possible dosage of Vetoryl so that I could try to calculate future cost to add to all the other costs being thrust on me, and he underlined that he was only answering me for that purpose, nothing more. If the disease is confirmed, he has suggested that safety dictates starting with a low dose, which he defined as 10mg twice a day. That's 20mg daily for a 34 lb dog.

I too am concerned about the low protein in the blood. The urinalysis points to protein being lost in the urine. This is a new hitch in the case. The diabetes and cholesterol issues are there, but I don't know if they would be that way even without Cushing's.

The literature I've read on Cushing's and Trilostane leaves me with more questions than answers. (I encountered this same problem two years ago when I researched my prostate cancer and had to decide what treatment to pursue. The matter is fuzzy, no one can guarantee anything, and in the end a lot is left to chance. I've been lucky so far, even though I went against the majority view in my case.)

One question I have is: exactly how effective is Trilostane? A lot of articles seem to describe it as almost a miracle drug (these articles seem to be underwritten by the manufacturer or clinics that promote its use). However, they don't say what degree of change I can expect to see. Will there will be a dramatic decrease in drinking, peeing, panting or, as one negative article countered, "minimal" effect? Promoters promise that metabolic issues will be arrested, maybe even improved, but I haven't actually read anything that gives me confidence in this regard. After all, "effectiveness" of treatment is basically determined by outward signs. And what about the pot belly? I have yet to read anything about whether that might be halted or reversed (although my previous vet claimed the muscles would regain strength and reverse the bulge!). I've tried a couple of herbal treatments (like lignans and melatonin) with uncertain effect.

Everyone agrees that Trilostane will not cure Cushing's. It is unclear whether it can prolong the dog's life. My vet almost seemed to suggest that, but he caught himself in mid-sentence as if he realized he could not make that claim.

The chemical is not benign, it is toxic (pregnant women are warned not to touch it, but it's OK to put it in your pet!). The matter comes down to "quality of life", which is subjective.

I'd like to hear from others with experience as to what to expect from Trilostane. (I know, every case is different, but there must be something to learn from all this.) Is it reasonable to expect enough change to justify putting the chemical into a dog? And to justify the cost? I know several elderly people who are paying hundreds of dollars a month on pharmaceuticals to keep themselves alive, while their bodies and minds slowly deteriorate. I'm not sure I would want to go through that, and wonder if I should I put Kobe through it?

Ha! First-world problems!

[Harley PoMMom]

If the disease is confirmed, he has suggested that safety dictates starting with a low dose, which he defined as 10mg twice a day. That's 20mg daily for a 34 lb dog.

I believe that's a reasonable dose of Vetoryl for Kobe.


The literature I've read on Cushing's and Trilostane leaves me with more questions than answers. (I encountered this same problem two years ago when I researched my prostate cancer and had to decide what treatment to pursue. The matter is fuzzy, no one can guarantee anything, and in the end a lot is left to chance. I've been lucky so far, even though I went against the majority view in my case.)

You're absolutely correct, there are no guarantees with Trilostane because all dogs are different and react differently. Vetoryl is a strong drug and it does have some pretty scary side effects, however, adverse effects are usually not seen unless the proper treatment protocols are not followed. We have many members that are treating their cushdog with Vetoryl/Trilostane and are experiencing success. The key to facilitating safe and effective treatment is an experienced vet and an educated pet owner, so the best advice I can give you is to do your research on Cushing's, the treatment protocols, and how it is diagnosed. With treatment dogs with Cushing's can have a good quality of life and there is every reason to believe that they can live out their normal life span. Also, ask all the questions you want and we will do our best to answer them!


One question I have is: exactly how effective is Trilostane? A lot of articles seem to describe it as almost a miracle drug (these articles seem to be underwritten by the manufacturer or clinics that promote its use). However, they don't say what degree of change I can expect to see. Will there will be a dramatic decrease in drinking, peeing, panting or, as one negative article countered, "minimal" effect? Promoters promise that metabolic issues will be arrested, maybe even improved, but I haven't actually read anything that gives me confidence in this regard. After all, "effectiveness" of treatment is basically determined by outward signs. And what about the pot belly? I have yet to read anything about whether that might be halted or reversed (although my previous vet claimed the muscles would regain strength and reverse the bulge!). I've tried a couple of herbal treatments (like lignans and melatonin) with uncertain effect.

Improvement in drinking/peeing are usually seen within 2 weeks of treatment, that pot belly may take much longer. What can be frustrating is getting that optimal dose for Kobe, this can take a while as cortisol can fluctuate so dosage adjustments are needed to achieve that therapeutic range.


Everyone agrees that Trilostane will not cure Cushing's. It is unclear whether it can prolong the dog's life. My vet almost seemed to suggest that, but he caught himself in mid-sentence as if he realized he could not make that claim.

The chemical is not benign, it is toxic (pregnant women are warned not to touch it, but it's OK to put it in your pet!). The matter comes down to "quality of life", which is subjective.

You are right, Trilostane is not a cure for Cushing's, the goal of treatment is to control the symptoms and elevated cortisol.



I'd like to hear from others with experience as to what to expect from Trilostane. (I know, every case is different, but there must be something to learn from all this.) Is it reasonable to expect enough change to justify putting the chemical into a dog? And to justify the cost? I know several elderly people who are paying hundreds of dollars a month on pharmaceuticals to keep themselves alive, while their bodies and minds slowly deteriorate. I'm not sure I would want to go through that, and wonder if I should I put Kobe through it?


I've never used Trilostane, Lysodren is what I started my Harley on but looking back I do wish I would of tried Trilostane first.

You're doing a great job!!

Hugs, Lori

[labblab]

Lori has done a great job of laying out answers to your questions, and I agree with everything she’s written. So it makes my job a lot easier — just to add a couple more thoughts ;-).

I did treat my Labrador retriever with trilostane. This was many years ago when the medication was first being introduced for veterinary purposes. At the time, the initial dosing range was much higher, so my boy started out on a whopping big dose. He was absolutely miserable beforehand and outwardly a poster child for the disease: panting all the time, excessive thirst/urination/hunger, bare haunches, always trying to find a cool place to lie down, hind end muscle weakness such that he could no longer jump in the car or on the couch, or even easily negotiate steps. The one thing he did not have was the pot belly. Within three days of starting the trilostane, his thirst and urination significantly subsided. Over time, there was also significant improvement in the other issues, as well. His hair grew back, he regained muscle strength — overall he was much more comfortable. I might not have seen improvements as quickly had he been taking a smaller dose to begin with. But for safety’s sake, starting lower is definitely the way to go.

I wish I could end the story of our journey on a happy note. But unfortunately within the first year of treatment, he started exhibiting neurological symptoms consistent with an enlarging pituitary tumor that was placing pressure on other parts of his brain. That is a risk that occurs in a certain percentage of Cushpups who have pituitary tumors, but I won’t dwell on it here. Because the main point I want to make is that I did see genuine outward improvement in my dog after we started the trilostane. Over my years here on the forum, I would say that by far the majority of our dogs treated with trilostane do see rather rapid improvement with thirst/urination. Improvement in coat, muscle strength, and pot belly are also seen, but over a longer time frame.

As far as metabolic changes, there is no question but that trilostane is very effective at lowering cortisol. So for disorders that are known to be aggravated by consistently elevated cortisol, presumably it is always a benefit to lower that level. Using the protein in the urine as an example, elevated cortisol is known to have the potential to alter kidney function in such a way that protein is allowed to pass through the kidneys into the urine. This dynamic can actually damage the kidneys if it persists for too long at too high a level. So if you read about diagnosis and treatment of “proteinuria” in dogs, one of the primary recommendations is to first identify whether there is an underlying condition (such as Cushing’s) that may be the basis for the problem, and if so, address that underlying cause. The same would be true for elevated glucose. It’s certainly true that dogs may suffer from diabetes separate from Cushing’s. But elevated steroid levels in the blood are known to have the potential to cause elevated glucose readings for any person or animal. In that case, glucose levels ought to normalize again if the steroid level is reduced. My mother-in-law had to take high doses of prednisone periodically for a skin condition. Each time, her glucose level went way up. But it lowered again once her prednisone was discontinued.

One last note I’d add is that the specific warnings against handling trilostane, especially for pregnant women, are not because it’s some sort of poison. It’s because of trilostane’s hormonal effect. If you don’t have elevated cortisol, you don’t want to be introducing the chemical into your system. For developing fetuses, hormonal imbalances can trigger birth defects so pregnant women are specifically warned. Actually, pregnant women are advised to avoid even certain OTC topical products due to possible hormonal effects. I know a lot of people get freaked out about the warnings against directly handling trilostane, but it’s not a poison like cyanide or anything like that.

From what I’ve written above, you may think I’m trying to push you into treatment and truly I am not. There can always be trade-offs. For instance, older dogs may see a worsening of arthritic pain once the high level of circulating cortisol is lowered. What a bummer that is — to solve some problems but to see others emerge. In my own case, treatment was a no-brainer. Outwardly my own dog was so physically miserable beforehand that we were seriously considering having him put down. As I said earlier, we ended up losing him within the year anyway. But he was far more comfortable during that time. But for most folks, it’s nowhere near that dramatic a decision. And I suspect that’s the case for you. So do continue to take whatever time you need and continue to ask us any questions.

[inheriteddog]

A couple of weeks have gone by as I recoup my expenses from last month's tests. Meanwhile, I am feeling more inclined to go ahead with the LDDS. Kobe's belly looks bigger, although he doesn't seem to have gained weight. It makes him clumsier and it's harder for him to sit. Some skin problems are showing up again on his face and between the toes. He seems more anxious and clingy. We had a couple of unusually warm days and he was panting. I fear the summer will be bad. And the blood test results from January are bothering me. He is a bit picky about his food now, but appetite remains good and his energy is the same too.

The vet said if the test is positive, he'd start Kobe on Vetoryl 20mg daily. He'd prefer 30, based on Kobe's weight, but the drug comes in 10mg doses, not 15, so can't split them in two. My fear is 20 won't be enough. Not sure what to do then. How easily do pets take Vetoryl? Kobe has been known to discover small pills in his food and spit them out.

[Harley PoMMom]

I do believe 20 mg of Vetoryl is a good starting dose, however if the vet prefers 30 mg, you can give 20 mg in the morning and 10 mg at night. Just remember these important rules: Vetoryl has to be given with a meal, and those ACTH stimulation tests have to be performed 4-6 hours after the Vetoryl is given with the meal.

Does he like hot dogs? If so, maybe try to put the Vetoryl in a piece of hot dog. I've used pill pockets before with my dogs and they ate them with no problem but my dogs always had a healthy appetite!

Hugs, Lori

[Squirt's Mom]

A couple of things that have worked for me with hard to pill babies. Tomlyn and Vetoquinol make a pill paste that is bacon flavored (DON'T get the cheddar cheese one...it's very greasy!). You can form the paste around any size or shape pill and I've only had one dog refuse it. And I've offered it to probably a 100 dogs or more over the years. Another that I just recently discovered thanks to our wonderful vet is Hill's Science Urgent Care canned food. I hate SD but this stuff is miraculous for getting pills down. You scoop a small amount onto something like a tongue depressor, spoon, etc and then push the med into it and around the pill. Then let the dog smell it and when they open their mouth scrape it off on their upper front teeth. It is VERY slippery in the mouth and just slides down the throat. I started using this when my Pug developed Addison's and wasn't eating anything....she never refused this tho. I tried it with my itty bitty girl who hates pill and it was the same...she loved it!

Now a trick...make 3 balls with the pill paste, cheese, hot dogs, etc. Put the med in one of the balls. Offer a plain ball immediately followed by the one with the med immediately followed by the second plain ball. Usually the dog is so interested in getting all the treats they miss that the second one has med in it. If you have more than one dog this works especially well. Use the same set up with 3 balls (all 3 plain except for the medicated dog's) and start with the ones who do not get medication, letting the medicated dog get the bites last. After watching others get treats they want theirs too!

[inheriteddog]

Well, the Vet called and Kobe's LDDS test confirmed Cushing's (I am awaiting the actual results from them by email). So now I'm looking at cost of Vetoryl, which seems to be higher today than the last time I looked it up online. 10mg twice a day is the staring dose. Any recommendations on pharmacies?

In any case, if the dose goes up I probably won't be able to afford it.

[inheriteddog]

Just got the results from the LDDS test for Kobe.
Baseline 8.8
4 hours 2.1
8 hours 2.5

I'm not sure how to interpret this. Please advise.

[Harley PoMMom]

It's been a while since I've interpreted a LDDS test but to me these results show that Kobe has the pituitary type of Cushing's (PDH), hopefully Marianne will be along to confirm. I also want to include a link to information regarding the pharmacies to buy Vetoryl and other cost savings: https://www.k9cushings.com/forum/showthread.php?9066-Cost-Savings-for-Owners-of-Cushingoid-Dogs&p=211096#post211096

Let us know if there is anything else we can do.

Hugs, Lori

[labblab]

Hello again, and yes, Lori is correct about those LDDS results. To explain, it’s the 8-hour value that determines the overall Cushing’s diagnosis. You’ve not included the lab’s normal reference ranges for the test, but typically the “normal” 8-hour cutoff is 1.4 or 1.5 ug/dL. This means that any result higher than that is consistent with Cushing’s — which is the case for Kobe. Next, you look to see whether either the 4 or 8-hour result is less than 50% of the baseline. If so, the result is consistent with the pituitary form of the disease. In Kobe’s case, they both are, and there you have it.

I’m very glad that Lori has given you the cost-saving link. Hopefully one of the options given there will be helpful especially if Kobe’s dose increases, including the possibility of a compounded version of trilostane. In terms of brandname Vetoryl, I’ll throw out one other option to discuss with your vet if Kobe’s dose ultimately does end up being increased to 30 mg. I know your vet is recommending twice daily dosing, which is a dosing regimen now favored by many researchers and clinicians. However, the maker of Vetoryl (Dechra) has consistently stuck with recommending that dogs initially start with a once daily dose given in the morning with breakfast. If it appears as though the effects of the medication are wearing off too quickly with symptom rebound later in the day, they then recommend the twice daily shift. I mention this because your daily cost of a single 30 mg. capsule would likely be significantly cheaper than three 10 mg. capsules. So if his dose does increase and the cost becomes prohibitive, trying the single morning dose could be an option to consider with your vet.

No matter what you decide, the best of luck to you and Kobe. And please continue with your updates!

Marianne

[Squirt's Mom]

You will also find that using Trilostane VS Vetoryl is often less expensive...especially the liquid form. This is because with the liquid you may not have to have a new prescription every time the dose changes...you simply increase or decrease the ml given using the same bottle. Not all vets will allow their client to use Trilostane but many will. Trilostane is the active ingredient in Vetoryl. A compounding pharmacy will take that ingredient and formulate it into forms (chewables, liquid, etc) and doses other than what Dechra produces with Vetoryl. You want to be sure the compounding pharmacy doesn't use bulk product but rather compounds from Vetoryl.

[inheriteddog]

Hello from Kobe's grandpa. Here is update on his treatment and situation. Started Vetoryl 20mg (10mg capsule given twice a day). I was glad to see the capsules are small so there has been no problem giving it to him hidden in pizza (his favorite). Tested its effectiveness by ACHT yesterday. Vet says results are slightly higher than he'd like, but good enough to continue at this dosage and retest in one month. So far no visible sign of improvement. Kobe still has big hunger, drinks, pees, pants, and skin infections are returning. Also, he apparently put on weight since last time. Doc says may take up to a month to see changes. Although Kobe did not show signs of med causing adverse reaction (i.e., no vomiting, diarrhea, lethargy), he sometimes looked sort of sad or not well for a while shortly after a dose. This condition did not last, however, and may not be due to Vetoryl. Now it's wait and see.

Checking the price at several pharmacies, I found most were exactly the same, pretty steep. A couple were cheaper but not sure if their shipping and customer service were reliable. So I chose a pharmacy with a good reputation. It is expensive to buy 60 capsules a month. I know this is not a new story, just sorry I have no advice for anyone else looking in.

Will try to keep you updated as time goes on. Take care and good luck.

[Squirt's Mom]

Good to know there have been to adverse effects from the dosage! I hope the next test shows better results and that you soon start to see some improvements. If the post ACTH # is still a bit high and his signs aren't improved by the next test then a small, SMALL, increase is in order.

As for the cost...it is steep but once he is settled on a dose you can talk to his vet about Trilostane. This is the active ingredient in Vetoryl and it can be compounded into other doses that Vetroryl doesn't come in OR into different forms like a chewable tablet or liquid. The liquid can save you money on top of the saving using the compounded Trilostane because you can easily increase or decrease the dose without a new 'script. So something to think about and discuss with his vet for sure. Not all vets will allow their clients to use the compounded but as long as the pharmacy uses the Trilostane and not a bulk product it usually works just as well while saving you money.

Thanks for the update!

Hugs,
Leslie

[inheriteddog]

It's been a while, but here's an update on Kobe's treatment and condition. About six weeks now on Vetoryl 20mg per day divided as 10mg given twice a day. He just had his second ACTH test last Monday, but it took a few days before I could get in touch with the vet for the results. Using 6 as a desired level, his results were 7 and later 10.4, in other words the cortisol is not under control. Physical effects I observed showed small improvement, but not dramatic. The first thing I noticed was that the raw spot on his tail was starting to cover up with hair. His drinking and peeing are diminished although that is irregular. Appetite lately is reduced, but he is picky with his food. He used to scarf up his kibble along with anything else, now he lets it sit until we mix something with it. He still pants quite a bit while walking and doesn't walk far before he seems to be tired. The infections in his feet remain bad and he recently showed a couple of bare spots on his underside. When he gets excited he seems a little more aggressive than before. He tends to sleep more in corners and under chairs. Sometimes I will see him trembling for a little while. He sometimes has trouble jumping into the car, but again this is inconsistent, like so many other things about Kobe.

I did not notice any of the typical adverse effects of Vetoryl such as vomiting, diarrhea, lethargy, etc. I think he tolerated the medicine well enough.

Vet recommended increasing dose to 15mg twice a day. Since there is no 15mg capsule for Vetoryl, this would involve two capsules, 10mg and 5mg. I told him this would cost more than I could afford. He then said we could consider a compound (which surprised me since he had earlier volunteered that he did not want to use compounds). Either that or try 30mg capsule once a day, although vet prefers dividing the dose. So we are looking into these options to see what might work and what I can afford.

One of my major concerns is how Kobe will respond when the weather gets hot. Even now when the temperature is mild, he pants too much. I hope we can bring this down. Along with that are the skin infections, which need to be reduced.
That's about it for now. Take care all.

[Harley PoMMom]

, his results were 7 and later 10.4, in other words the cortisol is not under control. Physical effects I observed showed small improvement, but not dramatic.

Could you clarify his results for me, was the 7 a pre and the 10.4 the post?

If the vet wants to increase the dosage to 30 mg and prefers it to be split, as an option you can give 20 mg in the morning and 10 mg at night.

Hugs, Lori

[inheriteddog]

I goofed in explaining the ACTH results. These are the ACTH tests used to determine if Vetoryl is working to control cortisol, not to be confused with the tests to find out if the dog has Cushings (hence the results are not pre and post). I should have said the 7 was from his test in March (following two weeks of treatment) and 10.4 from April (another 3-4 weeks later). It thus can be concluded that the dosage was not working.

[inheriteddog]

I goofed in explaining the ACTH results. These are the ACTH tests used to determine if Vetoryl is working to control cortisol, not to be confused with the tests to find out if the dog has Cushings (hence the results are not pre and post). I should have said the 7 was from his test in March (following two weeks of treatment) and 10.4 from April (another 3-4 weeks later). It thus can be concluded that the dosage was not working.

New note: It is May 20. Kobe has been on Trilostane compounded 30mg/daily, in divided doses of 15mg morning and 15 evening for three weeks. About to do a new ACTH stim test Monday to monitor effectiveness of new dosage. I have not noticed difference in outward symptoms over the 20mg treatment. Some reduction in drinking and peeing. Still pretty hungry. Skin infections come and go. Bad infections between toes, treated with antibiotics for two weeks; infections subsided but did not fully resolve, they popped back up after ended pills. No obvious side effects from Trilostane, just not sure they are working much. Anticipate vet will want to increase dosage.

Question for experienced pet owners. My understanding of ACTH stim test to monitor Trilostane is that one sample is taken 4-6 hours after medicine is given to measure cortisol level. Nothing else is done, before or after sample is taken. Is this correct? The reason I ask is that I am confused by how the vet is doing the testing, requiring me to drop off dog early in day, and last month I could not pick him up until later afternoon. Seems like an awfully long time if all they need is a few minutes to take one sample. Please advise.

[labblab]

Hi again. As far as the ACTH stimulation test, the procedure is identical regardless of whether the test is being performed to diagnose Cushing’s or whether it is being used to monitor treatment. The results are just interpreted differently depending upon the purpose of the test. An initial baseline cortisol sample is first taken. Then the stimulating agent is injected. Then, an hour later a second cortisol sample is drawn after the stim agent has had time to act. So there should always be both a pre- and a post-stimulation cortisol level reported with every ACTH test. Typically the post-stimulation level is the one that’s of greatest interest. But the pre-stimulation baseline level can also add context.

On occasion, members in Canada and elsewhere in the world have reported a two-hour delay between the initial baseline draw and the post-stimulated draw, sometimes even with post- values reported at both the one hour mark and the two hour mark. But here in the U.S., it is typically just a one-hour test. I’d not be surprised if it took your vet longer than just an hour to get Kobe settled and to proceed with both of the blood draws as well as giving the stimulation agent. But I’m not sure why your vet would require Kobe to stay most of the day. Actually, that would be a good question to ask.

Marianne

P.S. Just wanted to add that you may be confusing the ACTH stimulation test with the “Pre-Pill” Vetoryl monitoring protocol that has recently become more common in Europe. Some vets in the U.S. are using it, too. With the pre-pill protocol, only a single resting cortisol level is taken immediately *before* the next daily dose of Vetoryl is given. So there is no stimulation agent involved with that, and only a single blood draw.

[inheriteddog]

Finally got to talk to vet regarding latest test results. As I expected, the dose of 30mg daily had only small impact, so he wants to increase to 40 (twenty twice daily). Due to lag in getting a response, I already ordered refill on the 30mg to avoid interruption in treatment. We will begin 40 at end of month. Kobe's improvements include his tail looking better, somewhat reduced drinking and peeing, occasional bouts of playful energy, which I haven't seen in a while. On the other hand, he still craves food, pants, and his skin infections are spreading and not responding to shampoos. Two weeks of Simplicef helped his paw infection until the medicine ran out, then they popped up again. I suspect the infections are triggered by fleas (many in the area due to dry weather). Topical flea med is of moderate help. I don't want to try oral anti-flea med because Kobe has had seizures in the past.
Compounded Trilostane is more affordable than the straight kind. Vet wants to test every new dosage but I informed him that I can't afford a test every month. By standard practice, new tests won't start to spread out until the condition stabilizes at desired degree. That could be a while. Fortunately, no adverse reactions to Trilostane yet.
Any suggestions re shampoos for skin lesions and crusty spots?

[labblab]

Thanks very much for this update. I’m sorry to hear that Kobe is in need of an increase, but glad to know that at least some of his symptoms have shown some improvement. I surely understand the financial drain of ongoing monitoring tests in conjunction with the dosing increase. In lieu of performing a full ACTH test at every monitoring visit, perhaps one thing you and your vet may decide to consider is sometimes substituting the single, simple pre-Vetoryl resting cortisol blood draw that I was describing in my previous reply. To find out more about this option, click on this link and then scroll down to the bottom of the page:

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

As far as a shampoo, I was poised to recommend a medicated product that I had used quite successfully a few years ago to control a recurrent staph infection on my non-Cushing’s Lab girl. It was called Douxo Chlorhexidine shampoo, with an accompanying spray and wipes. However, I just checked it out and apparently some changes have been made to the formula fairly recently that have garnered both positive and also negative reviews from owners. Darn! Still, it may be something for you to consider. I know how frustrating the skin situation can be. For us, oral antibiotics would work for the time that my girl was taking them, but the infection always bounced back when she stopped. It took several months, but this shampoo alone finally resolved her problems. But as I say, I cannot vouch for this new formula.

Anyway, continued well wishes to you both, and we’ll continue to watch for your updates.

Marianne

[Squirt's Mom]

My sweet sweet boy, Bud (non-cush pup), has developed some sort of skin issue as of last year. He gets spots that start out itching then the hair comes out leaving a bloody raw area that looks painful but he doesn't act as if it is. He had several tests and all were negative for various bug bites, infections, diseases, and allergies. I did take him off all chicken and beef as they are common food allergens and started giving him some fish oil and coconut oil. Along with those changes, we have been treating him as if it were a fungus and it has helped. We use a topical mix of Betagen and an antifungal who's name I cannot remember (maybe Clotrimazole?). This mix does treat and heal the spots that come up but it doesn't stop other spots from firing up. He is not bothered by this during the fall or winter but once the temperatures start to rise, his skin starts breaking down. We considered an oral antifungal but those are so hard on the liver we decided to try this route.

So Bud and I can empathize with the skin issues and hope you can find something that will help your sweet baby.
Hugs,
Leslie

[inheriteddog]

So now I'm wondering if Kobe is regressing. The past week or so he's been drinking more than before. The skin infections are still bad. As well, he's recently been licking the carpet, something I haven't seen in several months. Does a dog become resistant to trilostane after a time? Or is it likely his condition is simply worsening and the dosage isn't helping anymore? I still plan to increase the dose at the end of the month when the current medicine runs out.

[labblab]

Hi again. In our experience here, it’s not unusual over time to to see the need for trilostane adjustments both up and down. I wouldn’t say that Kobe’s disease itself is necessarily getting worse, but rather just that the current dose is simply not suppressing his adrenal function sufficiently. I’m guessing this is disappointing after initially seeing a better outward response. But we’ll assume that you’ll once again see his symptoms come under better control once he’s consistently on the higher dose.

Marianne

[Squirt's Mom]

This is standard with Vetoryl/Trilostane. It is not a stable drug so it doesn't maintain control very well over time in most dogs. This is why it is so important 1) to know the signs of not only low cortisol but high and 2) to keep up the very sspecific testing schedule for this drug. The monitoring ACTHs are the only way to be sure the cortisol is once again elevated (and rule out other possibilities for the changes seen) so be sure to have that done before the vet increases the dose. Typically increases are no more than 25% of the current dose. Just a reminder....once the dose is increased the testing schedule starts all over at the 2 week mark. ;)

I'm lazy today and haven't read back thru Kobe's thread so I apologize you have already given this info....has his skin been checked for Calcinosis cutis? This is usually diagnosed via a punch biopsy.

Let us know what the ACTH shows and how things are progressing for your sweet baby boy!

Hugs,
Leslie

[inheriteddog]

This is standard with Vetoryl/Trilostane. It is not a stable drug so it doesn't maintain control very well over time in most dogs. This is why it is so important 1) to know the signs of not only low cortisol but high and 2) to keep up the very sspecific testing schedule for this drug. The monitoring ACTHs are the only way to be sure the cortisol is once again elevated (and rule out other possibilities for the changes seen) so be sure to have that done before the vet increases the dose. Typically increases are no more than 25% of the current dose. Just a reminder....once the dose is increased the testing schedule starts all over at the 2 week mark. ;)

I'm lazy today and haven't read back thru Kobe's thread so I apologize you have already given this info....has his skin been checked for Calcinosis cutis? This is usually diagnosed via a punch biopsy.

Let us know what the ACTH shows and how things are progressing for your sweet baby boy!

Hugs,
Leslie

It's now August 17. For the past few months I've been dealing with personal health issues and delayed Kobe's testing. This week he got his ACTH stim test and the results indicate his condition is stable, so he can remain on the 40mg dose for now (his weight is 33.6). Improvement seen in basic signs: drinking, eating OK. Pants in hot weather. Still has sensitive skin and scabby spots, interdigital infections are bad. Vet is giving a three-week regimen of antibiotic (previous episodes have been given two-weeks' worth), says it won't resolve the issue completely but can bring down the swelling and redness. Meanwhile, Kobe has a lump that appears to be a hematoma on lower abdomen about the size of a quarter. Doctor suspects some type of cancer, proposed removal and biopsy. Kobe is middle-aged (ten). No signs of problems right now from the lump; smaller lumps have formed and broken open, healed over. Vet discussed risks of cancer spreading, etc. etc.

So, there are more things to consider. Having decided to treat the Cushings, I'm presented with another problem, to treat or not to treat possible cancer. Kobe's age is middling. (I have the same situation with my health issues, being neither too old nor too young to sway me one way or another.) Now, does having Cushings make cancer treatment more problematic? For example, is his immune system compromised? I've heard Cushings can cause problems with regard to vaccinations. Overloading a dog's system can be fatal. An otherwise healthy dog might be treatable for cancer, but a dog with a serious condition??? And again there's the money factor. Just testing and screening with lump removal and biopsy is in the many hundreds, let's not even discuss treatment like chemo.

That's about where I'm at. Kobe's a good dog. Be well.

[labblab]

Welcome back to us. I’m so sorry you’ve had health issues of your own to deal with. I know that makes it so much harder to try to resolve other issues. But turning to Kobe, as long as his elevated cortisol is under reasonably good control, I don’t think that the disease itself would be a physical contraindication to cancer treatment that otherwise carries a good prognosis. The cost of treatment is another issue entirely, and I do understand that.

I do have one question for you, though. Is the vet unable to first perform a simple needle biopsy in order to gain a better sense as to the nature of the lump? I’m not a vet myself, and seemingly there must be some reason why a needle biopsy hasn’t been suggested. But that’s always been the first step in assessing lumps on my dogs. Most have turned out to be benign fatty tumors, but one was a cancerous mast cell tumor which fortunately was removed pretty easily with clean margins. So that was the end of the issue. The initial needle biopsies have always been relatively inexpensive and delivered important information. And in Kobe’s case, I’d think that first determining the nature of the lump would play a major role in deciding how, and even whether, to move forward. So I’m just wondering if a needle biopsy is an option.

Marianne

[inheriteddog]

Vet offered two options. Fine needle aspiration and cytology (approx. $100 total) "has disadvantages with poor exfoliation of cells or blood-filled lesions" (wording per vet's post-visit notes). Second option was "mass removal with histopatholgy", deemed the better choice to confirm diagnosis. Kobe would first need blood workup and x-rays (close to $400) to determine if he's healthy enough for total anesthesia. Cost of actual surgery, anesthesia and biopsy will be provided to me later by the surgery team. Based on the look of the lump Vet strongly suspects cancer. If confirmed, of course, followup treatment will depend on what actually is discovered. Kobe' had smaller bumps, some of which have opened up and bled, then healed over.

I'm not a techie and don't know if I can attach pictures to these posts, but visuals might be helpful. Thank you for your concern.

[labblab]

Well dang, that’s certainly an enormous price difference between the needle aspiration and the tumor removal/biopsy. What a difficult position you’re in as far as making a decision :-(((((. Would the needle aspiration pose any danger of possibly spreading some tumor cells? If not, and if the only drawback is a higher likelihood of inconclusive results, I still think I might start there, myself. If you gain some useful information, great. If not, I realize you’re still faced with that original hard decision about removing the mass. And I think I do understand why that’s a hard call for you under the circumstances.

You say the vet does believe it’s likely cancer. If so, does he have any guesses as to the type? I know I’m kind of grasping at straws here, but any shred of info or even just conjecture about the tumor type might help you with a decision about advancing further.

As far as photos, even though I’m a staffer, I’m pretty helpless about that myself. My best advice would be for you to go ahead and create a personal photo album. That would definitely give you the ability to upload pictures to your album that we can see. Here are instructions on how to create an album:

https://www.k9cushings.com/forum/faq.php?faq=vb3_user_profile#faq_vb3_albums

Good luck if you want to give that a try!

[inheriteddog]

Yesterday I received a cost estimate for surgery and biopsy. $2000. That's in addition to the $400 for labs and x-rays before anesthesia. I don't need to make any decision right now. In any case, I have to figure out my own health situation before I can take care of Kobe. We'll see.

[labblab]

I totally understand. It sounds as though you’ve got an awful lot to deal with right now, and I surely hope there will be a positive path forward for both you and Kobe. Just let us know if and when we can help in any way.

Sending many healing wishes across the miles,
Marianne

[inheriteddog]

I totally understand. It sounds as though you’ve got an awful lot to deal with right now, and I surely hope there will be a positive path forward for both you and Kobe. Just let us know if and when we can help in any way.

Sending many healing wishes across the miles,
Marianne

I've been off line for a while and not sure if I am checking back in correctly. This setup confuses me.

A lot has been going on over the past few months. As far as Kobe is concerned, his Cushings seems to be stable at the dosage 20mg twice daily. Water intake is good, eats well although he can be picky. He walks less than before and occasionally has trouble jumping into the car or going up steps, though generally he manages. Weakness in legs is apparent. Main problems are skin rashes and sores between the toes which are only relieved by antibiotics, and I don't want to overdo that, so am using a lot of neosporin, sometimes hydrocortizone, and anti-itch cream, all of which help somewhat. Also still using the DouxoS3 shampoo, but not sure if that makes a difference. Have not seen fleas lately, presumably due to the weather. The vet wanted me to use a heavy-duty flea medicine, which I declined because Kobe has had seizures and these meds are wicked. I keep him bathed and combed, and as I say, no fleas lately.

The lump he had on his underside that the vet wanted to get biopsied resolved itself, there's only a blood blister left, no lump anymore. He has a few of these blister things, which he sometimes rubs open with blood coming out. Nothing serious. Oh, and he just turned 11.

I'd say he's doing pretty well given his age. I welcome any suggestions on skin sores and fleas for the summer. Otherwise, thinks for your support.

[labblab]

Welcome back to you and Kobe, and thanks so much for your update! I’m really sorry it took me so long to see your post, but I’ve been having some internet issues lately that are hopefully now resolved. Anyway, I’m really glad to hear that Kobe is holding his own. I wish I had some good alternative suggestions re: flea control and the skin sores, but it sounds as though you’re doing the very best you can under the circumstances. I do understand your worry about possible neurological risks to the flea meds, so as long as you’re not seeing any of the pests when you comb him, I think you’re good right now.

So even though I don’t have any great suggestions, I’m surely glad you’ve made it back to us for your report. Please give Kobe a big hug for me, and tak3 good care of yourself, as well!

Marianne