6 y/o cockapoo Bonnie recently diagnosed

[BonnieandDre]

Hi all,

My 6y/o Cockapoo Bonnie went in for her wellness appt last Monday and was diagnosed with Cushings. I'm crushed since since she's so young to be diagnosed - I was prepared for many more years with her. She's the absolute sweetest girl.
The vet noticed weight gain (16->18lbs) and her potbelly, so ran blood work. There are no changes related to her activity or mood.

Labs:
- Initial blood work: liver enzymes were high (ALP - 525 u/l; ALT - 148u/l); bilirubin high (1.7mg/dl); lipase very slightly above normal; everything else normal.
- Seeing high liver enzymes, recommended ACTH test: baseline was 9.2 ug/dl; 2nd reading was >30 ug/dl (so high the machine didn't even give a number, just ">30")

Rxs:
He prescribed Vetoryl (30mg w/ food 1x / day); Demarin for liver (½ tab without food)

Follow-up:
- Next ACTH test on 2/14/23; recommended ultrasound but very expensive (~$715!!)
- I also made an appt with UC Davis internal medicine doctor (Dr. Matthews) but this isn't scheduled until April due to their availability. I will keep trying to see about cancellations, but this is ~1.5 hrs away so not easy to get to)

[2/6: I brought her into the vet because she was having some blood in her poop. This isn't a new problem but it was worse today and now I'm hyperaware of everything . He rx'd probiotics Proviable Forte 2x/day with food, antacid Famotidine 10 mg) 2x / day; Sucralfate 2x w/out food (treats duodenal ulcers)] Will bring stool sample to my next appt on 2/14/23, to test for parasites.]

Qus for the group:
- Should I get an ultrasound? I understand this can help diagnose adrenal vs pituitary tumors, but the way I view testing is to INFORM next steps. From what I'm reading, adrenal gland surgery is very risky and expensive, so treatment seems to be the same for either location (Vetoryl). It could potentially tell me a better estimate of how long she will life, but do I want to know? The vet wouldn't say anything confidently, but suspects it may be adrenal tumors given her super high cortisol readings and young age. If adrenal tumors, I would then need to get a biopsy to determine if cancer? I do not have pet insurance so this is all out of pocket :(
- I'm really struggling with how expensive my vet is. Everything I'm reading estimates 1/2 the cost of the ultrasound quote I was provided at my vet. I've tried calling around different vets but they won't even given me a quote without an initial consult. How do you navigate this? I've already spend more than my rent on these last 2 appointments. I am in the Bay Area so understand it will be higher than a national average, but 200%!?
- Does anyone have experience with internal medicine at UC Davis?
- I'm not understanding why life expectancy is the same between untreated and treated dogs. I understand that this affects elderly dogs and they often die of non-Cushings diseases, but how does treatment not extend life given it keep cortisol in check?
- Does anybody have experience with Cushings in such a young dog?

Appreciate any insight. Grateful for the help.
Andrea and Bonnie (Bon Bon)

[Harley PoMMom]

Hi Andrea!

Welcome to you and Bonnie! I am sorry for the circumstances that brought you here but so glad you found us and we will help in any way we can. I'm a bit concerned that your vet diagnosed Cushing's so quickly based solely on weight gain and elevated cortisol because many health issues can cause high cortisol. Dogs with Cushing's generally display the most common Cushing's symptoms, such as increased drinking/urination, ravenous appetite, panting, exercise intolerance, difficulty or unable to go up steps or jump on furniture, and hair/skin issues. Does your sweet girl have any of those symptoms? Also, there are markers for Cushing's in the Chemistry and CBC blood results such as mild increases in the ALT, blood glucose, and high blood cholesterol concentration; in the CBC, a high total white blood cell count with increased numbers of neutrophils and monocytes and decreased numbers of lymphocytes and eosinophils are usually seen. Do you see any of these markers listed abnormal on Bonnie's CBC/Chemistry blood count?

Another concerning factor is her Vetoryl dosage is too high, the recommended starting dose is 1 mg per pound, so for Bonnie's weight of 18 lbs, her dosage should of not been any higher than 20 mg of Vetoryl, so please do keep an eye on her for any symptoms of her cortisol dropping too low such as inappetence, vomiting, diarrhea, or Bonnie simply not acting herself. If any one of those symptoms are seen just stopping the Vetoryl should help perk her up. With Vetoryl, it has to be given with a full meal to be properly absorbed and those ACTH stimulation tests have to be performed 4-6 hours after the Vetroyl was given with a meal.

Concerning the ultrasound, I feel the ultrasound is one of the most useful diagnostic tools, especially considering it's non-invasive. It can give an "inside look" at those internal organs and it might clarify whether or not there are primary issues with your girl’s liver or gallbladder, for instance, that might account for those high liver enzyme readings including the elevated bilirubin.

Cushing's is a treatable disease and 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. However, for the treatment to work safely and successfully it requires an educated pet owner along with an experienced vet as adverse side effects are mostly only seen when the proper protocols are not followed.

Please know you are not alone on this journey as we are right there beside you and if you have any more questions, please do not hesitate to ask them.

Hugs, Lori

[BonnieandDre]

Thanks so much, Lori.

She doesn't have all the symptoms you mentioned, so he diagnosed her based on weight gain/pot belly; elevated liver enzymes; and confirmatory ACTH test (From what I understand this is considered a pretty sensitive test?) She didn't have a CBC test so not sure on that.

Re: Vetoryl dosage, I called the vet to double check this since I read on this site how dangerous it is, and he said she's at the proper dose given her weight and how high her cortisol is. She has been tolerating it and we go back on Tuesday to check, but I will certainly keep a close eye on her for adverse events.

How do I find an affordable ultrasound?

[Squirt's Mom]

Hi Andrea,

Welcome to you and your sweet girl.

I want to second what Lori said about this starting dose....it is too high and could cause problems. Dechra, the drug's manufacturer, says to start at the LOWEST dose possible and for a dog of 18 lbs that is 1mg per pound...and that is in their literature for anyone to read. ;) Any higher than 20mg per day is putting your baby at risk and costing you more to boot. I would INSIST the vet give her no more than 20 mg a day. That would be 2- 10mg tablets either both in the am or 10mg am and 10mg pm. BUT this is the least of the problems....

Your baby has very few signs of Cushing's and the lab work is not conclusive at all...for any dog not just yours. This is a sign-driven disease, meaning the signs are just as important as the numbers and sometimes more important. The ACTH and the LDDS, the two blood tests for Cushing's, can easily return false positives if any other health issue is present...such as a urinary tract infection or digestive issues or infection. I know - I've had two dogs misdiagnosed. The second one only had the ACTH and her results was >50. She did NOT have Cushing's tho....she had a host of other issues (including colitis which causes bloody stools) and her necropsy (autopsy for animals) showed normal adrenal glands proving she did not have the disease (she was not treated at the time because I had stopped treatment a while before she passed from an inguinal hernia). Neither the ACTH nor the LDDS are fool-proof but the LDDS is considered the gold standard for diagnosing Cushing's. FYI...my first pup had a tumor on her spleen which caused false positives on the ACTH, LDDS, HDDS, and UTK panel. Once the tumor was removed all those tests returned normal levels of cortisol. It was the stress of the tumor that caused her cortisol to rise NATURALLY in response. Same with my other baby who registered >50...stress caused a false positive on the ACTH. Cortisol is a fight or flight hormone and it's job is to rise in the face of any stress to help the body cope. It is the same in humans.

About the ultrasound...it will have little value for diagnosing Cushing's if the dog is already on treatment because the treatment will cause the adrenals to return to a more normal appearance UNLESS the tumor(s) are on one or both adrenal glands. It will have value as far as looking for tumors, etc. but little to none for diagnosing Cushing's once the pup is on medication to reduce the cortisol. If there was a tumor present or some other issue with an internal organ that could impact the ACTH so that would have some value. It was the US that saved my first pup's life by finding that tumor. Not only could it have ruptured but had I started treatment without being aware of it the treatment could have made her very very sick - or worse. So the US definitely has value but it should be done during the diagnostic phase and not after treatment has started.

My Squirt, first one misdiagnosed, did eventually develop Cushing's and she was 7 at the time. She passed at the age of 16+ WITH Cushing's not FROM it and I had stopped treatment for her a year earlier due to her age and dementia. Our cush pups can do live out their normal lifespan IF correctly treated and none of the uncommon complications arise. So don't despair about the time you may have left just yet...the picture is far from clear for your sweet Bonnie.

I, too, am very glad you found us and look forward to learning more soon.
Hugs,
Leslie

ps...I hope this makes a little sense; I am writing in a rush unfortunately.

[Harley PoMMom]

An elevated bilirubin is generally not seen in dog's with Cushing's, Bonnie's is 1.7 which is pretty high, this is usually seen in dog's with a liver issue or a blocking or damaging of the bile ducts. Liver issues in dogs can often be accompanied by ascites, or fluid accumulation in the abdomen. Those with ascites will have an abnormally swollen belly which may be the reason for Bonnie's weight gain and pot-bellied appearance.

I think that seeing Dr. Matthews at UC Davis is a wonderful idea as IMS' generally have more knowledge about Cushing's than a GP vet because IMS' have seen more cases.

Concerning the cost of the ultrasound, for my vet visits I use CareCredit, it allows for 6 months to pay it off before interest is started. Here's a link to a thread in our Helpful Resource forum regarding "Financial Resources to help with Vet bills" https://www.k9cushings.com/forum/showthread.php?212-Financial-Resources-to-help-with-Vet-bills

You're doing a great job!!!

Hugs, Lori

[BonnieandDre]

Wow thank you both so much - you're providing such valuable information and giving me some hope it may not be Cushings! (Although I'm sure liver issues are quite serious as well).

Things that don't "add up" with a Cushings diagnosis:
- limited Cushings symptoms (pot belly/weight gain - which are unspecific); no increased thirst/peeing, skin problems, behavior change
- high bilirubin (1.7)
- her age (6 y/o)
- bloody poops
- normal baseline cortisol is very high (9.3) / Bonnie is generally an anxious dog

Evidence for Cushings:
- ACTH test
- not evidence, but a risk factor - Cushings is more common in cocker spaniels and poodles (she is a mix)

It seems very hard to tell cause and effect, ie, is elevated cortisol levels causing liver disease or is liver disease is causing elevated cortisol levels?

Wouldn't Vetoryl bring down cortisol levels regardless of the cause (liver or cushings)? If so, the follow up ACTH won't tell me any new information about root cause.

I'm wondering if I should stop the Vetoryl before going to the UC Davis specialist. Being on it would muddy the waters in deciphering the root cause (especially if I do an ultrasound, I want it to be as useful as possible).

Re: ultrasound cost, thanks for the suggestion. I'm mostly just annoyed/upset with mylocal vet for charging literally double the national average :/ If it's less useful to do now, may make sense to wait until I go to the specialist. How bad would it be to stop her meds before that appointment? (Vetoryl and Demarin, a liver supplement). The specialist is far, expensive, and takes ~7 weeks to get an appt, so want it to be as useful as possible.

I will report back what I hear on Tuesday.

Thank you!

[Harley PoMMom]

If this were me, and letting you know that I am not a vet nor have any experience in the veterinary field, I would stop the Vetoryl and most definitely see the IMS at UC Davis. I do believe something is going on with Bonnie's liver and Vetoryl should not be given to a dog with a hepatic disease.

Those ultrasounds are expensive to have done and not all ultrasounds are created equal. A good quality ultrasound/interpretation depends on a few things; the tool used, the technician performing it, and the physician interpreting. The technician, most likely, will perform their own and therefore, it should be those most experienced with capturing good windows and images. That would be a board-certified radiologist or board-certified Internal Medicine Specialist. Likewise, the one interpreting it should be the most experienced as well, and that's generally one of the 2 above.

Hugs, Lori

[labblab]

Welcome from me, too, although I’m so sorry that you have these new worries about Bonnie’s health. Lori and Leslie have already given you lots of helpful information, so I just have a couple of thoughts of my own to add.

First, in answer to your question re: holding off on giving any more Vetoryl until your UC Davis visit, I think I’d answer “yes” if Bonnie were my own dog. It’s probably fine to continue with the Denamarin since I think it’s intended to support the liver regardless of the specific cause of liver problems. But as far as the Vetoryl, here are my concerns.

First, as the others have noted, I have worries about the Cushing’s diagnosis itself. Secondly, I’m also worried about the dose. I’m especially concerned that your vet is justifying this dose on both the basis of weight (too high an initial dose for Bonnie’s weight), and also due to “how high her cortisol is.” According to all published dosing guidelines from the manufacturer, initial dosing decisions are based *solely* on weight. Cortisol levels are only factored into subsequent monitoring decisions after Vetoryl therapy is underway. So your vet’s explanation for his dosing decision seems wrong to me on both counts.

Secondly, I agree that you’ll likely have a more accurate diagnostic ultrasound assessment of Bonnie’s adrenal glands if she has *not* been taking the Vetoryl beforehand. Over the years I’ve seen conflicting info about Vetoryl’s effect on the size of the adrenal glands. I decided to do a little more Googling today and came up with this very interesting 2022 study. Quite surprisingly, it suggests using adrenal ultrasound results to monitor the effectiveness of Vetoryl treatment based on the premise that the *larger* the adrenals become throughout the course of therapy, the greater the likelihood that the Vetoryl is having an effective result. Since a bottom line of the article is that Vetoryl (trilostane), itself, causes enlargement of the adrenal glands, I would think that giving the medication beforehand would muddy the water for an initial pretreatment diagnostic ultrasound.

https://www.scirp.org/journal/paperinformation.aspx?paperid=119708

One final thought. I believe one cause of elevated bilirubin can be the presence of a gallbladder mucocele, and Cushing’s can increase a dog’s vulnerability to forming those mucoceles. But there are other causes of both elevated bilirubin and the formation of those mucoceles. Again, an ultrasound would be the tool to help diagnose a mucocele. But you want the best quality ultrasound possible.

I just now paused my own typing long enough to see Lori’s new reply, and she wrote in far less words exactly what I’m trying to say — I’d hold off on the Vetoryl, the ultrasound, and any more testing until you see the specialist at Davis! We are not vets ourselves. But that’s what I’d do if Bonnie were mine.

Marianne

[Squirt's Mom]

Andrea, count me as a third vote to stop the Vetoryl for now. I would want a second opinion based on an untreated status. Then any testing done can more accurately reflect what is going on with your sweet Bonnie. IF it is Cushing's, not treating is better than treating with a dose that is too high. Cush pups can live a long time (barring complications) without treatment so waiting til she sees the IMS shouldn't be a issue for Cushing's disease if that is in play (which I highly question).

One other tidbit....liver disease is one of the conditions that has caused false positives on the cush blood tests and it shares some of the same signs.

Hang in there! You've had a lot coming at you all at once and I KNOW how that can really get your head spinning. You are doing a great job of listening and researching! Bonnie is very lucky to have you on her team.

Hugs,
Leslie

[BonnieandDre]

Hi everyone,
My mom was able to get in touch with our old vet who sold his practice to the vet I have been going to. He was willing to speak with me on the phone and I shared Bonnie’s info and he seemed pretty convinced it is in fact Cushings, but recommended the ultrasound.

Marianne, interesting article - the vet mentioned the more you block the cortisol the more adrenals pump it out (needing to increase dose over time) so makes sense that they would enlarge over time. I wonder how long it would take to decrease though once I stop… to get an accurate read.

Will follow up with an update on Tuesday.
Thanks all, Andrea and Bon

[Tina]

Hi Andrea,

You might consider asking your vet about a bile acid test. It is a highly sensitive test that specifically assesses liver function. My pup Jasper had a lot more Cushing's symptoms than Bonnie, including very excessive drinking and peeing, along with the elevated liver values. Our vet had us do a bile acid test to rule out primary liver disease before she considered looking into Cushing's. His test came back normal and he was subsequently diagnosed with Cushing's after additional testing. He had just turned 8 when everything started. As others have said, the diagnostic tests for Cushing's can show a false positive if there is any other illness going on.

My other pup that I just lost did not have Cushing's, but she did have some level of liver disease, and also a gall bladder mucocele that was successfully removed through surgery. Her bile acid test at the time came back very elevated. We did an ultrasound after that.

Also, I didn't see that Bonnie had an LDDS test done? I think it used to be the gold standard for Cushing's diagnosis. Lori, Marianne, Leslie, please correct me if that is not right, I've been out of the loop with the testing protocol for a while!

Tina

[Harley PoMMom]

Looking forward to your update on Bon Bon!!

[BonnieandDre]

Hi everyone, and thanks for checking in.

We just got back from Bonnie's repeat ACTH test. She is responding well to the Vetoryl - her cortisol is now in a good range.

Baseline: 1.3 ug/dl (vs last time it was 9/3)
Post: 3.4 ug/dl (vs last time it was >30) - ref range is 1.8-7.2 for Vetoryl, "maintain current dose if pt is doing well"

Tx/Follow-up:
- Continue with Vetoryl 30mg once daily w/ day - I asked about the risk that cortisol continues to fall in the coming weeks and the risk of Addisonian crisis, and he said that it should be relatively stable now, so he is not concerned about that. I also asked about switching to twice daily and he said not necessary.
- Continue with Denamarin until out of Rx (6 more weeks) - The vet said the liver functioning takes longer to affect, so we'll test her liver enzymes at the 3 month followup
- Continue with probiotic until out of Rx (4 more weeks) - Her bloody poops are better.
- Repeat ACTH test at 3 months
- Monitor for any changes.

Tina, Bonnie didn't have an LDDS test done (in hindsight, I should have done that. I chose to do the ACTH test since it wouldn't require Bonnie staying at the vet all day, and she HATES the hospital. I didn't realize that ACTH doesn't tell me where the tumor was :/ )

Her specialist visit is early April, so I will do an ultrasound at that point. I asked about if the ultrasound is still okay to do once she's on treatment (since Vetoryl could increase size of adrenals), but he said still worth doing while she's on it, to confirm if adrenal tumors are present.

So glad her cortisol levels are better. Is there any reason to suspect it's not Cushing's at this point, given her response to treatment?

Thanks all,
Andrea & Bonnie

[Harley PoMMom]

I do still have my doubts about her Cushing's diagnosis because of that elevated bilirubin.
Cortisol can continue to drift downward during the first 30 days of treatment so do keep an eye out for too low cortisol such as: loss of appetite, lethargy, diarrhea, vomiting, or Bon Bon just not acting herself. If any one of these symptoms is noticed stopping the Vetoryl is required.

How is Bon Bon doing? Is her appetite normal?

You're doing a great job!!

Hugs, Lori

[BonnieandDre]

Yes will definitely keep an eye out!

Her stool sample came back positive for Giardia. We're starting metronidazole for 7 days and Panacur (dewormer).
At least that explains the bloody poops...

Poor Bon, so many meds the last few weeks!
Found a much more reasonable price for Vetoryl at Costco, and an ultrasound at another vet for about half the price! That appt is on 2/28.

[Harley PoMMom]

Poor Bon indeed :( Did you ask UC Davis what they charged for an ultrasound? If they're competitively priced, you may want them to do it as they are probably more experienced at ultrasounds.

Keep us updated please!!

[BonnieandDre]

I saw an ultrasound price in an full Adrenalectomy quote, and that was ~$500. This was in the context of a much larger operation though, so not sure if applicable.
The appt isn't til April, so would prefer to know sooner rather than later.
The one I'll get on 2/28 is w/ board certified folks so I think should be okay (and cheaper, ~$400) .

[Harley PoMMom]

Hopefully we'll learn more from the ultrasound on the 28th, good luck and keep us updated, please!

Hugs, Lori

[BonnieandDre]

I certainly will!

[labblab]

Although I haven’t had the chance to write much over the last couple of days, I’ve just now been catching up. And I’ll be wishing you good luck on the ultrasound, too! In the meantime, best wishes to both you and sweet Bonnie.

Marianne

[Squirt's Mom]

Glad to hear the update and pray all continues to go well. Tho I am like Lori and still question the diagnosis and dose. But you're doing a great job, Mom, so I'm sure you will catch any sign if things start to turn the other way. Never hesitate to stop treatment if in doubt. That is the one thing I like about Vetoryl...it is very easy to stop and restart without losing ground. Good luck with the US!

Hugs,
Leslie

[BonnieandDre]

Hi Everyone,

We did the ultrasound yesterday and are happy to report no adrenal tumors.

1) Bilaterally symmetric upper-normal to mildly enlarged adrenal glands are
likely secondary to pituitary dependent Cushing’s disease. No adrenal gland mass
lesions are seen. 2) Steroid or other vacuolar hepatopathy. 3) Colitis.

She's going to do more treatment for giardia, since that's likely still causing the colitis. Liver should improve with continued treatment.

Next steps:
Cushings - continuing 30mg Vetoryl, followup ACTH at 3 months.
Giardia - 3 weeks of antibiotics + finishing probiotics, followup stool test

I'm thinking I'll cancel the UC Davis appointment at this point. Both vets are in alignment this is no doubt Cushings. (Also have already spent ~$2k in the last 6 weeks.)

Thanks,
Andrea

[labblab]

Hi again, Andrea, and thanks so much for this update. I’m very glad you did have the ultrasound done, and yes, the results do sound consistent with Cushing’s. FWIW, I’d probably still hold on to the UC Davis appointment for the moment, though, mainly because it was so hard for you to get it in the first place. You can always still cancel later on if everything stays stable through March. But it seems as though it’s kind of nice to have that “ace-in-the-hole” should any further worries arise. In the meantime, we’ll be hoping that Bonnie can get rid of that darn giardia and otherwise remain stable and happy!

Marianne

[Squirt's Mom]

Hey Andrea,

Word of caution....you stated:
"continuing 30mg Vetoryl, followup ACTH at 3 months."

This is not protocol for Vetoryl/Trilostane. Because it is such an unstable drug the testing schedule set up by the manufacturer is as follows -
1st monitoring ACTH at 2 weeks after starting
2nd at 30 days after starting
3rd IF ALL IS WELL at 3 months
Then every 3 months

UNLESS there is a dose change up or down then the testing schedule starts all over at the two week mark. So waiting 3 months at this point can be very risky...especially with the high starting dose. Since treatment started in early Feb, the next monitoring test needs to be in early March. So unless you insist the vet follow the protocol, be extra vigilant in watching for any of the signs that the cortisol is dropping too low. I do understand the strain of expense but in the beginning it is very important to keep to the testing schedule. As time passes and she settles into a good dose you can take a bit more time between monitoring tests.

I agree with keeping the UC Davis appointment for a variety of reasons... not the least the length of time it can take to get one later if needed. ;)

Keep in touch and let us know how things are going!
Hugs,
Leslie

[BonnieandDre]

Hi Leslie,

Hmm, maybe I have that wrong and need to do a 1 month checkup. I can ask the vet.
Bonnie had her 14 day initial check up after starting the 30mg Vetoryl and her levels were good. I asked about the concern of levels continuing to fall, and the vet wasn't concerned (maybe because even if they did fall a bit more it would be fine?).

The other vet I talked to (where we did the ultrasound), also thought the dose was normal.

Good point about the Davis appt - I'll keep and decide closer to the date.

Thanks!

[Harley PoMMom]

The Vetoryl ACTH testing protocol that Leslie posted is correct; here's an excerpt from their pamphlet: "4. Long term monitoring. Once an optimum dose of VETORYL Capsules has been reached, re-examine the dog at 30 days, 90 days
and every 3 months thereafter. At a minimum, this monitoring should include: • A thorough history and physical examination.
• An ACTH stimulation test (conducted 4-6 hours after VETORYL Capsule administration) - a post-ACTH stimulation test resulting in
a cortisol of < 1.45 μg/dL (< 40 nmol/L), with or without electrolyte abnormalities, may precede the development of clinical signs of
hypoadrenocorticism.
• Serum biochemical tests (with particular attention to electrolytes, and renal and hepatic function).
Good control is indicated by favorable clinical signs as well as post-ACTH serum cortisol of 1.45-9.1 μg/dL (40-250 nmol/L)"

The link to where this information is found: Vetoryl Monitoring Form https://www.k9cushings.com/forum/showthread.php?185-Trilostane-Vetoryl-Information-and-Resources&p=1250#post1250

Looking forward to hearing more updates about sweet Bonnie!

[BonnieandDre]

Bonnie has been acting very funny the last several hours - she woke up in the middle of the night and won't stay still. She wont eat anything, doesn't need to go to the bathroom, breathing funny (choppy), pacing.

Any ideas? Should I bring her to the vet?

She's been on Vetoryl about 3 months now - will be bringing her in for a check up soon.

[Joan2517]

I would get her to the vet and get a Cortisol reading ASAP. Her Cortisol could have dropped too low. Don't give her anymore until it's checked.

[labblab]

I totally agree with Joan — I think Bonnie needs to be seen immediately. The breathing problem is especially worrying. We’ve just had another member whose dog developed a pulmonary embolism (Cushpups can be more vulnerable to these) and this is a life-threatening issue. Or as Joan says, Bonnie’s adrenal hormones (cortisol and/or aldosterone) may have dropped too low and may require emergency intervention. I really wouldn’t wait to contact your vet to get their guidance. Please do let us know what develops.

Marianne

[BonnieandDre]

She's acting more normal now. Didn't give her the dose today.
Is it okay to skip a few days and restart? I'd like to have her on the drug so we can do a real ACTH test and get an accurate reading.

[labblab]

She's acting more normal now. Didn't give her the dose today.
Is it okay to skip a few days and restart? I'd like to have her on the drug so we can do a real ACTH test and get an accurate reading.

It is always OK — and important — to withhold the med for any period of time that a dog is acting unwell. Let’s see if she continues to improve. Hopefully so. But if she were mine, I wouldn’t consider restarting the medication again until/unless she’s completely back to normal. And if she remains “off” by tomorrow, I’d still encourage you to contact your vet to report what you’re seeing.

Marianne

[Squirt's Mom]

How is Bonnie doing now?

[BonnieandDre]

Hi everyone,

Bonnie's ACTH level were too low on the 30mg, so now we're moving to 10mg 2x per day and retesting in a few weeks...
As this group suggested, the levels continued to drop between her initial test and the followup. When I had brought this concern up with the vet, he said he didn't see that being a problem.
So frustrating they don't know better, so grateful to you all for knowing to keep an eye on it.

Thanks for all the help. Hopefully this dosing will be right..

[Harley PoMMom]

How is Bonnie doing? Is her appetite normal, any diarrhea? What where the results of her recent ACTH stimulation test?

[BonnieandDre]

She's doing okay now. Until I can pick up her new dose at the pharmacy next weekend, I've been doing every other day of the 30mg.

ACTH results: Pre was 0.7, post was 1.3.
(So it fell a lot since the last test at pre - 1.3, and post - 3.4)

She had also lost .6 lbs which is good.
No diarrhea. Less appetite.

[Harley PoMMom]

If this were me, I'd stop giving the 30 mg dose of Vetoryl even though it's every other day, the day she gets that 30mg her cortisol could really drop and it is recommended that when cortisol drops too low that the Vetoryl be stopped completely until symptoms return and an ACTH stimulation test shows that cortisol is high.

[BonnieandDre]

Hi everyone,

At Bonnie's May appt, she had lost ~.5 lbs and her readings were very low: Pre 0.7 -> post 1.3
The vet decreased the dose from 30mg to 20mg.

In June she still wasn't eating enough so I decreased the dose myself from 20mg to 10mg.

At her ACTH appt yesterday, she had lost more weight (1.5 lbs, she's now 14.9 lbs) and her readings were still low/flat. Pre: 1.7-> Post: 1.9.
I can tell she's not eating enough, but otherwise she is normal.

The vet said to stop the Vetoryl for now, and see if her appetite goes back to normal.

It doesn't sound like Cushings ever 'resolves' like this?
Was this a misdiagnosis?
If so, something else is causing her liver problems..

Has anybody seen this?

Thanks!

[labblab]

Hello again. We’re glad to hear back from you, although I’m very sorry to hear that Bonnie is not doing so well. I absolutely agree with stopping the Vetoryl entirely at this point. Chronic oversuppression of the adrenal glands can definitely lead to loss of appetite, and it sounds as though Bonnie’s cortisol has been running too low for a couple of months now. Even for dogs who truly suffer from Cushing’s, medication overdoses can indeed lead to symptoms of oversuppression. For most Cushpups, temporary cessation of dosing will ultimately allow the adrenal glands to rebound. Once that happens, medication may be resumed at a lower level after cortisol levels once again elevate to abnormally high levels. On rare occasions, the adrenal oversuppression for Cushpups may become permanent. If that happens, not only is the Vetoryl never restarted, but supplemental prednisone may be required in order to make up for the permanently decreased level of cortisol.

In Bonnie’s case, though, I know we’ve always wondered about her true diagnosis — whether there is something else going on with her liver, either instead of or in addition to Cushing’s. If she doesn’t truly have Cushing’s at all, then Vetoryl at any dose would never be indicated.

Going full circle, for sure I think the first step is to entirely stop the Vetoryl and see whether her cortisol rebounds, her behavior normalizes and her appetite returns. If not, then I do think additional diagnostics are once again in order. I know you’ve held off on a UC Davis consult, but if Bonnie doesn’t rebound pretty quickly, you might gain some much needed peace of mind from a second opinion at the vet school if that is possible to arrange. Either way, please keep us updated as to how she’s doing.

Marianne

[BonnieandDre]

Thanks Marianne.
Sounds like a plan. We've stopped the Vetoryl and hopefully she'll get her appetite back in a few days.
I'll follow up in a week after I reconnect w/the vet.

[labblab]

That sounds good — we’ll definitely be anxious to hear what develops. I just want to add/clarify that if Bonnie does indeed have Cushing’s, she just may need only a very small dose to keep her cortisol in proper range. That remains one of the puzzles about treatment with this medication — there is really a wide variation in how effectively any individual dog metabolizes trilostane. Some small dogs may end up needing bigger doses than large dogs — some larger dogs may require only tiny doses. That’s why the ongoing monitoring is so important for all dogs.

Also, if Bonnie’s appetite still hasn’t improved by next week, or if any other worrisome symptoms emerge, I’d encourage you to ask your vet about going ahead and at least temporarily giving her a small daily dose of prednisone in order to offset the possibility that her cortisol is remaining at too low a level. If the prednisone perks her up, you’d have added evidence that her natural adrenal function remains overly suppressed.

[BonnieandDre]

Hello,
Its been about a month since stopping the vetoryl. She's eating and drinking a normal amount.
Can Cushings go away, or go away if overtreated? I'm still very confused on what happened here. If it was NOT Cushings, then something else caused her high liver enzymes.
Thanks,
Andrea

[Harley PoMMom]

Hi Andrea,

In a small percentage of dogs Vetoryl has eroded the adrenal glands so this may have happened to Bonnie. Has a follow up ACTH stimulation test been scheduled?

[Squirt's Mom]

Hey Andrea,

Here is a good link that explains liver enzymes and what they can mean.

https://www.dvm360.com/view/canine-liver-enzymes-so-many-questions

Also there is a very rare oddity with overdoses on Vetoryl. Dogs very rarely go into a sort of "remission" after an overdose and the med is stopped. We had a member here years ago whose lab would do this. Her cortisol would drop too low and she would remain med free for quite some time with no signs of the cortisol being too high or too low before the cortisol started to rise again. This is exceptionally uncommon but it has happened.

I would look into the liver link above and do a bit of research on what causes high liver enzymes in dogs as well to see if you find any other condition that fits Bonnie's history better than Cushing's. Be sure to stick to solid sites for research - vet schools, vet clinics, etc. and not things like Dog's Naturally (which is awful!).

Meanwhile enjoy your sweet girl and this break and just keep an eye out for any cush signs that may return. And know you are not alone.

Hugs,
Leslie

[BonnieandDre]

Hi everyone,

I had a checkup for Bonnie this week. We had stopped the Vetoryl about 6 months ago when she was losing too much weight even at the lowest dose. I was very pleased to hear her cortisol levels were good (3) and liver enzymes were also good (one was very slightly elevated, but the vet was not concerned).
So it seems we went into remission, like you mention Leslie, after starting on that high dose of Vetoryl.

She gained back some of the weight she quickly lost being on the Vetoryl, but her appetite is normal IMO.

We'll keep an eye out if anything new comes into the mix..
Thanks all,
andrea

[Squirt's Mom]

Andrea, all that sounds great! I am so glad to hear Bonnie is doing so well off treatment and pray it continues. Thank you so much for checking in and do let us keep hearing from you and sweet Bonnie!
Hugs,
Leslie