Seeking advice - 12 year old German shorthaired pointer

[Brusso89]

My 12 year old German shorthaired pointer was diagnosed with Cushing's as of yesterday and I'm not sure how to proceed. Due to my research, I feel like maybe his case is not the norm but maybe I'm just being naïve.



In January, I noticed an increase in drinking from my boy Trigger. My brother had Trigger's uncle and he was a year younger than Trigger and just recently passed from Cushing's disease, so I am slightly familiar with the symptoms of Cushing's. The week I noticed Triggers increase in drinking I started carefully looking for other signs. On a run in December, I remember looking at his tail from behind him and noticing a tiny bit or bare skin showing where it had used to be fur. Thinking back to that time and putting it together with the newly increase in drinking, it instantly sunk in. On 1/24, I had bloodwork done at my primary vet. The results did come back with signs of CushingÂ’s, but obviously further testing was needed. On 1/24 the blood levels that stuck out was ALT 327, ALP 626, GGT 24 and CHOL 368. Fast forward to 2/14, an ultrasound revealed no tumors but an enlarged liver and Adrenal glands. "Hepatobiliary - The liver is diffusely moderately enlarged and hyperechoic with smooth rounded margins. Adrenals - The adrenals are moderately generally enlarged, bilaterally, measuring 1.1 cm (left) and 1.3 cm (right) at the caudal pole; the glands exhibit otherwise unremarkable features." Since no tumor was found we did an ACTH test. Cortisol level pre ACTH is 6.0 and post is 33.7. Along with all the information, the blood work from 2/14 reads ALT 169, AST 28, ALP 521, GGT 20, CHOL 331 and Spec cPL is 212.



As of now, just the very tip of his tail and a small spot on his head has some hair loss (less than a square inch) and the increase in thirst. I feed him in the morning before I leave for work at 5am but the majority of the time he won't really eat until the second I come home. He gets excited and then eats which is around 4 and then he gets his actual dinner around 5-6. Weird eating times, I know. So personally, I think if he had an increase in hunger symptom, then he wouldn't leave the food sitting all day waiting for me to get home but then again this has been his routine all his life.



He has had some heart issues in the past 3 years that are for the most part under control thanks to 10mg of Vetmedin twice a day. He still has a level 4 heart murmur but gets an ecogram done every 6 months until this last one came back great so we pushed it out to a year (this coming September). Along with the Vetmedin, he takes fish oil, Dasuquin (for his arthritis) and the newly prescribed Denamarin as of a few days ago.



I don't think I'm missing anything given his current situation. Even though he is 12, he is a GSP which are high energy dogs. He has a decent amount of daily energy and if it wasn't for the arthritis, I think he would have the drive to run multiple miles a day like we used to in his younger years. We do a few miles twice a week now and he jogs/speed walks but doesn't run anymore. We did do hunting trips this past fall and winter but way less miles to keep him from having hard recovery days.

With no tumor on the adrenal gland and with them being slightly enlarged, it was explained to me that there could possibly a tumor on the pituitary gland which is making the adrenal glands overproduce causing the enlargement of these glands. So IÂ’m assuming Trigger is classified as having the pituitary version of CushingÂ’s? My specialist that did the ultrasound is suggesting no treatment at this time (besides the Denamarin for the liver) as the treatment really only treats the symptoms and not the actual disease. She is saying this is the very beginning of CushingÂ’s disease with Trigger. I should recheck blood work and urine tests in 2-3 months even if symptoms donÂ’t progress and base the next steps off of those numbers. She states, the average lift expectancy after being diagnosed with CushingÂ’s is 2 years. The reason it is 2 years, is because the majority of dogs that get it are senior dogs and that is about how much time they have left and that typically, they would die from old age or other complications and they donÂ’t normally die due to the sole reason of having CushingÂ’s. Does this sound accurate?

I guess my question is, how should I proceed? On a scale of 1-5 (1 being early stage and 5 being the end) where would you guys rank his journey with Cushing's based on these numbers? I have a phone meeting pending with my primary vet as well once he goes over all the numbers just to get a second opinion and to have more input. I know this is a lot to digest but any info/advice is gratefully appreciated more than I can ever express.


Update 6/2/23

It's been 4 months aka time for another blood/urine test to see how Trigger's internals are doing and how Cushing's is progressing in my boy. Here is a recap with the abnormal levels for a quick reference -

Blood test 1 in January: ALT 327, ALP 626 and GGT 24.

Ultrasound/blood test/ACTH test in February: Ultrasound - The liver is diffusely moderately enlarged and hyperechoic with smooth rounded margins. The gallbladder is unremarkable. - The adrenals are moderately generally enlarged, bilaterally, measuring 1.1 cm (left) and 1.3 cm (right) at the caudal pole; the glands exhibit otherwise unremarkable features. Mildly hyperechoic generalized hepatomegaly; bilateral mild to moderate adenomegaly. Collectively most compatible with Cushing's disease.
Mildly hyperechoic generalized hepatomegaly; bilateral mild to moderate adrenomegaly. Collectively most compatible with Cushing's disease. Cortisol pre ACTH - 6.0 , post ACTH - 33.7.

Blood test 3 in June : ALT 187, ALP 565 and GGT 18
There are some thyroid related concerns in this 3rd blood test. I will post the levels that are abnormal from this last blood test here but as a reference, I will put what those values were in [brackets] as of the 2nd blood test in February which were all within normal values.
phosphorus 6.3 [February test value 3.7], potassium 5.8 [February test value 4.7], na/k ratio 26 [31], cholesterol 463 [331], triglyceride 308 [103] and T4 .5 [1.4].

I am waiting for one more test result to come in that will provide in the vets words "will determine if Trigger's thyroid levels are something we need to treat/diagnose or his thyroid levels are abnormal due to Cushing's". I don't know the exact name of this test but my understanding is that it is just another more detailed blood test they are running but I am not 100%. A mixed bag here as to the liver values haven't changed much in 4 months which is good but either Cushing's is starting to impact his thyroid or I could have another issue on top of Cushing's. Figured I would chime in with an update on my situation.

[labblab]

Hello, and welcome to you and Trigger — we’re so glad you’ve found us! I was just poised to write a reply to you when I saw you had edited your post to add this new info gleaned from this afternoon’s conversation with your specialist:


With no tumor on the adrenal gland and with them being slightly enlarged, it was explained to me that there could possibly a tumor on the pituitary gland which is making the adrenal glands overproduce causing the enlargement of these glands. So I’m assuming Trigger is classified as having the pituitary version of Cushing’s? My specialist that did the ultrasound is suggesting no treatment at this time (besides the Denamarin for the liver) as the treatment really only treats the symptoms and not the actual disease. She is saying this is the very beginning of Cushing’s disease with Trigger. I should recheck blood work and urine tests in 2-3 months even if symptoms don’t progress and base the next steps off of those numbers. She states, the average lift expectancy after being diagnosed with Cushing’s is 2 years. The reason it is 2 years, is because the majority of dogs that get it are senior dogs and that is about how much time they have left and that typically, they would die from old age or other complications and they don’t normally die due to the sole reason of having Cushing’s. Does this sound accurate?

Yes, this info *does* sound accurate to me, and I think your specialist’s recommendation is very reasonable. Cushing’s is typically a slowly-developing disease, and as she has noted, for senior dogs who are not exhibiting uncomfortable outward symptoms or particularly worrisome lab results, treatment may be delayed or avoided altogether. For a younger dog, an important goal of treatment can be to halt or at least slow the development of ongoing systemic damage in the years ahead. But in my own opinion, immediate quality of life is of paramount importance with an older dog. Treatment necessitates ongoing vet visits and blood draws, as well as the potential for side effects from the medication. For a younger dog, or for *any* dog with uncomfortable symptoms, I believe the trade-off is worth it. But again, for an older dog who is still generally doing well, I wouldn’t rush into treatment, either.

I think it’s very good, though, that the specialist wants to keep tabs on any significant laboratory changes that might alter the future equation. It does seem interesting to me that Trigger’s liver values and cholesterol were actually lower this second lab draw. Typically over time those values consistently elevate in untreated dogs. Had he been taking the Denamarin during the interim? I know that it can indeed be beneficial to the liver. Or perhaps the labwork was performed by two different labs, and there just was a bit of variation in the results. At any rate, at least the values went down rather than up — yay!

Anyway, as I say, it sounds as though you are in good hands, and I can’t disagree with the recommendation. Please feel free to ask additional questions, though, and please do keep us updated.

Marianne

[Harley PoMMom]

Hi and welcome to you and Trigger from me as well!!

I agree with Marianne, as the goal of treatment for Cushing's is to control the symptoms of the disease. Cortisol is also a powerful anti-inflammatory hormone and since your boy does have arthritis that elevated coritsol could be helping. If the symptoms are not bothersome to you and your sweet boy, then if this were me, I wouldn't go forward with treatment right now.

Please know we will help in any way we can, and do not hesitate to ask all the questions you want.

Hugs, Lori

[Brusso89]

Marianne, thank you for the reply. The blood work was done by 2 different labs. One thing I did forget to mention and may or may not be important, is in November I started Trigger on adequan injections for his arthritis. 3 times a week for the first 2 weeks, once a week for the next month and once every other week after that. During this time is when I noticed the increased drinking. My primary vet doesn't think adequan had anything to do with it but I did see on adequans website, it states not to start injections in dogs with kidney or liver issues. Since the blood work came back with high liver counts, I chose to stop the injections until I knew more of what was going on. So maybe taking him off of that caused the liver counts to go down? The specialist didn't have an answer for that due to she wasn't too familiar with adequan. The only other difference besides different labs doing the blood work was Trigger wasn't fasted the first time and was fasted the second time. I'm interested to hear your thoughts on this.

Lori, thank you for the reply as well. I did read that about cortisol and arthritis. I had the same thoughts that a little more cortisol may not be a bad thing for him and his arthritis. His before cortisol level was a 6 which according to the test, was at the high end of normal cortisol levels. The specialist said his stress during his visit could have caused it to be a hair on the high side. Even if he was producing a level 6 before the test, wouldn't he not be to bad off in the cushings category or are those before ACTH numbers nothing to get hung up on?

[Harley PoMMom]

I assume that's Trigger as your avatar, awww, he sure is a handsome boy!!! When diagnosing and monitoring Cushing's, the "pre" isn't looked at as close as the "post" result.

[labblab]

Hi again from me, too, and I agree with Lori — I *love* your avatar photo!!! What a great shot! I also agree as to not worrying about the pre-ACTH cortisol level. From what we’ve always been told, the baseline cortisol level can be highly variable in all dogs, and stress can definitely elevate that reading even for dogs without Cushing’s. So I would not worry about it.

As for those othe lab values, I think that cholesterol is technically the only one that would likely be lowered by fasting beforehand. I don’t think that fasting is supposed to markedly affect liver enzyme readings. But perhaps the fasting did lower them a little bit. Or maybe it was just the different lab analysis. I’m afraid I don’t know enough about adequan, either, to speculate as to whether that might have had an effect. But maybe so. A couple of years ago I fell and hurt my back, and for a couple of weeks thereafter I was loading up on Tylenol. When I had my blood drawn, my ALT was higher than normal, for no apparent reason. But when I researched it myself, I found that transitory increases in ALT are initially common in people who start consistently taking Tylenol. The ALT normalizes again over time, even when the Tylenol dose remains unchanged, but apparently that initial surge is not uncommon. And in my case, the next time I had blood drawn, sure enough, it was normal again. So who knows, maybe the adequan did have that mild effect. But again, the difference was minimal, no matter what caused it. I do think, though, that it’ll be good to recheck things in a couple of months.

Marianne

[Squirt's Mom]

Hi and welcome to you and Trigger!

One thing that struck me the fact that Trigger needs help with arthritis. Cortisol is a natural anti-inflammatory and as such "treats" things like arthritis, allergies and other inflammatory conditions. Usually in cush pups we don't see any signs of those conditions until after treatment starts and the cortisol is lowered back to a more normal level. Then without that natural "treatment" those conditions come roaring to the forefront. So the fact that he needs Adequan gives me huge pause in accepting a diagnosis of Cushing's. Add that to the speed at which this came on, the heart disease already present, I would have to wait for some time before I even thought about retesting and certainly before starting treatment.

Something to keep in mind...some heart meds do not mix well with the drugs used to treat Cushing's - Vetoryl/Trilostane and Lysodren/Mitotane. So be sure to talk to the vet in depth about this IF you ever decide to treat Trigger for Cushing's.

Glad you found and hope you stick around to keep us update on his progress.
Hugs,
Leslie

[Brusso89]

Thank you both for the input and the complements. That is my boy in my picture this past summer at the lake. Believe it or not, he used to have a full brown head and face. The sugar face came with age over the past years but I like it, he looks seasoned. It will be interesting to see what the next test results show in the coming months. If it may help others, I will post some updates along the way. I feel like after doing so much research, there is no "normal" and most cases have their own unique set of circumstances. My unique set is the heart issues he has had for the last 3 years. I think I am on the team of no treatment for my situation until symptoms progress a lot more. Not sure when that can be expected, maybe in 6 months to a year? Since he already has increased thirst and full access to a doggie door (I wouldn't be able to really tell how much more he is peeing) the next most common signs to look out for would be panting and increased hunger. I live in Phoenix, AZ and the heat will be here soon enough so increased panting may not be the easiest thing to see but you bet I'll be looking extra carefully at everything involving him more than I do now (if that's possible haha). This forum has bought some good knowledge, being able to read up on other peoples experiences. I will be browsing often!

Leslie, I didn't think about it that way. I don't know how long he's had this first stage as I'm calling it of cushings. I just thought that if he wasn't over producing cortisol then how bad or worse would his arthritis pain be? I don't remember how long ago it was but in my initial research prior to posting on here, I read a thread on this website about a German shorthaired pointer having cushings. I believe someone replied saying once they treated cushings in their own dog, it revealed a severe case of arthritis because the dog couldn't walk. Took the dog off treatment and the dog was able to walk again. I'm paraphrasing but that was the short version. I believe Trigger has cushings due to the ACTH test results and due to his enlarged Adrenal glands found from the ultrasound.

[Harley PoMMom]

Could you measure how much he drinks? The normal amount of water a dog drinks is 1 ounce per pound of the dog's weight.

[Squirt's Mom]

When I was told my first cush pup, Squirt, had Cushing's I hit the internet and started studying, like you have done. In my case, it left me very confused. I joined a couple of list (EARLY social media! :D ) and they made matters worse by telling me horrible things, like I'd might as well put a bullet in her head if I followed her vet's advise. By the time I made it to my family here, I was a total mess. At that point the only test she had had done was pre-surgical lab work for a dental that showed high cortisol. After the dental we started testing in earnest. She had the ACTH, LDDS, HDDS, and UTK panel...all of which showed high cortisol and were diagnostic for Cushing's. BUT because of the people here I also knew how valuable an ultrasound could be. So before I consented to start treating I asked for the US. It saved her life. The US found a tumor on her spleen. Once that was removed her cortisol returned to normal and remained normal for several years. The stress of that tumor cause false positives on all those tests. Had I started treating based on them she probably would have died from a ruptured spleen or the treatment itself...because she did not have Cushing's at that point in spite of all those "positive" results.

My second pup diagnosed with Cushing's had a host of other health issues - COPD, chronic pneumonia, blind, anal gland disease to name a few. Her ACTH result was >50 - so high the machine couldn't read it. But in my heart of hearts I knew she didn't really have the disease but this was a repeat of Squirt's first diagnosis - a false positive. This pup had all the signs including the hallmark rat tail. Her Pom puff was nothing but bone and skin...yet I KNEW she did not have this disease. I did treat her with Lysodren for a short while and it didn't help much at all and made some things worse for her so I stopped treating her. When she passed I had a necropsy (autopsy for animals) done to try to find out why she died. That procedure proved she never had Cushing's. Her adrenal glands were perfectly normal even with all she had going on.

I share these stories with you so you know that false positives are very very easy to achieve with the tests currently available to diagnose Cushing's. None are fool proof, all are subject to false positive if any other health issue is present. In the years since I have seen dogs return a false positive who simple get very stressed going to the vet clinic.

Cortisol is a fight or flight hormone and its job is to elevate any time stress is present to help the body cope. It is the same with humans, cats, horses, etc. Cortisol has a job. The tests for Cushing's can only tell us IF the cortisol is high but not WHY. So unless there is strong evidence and plenty of signs there is no need to rush into treatment. With Trigger I would want some time to pass and just watch to see if other changes in behavior do occur or if things go back to a more normal state for him.

I currently have dog that I just knew was developing Cushing's based on his drinking, peeing, hair loss, and withdrawal. But his tests all came back normal. Our vet finally decided to treat for a rare form of diabetes that has nothing to do with blood sugar but rather with how the body processes water. This form is called Diabetes Insipidus...and my Bud has that disease instead of Cushing's. He's been on treatment for over a year now and doing quite well. He's still funny about water and I can tell the hour his medication starts to wear off but the other signs are gone. I got tunnel vision when I looked at him...Cushing's can to that to us AND to our vets. So he has been a good lesson for me as have my two girls mentioned above. I also have a Pug just diagnosed with Addison's which is the opposite of Cushing's. So my mutts are giving me a good education...not one I would have chosen but they could care less! LOL This just means mom has to devote more time to them and they love that! :D:D

You have now entered the wonderful world of "what in the devil is going on"! There is no telling what you will learn on your journey...and we will be here to learn along with you!

Hugs,
Leslie

[Brusso89]

Lori, I have just recently started keeping track of when I refill the water bowl but I do have another (a little blue tick coonhound) that drinks from the same bowl be she is not a big drinker. Trigger is 70 pounds and Jenny (the blue tick) is 50 pounds. Based on your 1 ounce per pound, that would mean they should be averaging about a gallon a day. Which is exactly what they are drinking. I'm filling up the 2 gallon jug at almost the same time every other day. I know I never used to fill it up every other day but I've never wrote it down and kept track of it like this before. It should be good to see how things progress in the coming months with keeping a log of the water.

Leslie, thank you for sharing all of that! I do think Trigger is in the beginning stage of Cushing's (if there even is stages). Obviously I hope I'm wrong and my two vets are wrong also. The ultrasound was extremely helpful in seeing what everything looked like inside of him. Yes, there very well could be something else going on in him that is disguising itself as what I'm thinking is Cushing's. The plan for now it definitely not to treat. Myself, my primary vet and the specialist all agree that the few symptoms Trigger is currently showing isn't worth any complications with treatment at this point. As long as new symptoms don't develop and his current symptoms don't get worse, I will do more bloodwork in 3 months to check on his levels and compare them with the two blood tests we did not to long ago. Then at least I will have some sample size of what is going on in a 3 month timeframe. I will post updates as they come on here. If anybody is reading this to compare to their own situation, I do think the ultrasound is a good way to go in diagnosing their pet. After the first blood test my primary vet recommended the ultrasound and to have it done through a specialist and not a standard practice vet. The reason was to make sure the liver didn't have any issues and to possibly see any tumors. He did tell me that in the event of a good ultrasound outcome, to expect to do the ACTH test after which is exactly what the specialist wanted as well.

[Harley PoMMom]

Rechecking the blood work in 3 months and then comparing, I think, is a good plan. Please do keep us updated!

Hugs, Lori

[Squirt's Mom]

I agree...I think that is an excellent plan!

HOWEVER, that does not mean you get to disappear. Oh no...you and your handsome boy are now family and we want to know how things are going. So please stay in touch when you can.

Hugs,
Leslie

[Brusso89]

I added this update to my original post but figured I would post it here too.

Update 6/2/23

It's been 4 months aka time for another blood/urine test to see how Trigger's internals are doing and how Cushing's is progressing in my boy. Here is a recap with the abnormal levels for a quick reference -

Blood test 1 in January: ALT 327, ALP 626 and GGT 24.

Ultrasound/blood test/ACTH test in February: Ultrasound - The liver is diffusely moderately enlarged and hyperechoic with smooth rounded margins. The gallbladder is unremarkable. - The adrenals are moderately generally enlarged, bilaterally, measuring 1.1 cm (left) and 1.3 cm (right) at the caudal pole; the glands exhibit otherwise unremarkable features. Mildly hyperechoic generalized hepatomegaly; bilateral mild to moderate adenomegaly. Collectively most compatible with Cushing's disease.
Mildly hyperechoic generalized hepatomegaly; bilateral mild to moderate adrenomegaly. Collectively most compatible with Cushing's disease. Cortisol pre ACTH - 6.0 , post ACTH - 33.7.

Blood test 3 in June : ALT 187, ALP 565 and GGT 18
There are some thyroid related concerns in this 3rd blood test. I will post the levels that are abnormal from this last blood test here but as a reference, I will put what those values were in [brackets] as of the 2nd blood test in February which were all within normal values.
phosphorus 6.3 [February test value 3.7], potassium 5.8 [February test value 4.7], na/k ratio 26 [31], cholesterol 463 [331], triglyceride 308 [103] and T4 .5 [1.4].

I am waiting for one more test result to come in that will provide in the vets words "will determine if Trigger's thyroid levels are something we need to treat/diagnose or his thyroid levels are abnormal due to Cushing's". I don't know the exact name of this test but my understanding is that it is just another more detailed blood test they are running but I am not 100%. A mixed bag here as to the liver values haven't changed much in 4 months which is good but either Cushing's is starting to impact his thyroid or I could have another issue on top of Cushing's. Figured I would chime in with an update on my situation.

[labblab]

So good to hear back from you, and also to learn that Trigger’s liver values have actually gone down. As far as his thyroid, I’m guessing the followup testing is a more comprehensive thyroid panel that measures several other levels beyond just the T4. If that’s the test, the combination of results can point to whether or not a thyroid deficiency appears to be an independent problem in its own right, or whether it indeed appears to be secondary to another disorder such as Cushing’s.

I believe the good news is that, even if a thyroid deficiency is independent in origin, typically it is easily treated by simply giving a daily oral thyroid supplement. So we’ll wait alongside you to hear more, but in the meantime, are very grateful for the update. Thanks for checking back in with us!

Marianne

[Squirt's Mom]

Sounds like Trigger is progressing nicely and that is always good to hear! And I agree with Marianne on the thyroid...it is easy to treat. But with a bit of luck this will turn out to be Sick Euthyroid Syndrome...the condition Marianne mention that is related to Cushing's and typically disappears as the cortisol is under control. That would mean your precious boy won't have to take another pill. It is easy to treat, yes, but fewer pills are always nice! :)

Looking forward to the next update on Trigger and hope it is as good as this one!
Hugs,
Leslie

[Brusso89]

An update along with a dosage question for Trilostane. The time has come to put Trigger on Trilostane. He had another round of bloodwork done in August and his thyroid numbers are back to normal with his new thyroid medication, His ALT is up to 220, ALP up to 741 and his GGT is actually down to 13. So far, he has only been taking a liver supplement as his only form of Cushing's treatment even though that isn't really a treatment but figured I would note that. He is still taking joint supplements and Vetmedin for his heart along with a few other health supplements and Gabapentin. The reason I was wanting to start Trilostane was due to the increase in panting, the onset of some restlessness at night and the continued increased thirst and urination. My biggest issue is the panting and the restlessness at night. The restlessness at night isn't terrible but he does get up 4 or 5 times in the night to walk around the room to find a comfy spot which lately has been on tile. The panting has me concerned. I'm in Phoenix and it has been a hot summer. We are starting to cool off at night but the panting, even after an indoor activity is increasing. I am told that even with winter coming, not to count on the outside temps to have a huge impact on his panting.

We started him on 30mg twice daily. Trigger has been on 30mg twice daily (60mg total) for 1 month. We didn't check levels at 2 weeks because he had no bad side effects and I wasn't seeing that much of a decrease in panting/restlessness/water intake. His ACTH test on 9/16, he had Trilostane at 7:30 am, his cortisol level at 11:30 was a 3 and his level at 12:30 was a 6.8.

Trigger being with the vet for that whole time was very stressful on him and when I picked him up, it seems like we took a step backwards as far as intensity of Cushing's symptoms . After 4 weeks on Trilostane(8/18-9/16) I'd say his symptoms improved about 25%. After his stressful test and up to today, I'd say we lost that 25% improvement and are back to square one with his symptoms. My vet who has been great to Trigger and I thought the test was stressful on Trigger but thought that he should be back to his 25% improved self within a few days after the test. That hasn't been the case. I had a long conversation with my vet on Friday and he wanted to try a medication to help with Triggers arthritis, thinking that may cause some of his restlessness at night. I(clearly an uneducated vet) kind of wants to up his Trilostane dosage in hopes to bring down the panting, restlessness and drinking but I understand that it can be very bad if Trigger's cortisol levels drop too much. I can tell Trigger is more aware of his old age and arthritis just how he lays down more cautiously now. I contribute that to Trilostane lowering his cortisol levels. My question to you guys who have experience with Trilostane and the ACTH testing, how do you interrupt the results? Info I find online states if his levels are 5.5 and higher, to up his dosage if symptoms are still present. That info doesn't state at what time that 5.5 level is reached. Trigger is down to a 3 for his cortisol at 4 hours post treatment, but at 5 hours post treatment he is at a 6.8. The vet is strongly against increasing the dosage saying those numbers are pretty much exactly what we could ask for, not too high and not too low. If that's the case, I'm not comfortable with the level of symptoms that Trigger is experiencing at the "ideal" cortisol range. Do I have any other options before I have to start thinking about calling it at this point?

[Harley PoMMom]

I believe the "ideal" cortisol range is where the dog is feeling well and those symptoms are not bothersome for the dog and owner, each dog is different. The first thing I would suggest is having an urine culture and sensitivity test done to rule out an UTI which will make a dog drink and urinate more. If that comes back clean than a small increase in the Trilostane is an option, maybe a 5mg increase twice a day.

Hugs, Lori

[labblab]

My question to you guys who have experience with Trilostane and the ACTH testing, how do you interrupt the results? Info I find online states if his levels are 5.5 and higher, to up his dosage if symptoms are still present. That info doesn't state at what time that 5.5 level is reached. Trigger is down to a 3 for his cortisol at 4 hours post treatment, but at 5 hours post treatment he is at a 6.8. The vet is strongly against increasing the dosage saying those numbers are pretty much exactly what we could ask for, not too high and not too low. If that's the case, I'm not comfortable with the level of symptoms that Trigger is experiencing at the "ideal" cortisol range. Do I have any other options before I have to start thinking about calling it at this point?


I join Lori — and you — in thinking that at least a small dosing increase is in order. You are correct that the monitoring guidelines recommended by Dechra, the maker of Vetoryl, state that a dosing increase is in order if the post-ACTH result is greater than 5.4 and clinical symptoms are not being controlled sufficiently. And just to clarify, it is indeed the second (or post-ACTH cortisol) reading that is being referenced. This is the reading that is taken after the ACTH stimulating agent has been injected.

I appreciate the fact that your vet doesn’t want to lower Trigger’s cortisol too far. But it seems to me that you still have a bit of room to work with in terms of trying to achieve better symptom resolution since, technically, post-ACTH levels are typically not considered to be too low unless they drop below around 2.0. (or the dog is showing outward signs of oversuppression). Since you’re giving him his trilostane twice daily, financially it may be easier to increase his dose only in the morning. For instance, if you choose to increase his daily total by 10 mg., it may be cheaper to give one extra 10 mg. each day as opposed to two 5 mg. capsules. If unequal twice daily doses are given, Dechra recommends giving the larger dose in the morning.

As you know, we are not vets either. But it does seem to me that you’re within Dechra’s guidelines if you choose to try a dosage increase. I also can’t argue, though, with your vet’s recommendation to start some arthritis medication. At Trigger’s age (and with the lowered cortisol as you rightly note), arthritic pain could indeed be contributing to his discomfort and restlessness.

I’ll close by adding a link to Dechra’s formal treatment guidelines. I’m confident you’ve already seen something similar, but the monitoring recommendations are contained in a flowchart near the end. Continued good luck to you and Trigger, and please do let us know how things are going.

https://drive.google.com/file/u/0/d/0B5RToo4GC5HPSlBUemlDZ09oejQ/view?pli=1

Marianne

[Brusso89]

Lori, you may be on to something. Now that you mention it, there are a few signs that would lead me to believe that he could have a UTI. Yesterday I had a urine test done and hopefully I'll have the results today.

Marianne, thank you for the info!
As far as me wanting to increase his Trilostane dosage, it's a relief to know I'm not crazy haha. I fully understand the risks of increasing it too much and him not being able to produce enough cortisol on his own. But on the other hand, I haven't come this far to just stop when I could be close to making him more comfortable. From my research, I get the picture that every dog reacts to the medication individually and there can be no rhyme or reason to predicting increases or decreases in relation to cortisol levels per mg or Trilostane. For example, if I added a 5mg or 10mg to Trigger in the morning, it could have zero effect on his cortisol levels or it could make a huge difference, correct? I have read a little about giving uneven doses. I'm not sure if I should start at 5mg, 10mg or greater. The ACTH test was stressful for Trigger. I didn't want to preform another one unless it was absolutely necessary. If I increase his dosage, I take it we would have to do another ACTH test within a week or two to see how his levels are correct? Again my vet has been very helpful and his willingness to communicate with me during his busy days is priceless to me. I have not flat out asked him if I was to increase Trigger's dosage against his opinion, how would that effect our relationship going forward. I have had bad experiences with vets in the past for a wide range or reasons. This vet is by far my favorite and he has gone above what I would think an average vet should do during my time with him and treating Trigger. I'm not gonna make a decision until I get the urine test back and at this point, I kind of hope Trigger has a UTI because that would give me hope to treat that in hopes of giving him more comfort vs the challenge of mixing and matching Trilostane and doing it against my vets opinion. Any words of wisdom if I do have to have that conversation with my vet?

[Harley PoMMom]

I want to make you aware that a regular urinalysis may not pick up any bacteria in a dog's urine, this is especially true when the urine is dilute like in dog's with Cushing's. In cushdogs when an UTI is suspected a urine culture and sensitivity test is preferred, this test can pick up bacteria and show exactly what bacteria is present and then the correct antibiotic can be prescribed, so if the regular urinalysis doesn't show an UTI I would recommend having the urine culture and sensitivity test done.

[Brusso89]

I just looked at my invoice from yesterday and it was a standard urinalysis that they preformed. Honestly I didn't know the difference until I read and researched your reply, thank you so much for the info. I can't change the test now but is it safe to say that a urinalysis should have just been skipped all together and started with a culture and sensitivity test to begin with?

[Harley PoMMom]

I believe when a dog has diluted urine, an urine culture and sensitivity test should be performed.

[EspressoAddict]

Lori, you may be on to something. Now that you mention it, there are a few signs that would lead me to believe that he could have a UTI. Yesterday I had a urine test done and hopefully I'll have the results today.

Marianne, thank you for the info!
As far as me wanting to increase his Trilostane dosage, it's a relief to know I'm not crazy haha. I fully understand the risks of increasing it too much and him not being able to produce enough cortisol on his own. But on the other hand, I haven't come this far to just stop when I could be close to making him more comfortable. From my research, I get the picture that every dog reacts to the medication individually and there can be no rhyme or reason to predicting increases or decreases in relation to cortisol levels per mg or Trilostane. For example, if I added a 5mg or 10mg to Trigger in the morning, it could have zero effect on his cortisol levels or it could make a huge difference, correct? I have read a little about giving uneven doses. I'm not sure if I should start at 5mg, 10mg or greater. The ACTH test was stressful for Trigger. I didn't want to preform another one unless it was absolutely necessary. If I increase his dosage, I take it we would have to do another ACTH test within a week or two to see how his levels are correct? Again my vet has been very helpful and his willingness to communicate with me during his busy days is priceless to me. I have not flat out asked him if I was to increase Trigger's dosage against his opinion, how would that effect our relationship going forward. I have had bad experiences with vets in the past for a wide range or reasons. This vet is by far my favorite and he has gone above what I would think an average vet should do during my time with him and treating Trigger. I'm not gonna make a decision until I get the urine test back and at this point, I kind of hope Trigger has a UTI because that would give me hope to treat that in hopes of giving him more comfort vs the challenge of mixing and matching Trilostane and doing it against my vets opinion. Any words of wisdom if I do have to have that conversation with my vet?

I think it's always best to be above board with your vet. We don't know for sure how they'll react as some might wash their hands off the case given that you're not listening up to the dot, but I believe most would remain helpful if things do start to go awry.