Hello, I'm a newbie!

[62niffer]

I'm Jen, and Jack is our 12 YO Cattle Dog mix. He's not officially diagnosed yet, but I'm going to be surprised if he doesn't have Cushing's. He goes in for an ultrasound on Tuesday (May 23). He hasn't had an LDSS or ACTH yet. We'll discuss that after the ultrasound.

I'm looking forward to getting approved so that I can look at articles and such that unapproved members don't have access to. I'm sure there is a wealth of information here. Glad that Facebook has some support groups!

https://www.k9cushings.com/forum/album.php?albumid=1309

[labblab]

Hello Jen, and welcome to you and Jack! We’re so glad you’ve found us and we will be happy to help in any way we can. Your membership has now been fully approved so you’re free to add any posts and access all our resources. Any additional info you care to share about Jack’s overall health history will be very much appreciated as he moves forward with his testing.

Once again, welcome to our family!
Marianne

[62niffer]

Thanks! Now I have to figure out how to get his photo to appear!

[62niffer]

The info on this site says "A positive response to a dose is interpreted as improvement in clinical signs and a post-ACTH stimulated cortisol concentration between 1.45-9.1 µg/dL (40–250 nmol/L); however, experience in this group shows that most dogs are best controlled in the 2.0–5.5 µg/dL (55–152 nmol/L) range."

In our case, clinical signs have improved a lot, with a few small exceptions. Our dog still has hair loss on his tail, and the hair regrowth after his shave for the ultrasound has been slow to grow back (but is growing back). He is also more food-crazed by the time we go on our late afternoon walk (will eat whatever he can find on the ground if we aren't quick enough) and in the evenings while we eat even if he has eaten a full meal.

He gets 5 mg Vetoryl in the morning only so far (started at 10 but symptoms indicated it was too high). Last week he had a 30 (closer to 40) day ACTH test, 4 hours after his morning Vetoryl. Our IM vet suggested we consider increasing his dose, to 2X/day - either conservatively by 2 mg, or as high as 5 again (so 5/5, or 5/2) since the results showed his Cushing's was "not completely controlled". If we increase I'd definitely start at the 2 mg (obviously it would need to be compounded).

His Cortisol level from this ACTH says:
Test Results Unit
Total T4 1.6 µg/dL lowest value 1 highest value 4
Dogs with no clinical signs of hypothyroidism and results within the reference interval are likely euthyroid. Occasionally, hypothyroid dogs can have a low normal T4 (1-2 ug/dL). Hypothyroidism may be further assessed in these dogs by adding a free T4 and canine TSH. For dogs on thyroid supplement, recommended therapeutic levels are 2.1-5.4 ug/dL. If this sample was drawn 4-6 hours post-pill in a dog on thyroid supplement, a low normal T4 suggests inadequate supplementation.
Cortisol 2.5 µg/dL lowest value 2 highest value 6

1) Is the Total T4 what we’re looking at, or the Cortisol of 2.5 at the bottom? How is this interpreted then? Is the value too low? OK? Not accurate because of how we tested? It has been suggested that we do the Pre-Vetoryl Testing instead of 4 Hr post, but I’m not sure if our IM vet does this. is the test we did is basically invalid, as someone suggested? I’m having a hard time understanding all of this. (Our vet has tons of canine Cushing’s experience.)

2) If the value is OK, I don’t want to increase the dose just because of the skinnier tail. As to the eating behavior, I’d like to look at other ways to address this if the value is OK. Melatonin? Keeping the 5 mg Vetoryl with 2x/day split dose? 3 smaller meals a day?

I’d love to hear thoughts from moderators especially.

Thanks!

[62niffer]

Additional question: the lab report also indicated that his ALT and ALP and blood lipids have increased (high now) compared with his tests in May. The vet said that this also indicated not completely controlled Cushing's. Do these numbers tend to go down with successful Vetoryl treatment? Could the numbers be higher now due to "not fully controlled cushing's" or likely due to something else?

Thanks again!

[labblab]

Hi Jen, and welcome back to you and Jack! You’ll see that I’ve merged your new thread into your original introductory thread. This way, we’ll be able to keep all of Jack’s history consolidated in one single thread and timeline.

You’ve asked a few different questions today, and I’m going to try to answer a couple tonight and then leave at least one until tomorrow (it’s getting close to my bedtime ;-).

The one I’m leaving until tomorrow relates to the T4 test result. This is a test of thyroid function, and not cortisol. So that one I’ll wait and address later on.

Turning to cortisol monitoring, it looks to me as though your vet simply tested Jack’s resting, or “baseline” cortisol level. The accompanying lab range is just the standard for what the resting cortisol level should be for a normal dog (non-Cushpup).


Cortisol 2.5 µg/dL lowest value 2 highest value 6

An actual ACTH stimulation test involves *two* blood draws taken 4-6 hours after Vetoryl dosing. First, a baseline cortisol level is taken. Then a stimulating agent is injected, and a second cortisol level is drawn one hour later. It is that second, post-stimulation level that is being referenced in the quote you cited:


The info on this site says "A positive response to a dose is interpreted as improvement in clinical signs and a post-ACTH stimulated cortisol concentration between 1.45-9.1 µg/dL (40–250 nmol/L); however, experience in this group shows that most dogs are best controlled in the 2.0–5.5 µg/dL (55–152 nmol/L) range.

If your vet is checking Jack’s baseline cortisol alone, then the only recommended monitoring test of baseline cortisol with which I’m familiar is the pre-Vetoryl test. This involves checking the baseline cortisol immediately *before* dosing with Vetoryl, not four hours later. Through the years, researchers have tried to establish dosing norms for baseline cortisol levels checked at other times of the day. But aside from the pre-Vetoryl protocol, baseline cortisols alone do not seem to have valid assessment value in terms of Vetoryl dosing. I should amend that by saying that I believe that randomly taken baseline cortisol levels can help establish that cortisol is not being driven too low by the Vetoryl. But I don’t believe they can accurately identify whether doses should be increased. So if your vet is indeed relying on a single baseline cortisol draw, it should be done right before the Vetoryl is given (and interpreted according to a specific monitoring protocol).

As far as the increasing elevations in the ALT, ALP and cholesterol, yes, that could be a result of cortisol that remains higher than desired. Those elevations may never completely return to normal in a Cushpup, but you do hope to see them decline once the cortisol level has been lowered to a more desirable range.

I’ll go ahead and close for now, but as I say, I’ll add some more thoughts tomorrow.

Marianne

[labblab]

Total T4 1.6 µg/dL lowest value 1 highest value 4
Dogs with no clinical signs of hypothyroidism and results within the reference interval are likely euthyroid. Occasionally, hypothyroid dogs can have a low normal T4 (1-2 ug/dL). Hypothyroidism may be further assessed in these dogs by adding a free T4 and canine TSH. For dogs on thyroid supplement, recommended therapeutic levels are 2.1-5.4 ug/dL. If this sample was drawn 4-6 hours post-pill in a dog on thyroid supplement, a low normal T4 suggests inadequate supplementation.

OK, I’m back again this morning to talk a bit more about the thyroid testing. It looks as though Jack’s T4 level falls at the low end of the normal range. Low thyroid levels can be responsible for many symptoms that overlap with Cushing’s such as thinning coat, flaky skin, and general lethargy. However, hypothyroidism can be a tricky problem to diagnose alongside Cushing’s, because low thyroid readings can be secondary to the Cushing’s itself. When low thyroid readings are secondary to some other condition, this is referred to as “euthyroid,” and the low thyroid readings may automatically improve once the underlying condition is treated effectively. However, some Cushpups also suffer from hypothyroidism in it’s own right and require daily medication to supplement their low thyroid levels. A more complete thyroid panel can help distinguish whether a low T4 is a primary problem that requires medication, or whether it’s a secondary problem that will likely end up resolving on its own. Is Jack currently taking any thyroid supplementation?

And finally, circling back to the Vetoryl…if it seems as though Jack’s symptoms such as excessive hunger tend to rebound later in the day, then twice daily dosing may well be an option. However, before increasing his dose either once or twice daily, I’d want to make sure that an accurate monitoring test has been performed. And that would require either a full ACTH stimulation test (two blood draws also involving the injection of a stimulating agent 4-6 hours after dosing), or a single baseline cortisol sample taken right before the Vetoryl is administered.

I think the reasoning behind the pre-Vetoryl testing is to see how high the cortisol has elevated once again at the end of the dosing period. Since Vetoryl is typically *most* active in the body for a period of less than a full 24 hours, the need for a dosing increase can be better judged by seeing how high the cortisol has gotten right before the next dose would be given. At four hours *post* trilostane, your vet is measuring Jack’s cortisol right when the medication is most active and Jack’s cortisol is theoretically at its lowest. The good news is that, at 2.5, his cortisol is not being pushed too low by the Vetoryl. But that level of control may only last for a few hours. That’s why you want to see how high his cortisol rebounds as the day wears on prior to making a decision regarding the appropriateness of a dosing increase.

Marianne

[Harley PoMMom]

I really believe that a full ACTH stimulation test is warranted to see exactly where he's cortisol is at. Was Jack diagnosed with the pituitary or adrenal form of Cushing's? Also, what were the findings of his ultrasound?

Hugs, Lori

[62niffer]

https://www.k9cushings.com/forum/member.php?13-labblab: Thanks so much for the very clear explanation. You explain things really well. Now I need to figure out how to bring some of this stuff up with our vet without offending her. She's been a good vet.

https://www.k9cushings.com/forum/member.php?89-Harley-PoMMom, he has pituitary cushing's. This was his 30 day check. I hate to think we threw away the $ to do a test that didn't measure what we wanted to. I'd be inclined to do the pre-vetoryl test but I may need to find a new vet if our IM vet doesn't do this for some reason.

For now, we've started him on a divided dose with no increase to see how he does in the evenings. Tonight we're having salmon which is so enticing to him that all bets are off ;)

[labblab]

You are very welcome, Jen! And in honesty, I don’t see why your vet would have a problem with checking Jack’s cortisol before his Vetoryl dose rather than afterwards. It’s the same test, but just different timing. And if you’re giving Jack his Vetoryl twice daily, I’d think the test could be run before either the morning or evening dose. Hopefully Jack could be seen at the clinic either right when they open or right before they close. FYI, here’s a link to the monitoring chart to be used with pre-Vetoryl dosing:

https://www.k9cushings.com/forum/attachment.php?attachmentid=8772&d=1659215520

I’m hoping your vet may actually appreciate getting this information — fingers crossed!

And I sure understand the temptation of salmon. I love it myself ;-)))))

Marianne

[Squirt's Mom]

I agree with Lori concerning the cortisol test. I would stick with the full ACTH for now. Others have explained how that works so I won't repeat. It is important to pay attention to the span of time used for the first ACTH and try to maintain that spread. For example, if the first ACTH was done 4 hours after taking the pill (which is optimal) then all following ACTHs should be done at the 4 hour mark. This gives a more consistent pattern over time.

From what I have seen, the Pre-Vetoryl test does better with dogs that are started out that way OR that are proven to be under good control via the ACTH before the switch. The pre test is NOT good for dogs who are anxious at the vet clinic or simply have a high strung personality. Here is a link to a good explanation of the pre test -

https://www.animalhospitalofwarwick.com/sites/site-4183/images/Vetoryl%20Monitoring%20Protocol.pdf

I also agree with the twice a day dosing based on the change in behaviors later in the day. And a SMALL increase is in order. The only way to get say a dose of 8mg is to use a compounded drug called Trilostane - this is the active ingredient in Vetoryl. But no all vets are open to compounded meds so you would need to discuss this with her. Bare in mind... not all compounding pharmacies are equal. One I feel comfortable recommending is CareFirst. Here is a link about them you can check out and share with her vet -

https://www.cfspharmacy.pharmacy/

All the things you are asking about - liver enzymes, increases in signs, slow hair regrowth - are all signs that the cortisol is still too high. And sadly melatonin, lignans, etc. will do nothing to help the corisol level. As an herbal medicine maker and user I wish with all my might I could tell people to take such-n-such herbal formula and their baby would be just great. But that is simply not the case in spite of all you may have been told contrary. If it were true, I would be on a rooftop somewhere shouting at the top of my lungs about the GOOD NEWS FOR CUSHING'S DOGS. ;):D I will tell you that the combination of melatonin and lignans can work in a complimentary way with Vetoryl. Excess cortisol usually causes other hormones to elevate too. These are called the intermediate, or sex, hormones. Melatonin and lignans COMBINED can lower those other hormones a bit. If you want to use these get the plain melatonin not extended, time released, etc. or melatonin with _________. Just melatonin only - 3mg. You have a choice of lignans - from flax (SDG) or from spruce (HMR). Both work but some dogs do better with one or the other. I used the SDG with my Squirt. We lost control when we switched to the HMR but the HMR works great for others.

You're doing a good job!
Hugs,
Leslie

[62niffer]

On the first day of splitting his dose, he was great. Even with the salmon temptation. He was able to settle down after he ate and didn't harangue us as much as usual while we ate.

Yesterday with less temptation (well, in MY opinion - but it WAS pizza so maybe not his!) he was more keyed up. Some of this is likely behavioral, or it might even be he's not getting quite enough to fill him up by the time he's done with dinner.

Thanks for the link!