Recent diagnosis; lab test recheck and dosage change

[TheBean]

Hi. I am a new member and my little guy Bean was diagnosed with cushings about 2 months ago. I am thankful to have found this group as this is our first experience with this disease. I know what an excellent resource a group like this can be for those struggling with the myriad of issues that arise in connection with a complicated illness like Cushings.
We recently had our 3rd stim test (stats & results posted below) and his numbers were "high" pre cortisol test, and "low" post cortisol test. He has recently been exhibiting a bit of an increase in some of his clinical symptoms (which had previously been decreasing on vetoryl) including hunger, thirst, anxiety. He had a bout of vomiting for a few days a couple weeks ago and the vetoryl was stopped for 2 days and then resumed without further vomiting.
There was discussion of adding an additional afternoon dose of 5 mg vetoryl to his current 10 mg dose he takes in the morning. Or adding an additional 10 mg dose in the afternoon. Absent clinical signs, there was discussion there would be no change to the dosage.
Since we have been noticing clinical signs over the past couple weeks we are wondering if anyone else who has been thru this type of scenario might comment on things we should be discussing and thinking about.
Thank you for any input - really appreciate it!
Age: 8 yrs
Weight: 7 lb 5 oz (3.35 kg)


DATE: PRE CORT / 1 HR CORT

10/31/23: 8.98 ug/dL / 55.7 ug/dL
Multiple clinical symptoms
(Initial diagnosis; started on 10mg Vetoryl 1x per day)

11/17/23 : 3.91 / 11.9
Clinical symptoms improving; No change to dosage

1/4/2024 : 6.97 / 6.22
Clinical symptoms starting to return

Update on 1/9/2024: medication change: vetoryl dosage increase to 10 mg in the a.m. plus 5 mg in the p.m.

2/9/2024: ACTH stim retest after dosage adjustment last month:
"Pre Cort: 6.47 ug/dL range: 1.0-5.0
1 Hr. Cort: 7.5 ug/dL range: 7.8-19.7
Pre-trilostane Cortisol Concentration
> 5 ug/dL (> 140 nmol/L)
Post-ACTH Cortisol Concentration
1.8 – 9.1 ug/dL (50 – 250 nmol/L)

[Harley PoMMom]

Hi and welcome to you and Bean!

I have manually approved your membership so now all your posts will be seen right away. Also, please just disregard the validation email that was sent to you from k9cushings.

Unfortunately there is tweaking that needs to be done with Vetoryl, getting that dosage strength correct can be challenging but it looks like you are on the right path. The vomiting episode is concerning, it could be that the Vetoryl is upsetting Bean's stomach so I would ask the vet if Pepcid AC could be added. How is Bean eating? Is the Vetoryl being given with a meal? Any diarrhea?

The therapeutic reference ranges for a dog being treated with Vetoryl are 1.45 ug/dl - 5.4 ug/dl and as high as 9.1 ug/dl if clinical symptoms are resolved. So, with Bean's last ACTH post of 6.22 ug/dl along with symptoms rebounding, adding 5 mg of Vetoryl in the evening could be an option.

Are Bean's ACTH stimulation monitoring tests being performed 4-6 hours after the Vetoryl is given with a meal? Does Bean have any other health issues? Is Bean taking any other medications?

Sorry for all those questions but the more we know about precious Bean the better our feedback will be....thanks! Again, welcome to the forum and know we will help in any way we can.

Hugs, Lori

[TheBean]

. Thank you so much for your response. We have a call in to the vet and should hear back within a few hours. Love all the questions and I will answer below. Questions are good as they help us focus on certain things amidst the many questions swirling in our heads.

We use the pepcid (2.5 mg) PRN - when we hear his tummy gurgling we know it's a pepcid night). Vetoryl is given with meal. His appetite is good (currently too hungry but hopefully an increased vetoryl dose will help with that). Poops are perfect, no diarrhea, (although he has recently taken an unusual interest in eating them which the vet thinks may be due to a new probiotic we started which we have now stopped using). The vomiting occurred 2 days in a row about 4 hrs after breakfast/vetoryl dosage. After discontinuing for 2 days we had no further vomiting when resumed vetoryl. It was suggested we freeze his vetoryl before giving him his dose which we also did with a few doses. Now back to room temp dosing and tummy seems back to normal with just occassional grumble-tummies in the evening.

Stim tests have been done 4-6 hrs after vetoryl given with a meal. No other health issues of significance (luxating patellas, old fractures and wound scarring from injuries he had before we adopted him 7 yrs ago). Only other meds he takes are Pepcid (PRN), probiotic (currently stopped). We also are considering melatonin and fish oil but have not started either yet.

Thank you again for your input. Love to talk about the Bean - he's our little man!

[Harley PoMMom]

Is the Vetoryl a liquid suspension? And if so, could you post the dosage amount, as an example 2mg/ml? I've never heard of freezing Vetoryl, did the vet contact Dechra, the makers of Vetoryl, to make sure this could be done? If not, you can and here is their contact info: "Please contact Dechra's 24-hour Veterinary Technical Support Team at support@dechra.com or 866-933-2472. One of Dechra’s best resources is our highly trained Veterinary Technical Support Team." This info was taken directly from their website here: https://www.dechra-us.com/contact/inquiry-form

[TheBean]

Not a suspension, just a 10 mg capsule. Thank u for the dechra info. They only had us do that for a couple days a few weeks ago, after vomiting incidents, stopping for 2 days, and then resuming vetoryl. No longer an issue, but know now to double check. Thx!

[judymaggie]

Hi! I wanted to add my welcome to you and Bean. As I am sure you have realized already, the Admins have a wealth of knowledge and experience. When working with my first two Cushing's pups, I relied on them heavily. I often came here to discuss my vet's recommendations and my vet learned that he could actually have discussions with me about treatment rather than me blindly following his treatment plan. He came to respect my research. I now have my third Cushing's pup and a new vet after moving so am back here again. I am looking forward to learning more about Bean!

[TheBean]

Thank you! We are looking forward to the wealth of knowledge and experience here on this forum!

[Squirt's Mom]

Just wanted to welcome you and your sweet Bean to our little family here at K9C. Lori has done an excellent job as always so I don't have anything to add at the moment other than the welcome! Looking forward to learning more about you and your Bean as time passes.

Hugs,
Leslie

[TheBean]

Thank you. The Bean is now on 10 mg vetoryl inthe a.m. and 5 mg. in the pm. He has been on the new dosage for about 10 days now and his symptoms that had returned are starting to get better. However he does struggle with late afternoon/early evening anxiety. I am wondering about people's experience with using melatonin for their cushings dogs. And/or adaptil phermone sprays? He is doing well otherwise. He's due for another stim test in about 2 weeks.
Thank you!
Ps. I'm guessing i should start a separate thread for that question :)

[Squirt's Mom]

Nah, we like to keep everything in one thread.

[Squirt's Mom]

Plain melatonin is fine for our cush pups (NOT diabetic dogs tho) but I would double check with the vet first. He's a little young for dementia to be starting but anxiety is not uncommon at all as they start to age into the senior years. I would talk to the vet about this possibility as well. My little Tilly had to have some help starting a few years back as she developed separation anxiety which has worsened over the years sadly. I now have a carry bag that goes over my shoulder so I can carry her around with me. Yes, I am well trained! LOL

Hugs,
Leslie

[TheBean]

Thank u! Good to know others have tried melatoninwith cushings. Bean's vet has said he could take up to 1/2 mg melatonin in the evening (7.5 lb dog) on anxious days. We are thinking its more cushings related than dementia as he seems anxious about food and water even if he's just eaten on these anxiety occasions - its not over the top anxiety or daily, it's just on an occasional basis. When it happens he's hyped up and stands and barks incessantly, then runs back & forth to food/water bowls. The vet just tweaked his vetoryl dosage recently so hopefully once he's on correct dose we can get a better handle on the occasional anxiety. The phermone spray works well at settling him so he can go to sleep later in the evening whenthis happens. We haven't tried melatonin yet. I guess we're just looking for anecdotal feedback on melatonin and phermone sprays. Thank you so much for your input.

[TheBean]

Is there any resource or even an anecdotal thread on eye conditions and cushings disease? The Bean had a series of corneal issues and dry eye just before his cushings diagnosis and we are curious if the vetoryl and getting his cushings symptoms under control might also possible resolve his dry eye. We have already noted a significant improvement in his eyes since starting the vetoryl. Thank you!

[labblab]

Hello and welcome to you and Bean from me, too! I see I hadn’t had the chance to write to you before this, but I’m so glad that you’ve heard from other folks :-). I’m also glad to hear that you’re now seeing improvement in his eye symptoms. Whether or not his eye problems have been Cushing’s related, I’m afraid I don’t know. Those are not symptoms about which I’ve ever heard a connection. But if you’re seeing improvement now, that’s a gift whether or not there’s genuinely any relationship with his treatment.

I’ll be hoping that you’ll keep seeing improvement in all his symptoms! We’re so glad you’re here, and please keep us updated.

Marianne

[Squirt's Mom]

Hi,

I was surprised to learn a few years ago that Cushing's can impact the eyes. Here are some links that offer information in the avenue:

https://www.dvm360.com/view/ocular-manifestations-systemic-disease-when-eye-not-primary-disease-proceedings

https://pubmed.ncbi.nlm.nih.gov/21575979/

https://veterinaryvisioncenter.com/cholesterol-related-eye-conditions-in-dogs/


And then there is SARDS - Sudden Acquired Retinal Degeneration Syndrome.
"Dogs with SARDS appear to go blind very quickly. Some owners report periods where their dog still appears to have some small degree of vision, but most dogs seem to be completely blind.
...
In some cases, dogs with SARDS have a history of clinical signs consistent with Cushing’s disease. These signs include increased thirst, urination, and appetite, excessive panting, weight gain or obesity, and lethargy. It is unknown whether Cushing’s contributes to SARDS or whether this association is coincidental. There may also be an association between SARDS and liver disease, though this is also unconfirmed."
https://vcahospitals.com/know-your-pet/sudden-acquired-retinal-degeneration-syndrome-sards

I hope this helps and that lowering the cortisol will have a beneficial impact on The Bean!
Hugs,
Leslie

[TheBean]

Thank you for this info. It was very interesting and helpful. ��

[TheBean]

Good afternoon.
We had a question regarding the bean and whether any additional blood work should be checked now that he has been on the trilostane Treatment for six months. Other than his initial bloodwork back in October 2023, he has had 4 ACTH stim tests (Results of which are all in my first post) and no other testing. If he should be having some additional bloodwork, what would be the normal blood work values that would be tested so that I can have an informed conversation with my veterinarian about next steps. He is due for another ACTH stim test in about 10 days.
His symptoms have not resolved although some are improved and some are new (like itchy skin). Thank youfor any info or links you might have. Advice always welcomed!
His last acth test was 2/9/24 - results copied below:

2/9/2024: ACTH stim retest after dosage adjustment last month:
"Pre Cort: 6.47 ug/dL range: 1.0-5.0
1 Hr. Cort: 7.5 ug/dL range: 7.8-19.7
Pre-trilostane Cortisol Concentration
> 5 ug/dL (> 140 nmol/L)
Post-ACTH Cortisol Concentration
1.8 – 9.1 ug/dL (50 – 250 nmol/L)

[labblab]

Hello and welcome back to you and Bean! As far as additional bloodwork, we’ve been told it is always a good idea to have a basic blood chemistry panel performed alongside monitoring ACTH tests for dogs taking Vetoryl. This is because, in addition to lowering cortisol, Vetoryl can also lower the production of another adrenal hormone named aldosterone. Aldosterone controls the balance of sodium and potassium in the body. If the aldosterone level gets too out of whack, then the sodium/potassium balance can be thrown off as well. This can cause Addisonian problems. So it’s a good idea to run a basic blood chemistry panel that includes sodium and potassium.

As far as Bean’s February ACTH results, I believe this was after you had increased his dose to 10 mg. in the morning and 5 mg. in the evening. If next week’s results are similar, I do believe you could consider increasing his dose again since he still suffers from some unresolved symptoms.

The desired therapeutic post-ACTh reference range for a dog being treated with Vetoryl is 1.45 ug/dl - 5.4 ug/dl, going as high as 9.1 ug/dl if clinical symptoms are resolved. The range that’s listed on your labsheet is the diagnostic range that’s given for a normal dog without the disease. So in Bean’s case, the goal is different than the numbers on that sheet, and another dosing increase may be reasonable if he’s still having symptoms and his cortisol level remains at the level that it was back in February.

Definitely let us know what you find out next week, OK?
Marianne

[TheBean]

Thanks so much Marianne. That is very helpful. As much as I try to read everything I can on cushings, it is somewhat confusing at times regarding these details. Thank you for taking the time to respond and help!

[TheBean]

The Bean had his bloodwork and I am attaching the results. The chemistry looks out of normal range in several areas. Hematology- less things appear out of normal range. It's still greek to me, and is frustrating as I struggle to help the Bean. As I learn more about cushings, I hope to be able to better understand and recognize what things are most important to understanding this disease and the impacts it (or the trilostane) may be having on his health and well-being. Thanks for your continued input as we move forward. Attaching the bloodwork once i figure out how to upload photos. The ACTH is scheduled for next week. Have a good weekend. And thank you.

Lab results:
https://www.k9cushings.com/forum/attachment.php?attachmentid=8868&d=1714193223
https://www.k9cushings.com/forum/attachment.php?attachmentid=8871&d=1714195705
https://www.k9cushings.com/forum/attachment.php?attachmentid=8869&d=1714195277

[labblab]

Thank you so much for giving us all these test results! I apologize that I haven’t yet had the chance to look things over in detail. But I’m having some extensive yard work done this week and my mind is swimming with all the decisions. I’m cringing right now as I see the crew digging trenches through my nest of underground cables — hopefully I’ll still have live internet by the end of the day………………

Anyway, I *will* return, but in the meantime wanted to thank you for giving us this info.

Marianne

[Harley PoMMom]

Some thing's that stick out to me are that his creatinine and phosphorus levels are elevated, these are indicators of kidney issues, I would suggest having a SDMA test done to see how the kidneys are functioning. Also, his WBC (white blood count) is slightly elevated which means that an infection may be brewing, for this I would advise having a urine culture and sensitivity test performed to see if an UTI is present. Cushdogs are prone to UTI's (urinary tract infection) which will cause a dog to urinate and drink more water than normal.

Hugs, Lori

[TheBean]

We finally recieved the Bean's ACTH recheck results from a week ago. Here are numbers and recommendations. As a little wee-tot At just 7 lbs, it's worrisome his trilostane needs increasing again.
_______
"Test
Results
12.1ug/dL (1-5 reference range) 17.4ug/dL (7.8-19.7referencerange)

Comments: Since his clinical signs are still somewhat present, our internal medicine specialist recommend at these values we go upto10mgtwiceaday. Pleaseletusknowwhenyouneedmoremedications.
Please make a recheck appointment. 8 weeks to recheck ACTH Stimulation to see if further adjustment is needed."
_______
After 2 urinalysis which apparently were too dilute due to his excessive drinking, he was put on clavamox for a suspected silent UTI based on his bloodwork, creatin and bun ratios. They suggested a renal food to supplement, but when inchecked its fat ratios the renal food was over 25% fat on a DM basis. We finally got his stomach woes resuolved by getting rid of high fat so we're still looking at the food issues (vet aware of this).

We've also added lignans once a day (vet okayed) hoping that helps, after changing his diet to a lower fat food (we were shocked to learn the pet food label as to fat content is completely misleading until you do the full math on a dry matter basis).

Is it accurate what i've read that cushings dogs have great difficulty processing fat? Is there a thread listing different foods people have tried with their Cush pups that work well? Is there a thread about experiences people have had with lignans and their cush dogs?

Thank you for your thoughts, comments, ideas, concerns :) Support groups are great for this type of thing and you all are so knowledgeable it gives me confidence as we work thru his difficulties with Cush.

Ps. Not sure its relevant, but Other meds he is on due to his continuing eye problems and a new injury: metacam liquid for recent eye injury pain (should be finished tomorrow), cyclosporin for dry eye, tobramycin drop for recent eye injury while traveling.

[Squirt's Mom]

Did they run the SDMA? This is a great fairly new test that lets us know much sooner if kidneys are compromised than BUN and CREAT can. If that was not done, I would insist it be done asap so you know the status of the kidneys.

I am also a tad bit concerned about the timing of the ACTH. IF there is a UTI present, that can easily skew the ACTH toward a false positive...meaning those high readings could be due to the UTI and not Cushing's IF the UTI is present. If he has strong signs again then I'd be less concerned but that isn't clear to me from your post. "Somewhat present" is kinda scary. LOL

Also IF he continues treatment for Cushing's, his first test is in 2 weeks, NOT 8 weeks. :eek: The testing schedule is very strict for Vetoryl/Trilostane for very good reasons....to lower the risk of the cortisol going too low, which is life-threatening. High cortisol can be lived with for quite some time in most cases but low cortisol is an emergency situation. His first test will be in 2 weeks, the next two weeks later (30 days after starting), the next in 30 days. IF all is well at that point, he will be tested every 90 days. Once the pup is settled it isn't quite so bad to let a little time pass between ACTHs IF the parents are well educated on what to look for but never, never in the beginning of treatment. And this restart is considered the beginning of treatment. ;)

Lignans are part of the treatment combination for Atypical Cushing's in which the cortisol is normal but 2 or more of the intermediate, or sex, hormones are elevated. So it won't help the Cushing's if the cortisol is elevated. The combination is lignans and melatonin. Lignans are high in fiber so watch for diarrhea.

There really isn't a diet for cush pups. What ever they were eating before is fine UNLESS something new like kidney disease, IBD, diabetes, etc. comes along that do require dietary changes. I started home cooking for my first cush pup and have continued to do so for most of my babies since, sick or not. If you would like to try this, I recommend Jody Zesko with Spot On Nutrition. I've used her for my babies in the past with satisfaction.

I don't see any issues with the other meds other than the Metacam (because it's hard on the liver) but that's a short term usage so no biggie. Long term could be a problem but short term is fine.

Hope this helps!
Hugs,
Leslie

[TheBean]

Thank you for this wealth of information. I will inquire about the SDMA. I don't know if this was done. He has finished his 2 weeks of clavamox for the suspected silent UTI and there was improvement after starting it in his overall demeanor and frequency/urgency of urinating. If the are kidneys are compromised is a recommended treatment a change in diet? The vet has susggested incorporating a prescription renal diet food into his feeding regime.
His increased cushings symptoms at the time of the acth test were increased water consumption and urination, increased food obsession, increased anxiety. He also was exhibiting some further weakness in his rear legs with some intermittent minor leg trembling. These symptoms continue although there has been marked improvement in his peeing urgency/frequency which might be? attributable to the clavamox. He's drinking alot, but able to "hold it" better.
I will follow up with the vet on retesting earlier than 8 weeks. They re-tested 3 weeks out after his last vetoryl increase. We have been traveling and are not increasing his dose while we are all on the road.
I guess now we are wondering if he needs an increase in dosage at all if his last stim test results might have been off due to a uti? They tested 2 urine samples but both were "too dilute" and the one they cultured out didnt grow anything. They said there seemend to be an infection somewhere based on his blood test, and the clavamox seemed to make some difference. Is water intake and food obsession and anxiety the right symptoms to look for? Otherwise he's pretty much a happy go lucky kinda guy. Not the sickly miserable fellow he was before we started vetoryl.
Thank you again so much for the advice of this group. It helps us better understand what to do best for the Bean. It is such a relief to be able to talk to people going thru this and who have the experience of having gone thru it. My heartfelt thanks to you all.

[Harley PoMMom]

I would definitely have the SDMA test performed to check kidney function, and if the kidneys are compromised, unfortunately Vetoryl isn't recommended in dogs with renal issues.

A change in diet is very important with renal impairment, blood pressure should be checked too.

Hugs, Lori

[TheBean]

Got it. Very helpful to know. Thnak you.