New Member - Kyro

[kyro]

Hi Everyone!

My name is Colbe and my wife and I have a 11 and a half year old Pomeranian named Kyro. We have had Kyro since he was just over 2 months old. He is our world. A couple of years ago, Kyro was diagnosed with Degenerative Mitral Valve Disease. When we heard this, we immediately changed his diet to home cooked, started adding some more holistic remedies to help slow the progress of the disease and he also began medications prescribed by our vet. We have been working with a clinic out in Japan to have the Mitral Valve Repair surgery performed on Kyro.

We had everything scheduled to leave out on May 27th and for his procedure to be on June 3rd. He needed to have some final tests done before we left and his blood work came back that he had high ALK Phosphatase and we needed to perform a Dex Suppression test to see if he had Cushings Disease. We had the test performed on May 13th and his results came back at 10.1 when he arrived, 2.2 at the 4 hour mark and 4.2 at the 8 hour mark. They are saying his results are consistent with pituitary-dependent Cushings disease. We reached out to the clinic in Japan and they told us that they are unable to perform the procedure until the Cushings disease is under control. This put us in a difficult decision. We obviously want to get his Mitral Valve disease taken care of as soon as possible since he is getting later into the disease, but of course what they recommended is Vetoryl (Trilostane) to take care of it. He is already on Enalapril, Furosemide, Spironolactone, and Vetmedin for his Mitral Valve. I have been looking at more holistic treatments such as melatonin, lignans, phosphatidylserine, liver support, etc. but a lot of the items for these I have been seeing have had mixed reviews of working and not working. I asked the vet if he was able to try these, but they said they do not think it would have the same effect as the medication would. They also said since there are no real guidelines the holistic way, they would be no real help in making potential adjustments or anything like that. We decided to put him on Vetoryl (Trilostane) and he is on 5mg morning and night, so 10 mg each day. He sits around 13-14 pounds, so we wanted to start off with the lowest dose possible. He is on a plethera of holistic items and I just added SDG lignans, melatonin, and phosphatidylserine last week. He is on about his 11th day of Vetoryl (Trilostane) and we have his check in test scheduled for next Thursday. Has anyone had any success with Vetoryl (Trilostane) as well as adding some holistic items alongside of it? Would anyone recommend other ones besides the SDG lignans, melatonin, and phosphatidylserine? Should I be considering something to help with his liver and kidneys as well?

Thank you!

- Colbe

[labblab]

Hello and welcome to you and sweet Kyro! I’ll come back later to add a more thorough reply, but I quickly wanted to let you know that your membership has been fully approved, so you won’t need to bother responding to a confirmatory email request should you receive one.

We’re so glad you’ve joined us, and I look forward to talking with you more!

Marianne

[Harley PoMMom]

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

Although the Low dose dexamethasone suppression (LDDS) test is the "gold standard" test to perform for Cushing's its drawback is that it can result in a false positive when a non-adrenal illness is present. Since Kyro has Degenerative Mitral Valve Disease, I'm a bit concerned with the Cushing's diagnosis. Dogs with Cushing's generally have clinical symptoms such as a ravenous appetite along with increased drinking and urinating. Does Kyro have any of those symptoms?

Also, could you post the results of his bloodwork, we just need to see those values that are abnormal with the reference ranges and units of measurement, as an example: ALT 150 UL (20-50)....thanks!

Hugs, Lori

[kyro]

Hi Lori! Thank you for replying.

I was actually thinking the same thing. To my wife and I, he never had any tell-tell signs of Cushings. The only thing that seemed remotely close to a diagnosis of that is he does seem like he was always hungry, but he has been that way ever since he was young. He does have some missing fur on his lower back, we thought this was due to shaving his fur so short all the time since he gets pretty hot. His first coat of fur grows, but not his second in that area. The reason why the Cardiology clinic had us perform the Dex Test was one, if he in fact did have Cushings, there is a big risk of blood clots and respiratory failure for the Mitral Valve procedure. Two, they said he should due to the missing fur on his lower back, his pot bellied appearance and high ALK Phosphatase. He never drinks tons of water, he doesn't urinate all the time, everything is normal that way. I have seen though that Cushings makes excess heat in the body and I know he does for sure run hot. Like right now he is pretty fluffy and he can never get comfortable. The only time he usually sleeps in one spot is when he is pretty shaved down.

I have also heard that one of the medications he is taking - Spironolactone could cause some issues on cortisol levels as well. So I am just not sure.

I can definitely add the blood work and everything else from his last exam last month as well as his Dex Test. If you can't seem them on the post, I have added an album on my profile as well.

I also added a photo showing his missing fur on his lower back.

Here is everything he is on and what he eats.

Holistic Items Added into his Meal

Canine Heart Formula - FiveLeaf (https://www.caninehearthealth.com/shop/CHT.html)
Hawthorne - FiveLeaf (https://www.caninehearthealth.com/shop/HAW.html)
Carnitine + Taurine - FiveLeaf (https://www.caninehearthealth.com/shop/CTCHH.html)
Dandelion - FiveLeaf (https://www.caninehearthealth.com/shop/DANDELION.html)
Dog Greens - FiveLeaf (https://www.caninehearthealth.com/shop/DogGreens-CHH.html)
Seaweed Calcium - FiveLeaf (https://www.caninehearthealth.com/shop/CALCIUM.html)
Power Probiotic - AskAriel (https://www.askariel.com/pet-probiotics-p/81.htm)
Resveratrol - Ask Ariel (https://www.askariel.com/resveratrol-for-dogs-p/149.htm)
Happy Paws - Ask Ariel (https://www.askariel.com/product-p/175.htm)
Lypozyme - AskAriel (https://www.askariel.com/LypoZyme-digestive-enzymes-for-pets-p/116.htm)
Canine Cushing's Support - AskAriel (https://www.askariel.com/phosphatidylserine-for-dogs-with-cushings-p/126.htm)
Melatonin - 3mg every 12 hours
SDG Lignans - 15mg every day

Staples Everyday

Grass Fed Ground Beef, either 90/10 or 93/7 - 2oz (https://www.walmart.com/ip/Marketside-Organic-Grass-Fed-Ground-Beef-93-Lean-7-Fat-1-lb/133893542)
Earth's Best Pureed Organic Carrots - 1oz (https://www.earthsbest.com/products/carrots-baby-puree-jarred)
Pureed Organic Sweet Potato - 1oz
Organic Ginger Juice - 0.2oz (https://gingerpeople.com/products/organic-ginger-juice/)
Organic Pure Beet Juice - 0.4oz (https://lakewoodorganic.com/products/lakewood-organic-pure-beet-juice-32-ounce-pack-of-6)
Pureed Organic Cucumber & Parsley - 0.4oz

Occasional Add-ins
Natures Best Pureed Organic Peas - 0.5oz (https://www.earthsbest.com/products/peas-baby-puree-jarred)
Shredded Plain Pork - 0.5oz (https://shop.sprouts.com/product/23204?retailer_id=279)
Grass Fed Ground Beef, 93/7 but cooked and sprinkled on top of food - 0.5oz (https://www.walmart.com/ip/Marketside-Organic-Grass-Fed-Ground-Beef-93-Lean-7-Fat-1-lb/133893542)

Eats Throughout the Day
Earth's Best Organic Sunny Days Fruit Bar - 1/2 a bar usually a day (https://www.earthsbest.com/products/strawberry-sunny-days-snack-bars)
Organic Teether Crackers - usually 1 package if that (https://www.happyfamilyorganics.com/shop/products/baby/strawberry-beet-amaranth-teething-cracker/)

Medications
Enalapril - 5 mg, 1/2 every 12 hours
Furosemide - 20mg, 1/2 Tablet every 12 hours
Spironolactone - 25mg, 1/4 Tablet every 12 hours
Vetmedin - 1.25mg / 1 1/2 Tablets every 12 hours
Vetoryl (Trilostane) - 5mg / 1 Capsule every 12 hours

Please let me know if you need anything else from me!

Thank you so much.

- Colbe

https://ibb.co/n771PzN
https://ibb.co/1QPzC9t
https://ibb.co/mNBG2tT
https://ibb.co/86zZtmD
https://ibb.co/7NwcjyX
https://ibb.co/7n75BcC
https://ibb.co/WV81x90
https://ibb.co/z460bFX
https://ibb.co/hHz0hjX

[kyro]

Thank you, Marianne! I appreciate it.

[labblab]

Hello again, Colbe, and thanks so much for all this wealth of testing information. As is the case for both you and Lori, I've also had questions in my mind about the validity of the Cushing's diagnosis based upon the LDDS results since that test can be skewed significantly by other nonadrenal illness. However, now upon reviewing all of Kyro's labwork and reading about some possible related outward symptoms, I'm more accepting that Cushing's may indeed be in play. And if so, I do understand why there is concern about increased risks of blood clots and respiratory issues. It also looks to me as though he may be exhibiting increased protein loss through his urine, and if so, Cushing's could be the cause of related kidney changes as well. Additionally, his platelets are mildly elevated which is also common with Cushing's. And I've also now learned what "fibrinogen" measures -- I was totally unfamiliar with that lab value. But apparently elevated fibrinogen can be associated with a higher risk of abnormal clotting, which may add to the concern about trying to initiate treatment designed to lower clotting risks.

So all in all, I think I now better understand the cardiac crew's concern about taking action to lower Kyro's circulating cortisol level prior to surgery. I so wish there was truly a definitive test for Cushing's that could put all our minds at ease as to whether or not any given pup is truly afflicted. But as I say, thanks to all the info you've given us, I have a better appreciation for Cobe's entire medical picture.

If we do go ahead and assume that the Cushing's diagnosis is accurate, here are a couple of my own thoughts and concerns. First of all, please know that I am not a vet and have had no related professional training. But based upon my own experiences and those of our members here, I'll offer these observations. First, I doubt that Kyro is probably benefiting from the melatonin and lignans, at least in the short run. Those two supplements likely offer the greatest benefit to dogs who are suffering from elevations in adrenal hormone levels *other than* cortisol (often associated with a diagnosis of "Atypical Cushings"), and can take months to produce changes. Any effect they might have on cortisol is probably minimal, and would be far outstripped by the Vetoryl. So I doubt there would be much benefit in Kyro's case, and any time you are introducing additional variables you are risking the potential for unwanted side effects or drug interactions. In that same vein, I am unfamiliar with AskAriel's Canine Cushing's Support. But if it's main goal is also to lower cortisol, you've already got that covered, undoubtedly far more effectively, by the Vetoryl. Through the years, we've had lots of folks here who have hoped that the use of supplements can ease Cushing's symptoms and forestall prescription treatment. But truly, I am unaware of any nonprescription supplement that has the same capacity to lower cortisol as does either Vetoryl or the older alternative prescription treatment, Lysodren. So if I were to once again have a dog who is suffering from Cushing's, I'd go straight to the treatments that have been proven to lower cortisol effectively through controlled clinical trials.

However, in relation to the Vetoryl and possible negative interactions, I do have a concern in connection with some of Kyro's other prescription medications. I see that he is also taking Enalapril and Spironolactone, and there are specific warnings about combining those classes of medication alongside Vetoryl. Here's a quote from the manfacturer's U.S. product insert for Vetoryl:


Angiotensin converting enzyme (ACE) inhibitors should be used with caution with VETORYL Capsules, as both drugs have aldosteronelowering effects which may be additive, impairing the patient’s ability to maintain normal electrolytes, blood volume and renal perfusion.
Potassium sparing diuretics (e.g. spironolactone) should not be used with VETORYL Capsules as both drugs have the potential to inhibit
aldosterone, increasing the likelihood of hyperkalemia.

I have to assume that your vets are aware of these warnings, but still, this is something I would want to clarify with them. We know that disturbing the balance of potassium and sodium in the body can have grave consequences, I would think especially for a cardiac patient. So I'd want to make sure that your vets believe that any additional risks to Kyro can be dealt with.

OK, I'm gonna stop here for right now. But please continue to ask any questions. And your pictures of Kyro are sooooooooooooo sweet!! Thanks so much for sharing them, and him, with us. We'll surely be hoping for a positive result moving forward.

Marianne

[kyro]

Hi Marianne,

Thank you so much for your thorough reply back to me. It is very appreciated! A few weeks ago my wife and I were stuck on we should do as far as the Vetoryl. We did know about the possible interactions with the Enalapril and Spironolactone, which is a big reason we were so hesitant. We were also hesitant due to having him on so many medications. He is 11 and a half, so we didn't want to put too much on his body and I did see that the Vetoryl could be harder on older dogs. He is getting in the later parts of the Mitral Valve Disease, so we are basically trying to get his Chushings under control as fast as possible to make sure we can get him the Mitral Valve Disease procedure. We will go ahead and continue the Vetoryl and see what happens. He does have a checkup on Thursday to see how his levels look as well as go over his kidney values and electrolytes due to the Enalapril and Spironolactone. I will let you know how that goes. I am not sure 10mg a day was enough for him, but I did see to usually start off with the lowest dosage first. So what does this mean then? Will he need to be on this medication forever now? We are getting it at Costco, but it is $49 every 2 weeks. He also has all of his other heart medications. Do you think his fur would start growing again on his lower back? It is weird it is not completely bald, his first coat is grown in, but his second more fluffy coat isn't. I saw melatonin could be a huge help in growing his fur back so I was hoping that would help.

[kyro]

Hi all, just checking back in with you. Kyro went in for his checkup after being on Vetoryl for about 17 days at 5mg every 12 hours. His kidney and electrolyte values came back good, but his results were still high. His first reading was 6.8 and his second reading was 10.1. i assume he is just on too low of a dosage. He got his breakfast with the 5mg at 9:33AM and had his first test at 12:04PM. I know I have seen 4-6 hours after or 2-4 hours after so not sure if that did much for the test results. The vet basically said though she is not wanting to up the dosage any higher due to the heart medications he is on. She referred us to an Internal Medicine provider and we have an appointment set for 07/16. Since that is nearly a month away, does anyone have any suggestions what we do from here? Just stick with the 5mg every 12 hours until we see them? If someone could help also answer the questions I had in my last post, that would be super helpful.

I have also added Kyro's new results on his profile.

Thank you so much!

- Colbe

[labblab]

Hi again, Colbe! I’m not seeing the new test results in Kyro’s album, so perhaps that photo hasn’t yet been successfully uploaded. But based on the info you’ve given us in your reply, I actually think that things sound pretty good. That’s great that his kidney and electrolyte results are normal. And his cortisol level actually isn’t all that bad, either, after only 17 days of treatment. We’ve been told that cortisol levels can continue to drift downward during the first month of treatment, even when the dose remains unchanged. It’s largely the second of the two ACTH readings that we’re most focused on, and as long as you end up seeing symptom improvement, a reading of around 9 can be considered an acceptable target goal for many dogs. So Kyro’s reading of 10.1 is not that far above the upper reach of the desired therapeutic range, and as I say, his cortisol may still lower further during the next few weeks.

I realize that given Kyro’s other issues, the vets may still hope to see even lower cortisol readings for him. But especially given the risk of the drug interactions, I’d definitely stick with your vet’s advice and leave his Vetoryl dose unchanged until you’ve had the chance for your specialty consultation. Given the circumstances, I think you guys are actually in pretty good shape!

As far as the fur regrowth, that is one of the symptoms that can take the longest time to resolve even when cortisol levels are ideal. It may even take a few months as opposed to weeks. And anecdotally, we’ve been told that the nature of the regrown fur may be a little different. My own Cushpup was a Lab, and he had lost a lot of fur on his haunches prior to treatment. After we started the trilostane, I was worried because it seemed as though his fur was even worse — he started shedding huge tufts. But I was told this was the result of the regeneration of a healthy fur growth cycle. And sure enough, there was new little baby fur growing in where the old fur was shedding. Since Labs are double-coated dogs, too, it took quite a while for his bad spots to really fill in. But over time, they did. So don’t give up hope! Once again, I’m not sure whether the melatonin will give you added benefit since my understanding is that it is primarily the lowering of the cortisol that rejuvenates the fur growth. But if Kyro tolerates the melatonin with no problem, then I guess you really have nothing to lose.

Thank you so much for your continued updates. Please give Kyro a big pat for me!
Marianne

[labblab]

Also, I just re-read your earlier post and see that you are wondering whether Kyro will need to always remain on the Vetoryl. Sadly for your finances, the answer is yes. It’s such a shame that it’s such an expensive medication without any generic alternatives. If cost becomes prohibitive over time, compounded trilostane could be an option. But for right now, when so much is riding on gaining effective and consistent control of his cortisol, I’d stick with the Vetoryl if he were mine.

[kyro]

Hi Marianne,

Thank you for getting back to me!

When you say his results are't looking too bad I am a little confused. His first test results showed numbers of 10.1 when he arrived, 2.2 at the 4 hour mark and then 4.2 at the 8 hour mark. Now his new results were 6.8 when he arrived and then 10.1 an hour later. We were told his numbers needed to be below 1.4. Is this incorrect? I was thinking we were way off on getting things controlled but you are saying a possible acceptable number could be around 9. Is it because they were 2 different tests potentially?

I apologize on the photos for the test results, you should be able to see them now!

[labblab]

Yes indeed, I can now see the new results -- thanks so much!

And yes, I believe we're talking about results from two entirely different tests, and that explains the discrepancy in the desired numbers. Your printed lab results are a bit odd, in that multiple cortisol levels are given but without any label as to the overall test that was being performed. So I'm making certain assumptions based upon our typical experience here.

Cortisol levels taken at baseline, then four hours later, and then eight hours later typically correspond with a specific type of diagnostic test: the Low Dose Dexamethasone Suppression Test (or LDDS). With this test, a baseline cortisol is first measured, and then the two subsequent levels are taken after a dose of dexamethasone has been administered. With this test, a dog without Cushing's should register a value less than 1.4 ug/dL at the 8-hour mark. If the cortisol level is higher than that, it means that the dog's adrenal function is so "overactive" that it has broken through the suppressive effect, and that result is consistent with Cushing's. Furthermore, depending upon the pattern of both the 4-hour and 8-hour results, you can draw conclusions as to whether the dog likely suffers from a pituitary rather than an adrenal tumor. In Kyro's case, his results were indeed consistent with the pituitary form of the disease.

Now, moving forward, a different test is used for monitoring treatment: the ACTH stimulation test. This test involves first taking a resting cortisol level, then injecting a *stimulating* agent and then testing the cortisol once again an hour later. FYI, the ACTH can also be used for diagnostic purposes, too, in addition to the LDDS. But the LDDS is solely designed to be a diagnostic test, whereas the ACTH is also used for monitoring treatment. So from this point onward, it will be the ACTH that will be given to monitor Kyro's response to the Vetoryl.

The norms that you are looking for are totally different for the two tests. In addition to the fact that your printed labsheets don't specify the types of test that were given, they also only give the normal baseline cortisol range for a dog who doesn't have Cushing's for every single cortisol level that was tested. And that is odd, for the reasons I gave above: the normal or desired testing ranges vary dramatically for the different cortisol levels taken on these two specific tests.

However, assuming I'm correct that the results on your labsheets were indeed for, first, a diagnostic LDDS test and then secondly, for a monitoring ACTH test, I'm going to give you a link to a technical brochure published by Dechra, the maker of Vetoryl. You'll see there the desired monitoring ACTH cortisol range for a dog being treated with Vetoryl. And that's where the upper limit of approx. 9 ug/dL on the post-ACTH reading comes in. Let me know if you have trouble downloading this brochure, because there are tons of other places where this same info is provided. I just like this particular link because it includes the U.S. Product Insert for Vetoryl, brief descriptions of the tests, as well as the monitoring ACTH flowchart. So do look this over, and then we can talk over any further questions.

https://www.dechra.us/Files/Files/SupportMaterialDownloads/us/US-046-TEC.pdf

Marianne