New Member-Cushings treatment side effects ~ Emmy has passed

[nrgrose]

Hello-

I apologize in advance for the lengthy post, as I am a new member and have alot going on with my dog. Emmy is an almost 10 year old (we think as she is a rescue) rat terrier who weighs about 16 lbs. She was diagnosed with Cushings in April by a LDDS test. Since the test results were not typical but technically a positive result (3.2 micrograms baseline, .3 micrograms 4-hr and 2.2 micrograms 8-hr), the vet consulted with the internist at the lab who recommended she investigate kidney disease (low urine specific gravity, elevated BUN, and increased creatinine and SDMA) before starting treatment with Vetoryl. She had been taking Galliprant for suspected hip arthritis and it was suggested that, even though Galliprant doesn’t typically affect kidneys, it is possible. The vet suggested a 2-week washout period without Galliprant and to retest urine, BUN and creatinine. We retested those and there was no improvement. The vet recommended we still proceed with treating the Cushings because she shows multiple symptoms (increased thirst/urination, excessive appetite, panting, pot belly, hyperkeratosis on nose). In consult with the internist at the lab, they started her on 5mg Vetoryl once/day. Three weeks later she had an ACTH Stim test and her baseline was 1.5, and the post sample was 9.0. We noticed no improvement in her symptoms. The vet gave us the option of continuing on 5mg for another month to see if symptoms improve, give her 5mg twice a day, or give her 10 mg once daily. After doing extensive research, we decided to give her the 10mg since our vet said a majority of dogs do well on single dosing and the 10mg is still well below the initial starting dose suggested by Dechra. She told us what to watch for regarding an Addisonian crisis. We are doing another ACTH Stim test on Tuesday.

Fast forward exactly two weeks after we increased the dose, Emmy started limping on her right leg. She had issues one or two times in the past (before she was diagnosed but after she showed some Cushings symptoms) when she overdid it on a walk, limped around that evening, but stopped limping the next day. 3 days later, in the morning, she started limping again and panting. She tried to lay down but immediately got up and couldn’t get comfortable. She couldn’t sit either. She tried to sit then would pop back up. She was putting her weight on her left side and she was almost falling over. I gave her Galliprant and she eventually was able to lay down after about an hour. The next morning was more of the same, except she was limping on her front legs. She also tripped and fell into her water dish. I took videos and sent to the vet and she is very concerned about a spinal/neurological problem that is seemingly progressing rapidly. She said it is possible that the reduced cortisol in her system is “unmasking” other conditions. She had a spinal x-ray in April which appeared normal. We agreed to the neurologist consult, but can’t get in for almost 2 more weeks.

In the meantime, we are very concerned about Emmy. We’ve given the Galliprant on an empty stomach (per manufacturers instructions) and the past two days she’s struggled to eat breakfast. She’s also panting in the house. Before she began treatment, she’d only pant outside on a mild day after starting a walk, in a car or when she was nervous (vet office). She never panted inside. She’s also very warm and her ears are hot. I don’t think she’s in an Addisonian crisis as she is not vomiting, still eats and isn’t totally lethargic (she is sleeping for longer periods since she’s been on Vetoryl). Has anyone had their dog’s underlying conditions manifest themselves on Vetoryl? I think the panting may be a result of increased pain from arthritis or a spinal condition, but am curious if anyone has seen Cushings symptoms get worse after treatment. Also hoping that the appetite issues are due to the Galliprant upsetting an empty stomach, which will go away if we give with food. I have reached out to the vet about these questions, but am curious about others’ experiences. When the vet mentioned neurological concerns, I saw earlier posts on this forum about macroadenomas, but don’t know if that’s applicable since she’s been on a very low dose of Vetoryl for less than 2 months. We are going to wait until the neurology consult, but I am concerned we may have to choose between treating the Cushings and her physical comfort. Thanks in advance for any insights you can provide.

[labblab]

Hello and welcome to you and Emmy, although I'm so sorry your sweet girl is doing poorly right now. I'll have time to write more later, but wanted to cut right to the chase -- I'd stop giving the Vetoryl and try to arrange for a cortisol test now rather than waiting. All of your vet's observations and recommendations make sense to me, including the possibilties that the Vetoryl is unmasking arthritic pain or that a neurological problem may be revealing itself. But whenever a dog becomes unwell while taking Vetoryl, we've been told that the possibility of low cortisol is the most immediate and serious risk. Even if Emmy isn't exhibiting all the symptoms of a full-blown Addisonian crisis, she is clearly unwell and she could deteriorate quickly if low cortisol or electrolyte imbalances are the issue. Vetoryl has the ability to lower aldosterone as well as cortisol, and aldosterone is the adrenal hormone that maintains the balance of sodium and potassium in the body. So if a dog becomes visibly unwell while taking Vetoryl, both the cortisol level and also a basic blood chemistry panel should be checked. And under these circumstances, if a full ACTH isn't do-able, even just a resting cortisol level can reassure you that her cortisol is not too low.

I know it may feel like you'll be taking backward steps if you discontinue the Vetoryl right now, but I do believe it's much better to be safer than sorry. You can always restart it again if her cortiol and chemistries are OK. I'm hoping that your vet will give similar advice right now.

I'll go ahead and quickly post this, and then come back later on to talk about the other possibilities. My beloved Cushpup was one who suffered from what we assume was an enlarging macroadenoma, and both my other non-Cushpups had orthopedic issues that raised a lot of question marks for us, as well. So I'll look forward to talking with you more. But for right now, I wanted to share my thoughts about stopping the Vetoryl.

Marianne

[nrgrose]

Thank you very much Marianne. Emmy was very reluctant to eat dinner (but eventually did with some coaxing and hand feeding), so we don’t think Galliprant is the issue since she had it 13 hours earlier. I described the symptoms she’s been having the past few days (limping, very reluctant to eat but eventually does, drinking more, panting and sleeping for several hours during the daytime in one position), and the vet was concerned. She said that the Vetoryl should be making her feel better, not worse. She said that an Addisonian crisis since typically happens a few days after beginning treatment (rather than 2+ weeks) so she’s not sure if that’s what is going on. To be safe, she told us to stop the Vetoryl for a few days and see how she responds. She also said to reduce her dosage of Galliprant to see if that helps her appetite (by easing stomach upset) and see if that controls her symptoms. When asked if she’s heard of cases where Cushings symptoms increase after starting Vetoryl, she said she’s only seen that in adrenal dependent cases, and the LDDS test indicated she was pituitary dependent. She offered to do an ultrasound to check for an adrenal tumor but we’re not sure that’s necessary given the LDDS test results.

[labblab]

I’m very relieved to hear that your vet agrees about stopping the Vetoryl for now. Out of the many Cushpups who have come to us over the years being treated with Vetoryl, it has actually not been all that unusual for us to see dogs who have required dosage breaks or decreases at almost any point in time. Sometimes it is even months after starting treatment. Especially when treatment is first begun or a dose is increased, though, we’ve been told that cortisol levels can continue to drift downward for a full month, even when the dose remains constant. So all in all, it wouldn’t be surprising to me if Emmy’s cortisol level has dropped lower than you’d like since you are only five weeks into treatment overall, and two weeks from doubling her dose.

Having said all that, adrenal oversuppression may have nothing to do with her behavior right now. But if she doesn’t show pretty quick improvement, I’d still encourage checking her cortsol level and basic blood chemistries. When adrenal function is oversuppressed, some dogs need to receive temporary supplemental steroids to replace what the body is not producing naturally, or fluids to remedy electrolyte imbalances.

I surely do hope that she’ll quickly feel better, though, no matter what is ailing her! Please do keep us updated.

Marianne

[Joan2517]

My Gable had to take a break many times during our battle with Cushing's. Stopping doesn't hurt them, but continuing the meds can. He started, I think, at 40mg, and eventually wound up at 5mg for the last few years before he died of what they think was an acute attack of pancreatitis.

Joan

[nrgrose]

Since Emmy was still hesitant to eat, drinking more and somewhat lethargic, the vet wanted to check her electrolytes to rule out an Addisonian crisis. Her electrolytes were “perfect”, and she had a sodium/potassium ratio of 30, and the vet said under 25 indicates an Addisonian crisis. She also did a brief physical exam in the waiting room and couldn’t find anything amiss. After observing her and after the test results came in, she said she was confident that Emmy was not having an Addisonian crisis. This morning, we gave her the whole Galliprant with food. My husband took her for a walk and she moved well. She got a little tired so he cut the walk short. She came home and slept for several hours. When she got up, she went outside (did both) and came in. She suddenly started limping on her left leg (it has been her right). Both back legs then started wobbling, and they stopped working temporary (she had to scoot her back legs). She was panting, trying to walk around the house, and would attempt to lay down and would shoot back up. It was horrible. I emailed the vet and sent her videos (she told me to email her with any new developments). I hadn’t heard back so I emailed them to the emergency vet, which is the same office where the neurologist is located. A nurse reviewed and said as long as she is eating, drinking, walking and able to go to the bathroom, then I didn’t need to bring her in. She said I could if I wanted to, and the ER doctor would determine if her condition warrants being “bumped up” in priority for the neurologist on Monday (right now the soonest I can get in is the 25th). She slept for a few hours after that episode, and when she got up, she was able to walk, pee, eat and drink. I’m waiting to hear back from her regular vet to see if she thinks I should take her to the ER, or if she agrees with the ER nurse’s assessment. She seems to do this without warning. However, both really bad episodes she The waiting is the worst!

[nrgrose]

Thank you Joan. I’m just baffled as to why she took a turn for the worse after 2 weeks on the increased dose. The dose she was on was lower that the lowest starting dose recommended by the manufacturer, and we did see improvement in her Cushings symptoms. Pure conjecture on my part, but I’m guessing that, since the vet ruled out an Addisonian crisis, that the issue is not an overdose of Vetoryl per se, but the uncovering of a spinal condition that was kept in check by excess cortisol, and is now inflamed with the cortisol reduction. However, we won’t know more until the 25th, which seems like an eternity. We go back to her regular vet on Tuesday to discuss how to proceed with restarting the Vetoryl. She has suggested that if the 10mg all at once caused problems, that we may try 5mg twice daily. Have you (or any others) had experience with twice day dosing (good or bad)?

[Joan2517]

We tried Gable on twice a day, but it was still too much. I think that some dogs must be highly sensitive to the drug. He also was on thyroid medication the first time he crashed, which they thought was what happened, but even after we lowered the Thyroid meds he never was able to handle more than 5mg a day after that.

[nrgrose]

Thank you Joan. Emmy has a vet appointment on Tuesday to discuss dosing changes. She spent 3 weeks on the 5mg once daily and we noticed no improvement. Perhaps we didn’t give it long enough, and that is something we’ll definitely discuss. I would prefer to keep her on 5mg only, given what is going on with her spine, but we’ll see what the neurologist says.

[Joan2517]

Have you done another cortisol test? I would not change the dose until one is done to see what her numbers are. Even 5mg can be too much for a dog who is sensitive to the drug.

[nrgrose]

Just wanted to give an update. Sadly, we had to let Emmy go Monday night. She had another neurological episode on Sunday evening and lost function of her back legs. We took her to the ER and when she arrived she was completely unable to walk and was drooling excessively. She was immediately admitted and they gave her anti-nausea medication (said excessive drooling was due to extreme nausea) and wanted to run additional tests. She had a painful abdomen and an ultrasound revealed a gallbladder mucocele, but they weren’t sure if this was causing the nausea issues. Bloodwork was normal except for kidney values which were even higher than before we started Vetoryl, and high blood glucose. Her urinalysis also showed a elevated glucose. The ER doc on intake thought it looked like intervertebral disc disease (herniated disc), but said she was going to push for the neurology consult in the morning (we were scheduled for one on June 25). In the morning she was still unable to walk, and around lunchtime the neurologist examined her. She was completely paralyzed in her back legs and had no reflexes. Her front legs still had reflexes but showed signs of neurological damage. She also had no pain reflexes. What concerned the neurologist the most was that she was severely obtunded. I had never heard this term before, but it means she was completely oblivious to her surroundings-she slept through the entire examination. Because of the severe obtundation, the neurologist’s primary preliminary diagnosis was a malignant neoplasm in the brain that may or may not have metastasized to her spinal cord. The secondary was meningeloencephalitis. She said a herniated disc was extremely unlikely and her prognosis was grave. She said she needed an MRI to confirm the diagnosis, and if no tumor was found, she’d need a spinal tap. She would have to undergo general anesthesia for this. I never got to speak directly to the neurologist, but spoke with the ER doc on duty who spoke to the neurologist. She said that a brain tumor may or may not be treatable, and the meningeloencephalitis is treatable, but they could not guarantee she’d ever regain function in her legs. She also said she would still have the other conditions (Cushings, kidney failure and likely diabetes). We wanted to speak to her primary care vet for her opinion but she was out Monday. We spoke to two ER vets who said the MRI would be very hard on her (she may not even survive the anesthesia), and it would be of no use to her-it would tell us what was wrong but wouldn’t change the outcome. She was never going to have a good quality of life in their opinion and that we should let her go. We had pretty much decided that evening to end her suffering, but we wanted to see her for ourselves. She was really bad. The ER vet described her condition as “almost comatose” and that there were no drugs in her system that caused her to act that way. We knew immediately we had to let her go, and she died peacefully Monday night.

The next morning, I received a call from her primary care vet. She got the lab reports and knew she had died. She had not yet received the neurologist report. I filled her in and she was shocked and she said she just saw her Friday and she was acting normally. She did say that symptoms of neurological diseases are notorious for coming on fast and strong. She said we 100% did the right thing and that she would have done the same thing has it been her dog. This makes us feel better since she had treated Emmy for years. We are comfortable with our decision, but are struggling to make sense of it all-what/how/why this happened and why it came on so suddenly. And of course, we are feeling guilty that there was something different we could’ve done to result in a better outcome (did giving her Vetoryl cause the brain tumor to manifest itself, or would they have been able to do something if we had brought her in sooner for tests). The two ER vets didn’t think Vetoryl had anything to do with this, and that there was nothing we could’ve done differently. When asked what happened to her, one ER vet’s explanation was that dogs are experts at hiding diseases, and that, unlike humans, dogs can adapt to diseases for a long time, until they can adapt no more. She thinks that is what happened here. They may be right, but I would feel better if the neurologist said all of this as well. The primary care vet is going to consult with the neurologist (who incidentally was her neurology professor in veterinary school), and will try to get more detail. Hopefully we can get some additional information that will help us make sense of it all.

Needless to say, my husband and I are totally devastated. We thought worse case scenario was a herniated disc. A malignant brain tumor was never on our radar. For the first time in 15 years we are without a dog, and we are lost (we had to euthanize our other dog in January who suffered from severe arthritis and advanced canine cognitive disorder). We want to thank everyone on this forum who gave advice on Emmy’s behalf. We really do appreciate it.

Nicole

[Harley PoMMom]

Dearest Nicole,

I am so sorry for your loss, losing our precious furbaby is indeed very heartbreaking and we understand the pain you are feeling. My heart goes out to you and your husband, I wish so much that there was some way that I could ease your pain right now. If you would ever need a comforting shoulder or support, please do come back and talk to us.

I have added Emmy to our "In Loving Memory" forum and if you want, we would be honored if you would want to provide us with a photo which we can link to her memorial line.

If you have an album you can upload it to there and then we can copy the photo, or you can email it to us at k9cushings@gmail.com.

Again, I am so very, very sorry.

Love and hugs, Lori

[labblab]

Dear Nicole, I’m so saddened to read this news. I’m sure it was a very painful note for you to write, so we’re deeply grateful to you for letting us know what’s happened. Under the circumstances, there is absolutely no doubt in my mind as to your decision having been the merciful final gift to your sweet girl. But now you’re left with the pain and the questions, and that is just so very hard. I wish there was some way we could relieve you of at least some of that burden. But since we probably can’t do that directly, please know that we’ll always be here if you want to talk things over or share any special memories as you navigate the days ahead yourself.

After so many years of love and companionship, the empty and quiet house must feel so hard to bear. I’ll be lighting a candle tonight for your dear Emmy. And I’ll be holding you and your husband in my heart as well.

Sending my sympathy and many hugs to you from across the miles,
Marianne

[medusa]

Your baby left this world surrounded by so much love and care, I wish I had the right words to comfort you.
Deepest sympathies, Ι am so sorry for you loss.

[Joan2517]

I am so, so sorry for your loss.