New here, Newly diagnosed. Stewie has passed

[MichelleJVM]

Hello fellow Cushingoid dog owners!

I have one main question. But thought I'd introduce myself as well. My dog 'Stewie' is newly diagnosed with cushing's (officially confirmed yesterday). This being after a long year of blood work tests, ultrasounds, food trials, supplements, medications, etc... He tested negative for cushing's just a few months ago. We decided to retest for cushings at recommendation of the ultrasoundographer. He had his first dose of Vetoryl today, just waiting to hear back from internal medicine as to whether we will be discontinuing fortekor from his medication roster.

Anyways, back to my Question. He has had a ravenous appetite for quite some time. Just this past week he has been leaving a decent portion of his meals untouched. I am curious if any others had this at the later stages of not being diagnosed yet. And if you guys would think I should have concerns about the appetite decrease involved with Vetoryl. My dog is NOT overweight by any means, and I don't really want him to loose any. Just curious what others experiences with appetite pre treatment/post treatment.

Thanks!
Michelle

[DoxieMama]

Hello Michelle and welcome to you and Stewie! A ravenous appetite is certainly a symptom of Cushings, but I don't know that having that decrease prior to starting Vetoryl happens all that often. It could be a concern once treatment has started but... without much knowledge on the subject, I don't want to lead you astray. I'm sure one of the more knowledgeable folks will be by later today to address your concerns.

How much does Stewie weigh, and what dose of Vetoryl have you started him on today?

In the meantime, we are always interested in having the full picture. Can you share with us the result of the diagnostic tests, as well as observations on the U/S? We also like to know the actual numbers of any bloodwork that is out of range, including the range (as normal ranges vary between labs).

Once again, welcome!
Shana

[Harley PoMMom]

Hi Michelle,

Welcome to you and Stewie! I am so glad you have joined our forum but sorry for the reasons that brought you to us.
Could you get copies of all tests that were done on Stewie and post those results here? In this way we can provide you with more meaningful feedback. Regarding the CBC/chemistry blood panel you need only post those values that abnormal and please include their reference ranges...thanks!

I have some questions about Stewie's Cushing's treatment and if could provide us with answers that would help us immensely. How much does Stewie weigh and what dose of Vetoryl is he taking? Dechra, the maker of Vetoryl recommends a starting dose of 1mg per pound of a dog's weight so if Stewie is receiving more than that it could explain a sudden decrease in food consumption. When is he scheduled for his next ACTH stimulation test (which is how the cortisol level is checked)? Where his adrenal glands visualized on the ultrasound and were any anomalies found with the internal organs?

Again, I am so happy you found us and we will help in any way we can.

Lori

P.S. I see that Shana were typing at the same time so please excuse my duplicate questions.

[MichelleJVM]

Thank you Shana and Lori. Lori, I'm afraid you didn't read my post thoroughly. The lack of appetite started prior to starting Vetoryl, so dosage really has absolutely nothing to do with it. I was just curious if any others had this order of events prior to treatment and whether there is a concern of even more decreased appetite after starting vetoryl.

As for results and dosages, of course I am happy to share. Although I would like to be clear I am not here to replace veterinary advice. I am not looking for dosage advice. I have done my research and am working very closely with my veterinarian for treatment.

Stewie is currently 11.8lbs, he is a dachshund cross, 9 years old.

His first ultrasound showed a gallbladder mucocele, possible nodule on adrenal gland, and thickened intestinal walls. This was near the beginning of this year. His most recent ultrasound shows bilateral enlarged adrenals.

We did a low dex test in June that was negative for cushings

Our most recent tests:

11/10/17 - Urine Cortisol/creatinine Ratio
Urine Creatinine: 2,481umol/L
Urine Cortisol: 833nmol/L
Urine Cortisol/Creatinine Ratio: 335.8
>=34 : Hyperadrenocoricism is possible, stress may affect test

11/14/17: Low Dexamethasone stim test:
Cortisol - Baseline: 301nmol/L
4hr: 116nmol/L (<50% baseline and/or <41 nmol/L is consistent with pituitary-dependent hyperadrenocorticism)
8hr: 135nmol/L (>41 nmol/L is consistent with pituitary-dependent hyperadrenocorticism and/or hyperadrenocorticism)

11/16/17: ACTH Stim
Cortisol Baseline: 397nmol/L
1hr post: >1380nmol/L

Vetoryl started on 11/16/17 @ 1.7mg/lb = 20mg once a day. No medication side affects seen to date.

[labblab]

Hello Michelle, and welcome to you and Stewie. I, too, am so glad you’ve joined us, and I thank you for all this additional information. In answer to your primary question, no, it is not common for Cushpups to exhibit a sudden loss of appetite prior to beginning treatment unless a secondary condition is flaring. Since intestinal thickening has already been noted for Stewie as well as a gallbladder mucocele, perhaps he is experiencing some type of GI distress. Have his stools remained normal throughout?

The timing of the inappetance is unfortunate, because decreases in excessive thirst and appetite are commonly used as gauges in determining dose appropriateness. So if something was already affecting Stewie’s appetite prior to beginning the Vetoryl, it will be hard to know whether additional appetite changes are the result of appropriate dosing, overdosing, or a secondary condition altogether. In this situation, you will want to monitor other behavioral markers very carefully: changes in thirst, vomiting, diarrhea, increased lethargy, etc. Our hope, of course, is that Stewie will start behaving more normally after beginning the Vetoryl, and not less.

As far as dosing recommendations, indeed we are not vets and our suggestions are merely that — suggestions. However, since our sole focus for over a decade has been canine Cushing’s, we’ve had the chance to share in many experiences and to monitor changes and innovations in treatment protocol. In 2004, my own Cushpup was a pioneer and was probably the first to be treated with trilostane in the area in which we live. At that time, the initial dosage recommendations were much higher and I shudder now to realize how much medication we were giving him. Since that time, initial dosing recommendations have consistently been scaled downward. There may be an important reason why your vet thinks that the dosing formula you are using for Stewie best fits his needs. But for the benefit of all our readers, here is a post that summarizes the rationale for the more generally accepted initial formula of 1 mg. per pound. The research noted here can be a good point of departure for discussing dosing alternatives.

http://www.k9cushings.com/forum/show...=1251#post1251

But most importantly, I surely hope that Stewie shows improvement in the coming days. We’ll be very anxious for updates, so please do let us know how things are going.
Marianne

[MichelleJVM]

Hi Marianne, thank you for sharing your thoughts. I was also wondering if it may be an underlying issue, that's a good point... His bowel movements have been normal. He has seemed to get even weaker the week or two prior to Vetoryl treatment, so that may or may not be related. I *think* he has gotten a decent amount of his appetite back, although he seems to discovered that the pills I have been giving him for the past year are not actually treats, he is turning his nose up at them now. Stewie's vet doesn't seem concerned about the lack of appetite at the moment. I am hoping that Vetoryl does the trick and gets him feeling better. I'll definitely keep you guys up to date on how he is doing. Thanks.

[labblab]

Do you guys have Stewie’s first monitoring ACTH test scheduled? You probably already know that Dechra recommends that the first test be done 10-14 days after starting treatment. Our experience here is that some vets defer the testing until around the 30-day mark, but it really should not be postponed any longer than that. Especially in Stewie’s current situation, the testing may be a better indicator of dose appropriateness than are changes in appetite and other observable behavior.

Actually, aside from hunger, can you share with us whether Stewie has exhibited any other common Cushing’s symptoms? You’ve noted the gallbladder mucocele which can indeed be associated with Cushing’s. Also, you mention that he’s been taking Fortekor: is this for high blood pressure or perhaps kidney issues? How about any observable external symptoms? I am just wondering what prompted the suspicion of Cushing’s in the first place. Thanks in advance for any additional info!

Marianne

[MichelleJVM]

We don't have the first ACTH test booked yet but I do plan to do it at the 10-14 day mark. I was trying to decipher if it mattered if it was at 10 or 14 days...

He is on ursodial for gallbladder, fortekor for protein loss, and zentonil for liver although there were no specific concerns on the ultrasound, on x-ray originally it looked slightly larger then it should be. I didn't realize gallbladder issues were associated with cushings, thanks for letting me know that!

As for symptoms, I originally brought him in knowing he needed a dental, I didn't notice at first other then him greying and not having a luscious coat, his bloodwork was off. Then I started noticing more the dry flakey skin, although he wasn't really itchy. Then the fact that he never grew hair back from the ultrasound shave or IV shave, his coat has thinned out. He has been drinking and peeing more, and in the last month or two he has had a few accidents. He has had a large appetite, I don't remember when this started or if it has just been so long it feels like its always been that way, I had him portion fed but once I knew he was loosing protein I started bumping up the food amount so he would gain some weight. His skin over the past 4-6 months has been really thin, to a point where he had 2 decently large gashes from unknown origin. He also had a few bruises also from unknown origin. Over the past 2-3 months I've noticed him tripping over his own feet more, face-planting up the back step, etc. He also licks the floor around the cats litter box like its nobodys business... (yes the litter is a safer type... I checked...)

The ultrasoundographer is the one who pushed testing for cushing's.

[MichelleJVM]

We just did Stewie's first ACTH since starting the Vetoryl. At 14 day mark. Results are as follows:

--
Cortisol - Baseline: 155 <28-120nmol/L>
Cortisol - Post ACTH: 252 <220 - 550nmol/L>

** aim for post cortisol between 60-140 for good control, alternatively, the
manufacturer suggests 250 is adequate if good clinical control
history and previous noted
--
He has not had any accidents since starting the vetoryl, although he still is drinking a fair amount. He is able to get up onto one or two things he was struggling to get onto within the previous month or so, but still has some difficulties. Appetite was wonky the week prior to vetoryl, it hasn't changed much. He still got a random bruise during vetoryl treatment. Still groans when being picked up.

His vet has opted to stay on 20mg dose for a little longer to see if it regulates with some more time.

[labblab]

Hi again, Michelle, and thanks so much for these results and the additional information. For the benefit of our U.S. readers, they convert to approximately 5.6 and 9.1 ug/dL. I totally agree with your vet’s recommendation to leave Stewie’s dose unchanged for the time being since cortisol levels often continue to drift downward during the first few weeks of treatment. By giving it a bit more time at his current dose, you’ll have a much better idea as to whether, and how much of, might be called for long term.

Continued good luck to you guys, and please keep us updated!
Marianne