Seeking advice - 12 year old German shorthaired pointer

[Brusso89]

Lori, I have just recently started keeping track of when I refill the water bowl but I do have another (a little blue tick coonhound) that drinks from the same bowl be she is not a big drinker. Trigger is 70 pounds and Jenny (the blue tick) is 50 pounds. Based on your 1 ounce per pound, that would mean they should be averaging about a gallon a day. Which is exactly what they are drinking. I'm filling up the 2 gallon jug at almost the same time every other day. I know I never used to fill it up every other day but I've never wrote it down and kept track of it like this before. It should be good to see how things progress in the coming months with keeping a log of the water.

Leslie, thank you for sharing all of that! I do think Trigger is in the beginning stage of Cushing's (if there even is stages). Obviously I hope I'm wrong and my two vets are wrong also. The ultrasound was extremely helpful in seeing what everything looked like inside of him. Yes, there very well could be something else going on in him that is disguising itself as what I'm thinking is Cushing's. The plan for now it definitely not to treat. Myself, my primary vet and the specialist all agree that the few symptoms Trigger is currently showing isn't worth any complications with treatment at this point. As long as new symptoms don't develop and his current symptoms don't get worse, I will do more bloodwork in 3 months to check on his levels and compare them with the two blood tests we did not to long ago. Then at least I will have some sample size of what is going on in a 3 month timeframe. I will post updates as they come on here. If anybody is reading this to compare to their own situation, I do think the ultrasound is a good way to go in diagnosing their pet. After the first blood test my primary vet recommended the ultrasound and to have it done through a specialist and not a standard practice vet. The reason was to make sure the liver didn't have any issues and to possibly see any tumors. He did tell me that in the event of a good ultrasound outcome, to expect to do the ACTH test after which is exactly what the specialist wanted as well.

[Harley PoMMom]

Rechecking the blood work in 3 months and then comparing, I think, is a good plan. Please do keep us updated!

Hugs, Lori

[Squirt's Mom]

I agree...I think that is an excellent plan!

HOWEVER, that does not mean you get to disappear. Oh no...you and your handsome boy are now family and we want to know how things are going. So please stay in touch when you can.

Hugs,
Leslie

[Brusso89]

I added this update to my original post but figured I would post it here too.

Update 6/2/23

It's been 4 months aka time for another blood/urine test to see how Trigger's internals are doing and how Cushing's is progressing in my boy. Here is a recap with the abnormal levels for a quick reference -

Blood test 1 in January: ALT 327, ALP 626 and GGT 24.

Ultrasound/blood test/ACTH test in February: Ultrasound - The liver is diffusely moderately enlarged and hyperechoic with smooth rounded margins. The gallbladder is unremarkable. - The adrenals are moderately generally enlarged, bilaterally, measuring 1.1 cm (left) and 1.3 cm (right) at the caudal pole; the glands exhibit otherwise unremarkable features. Mildly hyperechoic generalized hepatomegaly; bilateral mild to moderate adenomegaly. Collectively most compatible with Cushing's disease.
Mildly hyperechoic generalized hepatomegaly; bilateral mild to moderate adrenomegaly. Collectively most compatible with Cushing's disease. Cortisol pre ACTH - 6.0 , post ACTH - 33.7.

Blood test 3 in June : ALT 187, ALP 565 and GGT 18
There are some thyroid related concerns in this 3rd blood test. I will post the levels that are abnormal from this last blood test here but as a reference, I will put what those values were in [brackets] as of the 2nd blood test in February which were all within normal values.
phosphorus 6.3 [February test value 3.7], potassium 5.8 [February test value 4.7], na/k ratio 26 [31], cholesterol 463 [331], triglyceride 308 [103] and T4 .5 [1.4].

I am waiting for one more test result to come in that will provide in the vets words "will determine if Trigger's thyroid levels are something we need to treat/diagnose or his thyroid levels are abnormal due to Cushing's". I don't know the exact name of this test but my understanding is that it is just another more detailed blood test they are running but I am not 100%. A mixed bag here as to the liver values haven't changed much in 4 months which is good but either Cushing's is starting to impact his thyroid or I could have another issue on top of Cushing's. Figured I would chime in with an update on my situation.

[labblab]

So good to hear back from you, and also to learn that Trigger’s liver values have actually gone down. As far as his thyroid, I’m guessing the followup testing is a more comprehensive thyroid panel that measures several other levels beyond just the T4. If that’s the test, the combination of results can point to whether or not a thyroid deficiency appears to be an independent problem in its own right, or whether it indeed appears to be secondary to another disorder such as Cushing’s.

I believe the good news is that, even if a thyroid deficiency is independent in origin, typically it is easily treated by simply giving a daily oral thyroid supplement. So we’ll wait alongside you to hear more, but in the meantime, are very grateful for the update. Thanks for checking back in with us!

Marianne

[Squirt's Mom]

Sounds like Trigger is progressing nicely and that is always good to hear! And I agree with Marianne on the thyroid...it is easy to treat. But with a bit of luck this will turn out to be Sick Euthyroid Syndrome...the condition Marianne mention that is related to Cushing's and typically disappears as the cortisol is under control. That would mean your precious boy won't have to take another pill. It is easy to treat, yes, but fewer pills are always nice!

Looking forward to the next update on Trigger and hope it is as good as this one!
Hugs,
Leslie

[Brusso89]

An update along with a dosage question for Trilostane. The time has come to put Trigger on Trilostane. He had another round of bloodwork done in August and his thyroid numbers are back to normal with his new thyroid medication, His ALT is up to 220, ALP up to 741 and his GGT is actually down to 13. So far, he has only been taking a liver supplement as his only form of Cushing's treatment even though that isn't really a treatment but figured I would note that. He is still taking joint supplements and Vetmedin for his heart along with a few other health supplements and Gabapentin. The reason I was wanting to start Trilostane was due to the increase in panting, the onset of some restlessness at night and the continued increased thirst and urination. My biggest issue is the panting and the restlessness at night. The restlessness at night isn't terrible but he does get up 4 or 5 times in the night to walk around the room to find a comfy spot which lately has been on tile. The panting has me concerned. I'm in Phoenix and it has been a hot summer. We are starting to cool off at night but the panting, even after an indoor activity is increasing. I am told that even with winter coming, not to count on the outside temps to have a huge impact on his panting.

We started him on 30mg twice daily. Trigger has been on 30mg twice daily (60mg total) for 1 month. We didn't check levels at 2 weeks because he had no bad side effects and I wasn't seeing that much of a decrease in panting/restlessness/water intake. His ACTH test on 9/16, he had Trilostane at 7:30 am, his cortisol level at 11:30 was a 3 and his level at 12:30 was a 6.8.

Trigger being with the vet for that whole time was very stressful on him and when I picked him up, it seems like we took a step backwards as far as intensity of Cushing's symptoms . After 4 weeks on Trilostane(8/18-9/16) I'd say his symptoms improved about 25%. After his stressful test and up to today, I'd say we lost that 25% improvement and are back to square one with his symptoms. My vet who has been great to Trigger and I thought the test was stressful on Trigger but thought that he should be back to his 25% improved self within a few days after the test. That hasn't been the case. I had a long conversation with my vet on Friday and he wanted to try a medication to help with Triggers arthritis, thinking that may cause some of his restlessness at night. I(clearly an uneducated vet) kind of wants to up his Trilostane dosage in hopes to bring down the panting, restlessness and drinking but I understand that it can be very bad if Trigger's cortisol levels drop too much. I can tell Trigger is more aware of his old age and arthritis just how he lays down more cautiously now. I contribute that to Trilostane lowering his cortisol levels. My question to you guys who have experience with Trilostane and the ACTH testing, how do you interrupt the results? Info I find online states if his levels are 5.5 and higher, to up his dosage if symptoms are still present. That info doesn't state at what time that 5.5 level is reached. Trigger is down to a 3 for his cortisol at 4 hours post treatment, but at 5 hours post treatment he is at a 6.8. The vet is strongly against increasing the dosage saying those numbers are pretty much exactly what we could ask for, not too high and not too low. If that's the case, I'm not comfortable with the level of symptoms that Trigger is experiencing at the "ideal" cortisol range. Do I have any other options before I have to start thinking about calling it at this point?

[Harley PoMMom]

I believe the "ideal" cortisol range is where the dog is feeling well and those symptoms are not bothersome for the dog and owner, each dog is different. The first thing I would suggest is having an urine culture and sensitivity test done to rule out an UTI which will make a dog drink and urinate more. If that comes back clean than a small increase in the Trilostane is an option, maybe a 5mg increase twice a day.

Hugs, Lori

[labblab]

My question to you guys who have experience with Trilostane and the ACTH testing, how do you interrupt the results? Info I find online states if his levels are 5.5 and higher, to up his dosage if symptoms are still present. That info doesn't state at what time that 5.5 level is reached. Trigger is down to a 3 for his cortisol at 4 hours post treatment, but at 5 hours post treatment he is at a 6.8. The vet is strongly against increasing the dosage saying those numbers are pretty much exactly what we could ask for, not too high and not too low. If that's the case, I'm not comfortable with the level of symptoms that Trigger is experiencing at the "ideal" cortisol range. Do I have any other options before I have to start thinking about calling it at this point?

I join Lori — and you — in thinking that at least a small dosing increase is in order. You are correct that the monitoring guidelines recommended by Dechra, the maker of Vetoryl, state that a dosing increase is in order if the post-ACTH result is greater than 5.4 and clinical symptoms are not being controlled sufficiently. And just to clarify, it is indeed the second (or post-ACTH cortisol) reading that is being referenced. This is the reading that is taken after the ACTH stimulating agent has been injected.

I appreciate the fact that your vet doesn’t want to lower Trigger’s cortisol too far. But it seems to me that you still have a bit of room to work with in terms of trying to achieve better symptom resolution since, technically, post-ACTH levels are typically not considered to be too low unless they drop below around 2.0. (or the dog is showing outward signs of oversuppression). Since you’re giving him his trilostane twice daily, financially it may be easier to increase his dose only in the morning. For instance, if you choose to increase his daily total by 10 mg., it may be cheaper to give one extra 10 mg. each day as opposed to two 5 mg. capsules. If unequal twice daily doses are given, Dechra recommends giving the larger dose in the morning.

As you know, we are not vets either. But it does seem to me that you’re within Dechra’s guidelines if you choose to try a dosage increase. I also can’t argue, though, with your vet’s recommendation to start some arthritis medication. At Trigger’s age (and with the lowered cortisol as you rightly note), arthritic pain could indeed be contributing to his discomfort and restlessness.

I’ll close by adding a link to Dechra’s formal treatment guidelines. I’m confident you’ve already seen something similar, but the monitoring recommendations are contained in a flowchart near the end. Continued good luck to you and Trigger, and please do let us know how things are going.

https://drive.google.com/file/u/0/d/...ejQ/view?pli=1

Marianne

[Brusso89]

Lori, you may be on to something. Now that you mention it, there are a few signs that would lead me to believe that he could have a UTI. Yesterday I had a urine test done and hopefully I'll have the results today.

Marianne, thank you for the info!
As far as me wanting to increase his Trilostane dosage, it's a relief to know I'm not crazy haha. I fully understand the risks of increasing it too much and him not being able to produce enough cortisol on his own. But on the other hand, I haven't come this far to just stop when I could be close to making him more comfortable. From my research, I get the picture that every dog reacts to the medication individually and there can be no rhyme or reason to predicting increases or decreases in relation to cortisol levels per mg or Trilostane. For example, if I added a 5mg or 10mg to Trigger in the morning, it could have zero effect on his cortisol levels or it could make a huge difference, correct? I have read a little about giving uneven doses. I'm not sure if I should start at 5mg, 10mg or greater. The ACTH test was stressful for Trigger. I didn't want to preform another one unless it was absolutely necessary. If I increase his dosage, I take it we would have to do another ACTH test within a week or two to see how his levels are correct? Again my vet has been very helpful and his willingness to communicate with me during his busy days is priceless to me. I have not flat out asked him if I was to increase Trigger's dosage against his opinion, how would that effect our relationship going forward. I have had bad experiences with vets in the past for a wide range or reasons. This vet is by far my favorite and he has gone above what I would think an average vet should do during my time with him and treating Trigger. I'm not gonna make a decision until I get the urine test back and at this point, I kind of hope Trigger has a UTI because that would give me hope to treat that in hopes of giving him more comfort vs the challenge of mixing and matching Trilostane and doing it against my vets opinion. Any words of wisdom if I do have to have that conversation with my vet?