Rudy: New diagnosis, on Trilostane/Vetoryl, lethargic

[StarDeb55]

If Rudy had an active infection present, it's possible. The 2 main diagnostic tests are the ACTH & low dose dex test. The low dose is considered to be the gold standard when diagnosing Cushing's, but it has one huge drawback, the test may yield a false positive in the presence of any non-adrenal illness. I pretty sure that the ACTH is less likely to yield a false positive, although, my understanding is that an ACTH may yield a false negative. When trying to get a confirmed diagnosis of this disease, it's always best to confirm any positive result on either of the above 2 tests with a second test, frequently, an abdominal ultrasound to take a look at the adrenal glands & other internal organs. Confirming with a 2nd test is especially important with the low dose because of the false positive problem. If you might consider doing the ultrasound, you really get more "bang for the buck" as all of Rudy's internal organs will be checked, & you will have a better idea of his overall health. You want to make sure that the ultrasound is done on a high resolution machine, & read by an experienced vet.

Debbie

PS- When it comes to a referral, it will depend on the specialist. I will say that the majority will probably require a referral. We do have a link in the important information section about how to find a specialist in the US, if you need some help.

[MyRudy]

I had the ultrasound done already, it showed both adrenal glands were enlarged, which is why I deduced Rudy as PDH instead of the other 2 types of Cushings. And luckily my current vet was off that day, so my former vet, the older more experienced guy, is the one who read the results to me and explained things.

After that is when they did the ACTH and his cortisol levels came back 'super high'. I don't know if they did the other test you mentioned.

[StarDeb55]

With an elevated ACTH & bilaterally enlarged adrenals, IMO, you have a confirmed diagnosis.

Debbie

[MyRudy]

Just found this in another thread and I think it is exactly what happened to Rudy:

A small percentage of dogs may develop corticosteroid withdrawal syndrome within 10 days of starting treatment. This phenomenon results from acute withdrawal of circulating glucocorticoids; clinical signs include weakness, lethargy, anorexia, and weight loss. These clinical signs should be differentiated from an early hypoadrenocortical crisis by measurement of serum electrolyte concentrations and performance of an ACTH stimulation test. Corticosteroid withdrawal syndrome should respond to cessation of Vetroyl Capsules (duration of discontinuation based on the severity of the clinical signs) and restarting at a lower dose.

http://www.dechra-us.com/files/dechr...ts/Vetoryl.pdf

[StarDeb55]

This is a possibility. There can be such a rapid decline in cortisol levels with both drugs that the pup can start feeling kind "yucky" without the cortisol actually having gone so low that you may dealing with a low cortisol emergency. Cortisol is a sort of "feel good" hormone as it is a natural anti-inflammatory, & the pup is used to higher levels that are present. The only way to know for sure what might have happened with Rudy is to have run an ACTH or electrolyte check at a minimum. If that wasn't done, all we can say is likely, but we can't prove it.

One other thing to point out is cortisol normal ranges are completely different for our pups as opposed to a normal, healthy pup. Our normal range is 1-5 ug/dl. We have vets who get the normal ranges mixed up on a fairly regular basis.

Debbie

[MyRudy]

Just got back from the vet and going through the reports. I took Rudy with me so I could weigh him and he is down to 33 lbs

I think my first concern is putting weight back on, am I correct? He weighed 44 lbs just a few weeks ago when all this started.

Looking through the 6/27/10 test results on his Senior Screen, Chem 25 test, the following were flagged as high:

ALT (SGPT) 111 (5-107 U/L)
GGT 21 (0-14 U/L)
Cholesterol 345 (112-328 mg/dL)

and the following were flagged as low:

WBC 4.1 (5.7-16.3 THOUS./uL)
Eosinophil 1 (2-10%)
Absolute Neutrophil SEG 2911 (3000-11500/uL)
Absolute Lymphocyte 984 (1000-4800/uL)
Absolute Eosinophil 41 (100-1250/uL)

7/18/10 Bile Acids Test:

Bile Acids 21.0 (0.0-6.9 umol/L)
Bile Acids Post Prandial 18.0 (0.0-14.9 umol/L)

7/21/10 Ultrasound:

The ultrasonographic findings are strongly suggestive of pituitary dependant hyperadrenoocorticism (PDH). Adrenal function testing is recommended. (As I mentioned before, bilateral enlargement of adrenal glands was found, along with a generally enlarged liver and bladder; pancreas, spleen and kidneys were normal; gall bladder was moderately distended with inspissated bile. The gall bladder wall was normal in thickness).

7/21/10 ACTH Stim test:

Pre-ACTH 35.1 ug/dL
Post-ACTH 42.5 ug/dL

If there are other numbers you guys need to know, I will try to find them in these reports.

Thanks!
Donna

[frijole]

Donna, Was the ALK PHOSPHATE normal? If so that would not be indicative of cushings. The ALT sometimes is elevated in cushings. Did your vet discuss all of the other abnormal readings and what might be causing them to be off? I ask because most of the abnormal readings are not things we typically see with cushings.

Since there were things going on at the time of the acth test - I am not sure I could feel comfortable that it is a true positive result. The ultrasound sure looks like cushings.

Forgive me for not reading back - I just spent 2 hrs working the yard and am bushed. I am sure Deb will check in and give her more professional opinion.

Thanks for getting all of that info and posting. It will be a great help. I will check in after I get cleaned up. Kim

[MyRudy]

Kim:

Yes the ALK Phosphate was 116 and they list 10-150 U/L as normal range. The ALT (SGPT) was 111 with a 5-107 U/L listed as normal.

I am sure he has Cushings, but I suppose there could be something else going on that the vet might have missed? He did not discuss the flagged readings with me and I have no idea what they are (except cholesterol).

The stim test numbers really threw me, they were so darned high! Rudy is a very sensitive dog and scares easily, he normally shakes like a leaf when we are at the vet. At the time the stim test was done he had been at the vet's office all day and gone through an ultrasound already, so I am pretty sure his cortisol numbers were inflated due to that.

Thanks for your response!
Donna

[frijole]

I don't remember a single dog ever being diagnosed with normal liver enzymes. And when we are talking elevated -- my dog's ALK Phos was 2000+. Most vets won't even test if its under 250 because the likelihood is that it is something else.

Even if cushings is involved - it appears something else is going on which would explain the weight loss.

I am really glad you got those numbers.... now I reallly am going to go shower!

[MyRudy]

Kim, I edited the numbers for ALK and ALT above, I was looking at the test from 2009 instead of this year's test. The edited numbers are a bit higher, but still not all that high compared to your poor dog's!

Just to be clear, Rudy has only lost 11 lbs since the Vetoryl, which lasted only 11 days before I stopped giving them to him. After I stopped and got the prednisone, I gave him one of those and he perked up a bit the next day and has been slowly improving, but still not eating normally. I am having to supplement his food just to get him to eat at all.

The last day I gave him Vetoryl was Aug 2nd. He got one prednisone on Aug 3rd. Since then, no pills at all. He is back to walking more normally but he is still not eating like he was.

And the panting/drinking/peeing symptoms have returned in full.