Cushing's Crisis over Christmas still not good

[SamsonsMom]

Hi,
My name is Allison, and my dog is Samson. He is a 13-ish Schipperke/Pomeranian mix (we think) that I rescued 7 years ago. I first had Samson tested (low dose dex and ultrasound) in the summer of 2013 after he exhibited months of depression (shortly after the sudden death of our other dog), and then started developing the usual Cushing's symptoms of thirst, frequent urination and crazy hunger. His test results suggested Cushing's but I was advised to wait to treat and have him tested again by three vets (one an endocrinologist) because his results were very mild.

I had him tested again in early December 2013. His ultrasound showed both adrenal glands were enlarged, his liver was enlarged and had a "node" on it, and his kidneys were enlarged. His dex suppression test (I left the results with the endocrinologist) showed that he had Cushing's but they were unable to determine which type. Shortly after the test, Samson developed chronic diarrhea which was believed to be from stress, and was given flagyl and then tilan (which finally got it under control.)

Samson began to act strange on the Friday before Christmas--refusing to eat his food, not taking treats, so I took him to the vet and she gave him a mild antibiotic. He didn't improved over the weekend, so I returned and asked for blood work and a BP measure. They said his BP was normal.

I received a call the next morning saying to get him to the ER because he was in possible kidney failure. His Alk Phos was 1875 and his BUN/creatinine was elevated etc.

The ER gave him fluids and his kidney function improved immediately, however, they did a dopler blood pressure and said his BP was 250! They said he probably has pancreatitis, and possibly liver and kidney disease. So they kept him for 2.5 days. They also got him on trilostane 2x per day and BP meds.

Since Christmas we have had another emergency because (apparently) due to the high amount of BP meds (he was on two) his BP dropped so low that he had a fainting episode (which looked to me more like a seizure), and he spent two more days in the ER.

We have since adjusted his meds twice and he still is not the same. I understand it takes time for the meds to get in his system, but he is only eating chicken and rice (after he began refusing the canned food), and has now gone from chronic diarrhea to constipation. He doesn't want to walk or go outside except for brief moments. He is going off alone in the house, and sleeping on a dog bed which he always refused to use in the past. Samson is getting the ACTH stim test tomorrow and having his BP rechecked.

I guess I am just looking for advice from other people who are going through this. I was told Samson's case is more complex than usual (and I was also told all Cushing's is complex) so we are using a specialist. I want to make my guy comfortable and I just don't know what to do. I don't know if we waited too long to begin testing and treatment or what. We have committed to giving this guy a chance.

[Roxee's Dad]

Hi Allison and welcome to you and Samson,

I only have a minute to post but wanted to approve your message and ask a quick question. How much (mg) of Trilstane is Samson getting? Please take note of the instructions below so your post will not have to be approved.



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[SamsonsMom]

Sorry about the registration issue. I guess I tried posting too quickly.

Samson is about 19 pounds and is currently on 9 mg of Trilostane 2 times per day.

[Roxee's Dad]

A rule of thumb and even by the makers of Trilostane is to not give cushings meds to a dog that is lethargic, won't eat or drink or has diarrhea.

[labblab]

Your registration has now been finalized, so you can go ahead and post freely. I will come back later to reply in greater detail, but there are several things about Samson's situation that are troubling, including the initial diagnostic testing as well as giving trilostane to a dog who may have primary kidney/liver disease (those are contraindications to the drug). We will do our very best to help you sort things out!

Marianne

[lulusmom]

Hi and welcome to the forum.

It does sound as though your boy has a lot going on. My first thought was what was the ER thinking by giving a very sick dog on IV fluids Vetoryl and why weren't they able to confirm a pancreatitis diagnosis by doing a do a simple Spec cPL. I've been through the drill with two of my dogs and most recently, my mother's dog. It would help us immensely if you could round up all of the testing that has been done since you retested Samson in December. With respect to the blood chemistry and complete blood count (CBC), we need only see the highs and lows, and please include the normal reference ranges. I'm a huge Pom lover and have had two Poms with cushing's, both of whom have passed.

The LDDS test may not have provided a clue as to whether you are dealing with pituitary (PDH) or adrenal dependent disease but the abdominal ultrasound did. If a dog has PDH, both adrenal glands will be enlarged, or depending on progression of the disease, they could be normal. Samson had two enlarged adrenals which is indicative of PDH, which is the diagnosis most cushdogs have.

Having test results would help understand the er vet's suspicion of kidney disease but severe elevation in ALKP and a high BUN/Creatinine ratio is not unusual for a dog with cushing's. Nor would it be unusual for a dog with pancreatitis. A high ratio is indicative of low creatinine or high BUN. Dehydration from pancreatitis and frequent urination caused by Diabetes Mellitus or Cushing's can cause high BUN resulting in a high ratio. I'd be more concerned with a low ratio as that is indicative of high creatinine or low BUN. When both creatinine and BUN are elevated, that's when I start to get nervous. With respect to the high ALKP, dogs are the only species that have a steroid induced isoenzyme so if Samson has cushing's, his ALKP would probably had been elevated prior to becoming sick; however, there is another ALKP enzyme that comes from the gut so the elevation in ALKP is probably being triggered by two sources, cushing's and pancreatitis.

Most dogs with cushing's have enlarged livers due to fat accumulation as a result of cortisol's effect on fat metabolism. This does't mean a dog has primary liver disease. When the pancreas is seriously inflamed, it can also affect the liver and kidneys because they are so close in proximity. This could explain the enlarged kidneys.

Is your specialist a board certified internal medicine specialist? If so, was Samson being treated by this specialist before he ended up in the ER with suspected pancreatitis? Either way, has the specialist sat down with you to explain exactly what Samson's issues at this point in time? John already mentioned that it is not a good idea to give a sick dog Vetoryl and a cushdog that is not eating normally, should be considered sick.

Your response will really be helpful in our ability to provide you with meaningful feedback.

I'm sorry for the circumstances that brought you here but I'm very glad that you found us. We'll all try to help you figure out what is going on with Samson, and the more information you can provide, the better.

Glynda

[SamsonsMom]

Thank you all for your quick responses! I am so glad I found this website.

I will round up all of Samson's test results when I take him in tomorrow for the ACTH test. I read on the trilostane website that you are not supposed to give trilostane to dogs with kidney or liver disease so I did raise my eyebrows at this. I will ask the doctor why they proceeded with this course (she is board certified and has an excellent reputation.) I know that his kidney numbers responded quickly to the fluids so they did feel that dehydration caused theelevation in his kidney numbers.

I found some notes I wrote after the CBC he had when I was told to rush him to the ER: ALK Phosp was 1800 now (up from 475 in summer 2013). I don't understand my BUN/Creatinine notes because they look like I wrote BUN/Creatinine 96 and 2.5 which is unclear to me. The vet also wrote "Cyto?" on the records. Phospate was 6.6 and calcium was elevated. His platelets were over 200,000. I will get more info tomorrow.

I also know what his platelet count was on Friday 1/3/14: 192,000. They had to repeat it because on 1/2/14 when he "fainted" they said it was 45,000 and wouldn't let him come home. Luckily it must have been a mis-read the first time. His sugar was slightly elevated but not enough for them to say "diabetes." His BP was low for him --140. This poor dog has had so many blood tests :p

I was not taking Samson to a specialist prior to the problems he had over Christmas. I would have gone the route of the specialist even if Samson hadn't gone into crisis. We had just done the LDD and the ultrasound and I was waiting to get a referral but my vet was on vacation.

Although Samson refuses to eat dry food or canned vet formula, he eats chicken and rice with vigor. He was never a picky eater until Christmas. He is still constipated so I plan to slowly switch him to a lower fat Wellness canned formula and off the chicken/rice. He is sleeping a lot, and carrying his tail down. He shakes a lot--especially when lying down and when standing in place (I understand this can be a Cushing's symptom.)

I am very worried and a bit frustrated because he has had so many tests in the last month, and I don't feel like we are getting to the bottom of this. If all else fails, I will get a referral, take time off, and I will drive up into Fort Collins, CO to CSU to find out what I can.

[lulusmom]

Unfortunately, the numbers you posted are difficult to assess without the normal references ranges so it should make more sense when you get the actual tests and post the results. Keep in mind I'm not a vet, I'm just an educated pet owner and special needs rescuer who has spent much time going over abnormal blood and urine tests with vets. I can tell you that most of the abnormalities you mention can be explained by cushing's, pancreatitis and dehydration from pancreatitis.

Now that I know that Samson did not see the specialist until after the emergency, I have to assume that the specialist has all of the records from your gp vet and the er, right? I suspect she probably did additional testing as well??? If she is a board certified internal medicine specialist, she should have been able to get to the bottom of things; she should have explained in detail what is going on with Samson and you most certainly should not be forced to contemplate taking Samson to CSU for answers. She should be able to sit down with you and explain exactly what is going on with Samson and answer all of your questions. Once you post the results and we've had a chance to digest them a bit, maybe we can put a list of questions together for your discussions with her. When you see the specialist tomorrow, a lot of questions could be answered if she will just tell you 1) if kidney and liver disease have been ruled out; 2) does she believe that Samson's crisis was caused by pancreatitis and 3) is cushing's the only diagnosis at this time or are there other issues, and if so, what are they.

One of my cushdogs had serious muscle wasting caused by cushing's and he not only had constant tremors in his hindquarters, he would fall over if he tried to lift his leg to pee. His rear end was noticeably boney. I know it's difficult to visualize muscle wasting in a Pom with a full coat but if you feel their spine, down to the hips you can tell if there has been a lot of muscle loss. Have you noticed this in Samson?

[SamsonsMom]

Thank you for helping me put together questions to ask. She is a board certified internal medicine specialist. Her practice is at the same place as the ER (it is both an ER and a specialist facility.) This will be my first direct consult with her (I have spoken over the phone to her but not in-person to this point, and it has been frustrating. I believe it is because the previous events were "emergencies" and not treatments so I spoke to whichever doctor was on call.)

Samson has very little hair left at this point --just fuzz and a few random tufts (Samson without his hair...) and he does have muscle loss in his hind-quarters to some degree. He also has the drooping tummy.

You know, I failed to mention earlier that when Samson was first suspected of Cushing's I took him to a holistic vet. She seemed more concerned with his thyroid symptoms than anything else (did a free t-4 test on him and his thyroid showed low.) She put him on a hefty dose of thyroid meds which was against my regular vet's wishes.

Although Samson initially appeared to show improvement (had energy, depression went away), my regular vet said that thyroid meds can make a dog that is ill feel better even if it isn't curing anything. He said that thyroid numbers can get funky with Cushing's as a 2ndary concern, and the meds can cause BP problems, and that he didn't even agree with the particular thyroid test she ran. So I removed S from the thyroid pills about three weeks prior to his episode. His hair (which was already getting thin) really started going after that. I will mention this to the internal med doc too (they know he was on thyroid meds in the past.) The holistic vet has recently moved her practice to a swanky ski village.

[lulusmom]

If you saw my avatar pic, you'll see Lulu. That pic was taken when she still had some fuzz left. The picture below was taken later, after her skin turned black. She still had a bit of tuft left but that pretty much went away too. She did have primary hypothyroidism as well as cushing's so she had two strikes against her. It was purely cosmetic so I just made sure she had plenty of sweaters and onsies to keep her warm.

I'm hoping that you can sit down and talk at length to the specialist and get a lot of questions answered. Take a notepad with you and take copious notes because if you don't, you'll forget most of what she tells you. If you don't understand what she is telling you, ask her to draw a picture if you have to. :D You both need to be on the same page to make sure that Samson's treatment is administered safely and effectively. It takes teamwork.

Glynda

P.S. Was it the specialist who directed the staff to administer Trilostane while Samson was so ill? If so, I would have great concerns with that decision and would question her knowledge of the drug. If she didn't order Trilostane, she should be taking issue with the ER staff.

[SamsonsMom]

Glynda,
It was the ER doc that put Samson on the trilostane but this was three days after he was admitted so *maybe* they decided that his liver and kidneys were not an issue? I will ask.

I received the LDDS test results from 11/25/13 and the CBC results that sent Samson to the ER on 12/23/13 (prior to them giving him fluids.) I expect to get the rest of the results tomorrow.

Samson's LDDS:
Cortisol Sample 1 (Pre) 4.9; reference range: 1-5.0 mg/dL
Cortisol Sample 2 Dex (4 hour) 3.1 (high); Reference range: 0.0-1.4
Cortisol Sample 3 Dex (8 hour) 3.7 (high); Reference range: 0.0-1.4

Samson's CBC on 12/23/13: (not sure which ones I should include, i have more -- could not get pdf to open here)
Total Protein 7.6 (high); ref. range: 5.0-7.4
ALT (SGPT) 207 (high); ref. range: 12-118
Alk Phosphatase 1845 (high); ref. range: 5-131
GGT 25 (high); ref range 1-12
BUN 96 (high); ref range 3-31
Creatinine 2.5 (high); ref range 0.5-1.6
BUN/Creatinine ratio 38 (high); ref range 4-27
Phosphorus 6.6 (high); ref range 2.5-6.0
Glucose 162 (high); ref. range 70-138
Cholesterol 402 (high); ref range 92-324
Lipese 943 (high); ref range 77-695

WBC 12.2; ref range 4.0-15.5
RBC 6.3; ref range 4.8-9.3
Platelet count 282 ; ref. range 170-400
Monocytes (high) 975; ref range 8% 0-840

Urinalysis:
Specific gravity 1.016; ref range 1.015-1.050
Protein 3+ (high) (they cultured his urine at the ER and didn't find anything bad.)

[lulusmom]

I have to run to the vets before they close so will look at the test results you just posted when I get back but in the meantime, I'm providing you with a url to Dechra's client literature. It's very educational. Once you've had a chance to read through it, let us know if you have any questions. You will see a section that is very clear that you stop dosing if the dog is not well.

http://www.dechra.co.uk/files//dechra/Downloads/Pharma/ClientLiterature/Vetoryl_Client_Booklet_Final.pdf

[labblab]

Hi, I am finally back, but once again just for a moment. :o

But I see that Glynda has been taking great care of you, and I know she will continue to do so. In addition to everything else that you two have been talking about, I did want to point out one cautionary note re: the combination of trilostane and certain meds used to treat high blood pressure. I'd encourage you to double-check Samson's meds to see whether they fall within these categories:


Angiotensin-converting enzyme (ACE) inhibitors should be used with caution with Vetoryl Capsules, as both drugs have aldosterone-lowering 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 [elevated potassium].

http://www.dechra-us.com/files/dechraUSA/downloads/Product%20inserts/Vetoryl.pdf

I am especially wondering about this given his blood pressure crash after Christmas...

Marianne

[lulusmom]

I'm glad Marianne posted what she did because I didn't think about the contraindications for Vetoryl. The LDDS results are consistent with cushing's but it doesn't tell you if it's PDH, however, the ultrasound confirmed that with the two enlarged adrenal glands. The blood chemistry and cbc abnormalities can all be attributed to cushing's, pancreatitis and severe dehydration so I have to believe the specialist ruled out kidney and liver issues. However, I still have concerns about the specialist starting Vetoryl immediately following Samson's 2 1/2 days in the er. Dogs with severe pancreatitis don't get better in 3 days. All of my dogs have spent 2 days in the er on IV fluids and were sent home with meds and instructions to feed bland diet for three to four days. One of my boys didn't eat for three days and it wasn't until I gave him some slippery elm bark gruel that he finally found an appetite and started eating a little chicken breast and rice. Now this is just me talking, but knowing what I know about both conditions and my knowledge of Vetoryl, I would have asked the specialist what in the world she was she thinking when she started my dog on Vetoryl before he was barely out of the hospital with what looked to be a severely inflamed pancreas and next to no appetite. Argh! Again, that's just me talking and I'm just saying.....

So about those questions for the specialist.....in addition to the ones I mentioned before, let's add Marianne's concerns about any of Samson's meds that may be a problem when given concurrently with Vetoryl. Make a list of the meds Samson is taking and ask the specialist if any are contraindicated with Vetoryl. You should actually do your own research beforehand, based on what Marianne provided, so that you are armed with knowledge. What I would also suggest you do is read that literature I provided and try to digest it as best you can. Print it out, circle the section that talks about giving Vetoryl to a sick dog and any other information that raises questions for you, and take it with you when you see the specialist so you can share with her. When are you planning on seeing the specialist again?

Glynda

P.S. I don't mean to be a nag but is there any way you can get a copy of the blood chemistry and any other screening tests that were done by your gp vet before he did the LDDS test? Can you also get a copy of the thyroid test your holistic vet did? I'm asking for all of this because Poms are famous for sex hormone imbalances and hypothyroidism. Lulu's internal medicine specialist was very familiar with Poms and even though we had a LDDS result that was consistent with cushing's, he would not start her treatment until he sent a blood specimen to the University of Tennessee (UTK) for a full adrenal panel, including cortisol. The IMS wanted to make sure that Lulu's stimulated cortisol was consistent with typical cushing's, as apparently some dogs with extreme elevations in sex hormones can have false positive LDDS results. I'm just trying to leave no stone unturned.

[SamsonsMom]

Thank you Glynda and Marianne,
I just read the pamphlets and am printing them off. Our appt is at 11 since Samson takes his meds at 7AM. I do have all of his records from our gp vet--started collecting everything after our sweet Lab Jackson was missed for hemangio sarcoma and died a sudden and horrible death in April (at the same time Samson started showing signs of Cushing's.) I will sort thru the file and get those on here too. My head is swimming so I wrote everything in a notebook and have it waiting for me to grab as I leave today.

One thing that I am upset about -- and it is my fault -- is that we had to use a compounding facility to get Samson's trilostane and I received NO literature on it (I did a google search on it myself.) I was told to begin the meds when we received them. I don't like that so many vets give meds orders and don't supply the information we need for them. A doctor or pharmacist should NEVER get away with this with a human patient so why is it any different with a pet?

[lulusmom]

One thing that I am upset about -- and it is my fault -- is that we had to use a compounding facility to get Samson's trilostane and I received NO literature on it (I did a google search on it myself.) I was told to begin the meds when we received them. I don't like that so many vets give meds orders and don't supply the information we need for them. A doctor or pharmacist should NEVER get away with this with a human patient so why is it any different with a pet?

This is absolutely not your fault and I commend you for doing your own research. We've seen ignorant general practitioner's fail to counsel their client on the seriousness of this drug, but not a internal medicine specialist. Shame on her, again! Are you sure this woman is a board certified internal medicine specialist? She should have sat you down and explained how the drug works, what to watch for in the way of adverse reactions or signs of low cortisol, what to do if you see these signs, and she most certainly should have told you to make sure you have Samson to the office 3 to 4 hours after his morning dose given with a meal. Thank goodness you did your homework because stim tests are not cheap and it's not easy on a dog to have two blood draws and sit in the vet's office for an hour or two. If you don't follow proper protocol, the results are of no value. We've seen members who might as well have flushed their money down the toilet because their vet instructed them to fast the dog and/or they had the test done well after six hours of dosing.

[SamsonsMom]

I am totally SICK now. I was typing up all the meds test records into a table by date, and decided to check back here. I just googled the meds Samson is on, and it looks like the ER vets had him on one Ace inhibitor (benazepril) and a calcium channel blocker (amlodipine) before going on the trilostane. They took him off the benazepril prior to the trilostane, but I can't believe it was totally out of his system when he was placed on the trilostane. This is something I did ask about -- not the interaction but the possibility of the trilostane being enough to lower his BP and the question of whether he should still be on BP meds at all. They are doing a BP monitoring today as well, however, Samson gets really keyed up at the vets so his BP is likely to rise.

The certifications of the doctor who took Samson's case are DVM and DACVIM. There are only three DACVIM's in the practice, and to my knowledge, only one DACVIM has worked on his case; the rest of the doctors were all regular DVMs on an emergency basis.

Thank you again for your guidance. I am very interested in hearing what she says about pomeranians and the possibility of sex hormone imbalance and/or hypothyroid or not.

[goldengirl88]

I was told by Dechra that heart drugs Ace Inhibitors can really play havoc with Electrolytes that is why they do not want them in use when using Vetoryl. I am so sorry you are having so many problems, but it seems to me like Glynda said that these vets should be ashamed of themselves to say the least. Hope everything turns out ok for you and your baby. Blessings
Patti

[lulusmom]

Since you will be discussing sex hormones with the specialist, I've included a link to an interesting paper written by Dr. Ellen Behrend.

Here is an excerpt from that paper that supports that dogs with atypical cushing's can have normal cortisol and LDDS results consistent with typical cushing's.


A study of 23 dogs with clinical and routine laboratory findings suggestive of HAC was reported recently. Of the 23 dogs, 11 assigned to group 1 had typical HAC with elevated cortisol responses to ACTH. Of 10 dogs with normal ACTH response test results, 6 had positive LDDST results (group 2A), 4 had negative LDDST results (group 2B), and 3 had low plasma cortisol concentrations throughout testing (group 2C). Despite the variation in serum cortisol concentrations on the tests for standard HAC, all 23 dogs had elevated ACTH-stimulated 17OHP concentrations. Thus, Ristic and colleagues20 concluded that ACTH-stimulated serum 17OHP concentration is elevated in dogs with classic as well as occult HAC and measurement of serum 17OHP concentrations is a marker of adrenal dysfunction.

http://www.2ndchance.info/cushingsbehrend2010.pdf

[goldengirl88]

Please take in all of what Glynda tells you. She is an expert at this and still takes the time to help us on here even though she is busy rescuing babies all the time. She will be your best guide. Blessings Patti

[SamsonsMom]

Getting more results on Monday. I forgot to get the test results from his stay during Christmas and after so I will get those Monday too.

The vet said that since no imaging was done during his illness (prior to the emergency), they cannot say definitively that pancreatitis caused his crisis, but he did have signs of pancreatitis during his ultrasound. Also, kidney disease may be a concern. Although he did respond very well and very quickly to administration of fluids, his current creatinine level is at 1.9 which is just above "normal."

Samson had the ACTH stim test and a blood panel for thyroid done yesterday. The thyroid results won't be ready til Monday because she did a T4 ED and a TSH to see if he is truly thyroid or just "thyroid sick."
His ACTH pre value was 2.5 and post value was 9.2 and the vet called this "appropriate" results for where he is in the Cushing's treatment.
More info coming soon. Sounds like my appliance people are here (another story, must go.)

[Renee]

9.2 for the post is actually a little high, if he's on vetoryl. Dechra says post can be up to 9, if all symptoms are controlled. Otherwise, you'll want to get a bit lower.

[SamsonsMom]

Hi,
I was here recently about my dog Samson's Cushing's crisis. I became incredibly overwhelmed with his case, and didn't follow up with you -- I apologize.

Even though I am taking him to a board certified IMS I am very unhappy with his treatment, and I made an appointment with a specialty hospital that has 5 IMS's on staff which I will see next week.

I LITERALLY got to meet (in person) with the current IMS about 10 minutes--that's all--and to do that, I had to request to speak with her. Although she is supposedly managing Samsons's case (and will call me back if I phone her), I only ever see techs there. During our brief discussion after Samsons ACTH test, I found out that he had high potassium (and an "episode" that landed him back in the ER) because he was on an ACE inhibitor and trilostane at the same time. I asked her why they did this because the manufacturer says not to give dogs on ACE trilostane, and her response was that it is OK to do it, and that Samson was "sensitive" to benazapril so they took him off of it. Then she added that if his proteinurea doesn't improve, they might have to put him back on benazapril!

Samson has had two ultrasounds, numerous CBC work-ups, 2 LDDS tests (at his gp vets), a ACTH, thyroid tests (on my request--low T4ED but normal TSH) and many BP monitorings (his BP is seriously high even on amlodipine) and we don't have any answers other than he is definitely Cushing's, has high BP, probable pancreatitis and possibly kidney disease. I have spent over $5000 in just over a month trying to diagnose and treat him, and I will gladly pay more, I just need some answers. Does it usually take this long (since 12/24) to get things rolling? He's been on 9 mg trilostane 2 x per day since 12/27 (and he is about 19 pounds.)

He has HORRIBLE gas today and will not poop. I called there at 5:30 am with a request for a call, and the vet's response was she couldn't diagnose him unless I bring him in and probably give him an ultrasound. I pointed out that he just HAD an ultrasound and she looked at her paperwork again and said "oh, it looks like his bowels were OK but he had possible pancreatitis." I called back and am waiting for a response about how to treat his gas (which I believe is what is bothering him.) I also stated that he has been eating nothing but cooked chicken since his crisis because he won't eat anything else, and she said it is OK so long as he is eating (but is it? since he has never been picky ever before.)

I am so frustrated. I nearly cried when I called the new vet's. I asked point blank if I would be seeing an IMS and if the IMS would see me on a regular basis or if I should expect to be seeing a vet tech (no offense to vet techs.)

So sorry that this has become a rant. I just know my pup isn't feeling good and I am hoping that I am doing what I am supposed to for him.

[Squirt's Mom]

MODERATOR NOTE: I have merged your post about being away into Samson’s original thread. We normally like to keep all posts about each pup in a single thread as it makes it easier for members to refer back to the pup's history when needed. Thanks!

[doxiesrock912]

I'm glad that you switched IMSs. The previous one is clueless.
Canned pumkin from the baking aisle is really good for calming stomachs.I would not use it until Samson has a bowel movement though.

Daisy has chronic diahrrea. Ask the new vet about a low, daily dose of Tylan (TYLOSIN) powder. It's a natural antibiotic that can be used long term.

[goldengirl88]

Welcome to the forum. That was not a rant so don't worry. If it was, we do rants too! I feel your pain and torment. A lot of us have been thru similar circumstances. After all you have paid, and been thru you are deserving of much better treatment than what you have gotten. I would be calling the IMS and demanding a sit down discussion. You then need to have a list of all your concerns. As for the Ace being used with trilostane Dechra specifically told me that can be dangerous as it can play havoc with the electrolytes, which would be
In line with the potassium problem. How are the clinical symptoms on the 9mg dosage twice daily? Are they improved? As for jUST eating chicken, your dog will
need vitamins and minerals added that are essential for their health. I hope you
get thru this, we are all here for you. Blessings
Patti

[Trish]

My ears pricked up reading your thread as my boy has similar issues with BP and kidneys. He is even on the same drugs of Benzapril and Amlodipine. Apart from a few times when I think his BP has gone a little low he has been fine on them. But he is not on trilostane as he had an adrenal tumour that was not cushings related. He is 30lb and takes 1.25mg Amlodipine twice a day and 5mg of Benzapril at night.

Samson's blood tests do indicate renal problems and in that case they really need to work aggressively controlling his BP as that can be a huge contributor to kidney issues. High BP can and does occur in cushings dogs so this is a tricky case and your current team does not seem to be up to par in helping you sort this out. There are other things you can try with renal problems, I have not read back far enough to see if a urinary protein creatinine ratio has been done on Samson but hopefully your new IMS will do that to get a better handle on where his kidneys are at. Dietary modifications and things like fish oil can also help.

My dog also gets gassy on chicken, plus foul breath. Have his poops been normal up to now? I am wondering if you need to change the diet up a bit, hard when they will not eat anything else though like Samson is doing. Is he on any supplements as long term he will need his nutrients and vitamins. Although I am sure if Flynn had his choice he would eat chicken all day long, so I understand your frustration. I hope they have some answers for you today so he can get some relief from the gas.

I totally agree you need to see a new IMS, so pleased you have made an appointment for next week. Good luck and I am hoping you receive better support from the vets next week.

[SamsonsMom]

Wow, thanks everyone for the quick replies!

I had Samson on tylan for 6 days because he did have diarrhea (on tylan from last Friday through this Wednesday) and took him off of it because he wasn't going #2 more than once a day. He is not a fan of pumpkin but he will eat other squash -- go figure!

His clinical signs of Cushing's have changed in so much as he is asking to go out less but pees buckets when he does. He is drinking less often during the day, but drinks a lot when he does (he was up three times drinking last night, but I think it is due to his stomach upset.) I am really begining to wonder if the kidneys are what needs to be addressed -- his creatinine was 1.6 at last check.

We really need to get his BP under control. On Wednesday it was 200 and that was while he was on 1.5 tabs of amlodipine (2.5 mg tabs) 2x per day. They increased his med to 1.75 tabs 2 x per day. He was standing around confused and shaking a lot and the IMS said it sounded like BP spikes. He is not shaking at all now.

[Trish]

So that's a total of 8.75mg Amlodipine each day, divided into two doses? That does sound quite a hefty dose. With Flynn only getting a total of 2.5mg per day and he weighs more than Samson.

Hmmm hearing about the BP spikes makes me consider adrenal tumour like what Flynn had, pheochromocytoma. I think I have read you had adrenals checked though and were they both enlarged but no tumour?

I would get them to check his eyes too, when Flynn's BP was high like Samsons he got torturous blood vessels at the back of his eyes. It resolved once his BP came down.

[SamsonsMom]

During his second LDDS my gp vet actually thought Samson was adrenal dependent because of his slightly odd results so we did an ultrasound. I was under the impression that Samson is Pituitary because his ultrasound showed both adrenal glands were enlarged. I saw some posts about pheos the first time I came to this board--they would be able to see them on the ultrasound, wouldn't they?

[Trish]

Sometimes not, when Flynn was diagnosed it was on ultrasound. But when they looked back at a CT abdo scan he had a year prior they think they could possible see it as a teeny tiny thing that they would usually not worry about but it was only in retrospect they realised the significance of it. He had three more ultrasounds over the next year and it was not seen at all on the first two and then was picked up on the third. So they could like undetected like his for a while, on the third scan it had invaded out the adrenal and into the vena cava. But he has had successful surgery to remove it which is the good news!

I believe from what my vets and IMS told me at the time, if it is a pheo causing BP problems then the drug that works best on the BP is phenoxybenzamine. While we were waiting for his diagnosis the IM put him on Benzapril initially, he did have a funny turn one day which they though was due to that drug and they swapped him to phenoxybenzamine which dropped his BP over a couple of weeks. Were Samson's ultrasounds done on a top rate high resolution ultrasound machine? The scanners at local vets are often not clear enough to see little changes. Flynn's adrenals were both enlarged too on his scans prior to surgery. But he always suppressed on LDDS. One of our other members here Kim, had a dog with the same tumour. She had false positives on LDDS and it took quite some time to come up with the diagnosis which she got from memory (correct me if I am wrong Kim) from a specialist vet teaching hospital. But they can be tricky to diagnose, hypertension is a flag though. It can sometimes be episodic as with Kim's dog Annie, or constant like with my Flynn. REmember BP can be up even with just cushings so I do not want to alarm you with this, but some of what you are saying was quite similar to how Flynn presented ie proteinuria/renal/BP so worth a thought and discussion with IMS next week

I also noted on your bloods his glucose was a bit high, has that been repeated to rule out diabetes?

[SamsonsMom]

Hi again Trish,
All of Samson's glucose tests came back negative thankfully.
I believe the first 2 ultrasounds which were done at my GP vet were regular ones but I am not sure--I have copies so I will see if it says they are high res or not. The one at the IMS should be high res--however, they were done at the emergency room by a regular vet, and then reviewed by the specialists.

I will definitely ask about the possibility of a pheo on Tuesday because I really feel something isn't right with Samson's case, and my gp vet who is actually pretty good, said he felt Samson's case was unusual. The plan was to get Samson to an IMS all along--things just sort of spiraled out of control all at once. When I first came to this board, I told a friend who is not a vet but who has pretty keen diagnostic skills that I wondered if S has a pheo. She mentioned it to her vet (who is treating her dog for an auto immune disease) and her vet seemed to think this was definitely something to look into.

How old is Flynn? I am glad the surgery was helpful. I know one of the things we will be faced with is *what* we should pursue treatment-wise if it does turn out to be a tumor since Samson is ~ 13 years old, has a heart murmur, possible kidney disease, and high BP. :confused:

[Trish]

Glucose 162 (high); ref. range 70-138


Hi :) that is the glucose I had looked at which is a bit high, glad to hear they are normal now.

Flynn is 12 now, he was 11 at time of surgery which was 14 months ago. Pheo and adrenal tumours on the whole are fairly rare, although benign nodules are more common. Hopefully this is not the case but just wanted you to ask your vet the question when I saw the BP problems. Good luck for Tuesday, I will be keeping an eye out for results! :)