My Milo has Cushing's

[Sneji]

Hello lovely people,

Glad I found this amazing forum. I want to apologize in advance for my bad English.
Me and my almost 13 year old jack russell Milo are from Bulgaria.
I will try to briefly tell our story.
Ever since he was little, my Milo has been very attached to me and doesn't let anyone get close to me. He went through training, but there was not much result. Whatever we've been through with him, he's my boy. He was hardly sick.He was always greedy and very muscular. However, this summer it struck me that he started drinking a lot of water and urinating. He drank 2.5 liters of water per day at a weight of 6.5 kg. He became even more greedy and the muscles of his hind legs began to weaken.
I took him to the vet and they ran tests on him. What went out of the norm is:

LYM 0,51 0,83-4,91
MON 0,12 0,14-1,97
MCHC 392 300-380
PLT 562 117-490
MPV 5,9 8,0-14,1

ALAT 94,3 8,00-57,0
PRO 0,15 g/l
SG 1,010
His electrolytes were normal.
After these results, the vet decided to test for Cushing's (LDDS)
Results they are;

Pre-dose 11,02 ug/dl
4H Post – dose 7,32 ug/dl
8H Post – dose 7,81 ug/dl

So Milo started taking Vetoryl 5mg morning and night for 20 days now. His appetite hasn't diminished much, but he's always been a glutton. Drinking water decreased to 1.2 l-1.5 l.
However, it seems to me that his muscles are weakening more. On the tenth day, he was tested for urine and only PRO 0.30 g/l came out.
I said that on the 30th day they will run urine and electrolytes again. Unfortunately we don't have a test (ACTH) and I don't know how they will monitor cortisol.

Thank you for listening to me. I am open to any ideas and advice on how to help my treasure.

[labblab]

Hello and welcome to you and Milo! We’re so glad you’ve found us! And you don’t need to apologize for your English at all — it is excellent. There is no way I could write as clearly in another language, myself. You have done such a good job of introducing Milo to us.

I will come back again later when I have more time to answer your questions. But I wanted to quickly have the chance to at least welcome you to our group here, and to thank you for the information that you’ve already given us. So I will be back to write more soon.

Marianne

[Sneji]

Thank you very much for the kind welcome Marianne!
I look forward to your reply.

[labblab]

OK, here I am back again. Once again, thank you for giving us all this information on Milo. From what you describe as far as his behavior changes and also his lab results, I do understand why your vet tested for Cushing's. I'm assuming that the ALAT lab value corresponds to what we see listed as ALT here in the U.S. That is a liver marker which is often elevated with Cushing's. There is another liver marker that is listed here in the U.S. as ALKP or ALP which is most frequently elevated in dogs with Cushing's. I don't see any number on Milo's lab result that would likely correspond with that value, so I don't know whether that marker was tested by your lab or not. At any rate, in addition to the high ALAT, Milo had elevated platelets and also the specific gravity of his urine was on the low end. Both of those results are consistent with Cushing's.

The results of the LDDS are also consistent with Cushing's. Sometimes the pattern of the LDDS results will point towards a pituitary tumor as being the cause of Cushing's for a dog with the disease. However, in Milo's case, even though the test results are consistent with the Cushing's diagnosis, the pattern of his results could be caused by either a pituitary or an adrenal tumor. It would take further testing to try to figure that out. Here in the U.S., in this situation, an abdominal ultrasound is the most common next step if an owner wants to know more about the type of tumor. The ultrasound imaging of the adrenal glands will show whether or not a tumor is found there. Owners often ask for an ultrasound if they think they might consider adrenal surgery to remove a tumor if one is present. Removal of an adrenal tumor can provide a total cure of Cushing's. However, here the surgery is very expensive and very risky. So the majority of owners go ahead with medication treatment. Vetoryl is used to treat Cushing's caused by either a pituitary or an adrenal tumor. And the starting dose you are giving Milo seems to be appropriate for his weight. So further diagnostics to distinguish between a pituitary or an adrenal tumor may not be of any interest to you. But I did want to mention the fact that we cannot tell what type of tumor he has based on the LDDS test.

Finally, to answer your question about Vetoryl monitoring testing, an alternative to giving an ACTH test is for your vet to simply test Milo's resting cortisol level one hour *before* he is scheduled to receive his next dose. Milo's cortisol level was tested three times during the LDDS test, so your vet should not have any trouble with performing that simple blood draw once again at any time. Here is an informational chart that explains how this monitoring test is done:

https://drive.google.com/file/d/1aQO-aek8tZHFyehNYAoW81hCSIpmiXNe/view?fbclid=IwAR194mX2KFv2SsptINmTmkzyRhb97IG87EeV Ak1ubAxplZWjCrdlG4CE7p0

Take a look at this chart, and let us know if you have any questions about it. Also, here is a link to the thread where this chart is found. In addition to this chart, the thread has a lot of other helpful information about treatment with Vetoryl.

https://www.k9cushings.com/forum/showthread.php?8925-GENERAL-GUIDELINES-for-Vetoryl-(trilostane)-Dosing-amp-Monitoring-with-ACTH-Stimulation

So again, take a look at all this information and do tell us if you have more questions. Before I end this note, I want to mention that it is possible that Milo's hind end issues may be worsening after starting the Vetoryl if he is suffering from any arthritis in his hips or back legs. For the most part, Vetoryl treatment is helpful to dogs with Cushing's. But one way in which the previously high cortisol levels may have been *helping* an older dog is if the high amount of circulating cortisol was easing the inflammatory pain of arthritis. Once the cortisol levels are lowered, the arthritis pain may worsen and an alternative pain-killer may need to be prescribed. That may not be the problem for Milo at all, but I did want to at least mention it.

OK, I'll end for now, and once again we're so glad you've found us!

Marianne

[Sneji]

Hello Marianne,
I am extremely grateful for this comprehensive answer.
I forgot to mention in the previous post that Milo had an ultrasound. No adrenal tumors were seen. He has an enlarged liver.
I will ask about an alkaline phosphatase test.
I gave him a urine test today and the results are:
PRO 0.15 g/l
CA <=1.00 mmol/l
SG 1.015
CR 8.8 MMOL/L предната урина беше 17,7 mmol/l
PRO/CR <0.2

I'm going to run an electrolyte panel tomorrow and we'll do a blood prick cortisol test.
The vet was worried that he was losing muscle mass on his legs and back so quickly and asked us to reduce the dose to 5 mg, but in the evening. I have no explanation why evening.
When I get the results tomorrow I will write them immediately.

Thank you very, very much!

[Sneji]

Hello again,
Milo had his blood taken today for a cortisol test and it came out at 10.2 ug/dl and his electrolytes are norma.This is 24 hours after the last dose of 5 mg vetoryl.. He has been on only 5 mg in the evening for two days.He lost weight in 20 days with 300 grams (the vet therefore reduced it to 5 mg), I don't know if it is correct.

[labblab]

Again, I’m sorry for the delay in getting back to you, and especially sorry that Milo is not doing better right now. It is hard to know exactly what is continuing to cause the weight loss and weakness. As you’ll see in that monitoring chart that was in my earlier reply, his cortisol level was not too low when it was tested (10 ug/dL). In fact, it was much higher than you would like (ideally less than 5 ug/dL). I know this was two days after his dose was dropped to once a day instead of two. So we don’t know what his cortisol level would have been on the higher dose. Still, I doubt that that his cortisol was likely *too* low earlier even when on the higher dose.

One thing that I’m confused about is why your vet told you to cut back to the single evening dose instead of giving the one dose in the morning. The makers of Vetoryl recommend giving the medication in the morning when only one dose is given each day. This makes sense to me because, in that way, the dog is benefiting the most from the effect of the medication during the day when he is active, instead of at night when he is sleeping. By the time he awakens in the morning, the benefit from the medication may already be wearing off. So I would ask your vet why he has chosen to give Milo his single dose in the evening.

And truly, given that relatively high cortisol result, it seems possible that Milo actually needs to be on a higher overall dose of the Vetoryl rather than a lower dose. His symptoms may be continuing to worsen because his cortisol remains quite elevated at all times. I surely understand why your vet is being so careful to avoid overdosing with the medication. But given that cortisol test result, it seems possible that Milo’s main problem is that his cortisol has not yet been lowered enough to gain control of the Cushing’s.

Is Milo still on the lowered dose, and how is he doing now?
Marianne

[Sneji]

Hello Marianne,
After we reduced the dose and he immediately increased his water drinking and urination again (he had reduced them a little - not to the desired level of course). We increased it again to 5 mg in the morning and 5 in the evening and it was immediately felt. I continue to follow it like an eagle and will keep you updated on what happens.
I do have one question though: When they did the one time blood test for the cortisol test they told me the normal range was 6mg-26mg??(I had it done at another lab because our vet said that this sample wouldn't give us any information about his cortisol?!?)
I'm getting so confused now.

Sneji and Mailo

[labblab]

That range of 6 - 26 ug/dL is the normal range that you’d expect to see for a dog who does not have Cushing’s. So that’s the range that is commonly found on laboratory printouts. When a dog with Cushing’s is being treated with Vetoryl, however, you are looking for an entirely different cortisol range. I’ll give you the link to the monitoring chart once again:

https://drive.google.com/file/d/1aQO-aek8tZHFyehNYAoW81hCSIpmiXNe/view?fbclid=IwAR194mX2KFv2SsptINmTmkzyRhb97IG87EeV Ak1ubAxplZWjCrdlG4CE7p0

Please let me know if you can’t get this chart to load for you, and I’ll try to find a different way to link it for you. But if you can see it, you’ll find that that there are specific instructions about how to give Vetoryl to a dog, depending on the pre-pill cortisol level. If your vet doesn’t know about this, hopefully you can tell him about it, as well.

[Sneji]

Thank you so much Marianne,
I will look into it very carefully!

[labblab]

I’ve been thinking about Milo and hoping that he’s doing OK? If you’d like to add an update, we’ll be anxious to read it.

Best wishes, as always.
Marianne

[Sneji]

Hello Marianne,
I wish everyone a very healthy and happy year with all the fluff.
Marianne sorry for your loss I had a hard time reading it. You are an incredibly good and strong person.
Milo is doing well on 10mg so far. What I notice is that some crusts appear on his ears and when I touch them a little harder it clearly hurts because he whimpers.
In terms of drinking water he has decreased but his food is still the same (but he has always been more gluttonous.) Since he is alone during the day he has diapers that he uses and I get the impression that he occasionally eats his akita .
After two weeks we have to give urine, electrolytes and once cortisol.I will definitely share the results.
Thank you for your concern, thank you for being there, thank you for giving me strength and such invaluable information.

[labblab]

Thank you so very much for your kind words. I *really* appreciate them!

And thanks so much for this update on Milo. We continue to wish you both well, and we’ll be anxious to hear how his next set of test results turn out.

A happy new year to you and all your family!
Marianne

[Sneji]

Hello everyone,
Yesterday we ran urinalysis and by the end of the week we will run an electrolyte panel.
I'm a little mad at his doctor because the urine results were uploaded to the clinic profile but she didn't call me to discuss them.
Here they are:
PRО 2+ 1,00 g/l
CA <=1.00 mmol/l
SG 1.015
CR 8.8 MMOL/L
PRO/CR <=0,4

I am concerned about the high protein.

These spots that started appearing on his ears, the doctor said they were fungus.
Now I smear the ears with chlorhexidine.
He still drinks a lot of water in my opinion, and he urinates a lot, although it is much less than at the beginning.
Currently, he continues to drink 10 mg of Vetoryl in the morning.

Hearty greetings from us

[Harley PoMMom]

Here they are:
PRО 2+ 1,00 g/l
CA <=1.00 mmol/l
SG 1.015
CR 8.8 MMOL/L
PRO/CR <=0,4



Are these results from a regular urinalysis and an UP:C (urine protein-creatinine ratio) test?

[Sneji]

Are these results from a regular urinalysis and an UP:C (urine protein-creatinine ratio) test?

Yes, these are the results of a regular urinalysis.

[Harley PoMMom]

Да, това са резултатите от редовен анализа на урина.

I'm sorry, I don't understand this post.

[Sneji]

Sorry, the translator did not translate what I wrote.
Yes, these are the results of a regular urinalysis.

[Harley PoMMom]

PRО 2+ 1,00 g/l
CA <=1.00 mmol/l
SG 1.015
CR 8.8 MMOL/L
PRO/CR <=0,4


I'm not sure about interpreting these results, to me that PRO/CR <=0,4 looks like the results from an UP:C (urine protein-creatinine ratio) test, and if it is, than 0.4 is within the reference ranges, I would definitely ask the vet about this. Another test you might want to perform is the SDMA, it is sensitive for kidney disease so you may want to talk about this test with your vet as well. Sorry I couldn't be of more help.

Hugs, Lori

[Sneji]

Thanks Lori,
I will ask about the SDMA test.

Hugs from us too

[Sneji]

Hello from me and Milo,
my boy is still behaving.
We ran urea and creatinine, which came out normal. This prompted the vet to increase Milo's dose with another 5mg of vetoryl(total 15 mg) as he continues to drink a lot of water, but we have been cautious up until now because of his kidneys.
His blood yesterday was 180/100. I give him irc- vet kidney supplement.
We will do the SDMA test tonight, but it will be a few days because they are sending it to Germany.
That's it for now from us.
Hugs to all

[labblab]

Thanks so much for this update! We’re very glad to know that his urea and creatinine is normal, and it will also be very good to get the SDMA results as well. With this new dosing increase, Milo is now getting around around 2 mg. per kg. (or 1 mg. per pound), so that’s an amount that seems reasonable to me, given his weight and continuing thirst. Do let us know when you get these additional test results, and in the meantime, ongoing well wishes to you two!

Marianne

[Sneji]

Hello to all of us,
My boy is fine with the 15 mg dose.
Drinks less water, respectively pees less.
I also give him a kidney supplement.
The SDMA test is normal. With a reference limit of <0.65 umol/l, he has 0.33 umol/l, which makes me extremely happy.
Now it remains to increase the muscle mass a little and I still notice shortness of breath.

Greetings and kisses from us and good health to all the babies.

[Harley PoMMom]

That's awesome his SDMA results are normal! With his Vetoryl dosage increase an ACTH stimulation test should be performed to make sure his cortisol is not too low, even though he's acting fine his cortisol could still be in the low range.

[labblab]

I agree with Lori — that’s awesome news about the SDMA! As far as monitoring the cortisol, I think you’ve told us that an ACTH stimulation test is not available to you, but I believe you were able to have a pre-Vetoryl cortisol level checked before. As Lori has said, for safety’s sake it’s always good to have the cortisol level checked again after a dosing change. So hopefully that can be included in his next check-up, too.

Marianne

[Sneji]

Hello from us, just dropping by to share how my treasure is doing. Every day is different, in some he is a little more active, in others he is a little more sleepy. He eats well, drinks water a little above the norm still. However, a week ago he felt quite bad and did not want to get up. I took him to the doctor. The blood tests showed some kind of inflammation. They put him on a system and he drank an antibiotic for 7 days. The ultrasound did not show anything alarming. There was no diarrhea, vomiting. they suspected a vascular accident. After starting the antibiotic, she got better on the second day. Now she is fine and I am very happy.
This is at my grandfather's :)))))
Hugs from us :)

[labblab]

It’s so good to hear from you again! I’m so sorry that Milo was not feeling well, but thankfully it sounds as though everything is now back to normal. Thank you so much for giving us this update, and I surely hope that Milo remains healthy and happy!

Best wishes to you and all your family!
Marianne

[Sneji]

Hello again,
My joy was short-lived. My Milo has had a 4 root tooth inflammation since last night. He is currently on antibiotics again.
I am concerned that the only solution is to extract this tooth. I'm not sure if she'll make it and I'm very sad.......
Doctors are also worried….
In the last tests, the platelets were 773 with an upper limit of 490.
I find it hard...

[labblab]

I am so sorry to read this news. I surely understand why you’re worried, and I am worried for your sweet boy, too. I will be hoping that the antibiotics will take care of the problem once again! I will keep checking here to see how things are going, so please do let us know.

Sending my strongest healing wishes to dear Milo,
Marianne

[Sneji]

Thanks a lot for your support….
She means a lot to us. Everyone here is amazing!

[Squirt's Mom]

I would be worried sick myself. Please keep us updated as you can.

Hugs and gentle belly rubs,
Leslie

[Sneji]

Hello,
I am happy to say that we now have an ACTH stimulation test.
Of course, I immediately gave my Milo the test and the results are as follows:
Pre 2.26 ug/dl
Post 5.44 ug/dl
I'd love to hear your opinion.
Hugs from us

[labblab]

Those results are excellent — right where we want them to be!!! This is very good news :-)))).

How is Milo doing, otherwise? How did things end up with his tooth?

Marianne

[Sneji]

The tooth infection went away after 10 days of antibiotics. Everything is OK for now.
In general, the only thing that worries him is that his muscle mass is increasingly disappearing.
Otherwise, my boy is a hero :)))
Thanks for the support and strength you give me!

[Squirt's Mom]

I'm so glad you were able to find an ACTH test and get your sweet hero tested...and the results are wonderful! Losing muscle mass is common in Cushing's but it can be regained in some dogs. Water therapy (simply swimming or walking in water) can do wonders for muscle mass. Gentle walks are good, letting the dog tell us how much they want to walk then asking for a few more steps before stopping can also help rebuild muscles. The elevated cortisol makes the muscles weaker but as it is lowered they can function better. I hope Milo continues to do well and you are able to find ways to help him regain strength.
Hugs,
Leslie

[Sneji]

Thanks so much Leslie,
Yes, we do our best to walk more. Although he looks (as my son says) like a skin and bones dragon, he is quite energetic.
He is eating and so far he looks like an old dog.
I hope we have a lot more time with him :)
Hugs from us too!

[Sneji]

Hello again,
I'm just stopping by to write that my Milo continues to take his vetorila and the boy is generally feeling good.
It will soon be one year since the diagnosis.
The only problem is that it is very weak. When he was diagnosed it was 6.8 kg, a month ago it was 4.8 kg, and to date it is 4.4 kg.
Otherwise, he is energetic, cheerful, eats normally, walks...I can't figure out why he's losing weight so fast?
And actually the most important question, after losing so much weight is not 15 mg of vetoril too much?

[Harley PoMMom]

The only real way to tell if his dose is too high is to have an ACTH stimulation test done. Another option could be to skip his Vetoryl dose for a day or two and see if this helps, however since he is eating/drinking normally without any diarrhea or vomiting, I really do think an ACTH test would be more helpful.

[labblab]

Hello again! I just now saw your new photos of Milo, and I can see that he is indeed *very* thin. That much weight loss does seem like a worry to me. If he’s still eating the same amount of food, it’s very hard to know what would be causing him to lose so much weight. Has the vet seen him recently? I think a vet visit would be very important right now. Like you, I would worry that Milo’s dose of Vetoryl ought to be reduced. But additionally, it seems as though something must be going on to cause such a weight loss. The reason may have nothing to do with Cushing’s. But either way, I’d want the vet to have the chance to examine him to try to determine the cause, and also to perform any necessary testing as Lori has suggested.

Please do let us know if the vet is able to find out a reason for this. And best wishes to both you and Milo, as always.

Marianne

[Sneji]

Thank you very much for your support!
Next week we will be doing a lot of research to see what is going on with my boy.
I will keep you in touch.

Hugs from us!

[Sneji]

I took Milo to the vet today. He suspected pancreatic insufficiency. They took his blood for a test and now we are waiting. The ultrasound showed that everything was fine, except for a lot of gas in the abdomen.

Kisses and hugs from us!

[Harley PoMMom]

Do you know what blood test they are performing to check the pancreas?

[Sneji]

It says on the documents 3002EPI Profile - AST, ALT, albumin, sodium, potassium, chloride, calcium, glucose, TLI-test, vitamin B12

[Harley PoMMom]

Sounds like they may be checking for exocrine pancreatic insufficiency. Are Milo's stools normal?

[Sneji]

For me, they are absolutely normal in terms of color and consistency

[Harley PoMMom]

That's good news that his stools are normal, the majority of dogs with EPI have greasy or foul-smelling stools.

[Sneji]

Hello, everyone,

Adding an update for my Mailo.
The examination for pancreatic insufficiency (EPI) is normal.
I changed vets because his vet quit and the next ones didn't pay attention to him.
At the new vet we did a diabetes test - negative.
He listened to his heart on a stethoscope and found an arrhythmia. He looked at it on echofraf and saw a torn chord.
The liver and kidneys are fine.
The only thing that worried him was his intestines. He said that he had very rapid peristalsis, a lot of gas and a slight inflammation of the small intestine.
So far he only prescribed gut flora supplements, but to be honest he mentioned intestinal lymphoma which worried me.

Greetings and hugs from us!

[Harley PoMMom]

Thanks so much for the update on Milo, I'm glad to see that the EPI test was negative, no diabetes, and his kidneys and liver were fine. Does he have a plan for the heart? Is Milo still eating normally, how about his drinking and urination?

[Sneji]

I'll have to make an appointment with a cardiologist.
Regarding feeding - normal. He has always eaten everything and is not capricious. Drinking water has decreased a lot and so has urination. I expect they will deliver a test ACTH, because here in Bulgaria it is very difficult, and we will immediately track the cortisol.
Тhe supplement he was given to drink at the moment Enteromicro complex.

[Sneji]

Hello again,
I haven't joined because there were no changes with my beloved Milo. On 25.01.2024 he turned 14 years old and I have never seen such a fight for life. Very thin (started treatment November 2022 6.4 kg, currently 4.5 kg. Almost no muscle mass. Eats well. Our doctor informed me that yesterday was his last day of work and he managed to find us to do an ACTH test, as we did biochemistry and complete blood count.
Let me just add that since last week he has been having problems with his tooth again and is on antibiotics.
Here are the half-weekly results:
Pre 5.11 ug/dl
Post 5.25 ug/dl

However, biochemistry is by no means optimistic:
PLT 894 /117-490/
MPV 6.4 /8-14/
CREAT 20.5 /45-150/
GGT 12 /<=6.4

The only thing he decided to add was a liver supplement :(

Thanks for having you!
Kisses and hugs from us!

[labblab]

We are always grateful when you give us an update on sweet Milo, so thank you once again. Even though Milo’s body isn’t perfect, his spirit is so strong! I wish him a very Happy Birthday :-)))).

That was so kind of your vet to track you down for one more set of tests. I’m so sorry that it sounds as if he won’t be working any more, and I hope you’ll be able to find a new vet. I know that will not necessarily be easy for you. But you’ve done such a wonderful job of taking care of Milo throughout this illness, and I hope you’ll be able to find another vet soon.

As far as his ACTH test, those results are good. We are very glad to see that. Like you, I wish all his other results would also come back into normal range, too. But overall, Milo is doing his best to stay strong. And we’ll surely be hoping that his tooth infection will clear up again soon.

Thanks again for your report. And as always, best wishes to you and Milo!

Marianne

[mytil]

bumping up