Skippy has passed; 12 y/o Yorkie with likely pituitary tumor (Trilostane)

I'm following along too, and sending huge loving bugs.

Dehydration can cause a high BIN level and can even increase the creatinine temporarily. Getting fluids in by an IV or sub q would help with dehydration.

With kidney disease the phosphorus level will climb and when it gets elevated it does cause nausea. Did the IMS mention any increase with his phosphorus?

Hmm, yes if he is dehydrated then that could affect his kidney values (BUN and Creatinine) as Lori mentioned.

5ug is a good place to be cortisol wise if on vetroyl.

I've always been iffy as to whether to continue vetroyl if kidney problems arise, since dechra has said not to give to dogs with renal disease.

You don't want dehydration for sure. Would it make a difference if he were to get an iv for fluids do they think? Then take him off the vetroyl and recheck numbers in a week?

Thanks you guys. No mention of phosphorus level. I really wonder about the issue of dehydration; he continues to drink A LOT. Also, I give him beef broth in his food as he sure doesn't like dry kibble. I haven't measured water lately but I will. And, now that he's off Vetoryl I would expect him to drink even more. Also, while stool was firm this morning and I did't dose him with Metronidazole, soft stool has returned. No mention by IMS of further hydrating him. He is eating today but still very lethargic.

The "5" was basil cortisol. (Normal range is 1 -6.) On 10/9 it was 3. I am uncertain as to whether basil cortisol means anything with a Cush pup. My error was to not request a stim on 10/9 after he had been on 10 mg BID for three weeks. He tolerated that well but still had clinical symptoms of Cushing's OR maybe it was the kidney problem and not the Vetoryl increase to 15mg. But the dose increase was based on what they were "comfortable" with based on clinical signs and I agreed. We are where we are. If I see further signs of dehydration before next week, I'll call them immediately. Since he's off Vetoryl, I could try offering the Royal Canin Select and if he won't eat it. let him go without food until he gets hungrier. I just don't know. As he get's sicker, I get" stupider".

I know that feeling. Well normally the post is higher than the base. So he isn't being overdosed. That means the 15mg is likely okay. And if drinking that much probably not dehydrated either.
It is all so dang complicated to try and figure out. Grrrr

Yes, but I so appreciate your and everyone's support. Six outs so far tonight; but he is drinking steadily and ate including Royal Canin so I hope he's stable for the moment. Must sleep so I can do the 4 am shift!
Thanks heaps!

Hoping that skippy is doing okay. Is he still eating? How is the water levels doing?

Skippy is eating, drinking, peeing, and no diarrhea at the moment. He is much less lethargic, but no ball of fire. He does want to get up on sofa, bed, etc. and puts his paws up but won't try to jump. He shows no signs of renal failure but I have no idea of how he is doing overall. He will be tested Tuesday early AM; I'll post after I know more. Thanks for your support!

Well this sounds encouraging. Skippy is blessed to have you in his corner.

Kathy

This is super positive! Great he is eating, no diarrhea, and sounds much more energetic than he was.

Molly completely quit jumping up eventually and would put her paws up and wait for her "lift" I'd say, you need a lift up molly and she'd just look and wag her tail. If you ignored her she would eventually bark at you and put her paws back up. Which I always found just hilarious, but then it was all part of Diva molly and how she ran our lives.

Skippy is letting you know in his own adorable way, exactly what he wants you to do.

Oh my Carole, what a journey you & Skippy have been on! I'm so happy that your sweet, strong boy is doing better-you are both amazing! what may seem like small victories mean so much, don't they...
all the best to to you both

Thanks Annie, Kathy, Sharleen and everyone for your kind comments and support. Skippy spent nearly 12 hours at Purdue yesterday and enjoyed a fire drill whereby all of the peeps and pups were required to leave the clinic! Might as well start with the Cushing’s – he still has it of course. Fasted ACTH Stim #’s: pre – 10 and post – 30 plus. He’s been off Vetoryl for a week and counting. The IMS who saw Skippy yesterday was going to consult with Dr. Scott-Moncrieff, who’s away, regarding further treatment of his Cushing’s.

After another CBC yesterday, Purdue called requesting approval for another ultrasound. (This was number four in the past year.) I guess the good news is that the ultrasound revealed no masses, stones or other abnormalities. They characterized his condition as chronic kidney disease based on the last two BUN and Creatinine results but offered no firm opinion as to stage, maybe Stage II based on Creatinine of 1.9 yesterday and 2.7 on 10/24. Skippy’s liver values remain high but typical for uncontrolled Cushing’s. Pancreas and gall bladder values are high as well. Sinking into gloom, I spent my day researching kidney disease, a condition that I knew little more than zero about. Tonight, I received a call from the IMS who had consulted at length with Dr. Scott-Moncrieff and had gone back through the past year of testing. She found that his kidney values, especially the BUN, have been widely varied on both the high and low side. She now thinks that these values combined with his frequent episodic bouts of diarrhea are elevating his kidney numbers, perhaps creating false positives. They now suspect that he has ulcers in his digestive track that may be causing kidney, pancreas, gall bladder values to increase. I started him on Urisodol (sp.?) yesterday. She will prescribe another antibiotic for the anticipated diarrhea, Prilosec tablets, and another drug that I honestly can’t remember except it’s administered in slurry. Scott-Moncrieff wants me to start him back on Vetoryl 15mg twice a day, immediately. They sent me home with six kinds of renal kibble and when mixed with low fat, low salt beef broth, he’s eating it. Skippy is very hungry and is peeing like a drunken sailor, much more than before stopping the Vetoryl. I was up at 4, 5, and 6 for outs and he still peed once in the house. Total outs overnight were 7 or 8. I am very scared to restart the Vetoryl but will tomorrow; I’m equally scared, maybe more so, that he may have kidney disease as that is likely game over, sooner than later. Skippy remains about the same, pretty lethargic, will walk with gentle encouragement, but sleeps his days away; he will be tested again in two or three weeks and Scott-Moncrieff will see him then. I am well aware that Drecha recommends stopping Vetoryl when kidney disease is diagnosed, but Purdue is confident that they can manage him regardless. I wish I knew more, not to second guess, but just to understand more. I did ask about the SDMA test and the response was that it is used for diagnosis but they could do one and send to IDEXX, if I request it. I can post his blood and urine results but didn’t want to make this post longer still. If those of you who know light years more than me (probably everyone) have thoughts, ideas or feedback, I would be grateful for your input.

I've got nothing right now but hugs for you. All you want.

I'll sit with you and wait for someone else to come along.

Hey Doxie Mama, you are so good and kind. Big thanks to you and hugs back!

Personally, I would want the SDMA. And I would want those results before I restarted the Vetoryl. Dechra specifically says it is not to be used with kidney or liver disease. So I would want to be armed with all the info possible so I could decide how Skippy would want me to deal with things. :) But others with much more understanding of this drug than I may feel differently....just sharing what I would do in your shoes. ;-)

You're a good mom and I know whatever you decide will be done out of love for Skippy.
Hugs,
Leslie

Hi Leslie,
The IMS at Purdue is supposed to email me today with further instructions. I will ask if I could run Skipp over for an SDMA; if not there I could call the local vet. The new pharmaceuticals are now awaiting my pick-up. I haven't started the Vetoryl, yet. He is now scheduled for a recheck with Scott-Moncrieff on the 21st. Thanks for your opinion and I surely don't disagree if I can make it happen. I do think Purdue thought he might be in an Addison's state. Thank you,

Carole

Hi Carole,

You and Skippy are an inspiration to us all, I'm in awe of the courage you both are showing while dealing with everything that you both are going through...sending super loving hugs to you both.

Harley was diagnosed with kidney disease so if there is any way I can help please let me know.

Other things besides kidney disease can cause elevations in the BUN and creatinine. Dehydration, UTI, a high protein meal, and even some medications such as the ones used for high blood pressure can make those levels increase So, I agree with Leslie's recommendation on having the SDMA test performed to see if there is a loss of glomerular filtration rate. What are the reference ranges for the BUN and creatinine?

Lori

They should have a mini kidney panel they can do to evaluate where his levels are. I use to get BUN/Creatinine and an SDMA at every appt. The IMS did this on the inhouse panel which was cheaper and would give us a quick snapshot to anything going on and we would do an IDEXX panel if it looked like something was changing. We did this for a year. But I agree, I would want the SDMA and I used it as a consistent base of where Molly's kidneys were at and going. Along with the BUN and Creatinine.

Hi Carole & Skippy,
Just letting you know I'm thinking of you guys & hoping for the best, as always.
Hugs to you Both!

Hi everyone and thanks as always for your kind words and the helpful info regarding kidney evaluation. I had an email exchange with the Purdue Docs after his visit last week. They were confident that Skippy’s high BUN and Creatinine numbers are caused by ulcers and that with treatment and restarting the Vetoryl, we will soon have him back on track. Not so much. Beyond the treatment regime, Denamarin, Benazepril, Tylosin, Sucralfate slurry (his favorite/ not), Pepcid OC, Ursodiol, and Vetoryl, there is Royal Canin’s finest renal kibble and cans. He ate the kibble lightly twice after heavily doctoring it with a chicken thigh and no salt broth. (I tasted the broth; it’s pure poison!) For the past three days, it’s been an accelerating slide downhill from eating modest but adequate amounts of food, to handfeeding his favs, to nothing last night. I’ve tried eggs with parmesan, Stouffer’s chipped beef, hamburger, steak, chicken, salmon, cheese, spam, etc. He ate the Spam yesterday but no go last night. I stopped the Vetoryl but got the other meds down with chipped beef sauce. Emailed Purdue IMS yesterday morning stating no food, no Vetoryl; she replied that maybe we were trying to transition him too fast! I replied that he won’t eat anything! No response.
Question: Is it likely that he’s nauseous? Should I ask Purdue for a med for that? No vomiting or diarrhea and he’s drinking and walking pretty well when he’s not sleeping. He doesn’t appear to be in pain.
Although my mind is a bit of a blur surrounding Skippy’s tolerance of Vetoryl, I believe his loss of appetite has been a consistent problem each time we increased the dose beyond 20mg daily. His cortisol has never been under control since diagnosis. Soon he will weigh 20lbs so I can reduce the dose if I can ever restart treatment. Purdue is adamant that getting his cortisol under control is critical to his so called “long-term” health. He’s scheduled for a recheck on 11/21.
I’ve been researching KD; my head is swimming and I am awash in frustration and anxiety; this entire saga is like the Myth of Sisyphus. How many more times can I push the boulder up the hill and watch it roll back down?

It is very frustrating, Carole, that's for sure. The 21st seems a long way off to me.

Hi Lori,
I posted an update on the situation with Skippy below a little while ago. But, I just realized that I didn't respond to your question about his kidney values. On 10/31 his Creatinine was 1.90 with a reference range of .50 to 1.50. and his BUN was 117 with a range of 7 -32. I stopped the Vetoryl yesterday as he just won't eat. The IMS thinks it an ulcer. I just emailed Purdue again saying, "help"! I am certain that they think I'm a pain in the butt but I really don't care what they think at this point. Thank you for your kind comments although I don't feel inspirational - just someone in way over her head. Ole Skippy is tough little mongrel though. Best,

Carole

Purdue will see Skippy tomorrow. At least they are concerned about why he is refusing to eat.

Yes, he needs to eat, or get some nutrition in some other way. That has to come first. So , so frustrating. Can't dose Vetoryl unless he's eating, so his cortisol will remain high until then. Glad he's getting in tomorrow.

[/QUOTE] Purdue is adamant that getting his cortisol under control is critical to his so called “long-term” health.[/QUOTE]

I feel for you, I really understand the frustration of getting them to eat, offering anything, ANYTHING and just hoping & praying for a few bites. This coupled with all the questions and concerns and changing situations is so much to deal with. So thankful that he will be seen tomorrow. Wishing you both a restful night.

Thanks Annie, how well I recall that you know. I mean KNOW. There is some confusion between vets about taking hin to Purdue tomorrow but I hope to work through it in the morning. Skippy ate a few bites of Stouffer's barbecue chicken and potato parmesan tonight. I tasted it and the bbq was terrible, but...Can[t medicate him with anything without food...I will push for more kidney tests if they will see him tomorrow. Best to you and Tex. How did you name him Tex btw? Best to you,

Carole

Did you go to Purdue today? What did they say?

I agree this not eating is Very concerning. Have they confirmed there is an ulcer?

Hi Sharlene, My battery went dead in the Purdue parking lot (after five hours there); I had to call for a jump and then a new battery purchase at Sears so I just got back. Skippy is on IV hydration at Purdue overnight. Physical exam offered no evidence of dehydration but after CBC his Createtime had jumped from 1.9 to 2.9 in less than a week, with a reference range of 0.50 - 1.50. The IMS didn't give me any other numbers but was insistent on hydrating him overnight and they had given him some kind of nausea suppressant/appetite stimulant by injection. They are supposed to call me in the morning. She mentioned a test that they could perform to confirm an ulcer but I just can't remember the name. Maybe my mistake was failing to try to somehow get the kidney meds down him since last Sunday night, but I just didn't know how to force them down his throat. I really don't think the Purdue IMS (this is the junior who I hope is consulting with the senior) knows what's wrong with him except that he is in kidney failure. I asked again today about the SDMA and she responded that they would secure his blood chemistry values. (This was early in the day.) I am going to send her an email next and request the SDMA test; I have no idea why they aren't recommending it. Before going to Purdue, Skippy did get up and eat a small bowl full of boiled chicken thigh and I think he would have eaten more, but he wouldn't touch the renal kibble. Since three days of reading, I know now that I could home cook food for Skippy and I will if he makes it through this. It goes without saying I am very, very worried that we have reached the end of this over a year long often tortured journey. If I can't get this kidney disease under control and get his cortisol down, I see little way forward. And, I am prepared intellectually, not so emotionally. I will ask/ request the ulcer test and the SDMA. I truly wish I had the medical knowledge to comprehend all of this to figure out the best path forward, if there is one. I've read about canine ulcers, periodontal disease (Purdue says his is severe although his teeth were cleaned about a year ago.), binders, commercial food, home cooked food, a ton of holistic meds, but I feel like I'm fattening frogs for snakes at this point. Thanks for letting me vent, yet again. I would welcome any wisdom from any of you who are so knowledgeable and experienced.

Carole

Hi Carole,

I so wish I had something helpful or informative to add, but I’m afraid I am stumped and would need to defer to Pudue’s expertise just as you are doing. It is such a complicated situation with so many inter-locking puzzle pieces. I am guessing that perhaps they are thinking about an endoscopy to check for an ulcer? This would involve sedating him and putting a tube/camera down his throat and into his stomach. I don’t know that there’s any other way to definitively diagnose it without imaging.

Anyway, I’m hoping that you’ll hear a more positive update this morning! We’re here, anxiously waiting alongside you.

Marianne

Thanks Marianne, I just spoke with Purdue and the immediate crisis has past. His Createtime is back to 1.9 this morning. Skippy is eating and jumping around. But, they still don't know what's wrong with him. I'm going to see him now. The IMS treating him is consulting with a nephrologist and with Dr. Scott-Moncrieff at Purdue. They are looking for a kidney infection. She doesn't want to restart Vetoryl now although Skippy is eating. The IMS is now saying that they may have overloaded him with meds. His BP is near normal but he's still spilling protein. They are keeping him again overnight to continue fluids and testing. The IMS mentioned Miotane or the possibility of low dose Vetoryl if they try to lower the cortisol slightly versus simply trying to manage the multitude of other symptoms and conditions. IMS hasn't ruled out ulcers but seems to be discounting it more. I no longer know what to think and the cost has truly become astronomical; I could now open a pet pharmacy with the array of meds that have now been discontinued. I am certainly glad that he's feeling better and eating but I am beginning to lose confidence, yet again, that they have a clue of whether or how to treat him. Would you all seek a second opinion? His paper records are now at least two inches thick. Dr. Bruyette now offers a vet consulting service but I think he would defer to Dr. Scott-Moncrieff but, she really isn't treating him at the moment although she supervises the IMS who is. Thanks,
Carole

Many of you who weighed in on restarting Vetoryl were correct. Not because it has resulted in Skippy's adenoma growing, but because it has caused acute/chronic kidney disease. His BUN and Creatinine levels are jumping up and down by at least a point, i.e., 1.7 yesterday to 2.9 this morning. (Reference range 0.50 - 1.50) I've been visiting Skippy daily and they will keep him at least until Monday. They have no idea as to whether or not they can stabilize him or for how long. They took the IV out of him and I took him for a long walk today. Now, he seems alert, eating, pooping, peeing. But, if Creatinine increases each time they slow the fluids, we are likely done. He can't live on fluids in a cage at Purdue indefinitely. I will not give up and they are running more tests to try to figure out what is causing this but I'm pretty certain it's not treatable. And, I will not let this go on much longer as we are where we are. I could look back at my mistakes over the last two months, but I took a calculated risk. I could have never restarted the Vetoryl and certainly not restarted it three weeks ago when his kidney levels were creeping higher. But, I so wanted to control the cortisol/Cushing's. They were wrong and so was I. Thanks,

Carole

Oh Carole, I hope he can be stabilized. I totally understand how heartbreaking it is to try and do the right thing, the thing that will make everything better, and then the worry, fear that it might have done the opposite. I've been there with my molly and the cortisol levels and kidney disease. We too tried everything and did what we could to give her every chance. I know that you are doing that now for Skippy and I sincerely hope that he can turn this around.

It sure is a sucky position to be in, but remember, every decision made is made with the information you had then, not what you have now.

Carole, have the folks at Purdue told you that they think the Vetoryl actually caused kidney damage? I may definitely be wrong, but my understanding is that the warning against treating kidney patients with Vetoryl is not so much that it directly damages the kidneys, but instead that Vetoryl levels will accumulate at a higher level in the body than expected if dysfunctional kidneys are not efficiently “clearing” the metabolites out of the system. As a result, overdosing becomes more unpredictable and a greater risk.

I write this is an effort to keep you from judging yourself, or even Purdue, harshly. Restarting the Vetoryl may not have been a mistake at all, since uncontrolled Cushing’s, itself, can cause kidney damage. It has been such an extreme challenge to balance all of Skippy’s competing needs — as it turns out, perhaps just too great a challenge to overcome. But you have done a superhuman job of giving him every possible chance to rebound, all along the way. I sooooo hope that he’ll rebound once again. But no matter what, you’ve all done the very best you could with the information that was available at any given time and day.

Sending healing thoughts to you both, and my hopes that tomorrow will bring much better news.
Marianne

I just want to say that marianne is right about not knowing if vetroyl causes kidney damage and in our case, we know that the kidney damage was not caused by vetroyl, due to timing. We had hops that bringing the cortisol down would help with the protein leaking but likely the high cortisol is what caused the damage.

It doesn't matter, because no matter, what one does, you always tend to, being human and all, look back and say, what if I didn't do this or if I did that. The thing is that non of us knows what would have happened if the decisions had been different. Things could have just as easily been even worse instead of better, so don't go down that path. It won't help. I know.

You all are right of course; it doesn't matter whether it was Cushing's or vetoryl and likely it will always be speculation; the IMS thought Vetoryl because of the timing, i.e., the kidney labs have been normal for the past year until when we restarted the Vetoryl The student called this morning to say that they have confirmed that Skippy has an infection; the student doesn't know if the infection is bladder, urinary tract or kidney. They are treating him now with antibiotics. A major, perhaps fatal problem is that each time they reduce the BUN and Creatinine to near normal with the fluids and then reduce the flow, the numbers jump back up to acute levels. Skippy is eating, drinking and peeing still. The student said that the IMS and Scott-Moncrieff are working on a treatment plan, whatever that means. I know nothing but will go see him this afternoon.

Oh poor little guy & you too Carole. It must be so hard to be away from him during all this. Marianne and Sharlene are so right about beating yourself up over decisions you have made. I went through it, still am. "Should I?, what if we had?, maybe we shouldn't have?" over and over. But we do the best we can with what we have at the time, and in our cases, all decisions are made out of love. So there is no right or wrong answer, and all of us are here for you! Enjoy your visit with your sweet boy, and extra belly rubs and hugs from me & Tex too.
Annie

I really think that once the infection is gone the creatinine and BUN will drop down to more normal levels and stabilize. Sending huge loving hugs. Please stop being so hard on yourself, it is so very difficult making treatment decisions for our precious pups and most definitely those decisions are made with the deepest love we have for them. You are being an exceptional advocate for your boy.

I went to see Skippy again early this morning . He is a bit disoriented but was glad to get out of there for his fifteen minutes off the IV. I took him to a field close by for a walk; it was raining but he walked and then ate the small pile of chicken I brought him. His Creatinine was down to to 2.1 but BUN still over 100. Tonight the IMS called to say that she is going off clinic rotation and another IMS Doc will be assigned tomorrow. She has been consulting with the nephrologist and he says "patience". "Don't throw the book of meds at Skippy; let's see if the culture indicates that we are treating him with the correct antibiotic." Every time they try to lower the flow of fluids his blood values skyrocket and the IMS doesn't know why. I was pretty distraught and said that I don't want to continue to torture Skippy. The IMS suggested that I come over and
"look at Skippy tomorrow" to make a decision about whether to go forward. Of course, I will go over but what am I supposed to see?? The same Skippy that I saw today? I am going to try to reach Scott-Moncrieff in the morning to have a straight conversation. I don't know if everyone there speaks in code or if they don't actually know what's going on with him. If you all have any wisdom I would deeply appreciate your thoughts.

Skippy with you at his side, has fought a long courageous battle. You know him better than anyone. Would he want to continue in this way, or is he pushing through for you? Only you can answer that question. It is the hardest one that any of us ever have to answer.

We remain here for you always, regardless of what you decide to do. I am so very sorry.

Kathy

Oh Carole, I wish I could tell you what to do. Yesterday was 6 months that we said goodbye to Whiskey, it was truly one of the worst days of my life. My vet told us it was time, but more importantly, Whiskey himself told us in a way only he could. But we had a definite turning point and things went downhill quickly. It would be so helpful if the vets you are working with could not "speak in code", as you said, but hopefully you'll have some answers soon.
You're both in my thoughts.

Sweetheart, you know Skippy best of all. Listen to him when you see him and he will tell you what he needs. Know we are with you all the way and trust you as your precious boy does.

Hugs,
Leslie