REMY diagnosed last week

Hello Again, I used to be here as “Amanda’s Mom”. She had an adrenal tumor which was successfully removed and she lived another year of so before passing away from CHF. This time it appears to be the pituitary form. We adopted Remy four years ago. He is just now turning 11, a rescued Bichon and came from a backyard breeder after the man passed away. His teeth were beyond deplorable and he was never socialized. Even four years later he has only bonded with my husband and remains afraid of pretty much everything. I have wondered if the stress he lives with might even contribute to his Cushings. Remy always had high liver enzymes and we had an extensive work up in Feb 2018 including a liver biopsy, cortisol levels, bile tests, copper storage disease and liver shunt testing. The internist felt since he wasn’t having any clinical symptoms it was likely some chronic form of inflammation. Treated with prednisone for awhile then eventually discontinued. Never reached ‘normal’ liver enzymes levels. He was always a picky eater, a grazer and not at all food motivated. We would throw so much food away as it would sit all day untouched. In December I noticed he was actually looking for his food and eating it all up. Sometimes he’s looking to see if Angel has left him anything in her bowl. He isn’t ravenous, but definitely eating like most normal hungry dogs do. He has developed a pot belly and I feel his coat is a bit thinner. It was always horrific to get a clipper thru and I noticed at his last grooming it doesn’t seem as thick. He seeks out cool places such as the tile floors but he’s always done that. At night even with our bedroom chilled to around 66 and a fan over him he puffs and pants much of the night. He is sluggish and not at all active but he’s always been that way. He refuses to take walks or show any signs of being interested in activity. Favorite thing is a car ride or to go to bed. We have not had any increased drinking or peeing (yet!). But I felt there were enough changes to warrant asking about Cushings when he had his semi annual senior blood work. The vet ran a comprehensive panel plus urinalysis 2/7/20.
Liver Enzymes were more elevated than ever ALT 714, ALP 772, AST 58, GGT 60, TP 7.6, Cholesterol 443, Glucose 143, platelets 617, T4 1.8, urine protein 1+. He also did another ultrasound and both adrenal glands seemed slightly enlarged. The liver is also somewhat enlarged and hyperechoic (as it has been for several years).
ACTH performed 2/14/20, precortisol 7.8 and post cortisol 24. PIcked up trilostane yesterday with recommend dose 20 mg. Per day either as one dose or two 10 mg doses. Remy is right at 18 pounds. Do you think the two doses is preferable? As long as he’s eating we’re fine. But if he reverts to the old grazing and picky behavior that may complicate things.

I feel he is early stage with mild symptoms so I certainly don’t want to overdo the trilostane. You are a very smart group so I welcome your suggestions. My past experience with Cushings was 23 years ago and more recently Amanda a few years ago but removal of her Adrenal tumor effected a cure and she never did have any clinical symptoms. Remy’s liver situation has always been a concern but the internist felt until he actually exhibited clinical symptoms of something we were throwing money away to continue testing.

We have one other dog, our 14 year old rescue toy poodle Angel. She also has highly increased liver enzymes and TP and pretty much always has. She is missing a lobe to her liver and she is on chemo for Transitional Cell Carcinoma. We are just about at the one year mark and on our second chemo protocol but so far so good. Just started seeing some blood in her urine once in a while but as of 3 weeks ago there was no progression of her disease. We caught it exceptionally early and she has done well with no ill effects from the chemo. I know that isn’t going to last however so I am figuring out the next steps for her as well as for Remy.

I am aware of the team at Washington State University who has been successful with pituitary tumor surgery and it wouldn’t be out of the question but there are many factors including his ever present liver inflammation, his age and the risks of this yet rare surgery. Needless to say, life is consumed with my furry kid’s issues and I welcome your suggestions, comments, etc. Thanks so much to everyone here!! Claire

Hi Claire! It's so nice to see you again, but sad for the reason. I am also going through Cushing's again with my big guy, Gable. I don't have any answers for you, but just wanted to say hello. Joan

Hi Joan so nice to hear from you too!! So sorry to hear you are ‘at it again’. Sometimes it seems we are simply given those who need help the most sometimes repeatedly. This is my third Cushings, second with Transitional Cell Carcinoma and lost two boys to resistant kidney infections in the past few years. I hope things go well for Gable. It’s such a frustrating disease for sure!! Claire

Welcome home again, Claire! I want everybody to know that Claire deserves a standing ovation for her patience and perseverance in returning to us. Due to some weird glitch with our forum software, she’s been unable to log back in under her original username of “Amanda’s Mom.” But thankfully, we’ve finally gotten her re-registered in conjunction with Remy. In case anyone wishes to revisit Claire’s postings re: Amanda and her successful adrenalectomy, here’s a link to Claire’s original thread:

https://www.k9cushings.com/forum/sho...da-is-free-now

Also, in looking back, I’m remembering that Claire had also started a different thread about Remy and his socialization challenges back when he was first adopted. So here’s also a link to that thread, too, with a lot of very valuable suggestions and experiences related to behavioral shaping:

https://www.k9cushings.com/forum/sho...lter-Dog/page6

Reading through both those threads highlights Claire and her husband’s incredible ongoing devotion to their rescued babies. A huge “Thank you” to both of you for your love and your grace and your kindness to animals in need!

Finally, circling back around to Remy’s current situation, I can’t disagree with any of your internist’s suggestions thus far. I think you’ve been on the right track, and I also would have been cautious about leaping into treatment earlier. Now that you’re going to begin, I guess my only “different” suggestion would be to start off even lower than the 20 mg. Since you have 10 mg. capsules, you have the luxury of being able to introduce Remy’s body to the effects of the medication even a bit more gradually. If Remy were my own, I’d talk with the internist about starting with one 10 mg. capsule each morning for at least the first week. If all goes well, you then can consider adding the additional 10 mg. Or, if you might even wait until the first monitoring blood test before doubling the dose. Remy may well need the extra dosage, but time after time here, we’ve seen that dogs tend to exhibit fewer unwanted side effects when they start at a relatively low dose and work upward only as needed, rather than vice versa.

If and when you do increase to 20 mg., I’d suggest going whichever dosing route best suits your own schedule and Remy’s eating habits. Trilostane needs to be taken along with food to be metabolized properly. So if you choose to dose twice daily, then you need to arrange food intake alongside each dose. Different studies supply pros-and-cons for both once and twice-daily dosing. If one dosing pattern initially better suits Remy’s routine, though, I’d start with that. Once again, you can always make adjustments as you go along. For instance, if you start out dosing only once a day but it appears as though symptoms are rebounding before the day is over, you can always try switching to twice daily dosing.

OK, I’ll go ahead and post this much of a reply for now. But I’ll definitely be checking back to add more thoughts as they arise!

Best wishes to you and all your family, Claire ;-)
Marianne

Marianne thank you so much for your help getting back on the forum and also for the very warm welcome!! I especially appreciate your comments on starting with the lowest dose (10mg). This vet is not an internist (the one who worked Remy up previously moved away sadly) but this Dr was working along side him during that time. Still, internal med and especially endocrinology is a complex specialty and I may take him to LSU for a consult. Thought I’d see how this goes though. Especially since the ACTH wasn’t all that high and his ‘clinical symptoms’ are very minor at this point I like the idea of 10 mg once a day to start.

I had forgotten I had gotten into Remy’s socialization issues and sadly, they haven’t improved much although he barks and growls at me a bit less :). I often wonder if the fear he lives with might contribute to overproduction of cortisol simply because he is so nervous. It’s like he’s always ‘on guard’ and fearful that someone or something is going to harm him. So sad but I really don’t want to try any more drugs since they run the risk of increasing is already elevated liver enzymes.

I miss my sweet Amanda but I’m so thankful I was able to have her for a couple of years. Her adrenal surgery which I agonized over was a complete success and saved her one less complication in her precious little life. Being blind and with heart failure was quite enough.

We lost Pork Chop last January, my second with a resistant UTI which turned into kidney infection. I keep asking WHY? Why does this happen to these boys?? With Pork Chop it was. Klebsiella, Peyton had Pseudomonas. And then a month after Pork Chop, there’s Angel with Transitional cell carcinoma. UGH, sometimes the stress of wondering if I am attentive enough, making the right decisions, catching things quickly enough becomes a bit overwhelming. The support one finds here is so amazing and the kindness of all of you who have been down this path is such a blessing!! Love you all!!

Hi Claire!

So glad to have you with us again tho I am sorry it is with another cush pup! However, you know you are in the very best place for Remy. ;)

I can't add anything to what Marianne said but I did want to address a comment you made. You said -

Quote:

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UGH, sometimes the stress of wondering if I am attentive enough, making the right decisions, catching things quickly enough becomes a bit overwhelming.

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I think guilt is part and parcel for those like us who seem to be magnets for these little souls who need so much more than the usual level of attention. Especially if they have been with us for a while before they get sick. I always find myself asking "what was it that caused my baby to get sick this time?" or "what early signs did I miss?" or "what could I have done different?" But the very fact that we ask these questions of ourselves simply means that we are the right ones for the job, we are the ones who will go that extra mile to learn and do what we can to help them live the best life possible. Coming back to us with Remy says the same things. I also believe that is why we end up with more than one cush pup or more than one dog with cancer or _________ - the dogs know that we will do our utmost on their behalf. Remy knew you were meant for him. All of your babies have been ever so lucky to have landed in your home and they all knew they would be loved thru everything that came along by two wonderful humans. So remember this when you start wondering if you _________ and don't let the what-ifs or maybes get under your skin (and I know how hard that can be at times! :o ).

Hugs,
Leslie

I”m not sure I’m doing the replies right Leslie but hopefully you get this. I very much appreciate your thoughts. It is terribly difficult at times, an awesome responsibility to be on top of things and be attentive. Dogs can be such stoic creatures they don’t always make it easy for us.Life gets in the way too when we become overwhelmed by other responsibilities such as family or children. I do truly understand how important it is to be vigilant and not to simply trust that our veterinarian will ‘catch’ things. This is not a knock on veterinarians at all. Like most medical professionals they have many patients and not nearly enough time to devote to them. They too have their lives to live and other responsibilities. I know most do the best they can. I do wonder why I have so many repeat issues, is it simply coincidence or am I doing something wrong? This is #3 with Cushings. I’ve had 3 blind poodles and Angel’s vision is deteriorating fast too. Two males with life ending UTIs despite getting them in for treatment very early on. I have learned and cannot reiterate enough how important early detection is. So many things have similar symptoms and it is very easy at times to mistake one for another. So hard not to become overwhelmed, even consumed by trying to figure things out and keep everything straight.A forum such as this is such a Godsend and I thank all of you from my heart for the time you volunteer to help us benefit from your wealth of knowledge, compassion and support. Bless you all for your service, and it IS a huge service to us and our beloved fur kids!!

Claire, just wanted to reassure you that you’re replying exactly correctly! :-)))

So just keep on keepin’ on ;-).

Marianne

Thanks Marianne. Remy is on day 2 of the Vetoryl and I’m sticking to the 10 mg for now until we see how he does. So far he seems just fine. I did realize I don’t have any prednisone here apparently. I think I should ask for some just in case of a crisis. I would rather have it and never need it. Since Remy didn’t have much in the way of clinical symptoms it may be a bit tricky to know how he is doing until we retest.

I sure wish there was a similar forum for canine cancer. I have yet to find anyone as knowledgeable and supportive as all of you here!!

Day 4 and no problems at 10 mg. Can’t say I’ve noticed any changes in Remy’s behavior either. He was panting quite a bit last night so I turned the overhead fan on and that seemed to help. Water consumption and peeing haven’t been an issue with him so nothing to report there. I think I will continue at this dose until Friday which will be a full week and see where we’re at. I will be open to advice as to whether or not to go up to the prescribed 20 mg dose. Thanks to everyone!