French bulldog w calcinosis cutis - Qs on Cushings diagnosis & treatment

Hi Everyone,

The info here has been very informative, I'm still sifting through a lot of it. I'm sure I'll have some more questions beyond today...thank you to everyone who created this forum and to those who are active in it.

A few days ago my frenchie was diagnosed with calcinosis cutis - she has CC patches in several spots on her body and unfortunately one of them (just above her shoulder blades) is oozing and severely infected which we are trying to get under control - it is very scary-looking. She is on Zeniquin, Chloramphenicol, Mupirocin, Silvadene, and Trizchlor shampoo & spray. She doesn't seem to be in pain except for certain spots when I apply the ointment, and she doesn't try to itch too much - she's such a good-natured dog.

They gave her the ACTH Stimulation test to confirm Cushing's and it came back negative. The vet is certain that she has Cushing's and so she wants to run the Low Dose Dexamethasone Suppression Test to see if it returns positive for Cushing's. Given that CC pretty much is synonymous with Cushing's, is it even worth running this additional test?

Either way, it sounds like an ultrasound would be beneficial to help determine pituitary vs adrenal cushing's?

As for treatment, it sounds like there are really three options to choose from, is that right?:
- DMSO (that's what my vet is already leaning towards for some reason)
- Vetoryl (Trilostane)
- Lysodren

Is the choice between these dependent on whether the Cushing's is pituitary vs. adrenal? What other factors impact which treatment to choose?

FYI, my Lola is about 8 years old. I adopted her from a rescue group about one year ago, so I don't know if she's had prednisone in the past - definitely not in the last year. Since she is a frenchie, she is also very prone to skin allergies.

Thank you in advance for your advice and caring concern,
Lola's mom

Oh dear, yes, the dreaded CC can be quite painful to look at and hard to control. If it causes her pain, definitely see about getting her some tramadol. Please tell us how the CC was diagnosed? Biopsy? Does she have any other symptoms that would lead you to suspect cushings?

Can you please post the ACTH results including the reference ranges and any other bloodwork results? I know you said the ACTH was negative, but they may be dependent upon the lab. For example, the normal range for my lab is up to 22 for the post cortisol, but in many other people's results, their labs use a max of 18... so, you may be just on the border line for the ACTH results.

An LDDS is a good idea, as is the ultrasound. I would not say either of those are a waste, in my opinion.

As an aside, with her being on so many abx, I would urge you to add some probiotics to her diet. That much medication can really get her system out of whack.

Thanks for your note, Renee! I was sent to a dermatologist for the weird growths that the specialist immediately recognized as CC and confirmed via biopsy. Lola has also been drinking much more recently and having increased accidents inside which isn't like her. She has also battled UTIs for the last few months, thinned skin and weakened hind legs which I thought was the beginning of arthritis. Also a slight decrease in energy.

I will post the ACTH numbers when I'm able to receive them from the vet, and yes Lola has been on probiotics for a few weeks now. Her liver/kidney (?) values were slightly elevated - nothing that my two regular vets flagged, but the specialist really put all the puzzle pieces together.

Unfortunately Lola had a terrible reaction when I gave her tramadol combined with her other meds a few days ago (all require to be given with food and some are required three times a day, so I can't give her any more food!). She was shaking about 30 min after I gave it to her, I had never seen her do that before, so the vet recommended I omit the tramadol since she generally didn't seem to be in pain...

Poor girl. :( I am so sorry the tramadol gave her a reaction.

It sounds like you are on the right path. And, I am glad you saw a specialist about the CC.

There are a number of us (my pug included) that are dealing with CC. Please find our threads and read them. You can get some good information on how we have been treating them. Of course, the only true 'cure' for CC is lowering the cortisol. Everything else is just management.

I look forward to seeing the test results and seeing what the LDDS and ultrasound reveal.

Renee - I just read your entire thread about Tobey from early December through to your latest post. It has really helped me set expectations for the long and winding road ahead, thank you so much for all of that documentation (and for everyone else's care and advice!). It sounds like things have been improving for Tobey, how is she doing now?

Thanks again to everyone who is active in this forum - I hope to return the favor over time as I gain more knowledge and hopefully as Lola gets better.

Bless you for reading my thread! I remember when I first came here, I was reading threads from start to finish too. Its helps to not feel alone, and it is reaffirming to see that all of us have gone through similar experiences from the very start to wherever we are now.

It is a long and winding road, but the path gets easier and easier for many of us.

Symptom wise, Tobey is doing very well. I think we have hit her perfect dose, but I have not gotten an ACTH done yet, and that will tell some of the story. I was supposed to do it last week, so I thought I would do it this week, but her vet is out of town, so.... I have put it off another week. I know it's a break with protocol, but I feel okay with it at this point.

Her personality is still a bit off, but I am just giving that some time.

It really does feel better to know that others are going through this with their pets and that things can and do get better over time.

That's great to hear about Tobey, fingers crossed the numbers are positive.

Hope that you can get the cortisol lowered and then you should see things start to improve with the cc too. Eventually, it takes time.

Not all dogs react well to tramadol, sounds like Lola is one of them. They can maybe have it in a very, very small dose, if you need to try that.

Sharlene and molly muffin

Thanks so much Molly Muffin and Renee!

We had the LDDS test yesterday, so I'm hoping to receive the results today or tomorrow which I'll post here. In the meantime, here are the ACTH results:
Pre: 2.5 ug/dL (Reference range = 1.0-5.0)
Post 15.2 ug/dL (Reference range = 8.0-17.0)

I've read mixed things about DMSO and the risks associated with it - Lola is a french bulldog with a sensitive system so I'm conflicted on whether to try it out or not...thoughts?

Also, I'm having trouble finding the thread on here - is the general thought that Lysodren is better for resolving CC, or is it Trilostene? I just read that there were some sudden death cases with Trilostene, which is alarming.

Okay, the ACTH results do rule out cushings.. but, again, we know those can be wrong, so other diagnostics and analysis of symptoms will help lead to the diagnosis.

I personally had zero success with DMSO, and the smell of it was just horrible. It is often prescribed, and some dogs (Cosmo on here, who has passed) did have success with using it, in conjunction with vetoryl. If you are already on abx and using trizchlor spray, then I would not waste time with the DMSO.

Some people say that vetoryl is not as effective at controlling CC, while others (my Tobey included), are doing well using vetoryl.

Don't get scared away by the side effects of vetoryl vs. lysodren. They both are equally as effective and equally as 'dangerous'. You won't be able to choose one over the other based on which is safer. Neither one is safer than the other.

Thanks for the advice, Renee! I'll post the LDDS results as soon as I receive them.

Good info, thanks Renee.

Here are Lola's LDDS results, indicating Cushing's:
Cortisol Sample 1 (Pre) 2.0 ug/dL (Reference range = 1.0-5.0)
Cortisol Sample 2 Dex (4hrs) <0.7 ug/dL (Reference range = 0.0-1.4)
Cortisol Sample 3 Dex (8hrs) 2.5 ug/dL (Reference range = 0.0-1.4) HIGH

The lab results also said the following:
If the 8hr post dex. cortisol level is greater than 1.4 ug/dl, the following can be used to differentiate pituitary dependent hyperadrenocorticism (PDH) from an adrenal tumor:
1. Cortisol level less than 1.4 ug/dl 4hrs post-dex is consistent with PDH.
2. Cortisol level less than half the baseline level at either 4 or 8 hours post-dex is consistent with PDH.

The wording is confusing, but based on the above, it sounds like it is a pituitary-caused case of Cushing's. Given this, is it still worth getting an ultrasound?

My vet is inclined to go with vetoryl over lysodren given the potential damage to the adrenals with lysodren...

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My vet is inclined to go with vetoryl over lysodren given the potential damage to the adrenals with lysodren...

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You and your vet need to be aware of the fact that Vetoryl can and does cause the exact same damage to the adrenals as Lysodren. They can both cause permanent Addison's and even death - they simply work differently and stay in the body differing lengths of time. Make sure your vet is up to date on all the changes with Vetoryl since the drug insert was printed, too. ;)

Thanks, Squirt's mom, good to know.

FYI, my dog is about 22/23 pounds - and I've been reading here low and slow is the best way to start either medication. Any thoughts on suggested initial dosing for either medication?

Leslie is correct - while vetoryl does not erode the adrenals in the same fashion as lysodren, it can and has caused spontaneous addison's.

If your pup is 22-23 pounds, I would start at a max of 20mg vetoryl, and give it at least 30 days before adjusting the dose (if needed).

You're doing good!

As to your question re the ultrasound --- my personal opinion, and what I did, was to wait. I knew she (Tobey) had cushings, and I knew what treatment I was going with (vetoryl).... so, I saved the money and delayed doing imaging until later into treatment. We ended up getting a CT, and it confirmed PDH.

Great, thank you!

After starting the vetoryl, my vet wants to run the ACTH tests after 1, 3 and 6 months to see how Lola is doing. Do you think we need to be testing more frequently than that?

The "start low and go slow" applies more to Vetoryl (Trilostane) than it does Lysodren. Lyso is loaded at 50mg/kg/day and maintenance is 25-50mg/kg/week. There is no loading nor maintenance phase with Vetoryl - you start giving it and give every day. Vetoryl is often more expensive to use because it often requires frequent dose changes and with each dose change, the ACTH monitoring schedule starts all over.

Got it!

I'll be sure to let you all know what we end up going with for Lola and how she and the CC are progressing with the treatment.

Thanks again, all!

I "second" Renee's recommendation that you start off with 20 mg. if you are opting to treat with brandname Vetoryl. With that dosage strength, you could easily have the option of giving the full 20 mg. once daily in the morning or instead 10 mg. twice daily. There are pros-and-cons with both dosing options, and different specialists have different preferences in that regard so there is really no right or wrong approach. If once daily dosing fits more conveniently into your daily schedule, I'd see no reason to start out differently. Down the road, if it turns out that you are seeing a rebound in symptoms later in the day, you may want to try giving twice daily dosing a try.

As far as monitoring ACTH testing, Dechra's official published protocol is to conduct an initial test at the 10-14 day mark. Then, as long as the cortisol level has not dropped too low, the recommendation is to remain at the same dosing level until the one-month mark. This is because cortisol levels have a tendency to continue to drift downward during the early days of treatment, even when the dose remains unchanged. In this way, you have a better idea as to the maximal effect of that initial dose prior to making an increase.

We are finding that some specialists are holding off until the one-month mark to perform the first full ACTH test (omitting that first two-week test). I can only speculate that it may be because they don't intend to increase the dose until a month has passed, regardless. And as long as the dog is behaving normally and looking well, they are assuming that the cortisol has not dropped too low. One "twist" I have sometimes seen added is to perform a simple baseline or "resting" cortisol at that initial two-week mark. This involves only a single blood draw and is less expensive than a full ACTH. While not an accurate indicator alone of the need for a dosing increase, a baseline cortisol can give you some added reassurance that cortisol is not dropping too low (which is the issue that is most important for a dog's safety). As long as a baseline cortisol is higher than 2.0 ug/dl, there is some reassurance that the dog is not bordering on an Addisonian condition.

Of course, all bets are off if a dog is acting unwell at any time. Then the monitoring testing becomes a necessity.

It is true that we have seen many dogs here who have required periodic and even frequent tweaking of their Vetoryl doses. But we have also seen dogs taking Lysodren who have experienced lengthy loading periods or Addisonian scares that have also required a great deal of monitoring. We have seen very large dogs who ended up taking relatively small doses of Vetoryl, and vice versa (small dogs requiring larger doses). So in advance, I think it's hard to say which drug would end up being more expensive for any given dog. There are many times when a crystal ball would sure come in handy! :o

Marianne

Thank you so much, Marianne, this is very helpful info!

Based on what I've read on this forum, lysodren requires a loading time with ongoing maintenance after. Presumably that is dosed via weight as well? Any recommendations on what that would be if we took the lysodren route? Once again, Lola weighs 22-23 pounds.

My regular vet isn't familiar with lysodren and my dermatology specialist didn't feel too strongly about going with either vetoryl or lysodren - she just recommended that whichever vet I go with should be well-versed in the treatment they prescribe and test often. Reading through an overwhelming (and helpful!) number of threads here, it seems that on the whole, lysodren has been more helpful in clearing up CC than vetoryl for most dogs, so I'm more inclined to go that route.

My regular vet has been wonderful and has gone well out of her way to help diagnose Lola, and while she has been reading up on Cushing's treatment to ensure she is taking the correct route I am feeling like she isn't as well-versed in treating Cushing's as I'd like her to be, so I've found an internal medicine specialist (one who works closely with and is in the same building as the dermatologist) who treats many Cushing's cases and is equally familiar with both vetoryl and lysodren. I was able to get an appointment with him tomorrow, so we'll see exactly what he recommends - I'll report back on that here, stay tuned!

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Originally Posted by lola's mom

Thank you so much, Marianne, this is very helpful info!

Based on what I've read on this forum, lysodren requires a loading time with ongoing maintenance after. Presumably that is dosed via weight as well? Any recommendations on what that would be if we took the lysodren route? Once again, Lola weighs 22-23 pounds.

My regular vet isn't familiar with lysodren and my dermatology specialist didn't feel too strongly about going with either vetoryl or lysodren - she just recommended that whichever vet I go with should be well-versed in the treatment they prescribe and test often. Reading through an overwhelming (and helpful!) number of threads here, it seems that on the whole, lysodren has been more helpful in clearing up CC than vetoryl for most dogs, so I'm more inclined to go that route.

My regular vet has been wonderful and has gone well out of her way to help diagnose Lola, and while she has been reading up on Cushing's treatment to ensure she is taking the correct route I am feeling like she isn't as well-versed in treating Cushing's as I'd like her to be, so I've found an internal medicine specialist (one who works closely with and is in the same building as the dermatologist) who treats many Cushing's cases and is equally familiar with both vetoryl and lysodren. I was able to get an appointment with him tomorrow, so we'll see exactly what he recommends - I'll report back on that here, stay tuned!

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Awesome job mom! You are doing everything right so far. Lola is very lucky to have you. I look forward to hearing what the IMS has to say.

Thank you, Renee :-)

The IMS felt strongly about an ultrasound to rule out any adrenal growths, so Lola had that done today and the adrenals were all clear. He felt that vetoryl was the best route to begin with since he feels it's easier to adjust as needed and is FDA-approved for Cushing's, whereas he feels lysodren is a bit trickier when adjustments are needed (and apparently not FDA-approved for canine Cushing's even though it's used widely for that). He's used both for Cushing's patients and typically prefers to start with vetoryl as the first approach unless there are other hormonal issues going on, in which case he said lysodren would be the better one to start with. He said that if the vetoryl isn't working over a period of time, we can always switch to lysodren and feels the unmedicated time in between that switch doesn't need to stretch out to 30 days, but can be 10-14 days...let's hope that vetoryl just works for her and no switch is needed!

While he wants to start out dosing low and slow, since Lola has such severe CC which is spreading quickly, he wants to start her out at 30mg and he wants me to bring her back in within 2 weeks for the ACTH test to see how things are going. I'm a bit nervous about starting at 30mg instead of 20mg but he feels very confident about that amount and he has many Cushing's patients...We start her first dose tomorrow AM and I'll be keeping a close eye on her and logging everything. I'm nervous but cautiously hopeful that she'll begin to turn around in time.

We go back to the dermatologist in one week, and at that time if her infection is much improved they want to take Lola off the antibiotics and put her on DMSO so that the calcifications can begin to reabsorb into her skin (antibiotics won't do that presumably). The IMS agrees with that approach. I'm nervous about all that too, but we'll see.

Does all this sound kosher to you all? Thanks for your thoughts!

I'm glad you've had the ultrasound performed and are receiving the benefit of additional consultation. Yes, for the most part, things sound kosher to me and given Lola's rapidly spreading CC, I do understand why he is wanting to be a bit more aggressive with the dosing. Since you are starting at about 1.5 mg. per pound, I'm glad that he is recommending ACTH testing at that initial two-week mark. I know you will be watching her really closely and will be poised to nip any problems in the bud. I'll be watching anxiously for updates!

Marianne

I agree with Marianne, Lola's treatment plan sounds right to me, however; I do disagree with his statement below:

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Originally Posted by lola's mom

He said that if the vetoryl isn't working over a period of time, we can always switch to lysodren and feels the unmedicated time in between that switch doesn't need to stretch out to 30 days, but can be 10-14 days...let's hope that vetoryl just works for her and no switch is needed!

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On the dvm 360 (veterinary medical information) website they have a Q&A Cushing's article with Dr. Feldman. Dr. Feldman is a renown Cushing's expert who has published in many peer-reviewed, high-quality journals, he had this to say about switching from one drug to another:

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Any dog switched from one to the other should receive no medication for at least six weeks.

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Full article can be found here: Cushing's disease and other adrenal gland disorders

I am sure Lola's vet has heard of Dr. Feldman and I bet has read many of his published articles.

Will be watching for updates about Lola, and I am sure you'll do an excellent job, and remember we are here to help. ;)

Hugs, Lori

Thank you so much, Marianne and Lori! I will be sure to share the link to the Dr. Feldman Q&A with the IMS.

I have to say the more I think about it, I'm waffling on the 30mg vs 20mg start given the potentially scary side effects...The capsules I was given to start tomorrow AM are 30mg capsules.

Trilostane, which is the active ingredient in Vetoryl, has a short half life, so if Lola would start having any adverse effects, stopping the Vetoryl should perk her back up. Adverse effects to watch for (although I really don't think this will happen) are: vomiting, diarrhea, lethargy, or Lola just not acting like herself. Remember too, when in doubt don't give the Vetoryl, and we are here to help. ;)

Some of the ladies here have used a spray that is quite effective in treating CC. Maybe your IMS would consider a combination of 20mg Vetoryl and the spray. Trizchlor spray conditioner(smells nice) and mupirocin ointment for spots that crack open.

Val, Terry tells us that Lola is already being treated with these medications, as well as some others, but control has been difficult.

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A few days ago my frenchie was diagnosed with calcinosis cutis - she has CC patches in several spots on her body and unfortunately one of them (just above her shoulder blades) is oozing and severely infected which we are trying to get under control - it is very scary-looking. She is on Zeniquin, Chloramphenicol, Mupirocin, Silvadene, and Trizchlor shampoo & spray. She doesn't seem to be in pain except for certain spots when I apply the ointment, and she doesn't try to itch too much - she's such a good-natured dog.

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Terry, I surely understand your concerns about the trilostane dosing, and without that handy crystal ball that I already mentioned :o, it's impossible to know what will end up being the best dose for Lola. However, I also understand your vet's sense of urgency as far as getting her cortisol down relatively quickly. CC is a terrible condition that can explode when untreated or undertreated. Sadly, during our years here, we have had a couple of owners who were faced with end-of-life decisions for their dogs when unmanageable CC rendered quality of life unbearable. I do not tell you this to scare you unnecessarily, but to offer a bit more context for your IMS's recommendation. I cannot tell you what the "right" dose will end up being for Lola, but as Lori says, if you do opt for the 30 mg. you can simply stop giving the drug if Lola seems to be reacting badly. Plus, the fourteen-day ACTH will give you valuable info re: the drug's effect on Lola's system and I'm sure your vet would decrease the dose at that time if it seems to be higher than is optimal.

Marianne

I don't have any experience with CC thank God, but know many on here struggle with it, and I just wanted you to know you can lean on us for support to get thru this. Blessings
Patti

Thank you all so much for the pep talks!

The thing that scares me most is the rare sudden death issue, but there's just no getting around the need for the medication. I'm going to buckle down and go with the 30 mg dosing. Thanks again, all!

Good luck, and I'm betting that Lola will do just fine! But as Lori says, we are always here for you to talk to. ;)

Thank you all! I started her this AM and gave her the trilostane with her zeniquin and chloramphenicol along with her breakfast. Unfortunately, she had the same reaction as when I gave her the chloramphenicol + tramadol. About 30-40 min after her meal she started shaking, and it lasted for about 20 min or so. Then she napped for a few minutes, and then she was completely normal. She had some water and excitedly accepted a treat. She's been perfectly ok since. Do you think she just had an upset tummy with that combo of meds at one time? I'm waiting to hear back from the IMS to see what he thinks.

Terry, can you describe the shaking in greater detail? Did it involve her entire body, and was it constant or more in waves, etc.?

Marianne

It was upon her exhaling. I took a short video so that I could send it to the vet. Am I able to upload that here?

Unfortunately, no. But if you upload it somewhere like Youtube, you can then give us the link.

I am so sorry your baby is having these troubles, and I too am anxious to we what you have on video, as it is sort of hard to visualize I know. I hope everything turns out ok and not more shaking. Blessings
Patti

Thank you.

Here's a link to the very short video - you'll see my poor girl's CC...

https://www.dropbox.com/s/z6g8oa21fq...2013.17.28.mp4

I watched the video. It is definitely a shivering your baby is doing. My God that CC has to be the very worst part of Cushing's. Your poor little baby, I am so sorry this is happening to you. I wish someone would make some progress with this disease and find a cure. These babies do not deserve this. Blessings
Patti

Thanks Patti. It's actually really warm in my apartment, so she wasn't cold...

Thankfully, she's been ok for the rest of the day. I haven't heard back from the IMS yet, so not sure what to do for tomorrow's meds. Hopefully he will call before he leaves for the day.