Buster - 10 y.o. Lhasa/Tibetan mix (Lysodren) - Cataract surgery?

[frizzcurl]

I'm just writing to introduce myself and my dog, Buster. He's a Lhasa Apso/Tibetan Terrier mix, ~10 y.o., 27lbs, and was dx'd with Cushings about 2 weeks ago (after the 8-hr low-dose dexamethasone suppression test, followed by abdominal ultrasound which showed normal adrenal glands)... just started Lysodren tx on Monday.

I don't have copies of all the bloodwork so I can't post #s, but as per usual (from what I've read) there has been a LOT of testing in the last year (a 4-hr low dose dexamethasone suppression test which did not clearly suggest Cushings, a punch biopsy of his skin, thyroid testing). His main sx are hair loss (lots on his back, his tail is almost bald, and he has no undercoat at all), thin skin, and ravenous appetite (he inhales all his food in under a minute... not sure he even chews). His water consumption is mostly in the normal range for a dog his size. A punch skin biopsy suggested that the hair loss was hormonally-based. He's also been a persistent paw-licker for the entire time I've had him (3.5 years) so right now he's on Atopica for the allergies.

For the moment I just have one question... I'm wondering how subtle/clear the changes were for folks in sx during the Lysodren loading phase? I'm timing his eating and measuring his water and so far there's been no change from before, but I want to be sure I'm not missing anything.

Thanks!
Jess

[frizzcurl]

Of course after I posed my last message, I realized I forgot to mention that the ultrasound also found very small bladder stones.

I also have another Lysodren-related question... Buster's rx is to take 1/2 a (500mg) pill, twice a day. For now I just bought a pill cutter and split the pills in half myself. But the warnings on the medication about not touching them or inhaling the dust made me wonder how others handle splitting them. And the pharmacist at CVS told me he can't split them and to do it myself. (My partner, who's a nurse said that it's b/c it's a chemotherapeutic agent and should technically be done under a chemo hood.) I'm not pregnant and don't intend to become so anytime in the near future, but assuming Buster is around for a while yet that will be a concern at some point.

[StarDeb55]

Welcome to you & Buster, Jess! We are very numbers oriented people, so if you want to post Buster's test results, we would be very interested to see them. It's not that we are doubting your vet, but we have seen it too many times on these boards where a vet with little experience in treating Cushing's has not done sufficient testing to confirm or diagnosis or even misinterpreted the results of the diagnostic testing.

Now, to your lysodren questions. A couple of comments, the loading dose is calculated based on 25-50 mg/kg, to get to kg, divide lbs., by 2.2. Buster's loading dose is well within the appropriate range at 40 mg/kg. Signs of loading can be very subtle. For instance, the pup who takes one minute to empty his bowl to the point of being spotlessly clean, now, stops in the middle of eating to look at you. The pup who will his his kibble down to the last crumb, now, leaves a few pieces. We like to tell folks who are loading that any change in behavior that makes you stop & think, "Hmm, that's different or that's new." This is probably the sign indicating that the pup is loaded. One caution, a decrease in water intake usually occurs a little later on, than a decrease in appetite. There have been members who have even monitored the pup's stool during loading. They have noted that what starts as a normal stool will eventually become much softer, with the BMs softening, this can be a sign of loading. Each pup is an individual, so not all pups will show all signs. My first boy, Barkley, never showed a slowdown in appetite, but on day 9, his water consumption suddenly dropped by 40%. Fortunately, we had done an ACTH the day before, since there had been no change. His numbers came back very low, & he had to be put on pred immediately. Barkley was fine, after a few days of prednisone, & went to maintenance without a problem. I don't want to use this example to scare you, but just to illustrate that if I had counted on only a change in appetite, there might have been a serious problem. The other important point is that standard loading protocol states that if no changes are noted by day 8-9, you should run an ACTH to see where you are. If the cortisol isn't within range, you just continue loading.

Now, about handling lysodren, right now, it's really not a problem. I cut Barkley's tablets for years. If you are worried, now, I would simply wear gloves, & make sure you have a dedicated pill cutter that is only used for the lysodren. Wash everything thoroughly when your done with the meds. If you should become pregnant, someone else is going to have to take over Buster's medication. Expectant Mom's absolutely should not handle lysodren, even with gloves.

Looking forward to hearing more.

Debbie

[frizzcurl]

Thanks so much for your quick reply, Debbie! I got copies of all of Buster's medical and lab test records from the vet today so here's a more comprehensive history (with #s).

I adopted Buster in August 07 and his vet records that I got from the rescue estimated his age at 6.5, so presumably he's ~10. When I adopted him, he had terrible skin infections that his foster mom said were hot spots from being out in the sprinklers with the other dogs. Now, this is a dog that hates water so much that he will walk around puddles if at all possible. So that seems unlikely. But in retrospect, maybe that fits with thin skin/slow to heal/skin infections sx of Cushings? Also, from the time I've gotten him his coat has been VERY thin. He has never had much of an undercoat. His fur is white with black spots and for as long as I've had him, the black spots on his skin (including his abdomen) have not matched up with the black fur. I'm not sure how long he's had the black spots on his abdomen but the black spots on his torso were there when I adopted him.

Also since the day I adopted him, he has had allergies. At the time I adopted him, I did a food trial with a limited ingredient diet (Natural Balance Sweet Potato & Venison) that helped some, but the paw-licking was still pretty persistent so the vet put him on Temaril-P, which worked beautifully in controlling his itching. (One of my friends calls prednisone the "miracle poison.") He was taking 1 tablet/day for about 1.5 years.

In the fall of 2009, I noticed a bald spot at to of the base of his tail (where it meets his rear end) after a grooming. At first I thought that maybe the groomer just shaved there and dismissed it (even though I thought it would be weird for the groomer to do that). Over time, though the spot grew and in Feb '10 I brought it up with the vet and, thinking the hair loss might be related to the long-term steroid use, we started tapering him off the Temaril-P. That's when he started taking the Atopica for his allergies (which, incidentally helps some with the licking--enough that I'm not going crazy from listening to it--but still isn't as good as the Temaril-P was). After we stopped the Temaril-P I also noticed that he was limping more and more, esp after laying down for a while or after walking. Not sure if his energy level changed, but he's always been a pretty low energy dog to begin with.

Over the last year, Buster's hair has continued to get thinner such that now the top of his tail is almost entirely bald. Also the fur on the rear end of his torso is extremely thin such that you can see his skin. In April, the vet and I started talking about Cushings as a possible dx since the hair thinning kept getting worse even though he'd been off the Temaril-P for a few months.

In August she did an ACTH stim test and his cortisol levels at baseline were 3.6 ug/dL; after 4 hours they were 16.7 ug/dL. At that time we talked about how this isn't a clear dx of Cushings and did a bunch of things to rule out other possible causes of the hair loss: blood sample allergy testing (nothing notable came up), a punch biopsy of an area where his hair is thinning (report says "findings suggest an endocrine/hormonal dermatosis with secondary superficial pyoderma or Malassezia dermatitis"), and a thyroid test (T4 = 1.4 ug/dL). Also tested for ova and parasite (including giardia) and all were negative.

In September 2010 he got infermectin injections in case the hair loss was related to something parasitic (no change).

Since September, the hair loss has continued to get worse. In mid-December, I tried brushing him with one of those slicker brushes with the metal bristles (usually I use one with plastic bristles) and he started bleeding in the places where the brush had scraped his skin. I did a bunch of reading about Cushings and took him into the vet to talk about the thin skin sx. We decided to do the 8-hr LDDST. This time his pre-cortisol levels were 5.4 ug/DL; after 4 hours they were 4.1 ug/dL; after 8 hours they were 4.6 ug/dL. Apparently they also tested his thyroid at that time and T4 = 16 pmol/L.

At that point the vet told me that Cushings was very likely and that we should do the abdominal ultrasound to try to determine adrenal vs. pituitary. The ultrasound was done on Xmas eve and the report says that the adrenal glands were normal size. It also said that there were many tiny 2-3 mm stones in his bladder which may be calcium oxolates.

I decided to do the Lysodren loading now since I have this week and next off from work, and can keep a close eye on him. As I said in my previous post, he took his first dose on Monday morning and so far no change in water consumption (today it actually went up, but it has always been at or below 20 oz/day... average is probably 17ish) or eating (average is probably about 50 seconds, barely pausing to chew). Behaviorally, he's seemed fine...perkier than normal actually--last night he wanted to walk extra, which he NEVER wants to do, esp. when it's cold out.

I have results of other lab tests (i.e., CBC, Chemistry Panel from 12/5, superchem panel from 7/27 & 4/11, etc) that I could share if that would be helpful.

I'd love to hear what people think with this additional info! Thanks in advance for any input you have... this forum seems like a really great place!

[frijole]

Hi and welcome! Did you do an acth test? Normally it's done in addition to the 8 hr one prior to starting lysodren. Then you do it during loading to see if you are 'loaded'. It is a measurement of cortisol. Takes a couple hrs and the results are only 2 numbers. ???

Anyway - wanted to make sure you were briefed by your vet on using lysodren. It is a wonderful drug - I used it for over 4 yrs with my girl Haley. It saved her life. It is a strong drug however and so it is important you 'play by the rules' and understand how it works.

So here's a link that I used and it helped alot.
Kim
http://www.k9cushings.com/forum/showthread.php?t=181

[StarDeb55]

Jess, prednisone is indeed a wonderful thing when used very carefully. Now, I have a big question for you was any of the Cushing's specific diagnostic tests done while Buster was on Temaril P? If so, you can throw all of those results out the window. The prednisone in the Temaril would have screwed up those tests. Long term use of steroids can induce a 3rd kind of Cushing's called iatrogenic. There is only one way to fix iatrogenic & that's to slowly wean the pup from the meds. If Buster was not on the steroids, how much time between his last dose of Temaril & any of the Cushing's diagnostic testing?

Allergies & Cushing's are a tough 2-some to deal with, I know from experience as my first boy, Barkley, had severe allergies, along with his Cushing's. Because of the Cushing's, my derm vet could not use any sort of steroid for his allergy treatment.

Debbie

Debbie

[frizzcurl]

Wow, you are all quick at replying!! It's quite helpful for a somewhat anxious doggy-mom like myself.

To answer Kim's question, the #s I posted are the only ones I see on the lab printout. I asked the vet if they did the ACTH test during the 8-hour test and she said yes. I assumed the #s I posted were cortisol levels? (From the 8-hour one, I interpreted the first # as baseline, the second as cortisol reading after 4 hrs, the second as cortisol reading after 8 hours... I can call the vet tomorrow to make sure.)

To answer Debbie's question, Buster stopped taking the Temaril P in February 2010 and the first LDDST was done in August 2010. The second one was done in December. So there was a 6-month gap between when he was weaned off the Temaril-P and the initial Cushing's test. And none of his Cushings-like sx stopped after being weaned off the Temaril-P.

[StarDeb55]

I'm glad to hear that steroid use is not the issue in this situation. Believe or not, in rare instances, we have see inexperienced vets try to make a cush diagnosis while the pup was on steroids, this is why I had to ask the questions.

Debbie

[addy]

Hi,

Buster's hair loss sounds exactly like my Zoe's hair loss. That was exactly how we started our journey. Zoe is a Lhasa and will be nine years old in April. Well, I think, I got her from Animal Control and a rescue group four years ago. We can only estimate her age.

We have not yet started our lysodren, chronic diahreea keeps poping up.

Hoping things go well with your load. Keep posting. The moderators can help you along. They are very smart

Hugs,
Addy

[frizzcurl]

Thanks, Addy! I hope things improve with Zoe soon.

So far things with Buster's load seem to be going well though it does make me nervous that we're on day 6 and so far I haven't seen a noticeable change in eating or drinking. This morning I thought that maybe he's less excited about being fed than usual (was just following me around the kitchen closely while I got things ready vs. jumping all over himself like he hasn't eaten in 10 years) but I also wonder if I'm just over-thinking things. He still inhaled his food without stopping for a breath in 49 seconds.

My vet isn't in today and the office is closed tomorrow but I scheduled him for an ACTH stim test on Monday morning anyway (since that will be day 8).