Cocker Spaniel Bailey with Cushings and low thyroid - Bailey has crossed

[Help4Bailey]

Hi, I am Lynette and Bailey is my 11 year old, spayed, female cocker spaniel who was diagnosed with Cushing's on March 1, 2016. She presented with several peeing accidents, drinking lots of water, and has always been a voracious eater. Last year I had her tested for diabetes but that was and is still negative. She was originally brought to the vet because she was soaked in urine one morning which she never had accidents in the kennel she slept in. The vet thought that she may have a bladder infection so they did a urinalysis and blood work. The blood work showed low thyroid, <0.5, range 0.8-3.5ug/dL.
The urinalysis and culture came back negative. Vet placed Bailey on 0.2mg of Thyrosine two times a day. I wasn't given the actual full report until I brought Bailey back in two weeks later as she was barking to let her out 3 to 4 times a night, sometimes to pee, sometimes for water. I told the vet that something else must be wrong with her. She mentioned an ultrasound so we proceeded with the ultrasound that showed enlarged liver and adrenal glands. The radiologist suggested to vet that Bailey was likely to have Cushings so we proceeded with the ACTH Stim test. Bailey's results from the Stim test were Pre-Cortysn 26.9, range 1.0-5.0ug/dL and Post-Cortysn 39.5, range 8.0-17.0ug/dL. Her lab report also showed Alk Phosphatase 188(High), range 5-131 IU/L, Cholesterol 426(High), range 92-324 mg/dL, BUN 39(High), range 6-31 IU/L, as well as, PrecisionPSL 516(High), range 24-140 U/L. From this Bailey was diagnosed with Cushings and placed on 30mg of Trilostane once a day for a 24.3 lb dog. According to the vet, package dosing recommended 60mg once daily. I was uncomfortable starting out that high so I agreed to the 30mg once daily. Bailey started her Trilostane on March 2nd and took the meds for 4 days before I stopped the meds due to seeing her back legs shaking early in the day and after her collapsing on the floor later that night when she got me up. I was very scared as I thought she was going to die or had died! I lifted her paws and they were very limp and I tried to arouse her but nothing worked. I finally was able to get her up to stand but she looked mentally out of it. I moved her to another room where I could lay on the floor with her. She appeared to be breathing normally but still very groggy. I thought I was going to have to take her to an emergency vet but as I was getting ready to do that I opened the front door and she slowly got up and went to the front door. Since she had responded by getting up I postponed going to the emergency vet. I watched and listened to her all night long as she slept and got up and moved several times throughout the night. I did not give her the Trilostane that morning. After reading several posts from this forum, I contacted my vet this morning to tell her what happened to Bailey. She mentioned that about 63% of dogs will have Cortisol withdrawal and that I could give her 30mg of Trilostane every other day. I told the vet about the UC Davis recommendation that I read about later of 1mg/kg and she agreed that we could then give her 10mg capsules once daily but that she will still be Cushinoid. I am hoping that by reducing the level of Trilostane that it will be better for her to reduce her Cortisol levels more slowly. I don't know if she'll eventually have to go to back to 30mg but I would be very reluctant based on what happened to her earlier. Is it more likely that if Bailey shows some sign of improvement on her next ACTH Stim test but not enough to show that she is within the correct range that she could be given 10 mg twice daily rather than increasing back to 30mg? Bailey will be going back for another thyroid and ACTH Stim test on March 22. I was told to make sure she eats, takes her meds and then the ACTH Stim test would be performed within the 2-3 hour window from the time she eats. This wasn't the case when she was first tested as they had her fast when she had the ultrasound done an then they proceeded with the Stim test. Could her really high pre-Cortysn results been because she had no food or does that not matter until they start taking Trilostane? Is it likely that if and when the Trilostane corrects her Cortisol levels than she may not have to take Thyroid meds anymore? Sorry for such a long post and thank you in advance for any information you can provide. Lynette

[labblab]

Hello and welcome to you and Bailey! I am so glad you've found us, and thank you so much for already providing such helpful information. I regret that I only have time to post a couple of thoughts right now, but I certainly do want to welcome you to our family. I also want to tell you that I've shifted your thread here, to our main discussion forum, where more people are likely to see it and respond.

First of all, I do not know exactly what to make of Bailey's episode of extreme lethargy. But no matter what caused it, I applaud you for sticking to your guns and asking that Bailey's daily trilostane dose be lowered. Your vet is relying on outdated information (Dechra's current insert recommends starting as closely to 1 mg. per pound as is possible using available capsule strengths) and I am hoping that Bailey's experience will end up to be a "teachable moment" for your vet. There is no way that your vet can know in advance whether 10 mg. will turn out to be an insufficient dose -- different dogs of the very same weight can end up requiring widely variable dosages. Only time will tell. And in answer to your question, yes, increasing Bailey's dose to either 20 mg. once daily or 10 mg. twice daily will certainly be a doable option if she needs an increase.

As far as the ACTH testing, it is fine that Bailey was fasted at the time of the first, diagnostic test. The fasting only becomes an issue once the dog starts taking trilostane. This is because the drug must be taken along with food in order to be metabolized properly, which is very important on the day of the test.

I do want to point out that the testing timeframe that you have planned (2-3 hours after dosing) differs somewhat from the timing officially recommended by Dechra, maker of brandname Vetoryl (4-6 hours after dosing). We are aware that some clinicians prefer the shorter timeframe, and it should also be OK since trilostane supposedly reaches optimal effectiveness by 1.5 hours after dosing. But if that's the timeframe you are picking, you should stick to it consistently for all subsequent tests. That way, you are directly comparing apples-to-apples each time.

Oh, and yes, it is possible that Bailey's natural thyroid results will normalize once her Cushing's is well-controlled.

OK, I've got to close for now. But once again, I'm very glad you've found us and I hope that Bailey is doing much better today.

Marianne

[Help4Bailey]

Thanks Marianne for getting back so quickly!

No, I did not pick the 2-3 hour window from the time that Bailey eats, takes her Trilostane and then gets the ACTH test. I thought I read somewhere that testing was 4-6 hrs. I will make sure that each ACTH test is done exactly within the same timeframe. I do know that the vet said that subsequent tests will be about 1/5 the costs as they don't have to use the large amount of Cortysn.

I started Bailey on her new lower dose of 10mg Trilostane yesterday afternoon and she did very well last night with only getting up once! She did have to rush out to pee after she got up but she also ate better this morning.

I am wondering if it's better to have Bailey take her Trilostane in the afternoon with a small meal as it seemed to work well yesterday. Don't know if her appetite has come back because her dosing is less or because her stomach feels better after having been on a round of antibiotics. They first suspected she had a bladder infection before all the urinalysis and blood work testing came back.

I have been reading on different websites that a frozen raw diet is good for a dog with Cushing's. However, my vet is very much against a raw diet. She says that with Cushing's comes a weakened immune system and that all the bad bacteria would not be good for her and that I would be setting her up for more problems down the road. Bailey used to be on Natural Balance Salmon/Sweet Potato but now refuses to eat it. Does anyone have their dog on a frozen raw diet? If not, is there any food that is better recommended for dogs with Cushing's or ingredients to stay away from? Bailey is currently eating a bland diet of cooked chicken and rice as that was the only thing I can get her to eat on a consistent basis since the antibiotics.

Thanks, Lynette

[labblab]

Hi again, Lynette. I'm really glad to hear that Bailey seems to be feeling better! As far as the timing of the trilostane, it may be OK to stick with what you're doing for a few days if it seems to be agreeing with Bailey. But in the long run, Dechra's strong recommendation is that dogs who are dosed only once daily should be given their trilostane in the morning along with a full breakfast. There are a couple of reasons for this: the drug is metabolized best when given with a full meal, morning dosing allows the dog to receive the greatest benefit from the decrease in cortisol during the waking day when the dog is most active, and it also allows for the ACTH testing to be performed during most vets' normal office hours. Although there is variation among individual dogs, trilostane's effectiveness generally wears off after 12-18 hours. That's why some dogs seem to experience better symptom resolution if they are dosed every 12 hours instead of only once a day. But if you are dosing only once in the afternoon, her cortisol level will be peaking again throughout the morning hours.

As far as food suggestions, in honesty, I can't say that in my years on the forum, I have felt as though any particular style seems more suitable or more helpful for Cushpups. I am not a fan of raw feeding myself, but we do have some folks who feed raw food. Other folks feed the whole range of commercial wet, commercial dry, and homecooked. The general recommendation I often make is to serve a food that has a moderate level of good quality protein, and also lower levels of fat. Cushings can affect the kidneys in such a way that protein gets spilled into the urine. If a dog experiences significant urinary protein loss, then it's probably best not to include high levels of protein in the diet. The rationale for the lower fat is to due to the fact that Cushpups may have a higher vulnerability for developing pancreatitis, and higher fat diets may heighten this risk for some dogs. But as I say, these are just general recommendations. So any food with good quality ingredients that tempt Bailey is probably a fine option for you to choose.

I really hope the 10 mg. will do the trick for Bailey, and that she'll continue to feel better with each passing day.

Marianne

[molly muffin]

Welcome. I'm really glad you stuck to your guns and had her dosage lowered. There is no way to say for sure how any dog will react to any drug, but a complete collapse like that is more than cortisol withdrawal I'd think.

When do you do the follow up ACTH test to see how the levels are?

[Help4Bailey]

Hi again Marianne,

I wanted to give you an update on Bailey at the 10mg dosing level vs 30mg that she had serious reactions to and the reason why I was giving her Trilostane in the afternoon instead of the morning. Her next ACTH Stim test will be at 4:00pm with a 2-3 hour window from the time she is fed and given the Trilostane.

It took Bailey about a day and a half to recover and start to show symptoms of Cushing's after being off the 30mg dose.

The first night after the 10mg dosing level with a meal in the afternoon Bailey was able to sleep for 6 1/2 hours without waking us up with the need to pee. Of course when she did get up she peed a flood. She drank a moderate amount of water throughout the day, but not excessive. She had one accident in the house during the first day but otherwise jingled her bell to go outside.

During the 2nd day she was mellow in the morning, did a downward dog stretch that I hadn't seen her do in a long time. She was still alert but not overly active. She is always given her dosing of Thyroid meds with a smaller meal in the morning and in the evening. For most of this day she was very alert and followed us around during the day. She received her afternoon meal which I have made her largest meal along with the Trilostane at about 1:00-2:00pm. She was acting more like herself and even started to bark at her Kong and brought it to us. At about 9:30pm I put her to bed but she did wake me up at Midnight to go out and pee and get a drink. She went back to bed and didn't get back up until 8:00am!!! Yay! We were able to get some desperately needed sleep!

Day 3, so far continues to go well. She definitely drank and peed less today. When she goes in and out to pee I have noticed that her back legs don't whack on the threshold like they used to. She also tried to get up on the couch tonight but didn't make it. I hope that this is a sign that her muscle strength is coming back versus having more out of control cortisol like before. She was able to make a smaller jump up on our deck. What I have noticed is that when I give her the night time Thyroid med she seems to be a little more restless and pants some, but then it goes away. I plan to continue to watch this to see if it's a pattern. She won't have her thyroid checked until March 22 along with her ACTH testing. Maybe she won't need as much thyroid med if the Trilostane helps to improve things. I am hoping that Bailey will be able to sleep again tonight for 6-8 hours!! Keeping my fingers crossed!

I'll explain my thinking or questions about food pertaining to Cushing's in another post. Thanks for listening and your advice. Lynette

[Help4Bailey]

Need advice!!

Bailey is starting to show signs of back leg tremor. I noticed a little when I took her for a short, slow walk yesterday. It subsided after the walk. She had some loose stools on Thursday/Friday when I added some pumpkin to her meals. That seems to have helped.

She has been able to sleep and not get up and pee for 6 to 8 hours at a time at night. Her drinking and peeing during the day have dropped off as well, which is a good thing, I think. She continues to be interested in food and gets up when she thinks we are preparing food in the kitchen and eats her chicken/rice/pumpkin well.

She is on 10mg of Trilostane after having collapsed on 30mg. It was her 6th day of the 10mg that I noticed the tremors, now this morning after she went out to pee I noticed when she came in that her back legs were tremoring. The tremors dissipated after she rested. I also gave her the thyroid medicine this morning when she ate. She mostly rests during the day but gets up and follows us around or gets up when someone comes to the door. She's starting to act more like herself other than the off and on tremors.

Bailey is due to receive her dosing of Trilostane around 1:00-2:00pm with her largest meal and I am debating on whether I should give it to her. I'm not sure what to do? I don't want her to collapse again but so far she has never made it to the 10-14 days to get another ACTH Stim test to know where things stand! Do some dogs just have tremor as a side effect and are OK? Could it be a combo or her thyroid med and Trilostane, too much thyroid (shaking/tremor is a side effect in humans, but couldn't find anything for dogs). Bailey's thyroid levels haven't been re-checked yet as they were going to do them together when she gets the ACTH test. ACTH test to be done on March 22.
Please advise, Thanks, Lynette

[labblab]

Gosh, I know it feels like a hard call, given what you went through with her before. Tremoring is listed as a possible side effect of trilostane, though, so perhaps that is what this is about and it won't get worse. If Bailey is otherwise acting fine, I guess I'd be inclined to go ahead and dose her today in the hope that it is just a temporary issue. But you certainly know her best and if you are worried you can hold off for a day to see what happens.

Marianne

[Help4Bailey]

Thanks Marianne. I did go ahead and give her the Trilostane today. She has been eating and drinking and peeing normally throughout the day and I didn't see the tremors anymore before I gave her the dose.

I'm hoping for the best. March 22nd can't come soon enough so I can get some updated test results.

Lynette

[molly muffin]

My molly gets tremors sometimes. They sort of come and go and it hasn't seemed to affect her energy levels on her walks.

I'd just keep a close eye on her and as long as everything else is fine, then I'd continue with the dosage. If not, then I'd just call the vet and say, she has the tremors again and you want an ACTH done to check levels.
I say this based on her prior reaction.

Levels will continue to drop on the same dose for around 30 days normally.