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Thread: Thoughts on Possible Cushings? (Kiwi has passed)

  1. #11
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    Jul 2018
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    Default Re: Thoughts on Possible Cushings?

    Thank you. I have noted improvement since he started on Augmentin, we believed he may have a sub-acute infection, but he still is very vulnerable to any additional calories and needs a pretty big amount of insulin. So it is tough here, on one hand it looks kinda iffy that he has Cushing's on the other hand there are some indicators. With respect the question of pituitary tumor v. adrenal hyperadrenocortism, does ACTH determine that? What is the difference in treatment/protocol pituitary v adrenal origin?

    Mark

  2. #12
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    Apr 2009
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    Georgia
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    Default Re: Thoughts on Possible Cushings?

    Unfortunately, ACTH results do not differentiate between the two types. Another drawback is that a significant number of dogs with adrenal Cushing’s will register “false negatives” on the test. However, it does a relatively better job of correctly identifying the disease in dogs with pituitary tumors, and PDH is the more common of the two types of Cushing’s. The risk of returning false negatives is the reason why the LDDS is generally preferred in instances where no other known diseases are at play. But in deciding between the two tests, you’re basically weighing relative risks: will it be more damaging to miss making the Cushing’s diagnosis in a dog who truly has the disease, or will it be more damaging to mistakenly diagnose (and begin treating) a dog who doesn’t have Cushing’s and is instead suffering from a different ailment altogether. I am not a vet, but my personal preference for a dog of my own would be to first start with the ACTH if I know another illness is present. If the dog tests positive, then I’d find some reassurance in knowing that the positive result came on the test that is more specific to Cushing’s.

    As far as then differentiating between the two types, you’d need to proceed to additional blood testing or an abdominal ultrasound in order to actually visualize the adrenal glands. Most pituitary tumors are benign; adrenal tumors can be either benign or cancerous. Also, adrenal tumors can become life-threatening if they invade nearby critical blood vessels. If a dog is a good surgical candidate, surgery to remove adrenal tumors has the potential to offer a complete cure. The surgery is risky and very expensive, however. If surgery is not an option, Cushing’s symptoms are managed in the same manner as are those from pituitary Cushing’s: via medication.

    So that’s kind of a mini-crash course on the difference between the tests and the types of tumors ;-).

    Marianne

  3. #13
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    Jul 2018
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    16

    Default Re: Thoughts on Possible Cushings?

    Kiwi had his ACTH today.

    Baseline <0.5 ug/dl
    Post Synthetic ACTH - 25.8 ug/dl

    Vet felt, particularly in light of his insulin resistance, that it was pretty case closed that he has Cushing's. She also agreed with me that it probably doesn't make any difference whether the origin is pituitary or adrenal and it would be best to simply begin treatment. She started him today at 30mg trilsostane. We'll see how things go. For as long as I can remember he drank a hell of a lot and was heat intolerant, even before he had diabetes. I'm feeling this diagnosis explains a lot about him and I'm hopeful that treatment resolves some of his outstanding issues and insulin resistance. Could just be that it was cooler tonight but he went for a hell of a walk 3hrs after his first dose. So far so good.

    Mark and Kiwi

  4. #14
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    Apr 2009
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    York, PA.
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    Default Re: Thoughts on Possible Cushings?

    Hmmm, that baseline level is low, was Kiwi pretty laid back when the blood draw was taken? Does he still weigh 26 lbs? Is Kiwi getting his Trilostane with a meal so that it is properly absorbed? Has an appointment been scheduled for that 10-14 day recheck?

  5. #15
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    Tennessee
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    Default Re: Thoughts on Possible Cushings?

    Hi Mark. I only have a moment but would like to ask a few questions. Did your vet make sure Kiwi's blood glucose was well below 400 mg/dL before administering the uc:cr and acth stimulation test? This is very important because if bg is above 400 mg/dL both tests can yield a false positive results? One third of Mini Schnauzers have hypertriglyceridemia/hyperlipidemia. Since these can make it difficult to regulate bg, did your vet check Kiwi's triglycerides to rule this out as a possible cause? I've seen more than a few Mini Schnauzers, with and without diabetes, misdiagnosed with cushing's and since Kiwi has no skin and coat issues, I have concerns about the validity of the diagnosis. If you used the link Marianne provided to Dr. Peterson's Q & A website for vets, you will see that the dog being discussed is a Schnoodle. Much like Kiwi that dog was receiving insulin doses much below that which is usually defined as being insulin resistant. Most specialists set that threshold at 2.2 U/kg per injection and Kiwi is getting only 1 U/kg per injection so you have a long way to go before most experienced vets would be looking at insulin resistance. It is possible that Kiwi has cushing's but without further information from you, I would be hesitant to start treatment. If the diagnosis is correct, you need to know that cushdogs with concurrent diabetes should be on twice daily dosing of Vetoryl. The reason for this is that Vetoryl has a short half life, meaning it's effects start to wear off after 8 to 10 hours. By dosing every 12 hours, you are effectively controlling cortisol throughout the day, eliminating the possibility of spikes in bg. It is also recommended that dogs start on a dose of 1 mg/lb so if it were me, I would personally talk to the vet about changing the dosing to 15 mg am and pm. I will look forward to your reply.

    Glynda

  6. #16
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    Jul 2018
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    Default Re: Thoughts on Possible Cushings?

    Yes, he was below 400, in fact he was 147mg/dl on UC/CR and likely similar on ACTH. He was also quite chill on test. I like the suggestion of twice daily dosing. He has not had his triglycerides check perhaps we can do that on followup ACTH test in 30d. I think we need to see how he reacts to the trilostane at this point. Over the next few weeks. I will let you know.

  7. #17
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    Jul 2018
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    Default Re: Thoughts on Possible Cushings?

    Things were going rather well til Thursday. His need to drink has decreased, particularly at night, and he has had no peeing in the middle of the night crisises. I also was able to reduce his insulin by a small amount, 12iu to 10iu. However Thursday my friend who was taking care of him said he was disoriented and didn't even get up initially when he returned from work. I assumed it was a sharp case of hypoglycemia... which happened to me once a few yrs ago. He did recover from this incident, but he is still a little off. He seems a bit weak in his hind legs and while more alert still a little slightly confused. He will be having his follow up tomorrow morning so I will have them add CBC and Complete Metabolic panel to his ACTH Stim.

  8. #18
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    Jul 2018
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    16

    Default Re: Thoughts on Possible Cushings?

    So he had his follow up ACTH Stim test and his pre was 0.6 and his post was 2.5. The vet wants to lower the dose. Technically the RX insert says that one should continue that the present dose at 1.45-5.4ug/dl cortisol, but this vet isn't comfortable with a 2.5ug/dl. I'm actually fine with this for two reasons:

    1. His sugars are more in control when he takes his pill. Currently at 30mg 2x a day. Going to 10mg 2x a day would make for better control than the 1x daily dosing.
    2. He is arthritic and I think his arthritis has been worse since initiating the Vetoryl which would be consistent with having less anti-inflammatory cortisol in his system.
    3. He did seem to have a worrisome hypoglycemic incident while a friend was caring for him while traveling, I'd like to avoid this happening again and a lower dose may help in this regard as well.

    So off to 10mg 2x a day.

  9. #19
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    Mar 2009
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    Default Re: Thoughts on Possible Cushings?

    geez....2.5 ug/dl is PERFECT so the vet is way off base here wanting to up the dose based on the post #. They are also off base wanting to raise the dose in the first 30 days because the starting dose will very often continue to lower the cortisol for at least 30 days. Dechra says NOT to raise the dose in those first 30 days as a result. So your instincts are spot on - stay on the same dose for now....and watch closely for any signs of the cortisol going too low.
    "May you know that absence is full of tender presence and that nothing is ever lost or forgotten." John O'Donahue, "Eternal Echoes"

    Death is not a changing of worlds as most imagine, as much as the walls of this world infinitely expanding.

  10. #20
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    Apr 2009
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    Default Re: Thoughts on Possible Cushings?

    Hmmmmm, just to clarify, your vet is wanting to lower the trilostane dose from 30 mg. once daily to 10 mg. twice daily? If so, I agree that changing the dosing in this way seems to be reasonable. First of all, as you’ve already noted, twice daily dosing is definitely preferred in the treatment of diabetic dogs.

    Secondly, even though it’s typically the post-ACTH value that is of prime importance when evaluating appropriateness of dose, your dog’s baseline resting cortisol level is awfully low. I notice that the baseline was also quite low at the time of the diagnostic ACTH, too, and I honestly don’t quite know what to make of that. But if the resting cortisol consistently runs really low, then I agree with you that lessening the added suppressive effect of the trilostane might ease your dog’s increased arthritic discomfort.

    So all in all, I think the new dosing regimen is certainly worth a try. Do let us know how things go.

    Marianne

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