Lucas - My Beautiful 9 year old Shih-tzu Recently Diagnosed

[Nallelyta5]

Hi, first of all I want to say thank you for this forum full of warmth and support. I'm so glad I found it! It has given me a lot of hope for my newly diagnosed Lucas and it has relieved some of my anxiety as well. However, he is presenting most, if not all, of the physiological symptoms and his labs don't look good either, so I'm worried I'm late with testing and treatment. I have read a few posts and feel ready to post myself, with all the information I have as well as some questions. I want to be very thorough so please prepare for some reading.

My sweet Lucas is a 9 year old Shih-tzu (weight: 16.6 lbs) who has been pretty healthy most of his life. With the exception of sensitive skin and surgery to remove a small benign tumor on his cheek/ear area he's never had major health issues and rarely ever gets an upset tummy or anything like that. My parents have his mom and I adopted him when he was about 4 yrs old. He wasn't completely potty trained, and couldn't roam around the house as freely as his mom without being constantly monitored. I was partially successful at improving his potty training but he still had accidents. He was also known for being a picky eater, and while he was at a healthy weight according to vets, I still struggled a little to make him eat. He is also very emotionally sensitive, gets easily stressed out and nervous, but is very compassionate and empathetic with human emotions as well. He's never had any formal training but I always say he is like a therapy dog, as he will make sure to cuddle with you and calm you down if you're sad or anxious. It was evident he was the most reserved, shy and dependent on human protection out of the pack (5 puppies) since he was little.

The first signs of Cushing’s started about 1.5 years ago. I had to ask my parents for help keeping him for a few months due to an increased amount of travel I had to do for work. During this time they switched his food to what his mom was eating out of convenience and the fact that he started eating her food (Hill's Science Diet for reference). Since I struggled with his appetite, and there was a noticeable improvement, we were happy and thought maybe he just prefers this type of food. He started gaining weight as well, but my family always thought he was too skinny (regardless of vets saying his weight was ok), so they celebrated this and even though I felt like something was not right I got carried away with the positive take on it. We also had a couple of discussions regarding his extreme thirst. He had always drank more water than we thought was normal, but because his labs kept coming up normal and his vet wasn't raising any concerns we also didn't think much of it. We did look into diabetes but again, his labs were normal.

Other signs of Cushing’s that we had ignored and increasingly got worse include the following:
- Hair loss (thought it was just age)
- Obsession with licking/sucking his tail, especially at night (vet said he was bored or coping with anxiety, recommended exercise and keeping busy/distracted)
- Increased pee accidents (thought it was due to failing at potty training him)
Some signs that I did find very strange, more unusual and recent but were ignored given he still seemed energetic, was eating "well", and overall happy:
- Asking to be taken out for peeing in the middle of the night
- Dry crusty nose
- Dry flaky skin (thought it was seasonal allergies since his skin is sensitive)
- A dark spot on his tail that looked like black heads
- Increase panting and needy for attention (I would try everything from giving him water, food, taking him out to potty, playing fetch as he loves his squeaky toys, all of this trying to identify the need)
- Begging for table food and scavenging around the kitchen and dining area for any dropped food.

I started looking into Cushing’s about 3 months ago, after he experienced diarrhea for two days. I took him to the vet, and it turned out to be a bacterial infection. However, the vet pointed out his hair thinning and that he was "borderline overweight". She told me I should consider hormone testing as it was possible this was a hypothyroid problem. After I left the vet, I focused on getting Lucas back to health from his infection and then started to do some research. I found hypothyroidism to be unlikely as he was exhibiting signs of hyperthyroidism as well (excessive water consumption) – I thought he can’t possibly have both, can’t he? So after doing more research and noticing other signs (pot belly, visible veins on his belly, thin skin, more black head looking dark spots, skin darkening, kicking in his sleep, fat pads around his neck and bony head), I came across Cushing’s and felt like all the signs/symptoms were spot on.

About 3-4 weeks ago, he had another episode of diarrhea and mostly vomiting. This time he was evidently in pain, and very lethargic. I freaked out thinking of the possibility the pain was caused by major damage to his organs due to untreated Cushing’s, so I took him to an emergency clinic. I told the doctor about my suspicion of Cushing’s but it turned out to be another infection. She did mention he had signs of it and we discussed testing. However, since I knew this condition involves long term care I wanted to find a clinic where I felt comfortable with pricing and reputation, as well as how open they are to holistic treatment. I had read that frequent infections are common in dogs with Cushing’s, so I tried to establish care as soon as possible, and he got his formal diagnosis last week.

I’m attaching here the testing he’s had. They did the Dexamethasone suppression test and while it confirmed Cushing’s, it was inconclusive for the pituitary dependent type, so he’s pending the ultrasound. His doctor understands the cost of it (~$400) and considered what I’ve already spent (over $600) and gave me options. She said in most cases it will be pituitary dependent and the tumors are typically benign. She explained that the most important thing is to control his cortisol levels as this is what is causing all the symptoms and having a negative effect on his health, so she said we could start treatment (recommending Trilostane) and see how he does and I could do the ultrasound later on if I wanted to.

I would really appreciate feedback on the following:
- Is Lucas doctor on the right track?
- Do the options she is giving me match those of the field experts?
- How important is the ultrasound?
- This is very hard to ask, but how late am I at treating Lucas? And based on Lucas’s progress of Cushing’s what is his prognosis? And if it’s a few more years, what will be his quality of life?
- How safe is Trilostane?
- Any Holistic alternatives?
- Is there any specific diet that mimics Cushing’s?
- Any diet that would help?

Any additional feedback is welcome!
Nallely & Lucas

[labblab]

Nallely, hello and welcome to you and Lucas! I’m so sorry for the delay in responding, and even now I’m afraid I don’t yet have the opportunity to offer you an extensive reply. You’ve given us such a great summary of Lucas’ situation that I want to be able to take the time to really sort through it thoroughly before responding, and today has turned out to be “one of those days” for me in terms of chores that have taken longer than I expected! But I definitely want to tell you how glad we are that you’ve found us, and to let you know that I will indeed return by tomorrow in order to share some thoughts.

Once again, welcome, and please do stay tuned...
Marianne

[Nallelyta5]

Thank you so much Marianne, I appreciate your response and totally understand! I just want to add that I felt a little pressured with time and went ahead and made the decision to start him on treatment and hold off on the ultrasound for now. We're starting him on 10mg for about 3 weeks, and then the dosage will increase to 15mg, so any input on that will be greatly appreciated as well. Thanks again and looking forward to hearing from you guys!

[Harley PoMMom]

Hi Nallely,

Welcome to you and Lucas from me as well! One question I have, did they perform the LDDS test while Lucas was ill? The reason I ask is because the LDDS test can yield a false positive result when the pet has a non-adrenal illness.

Another thing I advise is discontinuing treatment until Lucas' infection is completely gone especially since diarrhea is one of his symptoms. My rationale behind this thinking is that with some dogs on treatment their cortisol can drop too low and diarrhea is one indicator of that, so if Lucas is still experiencing loose stools than it will be hard to determine if it's from the Trilostane or the infection unless you have his cortisol checked with an ACTH stimulation test which is a very expensive test.

Now, if Lucas is not having any diarrhea episodes and treatment is proceeded with, the 10 mg of Trilostane is a reasonable dose for his weight of 16 lbs. Also, there are 2 important rules to follow, #1) Trilostane has to be given with a meal to be properly absorbed; #2) Those monitoring ACTH stimulation tests have to be performed 4-6 hours after the dose of Trilostane was given with a meal.

Lucas' first monitoring ACTH stimulation test should be done 10-14 days after starting Trilostane, it is recommended that no dosage increase be made until the dog has been on Trilostane for 30 days, this is because cortisol can continue to drift downward during the first 30 days of treatment.

I do want you to know that a diagnosis of Cushing's is not a death sentence for a dog. Cushing's is a treatable disease and with treatment dogs with Cushing's can have a good quality of life and there is every reason to believe that they can live out their normal life span. However, for the treatment to work safely and successfully it requires an educated pet owner along with an experienced vet as adverse side effects are mostly seen when the proper protocols are not followed. I do urge you to look over our Helpful Resource thread and learn all that you can...link to that thread: https://www.k9cushings.com/forum/for...Cushing-s-Dogs

If you have any questions please do not hesitate to ask them.

We are here for you and will help in any way we can, again welcome to our family!

Lori

[labblab]

Hi again, Nallely!

I’m finally back again, and I’m so glad that Lori has greeted you in my absence. She’s given you so much helpful information that there’s really not a whole lot more for me to add right now. I do believe that Lucas exhibits both observable and laboratory abnormalities that are consistent with Cushing’s, so I don’t have reason to suspect that the diagnosis is amiss. And as Lori has written, 10 mg. of trilostane is a very reasonable dose with which to start treatment.

One thing that I did notice on his labwork was an elevated lipase reading. Taken in conjunction with his recent acute episode of pain, vomiting and diarrhea, I wonder whether he may have had an acute episode of pancreatitis. Hopefully he’s feeling much better now, though.

As far as the ultrasound, I’m assuming the vet has explained that a surgical option exists if Lucas is suffering from an adrenal tumor rather than a pituitary tumor. Adrenal surgery is both quite risky and also quite expensive, and not every dog would be a suitable candidate, regardless. If successful, surgery can offer a complete cure. But if adrenal surgery is not something you’d consider, anyway, then your vet is indeed correct that trilostane is prescribed to control excessive cortisol levels regardless of tumor type.

We do say that an abdominal ultrasound can provide a lot of bang for your buck, in that you have the opportunity to assess possible abnormalities in all the major organs in addition to the adrenal glands. But I understand why that may be held on the back burner for you right at the moment. One detail to be aware of: trilostane treatment itself typically causes enlargement of the adrenal glands. So for diagnostic purposes, waiting may muddy the water as to whether or the visualized enlargement of the adrenals is due to a pituitary tumor vs. the treatment itself. However, an adrenal tumor would be able to be seen at any point in time — waiting shouldn’t present an issue with that.

OK, I’ll go ahead and close for now. I hope that all is going well for you two as this week proceeds. We’ll be watching for an update!

Marianne

[Elizabeth513]

Hi Nallely! I'm here just to say hello and to say we've recently began this journey to health after a Cushing's diagnosis on our boy, Max! I don't have any advice as I am still learning, but wanted you to know that you are not alone and I am sending positive vibes your and Lucas's way!