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Thread: Skylar - loving ten year old rescue (Skylar has now passed)

  1. #1
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    Question Skylar - loving ten year old rescue (Skylar has now passed)

    Hi new forum friends!

    I am a relatively new Cushing's dog mom - I rescued an ~10 year old 16lb yorkie 9 weeks ago. When I got him, he'd been picked up from a shelter into a rescue, they'd done an initial senior blood panel and had some concerns about his heart. His kidney levels at that point I believe were slightly high. He was diagnosed first with mitral valve degeneration and we spent a few weeks getting his heart meds right.

    As I got to know him, his excessive thirst stood out to me, and the corresponding need to pee! He'd pant frequently, and had a hard time with being very restless at night (and we'd have to go out to pee a few times). His temperament was sweet, but he was quite docile and lazy (wouldn't walk far at all). I kept up with the vet, and we agreed to test him for Cushings and he was diagnosed on June 24th.

    For two weeks he was on 5mg of Vetoryl in the AM and PM. I saw no improvement in symptoms.... he went in for his first ACTH check, and they increased to 10mg in the morning, 5mg at night this past Friday (July 10th). They did say that the numbers looked great (though I dont have the results, will ask today) and that it was now more about symptom management. Well, his activity level since the 10mg morning dose change has skyrocketed! It's adorable, he runs and runs and runs. I didn't even know this was possible for him! It's pretty great to see such a happy go lucky dog. I did read on here not to change dosage that quickly, but I am hoping that these are good signs and we'll leave him on this for at least a month. We are getting re-checked 11 days from the increase in the meantime (July 20th). I will try to find the actual test results to share as a follow up (his initial and the ACTH follow up #1)

    Was curious if anyone else gives the Vetoryl twice a day? a lot of the threads I was reading administered only in the morning? What time of day?

    I have been doing 9am/9pm, and the full of beans activity starts as early as 6am! After I feel like we are on the right dosage for the long haul I may play with timing. Obviously still new 'results' but he's still up to pee during the night, so it's more the first thing in the morning change I am most noticing currently. I think he may be drinking less water during the day! But still drinks a lot of water when he's up to pee during the night.

    My other pressing question for the group, however, is eye related! Since June 6th, we've had three eye issues. First, a corneal ulcer which I suspected at the time was from dust after a very windy day. He completed 10days of meds, was re-checked at day 5 and all signs pointed to clearing up. He was then fine for about a week.... then had a green gunky eye discharge. Back to vet, clear of ulcer but with an infection. Treated with different eye drop antibiotics, cleared up quickly.... completed the 10 day course treatment. Again, a week of all good. Now here we are with discharge/eye irritation (this time more white discharge). Waiting to call the vet this morning. Is this Cushing's related? Unrelated? He has some cataracts, and I think it's time to see an ophthalmologist, was just curious if anyone else has experienced anything similar. I just feel bad for his gunky winky eye!

    Look forward to being a part of this community, glad I found it
    Lindsay & Skylar
    Last edited by gvlinds; 07-13-2020 at 12:12 PM. Reason: additional questions

  2. #2
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    Default Re: Skylar - loving ten year old rescue

    Hello Lindsay and Skylar! I’m sorry that I have only a moment to post right now, but I definitely want to welcome you two and to thank you for all the great information that you’ve supplied in your introduction. Unfortunately, things have been a little slow on the forum lately, but I’m sure that others will be by to greet you as well. And I’ll be back, myself, later today or tomorrow, in order to write more. But in the meantime, please know that we’re really glad you’ve found us!

    Marianne

  3. #3
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    Default Re: Skylar - loving ten year old rescue

    Hello once again! Gosh, it took me longer to get back to you than I had planned :-(. But hopefully, “late” is truly better than “never,” as they say!

    First of all, bless you for taking in this little guy, knowing that he has these health challenges to overcome. As far as the Cushing’s treatment, it sounds as though your vet is proceeding very appropriately. You’re right that the general recommendation is to leave an initial dose unchanged for the first month. But Skylar started off at quite a conservative dose, and this intermediate increase is really just bringing him up to the accepted starting formula of 1 mg. per pound. In other words, this is the dose that he could even have been started off at. So as long as his labwork and behavior show no signs of overdose, I think this increase is fine.

    Also, both once- and twice-daily dosing regimens have been researched, and are recommended as satisfactory options. Some clinicians believe that twice-daily dosing affords the most consistent control of cortisol levels, and it is definitely recommended for diabetic dogs or for dogs whose symptoms seem to rebound as the day wears on. However, that schedule is not the easiest for many parents to maintain, especially since every dose of Vetoryl should be given with a full meal in order to be metabolized properly. So if satisfactory symptom resolution can be achieved by dosing just once daily with breakfast, then that can be a much easier schedule for many folks to follow.

    In terms of arriving at the best dosing schedule for you and Skylar, I want to stress the importance of giving each dose with food. Above anything else, that may help determine which time of day works best for you.

    As far as his eye problems, it is generally the case that dogs with uncontrolled elevated cortisol levels seem to be more vulnerable to infections (and slow healing) across the board. But I’m not aware of any particular link between Cushing’s and eye problems. Hopefully Skylar’s new Cushing’s treatment regimen will end up improving his immune system, overall.

    Guess that’s all I can think of for now. But once again, welcome to you both. It sounds as though you’re on the right track!

    Marianne

  4. #4
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    Cool Re: Skylar - loving ten year old rescue

    Thanks Marianne!

    Appreciate the support, and the info! I've been doing dinner in sort of two parts, some at 7pm and then the rest at 8pm with his pills. He takes his heart meds at the same time.... so with a good amount of meal (dry and wet). But great point as we settle in to consider.

    His eye is still the corneal ulcer they believe slow healing, so I think you're right about general immune system...

    Still peeing 1-2x a night, so hopeful eventually we will reduce that some when he gets settled .

    Thanks for the support! Will share more of our journey.

    Lindsay and Skylar

  5. #5
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    Default Re: Skylar - loving ten year old rescue

    Hi Lindsay,

    Welcome to you and Skylar!

    I have a concern about the timing of the medication. You said -
    I've been doing dinner in sort of two parts, some at 7pm and then the rest at 8pm with his pills. He takes his heart meds at the same time.... so with a good amount of meal (dry and wet).
    I am reading this to mean that you give the Vetoryl at night and only putting one hour between the two doses. When Vetoryl is given twice a day it should be given AM and PM - with breakfast and with the night meal, dinner or supper depending on what term you use. Vetoryl has a short life in the body and giving it 12 hours apart allows the drug to maintain a better level throughout out the 24 hour period. So spacing the two doses out only by one hour is defeating the purpose of twice a day dosing and putting a much higher dose in the body all at once.

    In addition, another reason for an AM dosing are the testing requirements to monitor the drug. If the vet is using the ACTH then this test must be done 4-6 hours after the dog has had a meal and the Vetoryl. If the vet is using the newer PVC, or pre-Vetoryl, test then the test must be done within 3 hours of the time the dog would normally be given the drug. So unless the vet is open and able to do the monitoring test at night, giving the drug in the PM will not work, making the test given the next day invalid. I will post a couple of links below that detail the ACTH first and PVC second.

    ACTH monitoring protocol:
    https://drive.google.com/file/d/0B5R...lDZ09oejQ/view

    PVC monitoring protocol:
    https://www.dechra.co.uk/therapy-are...l-monitoring-1

    I may be misreading your comment but wanted to share this info just in case.
    Hugs,
    Leslie
    "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.

  6. #6
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    Default Re: Skylar - loving ten year old rescue

    Hi!

    Oops, sorry for the confusion. I had been doing Vetoryl doses 9am and 9pm, but just switched to 8am and 8pm with meals.

    For a few days I was giving him half his dinner (food no meds) at 7pm and then the rest with the PM meds at 9pm but he seems OK to just have meals now at 8am and 8pm with the medications. That's what I referred to below but didn't clarify. Apologies! But appreciate the reminder and info

    We just checked his levels again after the increase to 15mg.... the vet wants to get more aggressive and go to 15mg in the AM, and 10mg in the evening to try to get the excessive thirst and peeing under control. I know this is more 'in the middle' of the recommended dosing of 1-3mg per pound.... he's been at the 15mg (10mg am & 5mg pm) for two weeks.... I am thinking of keeping that level for another two weeks before increasing based on reading on here. Not sure I want to increase within 30 days? Anyone have thoughts?

    I was also reading about Cushex and some natural milk thistle supplements that can be tried along with Vetoryl..... thinking about all our options!



    [QUOTE=Squirt's Mom;212292]Hi Lindsay,

    Welcome to you and Skylar!

    I have a concern about the timing of the medication. You said -

  7. #7
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    Default Re: Skylar - loving ten year old rescue

    Oh ~~whew~~ so glad for the clarification. I feel better about that now.

    It is during the first 30 days of treatment that you don't want to increase the drug because the cortisol can continue to drop during that period on the same dose. After that period has passed then increases are based on both the test results and the signs. If the recent test results are good, within optimal range, then I would be hesitant to increase just yet myself in spite of the continued excess urination/drinking. However, if those test results were still higher than desired an increase would be the best option. Sooooo it all depends on what those test results are. Did you get copies of the tests?

    As for Cushex....I wouldn't waste my money. It will have no bearing on the cortisol, which is the enemy in Cushing's. As for Milk Thistle...it can help with the liver if needed. But I would want to wait until all the cush signs were controlled and the cortisol within optimal range before looking at adding that. The elevated cortisol will cause the liver to work extra hard, elevating many of the values associate with that organ. But once the cortisol is better controlled those values often return to a more normal level because the liver isn't working as hard as it was. Milk Thistle can cause some digestive upsets in some dogs, mine was one of them, which can cloud the picture by mimicking signs of an overdose/cortisol going too low. So I would hold off on the MT for now....and just forget about the Cushex.

    Thanks for the quick reply and setting my old mind at ease!
    Hugs,
    Leslie
    "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.

  8. #8
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    Default Re: Skylar - loving ten year old rescue

    I am hoping you guys are better than I am at figuring out what all of this means! As a reminder, he's currently on 10mg in the AM and 5mg in the evening, starting July 8th. The vet wants to increase to 15mg in AM and 10mg in evening based on the July 21st test results and on-going excessive thirst/peeing & check his ACTH & chemistry at next appt. Thoughts & any help understanding below would be greatly appreciated

    JUNE 22nd
    PRE-DEX
    4 POST-DEX
    8 POST-DEX

    Result Reference Range
    3.5 ug/dL 1.0 - 6.0
    0.4 ug/dL
    2.1 ug/dL

    July 6th (after being on 5mg AM & 5mg PM dosage of vetoryl, after this result increased to 10mg AM & 5mg PM)

    Cortisol Sample 1
    results 1.9
    ref range 1 - 5
    unit ug/dL

    Cortisol Sample 2
    result 6.2
    ref range 8 - 17
    unit ug/dL

    JULY 20th

    Cortisol Sample 1
    result 2.5
    ref range 1 - 5
    unit ug/dL

    Cortisol Sample 2
    result 7.1
    ref range 8 - 17
    unit ug/dL

    and here's results from his chemistry check on July 7th

    Superchem
    Total Protein 7.5 (ref range 5 - 7.4 g/dL)
    Albumin 4.5 2.7 - (ref range 4.4 g/dL)
    Globulin 3.0 1.6 - (ref range 3.6 g/dL)
    Alb/Glob ratio 1.5 (ref range 0.8 - 2)
    AST (SGOT) 25 (ref range 15 - 66 IU/L)
    ALT 88 (ref range 12 - 118 IU/L)
    ALP 493 (ref range 5 - 131 IU/L)
    GGTP 2 (ref range 1 - 12 IU/L)
    Total bilirubin 0.1 (ref range 0.1 - 0.3 mg/dL)
    Urea Nitrogen 44 (ref range 6 - 31 mg/dL)
    Creatinine 1.0 (ref range 0.5 - 1.6 mg/dL)
    BUN/Creat ratio 44 (ref range 4 - 27)
    Phosphorus 6.2 (ref range 2.5 - 6 mg/dL)
    Glucose 113 (ref range 70 - 138 mg/dL)
    Calcium 11.4 (ref range 8.9 - 11.4 mg/dL)
    Magnesium 2.4 (ref range 1.5 - 2.5 mEq/L)
    Sodium 147 (ref range 139 - 154 mEq/L)
    Potassium 5.1 (ref range 3.6 - 5.5 mEq/L)
    Na/K ratio 29 (ref range 27 - 38)
    Chloride 108 (ref range 102 - 120 mEq/L)
    Cholesterol 202 (ref range 92 - 324 mg/dL)
    Triglycerides 419 (ref range 29 - 291 mg/dL)
    Amylase 601 (ref range 290 - 1125 IU/L)
    PrecisionPSL 225 (ref range 24 - 140 U/L)
    CPK 133 (ref range 59 - 895 IU/L)

    Comment Albumin may be falsely elevated due to a Hemolysis 2+, Lipemia 2+ and could be in the Normal Range.
    Last edited by gvlinds; 07-22-2020 at 07:15 PM. Reason: bold

  9. #9
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    Default Re: Skylar - loving ten year old rescue

    Hello again, and I’m sorry to have been delayed in getting back to you. By now, you may have gone ahead with the dosing increase, and if so, I hope that all is well. However, I have to say that I think your vet is being overly aggressive with the dosing increases. Please know that I’m not a vet myself, but over my years on the forum, we’ve consistently witnessed fewer episodes of overdose or ill effects when dosage increases are instituted more gradually.

    Starting with the original diagnostic LDDS test, Skylar’s results are indeed consistent with pituitary Cushing’s. Elevated ALP and triglycerides are also common with Cushpups. So I understand why the Vetoryl treatment was started. However, given a post-ACTH result of 6.2 after only two weeks of dosing, I honestly wouldn’t have endorsed an increase at that time. I understand that he was (is) still exhibiting observable symptoms, but the most commonly accepted dosing recommendations are to leave the initial dose in place for the first 30 days, in order to allow the cortisol level to stabilize before deciding how much, or if, to change the dose. Since apparently Skylar didn’t have an ACTH performed prior to starting treatment, we don’t know how much of a decline is represented by that initial drop to 6.2. But that level is already well within the desired therapeutic range as long as symptoms end up under control. So no, I would not have increased already at the two-week mark.

    However, your vet *did* increase, and here’s the perplexing part: two weeks later, the post-ACTH is actually a bit *higher* at 7.1, and apparently you’ve still seen no improvement in his symptoms. The increased ACTH on the higher dose is definitely odd. I have no explanation for that. However, I don’t know that I’d feel comfortable with another significant dosing increases after just two weeks at that previous level. If it were me, I believe I’d prefer to leave things alone for that full month, and then reassess again. As I say, you may have already started the higher dose and if so, I hope all is well. But if not, I’d advocate for just leaving things status quo for a while longer. Because if you do end up seeing symptom improvement at the current cortisol level, you’re within the desired therapeutic range and there would be no need to increase at all. On the other hand, if his cortisol level is still increasing at that point, you may want to reassess whether other systemic stresses are affecting his endocrine system. For instance, how’s his eye doing at this point? He’s not receiving any eye medication that contains steroids, is he?

    Marianne

  10. #10
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    Default Re: Skylar - loving ten year old rescue (Skylar has now passed)

    No worries on time to reply!

    Sigh, this was all my suspicion after reading. I have not gone ahead with the increase yet.... I've ordered more meds to have on hand (since it's really just adding 10 or 5mg which he takes now). They arrive next week, and I think I will delay increasing at least for the 30 days on this.

    I was curious, and the vet didn't mention anything around his ACTH being higher the 2nd time. He is on Oflocacin for his eye, which is an antibiotic not a steroid I believe. Along with his heart meds (Vetmedin/Benazipril) which are not steroids either.

    His eye is... not "better" but has improved. No more squinting/excessive tearing but it's not 100%. We're going to an ophthalmologist, but our appointment isnt for three more weeks! GRRR.

    Thanks for the advice,
    Lindsay & Skylar

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