To treat or not to treat?

[Harley PoMMom]

To get an accurate result for the glucose, triglycerides, and cholesterol it should be drawn from a 12 hour fast. So, if this were me, I'd have that done.

[Squirt's Mom]

I put the abnormal results in bold so they will stand out.

[inheriteddog]

Urinalysis was performed on Tuesday, including protein:creatinine. Protein in urine was high, likely the cause of the low albumin in the blood. Vet considers this probably due to Cushing's, not a separate kidney problem. Ultrasound was conducted yesterday. Prelim results show both adrenals affected, suggestive of pituitary based Cushing's. Also liver enlarged. I am planning to ask a few questions on tests, but for discussion's sake this is how they stand so far.

Vet wants BP test performed at home. One was tried at office but Kobe was unable to calm down enough. Then vet wants to do the LDDST and go on to treatment for Cushing's, assuming a positive result.

Kobe needs a break (several vet visits in just 10 days and yesterday's ultrasound took 6 hours). Meanwhile, I have to look at finances. So far have spent about $1200 on tests and not finished yet. I estimate low-dose Vetoryl (as suggested by Vet if Cushing's is confirmed) will be around $100/month. And that's just to start. All this is not really workable on fixed low income. (And my home heating bill tripled this month.) Doctors don't seem to factor in cost to client when they recommend this test and that.

Back to my original question: will all this be worth it? Kobe gets along pretty well on day to day basis. Although drinking is heavy, volume of intake is inconsistent, as are panting and skin issues. He appears in good mood, sleeps well, gets excited when smells that a cat has visited the yard. I don't know how concerned I should be about metabolic issues like diabetes and BP at this stage. The low protein in blood does concern me, but I don't know how it is affecting Kobe right now. In cooler weather Kobe's panting has not been too bad, but come summer there might be problems. I need time t clear my head. Any thoughts are appreciated.

[Harley PoMMom]

Here are my thoughts, however, I want you to know that I am not a vet or do I have any veterinary experience so on that note! If Kobe were my furbaby and if symptoms were not bothersome to Kobe or me than I would probably not treat. The elevations in the glucose, triglycerides, and cholesterol could be because the test wasn't done while fasting. Although he does have elevations in the liver enzymes, a dog with Cushing's generally has much higher numbers, usually in the 1000's. This is just my opinion and hopefully the others will be along to share theirs.

If at some time you do wish to go through with treatment, there are ways to keep cost down and we will be happy to share them with you.

Hugs, Lori

[Squirt's Mom]

First, I agree with Lori on the test results and fasting. Now, three things stand out to me. One has to do with your decision ahead on treating, the second on the dosing, and the the last on the vet's comment.

We rarely see the ALP go down in an untreated cush pup. It typically rises and rises and rises well into numbers much much higher than Kobe's...I've seen the ALP in the 10,000's. So the fact that Kobe's ALP has gone down is enough to give me pause on the suspicion of Cushing's and certainly treating.

The vet said he would use "low dosing"...that is rather open-ended. Just so you know, for dogs under 40 lbs the correct starting dose is 1mg per pound per day. So let's say Kobe weighs 30 lbs - the maximum dose to start him on would be 30mg per day. Dechra says to start at the lowest possible dose and that is 1mg per lb. I have seen vets who think a low starting dose is 3mg per pound and the majority of the dogs get sick starting so high. So stick to your guns IF you decide to treat and accept no more than 1mg per pound per day IF he weights under 40 lbs. I have skimmed thru this thread and didn't see his weight so just in case I will tell you about larger dogs. Dogs over 40 lbs should start at no more than 0.5mg per lb per day....lower than the dogs who weigh less. This is because over the years since Vetoryl/Trilostane hit the market it has been observed that larger dogs are often much more sensitive to this drug. Studies have supported this observation and lower dosing protocol. Many vets are not aware of these studies and use out-dated guidelines from Dechra. Dechra does know about the studies, about the dogs getting sick (and worse) on the current dosing literature and they simply do not care. They refuse to change their literature leaving vets handicapped and putting dogs at risk. Here is a write-up from one of our Admins on this topic you can share with Kobe's vet.

https://drive.google.com/file/d/155a...gpCjmRdUz/view

Now what the vet said. You wrote: "Then vet wants to do the LDDST and go on to treatment for Cushing's, assuming a positive result". Treating based on an assumption is a great way to make Kobe extremely ill if not worse. You NEVER EVER start treatment without at least one positive blood test and a solid sign profile. So this has made me very nervous. Do NOT allow this vet to convince you this will be ok...it could be very very bad for Kobe and you, not to mention the pocketbook. These are very powerful drugs and should never be used based on an assumption.

Now a disclaimer if you will. I have had 2 dogs "diagnosed" with Cushing's. BOTH were misdiagnosed by different vets. So I am hyper-alert when it comes to any possibility a dog has been or could be misdiagnosed. I never ever advocate rushing into treatment for this reason. Take your time and be sure. Treating a dog for Cushing's who doesn't have the disease or starting a dog on a dose that is too high is much worse than not treating at all. So it is paramount to me to be as sure as possible that the diagnosis is correct and that the starting dose is correct. We are here to help you in any way we can but I did want you to know that much of my input is based on my own experiences as well as what I have observed in these forums/groups.

Hugs,
Leslie

[labblab]

Both you and Kobe have been through a lot during these past ten days, so I absolutely endorse you taking a bit of time to catch your breath and consider your options. You both deserve a break! I'm so glad that Lori and Leslie have given you their thoughts about all this, and I'll go ahead and add mine for your consideration as well.

I've already written to you earlier regarding my general thinking about the decision to treat in older dogs, and my initial reaction re: Kobe was that I probably would not be rushing into treatment. And that may still be your decision. However, these new test results do skew my thinking a bit as far as tipping the balance towards treatment. Here's why. At this point, I personally think the Cushing's diagnosis is likely accurate. As Leslie says, it's definitely true that ALP levels typically continue to trend upward in untreated dogs -- often to much higher levels than Kobe's. So that is one oddity in his bloodwork. But aside from that, basically all the other lab abnormalities are consistent with Cushing's including the new addition of elevated platelets, low eosinophyls, and urinary protein loss. I agree with Lori that a fasted sample would be preferred for glucose, cholesterol and triglycerides, but I think that 153 is somewhat high for even a random glucose sample in a dog. And of those three blood chemistries, the glucose is the one I'd be most focused on right now.

The ultrasound is also exactly what you would expect to see in a dog with pituitary Cushing's. So thus far, I think your vet has proceeded appropriately with the testing, and the LDDS is indeed the logical final step in the diagnostic process. I'm guessing that what you were intending to tell us is not that your vet is just assuming that the LDDS will turn out positive. But instead, that in the event the LDDS *is* positive, at that point he'd recommend starting treatment. If so, I think that would be an appropriate recommendation. So I'm guessing Cushing's is your culprit; the question is whether or not you decide to start treatment if the LDDS indeed turns out to be positive.

I absolutely appreciate the financial burden on you, as well as the stress on Kobe associated with ongoing vet visits and testing. So what might tip me over into treatment? The new discovery of protein in the urine, now being added to the risks of elevating glucose and history of skin problems. I think it's very good that the vet wants you to try to take Kobe's blood pressure at home, because if he is suffering from high blood pressure in addition to the proteinuria, I believe he is at an even higher risk of developing worsening kidney disease. Ongoing high blood pressure can also increase the risk of blindness and other systemic problems. In the past, I made note of comments by a leading veterinary endocrinologist that the presence of hypertension and proteinuria would be symptoms that would lead him to recommend treatment for a Cushpup who otherwise was not exhibiting bothersome external symptoms of the disease. I'm assuming this is because those two problems have the potential to lead to serious systemic damage. Would that necessarily be the case for Kobe? I don't know. And even if so, how quickly? Also a big question mark. However, since you're asking for our thoughts about treatment, these would be factors that I'd put on the scale.

Having said that, I still think you have -- and should take -- whatever time you need to fully consider things. One good thing is that, aside from the LDDS, the big expense of the diagnostics is now behind you regardless of what you decide to do. The cost of medication and monitoring testing is not minimal, by any means. But at least from now on, it would be spread out on a monthly basis as opposed to all coming due at once. Also, it is preferable to slow or halt the progression of systemic damage because, once it occurs, some or all of it may be irreversible. However, I'm not knowledgeable as far as the normal lifespan of a beagle. In other words, at his age, would we expect Kobe to soon be vulnerable to increasing health problems regardless of the progression of untreated Cushing's? How much additional quality time might we expect the treatment to grant him?

I hope I haven't muddied the waters even further! But these are the factors that I would be taking into consideration if Kobe were my own. Please continue to let us know what you're thinking, yourself.

Marianne

[inheriteddog]

As always, I appreciate the comments. I've read so many articles that it just gets overwhelming. Especially when they don't seem to address my specific questions. That's why I sought out a forum, to hear from people who have been there, done that.

For the record, Kobe's last weight measured 34.4 lbs. He has been consistent in that regard for the last few years, that is around 33-34. He is a relatively small beagle, which suits me because when he gets on the scent he can really pull hard on the leash. The pot belly has made it hard for him to climb in the car, even with the step I built for him, but he still manages. It is surprising to me how quickly he jumps up from a lying position when he smells food. He also gets up on his hind legs to sniff the table. He makes short runs when he senses an intruder and paces quickly around the yard sniffing for cats or other critters. He still goes on walks in the morning and evening and gets plenty of rest during the day.

In terms of the vet "assuming" a positive test, I did mean it to be "in the event that the LDDST is positive", not that he assumes it will be so. This doctor has been very careful to emphasize that he is only making recommendations when a diagnosis is confirmed and only a test can do that. I asked him about possible dosage of Vetoryl so that I could try to calculate future cost to add to all the other costs being thrust on me, and he underlined that he was only answering me for that purpose, nothing more. If the disease is confirmed, he has suggested that safety dictates starting with a low dose, which he defined as 10mg twice a day. That's 20mg daily for a 34 lb dog.

I too am concerned about the low protein in the blood. The urinalysis points to protein being lost in the urine. This is a new hitch in the case. The diabetes and cholesterol issues are there, but I don't know if they would be that way even without Cushing's.

The literature I've read on Cushing's and Trilostane leaves me with more questions than answers. (I encountered this same problem two years ago when I researched my prostate cancer and had to decide what treatment to pursue. The matter is fuzzy, no one can guarantee anything, and in the end a lot is left to chance. I've been lucky so far, even though I went against the majority view in my case.)

One question I have is: exactly how effective is Trilostane? A lot of articles seem to describe it as almost a miracle drug (these articles seem to be underwritten by the manufacturer or clinics that promote its use). However, they don't say what degree of change I can expect to see. Will there will be a dramatic decrease in drinking, peeing, panting or, as one negative article countered, "minimal" effect? Promoters promise that metabolic issues will be arrested, maybe even improved, but I haven't actually read anything that gives me confidence in this regard. After all, "effectiveness" of treatment is basically determined by outward signs. And what about the pot belly? I have yet to read anything about whether that might be halted or reversed (although my previous vet claimed the muscles would regain strength and reverse the bulge!). I've tried a couple of herbal treatments (like lignans and melatonin) with uncertain effect.

Everyone agrees that Trilostane will not cure Cushing's. It is unclear whether it can prolong the dog's life. My vet almost seemed to suggest that, but he caught himself in mid-sentence as if he realized he could not make that claim.

The chemical is not benign, it is toxic (pregnant women are warned not to touch it, but it's OK to put it in your pet!). The matter comes down to "quality of life", which is subjective.

I'd like to hear from others with experience as to what to expect from Trilostane. (I know, every case is different, but there must be something to learn from all this.) Is it reasonable to expect enough change to justify putting the chemical into a dog? And to justify the cost? I know several elderly people who are paying hundreds of dollars a month on pharmaceuticals to keep themselves alive, while their bodies and minds slowly deteriorate. I'm not sure I would want to go through that, and wonder if I should I put Kobe through it?

Ha! First-world problems!

[Harley PoMMom]

If the disease is confirmed, he has suggested that safety dictates starting with a low dose, which he defined as 10mg twice a day. That's 20mg daily for a 34 lb dog.

I believe that's a reasonable dose of Vetoryl for Kobe.

The literature I've read on Cushing's and Trilostane leaves me with more questions than answers. (I encountered this same problem two years ago when I researched my prostate cancer and had to decide what treatment to pursue. The matter is fuzzy, no one can guarantee anything, and in the end a lot is left to chance. I've been lucky so far, even though I went against the majority view in my case.)

You're absolutely correct, there are no guarantees with Trilostane because all dogs are different and react differently. Vetoryl is a strong drug and it does have some pretty scary side effects, however, adverse effects are usually not seen unless the proper treatment protocols are not followed. We have many members that are treating their cushdog with Vetoryl/Trilostane and are experiencing success. The key to facilitating safe and effective treatment is an experienced vet and an educated pet owner, so the best advice I can give you is to do your research on Cushing's, the treatment protocols, and how it is diagnosed. 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. Also, ask all the questions you want and we will do our best to answer them!

One question I have is: exactly how effective is Trilostane? A lot of articles seem to describe it as almost a miracle drug (these articles seem to be underwritten by the manufacturer or clinics that promote its use). However, they don't say what degree of change I can expect to see. Will there will be a dramatic decrease in drinking, peeing, panting or, as one negative article countered, "minimal" effect? Promoters promise that metabolic issues will be arrested, maybe even improved, but I haven't actually read anything that gives me confidence in this regard. After all, "effectiveness" of treatment is basically determined by outward signs. And what about the pot belly? I have yet to read anything about whether that might be halted or reversed (although my previous vet claimed the muscles would regain strength and reverse the bulge!). I've tried a couple of herbal treatments (like lignans and melatonin) with uncertain effect.

Improvement in drinking/peeing are usually seen within 2 weeks of treatment, that pot belly may take much longer. What can be frustrating is getting that optimal dose for Kobe, this can take a while as cortisol can fluctuate so dosage adjustments are needed to achieve that therapeutic range.

Everyone agrees that Trilostane will not cure Cushing's. It is unclear whether it can prolong the dog's life. My vet almost seemed to suggest that, but he caught himself in mid-sentence as if he realized he could not make that claim.

The chemical is not benign, it is toxic (pregnant women are warned not to touch it, but it's OK to put it in your pet!). The matter comes down to "quality of life", which is subjective.

You are right, Trilostane is not a cure for Cushing's, the goal of treatment is to control the symptoms and elevated cortisol.

I'd like to hear from others with experience as to what to expect from Trilostane. (I know, every case is different, but there must be something to learn from all this.) Is it reasonable to expect enough change to justify putting the chemical into a dog? And to justify the cost? I know several elderly people who are paying hundreds of dollars a month on pharmaceuticals to keep themselves alive, while their bodies and minds slowly deteriorate. I'm not sure I would want to go through that, and wonder if I should I put Kobe through it?

I've never used Trilostane, Lysodren is what I started my Harley on but looking back I do wish I would of tried Trilostane first.

You're doing a great job!!

Hugs, Lori

[labblab]

Lori has done a great job of laying out answers to your questions, and I agree with everything she’s written. So it makes my job a lot easier — just to add a couple more thoughts ;-).

I did treat my Labrador retriever with trilostane. This was many years ago when the medication was first being introduced for veterinary purposes. At the time, the initial dosing range was much higher, so my boy started out on a whopping big dose. He was absolutely miserable beforehand and outwardly a poster child for the disease: panting all the time, excessive thirst/urination/hunger, bare haunches, always trying to find a cool place to lie down, hind end muscle weakness such that he could no longer jump in the car or on the couch, or even easily negotiate steps. The one thing he did not have was the pot belly. Within three days of starting the trilostane, his thirst and urination significantly subsided. Over time, there was also significant improvement in the other issues, as well. His hair grew back, he regained muscle strength — overall he was much more comfortable. I might not have seen improvements as quickly had he been taking a smaller dose to begin with. But for safety’s sake, starting lower is definitely the way to go.

I wish I could end the story of our journey on a happy note. But unfortunately within the first year of treatment, he started exhibiting neurological symptoms consistent with an enlarging pituitary tumor that was placing pressure on other parts of his brain. That is a risk that occurs in a certain percentage of Cushpups who have pituitary tumors, but I won’t dwell on it here. Because the main point I want to make is that I did see genuine outward improvement in my dog after we started the trilostane. Over my years here on the forum, I would say that by far the majority of our dogs treated with trilostane do see rather rapid improvement with thirst/urination. Improvement in coat, muscle strength, and pot belly are also seen, but over a longer time frame.

As far as metabolic changes, there is no question but that trilostane is very effective at lowering cortisol. So for disorders that are known to be aggravated by consistently elevated cortisol, presumably it is always a benefit to lower that level. Using the protein in the urine as an example, elevated cortisol is known to have the potential to alter kidney function in such a way that protein is allowed to pass through the kidneys into the urine. This dynamic can actually damage the kidneys if it persists for too long at too high a level. So if you read about diagnosis and treatment of “proteinuria” in dogs, one of the primary recommendations is to first identify whether there is an underlying condition (such as Cushing’s) that may be the basis for the problem, and if so, address that underlying cause. The same would be true for elevated glucose. It’s certainly true that dogs may suffer from diabetes separate from Cushing’s. But elevated steroid levels in the blood are known to have the potential to cause elevated glucose readings for any person or animal. In that case, glucose levels ought to normalize again if the steroid level is reduced. My mother-in-law had to take high doses of prednisone periodically for a skin condition. Each time, her glucose level went way up. But it lowered again once her prednisone was discontinued.

One last note I’d add is that the specific warnings against handling trilostane, especially for pregnant women, are not because it’s some sort of poison. It’s because of trilostane’s hormonal effect. If you don’t have elevated cortisol, you don’t want to be introducing the chemical into your system. For developing fetuses, hormonal imbalances can trigger birth defects so pregnant women are specifically warned. Actually, pregnant women are advised to avoid even certain OTC topical products due to possible hormonal effects. I know a lot of people get freaked out about the warnings against directly handling trilostane, but it’s not a poison like cyanide or anything like that.

From what I’ve written above, you may think I’m trying to push you into treatment and truly I am not. There can always be trade-offs. For instance, older dogs may see a worsening of arthritic pain once the high level of circulating cortisol is lowered. What a bummer that is — to solve some problems but to see others emerge. In my own case, treatment was a no-brainer. Outwardly my own dog was so physically miserable beforehand that we were seriously considering having him put down. As I said earlier, we ended up losing him within the year anyway. But he was far more comfortable during that time. But for most folks, it’s nowhere near that dramatic a decision. And I suspect that’s the case for you. So do continue to take whatever time you need and continue to ask us any questions.

[inheriteddog]

A couple of weeks have gone by as I recoup my expenses from last month's tests. Meanwhile, I am feeling more inclined to go ahead with the LDDS. Kobe's belly looks bigger, although he doesn't seem to have gained weight. It makes him clumsier and it's harder for him to sit. Some skin problems are showing up again on his face and between the toes. He seems more anxious and clingy. We had a couple of unusually warm days and he was panting. I fear the summer will be bad. And the blood test results from January are bothering me. He is a bit picky about his food now, but appetite remains good and his energy is the same too.

The vet said if the test is positive, he'd start Kobe on Vetoryl 20mg daily. He'd prefer 30, based on Kobe's weight, but the drug comes in 10mg doses, not 15, so can't split them in two. My fear is 20 won't be enough. Not sure what to do then. How easily do pets take Vetoryl? Kobe has been known to discover small pills in his food and spit them out.