Molly, 13 yr, shih tzu - lhasa aspo - Molly has passed

[labblab]

Well, the eye specialist's response is rather puzzling! No, Cushing's wouldn't directly cause the bleed. And yes, hypertension is associated with renal disease. But Cushing's is also a known cause of secondary hypertension which, in turn, can cause hypertensive retinopathy. Here's a "human" blurb, but I assume the same is true for dogs:

The arteriosclerotic changes of hypertensive retinopathy are caused by chronically elevated blood pressure, defined as systolic greater than 140 mmHg and diastolic greater than 90 mmHg[2]. Hypertension is usually essential and not secondary to another disease process. Essential hypertension is a polygenic disease with multiple modifiable environmental factors contributing to the disease. However, secondary hypertension can develop in the setting of pheochromocytoma, primary hyperaldosteronism, cushing’s syndrome, renal parenchymal disease, renal vascular disease, coarctation of the aorta, obstructive sleep apnea, hyperparathyroidism, and hyperthyroidism.

Probably nobody can separate out one single cause of Molly's issues. The kidneys, hypertension, and elevated cortisol may all be intertwined. But it seems odd to me that the eye specialist would totally dismiss Cushing's from the picture. I mean, that is basically ignoring the known impact of elevated steroids on blood pressure.

[labblab]

Here's another quote, this time from a veterinary paper on canine ocular disease:

Hypertension can be defined as systolic BP greater than 160mmHg. Hypertension is associated with renal disease, Cushing’s disease, pheochromocytoma, primary aldosteronism, hypothyroidism, and hyperthyroidism. Initial response to hypertension is constriction of retinal arterioles and with sustained high BP, occlusion and ischemic necrosis occurs of the blood vessel walls. This results in increased vascular permeability. Serous retinal exudates, hemorrhages, and edema occur due to the vascular permeability. In addition, tortuous retinal vessels and hyphema and vitreal hemorrhage can be seen. A blood pressure should be performed anytime there is bleeding in the eye. If the blood pressure can be controlled, then often retinal detachment and hemorrhage can be reversible and vision restored. Some permanent damage is likely..

http://c.ymcdn.com/sites/www.invma.o...%20DISEASE.pdf

I wonder if your IMS would even consider contacting Dr. Peterson and asking his opinion about Molly?

[labblab]

And I know this is probably overkill, but here's even a more comprehensive veterinary article, containing this summary statement:

Ocular complications often are not considered among
the primary manifestations of HAC in small animals.
However, there is actually an extensive list of possible
ophthalmic consequences to the excessive levels of corticosteroids
present in this disorder. Some possible findings
vary, depending on the specific circumstances of the case
and the location of the primary causative lesion in the
adrenal glands or the pituitary. Conversely, systemic
hypertension and its repercussions are common regardless
of the site of the primary lesion, as are metabolic changes
associated with hyperlipidemia and lipoproteinemia.

Hyperadrenocorticism
(HAC,Cushing’s disease)
• Systemic hypertension
— Retinal hemorrhage
— Retinal detachment
— Hyphema

Ocular Manifestations of Endocrine Disease

I am so sorry if I am overwhelming you with this stuff!!! But I know you're preparing to talk to the IMS and I'm just trying to arm you with as much info as possible. It makes it really hard since the eye specialist has already dismissed the cortisol as an issue. But I know you're wanting to do everything you can to preserve Molly's remaining eyesight. So I just don't want to overlook anything that is worth discussing further with your IMS while you have the opportunity to do so.

[molly muffin]

Well I sent a comment in to Dr. Peterson, referencing his response to Glynda. So lets see if he responds.

I hope my IMS will contact me today and I can ask her further about this. I don't know when Dr. Peterson will have a chance to respond, if he does.

Cross fingers.

I think there is enough evidence at this point that treatment with a low dose of trilostane should be considered. I'd want to start it once I return from Calgary, which will be Oct 13. I have another appt on Oc 16 with the IMS. I don't want to add anything new to the mix till then as I won't be around to monitor her and in addition to starting the benazepril.
We are currently not doing the lignams and melatonin, as I stopped those when this new situation occurred. I think I mentioned that on here, but it might have gotten loss in the muddle of the thread.

hugs
Sharlene and molly muffin

[labblab]

Bravo for writing to Dr. Peterson! Let's hope he responds!!

[Dixie'sMom]

I'd like to throw out a few things for consideration. If its helpful, please use it, if not just ignore it. Cushing's is new to me but I'm an old hat at eye disease. My eye doctor is the Professor and Chairman of the Retinal and Vitreous Disease Dept. at Duke University which is the 4th rated Ophthalmology clinic in the USA.

When my eye disease began, the first thing EVERYONE (1 opthalmologist, 1 retina specialist, and 1 neuro-ophthalmologist) thought was that I had a pituitary tumor because the back of my eyes at the retina was consistent with tumor. No tumor was identified on MRI and after many more tests, it was found that I had a very rare autoimmune disease that is destroying my retina. What am I saying here? If Molly has indeed had a micro pituitary tumor, there is the possibility that it has grown and that could be cause of the retinal bleeds. Pressure in the brain causes pressure on the back of the eyes where the retina and optic nerve reside.

As part of my treatment for severe inflammation in the vitrious fluid, chorid tissues and retina area of the eye, I was put on high doses of steroids by mouth and steroid injections in the eyeball. As a result of that, I developed cataracts and glaucoma. Even after the steroid shots and higher doses of steroids were discontinued, the glaucoma (eye pressure) and cataracts remain. Proof positive that high cortisol, natural or synthetic causes eye damage. I have also had to be put on blood pressure medicine because of the continued steroid use which has created the elevated BP

In thinking about the pituitary tumor possibility, maybe low dose Lysodren would make better sense since it actually shrinks the tumor. At least a short course of it may be more beneficial, and then you could always switch to Vetoryl.

I know you are worried sick about Molly and with the hubby's surgery coming up as well, you are probably about at the end of your rope. I'm praying for good answers for you and a good treatment plan so Miss Muffin can retain her sight and kidney function and live many more happy years. I know she brings you and the hubby so much joy. I also understand the "disconnect" with your regular GP vet. Mine did the same thing and as much as I love and respect him, I moved Dixie to someone else who has been very on top of things with regard to her Cushing's. You have a lot to think about, but I think if you will address 1 problem at a time and get 1 answer at a time, you will move thru your list of concerns and get to that place where you can sigh a breath of relief again. (((((SHARLENE)))))

[labblab]

Wow, Suzie, it sounds like you have had more than your share of eyeball adventures!

That is all really interesting information. If Sharlene were to start treatment, I've also thought about low-dose Lysodren for Molly, too, since UTK feels that treatment is safe for dogs who have even normal cortisol levels but elevations in other adrenal hormones (which Molly has, too, in addition to the elevated cortisol). Lysodren does not shrink a pituitary tumor, but a small percentage of adrenal tumors do physically respond to the drug, alongside the cells of the adrenal cortex. We do know that Molly has an adrenal nodule of some sort, so who knows, maybe the Lysodren would have an effect on it.

If there are issues of kidney function beyond proteinuria, that may be another reason why Lysodren might be a better choice, too. I'm not sure about that, though -- maybe some of our Lysodren experts will know more about Lysodren and kidney function.

Marianne

[molly muffin]

So, blood work is all good.

We will repeat the ACTH on Oct 16 and see where that stands. The 2012 ultrasound showed change in the kidney, so she said it is hard to know if the kidneys came first or the cortisol came first. I shared my concerns of the cortisol contributing to the kidney protein loss, which caused the hypertension, which caused the retinal bleeds. Since that was our first ACTH and LDDS has been negative since 2010, she doesn't think a repeat of an LDDS would do any good as Molly flatlines it every time. She said, depending on what that tells us, we can look at at 1mg/1kg dose of trilostane, but that she wouldn't do lysodren based on what she knows of molly's medical history. That we also don't want molly in any pain and that a bit higher cortisol would help that. In 2012, she had one kidney stone (it must have been on the report but I don't remember it being a factor in anything, I thought it was a bladder stone maybe?) small and unobstructed. Now she has two and they are unobstructed at this time too.

She doesn't think the cortisol is high enough to have caused the problems in mollys kidneys but thinks that the kidneys might have started the cortisol going up, although that isn't a definite, just us throwing ideas back and forth at each other. Either way, likely we will go with low trilostane and see how molly reacts to that and stop it if she appears to be in any pain from the kidneys, etc. She'll be calling me next week, once we get the lepo test results back and we hear back from the nutritionist on food options.

I'm so tired. My brain is a fog. The internet here at the house isn't the greatest for some reason today. Have a call in about that too. And I have to get ready to go to the funeral home for a visitation as my friends dad passed away.

We are hoping hope that molly's BP stays down and we can keep this controlled. Whatever it takes to do so, we'll do.

Wow, you have had a lot of experience with eye issues and steroids Suzie! I mentioned all of these things inclucing Dr. Peterson's thoughts to the IMS. She said these are all valid concerns and that we'll do our best to figure it out and get it all under control. She doesn't think there is a macro tumor involved, she said the clinical signs and neurological signs aren't there for that in molly.

so address the protein loss, doing that, get her on food, working on that, get the cortisol checked, doing that the 16th, start on trilostane (based on results of acth), BP, so far down, so working on that too.
All of these things should help us to keep molly, as she is at least currently for awhile. She plays, she walks, she loves her treats, even her medicine treats, so step by step.

hugs and thanks everyone
Sharlene and molly muffin

[Dixie'sMom]

Marianne, thanks for clearing up my mistakes about Lysodren. I'm showing my lack of Cushing's knowledge. I'm glad you understood where I was going with that thought. Yes, my eye adventures have been quite amazing. Much, much more than I ever wanted to experience, but I'm not completely blind yet, so they are hanging in there. I actually have an apt. at Duke tomorrow. Yuk.

Sharlene, I'm glad you got to talk to the IMS and wrote Dr. Peterson. It will be interesting hear what he has to say and it sounds like you have a starting plan in place. Try to get some rest.

[addy]

Hi Sharlene, I am sorry you have so much on your plate. Hugs and love to you, hubby and sweet Molly. I have no words of wisdom, just our experience. Our ophthalmologist never saw evidence of high blood pressure in Zoe's eyes despite the IMS's claim she had high BP. Whenever he checked her BP it was not elevated. When the IMS would check it - it was higher. What the ophthalmologist did say was that with all of Zoe's eye issues, maintaining her cortisol at a lower level was important.

Zoe started out without the classic Cushings symptoms, even in her blood work. Dr. Peterson told me not all Cush pups will have the elevations we normally see. Her main problems were skin/coat issues. Dr.Peterson felt her cortisol was too high for a maintenance dose of Lysodren to work and that her IBD would not tolerate the higher Lysodren doses of a load. He opted for starting at a low dose of Trilostane.

I think if it were me, I would ask if a maintenance dose of Lysodren would hurt Molly and how and if her cortisol is not sky high, perhaps a maintenance dose would be enough to bring it down. Dr. Oliver did tell me he had dogs that did respond to a maintenance dose without a load.

Deciding when to start treatment and which treatment can be overwhelming. We all do the best we can and we listen to the experts and go with our gut.

So go with your gut, sweetie.

love you.