Yohnny 11 year old Shih-tzu with Cushing-like problems

[Jayessi]

Question about FORTEKOR. Yohnny was prescribed 2,5 mg yesterday by vet bcs he has protien in urine and leaking kidneys. So he has taken two tablets so far. This morning he threw up twice, and the second time he fainted for 2 seconds. I called hospital and the emergency vet said I should stop with Fortekor and that my primary vet will call me on Monday.

Anybody else been prescribed Fortekor or have expereince with this?

They have not checked Yohnnys blood pressure.

[Squirt's Mom]

I didn't know what that drug was so I looked it up....it is a heart medicine so I am confused why it was giving for kidney issues. My Squirt was incontinent and was given a drug called Proin....she reacted badly to it tho I didn't realize it was the medicine until she had a stroke, which I believe was also caused by the Proin. So I wanted to know if Fortekor and Proin were the same drug but they are not. I wouldn't give any more of this to Yohnnie at all as it seems his body does not like it at all. I would want to know more about why that drug was chosen, if he does have a heart issue as well as kidney issue, and have his BP checked because high BP will have a detrimental effect on the kidneys.

[Jayessi]

I didn't know what that drug was so I looked it up....it is a heart medicine so I am confused why it was giving for kidney issues.

Me too! She said it was prescribed for the "protein in the urine, which might be due to high blood pressure."

I didn't know what that drug was so I looked it up....it is a heart medicine so I am confused why it was giving for kidney issues. My Squirt was incontinent and was given a drug called Proin....she reacted badly to it tho I didn't realize it was the medicine until she had a stroke, which I believe was also caused by the Proin.

That is so scary. How is Squirt doing now?

QUOTE=Squirt's Mom;211753] I wouldn't give any more of this to Yohnnie at all as it seems his body does not like it at all. I would want to know more about why that drug was chosen, if he does have a heart issue as well as kidney issue, and have his BP checked because high BP will have a detrimental effect on the kidneys.[/QUOTE]

He does not have heart issues. But BP has not been checked so will put this on the list of things to ask for.

Thank you!

[Squirt's Mom]

My beloved Squirt passed in 2014 from simple old age, nothing to do with Cushing's. She was a little over 16 years old.

[labblab]

Hi again! I wanted to stop by and add some clarification about the Fortekor (benazepril). It’s among a class of medications known as ace inhibitors, and we’ve seen it prescribed both for high blood pressure and also to help stabilize proteinuria in dogs. I don’t know how it actually works in that regard, but we’ve had other dogs here who’ve had it prescribed for that reason. I think that in many cases, the dogs have also been diagnosed with high blood pressure, but perhaps not always. Given Yohnny’s fainting spell, however, it makes me wonder whether the medication might have actually dropped his blood pressure or heart rate too low. Ace inhibitors can also elevate potassium levels, and that may have caused a problem for him, too. We’ll see what the vet has to say on Monday. In the meantime, here’s a blurb about its use:

Benazepril (brand names: Fortekor®, Lotensin®, Apex®, Benazemav®, Benefortin®, Bexepril®, Nelio®, Prilben®, Vetace®) is an angiotensin-converting enzyme (ACE) Inhibitor used to treat heart failure, high blood pressure, and various types of kidney diseases such as chronic kidney disease and protein-losing glomerulonephropathies. It may also be useful for treating idiopathic kidney bleeding.
Its use in cats and dogs to treat cardiovascular and kidney disease is ‘off label’ or ‘extra label’.

For the treatment of proteinuria, in addition to an ace inhibitor, other options we’ve seen include supplementation of omega fatty acids and also moderate reduction in dietary protein. But once again, we’ll see what your vet recommends going forward. There are other ace inhibitors besides benazepril, and perhaps an alternative may suit Yohnny better.

And yes, it’s our understanding that both hypertension and proteinuria can be secondary to the effects of Cushing’s, so I’m not sure why the vet is suggesting that they’re not connected. Perhaps she’s just awaiting a confirmatory Cushing’s diagnosis before making that association.

Marianne

[Jayessi]

My beloved Squirt passed in 2014 from simple old age, nothing to do with Cushing's. She was a little over 16 years old.

My condolences. I am guessing that is her on your profile pic? She is so cute!

[Jayessi]

Hi Marianne and thank you for clarifications.

So proteinuria can be caused by Cushings - but may not necessarily be helped if dog is diagnosed or treated for Cushings?

I am trying to advocate for Yohnny and preparing questions for vet. If you have time could you look at these?

1. Can we check his blood pressure? Especially before giving him a medicine that can bring down blood pressure?

2. What other options are available for treatment of proteinuria? (include supplements/diet)

3. Should we do LDDS test it earlier so we can hopefully can get a diagnosis earlier? (First one was in November)

4. I asked about the ACTH test for Yohnny since you and others have mentioned doing this text too and IMS vet said that one is done when cortisol is low. So she did not seem to think it was an option for Yohnny. Should I ask about this again and if so what shall I say?

5. I know that as little stress as possible is important when doing the LDDS and ACTH test. So I will take Yohnny back and forth to vet (rather than leave him at vet all day) and ask them to do other testing after test or at another date. This is optimal yes? Is there any veterinary paper that writes about this? I would like to have "something" bcs me vet didn't seem to be aware of this.

6. This question is about being a dog mom and trying to do what is best. Just want to hear what you would do. Very few vets in Stockholm are proactive (and I have met a lot of vets) but I did meet one IMS vet that was amazing that took care of Yohnnys brother but she has unfortunately moved out of the country but has recommended an IMS vet for us close to where we live. I am thinking of contacting her for an appointment instead of the vet we saw on the 27th of march. What would you do?

Sorry for all these questions, am having a hard time wrapping my head around this disease even though I am reading through articles. I am feeling lost and in need of both emotional and factual support.

Thank you and hugs
Amanda

[Harley PoMMom]

Hi Amanda,

There is no need to apologize for asking questions, that's part of being an excellent advocate for your Yohnny!

5. I know that as little stress as possible is important when doing the LDDS and ACTH test. So I will take Yohnny back and forth to vet (rather than leave him at vet all day) and ask them to do other testing after test or at another date. This is optimal yes? Is there any veterinary paper that writes about this? I would like to have "something" bcs me vet didn't seem to be aware of this.

Here are a few that I found, hopefully this is what you're looking for and if not I'll try to find others.

“Basically, any kind of stress can potentially cause an adrenal response and increase production of corti*costeroids” Dr. Chapman said. So, the acute stress associated with hospitalization and drawing blood can affect the pet’s cortisol levels for the LDDS test, but will not alter the results of the ACTH stimulation test. Patients should be kept as quiet as possible to help reduce the effects of acute stress on LDDS test results.

https://www.americanveterinarian.com...shings-disease

To encourage acclimatization and minimize stress, the LDDST routinely was performed after at least 1 day of hospitalization, with no other procedures scheduled during the test.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5980256/

The LDDST is more sensitive but also less specific and affected more by stress.

https://www.ncbi.nlm.nih.gov/pubmed/21596349

6. This question is about being a dog mom and trying to do what is best. Just want to hear what you would do. Very few vets in Stockholm are proactive (and I have met a lot of vets) but I did meet one IMS vet that was amazing that took care of Yohnnys brother but she has unfortunately moved out of the country but has recommended an IMS vet for us close to where we live. I am thinking of contacting her for an appointment instead of the vet we saw on the 27th of march. What would you do?

Sorry for all these questions, am having a hard time wrapping my head around this disease even though I am reading through articles. I am feeling lost and in need of both emotional and factual support.

Thank you and hugs
Amanda

Since you felt that this other vet took excellent care of Yohnny's brother, if this were me, I would seek out the IMS she recommended.

Hugs, Lori

[labblab]

Amanda, I think all of your questions are excellent ones! Lori has given you some very useful quotes re: the LDDS and the effect of stress on that test. As far as the preferability of performing the LDDS vs. the ACTH, I cannot argue with first repeating the LDDS. This is because, of the two tests, it is more likely to produce a positive result if a dog does have Cushing’s. However, if Yohnny *again* tests negative on the LDDS, I’d want to give the ACTH a try since he has so many symptoms that are consistent with the disease. Since the two tests are measuring different aspects of adrenal function, occasionally one will be negative while the other is positive. Here’s a quote by noted endocrinologist, Dr. David Briyette:

When interpreting LDDS test results, first evaluate the eight-hour post-dexamethasone administration cortisol concentration. If it is above the reference range, the dog probably has hyperadrenocorticism (false positive results may occur in dogs with nonadrenal illness). If it is within the reference range, either the dog does not have hyperadrenocorticism or there is a 5% to 10% chance that the dog has PDH. (The dog may have early pituitary disease and the pituitary gland is still responding to a pharmacologic dose of dexamethasone by decreasing ACTH production, thereby reducing serum cortisol concentrations.) In those cases, an ACTH stimulation test is warranted.

So as you can see, it’s only a small chance (5 - 10%) that a dog with Cushing’s will test negative on the LDDS, and that’s why the LDDS is preferred by most specialists to be run first. But in Yohnny’s case, if he tests negative again, I’d want to give the ACTH a try. As far as the ACTH and low cortisol, yes, it’s true that the ACTH is the preferred test for Addison’s disease — your vet is right about that.

Regarding Cushing’s and proteinuria: if Cushing’s is the underlying cause, you definitely want to treat the Cushing’s to keep the condition from worsening. However, Cushing’s treatment alone may not resolve the existing proteinuria, so the two conditions may be treated in tandem. We’ve had several dogs here who have received both treatments. One note about that: I mentioned earlier that Ace inhibitors can elevate potassium levels. Vetoryl (trilostane), the medication that you’d undoubtedly use to treat Cushing’s, can also elevate potassium. So when the two medications are prescribed at the same time, you do have to regularly check blood chemistries to make sure that the potassium level isn’t getting too high. But we’ve had dogs here who have done fine with both.

Overall, aside from performing other tests at the same time as the LDDS, I think the steps that the new vet has recommended are reasonable. And who knows, maybe she intends to do the other tests after the LDDS has concluded (drawing additional blood at the end of the test, for instance, and drawing the urine afterwards). If so, that should be fine and shouldn’t affect the LDDS results. But I totally understand why you don’t want to leave any stone unturned. I’d be the same way if Yohnny were my own. If you’d always wonder whether you would have had more confidence in the recommendations of the other vet, and consulting with the other vet is possible, then you may well wish to do so. I definitely suppprt you 100% whichever way you choose to go!

Marianne

[Jayessi]

Hi Amanda,

There is no need to apologize for asking questions, that's part of being an excellent advocate for your Yohnny!

Here are a few that I found, hopefully this is what you're looking for and if not I'll try to find others.

https://www.americanveterinarian.com...shings-disease

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5980256/

https://www.ncbi.nlm.nih.gov/pubmed/21596349

Since you felt that this other vet took excellent care of Yohnny's brother, if this were me, I would seek out the IMS she recommended.

Hugs, Lori

Dear Lori! This is great! I totally trust people in this forum, but when talking to a vet I find it can "help" to present stuff other vets have said.
I am so touched that you spent time looking for me. <3