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

[Squirt's Mom]

I've been away from things for a few days but have been trying to read and keep up with our sweet Yhonnie. I want to second what Marianne and Lori have said....you are doing a great job being an advocate for him. Trust your gut, stick to what you believe is best for your baby boy, and know you are not alone...we are right by your side even tho you can't see us.

Hugs,
Leslie

[Jayessi]

I've been away from things for a few days but have been trying to read and keep up with our sweet Yhonnie. I want to second what Marianne and Lori have said....you are doing a great job being an advocate for him. Trust your gut, stick to what you believe is best for your baby boy, and know you are not alone...we are right by your side even tho you can't see us.

Hugs,
Leslie

Thanks Leslie. Your note means a lot to me.

[Jayessi]

Dear Marianne, Lori, Leslie and anyone else who might be reading this post

Yohnny did his second LDDS test last week her are results and what vet has diagnosed and prescribed. Just want to check we are on the right path.

LDDS test

Cortisol 274 nmol/l < 120 ulli

Cortisol 4 h 47,5 nmol/l < 40 ulli

Cortisol 8 h 53,2 nmol/l < 40 ulli


Urine
U-Protein/crea quot:
1,7 < 0,5 JEEK


Blood Pressure 
Average : 122/50 (75) 121

Sys/Dis (MAP), pulse

Animals position: Lying down on chest

Stresslevel (1-5) : 2

All measurements (minimum 5): 

Sys/Dis (MAP), pulse

133/48 (78), 120

124/49 (75), 119

131/46 (76), 117

109/51 (72), 123

112/54 (75), 128



ULTRASOUND GUIDED ASPIRATION OR BIOPSY: 10 ml of urine through cystocentesis without complications



What vet said

Vet discussed results with specialist since the LDDS was only very slightly increased and therefore she did not want to start any treatment risking that values become too low instead. But specialist said there was enough other indications to diagnose Cushings and that there was new findings that dogs with Cushings can have a glomeruli problem (Yohnny has protein in urine) without having high blood pressure.

Next steps
Yohnny has been prescribed 10 mg Vetoryl once a day and a follow-up with urine and blood test in two weeks.
Any thoughts or comments?

THANK YOU!

[labblab]

Hi Amanda! Given all of Yohnny’s symptoms and the elevated result on this LDDS, I do feel comfortable with the plan to move forward with starting the Vetoryl. I’m not sure whether you’ve ever told us how much Yohnny weighs, but the current recommendation is to follow an initial dosing formula that does not exceed 1 mg. per pound, or 2.2 mg. per kilogram. So as long as the 10 mg. dose falls within that guideline, I do agree that this is the place to start. And performing followup testing in two weeks is perfect.

I don’t know whether the vet mentioned this, but Yohnny’s LDDS result is consistent with the pituitary form of Cushing’s. Also, I know we expressed some concerns about checking the blood pressure and performing the cysto on the same day as the LDDS. Even if they were indeed performed on the same day, given all of Yohnny’s symptoms, I cannot argue with assuming that the elevated LDDS result is accurately pointing towards Cushing’s. So I think you’re on the right path, and I will be so anxious to hear how he responds to the Vetoryl.

Good luck to you both!
Marianne

[Jayessi]

Thank you Marianne for getting back so quickly.

He weighs 18lbs (8.2 kg) so it is well below the dosage, which would be 18 mg if I am counting correctly. Vet did not mention but thanks to all the good info in this group I have understood this.

After I talked to vet I read this:

ACTH stimulation monitoring tests are performed between 4 and 6 hours after the morning dose given WITH FOOD. Some vets prefer to perform the test from 2 to 4 hours after the morning dose. Whatever timing a vet chooses, each and every test must be performed at the same time, every time. NEVER fast your dog for this test as results will be invalid.
The 1st ACTH stimulation test should be done 10-14 days after starting treatment. A dose increase is rarely done at this time as cortisol is expected to drift downward over the next few weeks.

Vet did not mention ACTH test in the 2 week follow up. What she did say is that I could collect a urine sample in the morning and that he be fasting in case any blood samples need to be taken. She did not mention anything of the above. I am going to point this out and am also thinking of asking to see the specialist she consulted with instead, as she seems to have had more experience with Cushings.

The BP test and cysto was done after the LDDS test. I asked for this.

/Amanda

[labblab]

Given Yohnny’s weight, yes, that starting dose is definitely well within the guidelines. So that is good. But also, yes, I encourage you to clarify the planned monitoring testing protocol with your vet. It may be that she’s intending to hold off until the 30-day mark to test the cortisol. Although Dechra officially recommends that the first cortisol test be performed at the 10-14 day mark, some clinicians do wait until a month has passed to do so. Perhaps since Yohnny has been started out on a relatively low dose, that’s what she has in mind. But you’ll definitely want to find out for sure.

You may have read that Dechra has now also endorsed an alternative testing method to the ACTH. It simply involves taking a resting cortisol sample right before the morning dose of Vetoryl is given. In that situation, fasting is OK since the test would be performed ahead of dosing with breakfast. This “pre-pill” testing method is pretty much the norm now in the U.K., and it may also have gained popularity in Sweden. So all in all, you’ll indeed want to clarify what type of testing will be done, and when.

You’re doing such a good job, though, Amanda. Knowing that the cysto and BP check were done after the LDDS gives me even greater confidence in that positive result. So once again, I do think you’re on the right track in terms of treatment.

[Jayessi]

Thank you Marianne, for both info and encouragement. I am starting to wrap my head around this a little more and calming down thanks to you and the other who have supported me.

I am pretty sure the vet I am seeing is not familiar with the ACTH test for the 10-14 day check-up and definitely not the pre-pill test because then she would have prepped me for both of these.

But I read up about both of these after she called so I have decided to wait with initiating the Vetoryl until I have talked with her again and the plan is clear. Would you agree?

For example, she told me that Yohnny should be fasting "just in case they need to take some blood tests."

Sigh...she has not done a bad job so far...but Yohnny should have the best right? I am really considering changing to the specialist she talked to - or to the specialist I was recommended.

/Amanda

[labblab]

You can see what she says when you question her further. Perhaps you’ll feel more comfortable about her plans after that. But if not, that’s reassuring to think you have the option of moving on to one of the specialists.

As far as monitoring bloodwork in addition to the cortisol, it’s true that it’s recommended that basic blood chemistries be routinely checked as well. After starting Vetoryl, checking the levels of potassium and sodium in the body are particularly important because Vetoryl can also lower the level of aldosterone, another adrenal hormone. Aldosterone controls the potassium/sodium balance, so it’s good to make sure that those levels are remaining within normal limits. I don’t know that fasting is necessary for those particular results, but it’s true that you want a dog to be fasted for certain other results on a blood chemistry panel such as cholesterol and glucose. For this reason, it may be best to perform the blood draws for monitoring ACTH stimulation tests and chemistry panels on different days, depending upon which blood chemistries you’re most concerned about monitoring accurately. On the other hand, I believe a pre-pill cortisol test and blood chemistries can both be done on fasted samples.

So yes, I think it makes sense to hold off on starting treatment until you feel comfortable with knowing which vet will be following Yohnny from this point onward, and which testing protocol you’ll be using.

Marianne

[Jayessi]

Hello.

Talked to the vet I am seeing.

Her plan is to do only be looking at clinical signs and take a urine test to check the protein (that I will be bringing in with me) when we go see her at the 10-14 day mark of him starting Vetoryl and do ACTH or Pre-Vetoryl Cortisol Monitoring at the 4-week mark instead. Unless I have noticed something that makes me think he is not feeling well - then they may do an ACTH at the 10-14 day mark.

She said this is according to the latest findings and that it takes a while for his body to adjust to cortisol so that is why they wait for the 4-week mark to do test.

Does this sound right to you?

Amanda

[labblab]

Given the low dose of Vetoryl that Yohnny is starting out on, I personally do feel comfortable with this plan. As I wrote earlier, the formal recommendation is to go ahead and test the cortisol at that two-week mark, but I have indeed seen clinicians hold off until the 30-day mark for the first testing as long as the dog is looking and behaving well. Your vet is correct that the cortisol level can continue to drift downward during the first month of treatment even while a dog remains on the same dose. For this reason, no dosing increases are recommended until after the first 30 days, regardless of the interim results. The earlier test is really one for safety’s sake — to make sure the dose doesn’t need to be lowered. But as I say, since Yohnny is starting off on a very low dose, anyway, I would feel OK with your vet’s plan, especially since she will still be physically examining him earlier. If either you or she think that something looks amiss, you can and should go ahead and test at that time.

Marianne