Viva Sunday #9: Improved Treatment and Diagnosis of Cushing's Disease

The treatment and diagnosis of Cushing's disease is under constant improvement and research. During the years Viva had Cushing's, a lot already changed, and more changes are ahead. If there is one thing Viva and me learned, it is that this is not not a disease you can manage by sticking a pill, but you have to be constantly on your toes, and take the clinical signs you notice very serious.

Cushing's is caused by a tumor in the pituitary or the adrenal gland, causing an over production of ACTH hormones which in turn triggers an overproduction of cortisol. A life threatening condition affecting inner organs like kidneys and liver. Some of the most common signs are hair-loss, a pot-belly, lethargic behavior, incontinence, and being overly interested in food and water. Cushing's is many times mistaken with normal aging signs of dogs, making it a silent killer.

This is what we learned along the way:

Diagnosis
Back in 2011, Viva was diagnosed with Cushing's based on a urine test and a ACTH stimulation test. During her life, she continued to have ACTH tests quarterly to measure her cortisol levels for possible adjustment of her medicin dosage. Although the test is reliable to measure levels for treatment adjustments, it proved unreliable for the diagnosis itself, when the results are negative. Negative test results should always be followed up by at least an LDDS test, and even better, by an ultrasound, to indicate the type of Cushing's which is significant for what treatment options are available.

Large dogs
The recommended dosage of Trilostane (Vetoryl), the medication for Cushing's disease, was set too high for larger dogs. Something Viva found out the hard way. But thankfully our vet read the signs correct and adjusted her doses far below the recommended dosage for a dog of her size. Later, in 2012, research was done that confirmed that at least dogs weighing more than 30 kg. need a significant lower dosage of Trilostane, maybe even dogs weighing more than 15 kg.

Once or twice a day administering of medication
The last has not been said on this subject. Basically Trilostane works up to 8-10 hours, and that might require a twice-a-day administration, instead of an only once daily which is standard. Research is still being done, and some vets are already recommending twice daily administration of Vetoryl. At least some research here and here has shown, there is hardly risk in trying. We never got that far with Viva, it was something I was discussing with our vet, as I could see she consistently was showing more lethargic signs during the end of the day.

***

A dog with Cushing's requires continuous research, together with your vet, and to be vigorous about measuring the clinical signs of your dog. We always kept a Cushing's diary, and it was a great help in supporting Viva in her battle against Cushing's. Whatever research was available at the time, or not, the diary was always right.

A Hovie's Nose

The best summer ever in Denmark. According to meteorologists, the best since 1860.

The summer already started in early May, during our visit to the Danish West-coast. Viva's favorite place on the planet. We enjoyed being outside the whole day. Temperatures where not high, but nonetheless we all got a little sunburned. Also Viva was, on her nose.

The sunburn would soon heal we thought, and hoped the summer would stay, so we could go out into the light again and wash off the Danish winter and its short days.

Now, it is the end of August. We returned to the West-coast, and are looking back at this "best" summer ever. How different has the summer turned out to be. Viva's nose is still "sunburned". The vet thinks it is Lupus (DLE) - also called "Collie Nose" - an auto-immune disease, and in Viva's case, difficult to treat as the medication doesn't go along well with her Cushing's disease. We have been trying three different topical treatments so far that don't interfere with her Cushing's, to no avail.

The vet's best advice was to avoid the sun, as the ultraviolet rays seem to be a main trigger for lupus. We dodged the sun as much as we could in the short sunless window of opportunity, between 23:00 and 04:00, given to us in the South of Scandinavia.

We went for late walks, hunkered inside during the long summer days and only made short trips to potty in areas with an abundance of shadow. It did seem to help to an extend. Although about every two weeks it flared up again to it's worst state.

For us humans it is a strange experience going against the little Nordic voice in our heads telling us to suck up some sun and light now we had the opportunity. Although going nocturnal was counter-intuitive for us humans, Viva really doesn't care when she goes out, as long as she does go out. Her spirit is high, and I wonder how she can. When I look at her nose I know it must itch enough to make one crazy. It must be painful. I don't even have the stomach to add a close-up of her nose to this blog, it looks too horrible.

But somehow Viva sucks it all in and can muster enough fight to remain her cheerful self. Enjoying the little things like she always has. Tough girl.

Two vets and three treatments have not been able to help so far, leaving me in despair and self-hate for not being able to help my girl, and seeing no options other than doing a rain dance and pray this summer will soon end.

Let it storm, rain, hail and thunder. Go away sun and blue skies, you are not welcome any more.

Tweet

The Chronic Cushings Diary

It is just over one year ago Viva was diagnosed with Cushing's disease. And all that time she thrived on the prescribed daily medication - 120mg of Vetoryl, or Trilostane. Every quarter Viva was tested and the results were excellent. Such a test consist of an ACTH stimulation test and full blood-work. Viva's liver, battered by her Cushing's disease before we started treatment, was slowly but determinately recovering.

For a dog like Viva with several chronic diseases every vet visit can be turned into a puzzle. Has any of her known conditions worsened, like spondylosis, allergies or Cushing's? Or are we looking for something else this time? To be prepared we keep a diary of Viva's general state of health to note the changes as they come slow and first when compared over time you can really notice a difference. We write down things like:

• Meals: how fast did she eat her meal?
• Walks: after how long did she tire?
• Play: did she play with Kenzo? And who initiated?
• Cuddle: did she exchanged her infamous ear-nibbles with Kenzo?
• Greets: did she wagged her tail so her back moved?
• And more...

The list is specific to Viva. Like when she wags her tail a little less and the walks get shorter, we know we are up for an acupuncture session for the spondylosis in her back. So when the diary started to show a little less play and cuddles, we advanced her quarterly Cushing's test. And although Viva's cortisol levels related to her Cushing's were still perfect, the rest of her body and organs clearly were feeling unhappy as the blood work showed.

This meant we were looking at something new, or the Cushing's medicine - which is very aggressive and can be compared to chemotherapy - was giving side-effects. Based on what we knew from the diary and the lack of other symptoms we decided together with the vet to lower the doses of Viva's Cushing's medication. The most reasonably assumption was the doses was affecting her health adversely despite it kept her cortisol in place.

It took only a week for the diary to show us the first positive effects, and when we re-ran the Cushing's test at the end of that month, her cortisol level was still within the limits while her blood-work showed a lot of improvement on all area's. Would the diary not have shown any improvement, we of course would have been right back at the vet's again, discussing other options.

Having a dog with chronic diseases requires a chronic attitude. At first, it stressed me out having to watch everything she does through symptom-glasses. But now that I accepted what a chronic disease requires, it doesn't stress me out anymore. I became even more connected with Viva than before, and know she is living her life to the fullest despite the odds. That's just a terrific bonus, being able to give that to Viva.

Grooming a Lioness

Before - After

We started treating Viva for her Cushing's disease more than half a year ago, and soon we were confronted with a harmless side effect.

Viva's hair growth was exploding. Cushing's had been suppressing her natural hair growth so far. And now it was rapidly returning to it's normal state.

In Viva's case, that meant a lot of hair. She quickly developed a "Lion collar", any Hovawart male would have been jealous of. It couldn't be comfortable for her having that much fur. And it wasn't very lady-like.

When I read on Pamela's blog how Honey grew "Muppet feet" and how Pamela executed some do-it-yourself grooming with great results, I went to arms. Viva needed some wellness.

Thankfully I started on the area below the chest, a little out of sight. My few existing grooming skills, if any, seemed to have gone with the wind. I had to give that up and I frantically started to search for an alternative, while Viva's "Muppet feet" where developing into "Muppet flippers".

Armed with a list of test questions on how to groom a reactive dog, I called around to local groomers but was left empty-handed. Nobody seemed to be able to refer us. Not in the dog training club, not the vet. Finally, we got a tip from Viva's water-walker therapist. She gave me the contact details of a groomer that she knew could handle reactive dogs. When I called for an appointment, we got a time two months away.

When the day finally came I told all there was to know about Viva and her reactiveness to our newly appointed grooming-lady, Jannie. She nodded politely through my whole monologue, and reached for the leash to take Viva in. I didn't expect her to do that, as she was physically absolutely no match for Viva and assumed she would need my help getting Viva crated in the bathing area in the back. But Jannie, nodding politely again, said it will be alright and off she went with 90lbs of highly-explosive Hovawart.

The longest 3 hours in my life started. I think I phoned Jannie at least twice. "yes, everything is alright", and "no, Viva is not ready yet".

When I could finally pick Viva up, I rushed into the shop. One groomer was busy with a Corgi mix and Jannie was grooming a Poodle on her table. When I started to approach Jannie and said hello, I noticed a blondish shadow was rising from below the grooming table the Poodle was standing on.

It was Viva, and she was off-leash. I panicked, expecting Viva to lash out to the Poodle. I reached for her, in what felt like being in one of those movies where you see the hero flying through the room in slow-motion while shouting "noooooo...", equally in slow-motion. She was too far away for me to reach. The only thing I could do was to hold my breath in a feeling of helplessness and accept the laws of gravity.

But the Lioness didn't roar. Viva rushed passed both dogs and made a whole spectacle out of greeting me, and the remaining dogs in the shop happily joined in for the concert. Viva had been taking a nap at Jannie's feet while she continued grooming other dogs. My jaw-bone must have reached the floor on the very moment I realized that.

I was so baffled and relieved, I was not capable of having any kind of intelligent conversation about it. Jannie did not give a lot of detail either that could explain Viva's exemplary behavior: "She was nice". Most important, Viva was B.E.A.U.T.I.F.U.L as well. Her fur was soft from the bath and her trimmed coat had the highest cuddle factor. The Lion's collar was gone as well.

Here are some pictures of Viva new style, and Kenzo seems to approve it too:

Nice trim Viva !

Kenzo takes a sniff on arrival at home

It's OK, Kenzo sends a look of approval :)

Viva has Cushing's

Helping Viva to get better and improve health is a lot like peeling the layers of an onion. Just when we think all bases are covered and all issues addressed, we find out we are looking at yet another layer.

Warning signs

ear-nibble please?

The warning signs have been around all the time. High liver numbers returned from her very first blood-work. Not too high to worry about, treat or investigate further. But we kept on monitoring her regularly just in case. The first external signs came about one month ago. Viva was slowing down on our daily work-out. We gave her some rest, an additional acupuncture session - maybe she was in pain ? - but to no avail. She rapidly became more lethargic, and stopped playing and ear-nibbling with Kenzo, her favorite past-time!

We did a round at our vets and found out her spondylosis had not gotten worse, but her liver numbers had exploded. High liver numbers could be caused by just about anything and further testing was needed. We were in for a couple of painstaking weeks of further testing, investigating, and discussing theories. Our regular vet started suspecting Viva of having Cushing's disease after some additional testing. Although not all the signs have been adding up. She turned out to be spot on.

Cushing's disease

Cushing's is caused by a tumor in the pituitary or the adrenal gland, causing an over production of ACTH hormones which in turn triggers an overproduction of cortisol. A life threatening condition affecting inner organs like kidneys and liver. Some of the most common signs are hair-loss, a pot-belly, lethargic behavior, incontinence, and being overly interested in food and water. Apart from being lethargic, Viva had none of those signs. Yet she always had been overly interested in food and water as a former obese dog. Testing Viva for Cushing's sounded like a wild-goose chase, but I am happy to have followed our vet's gut feeling on this one.

To diagnose Cushing's we started with a urine test to measure cortisol levels. They were sky high. Next was an ACTH stimulation test, which was conclusive. Now it was final, Viva has Cushing's. The diagnosis was actually a huge relief, a month had already passed and I was so worried for Viva being in discomfort for so long and not being able to help her.

Treatment

We started treating Viva with Vetoryl (Trilostane). Already after 5 days Viva was feeling better. Kenzo got his first ear-nibble in a month, which we celebrated with the whole family that day. It was awesome to witness.

Vetoryl is a very aggressive medicine, that messes with the hormone level. Administering the correct doses is extremely important, as Viva can die when we administer either too much or too little. Viva will need Vetoryl for the rest of her life. The doses can vary over time, and Viva has to be tested quarterly to ensure the doses is correct. Those quarterly tests include an ACTH stimulation test and 3 different blood-work tests.

The onion

It was a hard month with no blogging but we are back! Just wondering how the onion is doing. We are three layers down: allergies, spondylosis and Cushing's. Maybe we are done, maybe we are not. Yet another lesson Kenzo and Viva taught me. Health is not a shopping list with items you can check off and wrap up.

A big thank you to all my anipals for all your kind words and your support on Twitter and Facebook during the last month. It meant a lot and was a huge help getting through all of this. You guys rock!