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Dr. Michael Salkin
Dr. Michael Salkin, Veterinarian
Category: Dog Veterinary
Satisfied Customers: 13010
Experience:  University of California at Davis graduate veterinarian with 42 years of experience
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My dog has Cushings and has been on Trilostane for a couple

Customer Question

My dog has Cushings and has been on Trilostane for a couple years. Recently she was vomiting, lethargic and week, the vet treated her for Pancreatitis. Since the treatment we are off her Trilostane but she is still not eating, losing weight and extremely lethargic. She can't walk well. She has always been very lively and now she is the opposite. The vet is suggesting an Ultrasound tomorrow. We just spent $1400 over the last three days dealing with treating Pancreatitis, what is an ultrasound suppose to do? Her symptoms sound like Cushings disease issues to me. What do we do now?  Is her dosage of Trilostane wrong?  Does she have Addisons--whatever that is? I don't want to lose her, but if she keeps starving herself, I'm afraid she'll be gone by the end of the week. 
She isn't eating, she is barely walking and only her Pancreatic levels were high in the blood tests.  But shouldn't she have recovered from the Pancreatitis by now--It's Sunday and we picked her up from the hospital Saturday afternoon.  She is on anti-vomiting meds (Cerenia, Metranidazole and a Pepcid). We are suppose to start up withthe Trilostane again tomorrow.  She is also taking an appetite stimulant.  But she looks very sick and is still not eating.  This came on suddenly.  Almost over-night, within two days she went from being her normal self to this dog I barely recognize.
Submitted: 3 years ago.
Category: Dog Veterinary
Expert:  Dr. Michael Salkin replied 3 years ago.
Aloha! You're speaking to Dr. Michael Salkin
Hi - You're correct in that her symptoms are suggestive of Addison's - which is the opposite of Cushing's - rather than overactive adrenal glands seen in Cushing's, Emma would have underactive adrenal glands with Addison's. This is seen when the trilostane dose has become too high and too much of the adrenal glands have become nonfunctional. This can occur from simple overdosing, or Emma has developed other problems (liver or renal failure, e.g.) that has slowed the excretion of the trilostane, in effect allowing the level of trilostane to rise in her body. Addison's is tested for by first looking at Emma's sodium and potassium levels (the ratio of sodium to potassium is usually less than 23:1), or more precisely, by checking her cortisol levels before and after a dose of ACTH (an ACTH stim test). Pancreatitis can resolve in a few days or linger for weeks or more - the ultrasound was suggested to best evaluate the pancreas and look for other new problems that may have arisen - that haven't been identified on her blood/urine work. It's terrific that Emma has done well for so long, however at two years post-diagnosis for Cushings we often see other internal medical diseases appear - major organ failures as I've mentioned (although seemingly ruled out by her testing), malignancies, and the dreaded thromboembolic diseases secondary to Cushings such as throwing a pulmonary embolis (a blood clot in the lungs). I understand your frustration - there's nothing pleasant about Cushing's and it's a very expensive disease to treat. Your vet needs to image Emma (ultrasound in this case) because nothing more than the pancreatic testing was abnormal...but, unfortunately, pancreatitis may be all that's present - and that can be enough to be life-threatening. While most dogs will remiss within the week, some with the peracute form of pancreatitis will be lost in spite of intensive care. Please respond with further questions or concerns if you wish.
Customer: replied 3 years ago.
No one told us that Cushings dogs had an expiration date on them. Emma is a survivor. Wwould you recommend the ultrasound? And when? today? next week? I'm hesitant to do it today because I'd live to get to the bottom of the Addisons and I'm tempted to give her more blood tests today to determine the corrected amount of Trilostane. Or should we try something else? Lysodren or Ketoconazole? Are they different than Trilostane? Anipryl? We were told to start the Trilostand back up today, but I want to wait another day because she isn't eating and I plan to bring her into the vet to for the ultrasound anyway. But I want to re-test her Cortisol levels again--do we need to wait longer? When should we re-test?
I also do not understand how the testing works. We usually give her the Trilostane, then take her to the vet and leave her there for 4 hours+. How exactly does the testing work and will the testing be different now that we know her levels are off and she just had pancreatitis? Addisons testing? How do I find a vet with experience working with dogs with Cushings and Addisons? I live in LA, we've gone to the same vet clinic for 7 years but I'm ready to switch. What diet is best for her? She' been on the same most her life--she's 10 yo.
Expert:  Dr. Michael Salkin replied 3 years ago.
I'll try to answer your questions in a semblance of your order of asking them! Yes, Cushing's is a fatal disease (there is an expiration date (!)) - 90% of the cases are due to a tumor of the pituitary gland and 10% are due to a tumor of the adrenal gland - if the hypercortisolemia produced by either of these tumors doesn't eventually kill my patients, the primary tumors will. Life expectancy is 1-3 years after diagnosis. Don't start the trilostane. She isn't well enough yet and needs to be tested for Addison's as I described in my last response (the testing is what was done when you leave her there for 4 hours+ - testing her cortisol levels with an ACTH stim test). We consider alternate therapies - Lysodren, e.g. - when our patients are not responding to the trilostane. In Emma's case we're worried that she has "responded" too well. Forget about ketoconazole and Anipryl. Ketoconazole is undependable and Anipryl is considered a joke. Yes, cortisol testing may be influenced by a concomitant illness such as pancreatitis - your vet must take this in to consideration when evaluating her ACTH stim test. LA is rich in internal medicine specialists. The VCA California Veterinary Animal Hospital on Sepulveda Blvd. is just one of many. Ask your vet for a referral to an internist near you. There are no special diets for Cushing's, but we do suggest a high fiber, low fat diet for pancreatitis patients and that would be sensible for Cushing's as well. For what it's worth, my major professor and best friend now for over 40 years "invented" the o'p'ddd (Lysodren) treatment for Cushings. I believe I've seen more Cushing's cases than most vets will see in many lifetimes. Please feel free to continue our conversation.
Customer: replied 3 years ago.
thanks. currently she's at Cal. Animal Hospital getting an ultrasound, She saw an internal medicine dr, and he is suggesting a neurologist and surgeon take a look when the results come in. She's been through a lot since I found her on the streets 10 years ago-benign tumor on her paw, a growth on her right lower eyelid, Elbow displasia (we just did that surgury 2 years ago). I can't remember what came first the elbow or her cushings. When my son arrived, 3 years ago, she seemed to age. I think the stress of being replaced as the baby in the house stressed her out. But she is amazing with him and smiles while he tortures her. I just can't believe she could have a tumor on her pituatary, but we'll hear later today if it is something internal or not. The next step is an MRI--we do not have insurance. anyway, her levels are not in the range for Addisons. I just reviewed them with the new vet (IM DVM- Internal Medicine Vet?) Anyway, i asked them to do another blood work and send the results out for more accuracy--inside lab is limited. I feel like someone just ripped a whole in my chest and took a piece of my heart. I love that dog like no other. Her sister/life partner, Sophie is sad. I found her 6 months before Emma came along and they have been together for almost 10 years. I don't have the same bond with her. So of couNrse I want to save Emma's life. But right now, she is so lethargic she doesn't seem like Emma. She can body surf--amazing swimmer. I wish I had video taped more of her body surfing, I only have two really small clips on my phone. That was something I kept saying i'll do later in the summer. It's so hard with a toddler. I have to stop crying in front of him and be strong. I sound hopeless. I'm looking for information that will give me hope. I'm not ready to lose her. I want to have more time with her, what can I do?
Expert:  Dr. Michael Salkin replied 3 years ago.
Now I'm jealous. I live on the only Hawaiian island where there's no body surfing. Well, I could if I wanted to become a paraplegic. Sounds like you're well on your way to getting the answers you're seeking. Think twice before doing an MRI - if no tumor is seen involving her adrenals, by default the tumor involves her pituitary, and I can't imagine doing brain surgery on a 10 year old dog...but perhaps you can so I'll be quiet. Curiously, I opened up my latest Journal of the American Veterinary Association to find an excellent study on trilostane. It seems that much lower dosages (1mg/kg) than previously suggested given twice daily work well and are safer. Keep me posted please.
Customer: replied 3 years ago.
The results of the Ultrasound are in--negative on any tumors around her abdomen or anywhere an ultrasound can detect. Next step.... MRI.
The neurologist took a look at her and said her staggering walk is consistant with dogs that have brain tumors. But they are pushing for an MRI to know for sure. We will have the rest of the blood tests tomorrow morning; liver and ACTH. Do you know what percentage of dogs with Cushings have a tumor on the Pituitary? I'm not working, we have tons of credit card debt from IVF's (took me 5 years and over a dozen to get my son). I'm so tired of throwing money at medical stuff that I feel should be covered by insurance (IVF's not covered one iota). But I love Emma so much, I'm willing to go further into debt if it will give me a couple more years with her. But what will the quality of her life be like? I doubt she can body surf anymore. Will the vet be able to answer that question? Can we assume it is a brain tumor and treat her with Prednizone or something? I don't really want to do the MRI to find out she is going to pass anyway. What would you do?
Expert:  Dr. Michael Salkin replied 3 years ago.
The most current literature tells us that 85% have pituitary tumors. I don't feel that you need to spend $3000 to find that out unless you're set on removing the tumor surgically. I will honestly tell you that there's no way on Earth I'm going to spend $3000 to find out what I already know - especially when I know I'm not going to do brain surgery. Goodness knows how my dog would turn out after surgery...no, I know when to stop. I also know that I have to offer every modality of treatment to my clients - as the specialists will do for you, and you have to weigh the cost, prognosis, and quality of life issues. Prednisone will be merely palliative - if effective at all - for a pituitary tumor. Your IVF had a better prognosis for your bearing a son than MRI/surgery would have for your dog. Please discuss this with the internists and your family - make a list of questions and concerns and make the vets address each one to your satisfaction.
Customer: replied 3 years ago.
Thanks. I want to extend her life. But I want to save her dignity and make sure she has a good life. I don't want her to be in pain, and not be able to walk, run or play, or know who we are. Sophie is really sad too. Emma was the best ball catching dog you could ever meet. You could throw a ball straight to another dog and no matter where Emma was, she would catch it. She was an amazing athlete. I sort of always felt she would live life hard and go out like a Roman candle. I couldn't stand to see her week and mentally out of it.
We were planning a trip to Hawaii for my 50th birthday in October. (calling it Hawaii 5-0). We've already downgraded our hotel when you factor in the costs thus far. If we do the MRI I'll be celebrating the big 5-0 in LA not Hawaii. But if I knew it would bring me back the dog i fell in love with it, i'd spend the money on the MRI, surgery, etc. and take a few friends to Trader Vics for the evening.
Expert:  Dr. Michael Salkin replied 3 years ago.
I vote for Hawaii. I have too much experience with this disease to push you towards MRI/surgery. But first we have to get Emma out of her current funk. I want to know any abnormal findings on her diagnostics please. I'll look for your response tomorrow after the ACTH/liver tests are back.
Customer: replied 3 years ago.
So after the ultrasound and further blood tests, everything came up normal for Cushings--not Addisons. No liver problems, everything looks good with the ultrasound and blood work. The neurologist thinks it could be a brain malfunction. They want to do an MRI. And suggested a Spinal Tap (cancer check) along with the MRI, if they don't find anything while doing the MRI. After long discussions with the current vet (Internal Med guy who is consulting the Neurologist), we decided to put her on Prednizone for a week (maybe more, who knows) and see if she starts to eat again, walk properly, gain weight and if she just does better. Her Cushings will not be treated--no more Trilostane.
I asked what adding steroids will do to a dog that has Cushings and I got what sounds more like a short-term answer, simply, "give her lots and lots of water, let her have easy access to pee, and basically, all of her Cushings symptons will return. Today, I've noticed that has already happened. It has been 5 to 6 days of no Trilostane and she is drinking and drinking (I'm carrying a 50 lb dog down 20 steps to a grass area to pee three times a day) and she is panting a lot, like she did before we realized she has Cushings. She is still week, and doesn't want to eat. I am force feeding her like a goose you fatten for pate, but she perked up! After getting some scrambled eggs in her and a/d canned food, she perked up a little and has moved from her "spot," to other spots in the house and even tried to jump on the sofa--I caught her with her front paws up and just standing there with her feet on the ground wondering, "can I get a leg up please?" I'm curious as to how long she was in that position. But it made me laugh. I stopped crying, invited two of her close friends over to visit her and she is perking up. I was writing her eulogy yesterday, but now I am hopeful! WE are hopeful. I have no idea what tomorrow will bring. I hope the Steroids shrink a tumor, or reduce swelling in the brain--if that is the problem. I hope there is no long term problems with putting a 10-yo dog with Cushings on Steroids, but she is with me now and I am NOT planning to put her to sleep; not today! Any advice on what to do now? How to medicate? when to stop or start Prednizone, when to blood test again, and what to test for? How do we monitor her progress? I'm going to call an acupuncturist, and see if that will help balance her hormones/Cortisol. It helped me with mine when I was trying to get pregnant. So, what do you think?
Expert:  Dr. Michael Salkin replied 3 years ago.
I can only imagine that this is a central nervous problem. Why else would a Cushingoid dog with a normal abdomen (excluding the hypertrophied adrenal glands) not eat? You know as well as I that Cushings causes dogs to eat anything that doesn't eat them first. Adding steroids to a dog with Cushings is one of the more bizarre therapies I've encountered. The extreme polydipsia, panting and weakness is doing nothing for her quality of life. Of course there are long-term problems with this - all the attenuating problems of excess steroids will be exacerbated. My advice is to try this craziness for no more than 10 days. At this point monitoring her progress consists of subjectively assessing her happiness and appetite - I would be at a loss to interpret the conventional bloodwork for Cushings while she's on steroids. An acupuncturist makes as much sense to me as anything else. If she regains her appetite, I'd consider restarting trilostane at the new lower recommended dose - 1mg/kg BID - even underdosed she'd be a happier dog. Don't get me started on a spinal tap and MRI. We're looking for another tumor in addition to that on her pituitary gland? Why? What would you do differently if another tumor is identified?
Customer: replied 3 years ago.
I agree about the MRI and Spinal Tap. I think the idea with Steroids is to shrink the swelling (if that is the problem/tumor) in the brain. We were planning on no more than 7 days on Prednizone. Hoping it will get her muscles strong again, and get her eating on her own as well as shrink the tumor. I was so relieved last night to see the sparkle back in her eye, and see her actually walking on her on. But the sparkle returned with her effort to live BEFORE we gave her the Steroids. We gave her the Steroids about 7:30pm and watched her drink water non-stop. We woke up three times, about 12:30am and then 3:45am and again at 5am to take her outside to pee, and give her more water. Obviously, we can't do this forever. But I'm hoping the steroids will shrink the swelling and release pressure on her brain. Then, we can continue with acupuncture and whole-istic medicine to keep the tumor in check. Change her diet to a strict diet for dogs on Cushings and I'll suggest the 1 mg/kg BID of Trilostane to her new vet. She weighs (did weigh 50 lbs) so how much Trilostane is that twice a day?
Expert:  Dr. Michael Salkin replied 3 years ago.
OK, I feel better. Get her to acupuncture sooner than later as any effect that the steroids will have will dissipate immediately after they're stopped. Special diets aren't recommended for Cushings unless there is a concomitant diabetes mellitus. 50#=23kg, so 23mg of trilostane twice daily. You're an amazing advocate for Emma. Keep up the good work.
Customer: replied 3 years ago.
We have an appointment with an leading vet/acupuncturist today. Tomorrow we are seeing another alternative medicine vet. I still don't know what effect the Steroids are having. I'm still force feeding her today--It's been one week since she's eaten oe pooped. This evening will be her second dose of Prednisolone 20 mg. What should I be seeing as far as changes in her behavior--eating, weekness, will to live...
She is also slightly anemic. All I can do is put wet food (a/d Critical Care) and scrambled eggs down her throat and hold her mouth shut.
What do you advise I do after the week on Steroids?
My brother-in-law has a Jack Russel with Addisons, age 12, who is also on Steroids and seems to be doing great. It's been since March when they took her to the vet to put her down that she has done a 180 on Steroids--with Addisons.
But the question I need to answer is, what do we do after we stop the Steroids? How do you treat a dog with Cushings who has brain swelling?
Expert:  Dr. Michael Salkin replied 3 years ago.
If the steroids were to work you would see increased appetite in addition to the increased water intake. You would see increased muscle weakness. Behavioral changes are all over the map - everything from aggression to depression. Since she's already been under the influence of too much steroid from her Cushings, the addition of yet more may not be readily apparent. I'm hopeful she can be back on the low dose trilostane by the week after steroids...but not if she isn't eating on her own. Steroid lack is a feature of Addisons - supplementing steroids normalizes Addisonians. Steroid excess is a feature of Cushings - supplementing steroids worsens Cushings. Surgery is the only option for a pituitary mass that is exerting pressure on the brain. It is unlikely that alternative therapies will have any noticeable effect.
Customer: replied 3 years ago.
So i hear you telling me i should prepare myself for letting go of her. The pain of loosing her is unbearable. But what would be worse is keeping her alive if she will be in pain.
We will stop the Steroids in a week. I'll talk to the vet about getting a Rx of 23 mg of Trilostane to administer 2x/day. Can you send me the article you read, or tell me where it is regarding this dosing so I can refer her Internist to it please?

If she doesn't start to eat on her own this week, what can i do?

Why won't she eat?
Expert:  Dr. Michael Salkin replied 3 years ago.
The article is in the June 1, 2011 issue of JAVMA. Yes, her prognosis is grave. I have no magic for Emma. If she doesn't start to eat on her own I see little recourse. She doesn't eat because her hunger trigger has been abolished by illness. There's nothing pleasant about end-stage Cushings, Maria.
Customer: replied 3 years ago.
She is eating--very little--but she ate the a/d dog food we had (can't give it to her anymore because it is too fatty), some turkey sweet potato baby food, cottage cheese and a bacon dog treat at the new vet. Her eyes sparkle, and I carried her down to our yard--about 30 steep steps--to potty, but she laid down in the grass in the sun, so I let her be. I walked up to the house and started chatting with a neighbor (one she doesn't trust) and she came up all the stairs by herself and walked in the house to keep an eye on us. This is the most activity I've seen from her since her Pancreatitis attack. Tonight is the third dosage of Steroids. She isn't wagging her tail or barking yet (she used to bark often and I haven't heard her bark once since the incident), but she seems alert and her eyes look normal again. I'm thinking of taking her to another Neurologist, I'm considering the MRI. She had acupuncture yesterday and is on a tincture to help out all her issues and she looks better. I'm not ready to give up, as long as I see life in her eyes.
I have a friend the had one over left and it was diagnosed with a tumor. The Dr.s wanted to remove it. She wasn't about to let them remove her last one so she saw an acupuncturist and did alternative medicine, and she shrank it down to nothing!!! Her Drs. couldn't believe it, but they saw the ultra-sounds--no tumor! Gone!!
Took a moment to give her her pills and feed her dinner. She ate pasta with sweet-potato turkey sauce (all home-made and warm) and some chicken and rice with potato--also home-made. She is EATING!!!
I don't know if it is the mirtazapine or prednizone, but she is eating!
She is eating, walking up stairs, alert and has a sparkle in her eyes. I am not putting her down yet.
Every day we have with her is a blessing and we are enjoying our time with her, taking it one day at a time. She is getting acupuncture 2x/week and she looks better.
Here is a question for you: Provided she does well on the Prednizone the next 4 days (total of 7 days on it), what do we do next? Take her off of it? Put her back on the low dosage Trilostane? Test her ACTH again? HOW DO WE MONITOR HER? How can we treat pain?
Expert:  Dr. Michael Salkin replied 3 years ago.
If she continues to eat, trilostane should be reinstituted at the new lower level. Forget the testing - it won't be accurate with prednisone in her system anyway. Monitoring becomes subjective. If she doesn't do well on trilostane, you simply stop giving it. Pain is managed with narcotics - tramadol (Ultram) will be suggested. I wouldn't put her down now either. May she keep eating, get back on trilostane, and do well.
Customer: replied 3 years ago.
Oh, her tail stopped working. She started holding it down when she first got sick--2 days before we took her in for the Pancreatitis treatment. What is that about?
And of course she is drinking like a sailor. She must drink a gallon of water a day. Does she NEED that or is it just a feeling of thirst? We are so tired and getting up at 3am and 5 am to take her out and give her more water--she can't go outside by herself because of the steps. Do you think we could skip giving her water at 3am? Or maybe just give her a little water, so we can sleep?
My husband and I still think (with no proof, it's just a feeling) that maybe she suffered a cardiac infraction from all the pain she was in with Pancreatitis. She behaves the same way my husbands mother did after she broke her hip. Turned out she had a minor stroke. She recovered pretty well from it--of course was never quite the same, but she was okay after a few months. What do I ask the vet to look for to see if maybe she had a small stroke? Should I take her to another Neurologist and get a second opinion--I found a more whole-istic one that the guy who wants to do the MRI/Spinal Tap.
Expert:  Dr. Michael Salkin replied 3 years ago.
If her tail really can't voluntarily move, she has a neurological problem - either a peripheral neuropathy just affecting her tail (usually seen with injury) or a central neuropathy (originating in her spinal cord). If she has voluntary movement but isn't using it, she's just ill enough not to want to wag. You must never restrict water. She drinks excessively because she's losing so much fluid through her kidneys - in other words, she's polydipsic because she's polyuric. Endogenous and exogenous corticosteroids are the culprit. Cushings is a thromboembolic disease - she could throw a clot anywhere - her heart (an infarction), her lungs (most common in Cushings), and her brain (a cerebral vascular accident). I see no point in seeing a neurologist unless your peace of mind will benefit. There is no effective treatment for whatever a neurologist would find.
Dr. Michael Salkin, Veterinarian
Category: Dog Veterinary
Satisfied Customers: 13010
Experience: University of California at Davis graduate veterinarian with 42 years of experience
Dr. Michael Salkin and 5 other Dog Veterinary Specialists are ready to help you
Expert:  Dr. Michael Salkin replied 3 years ago.
Thank you for your kind and generous accept. Please save our conversation so you can continue chatting with me.
Customer: replied 3 years ago.
Thank you. I really need someone to hold my hand through all this. We are seeing ANOTHER Dr. tomorrow, and I just sent her Internal Medicine Vet a list of 15 questions and suggested we take her off the Prednizone Tuesday and start back up the Trilostane at 1mg/kg BID (i assume bid is Dr. talk for twice daily).

She is eating on her own. My final question for now is, can't we take her off the Prednizone NOW, i.e., last dosage tonight, since she is eating on her own? And do we need to tapper it off, or just go cold turkey?

We only have 1 weeks worth of pills anyway, so Monday will be her last pill.

I also forgot to mention that we gave her surgery last summer--only a year ago, for Elbow Displasia. Both her regular vet and the Surgeon Vet knew she had Cushings and had been on medication for over a year, and NEITHER of them mentioned that we were spending $4000 on a procedure for a dying dog!
Expert:  Dr. Michael Salkin replied 3 years ago.
I'm a good hand holder. I'm going to recommend that her last prednisone be tonight - I couldn't see the point of it in the first place. It's really wonderful that she's eating on her own now. I'm scared about reinstituting the trilostane but I can't see any other reasonable way to proceed. If the surgeon weren't aware of her Cushings, then he/she wasn't aware that her healing would be delayed - a rather important thing to know pre-surgery. It's unthinkable that he/she wasn't aware of her condition and that he didn't comment on her life expectancy.
Customer: replied 3 years ago.
Today is Emma's last day on Prednizone (we think) calling her Internist this afternoon. She is eating on her own, running, playing with her sister, Sophie, jumping on the bed again and wagging her tail and even barking. Other than still being a little under weight, she appears to be just as she was before the Pancreatitis. I have learned a lot about Cushings, Veterinarians, and life in general from this. She has acupuncture twice a week now, homemade meals 5 times/day, and I am never taking her for granted again. I'll keep you posted, but right now, I feel very blessed and glad I'm a determined woman.
Expert:  Dr. Michael Salkin replied 3 years ago.
What a nice rewarding message! I'll await your next response.

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