Veterinary Insights: Cushing's Disease Explained by Dr. Z
Join us for a deep dive into the realm of canine health as Dr. Z offers her invaluable insights into Cushing's disease. In this podcast episode, we explore the various types of Cushing's disease and common symptoms to watch out for. Dr. Z provides a detailed breakdown of diagnostic tests and treatment options available to pet owners. The episode also covers the importance of regular monitoring and how to enhance the lives of dogs affected by Cushing's disease. This informative conversation equips pet owners and animal enthusiasts with the knowledge they need to ensure the well-being of their furry companions.
What You’ll Learn:
Common types of Cushing's disease in dogs
Recognizing the typical symptoms and clinical signs
The diagnostic process, including blood tests and imaging
The importance of regular monitoring in managing the condition
Various treatment options, from Lysodren (Mitotane) to Trilostane (Vetoryl).
How Cushing's disease can affect your dog's quality of life
Prognosis and expected lifespan for dogs with well-managed Cushing's disease
The impact of Cushing's disease on specific breeds
Strategies to enhance the lives of dogs diagnosed with Cushing's disease
Ideas Worth Sharing:
"Once we figure it out and they do pretty well most of the time.” - Dr. Xenia Zawadzkas
""The goal is to just control the symptoms. Whether it's in the brain or the adrenal gland." - Dr. Xenia Zawadzkas
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Read The Transcript:
Dr. Sugerman: [00:00:00] Hi, and welcome to Vetsplanation. I'm your veterinary host, Dr. Sugerman, and I'm going to teach you about veterinary medicine. In this podcast, we can dive deeper into the understanding of what our pets are going through and break down medical terms into easier to understand chunks of information. Just a quick disclaimer, this podcast is for informational purposes only.
This is not meant to be a diagnosis for your pet. If you have questions about diagnostics or treatment options, please talk to your veterinarian about those things. Remember, we are all practicing veterinary medicine and medicine is not an exact science. Your veterinarian may have different treatment options and different opinions.
The information I provide here is to help pet parents have a better understanding about their pets. If you like our podcast, please consider sharing this podcast with at least one friend or just somebody else who has pets as well. Now, let's jump into this week's episode.
Welcome back to another episode of Vetsplanation. I'm your host, Dr. Sugarman, and we have [00:01:00] Dr. Z here again. Thank you again so much for coming on again.
Dr. Z: My pleasure. Thank you, as usual.
Dr. Sugerman: Yeah. All right. So we're going to be talking about Cushing's disease today. Which is great because this is definitely a general practitioner thing that I don't know a lot about, so I'm really excited to dive into this today.
Dr. Z: Oh, good. I'm glad.
Dr. Sugerman: Yeah. All right, so let's talk a little bit about it. Can you tell me like what Cushing's disease is?
Dr. Z: Yes, it is the opposite of Addison's disease which hopefully whoever's listening you should listen to the Addison's disease podcast first because this is like repeating a few things that I won't go into as much detail because we already did in the last episode.
But anyway, so this is hyper- adrenocorticism instead of Addison's which is hypo. So hyper just means too much, or too high, and then adreno is the adrenal glands, and corticism, or the cortex of the adrenal glands is what we're talking about. And that's where these hormones are made, and in this specific disease, we're just talking [00:02:00] about the glucocorticoids. The mineralocorticoids, which are important for Addison's disease, are not a problem with Cushing's you can't have too many mineralocorticoids, but you certainly can have too many glucocorticoids.
And that's what Cushing's is, is when you have too many of those hormones circulating. And like we talked about in Addison's, the glucocorticoids do so many things for our body, basically helping us deal with stress and many metabolic functions. And one of the big ones is it talks to the liver, and makes it punch out glucose and energy, gets the liver going.
And it goes to the muscle and it has this breakdown in our muscles so that we can get proteins out and start having more energy. But if you have, like anything, too much of a good thing, if things start to break down, then you have some pretty horrible side effects if there's too much of those glucocorticoids.
And I also talked about last time the furnace, remember?
Dr. Sugerman: Yes, yes, the furnace, yes.
Dr. Z: The negative [00:03:00] feedback loop. This is like when the furnace would be, the temperature sensor in the thermostat is broken. And so the furnace is just constantly on. Constantly heating up the house. Yeah, so there's always more glucose corticoids even though we don't need it.
The temp just keeps going up and up. Okay. So that's what's happening in this hormone disease, is there's just too much of the glucocorticoids.
Dr. Sugerman: Okay. Great. Then, do you happen to know why it's called Cushion's Disease?
Dr. Z: Yes. One of my favorite historical things to do is talk about the naming of these diseases. There was a physician, a neurosurgeon in the 1800s, early 1900s named Harvey Cushing and we know a lot about him because he took very good notes and wrote lots of letters.
Dr. Sugerman: Sounds like you.
Dr. Z: Awesome. And he liked the brain, he studied the brain and he discovered the pituitary tumors that can cause Cushing's, we'll go into that in people that had the same kind of symptoms of [00:04:00] Cushing's disease.
So he, that's why the disease was named after him. Oh, very cool. Yeah, and a couple other fun facts about him. He was in World War I, and he was a doctor during that war, and he also had his own health problems later in life with like blood clots in his legs. Oh, jeez. And he figured out that if he stopped smoking, they got better.
Oh, wow. And so he was a very early advocate for stopping smoking, even before it was a thing, because back then everybody smoked. Nobody knew it was bad for you. Exactly. But he was early on a smart dude, and he was like, hey. Nice. Smoking's smoking bad for you. It causes blood clots in your legs.
Dr. Sugerman: Crazy. I did not know that.
Dr. Z: Yeah, I didn't either. Fun fact.
Dr. Sugerman: That's really cool.
So what are the symptoms then of Cushing's disease?
Dr. Z: So all related to the glucocorticoids which act on all those organs I was telling you about. They also talk to the kidneys and tell them to not conserve water.
One of the biggest symptoms we see is that dogs are peeing and drinking a lot. Yeah. [00:05:00] Just like diabetes, but for different reasons. They're just constantly leaking urine and peeing and super thirsty. And they're also very hungry. Glucocorticoids make you want to eat. Yeah. They're like getting in the trash and always hungry, just wanting more and more food.
Even after you've fed them, they're like, where's my food? And they're super hungry. And then their muscles start to waste away. You'll see like we talked about the pred head before. The muscles on the face go away. The muscles along the back kind of deteriorate too. And that makes their bellies look bigger.
Like a pot bellied pig. And also the liver, it's being stimulated so much, the liver starts to get really big. And together with the big liver and low muscles on the back, causes that big belly to happen. So that's a classic sign. The skin also is affected by glucocorticoids, so if you have a lot of them circulating, your skin gets really thin, you lose your hair, similar to many hormone problems, like it affects the skin a lot, and you'll see [00:06:00] hair issues with Cushing's too.
Thankfully, in only a small portion of Cushing's patients, there can also be mineralization of soft tissues. And the big one is it can mineralize in the skin. Yeah. Basically what's happening is those proteins are breaking down so much. For some reason phosphorus and calcium likes to build up in those areas where the proteins are breaking down.
Yeah. And so it's called calcinosis cutis, and they get like hard crusts on their skin that are secondarily infected, and there's just nasty plaques all over. Yeah. I've seen it a few times, it's pretty sad. And they can mineralize inside too, if you're taking an x ray, you can see mineralized fat in the abdomen, or all along the kidneys, or all along the liver, you can see white parts of calcium deposits. Even when the calcium is normal in the bloodstream. Yeah. This just starts to happen sometimes in Cushing's patients.
Dr. Sugerman: I was just actually talking, my last podcast was on cholecalciferol toxicity. Oh cool. Yep. And just about like vitamin D toxicity and stuff too. And we talked about [00:07:00] this is one of the differentials for that.
Oh. 'cause they drink a lot of water. They just become lethargic. They have the calcinosis cutis as well, oh, okay. It was a, I think this is a good follow up to that.
Dr. Z: Yeah, that's great. It's not like a symptom that you see that and you're like, oh, this is definitely Cushing's. It could be a couple different things. Exactly. Nice. Yeah. That's pretty much for the symptoms. More rarely though, I did want to mention, like if you have an intact animal, their testicles can atrophy and the females can never go into heat, like it causes a persistent anestrus.
And then they're more likely to have ligament injuries, too. I think when you have too many glucocorticoids, it weakens the ligaments a little bit, those are other problems that can happen. But the biggest one is drinking a lot, peeing a lot, and eating a lot. Those are the big ones.
Dr. Sugerman: Yeah. Yeah. Okay. And then, so if we, if somebody brings them in with all of these symptoms, how are you going to diagnose it then?
Dr. Z: Yeah. Lab work, as always, is our friend. There's a bunch of blood and urine tests we can [00:08:00] do and then there's imaging as well. So I'll just go through it because It takes a long time to diagnose.
It's tricky. And you have to put a lot of things together to come to the diagnosis. So first the, the complete blood cell count, the CBC we call it. You'll see a stress leukogram, most likely. And often times the platelets are high.
Dr. Sugerman: Real quick, can you tell me what a stress leukogram is?
Dr. Z: Yeah, that's something that happens when we're stressed and have high circulating glucocorticoids. It makes certain white blood cells go up and other ones go down. Okay. And a typical pattern on that. Blood count and so you'll see that go with Cushing's, but it's again It's not pathognomonic like lots of things make a stress leukogram.
Dr. Sugerman: Just being stressed.
Dr. Z: Yeah, but it's definitely there and then the platelets are high too, which kind of happens with any chronic inflammatory disease but they can be pretty significantly elevated like 700 Thousand. Normally they're less than 400. And then on the chemistries, one of the big things that I think starts us thinking about [00:09:00] Cushing's is one of the liver enzymes will be really high specifically the one called the ALP or the alkaline phos phosphatase yeah alk phos we just say for short.
Um, that one is really high it's very specifically induced by steroids. That's one of the reasons that can go up. And so if it's really high and we have all the symptoms of cushing's. We raise a red flag for it. Yeah But I have to point out that that's not the only thing that can make alk phos go up.
There's so many different liver diseases out there, including just like a liver tumor or gallbladder stone or something that can cause the alk phos to go up. It's definitely an indicator, but not, again, pathognomonic. There could be many things causing it. Sometimes they'll have high fats, like cholesterol and triglycerides are up, and the glucose can be high too.
Some 5-10 percent of cushionoid patients are also diabetic. It's pretty low percentage though. I don't think I really have a patient that I'm treating for both that [00:10:00] I can think of. That's good. Yes, I've never seen it. Seems hard to manage. Yeah, but it's supposedly a thing. It can happen. And then, let's see.
On the urine, this is important. The urine will be dilute. It's always watery urine. It's not concentrating well. We check what's called the specific gravity of the urine, which helps us see how concentrated it is. And it has to be less than 1.020 or 1.020 to be consistent with Cushing's. So for me, if I have a dog with kind of the symptoms, and the alkalosis is high, but then it's got super concentrated pee, like 1.040 I'm like, this is not Cushing's.
I stop there. I don't even. Because there's no way that they can have Cushing's. If they're concentrating their urine. Okay. They're usually very polydipsic. Drinking a ton. Okay. And peeing a ton. So that pee is. It has to be dilute for me to even consider going down that path.
Dr. Sugerman: That's a really nice kind of tool to tell you how to stop doing further testings.
Yeah, there's definitely so much more testing that we have to do. [00:11:00]
Dr. Z: Then I'm like, okay, it's probably not Cushing's. We probably have a liver tumor or something else happening. And so I don't even bother doing the next step, which is if all of those things are leaning towards it. Then we start measuring cortisol levels with a couple different tests that we can do to be more clear on the diagnosis of Cushing's.
So I prefer doing what's called the low dose dexamethasone suppression test, just because it's a little more sensitive than the ACTH stim test, which we talked about in Addison's. That ACTH stim test can also help diagnose Cushing's, but there's so many false negatives, like a lot of... dogs can have a normal stim test but still have Cushing's.
And so you're still like, I feel like it's a waste of time and money, because most of the time it's equivocal, or you're not sure.
Dr. Sugerman: And that's what we always used to do which was nice that we now have this other test that we can start doing too.
Dr. Z: Yes, yes. So the low dose DEX is better. I think the ACTH stim test, just to finish talking about [00:12:00] it, that's much better for diagnosing addison's like that's our gold standard for addison's for sure, it tells us an answer.
I don't think it's great for Cushing's. But the low dose dex, so it takes a longer time than the stim test. They're here all day. It's an eight hour test. We, we take a baseline cortisol and then we give a low dose of dexamethasone and then we test the cortisol level again four hours later and then one more time eight hours later.
They have to be here for the full eight hours.
Dr. Sugerman: What is dexamethasone?
Dr. Z: Dexamethasone, good question, is a steroid. So like prednisone or any glucocorticoid, we're giving them a little bit of it. And in a normal dog, the cortisol levels will go down after they have a little dexamethasone because it's suppressing that whole feedback loop.
But in a cushionoid dog, the cortisol levels will be elevated, and sometimes we can see, depending on what the number of it is, at four and eight hours, it can help us decide what kind of Cushing's it is, which we'll go into. So yeah, I like doing that low dose dex test. And then [00:13:00] together with the low dose dex test, sometimes even then I'm not 100%. Plus when they have that high, high liver enzymes going on, I want to look at the liver.
I think imaging is important to solidify my decision that it's Cushing's so you can take x rays which are helpful but you can't really see those adrenal glands on an x ray
Dr. Sugerman: Right. They are so tiny
Dr. Z: Yeah so I prefer an ultrasound and I prefer it be done by a radiologist so that they can really look and measure those adrenal glands which are tiny. My favorite combo is to do the low dose dex test and the ultrasound at the same time, because the dog has to be here all day for both anyway.
And so we just get both tests done the same day. Nice. And that usually gives me my answer if they're cushionoid or not. Yeah. So they're going to be looking not just at the adrenal glands, but also at the liver. And I'd say half the time they diagnose a liver tumor, and then I'm like, nope, this isn't Cushing's, it's a tumor and then we figure out what to do next.
But yeah, if we have just a generally big liver and maybe some big adrenal glands or one adrenal [00:14:00] gland has a tumor on it, and the low dose DEX test is showing high cortisol levels then I can say, okay, this dog has Cushing's, and we can shoot.
So yeah, in one other note I had written down here, don't bother doing these tests unless we have the symptoms. There's really no reason to treat Cushing's unless we have all of the horrible symptoms of it. Otherwise, if it's just a mild Cushing's or early Cushing's, we shouldn't be bothering doing any of this in my opinion.
Dr. Sugerman: Can't it also throw off your results when it's just really mild as well?
Dr. Z: Yeah, I think it can be like unclear. And then. You're like we're doing all this to decide if we should start treating, right? And if we're not having the symptoms, then what the heck are we treating? Yeah, it's just a big waste of time and money.
Dr. Sugerman: Got it. Okay. Perfect.
Dr. Z: Oh, I forgot to mention one more thing. If people want to go crazy with testing you can get an MRI. And have a look at the [00:15:00] brain and the pituitary gland because that can be I'm going to go into the types of Cushing's in a second, but they can actually sometimes diagnose a brain tumor as the problem too, and that works if they do a whole body MRI, they can really look at those adrenal glands and everything, and surgery planning and all of that is an option, but most people don't go to those lengths, and we can get a pretty good handle on things with what we have here.
Dr. Sugerman: And we do have CT here, so we could look at the adrenal glands, the, the, I think the pituitary gland would be the harder one.
Dr. Z: Yeah, isn't MRI better for the spinal cord, and the brain, yeah, exactly I don't think the CT, yeah, if you were gonna want to know, do that, I would refer you to a neurologist, a specialist that has an MRI,
Dr. Sugerman: Yeah, definitely makes sense. So you're mentioning the types of Cushing's. What types of cushing's are there?
Dr. Z: So there's there was a fourth one I was reading about that didn't make a lot of sense, I'm not even going to talk about it.
Okay. But there's three, three big ones. The first one, which is the most common, is the pituitary dependent. So [00:16:00] there's something wrong with the pituitary gland in the brain. Usually there's a little tumor on it, and again, we talked about the pituitary gland last time, it's got many functions, secretes many hormones, talks to many different parts of the body.
But for some reason, the part that secretes ACTH can be affected by these tumors, they can be malignant, but most of the time they're just benign tumors. 80 to 90 percent of Cushing's dogs have the tumor there.
Dr. Sugerman: That's a high percentage.
Dr. Z: Yeah. So it's most of the time that's what we're dealing with.
And in that type, the adrenal glands will both be big together. Like they're being overstimulated by all that ACTH. And they're getting, bilaterally large, which you can see on the ultrasound. And then the other type is the adrenal dependent. So the pituitary gland's fine, but one of the adrenal glands develops a tumor usually.
I guess in a rare case, both of them can have tumors, but most of the time it's just one. And this is only [00:17:00] like 15 percent of cases, about thereabouts, so it's less common. And then 50% I was reading of these tumors are malignant, so it can be a bad thing or it can be just a benign tumor and they cause too much cortisol to be released.
Yeah. So it causes the same exact symptoms, but it has nothing to do with the pituitary gland. It's all the adrenal gland itself that's malfunctioning. And overproducing. You can see that on an ultrasound too, you can see one giant tumor on usually one of the adrenal glands in these cases.
And there can be a surgery done to remove that, if you want to have a specialist go for it. It's tricky and they always want to screen for metastases and spreading in case it is a malignant tumor. Before even considering removing such a delicate, small tumor near,
Dr. Sugerman: It's very close to a lot of very big major blood vessels.
Dr. Z: Yes. There's the big caudal vena cava and the renal, the kidney vessels are all going right by there. It's really, really [00:18:00] tricky surgery. Riddled with complications you can imagine. So a lot of the times we treat them both the same whether it's adrenal or pituitary. The goal is to just control the symptoms.
Yeah. And who cares if there's a tumor there, we can still treat it.
Dr. Sugerman: Yeah, absolutely.
Dr. Z: Whether it's in the brain or the adrenal gland. Yeah. There is one more type of Cushing's that we can cause. It's called iatrogenic, meaning we do it on accident by our, by our treatments. That's when we just treat for too long with too high of a dose of the steroid.
And I see that a little bit when you send me your Addison's patients and you're like, start them out on too high a dose of prednisone and it's a whole month of that. But the good thing about iatrogenic is you can usually reverse it pretty quickly. I don't think you have to do like testing to figure it out.
You can just be able to know by the history, oh, he's on this dose of pred for how long? Okay, we need to stop it. Yeah. Or taper it off and find a different drug if he, if he needs a [00:19:00] long term steroid for something, maybe add a different immunosuppressant to eventually get off the prednisone so we stop having the Cushing's signs.
Yeah, so that one's a little bit different and not as serious in my mind. Yeah. It's very reversible. Good.
Dr. Sugerman: So then, we have at least three different types. So how is Cushing's disease treated then?
Dr. Z: Good question. So we have basically two big drugs that we can reach for. The older one is called Lysodren or Mitotane. Lysadren is the brand, Mitotane is the drug itself. That one is toxic to the adrenal cortex, so it actually just destroys it.
But in very small doses, if you're careful with it, you can counter the effects of hyperadrenocorticism. Yeah. There's a newer drug, it's probably 20 years old now, , it's not that new. Newer, yeah. But it's called Vetoryl or Trilostane is the drug name. Vetoryl is the brand name. I'll be using them interchangeably.
Yeah. It's a steroid analog and it suppresses the production [00:20:00] of the body's own cortisol. So in effect, it decreases the cortisol levels in the body. And does the same thing by not directly affecting the adrenal glands but just basically decreasing cortisol and then all the side effects go away.
So it's a pretty cool drug, it's a little bit safer. So that's usually what we start with. And the few Cushings patients that I've ever had, all of them have gotten Trilostane except for one. I've only treated one patient ever with Mitotane and that was just because she wouldn't respond to the Vetoryl.
She had really, really bad Cushing's.
Dr. Sugerman: That must be really bad, yeah.
Dr. Z: So most patients do fine on Vetoryl. And usually we give it twice a day. And it lasts about 8 to 10 hours. Some dogs can get by on once a day, but usually it just seems to work better twice. So I always try to give it twice a day. If there's an adrenal tumor, as far as treating the disease, you can again have a surgery, think about surgery.
The pituitary tumor, if there is one on the brain, there has been some dogs [00:21:00] that have had brain surgery. And they do that in people, too. Yeah. There's only a couple vet hospitals, I think, in the country that have ever tried it. You can imagine that's difficult.
Dr. Sugerman: Exactly. Brain surgery is a little hard.
Dr. Z: Yeah it really is hard to get to. I think you go through the mouth.
Dr. Sugerman: I think it's through the neck. I think that's what they do on people.
Dr. Z: Oh my god. So crazy. And, the pituitary does so many things that if you accidentally remove a different part of it then you'll start having all these other hormonal problems, right?
So it's yeah. I don't, I wouldn't ever recommend that if it was my dog,
Dr. Sugerman: The adrenal is already hard enough, now pituitary gland is like extremely difficult to do surgery on.
Dr. Z: Yeah. Just give him some Trilostane.
Dr. Sugerman: Yeah. Seems like it works just fine. So when we've given the trialistane, how do we know that it's working then?
Dr. Z: Basically all those symptoms go away, and that's a lot of the monitoring that comes with it. That's often a big part of it is talking about, okay, is he drinking less and peeing [00:22:00] less and. Eating normally again. Yeah.
Dr. Sugerman: So those, those symptoms will go away, but other things won't go away. Like the, the musculature being really like
Dr. Z: it will. So it takes, the symptoms of drinking a lot and peeing a lot usually go get better the quickest, like within a month of treatment. If you get to the right dose quickly enough, month or two, you can be back to normal. The muscle takes a while to come back, but it will. It will. Yeah.
Okay. Yeah. It always makes me think of there was a dog we were treating for IMHA, we were giving a lot of pred and we basically caused Cushing's, iatrogenic Cushing's. And he was only like two years old and he had the pred head. It was really sad. He was like a lab. Yeah. And he looked like a really, like a 15 year old lab.
Yeah. Poor guy. But, once we got finally him tapered off of that and back to normal a month or two later, he looked like a young, healthy lab again. His muscle came right back. That's awesome. Yeah. So it does come back. Okay. The pot belly can get better. I had that one Chihuahua that I had to put on the Mitotane.
Yeah. I remember her because she looked [00:23:00] like she was pregnant when she came in. Her pot belly was so bad. Oh, it was just like ginormous. Yeah. And that belly went back down. She had went back to a lean body condition. It was amazing. Yeah.
Dr. Sugerman: And the skin, does that get better too?
Dr. Z: Yes. That takes the longest, probably six months before skin issues get better. Unfortunately, if they get calcinosis cutis, that never resolves. Once you have those deposits of calcium there, it never like resorbs. Like if it was one spot, you could consider surgery maybe, but it's usually all over.
Dr. Sugerman: And same thing internally, those aren't going to resolve.
Dr. Z: No. Luckily, I don't think that causes usually too much secondary problems like you'll just incidentally see, oh yeah, there's some calcinosis or some mineralization of that colon or something but it's not really affecting anything, we just don't worry about it.
Dr. Sugerman: But good to know for us on ER too, like we're taking x rays and things, right? So we know that mineralization is probably from things like having Cushing's disease, not from something [00:24:00] else. We might be worried about.
Dr. Z: I would say there might be cases where it does affect things, like if you get a lot of calcium deposits in the lungs or something, it might affect breathing and but that's pretty rare.
I think overall it's just incidental and the skin though, the calcinosis cutis when the patients I've seen that have it, there's, that's no fun. Like it's itchy. It's gross. It's infected. You might have to do courses of antibiotics and there are topical therapies to try and help keep it comfortable, but that can be a limiting factor in their quality of life if it gets really bad for sure.
Dr. Sugerman: Or removing it like you were saying too.
Dr. Z: Yeah. But I've, whenever I've seen it, it's like their whole back. It's not you can remove all the skin on their back . Yeah. So no poor things. Yeah. It's pretty sad when that happens. Yeah. But luckily it's pretty rare.
Yeah. Usually. Usually, we can start treating this before that happens. Nice. I like to think.
Dr. Sugerman: Yeah. And then when we do treat them, are there any side effects to those treatments?
Dr. Z: Yeah, [00:25:00] let's see the main one with the lysogen, the mitotine drug is, it can destroy those adrenal cortices completely.
And then, can you guess what happens?
Dr. Sugerman: Then we end up having Addison's disease, yes.
Dr. Z: Yeah, then it becomes an Addison's dog and that one chihuahua did end up coming in on ER after all in an Addisonian crisis. And once we figure that out, like as long as we're carefully monitoring, which we do very carefully with Mitotane especially then it's not the end of the world.
We basically just switch gears and have to start treating as an Addisonian after that, right? So then they need their DOCP shots.
Dr. Sugerman: And then they need their pred again.
Dr. Z: They need pred again, yep. Because we took it all away. It's too much. So we just have to try and get back into balance with it.
Some people say that's actually easier than trying to treat a Cushing's dog. I don't know.
Dr. Sugerman: Oh, interesting. Do they, at that point, are they a typical Addisonian or an atypical? Will they, will it destroy the mineral corticoids as well?
Dr. Z: That's a great question. I don't remember, but I should look up that [00:26:00] one that we had that was on my Mitotane and see if we ended up, I think I remember giving DOCP shots, I think it did destroy the entire cortex, so that would destroy the mineralocorticoids too, and that's probably why she came in on crisis, cause her lytes were probably, really out of whack yeah.
Basically, to answer that question, I think they become typical Addisonian.
Dr. Sugerman: Okay. Got it. Yeah. Okay.
Dr. Z: That was for Lysodren. Side effects is basically causing Addison's.
Trilostane you can do that too, but it's a lot safer, and usually that drug is better tolerated. Sometimes you'll see some GI effects when you start it like vomiting and lethargy and stuff, but it's usually self limiting and mild. And when we tweak the dose, we can keep all that into consideration.
Okay, maybe give less if they're right having trouble with it, but yeah so I'd say side effects are pretty small with that one. The main thing we're worried about is causing Addison's. Yeah.
Dr. Sugerman: So is there any lab work or anything that we need to do to help make sure everything's working correctly?
Dr. Z: Yeah monitoring is [00:27:00] extremely important the best way to keep an eye on things is with your ACTH stim test after we have the diagnosis, we use that test then to make sure that we're at the right dose of either Mitotane or, or Trilostane.
And usually for the Trilostane you want to give it in the morning. So I'm always telling them to do it BID, twice a day anyway. But we want to start the test after the morning pill is given and a full meal. There's something important about eating a normal meal.
Dr. Sugerman: Is it like a certain time period after the pill?
Okay.
Dr. Z: Yeah, so breakfast and pill and then we need to start the stim test two to six hours after. Okay. So basically have breakfast and then make your appointment a couple hours after. Got it. And the stim test is short, it's just an hour, just like for Addison's, you take the first cortisol, give a little cortrosyn, and then take the next cortisol an hour later.
And then there's certain numbers that we want the cortisol level to be in the pre and the post [00:28:00] to be considered well regulated for Cushing's.
Dr. Sugerman: Okay. Is that a test you often send out or do you typically do it in house?
Dr. Z: I send it out. I was doing some reading. There is some discrepancy over in house cortisol levels versus the lab when we send it out too.
So I just always trust that one more, I think, and just send it out. This also helps us decide on adjusting the dose. Okay. Depending on the results and the patient's clinical signs, it's important to like, say the numbers look good, but the dog is still drinking a ton.
And I think he needs more, and we'll go up with it. So there's quite a lot of monitoring, and we have to for Trilostane anyway, after the initial diagnosis, we're going to do it ten to twelve days after the first diagnosis. 10 to 14 days.
And then we do it again at 30 days. And then it goes to every three to four months if they're doing well. But if we keep adjusting the dose, like I'd like to keep testing that stim test two to four weeks [00:29:00] later. And then once we're stable after that first year, every six to 12 months is fine.
Okay. So once things calm down and we're at a good level and the symptoms are well controlled. It's pretty straightforward after that.
Dr. Sugerman: Yeah. And so just for owners at home, it's also just monitoring their urination, drinking, eating habits, things like that, right?
Dr. Z: Exactly. Yeah. Yeah. And I think with Mitotane it's a little more intense in the beginning just because it's a more dangerous drug.
So we're like testing like a week later. Oh, wow. With the stim test. And then another week or two after that, depending on what things look like. And there's a specific protocol. I remember I had to look it up on that one dog that I had. Because It was so intense. Yeah. And then she did well for a year.
And we were not watching as closely. And then one day she came in on Addison's. So it, they can actually go into Addison's like a year or two after starting my routine. Like it just all of the sudden happens. So it just emphasizes how important it is to keep monitoring closely. And [00:30:00] regardless of the stim tests, I think doing a senior panel every year at least is a great idea because these dogs are old and usually we need to be looking for other things anyway.
Dr. Sugerman: We gotta try to fix things early on, especially with our Cushing's dogs. Than wait until they're really sick.
Dr. Z: Yeah, yeah, absolutely. As always preventative is better. Yeah. Exactly. And I think I forgot to mention earlier as far as signalment, this is a disease of older dogs. Super rare in cats. We hardly ever see it in cats.
I was reading I think most Cushinoid cats are diabetic as well. Oh, wow. Which is 80 percent of them or something, but I've never seen it.
Dr. Sugerman: Yeah, I was like, I don't think I've ever seen it, but, I don't know.
Are there any breeds that are very that are usually very affected by this?
Dr. Z: Typically, the smaller ones are more common for the pituitary dependent one anyway, like Bichon's, Terrier's, Lassa's and Yorkie's and Little Westie's. I have that Chihuahua. And then I've had a couple of Dachshund patients that [00:31:00] are cushionoid as well.
They get a really big pot belly. Yeah. Yeah. Because of their long back. You can really see it.
Dr. Sugerman: And you mentioned you've had a lab, so definitely other...
Dr. Z: Other ones, too. Yeah. And those are... It seems like those are the ones to have more likely the adrenal tumors, but not always. Yeah, any bigger breeds, pit bulls, German shepherds.
Yeah, we've seen Cushing's in lots of breeds.
Dr. Sugerman: And then, is this like a really expensive disease to manage?
Dr. Z: Not really. I would say medium. The hard part is diagnosing it initially because you have to do all of those things step by step. And then initially monitoring a stim test every two to four weeks initially is important.
Stim tests are about a couple hundred dollars each time, depending on the size of the dog. Yeah. Again, the cortrosyn is the expensive part. Yeah. And you need more of it for the bigger dogs. But once you get through that, then it, again, it calms down and you just have to do it, twice to three or four times a year to have a checkup depending on how things are going.
Dr. Sugerman: And the Trilostane stay isn't very expensive.[00:32:00]
Dr. Z: I looked it up actually, to pick up Vetoryl here, it's $200 a month, for an average sized dog. But if it's a smaller dog, it's probably cheaper. And we can, most of the time we end up scripting it out because there's so many different doses that are needed for different sized dogs. And usually the little dogs need it compounded anyways, I encourage owners to shop around.
Sometimes it's cheaper elsewhere.
Dr. Sugerman: Using 1 800 PETMEDS and all sorts of other things. Yeah, Chewy or whatever.
And then does this decrease the lifespan at all?
Dr. Z: I'd say the prognosis is actually pretty good if we manage it well. We have to remember these are usually older patients though.
I think the median age was 11 or something. And they found, I looked it up, the median survival time with Trilostane or Mitotane treatment for Cushing's is two to two and a half years, which is pretty good for an old dog, right?
Dr. Sugerman: Exactly. Better than some congestive heart failure and other things that I've talked about.
Dr. Z: Yeah. Yeah. I think things that [00:33:00] would make the prognosis worse would be if there's lots of comorbidities, like they also have heart failure, they also have diabetes. Or they had a big tumor on the adrenal gland and it looks like it might've been a malignant one. Or they have the calcinosis cutis that is really always infected and painful.
I'd say that those guys have it worse. But generally, it's not that hard to treat once we figure it out and they do pretty well most of the time.
Dr. Sugerman: Yep. Great.
Thank you again, Dr. Z. Next week I'm going to be talking about porcupine quilling. But you and I are going to be talking about doing parasites. Yes. Next time we talk, right?
Dr. Z: Oh, my favorite.
Dr. Sugerman: Yes.
Dr. Z: Which kind of parasites do you want to talk about? There's so many parasites.
Dr. Sugerman: Which we do just ectoparasites, the ones that are on the outside, versus endoparasites, the ones on the inside. Or you can do ticks and fleas and then do another episode. Something else, whatever, whatever you desire.
Dr. Z: Okay. I'll have to think about it.
Dr. Sugerman: Thank you again so much for coming on and talking about Cushing's disease. I learned a lot about this. Because again, it's not something [00:34:00] I typically see. Yeah, we really appreciate it.
Dr. Z: I think it helps. Yeah, you're welcome. I, and I think it helps you to understand what's happening when you see a patient that comes in that has Cushing's, and wha t's up, and the drugs are, and, yeah, so that's good for everybody.
Dr. Sugerman: All right. Thanks again.
Dr. Z: Thank you.
Dr. Sugerman: Thank you, everybody. Always make sure to remember to keep your pets happy, safe, and healthy. Thanks.
Thank you guys for listening this week. If you have any questions, comments, suggestions, or you just want to say hi, you can email me at Suggs, S U G G S @ VetsplanationPodcast.com or visit the website at VetsplanationPodcast.com or find us on Facebook, Instagram, or TikTok at Vetsplanation. Thank you all for listening and I'll see you back here next week.