Signalment
- Age: 8 years
- Breed: IndianPariah
- Species: dog
Disease Notes
- Certainty: confirmed
- Final Status: better as of day 361 of treatment
Treatment and Outcome
- September 7 Chem Panel View
- Placid Blood Work April 26 View
- Extended History View
- July 8 Chem Panel View
- December 17 Chem Panel View
Problem Notes
- Chronic UTIs: Every year in spring
- Cushings Disease: ALKP has been climbing, recent ACTH test was 56
- Forelimb Lameness: LF foot has "dropped" toes-- loose flexor tendons, no pedal arch on middle two toes of paw. Painful for walking.
- Nocturnal Incontinence: Especially when UTI
- Weight Gain: Was always around 45#, gained to almost 70# over three years
Treatments
- Xiao Chai Hu Tang With Gui Zhi And Bai Shao
- Ge Xia Zhu Yu Tang
- Four Marvels Combination
- Bu Yang Huan Wu Tang
- XCHT Modified With Bai Shao And Gui Zhi
- Trilostane
- Modified Ge Xia Zhu Yu Tang
- Angelica and Peony Combination
- Bupleurum and Cyperus Combination
Notes: Blood work from 2/1/22 after 5 weeks on XCHT with Gui Zhi and Bai Shao
Diet is largely raw
Files:
- Recent Blood Work View
Notes:
Since starting the modified XCHT, dog has been far brighter, more playful and full of energy. She is continuing to slowly lose weight-- weighed in at 57# yesterday, down from a high of 68 last spring. But continue to be concerned about seeming recurrent UTIs. UA from that day showed significant RBC and WBC, some bacteria, despite almost 3 weeks on amoxycillin-- indeed, her incontinence got much worse when she started the antibiotic. Owners swear she does not drink a lot, but also tends to be a "marker" when urinating and they feel she never completely empties her bladder.
She had an abdominal ultrasound yesterday at referral hospital, report uploaded here. Thankfully, no surprises! Exam supported early pituitary dependent adrenal enlargement, and most other things pretty normal. No bladder thickening, so can rule out TCC as source of issues. Slight increase in liver parenchyma echogenicity-- etiology? RV wonders if some storage disease. Owner reports that she personally had significant heavy metal intoxication-- possibly from municipal water. Could the dog have gotten same? Is there any way to test without a biopsy?
As per Dr. Marsden, starting on Ge Xiao Zhu You Tang. Would like to treat with MBRT, but not if local vet will just put her on antibiotics over and over. Trying to initiate a conversation about that.
Diet is largely raw
Acupuncture points were stimulated
Files:
- Abdominal Ultrasound Report View
Notes: Bloodwork trend-- ALT down, almost at normal levels, but ALP continues to rise, now at 1045 (23-212). Clinically dog doing pretty well: "Last week Tuesday-Friday no leaking. Sat and Sun leaking.Alertness is good. Energy is stable. Weight down to 55 last week. Chasing squirrels. Skin is having more dark spots and a few pimple like spots. Foot is bothering her again. I think the snow acted as a soft buffer for her. Still drinks a lot after eating. Some loose stool days."
Diet is largely raw
Notes: Had begun SMS back in March, since ALP kept rising. Owner reported incontinence better (no incidents) for a week. Then back to mild leaking, only when lying down, not necessarily sleeping. One toe on hind leg has collapsed like the two on front leg. Owner is very concerned about this ligament degeneration getting worse and wants to start Trilostane. Otherwise Placid is doing very well clinically-- lots of energy, good appetite, is now down to 53# from a high of 68 last spring. She still has the "look" of a Cushings dog, with the abdomen larger than you would expect. Today, bloodwork came back after 4 weeks on SMS and ALP is up further, and now ALT up too (last time, it was back in reference range. Am attaching blood work. I was going to start her on 50 mg Vetoryl SID, which is the very bottom of the recommended range. Will put this question on the forum. At the previous visit on 4/17, pulse was so weak as to be barely palpable at all levels, did not change with needling points for Shao Yang, Damp Heat or Bai Hui-- for yang def. I tried both tonifying and sedating.
Acupuncture points were stimulated
Notes: Placid's ALP continues to rise and another toe has dropped on hind limb. Discussed case with Dr. Heilman extensively, leading to him suggesting a change in herbal strategy, and also client wants to start on Vetoryl because she fears more loss of collagen and more toes dropping.
Diet is largely raw
Notes:
After a week on new combo (mod XCHT twice daily, BYHWT in morning, SMS in evening). incontinence is much worst-- she is leaking all the time.
Recommended she add back GXZYT, and d/c SMS and BYHWT
Diet is largely raw
Notes:
Incontinence improved but not perfect back on GXZYT. Dr. Heilman suspected the BY and SMS were too cooling. Next strategy from Dr. Heilman: "It sounds like moving influences are successful, as you’ve pointed out here. Xiao Yao San, modified Xiao Chai Hu Tang, Ge Xia Zhu Yu Tang, etc. Si Miao San was not. And perhaps it’s merely the cortisol level alone that is driving the only sign of Heat in this dog; increased thirst and appetite.
I’ve had a few cases of really stubborn incontinence respond to Dang Gui Shao Yao San:
Angelica, Peony, Atractylodes, Poria, Alisma, Ligusticum. It’s a bit like Xiao Yao San, but it drains more Dampness, which I think that this dog is, due to the Cushing’s syndrome. Xiao Yao San contains Angelica and Peony, but Bupleurum, Mint, Licorice, Atractylodes and Poria. We might be surprised what the subtraction of the licorice and the addition of alisma might due for this incontinence.
If those rising liver enzymes need a stronger moving component, then the use of Chai Hu Shu Gan San can be considered. Bupleurum, licorice, tangerine peel, citrus peel, ligusticum, cypress, peony. This formula is commonly paired with other small Qi tonic formulas to address hepatitis (Liu Jun Zi Tang, Wei Ling Tang, Si Miao San, etc.)
Long Dan Xie Gan Tang is:
Gentian, Skullcap, Gardenia; bitter, cooling, draining, drying
Clematis, alisma, plantago: drain Dampness, cooling, and on balance, drying
Angelica, rehmannia; nourishing, temper the drying action of the formula
Licorice; harmonizing; detoxifying, tonifying Qi, moderating harsh tastes of top three herbs
Bupleurum; mover
It sounds like the sum total of the gentian, skullcap, gardenia, clematis and alisma will likely be too cooling for this girl.
But I write this out, to show that you’re nipping around the most appropriate formulas. If you got the sense that Xiao Yao San worked in the winter, but she fell apart in the spring, perhaps the transition to the Dang Gui Shao Yao San will be the right move. The Si Miao San was too bitter, it would seem. You likely need a strong moving influence in that middle of the belly, so keeping bupleurum in the Rx plan makes sense, but adding more citrus (tangerine, citrus peel) and more ligusticum, could help percolate through that congested liver."
So new plan is Dang Gui Shao Yao San and Chai Hu Shu Gan San.
She had an ACTH stim test and her local vet felt it was within acceptable limits.
Diet is largely raw
Notes:
Client reports urinary leaking is decreasing in frequency and quantity, which makes her very happy. However, she broke out in a rash all over her body. Not itchy, doesn't seem to bother her. I suggested it may be some kind of exteriorization, and as long as she does not seem bothered, keep an eye on it and see if it passes off. If itchy, she could try Benadryl. Local vet is happy with Trilostane levels.
I referred Holly to PT Whitney Mitchell, who measured her for supportive boots to help the feet with dropped toes.
Diet is largely raw