Question Details
Cushings Disease In A Dog
by fdzenitsky - June 26, 2022    View Case Report
Good morning!

Steve, i just posted this case and have questions on current therapy based on new blood tests. Can you link the case to my question here and LMK what you think? Is there a way for us to link cases to questions w/o putting it on you?

Thanks!
Franchesca
Replies
by naturevet
June 27, 2022
Hi Franchesca,

The weak pulse and mild elevations in the other liver enzymes together with the breed make me think she is Liver Blood deficient. I'd look at adding Dang Gui to Si Miao San and seeing if that improves the situation. That's probably the first thing I'd try

Steve
by fdzenitsky
December 10, 2022
Hiya Steve,

Case update on this sweet dog. I added DGS to the SMS (20:100) early July. She had a recheck w/ her primary vet at end of August, ALP was slightly higher, but ALT was in normal range. She was cleared for a dental and had that done in October. Her person reported that she had been doing very well until recently, now incr. hunger and mm atrophy, thinner coat, sometimes shaky legs. On my recheck last week, liver enzymes all high now: AST 175, ALT 1106, ALP 3292, GGT 75; CHOL, PSL, and platelets all more elevated too, high MO and another UTI. ACTH stim check: pre 6.5 (1-5), post 56.8 (8-17), yikes! T is lavender, fleshy w/ darker warm pink below; P is deep, toned to wiry. I want to check your opinion on adding XCHT, I am thinking this probably needed along w/ the SMS at this time. Do you think worsening with adding the DGS v her Blood deficiency suggests Dampness is a bigger component of the problem and that needs to be taken out of the SMS? Low dose trilostane time? Any other suggestions to rescue this little dog are greatly appreciated!

Thanks again, Franchesca
by naturevet
December 12, 2022
Hi Franchesca!

Yes, it's time to add Xiao Chai Hu Tang. It's not clear to me you've seen any benefits of SMS. You can discontinue it if you agree. For sure the Dang Gui does not appear to have helped

I think you mentioned this dog is fed raw. Dogs that benefit from XCHT also need probiotics (Lactobacillus and/or Bacteroides) added to their diets, which should consist of about 1/6 to 1/10 soluble fiber and fermentable carbs. All of those are lacking in raw diets, so they need to be included

Since the dog has pancreatitis as well, review the fat content of the raw to make sure it is not too high

After a couple of weeks on the XCHT and amended diet, recheck labs again, so you can observe the impact of the changes. Then add trilostane if no improvements are seen. Waiting on the trilostane make sure the case is a learning opportunity for you, which is just as important an objective as quickly getting the dog better

Hopefully you agree with all the above. Let me know if you have further questions

Steve
by fdzenitsky
December 13, 2022
Thanks Steve! Two questions...

Recommend modifying XCHT at all to better target the liver enzymes or perhaps w/ a bit of SWT (or both)?
Do you recommend standard or mega dosing of the herbs?
by naturevet
December 13, 2022
Hi Franchesca,

Both XCHT and SMS work best for acute liver inflammation, which does not respond well to Blood tonics. The latter are more useful once the acuteness has passed. So I'd just go with XCHT for now.

If the dog seems very ill, use larger oral or even rectal dosing. If, clinically, the dog doesn't look too bad, normal dosing should be fine

Steve
by fdzenitsky
March 2, 2023
Hi Steve!

Update on Edelweiss. I changed her to the XCHT in December, started lignans, melatonin, and Lactobacillus, and asked that the local vet recheck bloodwork after a few weeks, but that didn't happen until 2 months later. Her liver enzymes are remarkably changed from last check: all back to normal except ALP (338), which is down 90%. I can hardly wrap my head around normalized liver enzymes in 2 months! PSL, TRI and CHOL elevated as well as WBC (high pmns and MO) and platelets are really high at 845. Creatinine is really low at 0.3 and P and K elevated, Cl low; Na/K is 27 With her electrolyte imbalance, she appears to be more Addison’s than Cushing’s. The vet did not order a resting cortisol or ACTH stim. She has a UTI that wasn't addressed in December, and I wonder if she might have some free fluid in her abdomen since ALB is mildly decreased at 2.6.

The local vet did not do a PE, but did start antibiotics based on C/S. Her owner reports she's still very hungry and hasn't noticed anything bad (except for her thin, dry flakey abdominal skin) or her health deteriorating and she is now sleeping through the night most nights. So, w/o cortisol testing or putting my hands/eyes on her, I just don't know what to do for her, but do think I need to change things up before I get to see her again next month. Dampness, Damp Heat, Stasis, and Blood deficiency. Should I add something like YGJ or DGSYS and keep the XCHT for now? Other ideas on your mind, would love your feedback.

Thanks again!
Franchesca
by naturevet
March 5, 2023
Hi Franchesca!

Yes, I'd add Yi Guan Jian in next, to address the flaking, high appetite, and PSL. The high platelets supports there is still a Shao Yang component to things. Note that Addison's often responds well to XCHT, so it's one more reason to continue it. You can always add more Ginseng and Licourice, later, if the dog otherwise has comprehensively responded to the YGJ + XCHT

Continued good luck with this dog and thank you for letting us know how things turned out!

Steve
by fdzenitsky
April 13, 2023
Hey Steve,

Update on Edelweiss who I rechecked last week. She is still Cushing's after all! Serial 2 ACTH stim tests both elevated and very much so (8.4, 48.2). Since putting her on YGJ last month, PSL is down to almost normal, but ALT and ALP are creeping up again at 182 and 546, respectively (not as bad as last Dec. at 1106 & 3292, resp.), and CHOL is back up in the 500's. Platelets also high. She has another (or same) UTI that was treated w/ Abx in February based on c/s. Her abdomen skin is still dry and flakey even w/ YGJ and topical salve. Despite it all, she is a happy, settled little log and her owner has no new concerns. Her T is dark pink w/ lavender hue and P is deep, deficient, toned. My question is should I stay the course for now (YGJ and XCHT) or maybe change out the YJG for XYS v the liver enzymes? Is there any hope of getting her cortisol down or do we just try to keep her feeling as good as she can for as long as we can?

Thanks again!
Franchesca
by naturevet
April 13, 2023
Hi Franchesca,

Another option would be to add Long Dan Xie Gan Tang to the mix. If you use the NPHC version, you can avoid drying out the liver too much, and it may help decongest the liver in ways the XCHT is not. Meanwhile, it ostensibly opens the Triple Burner, so could augment the action of XCHT. Biomedically, it's the first thing I ever found that worked for Cushing's. I don't use it a lot these days, but this kind of case is the sort where I would add it in and give it a try

S
by fdzenitsky
April 17, 2023
Thanks for the quick reply! I recall you used to use LDXGT v Cushing's though I can't find where it's referenced. Do you mean to add this as a 3rd formula or replace the YGJ w/ it? I'm trying to understand it's mechanism of action in this case. From what I read on the formula, it seems to address a variety of acute Damp Heat symptoms, similar to SMS that pulls circulation from the periphery, which didn't do the trick for Edelweiss. The SYD approach using XCHT alone seemed to quiet her liver enzymes, but her pancreas seemed worse. Adding in YGJ has helped the pancreas a lot, but LE creeping up (could this be a seasonal influence?). So, YGJ not a complete wash. She is not responding as completely as I'd like and is that b/c I am not addressing all her root pattern diagnoses (Damp, deficient, Stasis, SYD). I wonder if other insulin sensitizing formulas may be more appropriate than LDXGT, like WLT, or is that too warming? Finally, I recall that non-responders may have genuine tumors, and need more of an anti-cancer approach. What formula have you used for that and at what point does Trilostane warrant consideration?

When giving this patient 2 formulas, I have had her at 1/2 tsp. of each BID and wonder if I should've changed the ratio and how is that decided? With the LDXGT, do you suggest equal parts w/ XCHT and BID? And to be sure, if keeping YGJ, use it like during the day w/ LDXGT at night? Apologies for my sophomore questions and confusion, this case is quite challenging me! BUT, the dog and her owner appear happy, so there's that. I guess. ;)

Thanks as always, Franchesca
by naturevet
April 21, 2023
Hi Franchesca,

These are good questions. If a drying, draining cooling approach didn't help and she doesn't have the typical Damp Heat presentation of Cushing's, then you're right. LDXGT may not help.

For non-responders, we are exploring using 2 parts Chai Hu Jia Long Gu Mu Li Tang to 1 part Yi Guan Jian (or Halscion) to see if we get some benefit. It helps with excess adrenal output, but also likely has an anti-pituitary-tumor effect. We are toying with trying modified Xue Fu Zhu Yu Tang for those animals that partly respond to the mix.

Using this approach will allow you to keep the benefits of YGJ, but with a little less tonification because of the 2:1 ratio. It builds on whatever success you've had with the XCHT with the liver, but adds in a pituitary tumor effect. Maybe that's the way to go here?

Steve
by fdzenitsky
June 22, 2023
Hey Steve!

I started this dog on the 2 parts CHJLGMLT to 1 part YGJ in early May and the rDVM rechecked her early June (so no T&P). Her ALP and PSL have doubled and ALT and AST are a bit more elevated, blood was very lipemic, still on a lower fat raw diet. CHOL and Platelets are elevated but down some. K and esp. P are elevated, I sure don't know what to make of that, that elevated P is more Addison's and Na/K ratio is low like Addison's at 25. She has gained weight she doesn't need to carry and developed a Gr 3/6 systolic heart murmur. Sooo, I have her back on the XCHT + YGJ for now, not sure where to go next. You mention above mod XFZYT for partially responsive patients but response was not good, although I do consider XFZYT for cardiac complaints. Any other thoughts for me to help this pup out?

Many thanks!
Franchesca
by naturevet
June 27, 2023
Hi Franchesca,

If the Na:K actually dropped below normal, then one thing we've been trying is Bu Zhong Yi Qi Tang. You could just add it in. The dog is obviously not purely Cushingoid, That formula (or even Liu Jun Zi Tang) can normalize steroid secretion so it is not so abundant, helping to mitigate the Cushing's. By helping the adrenals conserve cortisol, you can get on top of the low Na:K ratio

Maybe give that a try?

S
by fdzenitsky
June 28, 2023
Thanks Steve, no she certainly has a lot going on that I don't even have a name for!! Yes, Na/K has trended down, it is low for sure. I'm not clear though on what you would recommend layering. Is it 3 formulas? Keep the XCHT and YGJ and add it either BZYQT or LJZT at full dose? I'm wondering what you make of YGJ 1:1 w/ XCHT as I had her on before or a 2:1 ratio wouldn't help the liver and pancreas enzymes? What about adding some milk thistle?
Thanks again!
by naturevet
June 28, 2023
If you've seen benefits from YGJ and XCHT, then continue those at whatever ratios make sense to you. Generally 1:1 is balanced, but if the dog is very Blood or Yin deficient, then you can go two to one of YGJ to XCHT.

I would add a full dose of the new herb. If she is wildly better, then you may be able to reduce the amount you're giving of the other two

Does that make sense?
by fdzenitsky
September 13, 2023
Hey Steve, I rechecked Edel last month. I have her on the BZYQT along w/ the XCHT and YGJ as you suggested (full dosage of each). On exam, she is down to a better weight, thinner coat, very dry skin, has developed a systolic heart murmur, 2/6, a return of UR noise on inspiration, moderate dark waxy debris AU, mild epiphora OU. Voracious appetite, norm. thirst, sleeps more, seems content.

The good news is that the Na:K has normalized and PSL is down ~50%, also we knocked out the UTI (w/ Abx), for now. The bad is even higher ALP, CHOL, and platelets. Edel is ready for refills and IDK if I should be tweaking or changing any of the formulas. I don't think we're winning the war on Cushing's but maybe we've been conserving cortisol just a wee bit? Her owner is generally pleased but I do wish I could get on this better...! Do you have any suggestions for me besides stay the course for now?

Many thanks again for helping out in this continuing medi-saga!
Franchesca
by naturevet
September 19, 2023
Hi Franchesca,

There seems to be a Damp Heat component there causing Yin deficiency, despite the previous lack of success with SMS. Since the Na:K levels are normal again, maybe we can sub in something like Qing Ying Tang for the Bu Zhong Yi Qi Tang, to nourish Yin, clear Heat, further harmonize the Shao Yang, and remove some interior stasis

It's a tough case for sure, but hopefully that will help you out

Steve
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