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Cushings

by CarolineJ - May 18, 2026

Romeo is a 9 years old Pitt mix, intact male with a recent Cushings diagnosis. He has been raw fed most of his life, has a history of ACL injury and is hypothyroid).

In January (right before his diagnosis), here were his labs:
ALT was 176 U/L, AST 31 U/L , ALP 125 U/L, GGT 11 U/L and Platelets at 446 K/µL
Reticulocytes: 22K/µL and Hct: 48 %
Total T4 1.0 µg/dL
Free T4 0.5 µg/dL
cTSH 0.15 µg/dL

March 2026 ULTRASOUND FINDINGS:
Interpretation
1. Bilateral adrenomegaly. A hypoechoic nodule is present in the caudal pole of the left adrenal gland.
2. Prostatomegaly with multiple cystic structures.
3. Moderate gallbladder debris.

Since there is bilateral adrenomegaly (similar dimensions), Pituitary Dependent HAC is more likely.

Recent labs in April :
Hematocrit 41.9 %
Reticulocytes 19 K/µL
ALT 167U/L
AST 45U/L
ALP 75U/L
GGT 7 U/L
Cholesterol 369 mg/dL up from 258 mg/dL
and Platelets down to 372 K/µL

Total T4 1.2 µg/dL
Free T4 2.1 µg/dL
cTSH 0.12 µg/dL

He was on Trilostane 30mg up to recently, but the owner decided to reduce it to 15mg since he is experiencing the following symptoms: muscle tremors, incontinence, testicles reduced in size (he’s an intact male), lower energy levels. I mentioned to the owner that being on Si Miao San and Trilostane may lead to us reducing his Trilostane, so I’m thinking that’s what we are bumping into with the above symptoms. Thought?

I would say his labs are improving, just looking at ALP value, thyroid function, platelets and ALT dropping a little.

Current supplements: Si Miao San (since February), Cessorex, Omega-3s, Muscle powder supplement, CBD, probiotics with enzymes.

Concerns on PE:
Keeps loosing hair, especially around the ears and along the pinnae
Dry pads, coat, nose is getting dry, large dry flakes over skin
Very atrophied muscles over body and especially temporal muscles
His water intake is now normal (since we started the Si Miao San a few of months ago)
He’s not restless, agitated or panting at home

I used to have him on Bu Gan Tang for a couple of months, but it didn’t yield much as far as the hair growth. Maybe we weren’t patient enough (he was on it for 8 weeks).
I view him as blood deficient (Bloowork now confirming it with low reticulocyte count and Ht %). I added the Cessorex because I watched once of your Liver webinars and Cessorex came up for Liver Blood Deficiency. I don't know about the effectiveness of combining Cessorex with Si Miao San though (are we draining our blood tonics with this combo?)

Another thought to treat the Liver Blood Deficiency is Xiao Yao San?

Your insight is appreciated !!

Thanks again
Caroline

by naturevet

May 23, 2026

Hi there,

Given he is raw-fed, the chances of him having Damp Heat are low, so Si Miao San is probably overkill at this point, especially when his labs were never really that bad. If the BGT didn't aggravate him, then he definitely isn't a Damp dog. The BGT might work better for these Blood deficiency symptoms if SMS is discontinued, or at least cut dramatically.

I would also cut the trilostane dose dramatically, or discontinue it altogether. The shrinking testicles, incontinence and fatigue indicated the drug is damaging Kidney Qi (and Yin/Essence, given the dryness). A deeper acting Kidney tonic like You Gui Wan may work better than BGT.

In trilostane overtreatment, I usually find myself using something Ginseng-based to rescue the animal. Boosting adrenal function overall should restore sex steroid production and allow the testicles to recover. To cover the simultaneous Qi and Blood deficiency while boosting the adrenals, you could use Gui Pi Tang instead of YGW and BGT.

In summary:
- slash the SMS dose or discontinue it
- add your choice of BGT, GPT or YGW. All are compatible if you want to hedge your bets
- discontinue trilostane. If you feel you have to use either trilostane or SMS still, then use a low dose of SMS
That should get things started again for you. I feel like maybe they misdiagnosed him during that work up, as ALP was never really that bad, and bilateral adrenal enlargements are seen even in diet-mediated cortisol increases.

Hopefully, this helps you out :-)

Steve

by CarolineJ

July 8, 2026

Hi Dr Steve, here is our latest update on Romeo:

We decreased the SMS and cut the Trilostane dose in half a few weeks ago. His ACTH stim test was normal a few weeks ago even with a half dose of Trilostane..The increased drinking started back up shortly afterwards though.

He's had a UTI a couple weeks ago that was treated for 5 days and addressing the UTI helped the incontinence, energy and increased drinking. The symptoms reoccured last week and another UTI was found. They probably didn't treat long enough the first time. They are also culturing it.

I added Bu Zhong Yi Qi Tang to his treatment plan today, asked the owner to stop the Si Miao San and continue with Gui Pi Tang and You Gui Wan.

I'm wondering how long we should keep him on the Gui Pi Tang, BZYQT and YGW before reassessing?

What are your thoughts on adding Xiao Chai Hu Tang? I read that you recommend adding Voltrex sometimes when it's clear that it's not a Damp Heat related issue and more of a Shao Yang Disharmony.

He is still very dry, his pulse is toned and deep.

Thank you for your help !

by naturevet

July 15, 2026

Hi there, a response to antibiotics implies Heat of some type, especially if their bitterness and coldness reduced the thirst.

The options, then, are Empty Heat (due to Yin deficiency), Excess Heat (which SMS should have resolved), and compartmentalized Heat, such as you might see in Shao Yang disharmony and Jue Yin excess. The latter problem is seen more in mid-winter, so we are really left with two options.

Minor Bupleurum is quite drying, so you wouldn't want to use it all by itself in Yin deficiency. You can use it with something like Yi Guan Jian to harmonize the Shao Yang while keeping the Stomach moist (thus preventing extreme thirst). XCHT can address Cushing's non-responsive to real food diets, so it's not a bad call. And it can help relieve UTIs, especially when used with BZYQT.

Otherwise, we could be looking at Yin deficiency causing cystitis. That is treated with Zhi Bai Di Huang Wan. It may not address Cushing's, but we don't know that this dog actually has it.

What about the pulse? It fits a Shao Yang condition. It doesn't as much fit Empty Heat.

Is there a way to merge the two approaches? If you tried Qing Ying Tang, you'd have a Shao Yang formula that nourishes Yin and clears Heat. It fits the pulse (and even severe Cushing's causing calcinosis cutis). It's not a huge cystitis formula, but that doesn't mean it can't help.

So, those are three approaches to consider. Hopefully, one of them helps stabilize your patient!

Steve

by CarolineJ

July 21, 2026

Thanks for your feedback on this. Romeo is currently on Gui Pi Tang (6 weeks) , You Gui Wan (3 weeks) and Galvanex (1 week). I stopped the Si Miao San about 2 weeks ago for him. He is on 5 mg of Trilostane am and pm.

The latest update on Romeo is a resistant E.Coli that was causing the incontinence, but the BZYQT seemed to address that behaviour. He still received a Convenia shot to clear out the infection..

We actually just got recent bloodwork results for Romeo.
Hematocrit 46% %
Reticulocytes 8.4 K/µL down from 13.2
ALT 391 up from 167U/L
ALP 391 up from 75U/L
GGT 25 up from 7 U/L
Cholesterol 329 mg/dL up from 226 mg/dL
and Platelets 408 K/µL Plateletcrit is 0.5%

His Cortisol pre-ACTH was 5.6 and post-ACTH is 8.9
(pre and post should be between 1.5-6)
The internist wants to keep increasing his Vetoryl dose to 30mg a day.

I do see that this latest bloodwork is a bit more consistent with Cushings, but I'm getting the feeling the Vetoryl isn't agreeing with him.

I like the idea of adding the Immunobalm, but what do you think about the current herbs he is on? I do think there is a Shao Yang component to this dog.

The owner is opened to stopping the Vetoryl and going 100% with herbal medicine. I'm wondering if the Si Miao San was helping the ALP levels and keeping ALT in check?

Thank you for your guidance.

by naturevet

July 26, 2026

I guess my temptation would be to remove the tonics and go back to just SMS.

If he needs tonifying, you can add in ZBDHW safely, without impacting the liver numbers.

Or, ImmunoBalm is compatible with QYT as well.

I'm wondering if he is getting too tonified by the GPT, YGW and BZYQT

Personally, I try to avoid Vetoryl, especially if symptoms are minimal.

If a real food diet is not in use, the only hope of a cure for Cushing's is if it is introduced

Hopefully, this helps!

Steve

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