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How to Treat Cushing’s Disease

How to Treat Cushing’s Disease

by Ronald Koh, DVM, MS, CVA, CCRP, CVCH, CVFT

Author: Chi Institute/Monday, August 31, 2015/Categories: Student Case Reports, TCVM Articles, 2015 Summer/Fall Issue

 Hyperadrenocorticism, or Cushing’s disease, is a condition where the adrenal glands produce excessive glucocorticoid hormones and results in clinical signs such as a increased thirst, increased urination, increased hunger, pendulous abdomen, enlarged liver, hair loss, lethargy, muscle weakness, obesity, increased panting, skin changes, and immunosuppression. Cushing's Disease can be subdivided into pituitary dependent (85% of all cases) and adrenal dependent (15% of all cases). Currently, two medications that are commonly used to treat pituitary dependent Cushing's disease are mitotane and trilostane. Both of these medications have their respective benefits and side effects. Side effects such as weakness, vomiting, anorexia, diarrhea, and ataxia occur in dogs receiving mitotane or trilostane. If not treated, Cushing’s disease is usually progressive in nature with a poor prognosis for quality.

Cushing’s disease can be treated and managed effectively by Traditional Chinese Veterinary Medicine (TCVM). A recent unpublished retrospective study done by me and Dr. Huisheng Xie revealed all 12 dogs in the study had moderate to marked improvement of clinical signs with no notable side effects following an average of 3 months of acupuncture and Chinese herbal medicine alone. 8 of 12 dogs with confirmed diagnosis had significant improvement in ACTH stimulation test results after an average of 12 months. Of the 8 dogs, 4 dogs had the results of basal serum cortisol concentration returned to the normal range in 8 months. We concluded that acupuncture and Chinese herbal medicine served as a safe and effective treatment for canine Cushing’s disease.

In TCVM, Cushing's disease correlates closely with Xiao-Ke in most instances. Xiao-Ke means thirsting and wasting disorder. Other disorders that also fall into this category include diabetes and hyperthyroidism. Cushing’s disease is particularly considered as Xia-Xiao pattern, which means Xiao-Ke in the Lower Burner (Xia Jiao) pattern. TCVM organs that are involved in Cushing’s disease include Kidney, Liver, and Spleen, with the Kidney as the root (Ben) of the disease. Thus the treatment principle is typically focused on managing the branch (Biao) and supporting/balancing the root, Kidney. The causes of Cushing’s disease include poor diet, obesity, lack of exercise, chronic drug therapy, stress and chronic diseases that have weaken the Triple Burner (San Jiao) resulting in Damp-Heat and Phlegm. Patients started to show signs of excess Heat, such as thirsty, increased appetite, irritability, and restlessness. If left untreated, the Heat can further damage Qi and scorch Yin, leading to deficiency of Qi and/or Yin. Signs of deficient Qi include weakness, fatigue, muscle atrophy, weight gain/loss, vomiting, diarrhea, pale tongue, and weak pulses. Signs of deficient Yin include polyuria, polydipsia, dry hair coat, small dandruff, insomnia, panting, red dry tongue, and thin fast pulses. The treatment strategy for Cushing’s disease is based on TCVM pattern diagnosis.

 

I. GENERAL TREATMENT STRATEGY

a)      Five common patterns: Qi deficiency with Phlegm, Liver Qi Stagnation, Yin deficiency, Qi-Yin deficiency, Yang Deficiency

  • Yin deficiency and Qi-Yin deficiency accounts for about 70-85% of all patients with Cushing’s disease

b)      General acupoints:

  • Nourish Kidney: BL-23, KID-3, KID-7
  • Support Spleen: BL-20, ST-36, SP-6
  • Soothe Liver: BL-18, LIV-13, LIV-3

c)      Modalities:

  • Dry needling for 20-30 minutes
  • Electroacupuncture, 20 Hz for 10 min, 80-120 Hz for 10 min
  • Aquapuncture with diluted vitamin B12 at BL-18, BL-20, BL-23, ST-36, LIV-13, KID-3, or acupoints based on patterns

d)     Acupuncture plan:

  • Once every 2-4 weeks for 3-6 sessions
  • Afterwards, 3-6 months intervals for maintenance

e)      Common Chinese herbal formulas

  • Yin deficiency: Mai Men Dong San (Ophiopogon Formulas
  • Qi-Yin deficiency: Xia Xiao Fang (Rehmannia 11)
  • 0.5 g per 10 lb (0.5 g per 4.5 kg), q8-12h for 3-6 months or longer

f)       Common clinical signs of Cushing’s disease and its indication on TCVM patterns

Signs

TCVM Patterns

Polydipsia (PD)

Kidney Qi and/or Yin def

Polyuria (PU)

Kidney Qi, Yin and/or Yang def

Polyphagia (PP)

Stomach Heat

Weight gain

Phlegm, Spleen Qi def

Muscle wasting

Spleen Qi or global Qi def

Weight loss

Spleen Qi def

Reduced activity

Spleen Qi or global Qi def

Excessive panting

Heat, Yin def

Hair loss

Heat, Qi/Yin /Blood def

Thin, dry, fragile skin

Lung Yin def

Recurrent skin infection

Damp-Heat, Wei Qi or Lung Qi def

Tissue calcification

Heat, Yin def, Blood stasis

Pot bellied

Spleen Qi def, Phlegm

Hyperpigmentation

Heat, Kidney Yin def, Blood stasis

Hypertension

Kidney Yin def with Yang floating

Urinary tract infection

Lower-jiao Damp-Heat, Wei Qi or Kidney Qi def

Increased liver enzymes

Liver Yin def

Hyperlipidemia

Phlegm

Vomiting

Stomach Yin def, Spleen Qi def, Phlegm

Diarrhea

Damp-Heat, Spleen Qi def 

 * def = deficiency

II. PATTERN DIFFERENTIATION & TREATMENT

1) Qi Deficiency with Phlegm

a)      Signs: early stage or all stages, overweight or obese, more PP, less PU/PD, diarrhea or constipation, lethargy, fatigue, excessive panting. Pale wet with thick coating tongue. Deep weak pulses.

b)      Treatment principles: strengthen Qi and transform Phlegm.

c)      Acupoints: general acupoints above; add LI-10, ST-40, BL-22 to strengthen Qi and clear Phlegm.

d)     Herbal formula: Fat Phlegm Formula; add Four Gentlemen for severe Qi deficiency.

 

2) Liver Qi Stagnation

e)      Signs: early stage or all stages, more PD, less PU/PP, irritability, depressed, nausea/vomiting, flatulence, intermittent diarrhea/constipation, red eyes. Red to purple with thin white coating tongue. Wiry and fast pulses.

f)       Treatment principles: regulate Liver Qi and clear Stagnation.

g)      Acupoints: general acupoints above; add LIV-3, GB-34, GB-41 to soothe Liver; add LI-4, GV-14, Er-jian, Wei-jian to clear Heat.

h)      Herbal formula: Chai Hu Shu Gan or Liver Happy; add Xiao Yao San for diarrhea or Xiao Chai Hu Tang for nausea/vomiting.

 

3) Yin Deficiency

a)      Signs: more PU and PD, less PP, general dryness, thin dry hair coat, alopecia, small dandruff, insomnia, excessive panting, warm body, cool seeking, restlessness, signs worse at night. Red dry with little to no coating tongue. Deep, weak and fast pulses, weaker on the left.

b)      Treatment principles: nourish Yin, generate fluids, and clear Heat

i)        Acupoints: general acupoints above; add KID-6, SP-9 to nourish Yin; add LI-4, GV-14, Er-jian to clear Heat.

c)      Herbal formula: Mai Men Dong Tang (Ophiopogon Formula) or Zhi Bai Di Huang (with severe deficient Heat); add Yi Guan Jian for elevated liver enzymes.

 

3) Qi and Yin Deficiency

a)      Signs: mid to late stages, more PD and PU, less PP, pendulous abdomen, hepatomegaly, thin fragile skin, calcinosis cutis, general weakness, muscle atrophy, trembling, may develop other complications. Pale to red tongue. Deep, weak, thin or thready pulses.

b)      Treatment principles: tonify Qi and nourish Yin

c)      Acupoints: general acupoints above; add BL-24, BL-26, Shen-shu, Bai-hui, CV-4, CV-6, LI-10 to tonify Qi; add KID-6, SP-9, SP-10 to nourish Yin.

d)     Herbal formula: Xia Xiao Fang (Rehmannia 11).

 

4) Yang Deficiency:

a)      Signs: terminal pattern, PD and PU with large amount of urine, decreased appetite, pendulous abdomen with emaciated body, poor hair coat, incontinence, lethargy, exercise intolerance, cool body, warm seeking, other concurrent diseases (diabetes, renal failure, heart failure). Pale wet and swollen tongue. Deep, weak and slow pulses.

b)      Treatment principles: warm Yang, tonify Qi, and nourish Yin-Blood

c)      Acupoints: general acupoints above; add GV-3, GV-4, Bai-hui, Shen-shu/peng/jiao, BL-24, CV-4, CV-6 to tonify Qi and warm Yang. Moxibustion at Bai-hui, GV-3/4, CV-4/6, BL-23/26.

d)     Herbal formula: Rehmannia 14 or Jin Gui Shen Qi Wan.

 

III. CASE EXAMPLE

Snowflake, a 10 year old, female spayed, Maltese was presented for TCVM evaluation for PDH Cushing’s disease that was diagnosed 6 months earlier with an ACTH stimulation test. She had a history of increased drinking, increased urinating and insomnia. Routine blood work revealed a persistently increased liver enzyme (ALP) and mildly elevated cholesterol. A grade 3/6 left systolic heart murmur was auscultated at that time with no associated clinical signs. The primary care veterinarian was treating her with trilostane. Snowflake had since been drinking and urinating less than previously observed. However, she was still restless at all times and had trouble resting at night, which had greatly affected the sleep quality of the dog and the caretakers. Her appetite seemed to have decreased. The caretaker was seeking TCVM to help improve her sleep quality and other signs, as well as be able to wean off the trilostane. On TCVM exam, Snowflake had normal Shen, thin hair coat with greasy skin, warm ears, feet and body. Her tongue was red and dry with cracks and her pulses were thin and fast (weaker on the left side). She was restless and panting during exam. The TCVM diagnoses were Qi and Yin deficiency with false Heat. Snowflake was treated with acupuncture once every 2 weeks, cooling diet, and daily Chinese herbal medicine with Zhi Bai Di Huang and Four Gentlemen for 2 months initially.  2 weeks later, Snowflake showed significant improvement. She had normal appetite and seemed to be calmer, panting less, and slept better at night. Herbal medicine was switched to Ophiopogon Formula and acupuncture session was then tapered to once a month. 4 months after the initiation of TCVM, Snowflake had normal appetite, water intake and urination. Her skin coat was normal and continued to sleep well at night. Trilostane was successfully weaned off over 2-month period without any signs of relapse of the disease. Snowflake continued receiving acupuncture every 3 months for maintenance, as well as daily herbal therapy based on pattern diagnosis.  

 

IV. SUMMARY

TCVM is a viable treatment option that is safe and effective for Cushing’s disease in dogs. It can be used in conjunction with conventional therapy to manage advanced or later stages of the disease and minimize the occurrence of side effects. It can also be used alone in patients that cannot tolerate medications, unresponsive to medications, early stage, or atypical Cushing’s disease. TCVM can help improve the quality of life of patients and exceed their life expectancy. TCVM patterns of Yin deficiency and Qi-Yin deficiency accounts for about 70-85 % of all Cushing’s disease cases. Treatment is typically focused on lifelong management of the disease. The most common Chinese herbal formulas for Cushing’s disease are Mai Men Dong Tang and Xia Xiao Fang (Rehmannia 11).  


 

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