Mypuppy:Princess (10 yr. old Lab on Trilostane) - has crossed the rainbow bridge

[mypuppy]

My almost 7 year old Lab was just diagnosed with Cushings, and I am simply devastated and rather confused at the mixed information received from my veterinarian and an internal medicine vet. One says not to treat with trilostane because it could be fatal, the other says treat? Seems like a catch 22. Where do I go from here? Has anyone on this forum ever used holistic treatment for their dog with Cushings and was it effective? What will happen if I don't treat my dog? Her only symptoms right now are excessive thirst and urination and increased appetite. Will she develop the other symptoms, hair loss, etc. in time if she goes untreated? Please help. Would like to do the right thing for my pup, and give her a happy comfort zone while dealing with this disease.

[maggiebeagle]

I know you are overwhelmed right now, we all were when we first came here.
You will have replies from many members who have successfully treated their dogs with trilostane or lysodren. I believe a few members have used chinese herbs. I don't think anyone has had much success with the preparations sold over the internet.
You may have been told that the life expectancy after a diagnosis of Cushing's is only two years. Most dogs are over 10 when diagnosed and are dying at or near their normal life expectancy. Maggie was diagnosed three years ago and is about 13 now.
I'm sure someone else will be along soon to answer more of you questions. I just wanted to assure you that you aren't alone.
Virginia and Maggie

[haf549]

I know you must be over-whelmed with the news that your pup has Cushings, but please be assured that it is a completely treatable disease. Though both medications (lysodren and trilostane) seem scary right now, it proper procedures are followed, they can help your dog immensely. Others will pipe in here soon asking what tests were done to confirm cushings and asking you to post any results that you get. You will also get input on the 2 main drugs. My dog is on trilostane and has been stable on the drug now for 9 months. She is doing very well and is almost her old self again. I say almost, because, well, she is 12 and that's not young for a Siberian Husky. She's got arthritis and that can give her grief. But the basic result of using the trilostane is that she is much better. She just had a 6 month stim test and her numbers for that are normal (for a cush pup). I was talking to the vet yesterday and she said that often they won't treat the dog if they are not showing any symptoms. But, your's definitely has the clinical symtoms, so you are probably at the point where you will need to treat. From all I've read here, methods other than the Lysodren and Trilostane really don't seem to help. Your decision at this point will be which med.

Hang in there; there's lots of help out here.

Heidi & Kira

[Harley PoMMom]

Hi and Welcome,

We are so friendly around here, and just starting out my post with "Hi...." :( so, what's your name, if you don't mind sharing it and what's your pups name. That's just the first few questions :eek::eek:

We tend to ask alot of questions around here so we can get to know your pup better, that way we can help you help your pup, ok. :)

Cushings Disease is a very difficult disease to diagnose, it usually can not be dx'd with just one test, luckily it is a slow progressing disease which gives one time to make sure they get a proper diagnosis for their pup. A proper diagnosis is vital for a proper treatment plan.

What tests were done on your pup (Chemistry panel, CBC) could you post any abnormal results here? Could you post the results of any Cushings tests done here (LDDS test, ACTH, HDDS test) with the units. Does your pup display any other symptoms other than the ones you mentioned? How much does your pup weigh? Is your pup on any other medications or supplements? Does your pup have any other health issues? I'm sorry for all the questions, but like I mentioned, the more we know, the more we can help.

These people here are amazing, they are very knowledgeable about Cushings disease and have years of Cushings experience under their belts.

Hang in there, you are not alone, we are here for you.

Hugs.
Lori

[Squirt's Mom]

Hi and welcome to you and your puppy! :)

Do you and your baby have names we could use? "Hey you, with the puppy!" can get really confusing around here! ;):p

Devastated and confused, huh? Yup, you're right where you are supposed to be for now. When I got the diagnosis for my Squirt, I fell to pieces :eek: :( ...started crying in the exam room, squeezing her til she could hardly breath, fighting a panic attack, just absolutely terrified and heart-broken. What I heard was, "Your dog is dying..." Thank all that is good, that is just not what Cushing's means - it is not the final notice!

But I didn't understand that until I got here and these kind, wonderful folks took me in and started my education...the most valuable thing a cush parent can have - knowledge. And I was a real mess when I got here! I, too, had been reading and talking for a while and was so confused...nothing I read made any sense, my poor old brain got things mixed up badly, and all I could understand was that my Sweet Bebe had this awful disease. I felt overwhelmed, helpless, hopeless, frustrated, guilty, angry, and yes, completely devastated.

As time has gone by, I have learned more and more about Cushing's and it's treatments and I feel much more confident and calm about the whole thing. (Notice, I didn't claim to be saner! :p ) The best thing you can do for your baby is educate yourself on Cushing's. The more you know the better off you both will be. You are your baby's first and last defense, their only voice, their advocate and knowledge will make you stronger in these roles. Please read the thread here, our Helpful Resource section and ask any questions you may have. We will do our best to help you understand.

We do play 20 Questions with new folks so we can get a better idea of the whole picture and be able to offer more meaningful input. So, here we go - How much does your baby weigh? Are there any other health issues you are aware of? Are they on any meds, supplements, herbs at the moment and if so what? What prompted you to have the Cushing's testing done in the first place? Do you have copies of those tests that confirmed the diagnosis and would you mind posting the results along with the units of measurement (ug/dl, mnol/L, etc) and the normal ranges for that lab? What tests were done to arrive at the diagnosis? Has an abdominal ultrasound been done?

Now, to your questions -
"Where do I go from here?" You have made the best next step you could have by coming here to us. For right now, try to relax a bit...then listen, read, ask, listen, read, ask and repeat. ;) Thankfully, Cushing's is slow progressing condition and based on the few signs you have listed, you have plenty of time to learn a bit to help you make an informed decision as to how to proceed. Some things you can start doing that will of great help to you on down the road is to get copies of all your babies testing from now on, not the bill but the actual result sheets. Also keeping a diary of your babies behaviors - eating and drinking, pee and poop history, sleep patterns, any changes you notice, moods, etc. This way you don't have to try to remember when they pooped that weird purple stringy thing last month! :eek::p A few things that need to addressed early on in the diagnostic phase are the ruling out of mimicking conditions like hypothyroidism and diabetes to name a couple. This can be done with the chem panel (blood work) so if you have those results, it would help to see them as well. And most important of all...start learning all you can!

Has anyone on this forum ever used holistic treatment for their dog with Cushings and was it effective? The term "Holistic" means a method of approach that looks at the whole dog; it does not mean no pharmaceuticals are used tho that is the common thought associated with Holistic treatment. Most of our members use either Lysodren (Mitotane) or Trilostane (Vetoryl) for conventional Cushing's treatment. Some of us treat another form called Atypical which is treated with melatonin and flax lignans, which could be considered a "natural" treatment. Several of us also used supplement and herbs to help our babies deal with the effects of Cushing's. If you are asking about TCM (Tradition Chinese Medicine) treatments, we have very few here to use that approach tho a few do include some Chinese herbs. If you are asking about things like Cushex, Supraglan and such that you find touted on the web - they are bunk and actually scary to me.

What will happen if I don't treat my dog? Here is a link that will answer this for you:

This one is about a few of the abnormal results that untreated Cushing's dogs may have:
http://www.veterinarypartner.com/Con...&S=0&C=0&A=628

Will she develop the other symptoms, hair loss, etc. in time if she goes untreated? Yes, more than likely.

Ok, now it's your turn...you must take care of yourself. It is so hard, especially at first, to relax, boy do I know that! :D But pulling your hair out, screaming at the computer, crying into the pillow, cussing your mate, and so forth don't help...trust me! :o So take a deep breath, lay your head back for minute and tell yourself that you and your baby are in good hands now. You kiss that big, ole blocky head and tell your puppy that ya'll now have a whole bunch of folks on your side who will help you both get through this. You don't have to take one more step alone, we will walk with you every step of the way.

I am so glad you found us and look forward to learning more as time goes by!

Keep your chin up!
Hugs,
Leslie and the girls

K9C Resource section:
http://www.k9cushings.com/forum/forumdisplay.php?f=10

[acushdogsmom]

My almost 7 year old Lab was just diagnosed with Cushings, and I am simply devastated and rather confused at the mixed information received from my veterinarian and an internal medicine vet. One says not to treat with trilostane because it could be fatal, the other says treat?Just curious - which Vet is saying what? I would make a guess and say that the Internal Medicine Specialist is the one who wants to treat?


Where do I go from here? Has anyone on this forum ever used holistic treatment for their dog with Cushings and was it effective? What will happen if I don't treat my dog? Her only symptoms right now are excessive thirst and urination and increased appetite. Will she develop the other symptoms, hair loss, etc. in time if she goes untreated? Please help. Would like to do the right thing for my pup, and give her a happy comfort zone while dealing with this disease.Left untreated, the dog usually develops internal organ damage due to high cortisol production, in addition to all of the symptoms that you can actually see. It's the organ damage that is very important to try to prevent by treating with a proven to be effective cortisol-lowering drug, such as Trilostane or Lysodren. We have folks here treating for years with one drug or the other, and whose dogs are doing really well. The so-called natural treatments (for Canine Cushing's) don't work, in my opinion. Cushing's is a serious disease that needs to be treated with serious proven medications, such as Trilostane (Vetoryl) or Lysodren (mitotane)

Here's a link to where you can read about some of the medical complications associated with untreated Cushings Disease:

http://www.k9cushings.com/forum/showthread.php?t=195

If your dog has been definitively diagnosed with Cushing's, then what you need to do is probably to have faith in the Vet who believes that treatment with trilostane is a good thing. And partner with that Vet to be a team who is dedicated to getting your dog well again.

My dog was treated with Lysodren by a Specialist and he did wonderfully well for more than 6 years. I'm sure you'll be hearing from our members who are treating with trilostane and who have found it to be a very good choice for their dogs.

[littleone1]

Hi and welcome,

Back in January my Boston Terrier, Corky, was diagnosed with Cushings. I had never heard of it before. My vet recommended not treating it. I got a second opinion, and that vet recommended treating the Cushings. I was also in contact with a vet in CA, who gave me valuable information in the past. She also said to treat it. If it is left untreated, it could affect the organs, and cause a lower quality of life for our babies, along with congestive heart failure. For some reason, Corky's clinical signs started to disappear, and his tests came back in the normal range. His signs were then in remission for 7 months, and started to reappear. Corky was recently rediagnosed with Cushings. He has a right adrenal tumor. He has taken his 7th dose of Trilo this morning, and seems to be doing well. I know, it really did a number on me, but this group has been very supportive, and has so much valuable information to help make this journey a little easier to cope with. There are also so many links on this site that will give you information that is really needed by us.

I wish you the best in making your decision.

Terri and Corky

[forscooter]

Hi,

I wanted to add my welcome and tell you I had two dogs with Cushing's. I lost one last Christmas and still have my other. We used Lysodren to treat but I have been around long enough to assure you that either medication can be a true lifesaver. I am also curious as to which vet doesn't want to treat it?

At 7, your pup still could have many more years. The 2 year rule, although I question its validity, is if we take it as fact, an average. That means there are dogs who live less time and dogs who live much much more. I have witnessed many dogs who have been on the end of much much more. So, there is no reason not to have faith in treating in my opinion. Many people are amazed how much better their dogs are on treatment.

That being said, I do have another question....and that is, does your pup have any other illness or condition(s) that would cause your vet to recommend not treating? If there is/are, depending on what they are, then I would suggest having that be a consideration. But barring that, I can tell you that treatment can give you your "old" dog back....one that is healthier and happier.

We all understand how overwhelming and scary this time is for you....we still feel that way sometimes ourselves. But this is a disease that can be managed and we walk each step at one time together. You will have a lot of support here. You read and learn as you can, and before you know it, you will be feeling much more confident!

Many hugs, Beth, Bailey and always Scooter

[jrepac]

7 yrs old is too young not to treat...unless other complications are present? It is odd for a vet to describe treatment as "fatal", particularly w/trilostane. Trilostane and Lysodren do have associated risks, that you need to be aware of. Trilostane was approved in the US earlier this year and many have used it w/success; some feel it is LESS risky than lysodren, but his may be debateable. Other, less popular/less effective drugs are anipryl (selegiliene) and ketoconozole; a few of us have used/use those too. Various herbs and supplements can help with symptoms of the disease. Many (most?) here are using something else in addition to an Rx treatment.

I would get the diagnosis fully confirmed first; perhaps get a full adrenal panel from University of Tenessee and go from there. Others may have mentioned, but you want to make sure what form of Cushings you are dealing with, e.g., Pituitary or Adrenal (non-pituitary), which would drive treatments. Plus, atypical cushings could be in the mix as well, so the UTK full adrenal panel is a good one to have, if you have not done an ACTH test yet.

No need to rush; take time and look into treatment options.

Good Luck

Jeff

[Roxee's Dad]

Hi,
I also wanted to welcome you and your puppy. You have already received so much good information and have been asked a lot of good questions. I just wanted to add my little story of what can happen to an untreated pup, which is why I am glad you found us.

I was one that did not find this forum back in 2006 when my girl was first dx’d. I was afraid of the treatment my vet offered and chose not to treat my baby girl. Besides all the damage done internally that you cannot readily see, I witnessed my healthy girl physically and mentally deteriorate. She lost the strength to use steps, so I built a ramp, eventually did not have the strength to climb the ramp. So I would carry her outside. When I tossed her favorite ball, she would try so hard to go after it but just couldn’t without falling on her face. She didn’t understand why she couldn’t fetch her favorite ball anymore. I watched my little athlete that loved to run, do backflips and swim get to the point that I had to hold her to stand up and do her business. My point really is that if I had found this forum of well experienced members, I would have been encouraged to treat knowing I had access to so much help, experience and resources.

I can only urge you to get a thorough and proper diagnosis. Read as much as you can, do not be afraid to ask any questions or raise any concerns you might have.

BTW - Love to know Puppy's name and we do like pictures of our pups :):):)

[StarDeb55]

I would also like to welcome you! You have already been given good information, so I will not repeat it. What I will tell you is that my 1st Cushpup, Barkley, was successfully treated with lysodren for almost 8 years, crossing the bridge at 15. Your pup is not too old to treat, & with treatment can live a happy, healthy life reaching his expected lifespan.

Debbie

[mypuppy]

Lori, first hand, thank you for such reassurance that there is some hope for my pup, Princess by the way. And my name is Jeanette. Princess is a chocolate lab, and she has simply been a wonderful, most well-behaved dog since we brought her home at 3 months old. I am a stay at home mom and while I send of the kids and hubby off to school and work, my four legged baby and I have kept each other company for almost 7 years now, and it's the best feeling in the world to have that companionship day in and day out, through daily chores, etc. She is my shadow. This is why the abrupt diagnosis just broke my heart thinking, this is the end for her. I have been doing nothing but breaking down in tears and visualizing my life without her--it's unbearable! I'm usually not one to be so pessimistic, but with the information or mis-information I have received, I can't but help myself feeling this down in the dumps...After joining this forum, I'm happy to say I'm starting to feel a bit different.

Now getting to your some of your questions. We first started with a CBC and urinalysis: These were the out of range results:
ALT (SGPT) - 225 (high)
AMYLASE - 388 (low)
T4 - 0.5 (low)
HGB - 18.6 (high)
NEUTROPHIL SEG - 80 (high)
LYMPHOCYTES - 10 (low)
EOSINOPHIL - 0 (low)
ABSOLUTE LYMPHOCYTE - 830 (low)
ABSOLUTE EOSINOPHIL - 0 - (low)
UA - 1.0045G prior to water deprivation test
UA - concentrated to 1.035 after water deprivation test.

Her regular vet performed water deprivation test to rule out DI (diabetes insipidus). He basically left the finaly diagnosis as psychogenic polydipsia (behavioral???). He never even suggested further testing for Cushings or even hypothyroidism and basically concluded his final diagnosis as psychogenic polydipsia (behavioral??) I asked him for copies of all medical records and labs and referred myself to an internal medicine vet at a veterinary hospital an hour away from home. I scheduled her in immediately, gave the specialist copies of all her tests, she performed an abdominal ultrasound to view her adrenals, kidneys, spleen, etc, and the ultrasound came back normal. At that point the specialist recommended to have her tested for Cushing's/Addison's with the ACTH stimulation test, which came back positive for pituitary Cushings. She also had a Free T-4 to rule out hypothyroidism, but still awaiting results on that test. Her symptoms are excessive thirst, urination, panting, excessive appetite, looking for cool place to lay. She is not on any meds or supplements at the present time and is not suffering from any other illness as far as I know...This is where we are at this point. I am scheduled to follow up on Monday with the specialist regarding treatment with trilostane, but I have a million questions before committing. Again, thank you and everyone on this forum for reaching out to me so kindly...It means the world to know there are so many of you out there willing to share your experiences, knowledge with others. I truly appreciate everyone's generosity here. Will update tomorrow after talk with specialist....

[acushdogsmom]

Jeanette - I just want to say that I am sooo glad that you found us!

Cushing's is not a death sentence! Really, it isn't. I may have already said this, but you need to know that my dog lived for more than 6 years in the care of a Specialist after being diagnosed with Cushing's. And once we got the treatment well underway, all of his symptoms disappeared and he seemed to get younger right before our very eyes. :) He was a Bichon Frise and he died suddenly (nothing to do with the Cushing's) when he was 16+ yrs old.

Our Internal Med Specialist once told me that if she had to choose a disease for her own dog to have, she'd choose Cushing's, because it really is treatable and the dog can live out a perfectly normal lifespan for the breed with proper treatment and monitoring.

Again, I'm gonna guess that it's the Specialist who thinks that you should treat Princess (and the GP Vet who wasn't exactly optimistic) - and if that's the case, I think you've already got a great start, getting Princess into the care of the Specialist. Since the Specialist is an hour away, maybe she can refer you to a regular GP Vet near where you live with whom she works well - someone who will have confidence in her treatment plan for Princess and who can be available to you if you ever need a Vet close to where you live.

[mypuppy]

Dear Leslie and the girls, I'm Jeanette and mypuppy is Princess. Thank you for all the information you provided, but most importantly, the comforting words which have just encouraged me to face this battle with a whole new different and positive outlook and realizing it is not as final as I visualized due to the lack of info. and due to the lack of support from regular vet who discouraged me from seeking treatment. The internal medicine specialist suggested treatment with trilostane. Princess is weighing about 70 lbs righ now. A 15 lb. drop from a year ago. Waiting on Free T4 results to r/o hypothyroidism. She is not currently on any meds or supplements. The internal medicine specialist prompted testing for Cushings. Had it not been for my gutt feeling to further evaluate, I may have never known about Cushings and may have just accepted the regular vet's final diagnosis of psychogenic polydipsia. Still can't believe we may have total missed it. I did post the initial test results on a previous thread to another post. I hope you can look through and read it and give me your thoughts. I am awaiting copies of the ACTH results which confirmed Cushings. Will post soonest I receive from vet. In the meantime, a world of thanks once again for your kind support. thank you.

[StarDeb55]

Jeanette, with the information you have posted today showing us Princess' results, some red flags have been raised for me. First of all, weight loss is not common with cushpup, just the opposite is the normal, weight gain due to the pup's voracious appetite. Weight loss is more common with diabetes mellitus, (regular diabetes), was diabetes ruled out?

Next, the general lab results show only a single abnormal liver function which is the SGPT. Most cushpups have multiple liver function tests that are elevated including the alk phos, ALT, AST, & cholesterol. In fact, an elevated alk phos is usually one of the primary things that will tip a vet off to look for Cushing's. Just to let you know, I'm a medical lab tech with 29+ years experience, so I'm very used to looking at these kinds of results. If you have only done an ACTH, along with the normal abdominal ultrasound, this concerns me, also. It is possible that a Cushpup's adrenal glands may be normal on an ultrasound, but more commonly the glands are either bilaterally enlarged, one gland may be enlarged with the other one of normal size or possible shrunken. Also, an ACTH does not differentiate between pituitary or adrenal forms of the disease, the ultrasound should have done this. Differentiating the types can be very important because surgery for an adrenal tumor may offer a permanent cure, & with Princess' age, if I were in your shoes, I would jump at surgery in a minute, if my pup were a good candidate. Also, trilostane is not the ideal drug to treat an adrenal tumor.

I'm not a vet, but after having had 2 pups with Cushing's, along with everything I have learned from the other members of this forum, I'm just concerned about Princess' diagnosis being accurate. These are just my thoughts & I hope they help you to formulate some questions for your treating vet. Cushing's is a slowly progressing disease, so you have plenty of time to make 100% sure you have an accurate diagnosis before you begin treatment. The accuracy of the diagnosis is critical as administering either trilostane or lysodren to a non-cushpup can make them seriously ill, & in the extreme, possibly life-threatening.

Debbie

[Harley PoMMom]

Hi Jeanette and Princess, :)

I know exactly how you felt when you heard those words " Your pup has cushings." I was terrified, in shock, crying my eyes out, didn't know what to do and then it hit me and I thought what the heck is cushings? :eek::confused:

Thank God I found this forum, Jeanette, these people on this forum are so knowledgeable about this cushings disease, they helped my boy Harley and me tremendously and I know they will do the same for you.

One thing I am doing is reading all I can about this dratted disease, we have a wonderful Resource Thread Section where you can get alot of information.

http://www.k9cushings.com/forum/forumdisplay.php?s=&daysprune=&f=10


She also had a Free T-4 to rule out hypothyroidism That's a good thing to do.


Her symptoms are excessive thirst, urination, panting, excessive appetite, looking for cool place to lay. These are symptoms of cushings but with a low T4 one just doesn't know, non-adrenal illnesses can skew ACTH and LDDS tests.

Cushings can not be diagnosed with just one test and a ACTH test can't tell if it is pituitary or adrenal cushings. When my Harley was first showing signs in Feb. 2009...well since then he's had a LDDS test, 2 ultrasounds, 2 endogenous tests, UTK full adrenal panel, 2 CBC and 2 Chemistry blood work panels, ACTH stim test, and he has pretty much all the symptoms of a cush pup. Did I go overboard with the testing...no I don't think so, I wanted to make absolutely, positively, without a shadow of a doubt that my boy was diagnosed properly.

Harley has an IMS that is 2 hours away, so we only see her for his ultrasounds which are every 6 months, Harley's regular GP confers with the IMS and with Dr. Oliver, whose specialty area is endocrinology. It is very important to find a GP and/or IMS that you can be a team player with, someone that you feel confident in and it would be exceptional if you could find someone that is cushings savy. But alas...the best of luck with that. That is why we read and learn as much as we can.

So if there are any questions you have, ask away and we will try to answer them for you, just remember you are not alone on this journey we are here for you and Princess.

Hugs.
Lori

[mypuppy]

Dear Debbie, Wow! Thanks for all your concerns. Of course, it just plants a seed in my mind to question whether Princess was diagnosed correctly with Cushings. I am due to speak to her specialist today, and of course, will certainly bring up all your important points. In the meantime, I just got back from her regular vet with copies of the last lab results (ACTH stim test, Free T4 and TSH) which of course, until I speak to the specialist can't make any sense of what I'm looking for. If you have time, would you mind reading these results and give me your input. Here they are:

PRE-ACTH CORTISOL - 16.6
POST-ACTH CORTISOL - 50.0
FREE T4-ed (ng/dl) - 1.2
FREE T4-ed (pmol/L) 15.4
cTSH 0.45 (high)

Comments: Increased canine TSH values may occur in dogs with untreated primary hypothyroidism. Sick euthyroid dogs are expected to have low normal TSH concentrations. Secondary or tertiary hypothyroidism (pituitary or hypothalamic lesions) are reported to occur in less than 5% of hypothyroid dogs.
-------------------------------------------------------------------
What does all this mean in ENGLISH??? I am quite confused. Again, I appreciate any comments at your leisure. In addition, would you mind explaining which test determines the type of Cushings? Not sure now if it is provided in the above test results??? I would consider surgery in a heartbeat if it were the adrenal based Cushings, but again, not sure at this point. As for treatment, you mean to say that trilostane is used only to treat pituitary Cushings and not adrenal? And lysodren is used for adrenal Cushings? Lots of questions for specialist today....Thanks you so much for reaching out to me and for the valuable information you have provided..Regards. J.

[StarDeb55]

Jeanette, I'm at work, so I don't have much time. I will respond more in detail when I get home this afternoon. I need the normal ranges for the thyroid testing, & the reporting units for the ACTH, without those 2 items, it's a little hard to give detailed input.

Debbie

[mypuppy]

Debbie, I appreciate your reply from work, and of course no pressure on this end. here are the reference ranges for the tests:

Pre-ACTH (resting) cortisol: 2 - 6
Post - ACTH cortisol: 6 - 18
Equivocal post -ACTH cortisol: 18- 22
Post - ACTH cortisol consistent with hyperadrenocorticism: >22
Post - ACTH cortisol consistent with hypoadrenocorticism: <2
Desired pre- and post - ACTH cortisol on lysodren therapy: 1 - 5

------------------------------------------------------------------------
THYROID PANEL #6 - FREE T4 (EQUIL. DIALYSIS)

FREE T4-ed (ng/dL): Result: 1.2 Reference Range: 0.7 - 3.7 ng/dL
FREE T4-ed (pmol/L):Result: 15.4 Reference Range: 9.0 - 47.4 pmol/L
-------------------------------------------------------------------------
THYROID PANEL #6 - cTSH

cTSH: Result: 0.45 - Reference Range: 0.05 - 0.42 ng/mL - Flag: H

Let me know if you need anything further, but that's basically all of it from her last tests. Thanks again. Jeanette...

[Squirt's Mom]

Hi Jeanette,

In looking at the results you have posted, I am a bit concerned about the Cushing's diagnosis right now. I am always nervous when a diagnosis has been made based on one test. Cushing's is complex and often difficult to confirm even with several tests. The ultrasound didn't show any of the adrenal changes which are typical and the chem results just don't indicate the usual liver involvement we see with our cush babies but each of those precious souls is different and we have seen some really strange things! ;)

There is one more test I would recommend, the full adrenal panel from UTK (Uni. of Tenn. in Knoxville). This tests looks at the other hormones involved in Cushing's besides cortisol. Those hormones are Estradiol, Androstenedione, 17-Hydroxyprogesterone, Progesterone and Aldosterone and they cause the same signs as conventional Cushing's. Since you are considering Trilostane, and Trilo always elevates one or more of these hormones, I strongly suggest you have this done before starting Princess on the med. Once you start it, the med will skew the test so you would need to do a wash-out (no meds) to get a clean picture of these hormone levels. Here are some links on this form of Cushing's called Atypical Cushing's:

Atypical Cushing’s*
(Estradiol, Androstenedione, 17-Hydroxyprogesterone, Progesterone and Aldosterone – an elevation in one, all, or any combination of these hormones, without elevated cortisol.)

http://veterinarynews.dvm360.com/dvm/article/articleDetail.jsp?id=485128&sk=&date=&pageID=1

Beware of false positives, negatives in canine hyperadrenocorticism testing
http://www.vetcontact.com/en/art.php?a=132&t

UT Panel
Explanation of hormones
http://www.vet.utk.edu/diagnostic/endocrinology/treatment.php

Cost sheet
http://www.vet.utk.edu/diagnostic/endocrinology/index.php

Dr O’s credentials
http://www.vet.utk.edu/faculty/oliver

The full adrenal panel will also check the cortisol again. It is done just like the ACTH; your vet will make the blood draws then send the sample directly to UTK. Don't be surprised if your vet is not familiar with this type of Cushing's, many aren't yet.

My advise to you right now is to take your time before starting Princess on any treatment. Do your best to make sure there is nothing else going on that could make the cortisol levels rise as a normal response to physiological stress. My Sweet Bebe is one that falls into that group - a splenic tumor caused her cortisol to rise and caused all her tests (LDDS, HDDS, ACTH, ultrasound) to support a diagnosis of pituitary based Cushing's (PDH). But once the tumor was out, the cortisol returned to normal and her docs now say the original diagnosis of PDH is "highly questionable". I did have the UTK panel run as well, thankfully, as Squirt is Atypical. So, don't rush into treatment. I didn't, even tho I was urged to, and I am so glad I took the time to try to make sure all the bases were covered first.

Keep your chin up! You are doing a wonderful job! Princess is lucky to have been found by you and to be in such loving hands.

Hugs,
Leslie and the girls

[mypuppy]

Leslie, so that means there is another form of Cushings aside from the pituitary and adrenal based? What is Atypical Cushings? and which one of the three Cushings is worse to get? Gosh, I am so glad I came to this forum because I would have not all these unanswered questions and may possibly be missing something else going on. I will most definitely mention the further work-up on Princess for the full adrenal panel...question, out of curiosity do you happen to know what a test like this runs in price? Can you tell me more about atypical cushings? Thank you for your help....

[mypuppy]

Deb, may I call you Deb or would you prefer Debbie? I wanted to say that I apologize if I'm coming across as if I'm just trying to drain all source of info. from you right now...Gosh, you are probably thinking how selfish and insensitive of me to not even ask about your personal experience with Cushings...I am soooo sorry. As I said in my previous posts, sooooooo overwhelmed and the not knowing what to expect is killing me inside...I ask myself "is my pup in pain, and she just doesn't show it?" Is she uncomfortable? I know she's extremely thirsty and hungry, and that totally bothers me, because being human I know what that feels like at times, but I can't imagine what she's experiencing....I look at her and her eyes are telling me something is not right, and it is saddening to me not to be able to help her the way I would want to....I wish I can make it all go away, but I'm not God to work miracles, although there are a ton of prayers going right now as we speak. I am very religious, and well I'm not preaching here, but I firmly stand of my faith and somehow feel the prayers will come through for her. Look, again, sorry if at times I may seem insensitive through these posts. I'm really not...In fact, I'm way too sensitive when it comes to these issues, so do not take anything personal.....Again, I reiterate to everyone on this forum who has helped me immensely in the last two days, you are all special people, kind-hearted and your comments are so inspiring to me at this time.....God Bless you and your beloved pets.....Jeanette.

[StarDeb55]

Jeanette, don't worry about how you have posted, I thought absolutely nothing of it. You can call me either Deb or Debbie, I answer to either one.

Now, let me say that thyroid testing is not one of my big areas of expertise, but I will tell you what I know which means I sort of have to relate this to human thyroid testing. When a person has a low total T4 or for our pups a low free T4, in most all cases the TSH test will be elevated in a person. The cTSH test is the equivalent for a pup, Princess' value is just a tick elevated. I have been doing some reading on cTSH testing in conjunction with a free T4, there are inherent problems with just looking at the cTSH result & saying that the dog is hypothyroid based on this result. cTSH testing apparently doesn't seem to be as specific for canines as the TSH test is in humans. You have to look at both results, & I'm thinking that since the free T4 is normal, the slight elevation in the cTSH may not be significant. It may be possible that the cTSH might be indicating early onset hypothyroid, too, I suppose. I know I sound like I'm really hedging my bets, but this is another set of questions for your treating vet.

The ACTH results are consistent with Cushing's, but as I mentioned last night, you can't tell what type based on an ACTH alone. Cushing's is a terribly frustrating disease to diagnose as no single test is 100% specific or sensitive. This is why we always recommend that you have at least 2 different tests done to get a confirmed diagnosis. Not to add to your confusion, but to give you an example as to how frustrating this disease can be to diagnose, the low dose dex test which is considered to be the "gold standard" for diagnosis, has one very big drawback. The drawback is that the test can generate a false positive results in the presence of non-adrenal illness such as diabetes, for instance.

As part of the general labwork that has been done on Princess, was a complete urinalysis done? If so, did the UA show either or both a positive glucose or ketones? On the chemistry panel, what was her blood glucose, & was the bloodwork drawn while she was fasting?

Leslie has given you some pretty good links to get you to the necessary info on Atypical. Just to give you my personal take on Atypical, when Harley was diagnosed in 4/08, I was fortunate enough that his GP vet had sent the blood to UTK for the full adrenal panel, & at that point, I was totally oblivious that Atypical even existed as a disease. Anyway, not only does Harley come back with an elevated cortisol, but all of the 5 other associated hormones that are tested on that panel were elevated, some of them pretty severely. All I did, then, was take Harley to the IMS I was seeing to get a consult for a confirmed diagnosis. She ran an abdominal ultrasound which showed bilaterally enlarged adrenal glands & that along with the full panel results gave Harley a diagnosis of Atypical + PDH Cushing's. He has been treated with lysodren, melatonin + lignans since that time, & has been doing pretty well for a "cranky little old man" of 14 yrs. old. In that visit with the IMS, I asked her, "I assume that since Harley is Atypical, trilostane is out of the question because of the drug elevating the intermediate hormones?" Her response was that is absolutely correct, he will need lysodren. The fortunate thing about lysodren is that it will control all of the hormones except for estradiol. Estradiol is a huge "crapshoot" to control as it has non-adrenal sources of production such as fatty tissue & brain tissue. The use of melatonin & lignans is to try to get the estradiol in line. I know a lot of people get really quite flustered with the possibility of using lysodren as they seem to be told that it's a chemo drug. I can assure that there is nothing to get flustered about as long as you are seeing a vet that is following standard loading/dosing protocols with drug, & that you educate yourself on what to look for in your canine buddy when they are taking this drug. I have used the drug with 2 pups, now, & I really don't think I would ever be that interested in using trilostane, if I should be unlucky enough to go through this a 3rd time.

Debbie

[lukex5]

Hi my name is Lisa and I am also new to this forum. I have a almost 9 year old pom just diagnoised with cushings. Like you a was scared to death with what everyone was telling me! They scared the blank out of me. Finally I got myself together and decided to treat her with lysodren. She did well the first week and levels were back in range so we are now on the maintence phase. I also use TCM! Ami has actually been on TCM for over a year for seizures because I did'nt want her on phenobarb. She has not had a seizure since. The herbalist that I use sent me a support formula for her liver and kidneys while she is on lysodren. Right now she is doing good all we can do is take one day at a time. I thank God i found this forum because they put hope back in my heart. You will know the right thing for your dog. I wish you well. Lisa and Amilu

[mypuppy]

Hi Lisa, so sorry to hear about your pup. I think, as you, am ready to take the initial step and begin treatment. I have been getting so many mixed opinions that it is simply overpowering my train of thought. I agree, need to get myself together and proceed for the pup's sake. The way I look at it, she has obvious signs of something wrong. I have taken the necessary steps to test for various conditions, and the specialist finally came back with Cushings. I am no dr. to question the validity of the tests nor question their expertise. At times, we have to face reality in the face and accept things that we have no control over. As for the lysodern, my specialist told me point blank today, she refuses to treat with lysodern. She favors the trilostane. When did you begin treatment on your dog? I wish you and him/her well too. Let me know how you both make out with treatment. Thanx for your post. Jeanette.

[Harley PoMMom]

Hi Jeanette,


I am no dr. to question the validity of the tests nor question their expertise.Oh Jeanette, honey...none of us are dr. here but we all have the right to ask the vet or IMS questions about the tests being performed on our furbabies, we have the right to know exactly why the test is being performed and we have the right to question anything they want to do to our furbaby. Oh Jeanette, you are Princess's voice, her advocate, just like I am Harley's and I will stand up to Harley's vet and IMS when it comes to his health, if I don't understand something they explain it or if I don't agree with something that they want to do, we come to an agreement...we're a team.

Harley's first vet fired us when Harley got dx'd with cushings, so we had to find a new one. I believe you need a vet/IMS who has an open mind about both Trilostane and Lysodren. They both are very good drugs for cushings.

I know this cushings journey is a confusing and stressful one, it is also heartbreaking to watch your loving furry best friend get ill and you can't do anything about it...yet. Please take the time to get a proper diagnosis, this will be the only way to get the proper treatment Princess needs.

Love and hugs.
Lori

[StarDeb55]

I agree with what Lori has just told you. I had to fire the IMS that confirmed Harley's diagnosis about 3 months after the diagnosis was confirmed because she nor her techs would listen to me about what was going on with him, he needed a repeat stim, etc. I could vent about what happened for hours. I got so upset & frustrated, I, finally, told one of vet techs that "Yes, I know quite a bit about Cushing's, but no, I'm not a vet.", I then said, "There is one thing I know more about than anyone else on the face of this earth & that is this little boy's behavior, when he's not feeling well, & when something is wrong. I concluded my conversation with those statements, got Harley into his GP vet that afternoon, told him everything that had gone on with the IMS, & that I was done, would it be a problem for him to take Harley's Cushing's care back over.

Dealing with this disease is stressful enough as it is, you don't need a vet who refuses to listen to your input. You need someone who wants to explain things to you, answer all of your questions, & explain again, if you aren't following something.

Debbie

[jrepac]

You may want to have a few more tests done....the signs point to Cushings, but not conclusively. Ultrasound test may be helpful...weight loss IS unusual for a cushings dog. And, your vet should be willing to discuss any tests and treatment options in detail with you. I wound up seeing 5 vets across 2 different practices over 18months. If the vet refused to discuss something w/me, or was 100% insistent on something that I had concerns about, that was a sign for me to walk away (which I did). Any vet who refuses to discuss tests or treatment protocols, is not someone I want to deal with. Cushings is pretty complicated, and I think some vets are not well informed and in other cases, simply overly opinionated. My current vet is not an expert, at any stretch, in this disease, but is very open to investigating/learning the treatment options...as well as testing; he was very impressed w/the UTK procedures.

Net, net, you need someone who is willing to listen...

Jeff

[StarDeb55]

Jeff, Princess had an ultrasound which was normal, no enlargement of the adrenal glands.

Debbie

[mypuppy]

Hi Jeff, thank you, I truly do appreciate your input. Princess has had a CBC and urinalysis, water deprivation test, abdominal ultrasound, ACTH stim, Free T4 and TSH tests. I did bring up the possibilities of further work-up (perhaps the full adrenal panel from UOT), as well as a high dose dex. And although she was not hesistant in complying with my concerns, she is ready to begin treatment with Trilostane. I do not know what other tests are out there now to reconfirm their Cushings dx.

[labblab]

Hi Jeanette,

As you can see from my avatar, I am a Lab-lover, too! My Cushpup was 8 years old when he was diagnosed, and I remember only too well all the heartache and anxiety associated with deciding upon a treatment plan.

For what it's worth, my boy also suffered weight loss instead of weight gain. I know that is not the norm, but it was the case for him. He did have a voracious appetite, but we closely controlled his food intake -- he was never able to scrounge for anything other than his daily allotment of kibble. So I've since wondered whether the weight loss was the result of metabolic changes associated with the elevated cortisol. And since he was not able to eat the extra food that he craved, he was not able to maintain his weight (let alone gain more). But that is purely speculation on my part.

He was diagnosed by an IMS on the basis of his symptoms (CLASSIC symptom profile), elevated liver enzymes, ACTH, and ultrasound showing bilaterally enlarged adrenals. So we really did not undergo any additional tests -- the enlarged adrenals were kinda the frosting on the cake in conjunction with the symptoms and the blood tests. Ironically, if only your pup exhibited ultrasound abnormalities, it would make the diagnosis feel a lot more comfortable (an odd thing to wish for, isn't it!).

We ended up treating with trilostane, and initially he responded very well. He ended up having problems later on that were probably associated with an enlarging tumor, but I'm not going to go into those right now as they had no bearing on his diagnosis. I do understand how your head is spinning from all the different advice and opinions. To me, the bottom line is that you need to trust your gut feeling as to the competence and approachability of your vet (assuming, of course, that your questions are being answered to your satisfaction).

And I do have one suggestion, myself (just what you need, right? :o). If you do decide to treat with trilostane, I would strongly encourage your vet to submit a blood sample to the Univ. of Tennessee so a full adrenal panel could be run BEFOREHAND. This has already been suggested here, and you've probably read about this panel elsewhere, since it has been a "hot" topic on the forum for the last couple of days. Since the ultrasound did not reveal any growths of abnormalities in your dog's adrenal glands, we can presumably rule out the adrenal form of Cushing's. But trilostane inevitably increases some of the other intermediate hormones at the same time that it lowers cortisol. These increases can cause problems down the road for some dogs. So it is really helpful to know the pre-existing status of your dog's adrenal profile prior to beginning trilostane treatment. Plus, if you are willing to pay the money, a second ACTH stim test can be performed in conjunction with the adrenal panel. The results of a second ACTH might give you additional peace of mind as to the original diagnosis, since it is the blood test that is the most specific for Cushing's (meaning, the least likely to give a "false" positive).

If you are willing to pay the money for the test, then I don't see why your vet should object to having it done, unless for some reason she does not believe that it is of particular value. But even then, you haven't "lost" anything by having the test done, regardless. And it is something that you won't have the opportunity to perform as meaningfully later on down the road, unless you are willing to suspend Princess's trilostane treatment for a time period prior to the testing.

I'm so glad you've found us, even though we're bombarding you with information. Just remember, you don't have to make any rush decisions about this. You can take the time you need to feel comfortable with the treatment that is being recommended.

Marianne

[lukex5]

Hi Jeanette! I started my Ami on lysodren 3 wks. agao. The first week she was on 1/4 everyday then had a stim test. Her levels were with in range so we cut her back to 1/4 pill 2 days a week for two weeks. This thurs. will be her last 1/4 and then she will go for another stim on mon. I had to stop with my fears and trust my vet. I am not saying to become a puppet and not have your own mind but you have to research and do your best. Often blood tests and knowing your dog is the key. Ami seems to be doing good. I have since relaxed now that she has taken the med and is still thriving with no side effects at all. I wish you well with what ever you choose.

[mypuppy]

Thanks Luke? I think I'm on the right path now after evaluating all my research, everyone's opinions about testing and treatments. I now feel quite more at ease about beginning treatment on Princess based on this forum and everyone's positive experiences with treatment on their own pups. It's reassuring. In fact, specialist will be calling today to schedule dosing, etc. Only problem now is I need to get a new vet ASAP in my area because I refuse to take Princess to him again. The specialist is an hour away from home, not totally convenient, but it's worth the trip, but would like to find reg. vet closer to me for all the testing while on treating Princess. Thanks again, and good luck to you too with your precious one. J.

[mypuppy]

Marianne,

So sorry about your pup. He is adorable! They are the best? No offense to anyone here, I love ALL dogs, I'm just a little bit partial to labs being that I'm the proud mommy of one, but all animals have my heart. Anyway, I do not know how old he is now, but I am at that same stage you were when yours was first diagnosed: (heartache and lots of anxiety). I just want to make my Princess better. All I've been breathing is for the last week and half is Cushings, Cushings, and more Cushings--my kids are going to dis-own me pretty soon-lol. All kidding aside, my oldest 13 is pretty torn up about this even though she doesn't fully understand it, how can she if I don't, so I have to try to hold up for her sake--she's the reason we brought Princess home in the first place when my daughter was 5 years old--that's her dog, but she's also became mine all too quickly, and that's ok, we are pretty good about sharing-lol. I now have a 5 year old also, but she's a bit rough still with Princess, and trying to explain puppy's a little sick lately, so goes around hugging and kissing her more now. Marianne, I did read your last post, and pretty soon I am going to take on "confused" as my middle name--lol. It is interesting that your dog suffered the weight loss just like my Princess even though they say not common in Cushings. Her appetite is way much, but quick question, do I need to monitor her intake or even switch her to a low fat diet due to Cushings? She's eating the usual amount I have always given her prior to dx...Please let me know if your vet/specialist suggested any changes to her diet (more/less?). Do you give her supplements? I asked my specialist, and she didn't seem to think it was necessary.

Now are for how you go to your diagnosis. I'm sorry, I'm not too keen yet on all the medical terms--what is IMS? Princess did have the abdominal ultrasound which was negative for any abnormalities, so we couldnt base a diagnosis on that test, but glad I had it done regardless. It was the ACTH stim test that came back positive. As for treatment, specialist would like to start her on trilostane, and my gutt is telling me just to go ahead with it and wait it out. I just still can't believe my gen. vet told me IT CAN BE A FATAL med to treat with...UGHHHHHHHH. If you have some time would you be able to elaborate a bit more on any side effects, if any, your pup experienced on the trilostane, vomitting, diarrhea, others? Did you get him off the trilostane due to complications? How is he doing now. Again, not sure when this happened to your pup and how old he is now. Would love to hear more about it really. I also know there is also a risk of developing Addison's disease on the trilostane, so this is why I am also so scared that we are treating one disease and it could cause another. Wish there was an easier way, but I'll quote you "that's an odd thing to wish for".

As for the full adrenal panel testing, it does seem like a very popular topic, but am not quite understanding the purpose for it? Is it basically for pups who have been diagnosed with Cushings and goes hand in hand with the treatment? I thought the test was to rule out any other underlying diseases or if anyone had any doubts the Cushings diagnosis was incorrect? Can you clarify the reason for the test again. Sorry! I am willing to spring for any other necessary tests that will give me peace of mind. We have spent quite a lot already, and my husband's starting to worry about the financial aspect since I do not work--it is very tough in this economy, but I told him that's what credit cards are for - lol. All in all, we agreed to our commitment to our pup and we won't let her suffer or go untreated if it unfortunately means using up the cards. Thanks again for reaching out. It means the world to me. Best regards, Jeanette

[mypuppy]

ps to Marianne,

I hope I don't seem too personal for asking this question, but would you mind giving me a ball-park figure as to how much you have spent on your pup since he was first diagnosed? I asked my specialist what one is expected to spend, and she couldn't answer that for me, so don't know what to expect? I know every patient is different, and every dr. charges different fees for their services, but if I can at least get an idea of the financial aspect we can at least try to cut corners and cut back on other things to make it work out.

[Squirt's Mom]

Hi Jane,

Here is a copy of a link I gave you the other day on Atypical Cushing's. It is by Dr. Oliver at UTK and does a good job of explaining these hormones and how they come into play.

http://www.vet.utk.edu/diagnostic/endocrinology/treatment.php

STEROID PROFILES IN THE DIAGNOSIS OF CANINE ADRENAL DISORDERS
Jack W. Oliver, DVM, Ph.D
Knoxville, TN

INTRODUCTION
Diagnosis of adrenal disease in domestic animals usually is dependent on the manipulation of the hypothalamo-pituitary-adrenal axis (HPA) and the measurement of cortisol (i.e., ACTH stim test; low dose dexamethasone suppression (LDDS) test; urine cortisol/creatinine ratio test; or the combined dexamethasone suppression/ACTH stimulation test). More recently, other steroid measurements have been utilized to evaluate the HPA, including steroid hormone profiles1,2, and 17-hydroxyprogesterone,3-5 which have revealed that suspected adrenal disease conditions may be caused by steroids other than cortisol (or in addition to cortisol).3 Determination of pituitary-dependent hyperadrenocorticism (PDH), or adrenal-dependent hyperadrenocorticism (ADH), is now usually made by evaluation of the 4-hour timepoint of the LDDS test6, by endogenous ACTH measurement,7 or by ultrasound visualization of the adrenal glands.7,8 Hyperadrenocorticism (HAC) is defined as an overproduction of steroid hormones by the adrenal cortex.4 Cushing’s syndrome refers to all causes of hyperadrenocorticism with excess production of cortisol,6 while atypical Cushing’s disease refers to hyperadrenocorticism caused by increased levels of intermediate adrenal steroids that frequently are referred to as “sex steroids”.9

STEROID HORMONE PROFILES/GENERAL
Steroid hormone profiling in veterinary medicine was begun at The University of Tennessee Clinical Endocrinology Service, with the premise being that multiple steroid hormone analyses would increase the diagnostic accuracy of adrenal function tests.1 Measurement of multiple steroids in Pomeranians2 led to the recognition of a syndrome called “Alopecia-X”11 by dermatologists. Others have reported on adrenal syndromes in dogs called “atypical Cushing’s disease”,3,9 or “adrenal hyperplasia-like syndrome”,9,10-13 that used steroid profiling. Cortisol is known to have negative control effect on the HPA axis, but it’s now also understood that other steroids can have this effect as well.9,14,15 Steroid profiling in dogs and cats has led to the realization that HAC can be due to primary adrenal tumors that secrete other steroids besides cortisol.16-21 Steroid profiling in ferrets led to the realization that HAC in this species is primarily due to increased levels in blood of estradiol, 17-hydroxyprogesterone and/or androstenedione,9,22 and measurement of these steroids has helped define medical control of ferret adrenal disease.23-27 Steroid profiles have also helped to better understand the condition of SARDS in dogs, where steroids other than cortisol frequently are involved.28 Steroid profiling is also helping to understand drug effects on adrenal secretory activity (mitotane, trilostane, melatonin).29-31

STEROID HORMONE PROFILES/SPECIFIC
Steroid hormone profiles are indicated when other routine tests of adrenal function are negative (ACTH stim; LDDS; combined dexamethasone suppresson/ACTH stim) and the dog still exhibits signs of Cushing’s syndrome, indicating the likelihood of atypical Cushing’s disease being present.3,9 The issue of non-adrenal illness has been raised as a possible consideration in atypical Cushing’s disease cases.21 Results of studies in dogs with chronic illness, but without clinical evidence of HAC, have shown that 17-hydroxyprogesterone (17OHP) concentration may be increased.21 However, results of other studies of adrenal function testing in dogs with non-adrenal illness have demonstrated only minor effects on test results.32,33 Also, in studies that have measured only 17OHP as a means of detecting HAC, the sensitivity and specificity of using post-ACTH 17OHP concentration as a diagnostic test for HAC were low, and post-ACTH 17OHP analysis was not recommended as a screening test for HAC.4 These studies provide evidence that measurement of a singular adrenal intermediate steroid (such as 17OHP) may give equivocal results, but when profiles of steroid intermediates are used, the sensitivity and specificity of the test procedure is much improved.29 It has been emphasized that adrenal function testing should be performed in dogs with clinical and/or biochemical evidence of HAC, and not in dogs with non-adrenal related disease.6
Steroids that may be involved with atypical Cushing’s disease are androstenedione, estradiol, 17-hydroxyprogesterone, progesterone and aldosterone.9 Other steroids that aren’t commonly measured may be involved as well, such as corticosterone21 and deoxycortisone.16 Estradiol is unique because treatment of excess estradiol can be difficult, the hormone can be secreted by tissues other than the gonads or adrenals35-38 and because secretion is independent of ACTH stimulation or dexamethasone suppression testing, as currently done. For dogs with atypical Cushing’s disease (PDH etiology), expect hepatomegaly, hepatopathy and bilateral adrenomegaly to be present along with increased endogenous ACTH level and the usual clinical signs, bloodwork and often haircoat problems. For dogs with atypical Cushing’s disease (ADH etiology), expect hepatomegaly, hepatopathy and unilateral adrenomegaly to be present (and maybe atrophy of contra-lateral gland) along with decreased endogenous ACTH level and the usual clinical signs, bloodwork and often haircoat problems. For primary hyperaldosteronism conditions, due to primary adrenal tumor or bilateral adrenal hyperplasia, expect hypertension in association with hypernatremia and muscular weakness (cervical ventroflexion, hindlimb weakness) due to hypokalemia.39 Retinal hemorrhage and blindness40 and renal disease41 can occur in cats. For hyperadrenocorticoid cases that also have low aldosterone levels, this pattern can be indicative of a primary adrenal tumor, and ultrasound is indicated to confirm a tumor’s presence or absence.29

Treatment Implications
Primary adrenal tumors. Adrenal steroid profiles reveal that adrenal tumors in dogs, cats and ferrets have a variety of secretory patterns, with serum cortisol levels often being normal.l9,17,18-22,29,39 Similar findings have been reported in humans with adrenoadenomas.42 In ferrets, mice, rats, guinea pigs and hamsters, sex steroid-producing adrenocortical tumors occur following gonadectomy, in association with the significant increase in serum gonadotropin levels that develop.43-47 The elevated luteinizing hormone (LH) level that occurs following gonadectomy leads to neoplastic transformation and expression of LH hormone receptors on sex steroid-producing adrenocortical cells in ferrets46,47 and rodents.48 Also, in humans, there is evidence of stimulatory effects of LH on adrenocortical cell growth and function,49 and LH receptor protein has been identified in the zona reticularis layer of the adrenal gland by immunohistochemical staining.50 In spayed female dogs, plasma gonadotropin levels post-gonadectomy rise to levels ten times what they were pre-gonadectomy, providing evidence of the strong and continuous LH stimulus that possibly plays a role in adrenocortical tumor development.51,52 Evidence is accumulating in human studies that some cortisol and other steroid-producing adrenal tumors or hyperplasias are under the control of ectopic or aberrant hormone receptors (e.g., gastrointestinal peptide, beta-adrenergic, vasopressin, serotonin and angiotensin II), and that these receptors may provide alternative mechanisms for pharmacologic control of adrenal tumors.53,54 Control of the secretory activity of adrenal tumors with beta-adrenergic and LH receptors has now been demonstrated by use of beta-receptor antagonists (propranolol)53 and gonadotropin antagonists such as leuprolide and deslorelin.23,24 Surgical removal of adrenal tumors is usually indicated, but age and health considerations impact this decision. If surgery is not an option, then mitotane is usually the next consideration. Adrenal profiles are indicated to determine the functionality of adrenal tumors in light of the multiple hormone secretion patterns that are seen.
Mitotane. Adrenal hormone profiles reveal that most intermediate hormones are decreased by mitotane the same as for cortisol, but that estradiol may remain unaffected. In cases that continue to have elevated estradiol levels, varying clinical signs of Cushing’s disease will be present.29
Trilostane. Enzyme inhibition by trilostane occurs for 3-beta hydroxysteroid dehydrogenase, but also for 11-beta hydroxylase.30 Thus, 11-deoxycortisol levels build-up in dogs treated with trilostane. It is also apparent that other intermediate steroid levels increase (androstenedione, 17-hydroxyprogesterone, estradiol and progesterone) in dogs treated with trilostane,29 which could be due to the 11-beta hydroxylase inhibition, and possibly 21-hydroxylase enzyme inhibition.29 The reason why only 11-deoxycortisol levels were increased in the above study30 may be due to the length of trilostane exposure (3-7 weeks), compared to dogs that are exposed to trilostane for extended periods. Trilostane reportedly offers effective control of Cushing’s syndrome,30 but the long-term effects of the elevated intermediate steroids remain ill-defined. Some dogs do have return of clinical signs of Cushing’s syndrome while on trilostane.29 Because trilostane seems to pre-dispose dogs to increased adrenal toxicity with mitotane, an acute switch from trilostane to mitotane treatment should not be done.29
Aromatase enzyme inhibitors (anastrozole, exemestane, melatonin). The aromatase enzyme occurs in gonadal and adrenal tissues (and other tissues such as fat and skin cells), and converts androstenedione to testosterone or estrone, both of which are then converted to estradiol. Neither estrone nor testosterone have been observed to be increased in dogs with adrenal disease, but estradiol frequently is increased, and causes many of the clinical signs associated with Cushing’s disease.29 Aromatase enzyme-inhibiting drugs will decrease estradiol levels, but currently are infrequently used (except melatonin) in animals due to cost considerations.
Anti-gonadotropin drugs (melatonin, leuprolide acetate, deslorelin acetate, androgens). Adrenal tissues in different species (e.g., ferrets, rodents, humans) are known to have luteinizing hormone (LH) receptors present.44-50 In ferret studies, anti-gonadotropin drugs are effective in lowering sex steroid levels.23-24,27 Sex steroid levels are also decreased in dogs with adrenal disease that are treated with melatonin,31 but it is not known if LH receptors are present in canine adrenal tissues. Androgenic drugs have anti-gonadotropin effects via negative feedback effects on the hypothalamo-pituitary tissues.
Melatonin. Results of in vitro cell culture (human H295R adrenocortical carcinoma cells) studies in our lab55 revealed that both 21-hydroxylase and aromatase enzymes were inhibited by melatonin. Also, in dogs with adrenal disease that are treated with melatonin, and repeat adrenal steroid panels are done, cortisol levels are consistently reduced, and estradiol levels are variably reduced.29 Inhibition of the 21-hydroxylase enzyme would lower cortisol levels, and inhibition of the aromatase enzyme would lower estradiol levels. Estradiol levels were decreased in a prior study of dogs treated with melatonin.31 Results of in vitro studies with human MCF-7 breast cancer cells also revealed that melatonin inhibited aromatase enzyme, which resulted in reduced estradiol levels.56 Melatonin treatment for cases of mild adrenal disease in dogs may be effective, and particularly in cases where sex steroids are increased.
Melatonin plus phytoestrogens. Melatonin has the above listed effects, and phytoestrogens (isoflavones, lignans, genistein) are known to inhibit 3-beta hydroxysteroid dehydrogenase.57,58 Lignans and genistein are also known to decrease the activity of aromatase enzyme in MCF-7 cells in vitro.58 So, combinations of melatonin and phytoestrogens may have efficacy in treating hyperestrinism conditions.

Hyperestrinism in Dogs
Hyperestrinism in dogs may be a new and emerging disease entity. In sample submissions to the Clinical Endorinology Service (2005) at The University of Tennessee, 40% of adrenal panels had elevated estradiol levels present (>70 pg/ml).29 In hyperestrinism cases, estradiol is the estrogen that is increased, ACTH stim and LDDS tests are usually normal for cortisol, thyroid function is normal or controlled, liver problems are frequent and typical (very elevated alkaline phosphatase, hepatomegaly, steroid hepatopathy, hyperechoic liver by ultrasound), PU/PD is frequent, panting may be present, haircoat problems often are present, skin biopsy results suggest an endocrinopathy, there is no change in estradiol level in response to ACTH stim or LDDS tests as currently conducted, resistance to mitotane may occur and increase often occurs in response to trilostane. Effective treatment options for hyperestrinism in dogs is limited at the present time, and drugs that could be expected to be efficacious (aromatase inhibitors – excluding melatonin) often are limiting due to cost. Melatonin and phytoestrogen treatment may be effective for the above listed reasons. Mitotane will likely be effective if the source of estradiol is the adrenal tissues. Trilostane treatment frequently results in increased estradiol levels,29 and this may be a reason why less than effective treatment with the drug sometimes occurs.


CONCLUSIONS
Steroid hormone profiles in dogs are indicated when hyperadrenocorticism is suspected due to typical clinical and/or biochemical signs of disease, but the usual tests of adrenal function have been normal. The profiles are effective in ruling out presence of atypical Cushing’s disease, cases of hyperestrinism and for delineating the secretory profile of adrenal tumors (functionality), which often are associated with elevated levels of steroids other than cortisol.

KEY WORDS
Hormone, Tumor, Endocrine, Atypical, Hyperadrenocorticism

REFERENCES

1Lothrop CD, et al. AJVR 1984; 45:2304.2Schmeitzel LP, et al. JAVMA 1990; 197:1333.3Ristic JME, et al. J Vet Intern Med 2002; 16:433.4Chapman PS, et al. Vet Rec 2003; 153:771.5Benitah N, et al. JAVMA 2005; 227:1095.6Feldman EC et al., In Feldman E, Nelson R eds. Canine and Feline Endocrinology and Reproduction, 3rd Ed. St. Louis: WB Saunders, 2004; 252.7Gould SM, et al. J Sm Anim Pract 2001; 42:113.8Saunders MH, Proc of the 24th ACVIM Forum, 2006; 523.9Oliver JW, Proc of the 20th ACVIM Forum, 2002; 541.10Schmeitzel LP, et al. Kirk’s Current Therapy XII, Small Animal Practice, J Bonagura and R Kirk, eds. Philadelphia: WB Saundsrs, 1995; 600.11Schmeitzel LP, Proc of the 15th AAVD/ACVD, 1999; 131.12Kintzer P, Proc of the 17th ACVIM Forum, 1999; 435.13Rosychuk R, Proc of the AVMA Annual Meeting, 1999.14Selman PJ, et al. Eur J Endocrinol 1994; 131:422.15Selman PJ, et al. Steroids 1996; 61:133.16Reine N, J Vet Intern Med 1999; 13:386.17Syme HM, et al. JAVMA 2001; 219:1725.18Hill KE, et al. JAVMA 2005; 226:556.19Boord M, et al. JAVMA 1999; 214:666.20Rossmeisl JH, et al. JAAHA 2000; 36:512.21Behrend EN, et al. JAVMA 2005; 227:1762. 22Rosenthal KL, et al. JAVMA 1996; 209:1097.23Wagner RA, et al. JAVMA 2001; 218:1272.24Wagner RA, et al. AJVR 2005; 66:910.25Ramer JC, et al. JAVMA 2006; 229:1743.26Johnson-Delaney CA, Exot Mammal Med Surg 2005; 3:7.27Murray J, Exot Mammal Med Surg 2005; 3:1.28Carter R, et al. Proc of the Am Coll of Vet Ophthal, 2003.29Oliver JW, Clin Endo Serv Univ TN; unpublished data.30Seiber-Ruckstuhl NS, et al. Dom Anim Endocrinol 2006; 31:63.31Ashley PF, et al. JAVMA 1999; 215:1111.32Kaplan AJ, et al. JAVMA 1995; 207:445.33Gieger TL, et al. J Vet Intern Med 2003; 17:154.34Behrand EN, et al. JAVMA 2005; 226:1662.35Bulun SE, et al. Semin Reprod Med 1999; 17:349.36Bulun SE, et al. J Ster Biochem Molec Biol 2003; 86:219. 37Simpson E, et al. Endocrine-Related Cancer 1999; 6:131.38Ackerman GE, et al. J Clin Endocrinol Metab 1981; 53:412.39DeClue AE, et al. J Vet Intern Med 2005; 19:355.40Ash RA, et al. J Feline Med Surg 2005; 7:173.41Javadi S, et al. Dom Anim Endocrinol 2005; 28:85.42Glaz E, et al. J Ster Biochem Mol Biol 1993; 45:57.43Russfield AB, Meth Achiev Exp Pathol 1975; 7:132. 44Bielinska M, et al. Endocrinology 2003; 144:4123.45Bielinska M, et al. Endocrinology 2005; 146:3975.46Bielinska M, et al. Vet Pathol 2006; 43:97.47Shoemaker NJ, et al. Molec Cellular Endocrinol 2002; 197:117.48Apaja PM, et al. Endocrinology 2005; 146:3224.49Breuschlein F, et al. Horm Metab Res 2004; 36:392.50Pabon JE, et al. J Clin Endocrinol Metab 1996; 81:2397.51Olson PN, et al. AJVR 1992; 53:762.52Reichler IM, et al. Theriogenology 2005; 63:2164.53Lacroix A, et al. Endocrine Reviews 2001; 22:75.54Lacroix A, et al. Trends Endocrinol Metab 2004; 15:375.55Fecteau KA, et al. Clin Endo Serv Univ TN; unpublished data.56Cos S, et al. J Pineal Res 2005; 38:136.57Wong Z, et al. J Ster Biochem Molec Biol 1999; 71:191.58Brooks JD, et al. J Ster Biochem Molec Biol 2005; 94:461.

Proc. 25th ACVIM, 471-473, Seattle, WA 2007

I know this seems to be in Greek, but we will help you understand. Read this and then ask any questions you may have, ok?

Hugs,
Leslie and the girls

[lucygoo]

Hi Jeannette...

My dog was treated with trilostane for two years with much success. Sure, she had hair loss and other symptoms associated with the intermediate hormones, but the most important thing to control is the cortisone. I never had the UTK panel done on her, either. For MOST dogs, the other hormones don't cause a problem. The trilostane worked so well for my Lucy that she was able to have surgery done to remove a large pituitary tumor in May. I'm not saying NOT to have the panel done, but if finances are a concern, that is the last thing I would be concerned about if I were you. I know I'll probably get flack for saying that, but really, just listen to the specialist.

Good Luck!

Gina and Lucy

[labblab]

Gina, I hope you know that I, for one, will not be giving you any flack for any thought or opinion that you offer out here :p! That's what a message board is all about -- different people offering out their own thoughts about things.

And Jeanette, I'll definitely be writing back to you in more detail later on...hopefully by this evening. I've got to leave the house shortly and will be gone most of the day. But I'm happy to tell you about my own experiences with trilostane, and also to talk some more about the full adrenal panel (not to be giving Gina flack ;), but just so you'll know more about what's involved and why some people and vets choose to go forward with it).

Marianne

[gpgscott]

Hi Jeanette,

I have to comment on Gina's post. Yes we do welcome all points of view but it is important to note that many pups have issues with intermediate hormones and the only way to learn this is with the full adrenal panel. If it is done with the first stim prior to beginning treatment the upcharge is only about $100.00.

The downside of not performing it is that if the pup already has elevated intermediates and you proceed with Trilo your pup will likely require a change to Lysodren after a period of time. Add to this that a well monitored Lysodren treatment has the potential to be less costly over the long haul than Trilostane.

We have also seen that not all Drs. are created equal and have heard from a large percentage of members whose Drs. were not aware of the use of the full adrenal panel or of the negative effects of Trilostane on those pups with elelvated intermediate hormones.

I just also have to say that I could not continue with a Dr. who refuses to consider a long standing well recognized treatment. I am not a Dr. but what I want from my Dr. is to allow the diagnostics to inform the treatment not an insistance to force the pup into the mold of a treatment favored by the Dr.

Best wishes. Scott

[Harley PoMMom]

Hi Jeanette,

When my boy Harley was first dx'd with cushings in February, 2009 by a LDDS test his former vet wanted to treat him with Trilostane. I didn't know what to do, didn't know what cushings was...I was so confused and scared, and by some miracle I found this forum with these amazing and knowledgeable people.

They took my hand and calmed me down and then told me about the UTK full adrenal panel and how my boy should be tested...Oh Jeanette, I thank God I listened to them and had that UTK panel done, my boy Harley has Atypical cushings; mainly his estradiol hormone is very elevated and if I would of treated him with Trilostane, well Trilostane would of raised this hormone even higher and I hate to think of what would of happened to my boy.

I realize every dog is different and some may not have elevations...but I couldn't take that chance with my boy, I had to know if he had elevated intermediate hormones.

Best of luck to you and Princess.

Love and hugs.
Lori

[mypuppy]

Hi Lori, wow, that was a close call huh! Just got off the phone with my specialist. I had actually faxed her info from Dr. Jack Oliver at UTK re: full adrenal panel, and her take was she has no problem testing, however, she still refuses to treat with lysodern because she has come across a lot of problems. She also suggested for peace of mind to make sure it is a cortisol related issue, to have the LAB ONLY on the ACTH stim test, so I think this is the route I am taking at this point because time's a wasting and I want to begin treatment for Princess and get her back some of her quality of life. Thank you immensely for all the valuable input on your part. It really is difficult to make the ultimate choice for one's pet based on all the findings and different opinions, so again, it's time to move on and get her treated. KIT, and I will too. Regards, Jeanette

[mypuppy]

Gina, point taken,

Spoke to specialist and we will perform one last LAB ONLY ACTH stim test to check the cortisol levels, and then proceed with treatment with trilostane...It's time. I'm beating myself up about this, and have not taken the necessary steps to treat. As they say, "it is what it is" and I must deal with it accordingly and allow the doctors to do their part. Thanks for all your inputs. Regards, Jeanette...

[gpgscott]

"it is what it is"

Jeanette, please excuse my bluntness but until you have a complete diagnosis including the full adrenal panel, you don't know what 'is, is'.

From what you have said here, you have a Dr. who refuses to consider a time tested and proven treatment, and who has not done or will consider complete diagnostics.



and then proceed with treatment with trilostane...It's time.

Sorry to belabor the point, but it seems this Dr. is bent on Trilo, why not do the full panel?

I have been around this issue for three years and many of our members have even more experience. None of us are Drs. and as such we are not influenced by professional pride or position. We are just concerned about our members and making sure we give them the benefit of our experience.

Best wishes. Scott

[littleone1]

Hi Jeanette,

I know what you're going through. I know it's not an easy decision to make. Right now, Corky has been on Trilostane for 12 days, and has been doing very well. Both medications scare me. He did have a full adrenal panel done on Monday. We're waiting for the results. I feel that if Corky can have a better quality of life for his remaining time, that's what's important to me. So far, thank God, he's been doing well. I know you're concerned about the expense of the treatments. Corky's vet's and IMS costs have been close to $7000.00 since December, but he's had many other issues. He's had to be hospitalized twice due to respiratory problems. As far as the tests and treatment for Cushings, in my opinion, these costs have been very minimal.

I wish you the very best for you and your baby. I know it can be very devastating.

Terri

[Squirt's Mom]

Hi Jeanette,

I have been battling a migraine all day but had to come talk to you before my meds kick in and I can't.

First, I want you to know that no one here is trying to make you do anything or make any certain decisions that fit with our idea of what you should do. Princess is your baby and what you decide is up to you ultimately. Our job is to try to help you make the very best decision for her.

Princess was just diagnosed less than a week ago and you have had a lot of info to try to absorb - from what you have read on the web, from us, and from your vets. I know you feel the need to do something right NOW, but that may not be the best move for Princess. The worst thing one can do with a cush pup is not treat, the next worse, and almost as bad, is to rush into treatment. One of your vets told you Trilo could be fatal, one says they will not treat with Lyso. The simple fact is that both drugs can be life-savers and both can be fatal. A vet with such a narrow-minded approach as either of these two statements seem to indicate these vets are, is a good first step toward a fatality.

Princess has few signs and they seem to be mild from what you have described, which means the condition is in the early stages and you have plenty of time to become informed on all your choices, and all the possibilities of what Princess can face with those choices. Signs are critical in diagnosing and in monitoring once treatment has begun. Without solid signs, an overdose becomes much more of a probability than possibility.

Please understand that I am not trying to scare you, but I am trying to give you a bit of a wake-up call. I urge you to take a step back for a bit and give yourself and Princess the opportunity for the best possible outcome. Personally, I would love to see you get a second opinion from another vet unassociated with Princess so far, if you can.

There is a form of practicing medicine, human and animal, called evidence based medicine. Sounds good, huh? Not really. What that means is that the doc relies solely on studies, texts, etc. to treat their patients, NOT THE PATIENT. So even if the person/pet in front of them has shown they don't fit the profile, the docs continue to treat as if they do. Ideally our docs will treat us, not those few folks who participated in a certain study and reacted in a certain way. We are each individuals, called bioindividuality, and as such we do not all react the same to the same stimulus. For this reason, the narrow-minded statements your vets have made really make me quite afraid for Princess.

You and Princess are family and as such we are doing our best to see that you both face the coming years with as little upset as possible. As Scott said, we are not vets and don't have the book learning they do. But we do have a couple of things they don't have - a collective of years of first hand experience and a deep love for each and every one of our babies here, including Princess. So when it seem that we are bashing you over the head with something, that is not the case. We are simply desperate to help Princess have the best years she can with you and her family. Whatever you decide to do, we will support you and do our best to continue to help you. Our goal is only to see happy, healthy cush pups.

Hugs,
Leslie and the girls

[Squirt's Mom]

It's me again....I still have a few minutes before I am belly up :p and wanted to talk to you about you.

When Squirt was first diagnosed, I became engulfed in Cushing's - I read everything I could find, talked to anyone who would listen, and cried for weeks on end. The result of all that was mass confusion in my little brain. I had been told Squirt had a tumor on her pituitary and so everything I read seemed to say pituitary when it was actually saying adrenal. I had so many things mixed up it was unreal! And all I was trying to do was what was right for her but I made a real mess of it.

Now I'm not saying that is where you are, but I do feel that you are rather emotionally involved, well, ok, highly emotionally involved. ;) Which is perfectly normal.

I would like for you to do something - the weekend is coming up; make plans to do something with your family that is fun and relaxing for ya'll. Don't even turn on your computer, don't read the forum, don't research, don't talk to the vets, don't even say the word Cushing's. Do your best to put it out of your mind for a few days, just enjoy your family and Princess. Take a bubble bath with a good book and glass of wine; take a walk or two; go to the movies and out to eat; visit with friends or family - anything as long as it isn't related to Cushing's. Give your brain a chance to regroup as well as your heart. Then come back to us on Mon. and we will be here waiting on you.

You are a great mom, Jeanette, no one doubts that at all, and Princess is so very lucky to have such a loving, devoted mom. You will make the right decisions because you do love her so much and I know you want what is best for her. Do not doubt yourself. You are doing everything that needs to be done at the moment and Princess knows that you will continue to do so - as do we. :)

So, please take a break from all of this and enjoy a weekend with your family and Princess. I think you will feel much better afterward. I care about you, too, Jeanette, we all do.

Hugs,
Leslie and the girls

[mypuppy]

Hi Scott, I value your inputs, however, I think perhaps there has been some miscommunication on my part here. I spoke to my specialist today and discussed the full adrenal panel testing. At no given time did she refuse to do further work-up. She basically left the decision up to me. She said we can do the adrenal testing or repeat the ACTH stim. I chose the latter. Now getting to the other issue related to treatment with trilostane. Yes, my specialist favors the trilo against lysodern because she has had many negative responses with the lysodern and and many positive ones with trilo, so how can I argue with her hands-on expertise against mine? My questions to you are, if i were to continue with the full adrenal panel, what would change for me in terms of treatment? Do we then need to treat for another issue and wait on treating the Cushings? still confused. I want not to waste a single more moment. I feel good about my final decision in getting the appropriate help for Princess. Again, I do thank you and everyone else on this forum for all the valuable info--it has helped hugely in making my decision. Thanks. Jeanette

[mypuppy]

Hi Leslie, you may be belly up by now, but there's always tomorrow. Wow, you sound like a pretty amazing and loving person. You are absolutely right, I can probably use a break from all this since I have been buried in nothing else but Cushings since the dx. Thanks for the pep talk. At times I feel every minute counts for Princess, and that is why I've been working so diligently to reach my decision. You are too sweet honestly with all your kind words. And I think I will take your advice and try to just concentrate on family this weekend, God knows they must think I have totally abadoned them...You know the feeling so no need to explain myself. Thank you, thank you for your friendship. KIT, ya hear? Jeanette
.

[jrepac]

I'm sure the others will weigh in, but if you are going to test with UTK you might as well get the full adrenal profile; UTK is the only lab that does this particular test. UTK not only tests for "regular" cushings but atypical, which involves other hormones. Their test will tell you if these other hormones are out of whack....that result might influence your decision to use/not use trilostane, as one particular hormone, I am pretty sure is raised by trilostane. Depending on the results, UTK will suggest a variety of treatment options. If you are only interested in repeating the ACTH test, well that can be done almost anywhere.

UTK's full adrenal profile will cost you more (roughly $100 more than an ordinary ACTH), but it is a more complete test....it's sort of an ACTH "Plus" test....

I have heard of some vets preferring trilo over lyso...again, vets have opinions, just like we do. A co-worker of mine has a cocker w/cushings, and her vet strongly prefers trilo and the pup is doing well. My vet is a little wary of lyso (as am I), but every case is different. Another vet locally here strongly prefers lyso....different POVs from different vets.

[gpgscott]

At no given time did she refuse to do further work-up. She basically left the decision up to me. She said we can do the adrenal testing or repeat the ACTH stim. I chose the latter.

Jeanette,

Did the Dr. explain why the full panel is important and why it would help to direct the treatment. Did the Dr. tell you that Trilostane is not indicated for Atypical Cushing's in most cases? Did the Dr. tell you why she refuses to treat with Lysodren?

Bottom line is the wrong treatment is way worse than no treatment.

There is no reason to rush into a treatment, and I hope you will wait a bit, digest what you have learned in the last couple of days and go forward on your terms in the best interest of Princess.

Scott

[StarDeb55]

Jeanette, the 5 intermediate hormones produced by the adrenal glands can show elevations in one or more of them to reach a diagnosis of Atypical Cushing's. The pup can have Atypical without a concurrent elevation in cortisol or the cortisol can also be elevated which means you are dealing with regular Cushing's + Atypical. Trilostane is KNOWN to eventually raise the levels of some of these intermediate hormones. This is not a maybe or a possibly, it's a known fact the trilostane acts in this manner. If you have a pup with Atypical, this means that the use of trilostane which will, indeed, control the cortisol will eventually further raise the levels of these intermediate hormones. The increasing levels of intermediate hormones will probably lead to a return of symptoms & a probable exacerbation of symptoms. This is why treatment with trilostane is not recommended for Atypical pups. The only way to reach a diagnosis of Atypical is to have the full adrenal panel done by UTK. For example , when my Harley was diagnosed as Atypical +regular Cushing's, I made the comment to IMS about trilostane not being an option for Harley because of the Atypical, her comment was absolutely not, trilo can't be used on an Atypical pup.

I'm not sure anyone has explained what an IMS is today, if they did I did not see it.

IMS= internal medicine specialist.

Debbie

[mypuppy]

Hi Debbie,
Thanks for that clarification. So you are saying if this full adrenal panel comes back positive with those elevated hormones, we need to treat that first prior to even beginning a treatment for Cushings? And I am also understanding that if that is the case (elevated hormones) she may not be able to be treated with the trilostane because it can increase her hormone levels even more and risk other complications? My problem is that my vet refuses to treat the elevated cortisol problem with lysodern, so if I were to go ahead with the full adrenal testing and it comes back positive, what is my other option for Princess in terms of treatment for the cortisol issue being that my specialist does not treat with lysodern? what is the next drug if we come across these two issues? Perhaps you don't know. I would imagine, my specialist would have to. It totally makes sense. I am not going to rush into it, and think I may end up with the adrenal testing just to rule it out. Maybe I'll get lucky and end up with no hormone issues and then I can contently begin treatment. UGHHHH.....Thanks again for this. It was very helpful to say the least. Take care and will keep in touch...Jeanette.

[mypuppy]

ps: Debbie, with the full adrenal panel test, is it basically just drawn blood work from a vet. Do they have to IV the dog with any chemicals, like the LDDS? Sorry for picking your brain. Want to make sure it's done correctly. My specialist is an hour away, I have one other vet in the area I am looking into and hopefully he can perform this test. Will have to call....Thanks again.

[StarDeb55]

My answers are in blue.


So you are saying if this full adrenal panel comes back positive with those elevated hormones, we need to treat that first prior to even beginning a treatment for Cushings?


You can treat both at the same time. My Harley was diagnosed with both regular +Atypical, & has been treated for both. the past 18 months.



And I am also understanding that if that is the case (elevated hormones) she may not be able to be treated with the trilostane because it can increase her hormone levels even more and risk other complications


Correct. Dr. Jack Oliver at UTK has repeatedly emphasized the point to a number of members of this group, that trilostane will eventually elevate the intermediate hormones. He has told us in the past you can try trilostane, but if you have a return of symptoms while ACTH testing demonstrates that the cortisol is well controlled, the high probability is that trilo has increased the intermediate hormones causing the return of symptoms. The only other option is lysodren, there is nothing else. Lysodren will control ALL adrenal produced hormones. The one big exception to this is estradiol. Estradiol has non-adrenal sources of production such as fatty tissue, & brain tissue among other which lysodren will not touch. This is why melatonin + purified lignans are used to control this type of estradiol.


Debbie, with the full adrenal panel test, is it basically just drawn blood work from a vet. Do they have to IV the dog with any chemicals, like the LDDS?


The panel is basically an expanded ACTH test. A baseline blood level is drawn, then a stimulating agent such as cortrysyn is given. Another blood level is drawn either 1 or 2 hours after the stimulating agent is given, timing is dependent on what agent is used.

Right now, I would not worry just yet about the trilostane issue. I would get the full panel done. If the results come back showing elevations in any of the intermediate hormones, I would strongly encourage you & your treating vet to contact Dr. Oliver directly at UTK, so both of you can hear directly from him as to what happens when an Atypical pup receives trilostane. Dr. O is more than happy to consult with treating vets & owners at no charge, either via e-mail or he will talk to vets by phone. Dr. O is probably the foremost expert in the world on Atypical & ranks pretty high for regular Cushing's, so most of us highly value his input.

Debbie

[Squirt's Mom]

Hi Jeanette,

Let me see if I can simplify things a bit for you...this stuff is so confusing, I know!

There are basically 4 kinds of Cushing's -

1) Iatrogenic- caused by external influences like prolonged use of steroids and is treated by slowly weaning off the steriods. Once off the steroids, the signs go away and the pup is "cured"

2) PDH (Pituitary Dependent Hyperadrenocortism)- caused by a tumor on the pituitary gland that tells the adrenals to constantly release cortisol and is treated with Lysodren, Trilostane, or Ketochonozole (rarely), and in some cases radiation or surgery

3) ADH (Adrenal Dependent Hyperadrenocortism)- caused by a tumor(s) on the adrenal glands again causing constant release of cortisol and is treated with surgery to remove the tumor if the pup is a candidate, and the pup is cured. If surgery is not an option, then treatment with Lysodren, or sometimes Trilostane, is started

4) Atypical - may or may not involve a tumor, and is caused by an elevation in the intermediate, or sex, hormones which are estradiol, androstenedione, 17-hydroxyprogesterone, progesterone and aldosterone and is treated with melatonin and lignans; Atypical does not involve cortisol

Now, it is possible for a pup to have more than one form of Cushing's at a time. Rarely a pup will have both PDH and ADH, but it does happen. More commonly, pups will have either PDH or AHD and elevated sex hormones (Atypical). The two forms will be treated at the same time with Lysodren, melatonin, and lignans.

(As you can see, Lysodren is an integral part of Cushing's treatment regardless of the type. This is what worries me about the vet that refuses to treat with Lyso...they are severely limiting Princess's options for a quality life.)

I hope this helps you understand things a bit better. Keep asking questions, honey! You are doing great!

Hugs,
Leslie and the girls

[jrepac]

Confused yet?

As you can see, there are many different permutations that are possible.

Get the Full Adrenal Panel done first and go from there, I'd say is the best course of action.

If you are dealing with Atypical and/or "regular" Cushings, they can be treated simultaneously.

UTK will recommend lyso as a first choice if both atypical AND typical are present...but they do present a few other options to you...I've had this exchange w/them, since this is the situation I am dealing with.

you and your vet will then have to assess and decide what is best

[lucygoo]

Okay...I have a question for you all.

Has anyone had this full adrenal panel done and had it come back NOT atypical? It seems to me that every single one comes back "atypical". My understanding is that the rise in intermediate hormones is a naturally occuring thing with cushing's anyway, but the issue is whether it becomes a problem clinically with the dog. I know Lucy had symptoms of that, but it was not a problem clinically.

Thanks,
Gina

[StarDeb55]

Gina, as long as the dog is being treated with lysodren, there really isn't a huge issue because lyso will control ALL adrenal produced steroids. Where the catch to this is an elevated estradiol level, since estradiol is produced in non-adrenal tissue. If you are dealing with an elevated estradiol, then you have to include melatonin + lignans to control that type of estradiol.

Debbie

[lucygoo]

Hi Debbie,

Thanks, but I still would like to know if anyone has gotten this full adrenal panel done and gotten results back that were not atypical.

I was advised against using lysodren by my general vet, and Dr. Bruyette only uses it as a last resort, when all else fails.

I just want to know if anyone has had a non-atypical diagnosis returned from this utk panel.

Thanks,
Gina

[StarDeb55]

Gina, I've been a member of this group for 18 months, now. To the best of my recollection, the UTK panel results that have been posted have shown Atypical without a concurrent elevation of cortisol, but as far as I can recall all panel results have been Atypical, only varying in which hormones are elevated. I have had this discussion with my vet & both of us think that this is a case of most cases of Cushing's are Atypical to some extent, but since Lysodren will control everything, it's usually not a huge issue. The biggest issue is that the full adrenal panel testing has only been available, I believe, for about 3-4 years. Prior to that, a dog was treated with lysodren, the cortisol was kept in control, the dog's condition improved, & nobody was the wiser because these other hormones could not even be tested.

Debbie

[lucygoo]

Thanks, Debbie..

This confirmed my suspicion. I too believe that all cushing's dogs have a rise in the intermediates. This is not a reason to not treat with trilostane. Only if it becomes an issue clinically.

Gina

[labblab]

Gina, I've been a member of this group for 18 months, now. To the best of my recollection, the UTK panel results that have been posted have shown Atypical without a concurrent elevation of cortisol, but as far as I can recall all panel results have been Atypical, only varying in which hormones are elevated. I have had this discussion with my vet & both of us think that this is a case of most cases of Cushing's are Atypical to some extent, but since Lysodren will control everything, it's usually not a huge issue. The biggest issue is that the full adrenal panel testing has only been available, I believe, for about 3-4 years. Prior to that, a dog was treated with lysodren, the cortisol was kept in control, the dog's condition improved, & nobody was the wiser because these other hormones could not even be tested.
Debbie
Debbie, that is REALLY an interesting thought (and that was really an interesting question, Gina).

Jeanette, after reading all the good info that has been offered here over the last couple of days, this is where my own thoughts have ended up. I, too, hold Dr. Oliver in high esteem. And if it were my own dog, I personally would want to have the full UTK panel performed prior to starting my dog on trilostane (and I would consider Lysodren as an alternative treatment if my dog showed high pre-existing elevations of intermediate hormones). However, I do believe that there are other specialists who would also join your vet in making the decision to initially treat with trilostane -- regardless of the status of the intermediate hormones. I think that there are differences of opinion about this among the professionals.

So if you and your vet decide to go ahead with trilostane without the UTK panel, I will definitely be hoping that Princess does well and that you will see significant improvement in her symptoms. That will be the best news possible!!! But if the trilostane does a good job of lowering her cortisol level but her symptoms remain (or if they return later on down the road), then I'd return to this same question about her intermediate hormones and reconsider performing the UTK panel.

Marianne

[mypuppy]

Marianne, the information was extremely helpful. Now I'm finally understanding a lot of things to consider. And Marianne, I would be most interested in further work-up for Princess and making sure she is accurately diagnosed. I actually called my specialist today to get an idea of the fees involved with all these tests, and the full adrenal is a whopping $500.00....now don't get me wrong here anyone, I'd give my right arm for my pup...yes i would. i know that sounds insane, but she means the world to me. i want nothing more than to make her well and make her happy...she's an important part of my life, but i feel perhaps that's $500.00 that can go toward her treatment also. Again, my husband is the sole provider in the family (perhaps I will take a job?), and I do have little ones as well. But then again, there are the all so "get you into trouble" credit cards to consider...As I said, we have incurred quite a large amount so far with testing alone and would like to leave some finances for the treatment...God knows how much that will be, but we will make it happen somehow. I know we will. Down the road I will most definitely consider the adrenal testing regardless. For now we are going to repeat the ACTH LAB ONLY which will cost half of the adrenal panel just to reconfirm the cortisol levels are increased, and then proceed with treatment....Thanks again, will definitely keep everyone informed of Princess progress. I have faith it will be a great one. God Bless you all and Best regards, Jeanette.

[jrepac]

Marianne, the information was extremely helpful. Now I'm finally understanding a lot of things to consider. And Marianne, I would be most interested in further work-up for Princess and making sure she is accurately diagnosed. I actually called my specialist today to get an idea of the fees involved with all these tests, and the full adrenal is a whopping $500.00....

That is serious overcharging....UTK charges $140 for the test...your vet should really only be adding on cost for the shipping & handling plus some moderate fee. For example; my vet charges $180 for the usual ACTH he does w/a local lab; he charged me $250 for the UTK full adrenal ACTH.

Good luck w/your testing and treatment!

[jrepac]

Hi Debbie,

Thanks, but I still would like to know if anyone has gotten this full adrenal panel done and gotten results back that were not atypical.

I was advised against using lysodren by my general vet, and Dr. Bruyette only uses it as a last resort, when all else fails.

I just want to know if anyone has had a non-atypical diagnosis returned from this utk panel.

Thanks,
Gina

Perhaps most here who get the UTK full adrenal done are typically dealing with a cushings pup already and are inclined to get this test secondarily? As opposed to a clear cut case where only Atypical cushings is suspected? I thought we had several cases of Atypical only on this board, for certain. When I had the test done, 4/5 of the intermediate hormones were very, very high. Relatively speaking, worse off than the cortisol was. So, I am treating both the "regular" and the atypical versions of the disease, as opposed to just one or the other. [Lyso would be the most obvious/direct treatment since it tackles both conditions, but for the moment I am not using it.]

Jeff

[Squirt's Mom]

$500.00!!!!!!!! :eek::eek::eek::eek:

That's hiway robbery!!!! geez....even through my GP vet who has to order the gel in, it is about 1/2 that....WOW! Where are you located? Lord have mercy, girl! Jeff is correct - UTK charges $140.00 and your vet would tack on their charge for the blood draw and shipping but that seems really out of line...unless you are out of country, maybe?

Don't blame you if that is the best price you can find in your area but I would start saving my pennies to have the $$ just in case it is needed later down the road.

Hang in there!
Hugs,
Leslie and the girls

[acushdogsmom]

For example; my vet charges $180 for the usual ACTH he does w/a local lab; he charged me $250 for the UTK full adrenal ACTH.That's a good price for a stim and for the extended adrenal panel too. My Vet charged me more than $200 (maybe it was around $250 or more, I can't remember exactly) just for the regular ACTH stim (she doesn't set the pricing, she just works there). I used to wish that the cost was less, but if the choice was between staying with the Specialist Vet I love and moving to another Vet to maybe get a cheaper price on a stim test, I chose to stay with the Vet I trusted and to pay the higher price.

Shipping cost to UTK varies, too, possibly depending on how far away UTK actually is from the point of origin of the shipment.

We've just recently posted the first of several polls in our Polling Sub-forum, to see what our members in different countries pay for this kind of testing (diagnostic and monitoring) that we need to do for our Cushing's dogs:

http://www.k9cushings.com/forum/forumdisplay.php?f=28

We've noticed, over the years here at our message board, that testing prices vary greatly, from region to region and from Vet to Vet. And from what our members have posted and the poll results we've had so far, $200 or more for a regular ACTH stim apparently isn't really all that unusual.

[labblab]

Jeanette, I sure do understand the financial issues. :(

And in honesty, my suggestion that you might want to repeat the ACTH was largely due to thinking it would just be easy to include that along with the full UTK panel if you had decided to have the full panel done. You are definitely going to need more ACTH tests along the way to monitor Princess's trilostane dosing after you start her on the medication. So if your specialist doesn't think a repeat diagnostic ACTH is really necessary beforehand, then I certainly won't think poorly of you if you decide to save the money to apply to the testing later on down the road...

Marianne

[gpgscott]

Here are a few facts.

Cushing's is not a disease, it is a syndrome.

The syndrome can be brought about in various ways.

Elevated cortisol is classical.

Elevated intermediates are a more recently understood issue.

It can be induced.

Certain meds address cortisol elevations exclusively.

Other meds address cortisol elevations and exacerbate elevations of intermediate hormones.

All I am saying is that to dismiss the administration of a proven treatment because the 'Dr. does not like it' and to dismiss a diagnositic which would inform the treatment is; Well the only word I can find for that is strange.

Scott

[mypuppy]

Hi Leslie, Yes, I thought the same thing. $500.00 is steep considering I read on this forum UTK charges $140.00. I actually live in New York State (border with New Jersey), and my specialist is in Paramus, New Jersey-- (an hour away from home), in the U.S. I guess inflation has increased even more since the last time I checked....ughhhhh....and yes, i'll be penny pinching for a while just to treat the pooch. maybe I should move to another country - lol....Somehow it'll all work out...

[mypuppy]

Scott, as I said, my specialist did not refuse me the further work-up, but if she swears by the trilostane and emphasizes she will not treat with lysodern, there must be a perfectly valid explanation...she told me she has had a lot of problems in the past treating with the lysodern and trilostane has been more effective in her patients....that's really it. i can have which ever test i choose, she's not stopping me nor steering me away from it...but the fee for that test is quite more than i can afford at this moment unfortunately....thanks for your concerns. i do appreciate them....regards, Jeanette.

[StarDeb55]

Jeff, just to let you know my Harley was diagnosed both with Pit Cushing's + Atypical at the time of his diagnostic workup. My GP is relying solely on the UTK panel for suspected Cushing's cases, so Harley's diagnosis did not come "after the fact". When I took him to the IMS for confirmation, she wanted to do a US, also. I asked her if she needed anything else to make the diagnosis such as an LDDS, her response was no, all she needed was the UTK + the US. Harley showed an across the board elevation on the whole panel with substantial elevations in most of the associated hormones.

Debbie

[jrepac]

Jeff, just to let you know my Harley was diagnosed both with Pit Cushing's + Atypical at the time of his diagnostic workup. My GP is relying solely on the UTK panel for suspected Cushing's cases, so Harley's diagnosis did not come "after the fact". When I took him to the IMS for confirmation, she wanted to do a US, also. I asked her if she needed anything else to make the diagnosis such as an LDDS, her response was no, all she needed was the UTK + the US. Harley showed an across the board elevation on the whole panel with substantial elevations in most of the associated hormones.

Debbie
Thanks for letting me know; I had also considered the LDDS, but settled on the ACTH full adrenal panel (I had done a regular ACTH one year prior that was "high normal") and figured the UTK one was the way to go. I was glad I did it.

On another note, I also live in central NJ...Middlesex county. Some of the vets in Northern Jersey (Bergen County, for instance) charge absolutely BLACKMAIL prices, as they figure the people living up there are fairly wealthy...Oradell Animal Hospital is one.....I've heard all the stories. It pays to call around, unless one has very deep pockets and doesn't mind the cost.

[mypuppy]

JREPAC....I'm curious to know the name of your Veterinary Hospital and IMS in Middlesex county. And yes, Oradell Animal Hosp. in Paramus, NJ are the ones I have been dealing with being that they are the only facility one hour away from my home who have specialists experienced in dealing with these doggie problems...I moved from Bergen county, New Jersey to New York state because you are absolutely right, the business mentality down there is that everyone can afford to pay top price. It's ridiculous what that county is doing and driving people out to other remote areas...Of course, I do miss the conveniences I used to get there, but just the same. Now I'm stuck with the predicament of paying top dollar for further work up on the pup and treatment at Oradell because again, it's the closests facility to my home, and I do need the convenience when I'm dealing with a sick pup. I would be interested in knowing if you are happy with your specialist and what they charge you for an office visit. Oradell charged me a whopping $180.00 just for a consultation, add $600.00 for an abdominal ultrasound. It's outrageous. This is why I can't afford to do the UTK full adrenal panel, as much as I would love to, and no one else in my area performs this test....Now I regret not going to veterinary school. I could've treated my pup myself....

[jrepac]

Hi Jeanette...

I just had a "feeling" that you were dealing w/Oradell Animal Hospital, call it a hunch! I worked up in Teaneck, NJ for 6 years and several of my colleagues had gone to Oradell and encountered their extremely high prices. I know they position themselves as experts, but their prices seemed sky high to most of us going to GP vets; particularly for procedures that were priced much more reasonably at other vets. There is no acceptable rationale for such price gouging.:mad:

I am not currently using/seeing a specialist...just going to my regular vet (Rahway Animal Hospital)....and I had also been over to Iselin Animal Hospital (they also run/own Woodbridge Vet. Hospital), because the latter has more advanced equipment and can do more tests...like the ultrasound. I did pay $600 for my ultrasound as well, so that may be the going rate. I just did not care much for their bedside manner, so to speak, and went back to my regular vet. At this point, I had seen 5 different vets and each had a somewhat different opinion on things...Anyhow, things worked out just fine w/my regular vets as they were willing to consider what the other vets had done, the ultrasound, etc., plus they agreed to do the UTK testing for me...so all's well that ends well.:)

My vet usually charges $36 for office visit, but if I am coming in for something specific, i.e. shots, or existing condition, bloodwork, etc., he does not charge me that fee (but, I have been a customer there for many, many years)

I think the best thing to do is talk to friends and neighbors with pets and see who they go to, ask their experiences, etc. You may not need a specialist 100% of the time, maybe only for certain procedures/tests. I do think it is a good thing to locate a vet who has had cushings patients before and is open to having a dialogue w/you regarding treatment options.

The only other specialists in NJ that I am familiar with are Garden State Veterinary, but they are down in Tinton Falls, which is likely too far for you. They are expensive too, but my Mandy needed 2 leg surgeries 6 years ago and my regular vet felt that GS was the best place to have it done; they did do an excellent job ($3200 later).

Good luck!

Jeff

[forscooter]

Just a Jersey girl chiming in quickly bc I am at work....there is also Red Bank Vet Hospital which is supposed to be excellent. Not sure how far you are from there....or if you would even want to try it....or what the prices are like.

I pay about $260 per ACTH test at my GPs....

everything costs more in Jersey....part of the attraction of living here!:(

Will check back soon....

but I hear ya on the costs....it's crazy! Beth and the rest of them

[gpgscott]

Jeanette,

Please understand my position.

You don't owe me or anyone here or elsewhere an explanation of why you are treating the way you do. This is between you and your Dr.

This forum is a place for may people to come together and share experiences. I am sharing my experiences and opinions with you.

Whatever path you choose is yours and we all want to hear about it to help us understand. I do have issues with what you have been told and I have told you about them.

Please continue to let us know how you proceed and I also continue to wish for the best outcome for you and Princess.

Scott

[k9diabetes]

Bonnie's dog Crissy Ann was atypical only. She went through a long period of looking absolutely Cushinoid - all the symptoms - but no cortisol elevation.

I too wonder whether any UTK results have come back with (1) elevated cortisol but (2) no elevated intermediates.

Seems like Dr. O would be the one to ask about this question - does he routinely see UTK panels come back with elevated cortisol and no elevation in the other hormones.

Natalie

[forscooter]

Natalie, I think that is a GREAT question....sorry for the sideline here, Jeanette!! :) But honestly, I would be curious about that.

One thing I know in my exchanges with Dr. Oliver with Scooter when I was considering if he was in fact Atypical was if I should have Scooter tested. While Dr. Oliver is not against trilostane so please do not take it like I am saying that at all!!!!!......is that Lysodren does act on all the hormones with the exception of estradiol so he thought by adding the melatonin we were covering all bases anyway and the panel would not be needed. If however, Scooter had been on trilo, a goal would have been to do the full panel.

Jeanette, to get back to you, I think everyone is just trying to give you the benefit of experience as Scott said. To hopefully make you feel a little better, I understand the financial issue. I had 2 dogs with Cushing's and ran up so much debt I can't even tell you....and that was including the skimping with some testing and treatments bc I just could not manage.

But everyone here understands...and remain supportive. We all do the best we can with what we have and can do....and there is no doubt you are doing that for Princess as well. Maybe someday you can do the panel....this is all just so you know what you may run into and what you may want to consider as you move forward.

Sending our very best, Beth, Bailey, always Scoobie, Allo and Pallie

[mypuppy]

Hey Debbie, no problem. I do want the best for my dog, she's like my child. And I don't take anything here personal in the least. I understand and appreciate Scott's and everybody else's wonderful advice, opinions and I thank each and everyone one of you for sharing all your experiences with me related to this dreaded syndrome. In a nut shell, all of us here are or have been in a hard place with our precious pups. The fact that we can all exchange valuable information is priceless to me. I have and still learning a lot from all of you. I wish I could read and reply to everyone's posts, but there are not enough hours in the day. Have 2 little ones to tend to and give extra TLC to my 4 legged baby. I wish everyone well with your pups, keep up the great work on this forum, and lots of hugs and kisses to all your pups. xo Jeanette

[mypuppy]

ps: to Beth, OOPS! in my last post, I addressed you as Debbie, sorry....my mistake....I meant you...Regards.

[mypuppy]

Scott, no offense taken. And I totally understand where you're coming from here. Your resources are very valid and they make a ton of sense. I know my specialist seems quite a bit close minded about other treatments and is dead set on treatment with Trilostane. Unfortunately, she did come very highly recommended, not that I'm under any obligation to stick with her, but for now I do need to remain with her since there are no other IMS's in my area. She's the closests to me (1 hour), and well anything further than that would not be ideal when you are treating a Cushings pup I presume. In the meantime, I will be opening my UTK adrenal test fund and I am seriously hoping to have Princess tested a little further down the road. BTW, I notice your pup is a chocolate lab. Princess is too. They are great, aren't they? Licks to him from Princess....lol....Best regards....Jeanette and Princess..

[mypuppy]

Jeff, I don't understand the astronomical fees myself. I'm guessing they are trying to make up for their overhead in building such a state of the art facility...Geez, I remember when Princess was a mere pup going to them when they were actually in Oradell, but their fees where not as absurd 7 years ago. It really is a shame. At any rate, that's wonderful that you were able to perform the full adrenal panel. What was the outcome of your tests? I'm curious, and how did your specialist treat? Anyway, in terms of IMS, I am forced to stick to Oradell's because there are no other in my area, and as you said, would like to remain with a specialist that has experience in treating quite a few cases of Cushings against the veterinarians in my area who do not have much knowledge on the syndrome itself. I mean come on, my reg. vet didn't even suspect, suggest testing for it and left it as a "psychogenic" condition....Ask me who's the crazy one here? Def. not the dog....That's where Oradell came into my mind for me because I know they are highly equipped to deal with these problems. Oh, and I have heard of Garden State Vets but that is a long hike from where I am. It would not be ideal for me. Anyway, thanks for all the info. Will keep everyone up to date on any progress. Regards. Jeanette.

[mypuppy]

I would also like to ask everyone on this forum, or whoever is willing to share more info with me. I was curious to know if anyone experienced any aggressive behavior with their pups after being diagnosed with Cushings or while on treatment? Princess has not changed her behavior other than symptoms associated with this thing, but she is still lovable. Family members keep asking me if she will become aggressive, etc. I can't even imagine my pup turning on me one day because she's in pain or anything associated with Cushings, but I do have little ones that I have to constantly watch and make sure they don't overdo it with her when she wants to be left alone. My other question is regarding Trilostane, I know a lot of you here have not treated your pups with the trilo, but those who have, can you detail what side effects, if any, your pups developed while on it? Thanks again to anyone who would want to answer these for me.....Regards....Jeanett....

[Harley PoMMom]

Hi Jeanette,

We will always, always share information with you, ok, this forum, as far as I am concerned is about our pups and their health and welfare.

Now my boy Harley is a Pom. he is 13 y/o, he weighs 20#, so I can pick him up, BUT I have to be so very careful how I do it bc of his enlarged liver, his tummy tends to be sensitive. Also when he was at his IMS last time she gave his a rectal exam that he did not like one bit and now that anyone else but me goes to put their hands on his rear...well he wants to growl and show teeth and snap. These things can happen bc our pups have to have so many tests, exams and being poked at, sometimes they just have had it...can you blame them?

Love and hugs.
Lori

[mypuppy]

Hi Lori,
Thanks for your reply, and oh poor Harley! No, I can't blame him at all for being sick and tired of being poked and pricked, and not even understanding why? Geez, I wonder if they can even reason why all these horrible things are being done to them? Unlike humans, we understand. After Princesses last water deprivation test, I think she got quite a bit traumatized when I had to take her back for the ACTH stim. She was trembling and shivering in fear in the car, as if she knew where she was going. It's terrible to watch our pets this way. It breaks my heart, and I am sooo dreading starting the treatment because I don't really know what I'm up against in terms of side effects from meds. But anyway, being that I've lost track of everyone's stories here--how old was Harley when he got diagnosed. 13 is a great life span for a dog. I am so hoping my Princess will get there too, even with this condition. How do you feel, aside from all the treatments and testing, was Harley's quality of life with this disease? Did you find him happier most of the times or uncomfortable? How about his symptoms, did they go away altogether or did they reappear after treatment stopped and had to restart his treatment? So many questions, so little time right....I am scheduled to speak to my IMS tomorrow regarding treatment, so I'm a bit nervous right now and would like to know more if possible. Thanks again for all your support....Hugs to you too, Jeanette.

[Squirt's Mom]

Mornin' Jeanette,

Uh-hum...what happened to taking a weekend off from Cushing's?!?! :p

Aggression with Cushing's - as long as the pup is treated, pain isn't an issue, in fact, Cushing's itself isn't painful, it is the effect it has on the internal organs that can sometimes become sensitive like Lori was describing. Plus the point she made about the numerous testing, poking, etc. they go through at the vets - they can get a bit testy there or about certain areas of their body, but if you have a good vet who is gentle and takes their time, this may not become an issue. A lot depends on the nature of the pup, too.

If you see a behavior change like aggression, I would suspect something unrelated to Cushing's, like hypothyroidism, and have that checked out first as well as ruling out any other cause for the change.

There is the possibility with PDH that the tumor will began to grow, putting pressure on the brain itself, which could cause behavior changes such as aggression, but you would more than likely see other changes as well that would point to this scenario. Most pups do not develop a macro-tumor, tho, that is why I would look into some other cause first.

Tell your family that they can expect Princess to stay the sweet loving lady she has always been. And once the Trilo has started to work on the cortisol, she will feel even better and show it in her behavior.

We don't treat with Trilo, but maybe I can help with your other question. The side effects you should be prepared for are the same as with Lyso as far as an over-dose goes - vomiting, lethargy, weakness in the hind legs, diarrhea. Some of the things I have read here about pups on Trilo are how fast Trilo drops the cortisol which can put the pup in a sort of withdrawal - like coming off of speed, in fact, in a human. You may see trembling in the legs, a bit of lethargy, and loss of appetite, but these generally go away as they adjust to less cortisol. Loss of appetite is something that may happen with Trilo pups and should be watched for as it can reach the point of anorexia, but that is not common. Once the pup has been on Trilo for a bit, you may see some weird hair and skin changes, like sloughing off of dead skin, hair loss to be replaced with a downy new coat that may be different from the original one. These are some of the things I have read about with pups on Trilo - hope it helps you some. Here is a link about Trilo, too, that may give you a better understanding of the drug. You will notice this was written prior to approval in the US.

Trilostane info
http://veterinarymedicine.dvm360.com/vetmed/article/articleDetail.jsp?id=491107&pageID=1&sk=&date=

Sweetie, we will always talk with you and listen to you - even if we believe you are absolutely out of your mind! :eek::p;):D I can recall only one person in the almost 2 years that I have been here that caused us ALL to back off, and that person came basically asking us "permission" to kill her pup just because he drank and ate all the time - she didn't want to deal with the Cushing's. I was very bad and told her off. :o:( And she did kill her baby. :(:(:( That is the only reason we would ever stop talking to you or anyone else - when we realize they are not interested in saving their pup or helping it, but just want to be rid of it or to let it suffer needlessly. I just don't think you are that type of person, honey, in fact, I know you aren't. So don't ever worry about us not responding! If things get busy on the board, a post is sometimes overlooked, but it is never on purpose. OK? You are family, you and Princess both.

Hugs,
Leslie and the girls

[Squirt's Mom]

How about his symptoms, did they go away altogether or did they reappear after treatment stopped and had to restart his treatment?

Honey, I don't want you to be misguided here - treatment for Cushing's is life-long. Remissions are rare, even on Trilo. So don't expect that you will treat Princess until the signs are gone and she will not need further treatment. Any time treatment is suspended for any reason, expect the signs reappear and the discomfort for the pup to return and the damage to start up again. Treatment is for a life-time in the majority of cases. I hope your vet hasn't mislead you about this - don't count on a remission with Trilo - it is uncommon based on what we have seen.

Hugs,
me and the girls again :p

[Roxee's Dad]

Hi Jeanette,


I was curious to know if anyone experienced any aggressive behavior with their pups after being diagnosed with Cushings or while on treatment?

Roxee was dx'd in early 2006, she was always a lover girl and remained so the entire time. :)The only aggression she had was over food and that ended once she started her treatment (Trilostane)


My other question is regarding Trilostane, I know a lot of you here have not treated your pups with the trilo, but those who have, can you detail what side effects, if any, your pups developed while on it?

Roxee was started on a lower dose and had no undesirable visible side effects. She regained her muscle tone, lost her pot belly, and grew her hair back, reduced appetite and thirst. :) Biggest thing was to know what to watch for and convincing my vet to admin the proper dosage. Originally he wanted to start at a higher dose than recommeded by Dechra.:(

In the end she succumbed to neurological problems. The vet said it could have been a macrotumor, myotonia or a myopathy of some kind.

At times during the treatment, she had totally lost interest in food and began to lose too much weight. Could have been due to the neurological issues? Could have been a side effect of the trilo I just don't know. I do wish I had the UTK performed just to rule out any other adrenal issues.

If I had a do over, First, I would have proceeded with treatment back in 2006. I would have had a CT or MRI just to check the pit tumor size to be able to monitor it. Fianally, I would have the UTK just so I would know what was going on inside. But that is just me.

The most important part of treatment, whichever you choose is a proper diagnosis, following proven protocol of treatment and monitoring, and working with a vet that is experienced and willing to have an open discussion with you about symptoms, side effects, and your concerns. If your vet doesn't like to be questioned about his or her decisions, then his paycheck would not be lined with my money!

I wish you and Princess the best in whichever route you take. Either route will require a diligent pet owner to watch for any little signs. She is still young at 7 years old. :) I am grooming labs that are so sweet and lovable that are 13 years old.:):):)

[haf549]

Hi Jeanett:

You were asking about reaction to trilostane. Well, Kira has been on it for a year now and I am happy with the results.

In the beginning, it was a real trial and error and it took us until January to stablize her. She started out with 120mg a day (she weighed about 80lb at the time and that is the right dosage for a dog her size). She got very lethargic and had a touch of diahrea. I say a touch, because it wasn't that constant horrible runny stuff. It was soft though (sorry for the description, but you asked) and not what I normally expected from her. However, I was able to control it and get her back to normal by mixing rice into her meal. As dessert, I also gave her yogurt (regular or as a treat, frozen). At the time, I had also changed her food (the vet suggested that she go on food that was 18% protein, as opposed to the food I was giving her, which was 32% protein), so that could have contributed to the soft stool. It was the lethargy that particularly worried me; I was told to watch out for that. So the vet and I discussed it and we decided to change her to twice a day dosing. At the time, the vet said I should give Kira 120mg twice a day, but that didn't seem right to me. I insisted that it should be 60mg twice a day. The vet said that she had checked with an IMS and he had told her that the dosage should be the same both times. I dug my heals in on that and insisted she double check the the IMS. Well, lo and behold, I was right; the IMS told her the dosage should be halved, not doubled. Bottom line; if it doesn't feel right to you, don't be afraid to question the vet.

Before the meds, Kira was drinking up to 5 litres of water a day, panting excessively and eating anything within snout height. Well, her clinical symptoms started to dissipate (I finally got her down to about 1 litre of water a day, which is about right for her and she started to become her old picky self with the food). I've got to admit, the eating of her food was the one symptom I didn't mind so much. She was always such a picky eater and now she would eat whatever I gave her, but..... However, even with the twice a day dosing, she was still just lying around and sleeping all the time. I was winter (her time of year) and all she would do was lie on top of the snow, dozing. She was also still panting quite a bit and at night some times her breathing was really raspy. Twice her nightly breathing was so bad, that I panicked and gave her prednisone (make sure you have some on hand in case of an overdose). Each time I took her to the vet the next day and they found that the raspy breathing was due to a respiratory infection; not the trilostane. We cleared that up with anti-biotics.

In January, Kira's regular vet (who was out on medical leave) came back. It was after one of the prednisone incidents and we had a very nice chat. He is a very calm person. So he sat down with me and discussed all my concerns. Then he pulled out a calculator and calculated what the minimum dose for a dog Kira's size should be. It turns out 75mg was the magic number. Since I had 20mg tablets, I switched her to 40mg twice a day. We haven't looked back since. Her clinical symptoms have all disappeared (except for panting) even though her stim numbers are a bit on the high side of normal. However, the vet said, 'we are treating the symptoms, not the numbers'.

It took until early summer before she was pretty much her normal self again. Dogs usually pant for 1 of 3 reasons; they're warm; they're in pain; they're nervous. Well, Kira falls into all 3 of those categories. She's a husky, so the warm weather is a real trial to her. She's got arthritis and that got worse as the medication kicked in. Cushings increases the cortisol in they're systems; the treatment reduced the cortisol; cortisol controls the arthritis pain. Therefore, once the cortisol levels were reduced, her arthritis pain got worse. Occasionally, when it appears to be really bad (rainy days) I give her about 25mg of metacam, but I try to hold off on that because I'm not sure how NSAIDS react with the trilo. She's also a really nervous dog. She hates any kind of rainy weather weather, not just thunderstorms. She's usually a better predictor of rainfall than the weatherman. Usually a couple of hours before a rainfall, she starts panting and getting nervous and hides in the basement. I also suspect she's afraid of the dark and things that go bump in the night. Her panting is usually worse at night.

I know this is all a bit long-winded, but I wanted to show you examples of what I experienced with Kira during her introduction to trilostane. Things to watch out for: lethargy, vomiting and diahrea and anything else that is out of the norm for your baby. Make sure you have some prednisone on hand just in case. You're probably wondering when it should be given, well first off, ask your vet for some direction on that, but also trust your gut. If you think your baby is in some trouble, give the med; it won't hurt them and they usually respond to the pred within a couple of hours. But once given, make sure you take them to the vet the next day and tell them about what made you give the dog the pred. Also, once you give the pred, stop the trilo. You should give them at least 3 or 4 days (or whatever the vet says) before restarting the trilo. Monitor your dog carefully in the beginning. Measure the amount of water she's currently drinking and the time it takes her to eat her dinner. As the trilo kicks in, the amount of water should gradually reduce and the time it takes her to eat her bowl of food should also reduce.

And most of all, don't expect miracles. The trilostane can work very quickly (2 or 3 days) but in some instances (like Kira's) it can take months. Work with your vet to get the dosing right and most of all, don't give up.

Heidi

[forscooter]

Jeanette,

I have to chime in and tell you that yes, they can be aggressive....not to alarm you. But, when the cortisol levels are high, it is the same feeling as the flight or fight response as cortisol is one of the hormones released during that time. Not every dog experiences it, and I think if Princess were to be feeling that way, you would see it by now. But, I did notice it with one of mine and I did some research. He was a little aggressive to begin with so that may have tipped the scale for him.

I asked the vet about this and also looked at some publications. I can't remember where now bc it was a while back. But high cortisol levels themselves can cause a dog to feel nervous, anxious, on-edge....add to that that they just feel kind of punky with those levels anyway and the potential does exist.

My dog, even though he would bite, never displayed that level of aggression while his cortisol was elevated. But he was most definitely more easy to "tick off" and we just knew to back off.

If you think about how the body responds when stress hormones are released, how you yourself feel, that's kind of what they can feel like just for no reason.

I think you are fine with Princess....but I did want to add this in bc it can affect behavior....

Lots of hugs, Beth (aka Debbie, LOL ;)) and the crew

[jrepac]

At any rate, that's wonderful that you were able to perform the full adrenal panel. What was the outcome of your tests? I'm curious, and how did your specialist treat? .

The UTK full adrenal came back positive for both types of cushings...the cortisol was elevated plus 4/5 of the intermediate hormones were off the charts.

I had already been treating w/anipryl (generic selegiline) under strong suspicion of cushings syndrome. Once the UTK test came back, we added flax seed and melatonin to the mix. She also gets cranberry (for preventing UTIs), SAM-e and Milk Thistle (the latter 2 for her liver). It's been about 4 months on the new regimen, so pretty soon we'll have to check progress (likely I'll do a multi-day urine sample and get the cortisol checked, simply to see if it is higher/lower than about 6 months ago). However, observationallly, behaviorally, symptomatically, my Aussie seems to be doing quite well.

Also, I must note that her symptoms were mild and uncomplicated to start with, so the anipryl may be doing just enough to keep her condition under control. This drug has minimal side effects (is milder), but deemed relatively less effective than some of the others out there (for some, it may have no effect).

Jeff

[Harley PoMMom]

Hi Lori,
Thanks for your reply, and oh poor Harley! No, I can't blame him at all for being sick and tired of being poked and pricked, and not even understanding why? Geez, I wonder if they can even reason why all these horrible things are being done to them? Unlike humans, we understand. After Princesses last water deprivation test, I think she got quite a bit traumatized when I had to take her back for the ACTH stim. She was trembling and shivering in fear in the car, as if she knew where she was going. It's terrible to watch our pets this way. It breaks my heart, and I am sooo dreading starting the treatment because I don't really know what I'm up against in terms of side effects from meds. But anyway, being that I've lost track of everyone's stories here--how old was Harley when he got diagnosed. 13 is a great life span for a dog.

Harley was 12y/o when he was dx'd with cushings...but he did not get his "proper diagnosis" until recently, Jeanette it took me almost 8 months to get him properly diagnosed.

I am so hoping my Princess will get there too, even with this condition. How do you feel, aside from all the treatments and testing, was Harley's quality of life with this disease?

Harley is doing great, he still plays frisbee every day, and at night he always wants to throw one of his toys around...now at 13 he can't go for the long walks like we used to, but other than that Harley is much like his "pre-cushings" self.

Did you find him happier most of the times or uncomfortable? How about his symptoms, did they go away altogether or did they reappear after treatment stopped and had to restart his treatment?

His treatment will be forever and more than likely I will have to put him on Lysodren in the future, as of right now he is a happy fellow who every now and then does have some pain from his pancreatitis or arthritis, but tramadol takes care of that for him. He still has a pot-belly but it's not as big as it once was, he's not panting as much as he used to and the same goes for his drinking and peeing. Now his appetite, that's another story, but Harley's always been a little piggy. Harley's is gaining muscle back in his hind quarters.

So many questions, so little time right....I am scheduled to speak to my IMS tomorrow regarding treatment, so I'm a bit nervous right now and would like to know more if possible. Thanks again for all your support....Hugs to you too, Jeanette.

Ask all the questions you want, anything, I understand about the nervousiness...I do have a suggesstion for when you go see your IMS, I take a tape recorder bc I always forget alot of what was said between Harley's IMS and me, my feeble mind and usually she and I talk alot too. :eek::)

Love and hugs
Lori

[mypuppy]

Good afternoon to you Leslie,

Yes, so much for taking a break away from this! What can I say, I feel I should NOT waste a single second and learn as much as possible prior to treating Princess, so I at least know some of the things I will be faced with. I'd rather sacrifice now but at least I won't be totally ignorant later. As for hypothyroidism, we did rule that out before anything, with the Free T4, so I'm at least relieved in that respect. What worries me is the fact that she may have a tumor, and we can't even do much to remove it considering it's pituitary..Such a shame. The other concern I have after reading Lori's post was how long it took her to properly diagnosed her pup...8 months. Geez! I am so torn on how to proceed now because I finally made up my mind to go ahead with treatment, waiting for specialist to call today, and at the same time, feel what if there's something else going on, and she will be treated in vain. This is where we go back to that UTK adrenal test...As for the side effects, I read them online as well--it scares and saddens me for my Princess.

BTW, her excessive drinking and having to let her out does not bother me in the sense that I feel I'm being put out....It bothers me that she feels that way all the time, and I won't even drink water in front of her because I know she'll be right by my side wanting some. Same thing with the appetite, she's scrounging for food everywhere. In fact, we recently had a bear coming for our garbage, not that we are filthy people who keep garbage out. We actually keep it inside the garage, and unfort. my hubby rolled one of the bins to get something inside the garage and he assume it was an empty bin and left it in the driveway, well that bear did some damage that night, garbage all over my yard, and Princess was all over that when I let her out first thing in am. Only I didn't know that happened until I let her out, but anyway, that person obviously should not have been a dog owner if she couldn't accept her pup had a condition that made her have those symptoms. when one of our family members get stricken with an ailment we don't leave them to die because they are a burden, we treat them, but that's insensitive people for you. And NO I am not that type of person. I LOVE MY PRINCESS TO DEATH, as the saying goes. Ugh, everytime I look at her, I just have to kiss her and hug her. Ok, getting a little emotional now, tears, tears, but enough of that. Now let's see, you are such a loving person Leslie, right along with some others here, Lori, Beth, Debbie, etc. Wow! I feel as if I've know you all for a lifetime in such a short period of time. Thanks again for your friendship...xo Jeanette

[Harley PoMMom]

Hi Jeanette,

I should clarify with you about Harley, altho one should take the time they need to make sure they have a proper diagnosis for their pup, it usually does not take 8 months, Harley's case was a perplexing one, even tho we ( Me, Vet, IMS, and Dr Oliver), were positive he had PDH cushings and he was Atypical, we just couldn't figure out if we wanted to start him on a maintenance dose of Lysodren or load him, then with the help of this form, I decided to stim my boy bc when I had his UTK adrenal panel done, which was done in April 09, his cortisol levels were within normal ranges. Low and behold he stimmed again within the normal ranges, this was done in Sept 09...you see his IMS and his vet wanted to put him on Lysodren even tho his stims are normal, which I did not want to do. I emailed Dr Oliver and asked his advice and I asked the advice of our knowledgeable members here too. Dr Oliver's response was to NOT use the Lysodren when his cortisol is in the normal ranges. Dr Oliver truly believes, and I do too, that Harley's symptoms are due to his very elevated estradiol level.

So altho my boy was dx'd in Feb 09 it did take me until the beginning of Oct 09 to get my boy properly dx'd, but like I said his was a wild and bumpy road. If you care to read my boys thread it is here...:eek:

Harley's visit to the Univ. of Penn./Atypical

http://www.k9cushings.com/forum/showthread.php?t=421

Love and hugs.
Lori

[lulusmom]

Hi Jeannette,

My little Lulu was diagnosed at three years old and based on her long standing symptoms, her internal medicine specialist suspected that she had gone undiagnosed for at least a year. She is one of the rare dogs that was diagnosed with the disease at a very early age. If Lulu's coat didn't look like something the cat drug in, you wouldn't know she was sick with any disease. She panted like a freight train, drank volumes of water, peed whenever and wherever, sucked up food like a hoover vacuum and looked like a Vietnamese Pot Belly Pig. She acted slightly uncomfortable; however, when she was dealing with oxalate bladder stones which are common in cushdogs. Her gp vet was a total moron and couldn't spell the word cushing's so she had two bouts of stones requiring surgery 11 months apart before an internal medicine specialist did a thorough job of diagnosing her. We loaded her with Lysodren and she aced it with no ill effects.

Please don't fret about taking your time to do things right and try to remember that cushing's is a very graded disease that takes a very long time for a dog to suffer from the affects of excess cortisol. Unless a cushdog has a concurrent disease or chronic infections that are causing some discomfort, cushdogs are really not in pain. Cortisol is a natural anti-inflammatory and in excess it makes a dog hungry and affects their ability to concentrate their urine which is why they pee so much but otherwise it's a feel good thing. I want to point out that cushdogs do not pee a lot because they drink too much, it is the opposite....they drink to keep up with the peeing. Otherwise, they can quickly dehydrate, get very sick and even die. It is therefore, extremely important that you give Princess free access to fresh water at all times.

I have a second cushdog, Jojo, who was a foster dog and my husband and I decided to adopt him when we discovered he had cushing's. I actually diagnosed him after living with him for two weeks. I suspected that he had lived with the disease for years as he had severe ear, eye and skin infections, could barely walk from muscle loss, would take you down for a morsel of food and drank and peed like nobody's business. He was officially diagnosed after having an LDDS, HDDS, and abdominal ultrasound. The disease has been effectively controlled for two years; however, his drinking and peeing never resolved. You wouldn't recognize him as the same dog that came into our home two years ago. He is a bouncing baby boy and a happy camper that will always drinks like a fish and pee like a racehorse. Oy!!!

Lulu is a Pomeranian and her internal medicine specialist explained to me that Poms, along with other breeds have a predisposition to hormonal imbalances. He therefore requested a UTK adrenal panel and yes, she had a few elevated sex hormones.


I too believe that all cushing's dogs have a rise in the intermediates. This is not a reason to not treat with trilostane. Only if it becomes an issue clinically.
Gina

I tend to agree with Gina on this but only because Princess is not a breed that is predisposed to hyperadrenal activity. My dog is predisposed and I made the mistake of switching her to Trilostane for two years. The effects were total loss of the fuzzy coat that she regained with Trilostane and severe elevations of all adrenal hormones. She has been back on Lysodren for a year.

Dr. Mark Peterson, a very well published expert on cushing's, states that "most" dogs with classic hyperadrenocorticism also have elevations of other steroid adrenal hormones both before and after stimulation with ACTH. Dr. Oliver is the UTK expert in adrenal steroids and I have an immense amount of respect for him. There is not doubt in my mind that his published studies showing that trilostane will, over time, increase one or more the intermediate hormones is absolutely credible; however, he has stated; "Trilostane reportedly offers effective control of cushing's syndrome but the long-term effects of the elevated intermediate steroids remain ill-defined. Some dogs have return of clinical signs of cushing's syndrome while on Trilostane."

I am intimately familiar with both Lysodren and Trilostane and believe that both are extremely effective drugs and Princess would benefit from either one. I also believe that it is more important to treat with the drug that your vet feels most comfortable with. They are both extremely serious drugs and the key to facilitating safe and effective treatment is that protocol be followed to the letter and the pet owner is educated and montitors their dog vigilantly.

At this point, I would be more concerned that an accurate cushing's diagnosis has been confirmed by way of testing other than the UTK adrenal panel. You have a very active thread and I am a slow reader so would appreciate it if you could save me a few hours of reading by telling me if your vet and/or IM have told you whether Princess has adrenal or pituitary based cushing's. I did note that the ultrasound was normal. Given Princess' extremely high post acth cortisol of 50 ug/dl, I would think there would be some noticable enlargement to one or both of the adrenals. Depending on how long this high level of cortisol has been going on, I would also think the ultrasound would have shown liver enlargement or at least some type of change in the liver. Do you have a copy of the ultrasound finding that you can post here? If not, can you get a copy from your vet? I don't consider Princess' age to be that senior so if an adrenal tumor is involved and she is otherwise healthy, surgery could be a terrific option. Forgive me if I may have missed a page or two that already covered this.

Glynda

[gpgscott]

As for hypothyroidism, we did rule that out before anything, with the Free T4Jeanette

Jeanette,

I think it is important for you to find out if a TSH (thyroid stimulating hormone) was done in conjuction with the free T4.

It is my understanding that the preliminary diagnosis of thyroid sufficiency requires the TSH in conjuction with either T4 or free T4.

You can have a normal or low normal T4 (or free T4) which in the presence of a normal TSH is normal thyroid function, but in the presence of elevated TSH is indicative of primary hypothyroid.

Thyroid is a big under-diagnosed issue.

Scott

[mypuppy]

Hi Scott, Below are Princesses Free T4 and yes, she also received the cTSH test: here they are: These were used to r/o hypothyroidism. What's your take?

FREE T4-ed (ng/dL)
Result: 1.2
Reference range: 0.7 - 3.7 ng/dL

FREE T4-ed (pmol/L)
Result: 15.4
Reference range: 9.0 - 47.4 pmol/L

cTSH
Result: 0.45
Reference range: 0.05 - 0.42 ng/mL
Flag: High

comments:
Increase canine TSH values may occur in dogs with untreated primary hypothyroidism. Sick euthyroid dogs are expected to have low normal TSH concentrations. Secondary or tertiary hypothyroidism (pituitary or hypothalamic lesions) are reported to occur in less than 5% of hypothyroid dogs.

[gpgscott]

Hi Scott, Below are Princesses Free T4 and yes, she also received the cTSH test: here they are: These were used to r/o hypothyroidism. What's your take?


Thanks for posting this Jeanette,

Not a Dr. here, but it looks like hypothroid to me.

Let's see what some of the others think.

Scott

[lulusmom]

Scott, I dug through my paperwork on interpreting hypothyroid testing and I found a paper by Michigan State University Diagnostic Center for Population and Animal Health. They stated that they were aware of a few circumstances of normal thyroid hormone concentrations with elevated thyroid stimulating hormone. There are possibilities they have probably yet to learn but they state:


Spurious elevations in TSH are occasionally seen both as a laboratory artifact and as a non-repeatable physiological anomaly. These two possibilities are identified by submitting a repeat sample for analysis. Physiologic explanation for this pattern of test results include recovery from significant non-thyroidal illness when that illness had been associated with low serum thryoid hiormone concentrations, and recovery from a reversible sulfa-drug-induced hypothyroidism. In these instances, elevated serum TSH concentrations are observed as the pituitary encourages the suppressed thyroid glands to return to function. A similar finding might follow withdrawal of prolonged thyroid medication from a dog which had normal thyroid function."

I goes on but basically but the best approach to this type of result is to retest at a later date.

[mypuppy]

Dear Glynda,
Thanks so much for your input. And so sorry to hear your Lulu was diagnosed with this condition at such an early age. BTW, when was it actually diagnosed? How is she doing these days?

At any rate, I'll summarize Princesses history which brought her to a Cushings diagnosis. She began with the clinical symptoms, extreme thirst and urination so I took her in for a CBC, urinalysis, thereafter they performed a water deprivation test to r/o diabetes insipidus and came back negative. Hooray! However, her general vet (another moron!) left her final diagnosis as psychogenic polydipsia.

Something told me there was more going on here so I persisted with further work up and referred myself to an IMS. At that point, the IMS performed the abdominal ultrasound which came back inconclusive for any abnormalities. Therefore, she proceeded with the ACTH stim test with LDDS which finally came back with the high cortisol results. Her recommendation is to treat with Trilostane, but after signing up for this forum, I have been receiving so many different opinions on treating with that particular med. because there's a possibility of it interfering with the intermediate hormones which is where I learned about the UTK full adrenal panel testing. At that time, I was so confused with all the info I have been receiving and thought the adrenal panel would reconfirm a Cushings diagnosis, but now I finally understand it is a whole separate test to r/o elevation with the hormones. Nevertheless, this test is on the back burner and I will most definitely proceed with it down the road.

Now let's get to your point about whether Princess suffers from the pituitary or adrenal dependent Cushings? That raised some doubts on my end because after numerous conversations with my IMS, I always gathered it is a pituitary issue being that the abdominal ultrasound cleared any adrenal problems. But again, have some doubts now after you raised the point related to her ACTH stim test result being so high wherein you suspect one or both of her adrenals may be enlarged which leads you to believe it could be adrenal based. Confused here again!!! UGH, UGH.

Now regarding treatment: There are two main drugs that have been discussed on this forum to treat Cushings, lysodern and trilostane. It seems there are a lot of mixed opinions here as to which is more effective, which is more dangerous, etc, so it leaves me a bit scared as to how to proceed. I have questioned my specialist numerous times, and she still insists and swears by the trilostane because she has had many effective results treating with it against the lysodern. In fact she went as far as saying lysodern has had many negative effects on most of her patients in the past, and at this point she has steered completely away from it. That's where your point comes in when you say to stick to the treatment my specialist is most comfortable with and has had more experience in.

At any rate, I would be most interested in your further input related to the abdominal ultrasound results you asked me to post here. I will post them at the end of this message.

In addition, I also have a copy of the specialist evaluation Princess received at the time of her ultrasound, and found a notation from her IMS which I for some reason neglected to see. Maybe you can make some sense out of it. This is it: Abd palp.: soft - possible cranial organomegaly- Do you know what on earth that means? I am scheduled to speak with my IMS and I will most certainly ask, but in the meantime, perhaps if you've ever heard of it, I would be most interested in your further input.

In the meantime, just wanted to say what a wonderful person you seem to be to have taken on the responsibility of adopting yet another dog with this condition. Wow! That only says a lot about the kind-hearted person you are. That's priceless in this sometimes unsympathetic world. Jojo and Lulu are truly blessed to have such a loving mommy. Take care and I look forward to any other input. In the meantime here are the abdominal ultrasound results as promised: What do you make of it?

Liver/Gall Bladder: Homogenous, no distinct masses
CBD: Large gall bladder with sludge, but no evidence of obstruction
Spleen: Homogenous
Kidneys: Normal architecture bilaterally
Adrenals: Left normal, right hard to identify but suspect is normal
GI tract/Pancreas: empty stomach, bowel normal, no evidence of pancreatitis

Lymph Nodes/Urinary: No nodes seen
Bladder: Huge urinary bladder - architecture normal - sample obtained: urinary sample

Additional comments: no ascites
Assessment: Huge bladder from apparent polyuria, no architectural changes to explain etiology

[labblab]

Now let's get to your point about whether Princess suffers from the pituitary or adrenal dependent Cushings? That raised some doubts on my end because after numerous conversations with my IMS, I always gathered it is a pituitary issue being that the abdominal ultrasound cleared any adrenal problems. But again, have some doubts now after you raised the point related to her ACTH stim test result being so high wherein you suspect one or both of her adrenals may be enlarged which leads you to believe it could be adrenal based. Confused here again!!! UGH, UGH.

Hi Jeanette,

I'm sure Glynda will be back before long to give you some more feedback re: your questions. But I just thought I'd tackle this one piece. Abnormalities with the adrenal glands can signal either pituitary OR adrenal Cushing's, depending on the abnormalities themselves. Dogs suffering from adrenal Cushing's will typically exhibit only one single enlarged adrenal gland, and a mass or a tumor may be visualized on the one enlarged gland. BOTH adrenal glands will typically be enlarged in dogs suffering from pituitary Cushing's. However, this is not always the case. Dogs with the pituitary form may not show adrenal enlargement on an ultrasound.

The ACTH stim test cannot indicate which form of Cushing's a dog suffers from. But I'm guessing that what Glynda meant is that, with as elevated an ACTH result as Princess had, she would have expected to see an adrenal abnormality of one type or the other. (If I'm wrong in my guess, I know she'll feel free to correct me! ;)). But once again, not every dog with pituitary Cushing's will have enlarged adrenals.

One quick question for you: you also mention the LDDS test...do you know if Princess had an LDDS performed in addition to an ACTH? It is another blood test, and unlike the ACTH, it does have the potential to indicate which form of the disease a dog suffers from. It is a test that takes 8 hours to perform, though, so I'm guessing you will know whether or not Princess had that done.

As always, thanks so much in advance for the additional info.
Marianne

[jrepac]

Hi Jeanette,

Abnormalities with the adrenal glands can signal either pituitary OR adrenal Cushing's, depending on the abnormalities themselves. Dogs suffering from adrenal Cushing's will typically exhibit only one single enlarged adrenal gland, and a mass or a tumor may be visualized on the one enlarged gland. BOTH adrenal glands will typically be enlarged in dogs suffering from pituitary Cushing's. However, this is not always the case. Dogs with the pituitary form may not show adrenal enlargement on an ultrasound.



Yes, it is possible for the ultrasound to come back normal...that's what I experienced. We eventually concluded that pituitary Cushings was present, based on all the other factors at work

[Harley PoMMom]

Adrenals: Left normal, right hard to identify but suspect is normal
Hi Jeanette,

This is one thing that really caught my eye, when Harley had his first U/S in April, it showed that his right adrenal gland had a 7.3mm nodule on it and his left adrenal gland was of normal size, but on the high end of normal.

In August I took him back to get another U/S and they found that the nodule on his right adrenal had grown to 8mm and his left adrenal gland is enlarged and it says Enlarged, more the caudal pole (1cm).

Now this is JMO, but maybe your IMS is not using a well-equipped ultrasound machine and it can't pick up the right adrenal...I just don't know. But do you realize how very small 7.3mm is? One has to have a well-equipped ultrasound machine to pick up such small things.

Harley's IMS also used an endogenous test on him to diagnose his PDH, but this test has to be handled very carefully.

Like Marianne has said Glynda will be along soon I am sure, and she, along with others will be able to give you more advice.

Love and hugs.
Lori

PS - I do want you to know that we do understand how depressing this can be to watch your precious furbaby have this dratted disease, this forum is not only for your beautiful Princess but for you as well, if at any time you feel like talking about anything, you can start a new thread in the "Everything Else" section, ok.

[StarDeb55]

Lori stated:


Now this is JMO, but maybe your IMS is not using a well-equipped ultrasound machine and it can't pick up the right adrenal...I just don't know. But do you realize how very small 7.3mm is? One has to have a well-equipped ultrasound machine to pick up such small things.

Jeanette, I want to doubly emphasize the point that Lori has stated above. It is critical that the abdominal US be done on a high resolution machine to make sure that both adrenals are clearly visualized, & the films need to be read with someone who is trained to read these type of films like a vet radiologist. I agree with Lori that the US report makes me very suspicious that this was not done on a high resolution ultrasound.

When it comes to what drug your IMS is most comfortable using, I agree that you basically need to go with what they want to do. I do question the bad lysodren as, possibly, being a case of not giving clear instructions to the owner as to what to look for when a dog is loaded, signs of a lysodren overdose, & what to do if an overdose is suspected. If an owner is give clear instructions & strict protocol is followed, lysodren is just as safe & effective as trilostane.

Debbie

[labblab]

Yeah, I was also sorry to read that the right adrenal gland was not visualized clearly. It would have made us all feel more comfortable had the result been more definitive.

HOWEVER (and I am confident that there are others here who will hold a different opinion and that is the beauty of being a member of a message board -- to get different opinions), if I were you I believe I would go ahead and give the trilostane a try. Princess has classic symptoms of Cushing's: "Her symptoms are excessive thirst, urination, panting, excessive appetite, looking for cool place to lay." You have ruled out DI, DM (I'm assuming), thyroid issues calling for immediate attention, and Princess does not suffer from any other known illness. Her ACTH result was sky-high, and the ACTH is the most specific blood test for Cushing's. Even if it turned out that Princess does have adrenal rather than pituitary Cushing's, I am guessing that surgery might not feel like a viable option right now due to the cost. Your vet is comfortable with trilostane, and has had good results with it. I know you will watch Princess like a hawk, and if she appears to be unwell while taking trilostane you would stop it immediately. But my heart just goes out to your baby, reading about her poor distended bladder...:( I surely hope she will soon get some relief.

You have been through the mill with trying to arrive at a decision. As I say, others may certainly advise you differently. And I am still interested in knowing whether an LDDS blood test was performed. But at this point, I believe I would go ahead and give the trilostane a try. And of course (since there is always "another" question :rolleyes:)...what dose does your IMS want to begin with?

Marianne

[AlisonandMia]

Hi,

I'll also add that a great many dogs with an adrenal tumor will not have a very high stim test result and some will even be at the low end of normal. This is because a great many adrenal tumors don't respond strongly to ACTH. So a really high ACTH stim result suggests (but doesn't prove by any means) that PDH is most likely.

Alison

[mypuppy]

Thanks Alison, I actually never knew that--it does make me feel a little more relieved now that my specialist properly diagnosed Princess based on her results.

[mypuppy]

Hi Marianne,

I agree, I was not very happy knowing they could not view the other adrenal gland. I mean, here we are with high tech equipment, and $600.00 after, and you tell me it wasn't visible...UGHHH. Yes, DI and DM were totally ruled out by the general vet after the water deprivation test. I was simply baffled and quite unhappy with his final diagnosis and then learning her diagnosis was Cushings, and he didn't even pick up on any of the symptoms that would lead him to test for it. It's insane. How do these doctors earn their paychecks? I know to err is human, but the clinical signs were there and he completely missed. Thank God for the specialist. I guess that's why we have IMS? Who knows, but I think a general vet should be able to at least recognize signs of certain conditions and thereafter refer to an IMS for further evaluation. Princess does not suffer from any other illness that we know of, she's always been a pretty healthy dog, aside from your common ear infections once in a while, but other than that, no other issues. Regarding thyroid issues, I asked my IMS again yesterday, and she ruled out any hypothyroidism as well. Now as for surgery if it turned out it was an adrenal dependent condition, I would jump all over that one if Princess was a good candidate for surgery and if they could confirm it would get rid of Cushings altogether. Yes, the cost is something to consider. I don't know what a surgery like this would run, but we would probably use the credit card for that one and pay it off as we go along, if it means a better quality of life for the pooch. Yes, Princess received an LDDS along with the ACTH stim test. Regarding the trilostane dose, I believe she will begin her with the 60mg, once a day. If I'm not mistaken from my conversation with my IMS yesterday, she says it goes by weight, therefore that is the proper dose for Princess. And you bet I WILL WATCH HER LIKE A HAWK while she's on this med, but thanks for emphasizing it. Thanks again, and tune in once in a while for further updates on Princess. Take care. Jeanette

[labblab]

Jeanette, thanks so much for the confirmation that Princess DID have an LDDS. Of course, being the nosy crew that we are, we'd love to see those test results if and when you are able to post them :p. But since the LDDS can possibly indicate one form of Cushing's or the other, I'm guessing that the results may have also led your vet to believe that Princess has PDH. Plus, it's very good to know that she had a second blood test that confirmed Cushing's, in general.

Thanks also for the dosing info. You are absolutely correct -- the initial dosing does go by weight. I don't know whether you've ever told us how much Princess weighs, but if she's a typical Lab, 60 mg. should be a reasonable dose. Here's the link to a reply that I posted last weekend to another member who is beginning treatment with her Lab. You may have seen it already, but it does discuss some differences in dosing protocol, sources for buying trilostane, and also a link re: interpreting the results of an LDDS test:

http://www.k9cushings.com/forum/showthread.php?p=17523#post17523

You bet your bottom dollar that I'll keep checking for updates!!! ;)

Marianne

[Harley PoMMom]

I have a question, now from what I've read, a cushingnoid pup usually would not have had a USG of 1.035, yes or no?

Hi Jeanette,

Since Princess has been diagnosed by only a ACTH test, and bc her u/s showed normal adrenals, this is JMO, but if Princess were my pup, I would at least run a LDDS test. If the LDDS test comes back positive then if I were you then I would feel safe to use the Trilostane. That's my 2 cents worth. :p:D



Now getting to your some of your questions. We first started with a CBC and urinalysis: These were the out of range results:
ALT (SGPT) - 225 (high)
AMYLASE - 388 (low)
T4 - 0.5 (low)
HGB - 18.6 (high)
NEUTROPHIL SEG - 80 (high)
LYMPHOCYTES - 10 (low)
EOSINOPHIL - 0 (low)
ABSOLUTE LYMPHOCYTE - 830 (low)
ABSOLUTE EOSINOPHIL - 0 - (low)
UA - 1.0045G prior to water deprivation test
UA - concentrated to 1.035 after water deprivation test.

I scheduled her in immediately, gave the specialist copies of all her tests, she performed an abdominal ultrasound to view her adrenals, kidneys, spleen, etc, and the ultrasound came back normal. At that point the specialist recommended to have her tested for Cushing's/Addison's with the ACTH stimulation test, which came back positive for pituitary Cushings. She also had a Free T-4 to rule out hypothyroidism, but still awaiting results on that test. Her symptoms are excessive thirst, urination, panting, excessive appetite, looking for cool place to lay. ....


Hi Jeff, thank you, I truly do appreciate your input. Princess has had a CBC and urinalysis, water deprivation test, abdominal ultrasound, ACTH stim, Free T4 and TSH tests. I did bring up the possibilities of further work-up (perhaps the full adrenal panel from UOT), as well as a high dose dex. And although she was not hesistant in complying with my concerns, she is ready to begin treatment with Trilostane. I do not know what other tests are out there now to reconfirm their Cushings dx.

I have to admit you are doing an excellent job putting up with me rambling on and on...:eek::rolleyes:;):) and you're also doing a wonderful job taking care of Princess.

Love and hugs.
Lori

[labblab]

Hi Lori,

Jeanette just let us know in her post this morning that Princess DID have an LDDS done. :)


Yes, Princess received an LDDS along with the ACTH stim test.

I've asked her to please post the results. But I know this additional news makes us all feel better about the diagnosis! ;)

Marianne

[mypuppy]

Debbie, I appreciate you pointing that out. Luckily the facility I take Princess to has the latest state of the art equipment to perform these tests accurately, and I do feel totally comfortable that the ultrasound was performed by a DVM Diplomate ACVIM in internal medicine. Please read the following, and again, thanks for double checking: Jeanette

"Oradell Animal Hospital now has Digital Imaging Technology. This allows us to have the capability of viewing high resolution images to enable us to detect the slightest differences that can not be seen with traditional radiography. The images are stored like any computer file and can be viewed on a computer screen, transmitted electronically, or printed out on paper or transparent film similar to x-ray film. Computer software allows manipulation of the digital images to enhance viewing and diagnostic capabilities.

Digital imaging creates increased efficiency and better diagnostic analysis, and improves timely decisions about patient care."

[labblab]

I have a question, now from what I've read, a cushingnoid pup usually would not have had a USG of 1.035, yes or no?

Lori
I am a dummy when it comes to interpretation of USGs, but I'm thinking that it would be the USG prior to water deprivation that you'd be looking at in terms of a Cushing's diagnostic? And that pre-deprivation result for Princess was 1.00456.

But somebody who knows more about this, please help us here. Or Lori, please tell us more from your reading.

Marianne

[StarDeb55]

Marianne, you are correct. The USG needs to be looked at prior to any testing, as far as I know.

Debbie

[labblab]

Thanks for the clarification, Debbie!

[mypuppy]

Thank you Marianne and Debbie related to the USG for Princess. This is another thing I learned today from both of you.

[mypuppy]

Lori, thank you for bringing your point forward. I would have never known that. Unfortunately, again, my general vet missed on a lot of red flags that were on the report and right in front of his face. Yeah, I know I need to get over it, but can't help but feel quite disappointed in the dr. I put my dog's care in? UGH< UGH< UGH....Thank you sooooooo much. xo Jeanette

[Harley PoMMom]

Unfortunately, again, my general vet missed on a lot of red flags that were on the report and right in front of his face. Jeanette, please do not blame your vet, you have to remember that they don't know everything about this dratted disease, but here on this forum there are many people that have pups that live/lived with this disease for many years, so people like you and me have the blessing and the privilege to learn all about this cushings disease from them.

Love and hugs.
Lori

[mypuppy]

Lori, you may be right, and my apologies, but I do have a bone to pick with my general vet because he told me point blank, "this is not a cushings case", so that lead me to believe that he had knowledge on this disease or at least it's obvious symptoms, and he neglected to at least suggest further work up. What if I had accepted this general vet's professional evaluation and not pursued further testing on my own, and what if I was the type of individual who didn't try to educate myself online and do research or NEVER been "priviliged" to have found this forum which has greatly educated me as well as every other person here? At this rate, it really does not matter because luckily I feel Princess has been properly diagnosed, and we can now take care of her health. All in all, no looking back now. Just have to face this full force. Thank you once again for all the support. xo Jeanette

[lulusmom]

Hi Jeannette,

With cushing's, excess cortisol interferes with the production of antidiuretic hormone (ADH) which regulates water conservation by the kidney. Therefore, an uncontrolled cushingoid dog will usually not concentrate to the extent your Princess did when your vet did the water deprivation test. Like Lori, I thought I had read that a cushdog normally won't concentrate after water deprivation but to double check my memory, I asked the the director of Banfield Hospital at Western University Teaching Hospital that question. He said it is not impossible but an untreated cushdog normally wouldn't concentrate to 1.035. Therefore, because Princess concentrated to 1.035, your vet may have ruled out cushing's so you may want to give him the benefit of the doubt. However, as others have mentioned, not all vets are cushing's savvy so it's possible that he is like our old gp vet and wouldn't know cushing's from a hole in the ground.

Marianne was correct in interpreting my post regarding the normal ultrasound results. Thank you, Marianne. I just found it unusual that with Princess' high post circulating cortisol of 50 ug/dl, the Alkaline Phosphatase (liver enzyme) was not elevated and neither the adrenal glands nor the liver showed any abnormalities associated with cushing's. The answer could very well be that Princess is in the very early stages of the disease but it's still odd to me.

The normal pre acth (basal) cortisol level is 2 - 6 ug/dl so Princess' pre cortisol of 16.6 ug/dl is pretty darn high. A dog under extreme stress or suffering from a non-adrenal illness usually will have high basal cortisol number but quite frankly, I don't ever recall seeing a pre number that high. Dogs with adrenal tumors usually have a high basal cortisol and the post can be all over the board from normal to very high. This is because functional adrenal tumors secrete cortisol independent of acth and their secretion patterns can be very random. On that note, I will tell you that the fact that the left adrenal could not be visualized during Princess' ab ultrasound bothers me.

Adrenal tumors may be a lot more rare than pituitary tumors, but if it were me, I would still want to know which one I was dealing with. If it is pituitary, then Trilostane is a great choice; however, if it is an adrenal tumor, I would certainly consider surgery if at all possible. If surgery were not an option, then treatment with Lysodren is usually favored for the simple reason that it has the ability to shrink the tumor. I too noticed that you mentioned an LDDS and sometimes this test can differentiate between pitiutary and adrenal based disease so it would be great if you could post the results of that test. This is an all day test so Princess would have spent the day at the vet's office. Does that ring a bell?

Thanks for asking about Lulu. She is going on her fifth year of treatment and aside from her lack of coat and crappy skin, she is doing fine. She had a seizure on 10/17 so I took her to the vet on the 18th. She had the works done, including a stim test which was perfect at pre 3 ug/dl and post 3.4 ug/dl. Her white blood cell count was mildly low and so was her creatinine so we have to go back in two weeks to retest.

Okay I think I've typed a novel and probably rambled on way too long so I'll spare your eyesight and quit for now.

Glynda

[Harley PoMMom]

Lori, you may be right, and my apologies, but I do have a bone to pick with my general vet because he told me point blank, "this is not a cushings case", so that lead me to believe that he had knowledge on this disease or at least it's obvious symptoms, and he neglected to at least suggest further work up. What if I had accepted this general vet's professional evaluation and not pursued further testing on my own, and what if I was the type of individual who didn't try to educate myself online and do research or NEVER been "priviliged" to have found this forum which has greatly educated me as well as every other person here? At this rate, it really does not matter because luckily I feel Princess has been properly diagnosed, and we can now take care of her health. All in all, no looking back now. Just have to face this full force. Thank you once again for all the support. xo Jeanette

Hi Jeanette,

I don't think what I typed came across right, and I am so sorry for that :(...that's the one bad thing about this computer stuff. :rolleyes::eek: You definitely have the right to feel utterly disgusted with your vet...one would think that when your vet was told of her clinical cushings signs and after doing other bloodwork and checking for and ruling out diabetes and hypothyroidism, your vet would of tested her for cushings, You should NOT of had to ask him to check for cushings yourself, I totally agree with you.

What I was trying to say was when I had to find a new vet for Harley bc his former vet fired us, well the vets around here are not that cushings savy. Harley's new vet has treated some cushings dogs but not alot, and she's never treated an atypical cushings case. So when I wanted the full adrenal done, Harley's vet never heard of it, didn't know what it was, but she was very willing to learn everything about it and even called Dr Oliver to make sure she would do it right...this is what I mean about our vets not knowing everything, ok...I am so sorry for the upset I just put you through.

FWIW, please know that I think you are doing a wonderful job...you are educating youself about cushings and that is very, very important and the fact that your diligence to find out what was wrong with Princess, these two things are vital to making her better. The very deep love you have for her definitely shows and she is very lucky to have such a wonderful mom.

Love and hugs.
Lori

[labblab]

With cushing's, excess cortisol interferes with the production of antidiuretic hormone (ADH) which regulates water conservation by the kidney. Therefore, an uncontrolled cushingoid dog will usually not concentrate to the extent your Princess did when your vet did the water deprivation test. Like Lori, I thought I had read that a cushdog normally won't concentrate after water deprivation but to double check my memory, I asked the the director of Banfield Hospital at Western University Teaching Hospital that question. He said it is not impossible but an untreated cushdog normally wouldn't concentrate to 1.035.
Glynda
Glynda, I'm glad I could live up to my self-proclaimed title of USG dummy, and I am bowing low to both you and Lori ("I am not worthy"...:p).

Marianne

[AlisonandMia]

Glynda, I'm glad I could live up to my self-proclaimed title of USG dummy, and I am bowing low to both you and Lori ("I am not worthy"...:p).



Errr - I had to think hard to work out what USG stood for at first.... and then read a few posts - first thing in the morning for me but still....:o So you are doing better than me, Marianne.

[mypuppy]

Hey there Glynda, Oh boy! I feel as if I'm stuck between a rock and a hard place with your last post. UGH....Just when I thought I had made some progress and finally came to terms on treatment (the trilostane will be delivered tomorrow), I now have more doubts based on your comment about a cushdog would not be able to concentrate his urine to the level Princess did...and guess what, you open an even bigger can of worms regarding the LDDS test. At my specialist's request, she recommended to have the ACTH stim with LDDS, and said I could have that done at my regular vet, so that's what I did, but now that you mention, Princess did not stay the whole day there. In fact, I knew that the specialist mentioned that she would have to spend the day for this test, but when I dropped Princess off at 8 a.m., the vet's office called me at 11:30 a.m. to say she was done, and I asked them "that quickly?" and they said yes, so now I question whether the LDDS was actually done or not? This is another reason why I started to second guess my regular vet and his staff. The front desk staff was most of the time rude and very unfriendly, and I always seemed rushed by my general vet and at times bothered by me constant questions....this is why I left. Today I called though and left a message asking if the LDDS test was actually performed. I totally assumed that an LDDS test was in conjuction with the ACTH stim test, meaning they always go hand in hand with each other, but I am interpreting that is not the case here? As I said, this changes everything for me now because not sure now if Princess may even have Cushings as diagnosed, even though she's completely showing the clinical signs, and if she does, again which type, Pituitary or Adrenal??????? I guess I can always put the trilostane aside until I decied if further evaluation is needed at this point to reconfirm again....Everyone, this has been, by far, the craziest roller coaster ride I've ever been on..someone get me off...Please kiss Lulu for us and I hope she makes out at her next check up...Take care....Jeanette.

[AlisonandMia]

If she wasn't there for at least 8 hours then, IMO, she simply could not have had the LDDS test. The two tests can be done on the same day - I believe they run the LDDS test first and then run the ACTH stim although usually they are done separately.

The aim of the LDDS is to see if the activity of the adrenals can be suppressed and the aim of the ACTH stim test is to stimulate the adrenals to see how much cortisol-producing capacity they have, so as you can see, you couldn't run both tests at exactly the same time. And the LDDS always takes 8 hours as they need to do a draw at baseline, then give an IV dose of dexamethasone and then do another draw at 4 hours and then at 8 hours (some do another at 6 too). Have you got an account from your former vet - that might give you some idea of what tests were run and what you were charged for.

Alison

[Harley PoMMom]

I finally found one of the articles that I read about the USG, sorry it took me so long...I couldn't copy from it, so it took me awhile to type this. :eek::)

Urinalysis--Page 1552 / Section XI--The Endocrine System


The most frequent abnormality is the finding of dilute urine (specific gravity of less than 1.013) which occurs in 85% of our cases...It is less reliable to measure water intake in the hospital. Most water-deprived or frightened dogs with Cushings can concentrate their urine to an osmolality well above plasma osmolality, although their concentrating albility usually remains less than normal.

http://www.io.com/~lolawson/cushings/articles/feldman2.pdf

Love and hugs.
Lori

[gpgscott]

Jeanette,

Just because you have the Trilo does not mean you need to begin administering it right away. Another few days will make almost no difference in the outcome if it is needed and can cause Princess problems if it is not.

Just to be clear though, the LDDS is not considered a clear indicator of Pit vs. adrenal, it can give a clue but the abdominal U/S is the main diagnostic for adrenal.

As has been mentioned, if Princess was not with the Dr. for at least nine hours you have not had an LDDS.

Scott

[Buffaloe]

My dog, Shiloh, had a combination ACTH/LDDS test with a full adrenal panel done and sent to the U. of Tennessee. She was only at my vet's for about four hours for this test. The results gave us a very good idea that she had an adrenal tumor. It was confirmed by her ultrasound. This is just an FYI.

As Scott said, the LDDS test can sometimes give you an idea of whether or not there is an adrenal tumor but it is not definitive. A good ultrasound is by far the best way to diagnose an adrenal tumor. Hey, you can just hang on to the Trilostane for a while until you are comfortable with the diagnosis.

Ken

[AlisonandMia]

Looks like the combined LDDS/ACTH stim does only take four hours:

(http://www.vet.utk.edu/diagnostic/endocrinology/pdf/endo_tests_info_07.pdf (2nd page))




b. Cortisol-Dex Supp/ACTH Stim Test -DOG, CAT, HORSE.
i. Collect baseline serum sample (1.0 ml). Administer dexamethasone at 0.1 mg/kg (IV).
ii. For horse, use 10 mg Dex (total dose, IV).
iii. Take a post-Dex serum sample 4 hrs later.
iv. Following the Post-Dex collection, perform the Cortisol-ACTH Stim Test as above.

c. Cortisol-Low Dose Dex Supp Test -DOG.
i. Collect baseline serum sample (1.0 ml).
ii. Administer dexamethasone at 0.01 mg/kg (IV).
iii. Collect Post-Dex serum samples at 4, 6 and 8 hrs (1.0 ml).

You'll see the plain LDDS (set out c. above takes 8 hours). I'd think that that short one would be nowhere near as informative as the normal 8 hour one, depending on the circumsances. A dog with PDH could well look normal on the shortened LDDS test as a proportion of PDH dogs will suppress at 4 hours and then "escape" from suppression by 6 or 8 hours (a normal (unstressed) dog will stay suppressed until the 8 hour mark). Dogs with ADH and (quite a few dogs with PDH, too) will not suppress appreciably at the four hour mark. The four hour LDDS is probably good for re-enforcing suspicions of an adrenal tumor but fairly questionable when it comes to being able to positively diagnosing PDH. The 8 hour test doesn't necessarily positively diagnose PDH (but sometimes does) and an abdominal ultrasound is always a good idea anyway.

Alison

[Roxee's Dad]

Hi Jeanette,

I just wanted to summarize Princess’s ongoing diagnosis history for ease of reference. If you do have the LDDS test results or any other additional testing results, I would be happy to insert the information. :)

Princess - A very beautiful 7 y.o. – Choc. Lab

Weight – Approx. 70 lbs. right now. (15 lb. drop from a year ago)
Trilostane dose- 60mg, once a day. (not yet started)

Symptoms:
Her symptoms are excessive thirst, urination, panting, excessive appetite, looking for cool place to rest.

ALT (SGPT) - 225 (high)
AMYLASE - 388 (low)
T4 - 0.5 (low)
HGB - 18.6 (high)
NEUTROPHIL SEG - 80 (high)
LYMPHOCYTES - 10 (low)
EOSINOPHIL - 0 (low)
ABSOLUTE LYMPHOCYTE - 830 (low)
ABSOLUTE EOSINOPHIL - 0 - (low)
UA - 1.0045G prior to water deprivation test
UA - concentrated to 1.035 after water deprivation test.

Vet performed water deprivation test to rule out DI

UltraSound
Liver/Gall Bladder: Homogenous, no distinct masses
CBD: Large gall bladder with sludge, but no evidence of obstruction
Spleen: Homogenous
Kidneys: Normal architecture bilaterally
Adrenals: Left normal, right hard to identify but suspect is normal
GI tract/Pancreas: empty stomach, bowel normal, no evidence of pancreatitis

Lymph Nodes/Urinary: No nodes seen
Bladder: Huge urinary bladder - architecture normal - sample obtained: urinary sample

Additional comments: no ascites
Assessment: Huge bladder from apparent polyuria, no architectural changes to explain etiology

Notation: Abd palp.: soft - possible cranial organomegaly

ACTH Stim test:
PRE-ACTH CORTISOL - 16.6
POST-ACTH CORTISOL - 50.0

Ref Ranges:

Pre-ACTH (resting) cortisol: 2 - 6
Post - ACTH cortisol: 6 - 18
Equivocal post -ACTH cortisol: 18- 22
Post - ACTH cortisol consistent with hyperadrenocorticism: >22
Post - ACTH cortisol consistent with hypoadrenocorticism: <2
Desired pre- and post - ACTH cortisol on lysodren therapy: 1 - 5



------------------------------------------------------------------------
THYROID PANEL #6 - FREE T4 (EQUIL. DIALYSIS)

FREE T4-ed (ng/dL): Result: 1.2 Reference Range: 0.7 - 3.7 ng/dL
FREE T4-ed (pmol/L):Result: 15.4 Reference Range: 9.0 - 47.4 pmol/L
-------------------------------------------------------------------------
THYROID PANEL #6 - cTSH

cTSH: Result: 0.45 - Reference Range: 0.05 - 0.42 ng/mL - Flag: H

Comments:
Increase canine TSH values may occur in dogs with untreated primary hypothyroidism. Sick euthyroid dogs are expected to have low normal TSH concentrations. Secondary or tertiary hypothyroidism (pituitary or hypothalamic lesions) are reported to occur in less than 5% of hypothyroid dogs

[mypuppy]

Hi John, That was extremely helpful and very sweet of you. Thanks. I've had all my test results in front of me and have been flipping through them each time I've needed to post results. I am waiting to hear back from my general vet regarding the LDDS which again, I assumed was done at the same time of the ACTH stim test. Will post results if in fact it was done. Thanks again. I appreciate your kindness. Regards, Jeanette

[mypuppy]

Awww Lori, don't apologize. I understand what you mean. I think it's just me being so on edge about this whole thing that perhaps I have been unfairly blaming my vet. At times like these I admit we experience such anger, frustration and feel let down and expect others to give us straight answers and fix our problem. Nevertheless, you are probably correct in saying there are not many vets who are educated or experienced with this condition, unfortunately. Listen, as always, thanks for the pep talk and the sweet words of comfort. I am trying my hardest to make sure my Princess is well taken care of--she deserves it. Luv, Jeanette

[mypuppy]

Hi Scott, I thought the same thing, I can hang on to the meds until I am absolutely 100% sure, and that is what I will do. Princess did have the abdominal ultrasound and the results have been posted previously, so I believe the adrenal issues has been ruled out. As for the LDDS, I am awaiting for my general vet to call and inform me if the LDDS had been done when Princess had her ACTH stim test. There seems to be some controversy as to how long the actual test should take. I am getting mixed opinions from a few on this forum. Some, including you say at least 8 hours, and others are saying 4 hours, and that is the amount of time Princess was in for. So until I hear back from my vet, I won't make any conclusions, but as always, thanks for your inputs. Regards, Jeanette

[mypuppy]

thank you Ken. I will hold on to the meds until further confirmation. Jeanette

[mypuppy]

Hi Alison, Thank you for the info. I will print out to read completely. I am awaiting confirmation from general vet on whether she in fact had the LDDS with the ACTH stim. Will post those results if and when I get them. Thanks again. Regards, Jeanette

[mypuppy]

Lori,

Meant to ask, if and when I begin treating Princess with the Trilo, have a few questions regarding her water intake. Obviously, now she gets all she wants based on her needs, however, once she begins treatment, need I begin to monitor her water intake? I know this is a question for my vet, but in the meantime, would like to get yours or anyone else's comments on this. Btw, would you know what her recommended water intake would be weighing at 70 lbs? I think her vet mentioned 2 liters per day, but again, not sure if I need to stick to that amount with treatment or give her want she still wants???? Thanks....Jeanette

[Harley PoMMom]

It is helpful to know how much she is drinking, so a reduction is water consumption is a sign that the Trilostane is working, but I think this is more helpful with people during the "loading phase" of Lysodren.

Hopefully those more knowledgeable will be able to give you a better answer then mine.


give her want she still wantsYes, all the water she wants, since my Harley does have accidents in the house sometimes, I buy those puppy training pads and place them in the places he likes to pee (it usually was on a rug that was a bugger to wash, or on the carpet somewhere! :eek: which I would find with my sock covered feet. :eek::eek: :))

Love and hugs.
Lori

[mypuppy]

OK ALL,

Just received word from Princesses former vet, and as I suspected, she DID NOT receive the LDDS test along with the ACTH stim. I just received the Trilo today, but will be holding off until we have the LDDS which I have scheduled for next Thursday. In the meantime, I would appreciate any info on this test, and of course, I am going to research it online as well. Also, my vet mentioned Princess does not need to fast for this test, and she can have water as well. Is this accurate info, because I had the understanding an animal DOES need to fast for an LDDS. Can anyone clarify just so we don't mess this test up. Thanks all, and I'm glad I got all this cleared up before I proceeded with treatment. THANKS, THANKS, THANKS ALL. Best regards, Jeanette

[acushdogsmom]

will be holding off until we have the LDDS which I have scheduled for next Thursday. In the meantime, I would appreciate any info on this test, and of course, I am going to research it online as well.


Also, my vet mentioned Princess does not need to fast for this test, and she can have water as well. Is this accurate info, because I had the understanding an animal DOES need to fast for an LDDS. Can anyone clarify just so we don't mess this test up. I've heard it said that fasting is preferred, but that may be because other blood tests or procedures may be performed at the same appointment for which fasting is abolutely necessary or it may depend on the lab's preference.

Here's an article that explains the LDDS test and mentions that fasting depends on the Lab's preference.

http://veterinarymedicine.dvm360.com/vetmed/Medicine/ClinQuiz-Interpreting-low-dose-dexamethasone-suppr/ArticleStandard/Article/detail/580093


The LDDS test is typically performed in dogs that have fasted for eight hours (check whether your laboratory requires fasted samples).

Another place to find info about the LDDS test:

http://www.k9cushings.com/forum/showthread.php?t=217

Hope this helps. :)

P.S. Depending on the results you get from the LDDS, you may or may not get strong evidence that it is Pituitary vs Adrenal. In some dogs with Pituitary Cushing's, a certain pattern of suppression at 4 hours and then escape from suppression at 8 hours is shown, which is actually consistent with Pituitary Cushing's. But if they don't show the pattern of suppression known to be consistent with Pituitary Cushing's, that doesn't necessarily mean that it's adrenal. Inadequate no suppression on the LDDS is only consistent with a diagnosis of Cushing's - i.e. dogs who do not suppress cortisol production at all on this test or who do not suppress in a pattern consistent with Pituitary cases may have either Pituitary or Adrenal Cushing's.

The LDDS test is the Cushing's diagnostic test which seems to be most preferred by Specialist Vets in particular. I'm not a Vet, but personally, I think it is part of a thorough diagnostic process and that it's important to have both the ACTH stim and the LDDS test done, along with an ultrasound exam when trying to confirm a possible case of Cushing's because you want to try to as much test result evidence as possible along with clinical symptoms to confirm the diagnosis.

[mypuppy]

Yes it does, thanks a million....

ps: TO ALL AGAIN: does anyone know if the dexamethasone used in the LDDS causes any side effects on a dog, is it a safe procedure? Thanks again. So many questions I know. Sorry....Jeanette

[StarDeb55]

The LDDS is considered to be the gold standard for diagnosing Cushing's, so a huge number of pups on this board have had the test done with no ill effects. The dexamethasone is basically a steroid injection. Keep in mind that with any medical procedure, both for pups & people, there may be a slight risk, but I'm pretty confident that it's extremely minimal for this test.

Debbie

[littleone1]

Hi Jeanette,

I was also concerned about reactions from the dex, as Corky had a bad reaction when his vet used the gel in Corky's first stim test in January. He didn't have any problems with the LDDS test. Corky also didn't need to fast for this test. His IMS uses Cortrosyn for his stim tests. He's been fine with that.

My best to you and Princess.

Hugs,

Terri

[mypuppy]

Hey Terri, how are you and Corky doing these days? I don't know about Princess....everyday I notice her weaker and weaker...her hind legs seem to be giving her a problem with jumping. It really is sad. We would on ocassion, allow her on our bed during the day, and she would "jump" (no punn intended-lol) at the chance, and now we say the command, and tries to jump and ends up with only her front legs on top of the bed, and can't manage to get up there...UGH, UGH, UGH.....My poor baby....as for exercise, we threw the ball around in the yard two times, and she had it at that point, again, here's my lab who's accustomed to chasing every ball and stick all day if she could...I am hoping once this final LDDS test is done, we can move on with treatment accordingly, and hopefully bring back some of her mobility, I hope????? Not sure if the treatment works toward the goal? Anyway, thanks for the info...I felt compelled to ask that question because any medical procedure scares me, specially when they are injecting some chemical into her....Hopefully it will be alright. I'm just a bit upset they could only schedule her for Thursday. Seems like an eternity, but will try to be patient. Take care of you too and Corky and of course, will continue to probably ask questions as they pop in my mind, and will keep everyone updated on Princess. I'd ask the same of you and everyone else and their pups here. Ya here? Luv ya, Jeanette

[mypuppy]

Thanks Debbie, I'm a little impatient having to wait till Thursday, but we'll get there. Regards, Jeanette

[littleone1]

Hi Lori,

I wish they could see Princess sooner. Corky had the same issues with jumping up on the bed. We actually started sleeping on a lower bed so that he could get on it. I know I had to pick him up and put him on the bed at night. His activity level was not like it use to be. There were times that he would walk very slowly and only walk around the block. Before our morning walks, he would always jump up to give me kisses. It got to the point where I had to get on the floor so he could give me kisses. Shortly after he started taking the Trilo, he started walking faster and farther again and started jumping up to give me kisses. The last two mornings he actually ran quite a bit during his walks.

Once they do the test, you'll be able to move forward. I know it wasn't long before I started seeing improvements in Corky. My thoughts are with you and Princess.

Love and hugs to you both.

Terri and Corky

[mypuppy]

Dear all, i just realized after opening the package with the trilostane, the dose is 2 capsules once a day (60mg) and not what i had originally stated as one tablet once a day....the specialist recommended this dose, but i'm a little scared now that she's getting two pills per day right off the bat. Yikes. Can anyone tell me who has treated with trilostane if that is the dose your pup started with initially, of course, we need to narrow it down because some of you have small breeds and princess is a large breed so that obviously needs to be taken into consideration. But if there's anyone here with a large breed who has treated with trilostane, could you let me know what your specialist started her with? Just need to compare notes here. Thanks a whole bunch to all....regards, xo, jeanette

[StarDeb55]

The following link is from the important information section of the forum, it contains both the package insert with dosing information for trilostane, along with the UC-Davis protocols for dosing.

http://www.k9cushings.com/forum/showthread.php?t=185

After looking at the package insert, 2 60 mg. capsules per day is what the manufacturer recommends. The UC-Davis vet school which has years of experience treating with trilostane has found that starting on a lower dose, & working up as needed seems to give better results. There recommendations are 1 mg/ kg, given once daily. For Princess' weight of 70 lbs. which is 31.8 kg. Since trilo is only available in 30 or 60 mg capsules, you would be giving 30 mg. once daily. There is an option of getting trilo compounded to get the exact dose you need, but that decision needs to be made by you & your vet. I would really suggest you thoroughly review the information on the trilostane link I've posted as I think you will find answers to most of your questions there. Of course, if the link misses something or you're unsure of something, please ask away.

Debbie

PS- I believe Dechra's specific dosing schedule states a starting dose of 1-3 mg/kg body weight.

[littleone1]

Hi Jeanette,

Just an FYI. Corky was started on 20 mg once a day. At that point in time, his weight was 20.6 pounds. After the results of his adrenal panel came in, he is going to remain on 20 mg a day until his next stim test, unless there are things that start going askew. Then I need to call his IMS right away, so we can see what's going on.

Love and hugs,

Terri

[haf549]

Jeanette:

Kira started out with 1 120mg tablet once a day. That didn't work out very well, as her symptoms were still more obvious at night. Because trilostane has a half life of 8 - 12 hours, the vet decided to have her dosed twice a day, at 60mg each time. That helped somewhat, but it turns out that Kira didn't need that high a dosage, so finally in January of this year, we worked out the minimum dosage for a dog her size, which worked out to 75mg a day. So we split the difference and I am now giving her 40mg twice a day. BTW, Kira weighs in at about 80lb. That is a very low dose for a dog her size, but she seems to do well on it. I talked to the Cushings specialist, who told me that though the size of the dog dictates the dosage, it doesn't necessarily follow that a bigger dog requires a bigger dosage. Though the 60mg twice a day was correct for Kira's size, she didn't require that amount to get her symptoms under control.

When you start giving Princess the pills, watch her closely for the first few days. If you notice serious vomiting, diahrrea and lethargy, stop the pills; you may need to re-consider a lower dosage. Princess might get a touch of diahrrea (not the really serious stuff). If that should happen, you could try to control it by mixing rice in with her food. That should help with a MILD case of the runs. If it persists, stop the meds and re-evaluate the dosage. Also, when you give her the pills make sure you give them to her with a full meal. It helps with the absorption of the medication. Also, try to give her the pills about 12 hours apart (give or take an hour here and there). I usually feed Kira at 8 am and then again between 6:30 and 7 pm.

Do you have prednisone on hand (just in case)?

Hope this helps.

Heidi

[StarDeb55]

Jeanette, I owe you a huge apology & this is why I wanted you to verify the information on the vetoryl link I posted. I made a very large mistake when I posted that Dechra suggests an initial dosage of 1-3 mg/kg body weight. The actual Dechra recommendation is 1-3 mg/lb body weight. This means that the suggested dose would be from 70-210 mg. for Princess.

Again, I am very sorry, & believe me I will exercise one heck of a lot more caution in the future.

Debbie

[labblab]

Hi Jeanette,

My boy weighed about 65 pounds at the time we began him on trilostane. Per Dechra's recommendation, we started him on 120 mg. This was five years ago, and right at the time when the first research was being done on possible advantages to dosing twice daily, instead of just once. So we decided to try going that route, and gave him 60 mg. twice daily. We ended up increasing his dose, and at one time he was actually getting 120 mg. twice a day. We later decreased again further down the road, and finally ended up back at the 60 mg. twice daily. In retrospect, I wish we had started with once daily dosing and only moved to twice daily dosing in the event that it had actually seemed called for (i.e., if his symptoms had started rebounding later in the afternoon or evening). I think it just would have been easier, both from the standpoint of administration and also dosage tweaking.

I have read about UC Davis' dosing protocol, and understand their rationale for starting dogs at a more conservative dose. However, my own experience would have been that 30 mg. would have been SUCH an ineffective dose for my boy that I would probably have felt very frustrated and downhearted about the medication. I doubt that we would have seen any symptom relief at all, and we would have gone through several additional dosing "tweaks" and ACTH tests to have gotten him where he needed to be. So my own personal bias is more towards Dechra's recommendaton of beginning at 1-3 mg. per pound. If you go by their written dosing range instead of their dosing chart, that would mean that 60 mg. would be their conservative beginning dose for Princess. And since you have 60 mg. capsules on hand, that seems like a very reasonable place to start. So maybe your vet would be agreeable with your beginning there for at least the first week or so -- at 60 mg. daily. Depending on how Princess does at that dose, you can then consider increasing her to the 120 daily, or just remaining at 60 mg. until the time of her first ACTH test.

Marianne

[mypuppy]

Debbie, don't be silly. This stuff is hard to understand at times, so you don't need to apologize, trust me. So now does that mean Princesses dosage is correct? Her specialist will be starting her on 2 tabs (60mg per tab) once a day. I questioned it because I really thought it was 1 tab (60mg) once a day. Thanks for your info. Regards, Jeanette

[Franklin'sMum]

Hi Jeanette and Princess,
Hope everything is happy in your world.
Just popped in to give a comparison on the dosage.
Franklin (who is currently 7.3kg
/16 lb )started trilo at 60mg.
As Heidi said, give the meds with food, or Princess might develop an upset tummy.
All the best
Jane and Franklin xx
________
DEPOSIT PREMIUM FORUM (http://www.insurance-forums.org/deposit-premium/)

[StarDeb55]

Jeanette, the dose looks to be right in the middle of what Dechra recommends, but since I don't have hands on experience with Trilo, i will defer to the members that do. Hang tight as I'm sure Marianne will see this eventually.

Debbie

[mypuppy]

Hey Marianne, I appreciate your reply and sharing your experience with the trilo. It does get confusing when it comes to dosing, but I have to trust my specialist is following the Dechra's guidelines, it just threw me off when I realized she needs to take 2 pills of 60mg once a day instead of one 60mg once a day. This is where all the confusion comes in. Is there a difference in dosing once a day against twice a day even though the dose adds up to the same amount, like your pup for instance who was receiving 60mg twice daily but still adds up to Princesses 120mg per day? Let me know if I just confused you too? UGH UGH..At any rate, I am praying and hoping the specialist will get it right and we won't need to increase. Maybe decreasing would be ideal, No? We will figure it out. Princess is scheduled for the LDDS test this coming Thursday because I want to be absolutely positive of her diagnosis before I begin treatment. I will post those results soonest I have them for everyone's input, and then proceed with the trilo. btw, would you happen to remember how much you paid for the trilo? I filled them through my specialist pharmacy, but wow, they are rather expensive at $100.00 for 30 pills. Do you know if there is another company out there where I can purchase these for less? Thanks again for your replies and support. Best regards, Jeanette

[mypuppy]

Hey Jane, thanks so much. I will definitely remember all the suggestions when it comes to administering the meds. Regards, Jeanette

[StarDeb55]

Jeanette, the rationale for twice daily dosing is since Trilo clears the pups system in about 10-12 hours, some pups do see a return of symptom in the evening. If that happens, then it is usually suggested that twice daily dosing be tried, usually by splitting the dose. You & Princess are in a good position, if this should happen, you would probably just be giving her 60 mg. twice per day, rather than 120 mg. once daily.

Debbie

[Harley PoMMom]

Hi Jeanette,

Hope this helps. :) You can get Trilostane at Diamondback too.


I filled them through my specialist pharmacy, but wow, they are rather expensive at $100.00 for 30 pills. Do you know if there is another company out there where I can purchase these for less? Thanks again for your replies and support. Best regards, Jeanette


You can probably get the Lysodren cheaper at:
http://www.diamondbackdrugs.com/

You fill out the online quote form... the first time I did it, they emailed me a quote for 500mg Lysodren tablets (like I asked) and in addition, they gave me a quote for 500mg Mitotane capsules - both are going to be cheaper than what you can get at the vet, but the Mitotane will be significantly cheaper. I had my vet call in the prescription to their 800 number and then Diamondback called me for my cc number and I got the meds in the mail in a couple days. Wylie is currently on 2 prescription meds - Lysodren/Mitotane and Ursodiol, they are both cheaper at Diamondback drugs than at my vet or Walmart.

-Susy


There are other ideas on this site:
http://www.dolittler.com/2008/11/21/Pet-pharmacy-smarts-Ten-ways-to-save-BIG-on-your-pet%E2%80%99s-Rx-bill.html

Love and hugs.
Lori

[Harley PoMMom]

Hi Jeanette,

I wanted to include this one too. :)
Hi Glynda and Jeff –

If we adopt Bree, we will keep Diamondback Drugs in mind. I will also contact them to inquire about medication for our epileptic dachshund, Tazmyn. She takes 2 different medications, one of which needs to be compounded. We recently had her compounded drug filled at a local pharmacy and it was $75.00 for 90 days and cherry flavored! (They wanted $90.00, but lowered it to $75.00.) In searching online for a cheaper solution, I stumbled across Center Pet Pharmacy, http://www.centerpetpharmacy.com, and when I called I actually spoke with the owner, Kenny Kramm. I was so impressed that the next time I need to order Tazmyn’s medication I will most likely use them. He talked to me for about an hour about the pitfalls of ordering online. He gave me a couple of websites to check out scam fraud, http://www.nabp.net (The National Association of Boards of Pharmacy) and http://www.nextag.com. He also said to check him out, so I did. I read “The Heart Of A Company” (just Google his name and it is the second link) and cried through a good portion of his family’s story. In a nutshell, he invented palatable flavors for children’s medicine when he had a daughter born with medical problems who refused to swallow her medicine. He then expanded the company into pet formulas. Finally, he sold the company, FlavoRx, and started Center Pet Pharmacy. It will be between 2-3 months before I need to order her medication and if I do order from Center Pet Pharmacy will post my experience on the forum. I almost skipped calling this pharmacy because there are no prices listed on his website. He does this purposefully because he wants his customers to call so he can get to know them and their pets. He says this is the closest he can come in this day and age to the face-to-face service he loves from years gone by.

Myrna

Love and hugs.
Lori

[littleone1]

Hi Jeanette,

I got Corky's Trilostane at Diamondback Pharmacy. His dosage had to be compounded since they don't make the Trilo in 20 mg pills. I know that Cork's dosage is lower than Princess's. I paid $23.95 for 30 pills.

[mypuppy]

Thanks Terri, I guess that would even out to Princesses dose and price then. xo Jeanette

[mypuppy]

Lori, of course it helps. I will go online in a moment. Thank you, thank you for being so helpful.....xo Jeanette









Love and hugs.
Lori[/QUOTE]

[mypuppy]

By the way Lori, you must be wondering where my manners went? lol....how is little Harley doing these days? he is sooooo adorable, well if that's an actual pic of him on your avatar? Best regards, Jeanette









Love and hugs.
Lori[/QUOTE]

[littleone1]

Hi Jeanette,

I just spoke with Diamondback Pharmacy, as they are local. They can't do 60 mg. as the brand name does come in 60 mg. They do 61 mg. The cost for 30 pills is $36.00. There is a standard mailing fee of $4.00. This would be so much cheaper than what you're paying now. If you do need to start using the Trilo, I would check with your vet, and than have your vet fax the presccription to Diamondback Pharmacy. I hope this helps to relieve your mind about the cost of the Trilo.

[Harley PoMMom]

Hi Jeanette,

Oh Jeanette, the one thing I do remember when Harley was first diagnosed with Cushings was :eek::confused::eek::confused: that was me, all confused and scared. Your manners are impeccable :) but since you asked and that was so very sweet of you to do so, and yes that is my boy Harley at around 9 y/o as my avatar, since then he has some more gray hairs, but he is 13 y/o now. :p:D

He is doing great, still running after his frisbee during the day and tossing his toys around at night. He does something now that I think is really cute; when I scold my cat Alex for something, like if he's chewing on a plant that's on the counter-top and I chase Alex down and tell Alex "bad cat," well Harley has to put his 2 cents worth in too, he'll bark at Alex and chase after him...playfully. It makes me chuckle to see Harley do this, it's as if Harley is trying to scold Alex too, because Harley will only do this when I say "bad cat." :rolleyes::)

Now, how are you and Princess today?

Love and hugs.
Lori

[mypuppy]

OMG Terri, that was so sweet, I actually did call them directly myself because I got a little sidetracked with the online quote so the phone was quicker. They did mention the issue with the dose being 61mg instead of the 60mg, but of course, now what to do, doesn't that change things with dosing? so instead of Princess receiving 120mg per day, she will get 122mg? duhhhhhhh...Im terrible when it comes to this stuff. The other thing is that I had already purchased the two months worth of the 60mg from my vet, and don't know if they would take it back....do I call my specialist and possibly get her a little annoyed with me, and then again, what happens with dosing? so sorry for ranting so much. I'm just surprised that this pharmacy does not carry the 60mg? You would think, no? oh well....listen, we'll figure this one out. I'm not concerned. I still have time since waiting on the LDDS. Thank again for checking with the pharmacy, you didn't have to go out of your way, but I totally appreciate it....Luv lots, xo Jeanette

[littleone1]

Hi Jeanette,

You are more than welcome. I do know that once any medication leaves a vet's office or a pharmacy, they cannot take the medication back. I don't know if 2 mg more a day would make much of a difference. According to Dechra's dosing, the dosage of Trilo can be 1-3 mg per pound. I would check with your specialist to see what she thinks. I know my IMS has been very tolerant with me. I think that most of them are. They know that we're not going through any easy time, and they are usually very understanding. I always have a list of questions I take with me. I always apologize for the long list. She always tells me that that's what she's there for.

[mypuppy]

Hi Lori, Yup, that would be me with all the smiley faces since I discovered this Cushings non-sense. Sometimes, I'm running like a chicken without a head as the saying goes, but I've made a lot of progress from 3 weeks ago....thank you for your kind words. and Awwww again, Harley was adorable at 9, and I'm sure nothing has changed now that he's 13 and with a few more grays--from what I can tell by your sweet nature on this forum--I feel he is loved for who he is and not for his looks, and that's the way it should be with all our pups right! I will love Princess no matter how much she ages. I love her heart....And it is so wonderful to learn Harley's doing well, and that he's pretty active still and chasing frisbees. I can't stress how I long to see the day for my Princess to chase her balls all over the yard again. That will be a youtube moment...lol....Now you made be roll on the floor with your little story with Harley and Alex, the "bad cat"...That is soooooo hilarious! haaaaaaa....too cute for words...and a very smart pup, if I may add....On another note, Princess is ok, thanks for asking. Still with the symptoms and can't wait to get her started on the meds already so she can feel some comfort. Poor thing lays in the tiled bathroom all night just to stay cool--I miss her laying at the side of my bed every night. I want my old Princess back. I want the happy Princess, not the sick one....It's still upsetting for me, and I have my moments of breaking down into tears about her, but not as bad as the first two weeks, and I think it's because I found you, Terri, Debbie, Marianne and so many others here. Thank GOD! Listen, take care of you, keep in touch and God Bless! Luv ya, Jeanette and the Princess....xo

[Harley PoMMom]

Hi Jeanette,

I think, if I were in your shoes, that I would hold off buying any Trilostane in any other dosage until: #1) Princess's LDDS test is done and it does indeed confirm cushings and #2) if the LDDS test confirms cushings; Getting her started on her Trilostane and seeing how she responds and then getting her stimmed in the required time and then seeing if she needs her dosage adjusted.

I just hate to see you buy the Trilo (61mg), even tho it is alot cheaper and then not be able to use it, some pups on Trilo do require a lower dose of Trilo after being on it.

Love and hugs.
Lori

[littleone1]

Hi Lori,

I didn't mean to make this sound like I was telling Jeanette to buy the Trilo now. I just wanted to let her know that this option was available to her.

[Harley PoMMom]

Hi Lori,

I didn't mean to make this sound like I was telling Jeanette to buy the Trilo now. I just wanted to let her know that this option was available to her.

Oh Terri,

No way did I take it like that, gosh darn this computers...I know you...you know me...remember?? I need to write better! Sorry!

Love and (((hugs)))
Lori

[lulusmom]

Hi Jeannette,

I agree with Lori and would wait until you have the results of the LDDS before ordering any Trilostane. As others have mentioned, this test does not always distinguish between pituitary (PDH) and adrenal (AT) based disease and I truly hope that Princess' results will. In the unlikely event that it is consistent with an adrenal tumor then Trilostane would not be the drug of choice....or at least for vets that are familiar with treating all forms of the disease. If it is determined that Princess has PDH then you can order Trilostane. If you decide to order from Diamondback, you are not limited to 61mg. You can opt for 59mg which is probably what I would do.

Dogs are usually very sensitive to Trilostane in the first few days and some pet owners report seeing improvement in symptoms quite quickly...within two to three days. Even though Trilostane does not have a cummulative effect like Lysodren/Mitotane, it often times will continue to lower cortisol well into 30 days. We have had one or two members that reported continued drop in cortisol for up to three months on the starting dose. It is for this reason that unless the 14 days acth stimulation test shows little to no improvement in circulating cortisol, it is not a good idea to make an upward adjustment until the results of the 30 day acth stim test can be assessed by the vet. Both of my dogs showed good results at 14 days post treatment but we did ultimately have to increase Lulu's dose after 30 days. To show you how differently each dogs responds to Trilostane, Lulu weighs less than 5 lbs and did great on 30mg once a day for two years and Jojo, who weighed 8 lbs at the time, did great at 15mg twice daily for a year or so.

Dechra recommends a starting dose of 30mg once a day for a dog of Jojo's size but because our vet took the time to research the drug thoroughly, she was aware that UC Davis did their own studies and recommended a much lower starting dose. She therefore split the recommended 30mg into two dialy doses. This worked beautifully for him and I can't help but think that had we gone with the Dechra recommendation, Jojo would have crashed and possibily ended up in an Addisonian crisis. There are a good many of us that are familiar with Trilostane and I don't think any of us would disagree that it is much safer to start with a lower dose and make adjustment(s) if necessary. Dr. Edward Feldman (UC Davis) stated that they usually start their cushdogs at 1mg/kg but some of them will ultimately stabilize at an amount sometimes 8 to 10 times greater.

It is possible that Marianne and others have already shared a lot of this information with you but it never hurts to duplicate this type of important information.

Glynda

P.S. Terri, I too did not think that your post was meant to encourage Jeannette to order Trilostane now. As a matter of fact, I thought it was very insightful of you to remind her of the recommended starting dose and to suggest that she discuss it with her vet. Good job!!!

[mypuppy]

Lori,
You are absolutely right. I had called the pharmacy just to get a price quote and possibly getting the meds at a much lower price, but being that I already received 1 month's worth of trilo, as Terri mentioned, my specialist will probably not take it back at this point. Once I get everything confirmed and she starts the meds and has the 14 day acth, I can then determine if they need to adjust the dose and can probably purchase from the new pharmacy. So as you suggested, I will do nothing for now.....Thanks again....Luv, Jeanette.

[mypuppy]

Terri and Lori,
You silly gals are making me lol...haaaaaaaa.....We're just gonna have to attend an annual Cushings conference and sort all these issues in person..lol....Wonder if there is such a conference? It would be nice, in perhaps Hawaii...haaaaa....Thanks for the little laugh. luv ya both, Jeanette

[littleone1]

Thanks Lori and Glynda.

I feel better about this now.

[littleone1]

Hi Jeanette,

I'm glad we were able to make you laugh. I would love to be able to attend a Cushing's conference in Hawaii. That's one place I've always wanted to go.

[mypuppy]

Hi Glynda, Im sorry I havent replied to your last post. I will soonest I get to it and the little ones are at school.....Regards, Jeanette

[labblab]

Hi Jeanette,

Just wanted to wish you and Princess GOOD LUCK! tomorrow on your LDDS test. I hope that all goes well for Princess, and that you are able to receive an answer that will permit you to move forward with greater confidence.

Many (((hugs))),
Marianne

[gpgscott]

Hi Jeanette,

Good luck from us as well.

She will do just fine and we will all be waiting for the report.

Scott

[Harley PoMMom]

Hi Jeanette,

I too, wanted to wish you and Princess the best of luck tomorrow on your LDDS test, and I am hoping also, that the LDDS test will confirm her cushings more clearly so that you and Princess can move on to treatment.

We all will be axiously waiting with you for the test results. :)

Love and hugs.
Lori

[mypuppy]

Awww Lori, you are just too sweet...I love you gals on this forum...I feel so encourage and supported by all of you here during this difficult time. thank you from the bottom of Princesses and my heart....Luv ya all....Jeanette ps: I will post the LDDS result soones I have them, trust me.....

[mypuppy]

Scott, so great to hear from you....Thank you for the encouragement. I definitely need it...I feel as if Princess has been put on hold too long with all these horrible symptoms, and I do need to move forward after tomorrow. It's time. Thanks again, and again, I will post those results as soon as I have them....Best regards, Jeanette

[mypuppy]

Hi Marianne, Thanks a million for the good luck wishes. I sure do need them, as Princess just stoled my little one's dinner biscuit right off her plate while she went to potty...this is not Princess behavior at all, so yes, we need to act soon and reverse some of these uncommon behaviors she is recently exhibiting. She has NEVER, and I mean NEVER ever taken a bit of food from the table or the counters or anywhere. This is rare for her, and I don't enjoy that in her. Nevertheless, I still managed not to yell at her, and instead of reprimanding her I hugged her because I know it's not her nature taking over, it's this "dratted disease" as Lori refers to it...UGH, UGH. UGH....Anyway, sorry for the frustrating post, but I want my old well behaved doggie back....Thanks again. Luv, Jeanette.

[Harley PoMMom]

Hi Jeanette,

The stealing of food...I know what you mean, my boy Harley pre-cushings, you could of put a plate of food in front of him and he would not of touched it...stared at it but not touched it. He also had, what I call a very soft mouth...when I would give him a piece of food by hand he would take it ever so gently. That all changed when he first got this cushings disease but he is getting alot better, his soft mouth is coming back again :) and I can put a plate of my food down and he doesn't go head first and start eating it :)


it's this "dratted disease" as Lori refers to it.Actually, I think I got this phrase from Debbie (StarDeb55), one of our Moderators, but it definitely says it all.

Oh Jeanette, I hope your little one wasn't too upset/frightened with what Princess did. I mean I hope she is ok. I know it is so hard for them to understand, especially when, sometimes we don't even understand ourselves, this cushings is so :eek::confused: We are always here for you, you need to vent or whatever, you can take your frustrations out on here, ok.

Love and hugs.
Lori

[littleone1]

Hi Jeanette,

I know it's hard to fathom our babies doing something like this. I always use to set my plate of food on the coffee table and Corky would never touch it. One evening we were having a birthday party for one of our friends. One of our new neighbors mentioned something about Corky trying to get the food. I told her she didn't have to worry about it, as Corky never touched anything but his own food. However, Corky kept trying to get the cheese. Everyone that knew him was totally stunned by his actions. They had never seen him do that before. It was shortly thereafter that he was diagnosed with Cushings.

Is your little girl okay? I hope so.

Once again, I wish you the best tomorrow.

[littleone1]

Hi Lori,

I know exactly what you mean. Corky was the same way. Even when I would give him something to eat by hand, he was always such a little gentleman. Then all of a sudden, he really started going after the food. He is now really a gentleman again.

[mypuppy]

Lori, so nice to hear from you always. This forum and you, Terri, Debbie, Marianne and the others have become my venting outlet. It feels good to let it all out. My little one is 5 years old, and no, she absolutely DOES NOT understand what Princess is going through. She's so innocent still, and this is why I am constantly monitoring her closely because she does tend to be all over Princess and wanting to play rough, and this is definitely not Princesses time for rough play. Everytime she tries to engage with Princess I have to somewhat catch her and reiterate that Princess is a bit sick lately and needs to be left to rest. That's as best as I can put it to a 5 year old. She wasn't totally bent out of shape about the biscuit, so long as there was another one at hand--lol---she loves her biscuits, and I guess so does Princess....lol....my poor precious pup, so hungry all the time. Do I feed her all she wants also as well as letting her have free access to water? I have been giving her extra treats here and there since the symptoms began, but oh I don't know? Anyway, LDDS test here we come. Will keep you posted on that. Great to hear from you. Luv, xo Jeanette ps: did you read my earlier post to Terri? We actually spoke on the phone today....she's lovely to talk to. Maybe you and I can speak soon too....Regards.

[Harley PoMMom]

Oh Jeanette,

5 years old, poor little girl, of course she's not understanding what's wrong with her puppy and why her puppy's acting "strange." I totally see your frustration and sympathize with you as well...wish I could do more than what I am doing.


Do I feed her all she wants also as wellNo, obesity is not good for them, and this is the really hard part, not overfeeding them because you know they want food, but you can feed her, like, carrots because they don't have many calories, as long as her glucose (bloodsugar) is ok. Just make sure she has free access to water like I know you're doing. :D

I did see your post to Terri and I am so happy that the two of you got to talk, I will PM you my phone #, ok. Terri is a wonderful person, isn't she! :D

Love and hugs.
Lori

[Harley PoMMom]

Hi Jeanette,

Another thing you might be able to add to her food, but check with your vet first and ask too about the carrots, but the other thing is rice. Rice is pretty low in calories and is a filler. Harley's diet has rice in it and I use what's called a "sticky rice" it is usually found in the international section of the grocery store, and not with the regular rice. I hope this helps.

Love and hugs.
Lori

[littleone1]

Hi Jeanette and Lori,

Thank you both so very much for the wonderful comments that you made. I think that both of you are fantastic ladies.

[Squirt's Mom]

Hi Jeanette,

Been out of pocket again, but wanted to let you know that you and Princess are in our thoughts and prayers for tomorrows testing. I know you both will do just fine!

Keep on keepin' on!
Hugs,
Leslie and the girls

[littleone1]

Hi Jeanette,

I hope everything went well for you and Princess today. I know you both had a long day. Extra hugs for both of you.

[mypuppy]

Hi there Terri,
Yes indeed it's been a very long day. Dropped off Princess at 8:30 and picked her up at 5 today. She couldn't run in the car fast enough when I picked her up, poor thing. It breaks my heart leaving them at the vets all day, but it's over for now anyway. She's home, she drank, she ate and now relaxing in the comfort of her own home and loving family, as it should be....I missed her soooo much I could not concentrate on anything else. Thanks for checking in on us. We are fine now. I asked if we would have any results tomorrow, but they seemed to think by Saturday, so we'll see. I will keep you afloat on the results. Thanks again, and I think I'll go mush her up a bit to make up for this long day without licks or kisses..lol. Take care of you, and talk soon. Luv, xo Jeanette

[mypuppy]

Hey Leslie,
So nice to hear from you. Thank you so much for the thought and prayers. We got home around 6 p.m. and she's just relaxing now in her bed. I missed her all day, but glad it's over, at least for today. Thanks again for all your great wishes. Will keep everyone posted on the results. Luv, Jeanette.

[mypuppy]

Hi Lori, thanks for all the good tips on what to feed her. I usually do give her boiled carrots and sweet potatoes once in a while, and she gets her nice venison backstraps as a treat as well--she loves it, and it's soooo lean, no fat whatsoever, so i know it's not doing any damage...i also give her brown rice on ocassion as well. we don't give her junk stuff. i mean once in a while we will give her a slice of cheese, piece of bacon, but no sugary or salty treats. thanks again. xo Jeanette

[littleone1]

Hi Jeanette,

I'm glad Princess came home and ate. I could just see her running to get in the car to go home. That's how Corky was when he had to stay in the hospital over night and most of the next day. I'm sure it was hard to concentrate on anything else.

You both have a good night. I'll talk to you later.

[mypuppy]

Hi Glynda,
Im so sorry for the late reply. Princess had her LDDS today, she did fine and is home relaxing now. I missed her dearly today. I certainly do hope they will be able to distinguish/confirm if in fact it is pituitary. Unfortunately, my specialist and I had already decided on the treating with trilostane prior to my going for the LDDS, so she had already shipped it, and it's in my cabinet, but I am awaiting the final results of this last test, and will proceed accordingly. I appreciate all your comments and experience with trilo. It makes sense. I will discuss with my specialist once I receive the LDDS results, and ask if starting with a lower dose would be the way to go for Princess? Will let you know how that goes. In the meantime, I hope you and Lulu are both doing well these days. Can't wait to move on with this. Thanks again, and keep in touch....xo Jeanette

[haf549]

Glad to hear all went well today with the LDDS. I'm keeping my fingers crossed for a positive result for Princess.

Heidi

[Franklin'sMum]

Hi Jeanette and Princess,

We're keeping fingers, toes and paws crossed for you both.
Jane and Franklin xx
________
Light Bulb Vaperizer (http://vaporizerinfo.com/)

[mypuppy]

Hi Jane,
Thanks a bunch. I am very anxious to get those results. Thanks again. xo Jeanette and licks to Franklin from the Princess

[mypuppy]

Heidi how are you? Thankful for your encouragement. Can't wait to hear something. Who knows maybe I will today. Best regards, xo Jeanette

[labblab]

Hi Jeanette,

I, too, am so glad to hear that Princess is safely home again! And now the "waiting game" begins again...:o But hopefully you'll get the test results tomorrow.

Also, I just wanted to give you the link to the U.S. Product Insert that accompanies Vetoryl sold here in the states:

http://www.dechra-us.com/File/prod_vetyrol.pdf

It may have been included in your box of medicine, so you might already have it on hand. But if not, you can take a look at the written paragrah under the heading of "Dosage and Administration." It is just above the dosing chart on the left-hand side of the page. And there you will see the written recommendation that the starting dose can range from 1-3 mg. per pound of body weight. The 120 mg. dose that your vet has prescribed is right in the middle of that range (and corresponds with the chart). But as several of us have suggested, if you do end up treating with trilostane, you may want to discuss starting off at the lowest end of the range -- at 60 mg. per day. I don't want to seem as though I am harping on this, because your vet's recommendation is certainly well within Dechra's guidelines. But I just wanted to make sure you have the written information "in hand" if you do want to discuss the dosage question further.

Here's hoping you'll get some helpful test results tomorrow!!

Marianne

[haf549]

Morning Jeannette:

I just wanted to put my 2 cents worth in about the dosing. I agree with Marianne; I think it is better to start at a lower dosage. It took over 3 months to get Kira stabalized on trilostane. She started out at 120mg per day; then went to 60mg twice a day. She wasn't seriously sick, but she certainly wasn't herself on that dosage. Finally in January, we started her on 40mg twice a day and haven't looked back since. Starting on a lower dosage means more stim tests, but in hind sight, I now wouldn't start her on the higher dosage.

Heidi

[mypuppy]

Marianne, I take everything I read here from everyone quite constructively and appreciatively. Thanks for the Vetoryl dosing guidelines, it's very helpful, and yes, it seems my specialist is following the chart. I would want nothing more than to start Princess on a lower dose, however, I'm just not sure how to go about suggesting that to my specialist without her thinking I am trying to do her job??? It's such a tough call, and well again, she is following the guidelines. I just feel it may be out of place being that I totally questioned her several times about her choice of treatment with trilostane, and well I don't want to rock the boat, as they say. I don't know. If I work up the nerve to slightly hint regarding starting a at a lower dose, I will. Will let you and the others know. Either way, I do thank you for your concern and opinion. Best regards, Jeanette

page. And there you will see the written recommendation that the starting dose can range from 1-3 mg. per pound of body weight. The 120 mg. dose that your vet has prescribed is right in the middle of that range (and corresponds with the chart). But as several of us have suggested, if you do end up treating with trilostane, you may want to discuss starting off at the lowest end of the range -- at 60 mg. per day. I don't want to seem as though I am harping on this, because your vet's recommendation is certainly well within Dechra's guidelines. But I just wanted to make sure you have the written information "in hand" if you do want to discuss the dosage question further.

[mypuppy]

Hi Heidi, I appreciate your suggestion, and wow! I can't believe it took that long for Kira to find the right dose. As I told Marianne, I will try to work up the nerve to suggest to my IMS. Just waiting on the LDDS results and will discuss dose with her at the same time as results. Thanks again and best regards, Jeanette

[littleone1]

Hi Jeanette,

I understand how you feel about not wanting your IMS to think that you are second guessing her.

When you talk to her, you might want to mention, as in one of your posts, that you were under the impression that Princess would be taking 60 mg of Trilo daily, and just ask her if that would be a good starting point if Princess has to take the Trilo. Since you thought that's what she said, it's possible that when they sent the Trilo, the packaging information was inserted and is to be used as a guideline.

I know that Corky's IMS started him on a lower dose. He's really been doing great on it. I know that if I mention something to her, she tells me that it looks like I've been doing alot of research. When I tell her I have been, she chuckles. She doesn't mind me asking about different things. I know that when it comes to Corky, I need to do what I feel is best for him.

I hope this helps a little.

[lulusmom]

Hi Jeanette,

If you are comfortable with the dosing your specialist has prescribed, then don't worry about it; however, if you aren't, then don't ever be afraid to ask questions. You are Princess' only voice so if you have concerns, express them. Cushing's is a frustrating and complicated disease so any concerns are valid and your specialist should not dismiss them. If your IMS has treated a lot of cushingoid dogs, she should know that treatment is much easier and safely facilitated when the pet owner understands what she is telling them so that you can work as a team.

I am sure that my IMS hates to see me coming because I can be a royal pain in the butt when it comes to my dogs. If I don't understand something or am concerned about his approach to things, I'll ask him to draw me a picture if he has to. I make sure I get my money's worth at every visit. :D While I am not sorry for asking questions, I respectfully apologize for being so anal but remind him that my dogs are my kids. He needs no reminder of that anymore and the good news is that he actually appreciates the fact that I have taken the time to educate myself, which makes his job easier.

You can bolster your credibility with your specialist by taking supporting documentation to validate your questions or concerns. If I were to question my IMS regarding safe dosing of Trilostane, I would print out a copy of an October 1, 2007 article in DVM Newsmagazine written by Dr. Johnny D. Hoskins. UC Davis has developed their own treatment protocol based on their own extensive experience with Trilostane. Drs. Edward Feldman and Richard Nelson are high ranking faculty at UC Davis, are well published experts on cushing's and both lecture around the world. I am sure that your specialist is very familiar with all three of these prestigious gentlemen.

I am providing a link below to the article as well as an excerpt that talks about UC Davis' experience with Trilostane.

http://veterinarynews.dvm360.com/dvm/article/articleDetail.jsp?id=460965&sk=&date=&pageID=3


Experience at UC-Davis differs quite a bit from that in the literature and the United Kingdom. It is not clear why the results have not been similar. It seems that the most common reason for choosing this drug over o,p'-DDD is safety. In other words, trilostane has been viewed as much safer and, perhaps, more effective in controlling clinical signs of pituitary-dependent hyperadrenocorticism.

Some of the dogs we have treated have done remarkably well on a once-daily protocol. However, a significant percentage of dogs we have treated with trilostane have become ill (including deaths), either from glucocorticoid deficiency or from glucocorticoid and mineralocorticoid deficiency (hypoadrenocorticism). Some of the iatrogenic hypoadrenocortic dogs appear to have this condition permanently. In addition, treated dogs that fail to exhibit resolution of polyuria despite having ACTH stimulation test results within the recommended range do occur.

Therefore, trilostane is neither more effective nor safer than o,p'-DDD. Of greatest concern is that trilostane has been less predictable regarding underdose, overdose, resolution of signs or need for dosing more often than once daily.

The UC-Davis current recommendation is to initiate trilostane therapy at 1 mg/kg once daily. That dose is continued for about one week until a veterinary re-check can be completed.

I hope this helps.

Glynda

[mypuppy]

Hey All, Sorry this took so long. I just received Princesses LDDS results today. Spoke to gp and IMS and they both confirmed the results were consistent with pituitary dependent Cushings. Nevertheless, I would highly appreciate anyone's input on them. It never hurts to double check. Thanks a whole bunch. Best regards, Jeanette....Here they are:

PRE DEXAMETHASONE:
Result: 15.2
Reference Range: 1.0 -6.0 ug/dL
Flag: High

POST 4 HR DEX:
Result: 7.4
Reference Range: LESS THAN 1.5 ug/dL

POST 8 HR DEX:
Result: 11.5
Reference Range: LESS THAN 1.5 ug/dL

Comments:

Low-Dose Dex Diagnostic Intervals (Canine)
4 hours: 8 hours: Interpretation
<1 <1 Normal
1.0 - 1.5 1.0 - 1.5 Inconclusive
>1.5 and >50% >1.5 and >50% Consistent with
of baseline of baseline hyperadrenocorticism
Further testing required
to differentiate adrenal
tumor from pituitary
dependent h.adrenocort

<1.5 or <50% >1.5 and >50% Consistent with pituitary
of baseline of baseline dependent h.adrenocort

<1.5 or <50% >1.5 and <50% Consistent with pituitary
of baseline of baseline dependent h.adrenocort

>1.5 or >50% >1.5 and <50% Consistent with pituitary
of baseline of baseline dependent h.adrenocort

[mypuppy]

Sorry ALL. The comments area got somewhat distorted when I sent my post. will have to figure out best way to post properly, but can anyone decipher in the meantime without the comments area? Thanks all. Jeanette

[labblab]

Hi Jeanette,

Yes, I think the LDDS results are consistent with PDH. The 8-hour value is higher than the normal reference range, so that is consistent with a Cushing's diagnosis, generally. And the 4-hour value is less than 50 percent of the basal value (barely less, but it IS less). And that result is consistent with PDH.

SOOOOO, there you have it!!! I'm guessing these results are finally going to clear the path for beginning trilostane treatment? Have you and your vet settled on the starting dose for Princess?

Marianne

[littleone1]

Hi Jeanette,

I'm glad you got the results back today. I'm not very good at interpreting results. I'm sure others will be along to answer your questions.

Did your IMS tell you whether or not to start Princess with the Trilo? If so, how many mg is she suppose to start with?

I'm sure that finally knowing what is wrong is somewhat of a relief. At least now you can go forward.

My thoughts are with you and Princess.

[mypuppy]

Hi Marianne, Yes, this was the final confirmation in order for me to proceed with treatment. And yes, my IMS also confirmed 2 (60mg) pills once a day is the appropriate starting point for Princess, therefore, that is what we will do for now until the 14 day ACTH stim says otherwise. I feel so much more relieved now that I had these final test results and not fear of treating her with the wrong med if it was not pituitary dependent. Thanks so much for your input on those results, and btw, I accepted your friend request also...Just not sure how it works now. lol.....Best regards, Jeanette

[mypuppy]

Oh thanks so much again Terri....and thank you for the phone call. It was great talking to you although short. And yes, BIG sigh of relief for now that we have confirmed both the condition and which type....much more at ease....Luv, Jeanette

[labblab]

Jeanette, I'm really glad that the test results are permitting you to go forward with treatment for Princess. I am so hoping that your baby girl will quickly gain some relief!!

I do appreciate the fact that you have considered all of our alternative dosing suggestions. But as we've already discussed, your vet's recommendation is consistent with Dechra's dosing protocol, and so I cannot consider it to be unreasonable. I also know that you will be monitoring Princess very closely. So if it should be the case that this dosage level does not suit her, you will be quick to notice any adverse side effects and bring them to the attention of your vet for readjustment.

I'll be keeping my fingers crossed that your initial experience turns out to be similar to mine with my boy. Within just a couple of days, we saw improvement in his thirst and urination. Many people do not see results so quickly, but I'll surely be hoping that you guys DO!

KEEP US UPDATED!!!
Marianne

P.S. I revised your thread title to reflect the fact that you are now beginning your trilostane treatment...

[ladysmom06]

Hi Jeanette,

Wanted to wish you luck with the trilostane. We used trilo and had very good results with it. Lady did really well on it. After being on it for a couple of weeks her pot belly disappeared, her fur grew back and the panting stopped. She was also diabetic - we could never regulate her bg's till after she was on the trilo for a few weeks. All of her following stim tests showed her cortisol was well controlled - she never had a return of any cushing's symptoms. Again good luck. Hugs to the two of you.

[mypuppy]

Hi Lynn. Thank you so much for the great wishes. I too am hoping for some good results for Princess, and that is amazing it worked so quickly on your "Lady", she's a beauty too, if I may add. Is she a Jack Russell Terrier? At times, it's hard to decipher with the small image, but she's precious either way...THEY ALL ARE! Anyway, of course I will keep you and everyone informed on the initial stages of Princesses treatment, 14 stim test and hoping from that point on we can just see some improvement with her symptoms and try to enjoy our puppy again. That's all I can hope and pray for. It's better than winning the lottery at this point. Take care of you and Lady and Best regards, xo Jeanette

[littleone1]

Hi Jeanette,

You are very welcome. I also enjoyed our conversation.

I hope all goes well with Princess's treatment. I'm looking forward to your posts saying how Princess is improving. I know that you are very anxious for that day to come. You are in my thoughts.

[mypuppy]

Hi again Marianne,
I would definitely have considered going with the lower dose as suggested by you and some others here, but as I said, my IMS felt confident with Dechra's protocol. And you bet I will be watching her like a hawk once she begins treatment. In fact, we were suppose to go away for Thanksgiving, but we changed plans to stay home with her and make sure all is well while she's in the initial stages of treatment and testing and getting her on the proper dose. I can't wait for our lives to get back to some normalcy, but most important, get Princess back to a better quality of life. Thanks again to you and everyone here for getting me through each day. Wow, I feel very blessed to have found you all! I will most definitely keep you and everyone updated on the next process. Btw, I did notice my new thread title. I was wondering who did that? Thanks. How did you do that? Lol.....xoxoxoxo Jeanette and Licks to all from Princess

[labblab]

Btw, I did notice my new thread title. I was wondering who did that? Thanks. How did you do that?
Unfortunately, members do not have the ability to change thread titles themselves -- title changes can only be made by Administrators or Moderators. That is just the way the forum "software" works. So we try to keep watch and make revisions on the behalf of our members if a dog's situation changes, or if there is important information to be conveyed. However, any member can also feel free to PM one of us staff members in the event that they would like to see a different or additional change made in their thread title. We will be happy to do that for you all. :)

Has Princess already started with her trilostane today, or are you waiting until tomorrow? You probably already know this, but it is best to give her the medication along with some food (it is absorbed into her system more efficiently, and also is less likely to upset her stomach). As I say, you may already know this, but I can't help but be a "mother hen"...:o

Marianne

[MiniSchnauzerMom]

Jeanette,

This is the first time I've posted to your thread. Just wanted to drop by and wish Princess lots of success with the new Trilostane treatment.

Munchie sends special slurps for Princess. :D Will be watching for your updates.

Louise

[mypuppy]

Dear Mother Hen -- LOL....Are you kidding silly! Even though I did receive instructions to give medication with food from my IMS, please know I DO NOT mind you or anyone here reminding me of certains things. It's so good to know that you and so many others are on top of things and remind us, the less experienced, when it comes to this condition. Thank you, thank you, thank you. And btw, I think it's wonderful we have you as a moderator. Obviously, you have well earned that honor, right along with Lori since you both seem to be extremely knowledgable, and well liked if I may add...Keep up the great work. xo Jeanette

[mypuppy]

Aww Louise, thanks so very much for writing. I get so encouraged when I read everyone's posts, and it's very heart warming as well. Definitely peek in from time to time because I will be reporting on Princesses progress. Licks to Munchie and best regards to you. Jeanette

[mypuppy]

ps: Oops! Sorry, I'm getting everyone's titles mixed up here too. I see you are the "administrator" and not "moderator"...Sorry. What is the difference, and Im curious how one is promoted? Sorry for all the questions, I just like to know how things function sometimes. Regards, Jeanette

[MiniSchnauzerMom]

Aww Louise, thanks so very much for writing. I get so encouraged when I read everyone's posts, and it's very heart warming as well. Definitely peek in from time to time because I will be reporting on Princesses progress. Licks to Munchie and best regards to you. Jeanette

Yes, Jeanette, I definitely will be peeking in on a regular basis to see how Princess is doing and Munchie says "thanks Princess for the licks." ;)

Louise

[Harley PoMMom]

Hi Jeanette,

Ahhh...finally treatment can begin, huh! I too wanted to wish you and Princess the best of luck with your treatment plan.

You're a wonderful mom and you're doing a wonderful job, don't forget that, ok, and you have some excellent Trilostane mentors here that I am sure will help you too.

I will be definitely be peeking in too for your updates.

Here is some important information on Dechra's U.S. Product Insert and there is alot more info on the Product Insert:

Re-examine and conduct an ACTH stimulation test 10-14 days after every dose alteration. Care must be taken during dose increases to monitor the dog’s clinical signs and serum electrolyte concentrations.

ACTH stimulation test (conducted 4-6 hours after VETORYL Capsule administration), and serum biochemical tests (with particular attention to electrolytes, renal and hepatic function).

Wash hands after use.

http://www.k9cushings.com/forum/showthread.php?t=185

Love and hugs.
Lori

[labblab]

ps: Oops! Sorry, I'm getting everyone's titles mixed up here too. I see you are the "administrator" and not "moderator"...Sorry. What is the difference, and Im curious how one is promoted? Sorry for all the questions, I just like to know how things function sometimes. Regards, Jeanette
Oh Jeanette, no worry at all about "title confusion." :) There ARE a lot of different titles here, but the differences largely relate to behind-the-scenes "housekeeping" duties and responsibilities. You've probably seen the original "Wizard of Oz" movie, where the great Oz is revealed as just a little man pulling a bunch of cords and levers behind the curtains :p?? Well, kinda in that same way, there are a bunch of control panels and organizational responsibilities behind-the-scenes here that have to be overseen to keep the forum working properly. So that's what we staff members do. And the different titles correspond to different areas of responsibility "behind the curtains." I'm just one of several Administrators, and we also have several Moderators and a Forum Host, as well. As a group, we make decisions about staffing needs and the other organizational issues that arise.

For the purposes of the members, the important thing to know is that you can ask any staff member about a question or a problem that you may be having. You really don't have to worry about the different "titles." Because the staff member will know which one of us will be best able to help in any given situation, and they will forward the question on appropriately if it doesn't fall within their own area of expertise, or if it doesn't relate to a forum for which they are responsible.

Hope this helps to make some sense of the cords and levers behind OUR magic curtain...:p:D

Marianne

[haf549]

Jeannette:

Just wanted to pipe in Kira's and my best wishes for a successful result to Princess' treatment. I'm sure she'll do fine.

Heidi & Kira

[Franklin'sMum]

Hi Jeanette,

Just adding my best wishes to you and Princess.
We will also be peeking back often to see how you both are.
Thinking of you,

Jane and Franklin xx
________
ZOLOFT SETTLEMENT NEWS (http://www.classactionsettlements.org/lawsuit/zoloft/)

[Squirt's Mom]

Hi Jeanette,

I know you will do just fine with the treatment for your sweet Princess! :) You have been doing such a great job so far there is no reason to think you would do any different now. Remember we are here if you need us and behind you all the way!

Hugs,
Leslie and the girls

[mypuppy]

Leslie, that means so much to me. I appreciate every kind word. Although not perfect, I will try to give it my all and do my very best in taking care of my sweet pup. Thanks again, and for the record, I feel the same way about you and all the others here. I can't believe there are sooooo many people who take pride and devotion for their precious furry friends and with so much passion, as it should be--they are all blessed to have such wonderful moms and dads to watch over them. Best regards and Luv....Jeanette

[mypuppy]

Hey Lori,

As always, so thankful for all the important info you so generously offer and remind me of. So kind.....I will keep everything in mind, and if you think of anything else, post it over. LOL....Still need to sneak that phone call in. I have not forgotten you, and look forward to talking to you.....Luv lots, Jeanette

[mypuppy]

Marianne, LOL....so well put! And yes, that clears things up for me. Thanks again and talk soon....xo Jeanette "member" - lol.

[labblab]

Hi Jeanette,

I'm thinking about you guys this morning, and wondering how Princess is doing...Good, I hope! :)

Marianne

[mypuppy]

Hello Marianne, so great to hear from you, thanks for the sweet thoughts. Unfortunately, I did not start Princess on her treatment because her IMS was scheduled to be away at the time she was due for her 2 weeks stim, therefore, I decided to delay her treatment until this coming Monday. I was not very happy to make this decision since I was pretty anxious to begin, however, I truly wanted her specialist to perform the stim based on the fact that she knows Princesses history, and I just feel more comfortable with her carrying through this process. I feel terrible for holding her off a couple more days, but at the same time I thought it made more sense to stick with the Dr. I feel more comfortable with. Thanks again and tune in on Monday. Best regards, Jeanette

[Squirt's Mom]

Hi Jeanette,

Don't feel bad for wanting to do the best for Princess. Your comfort level is well worth waiting a few days to start treatment. The calmer you are about this, the calmer she will be and the better the whole deal will go, so don't get down on yourself because she is waiting a few days - you are doing what you feel is best for both of you.

Remember we are all here with you even tho some of us may not post that often, 'k? So you come talk any time you feel the need and I promise there will be 100's of caring ears listening. :)

Enjoy the weekend!
Hugs,
Leslie and the girls

[Harley PoMMom]

Hi Jeanette,

I agree with Leslie, and as we say around here always trust your "gut" :) I would only want Harley to be seen by his regular GP and IMS, they know his "story." But if an emergency would arise I do have a back-up GP for Harley who has a 24 hour emergency service.

I believe feeling comfortable with the Dr. treating Princess is very important and you should not feel the least bit uneasy about your decision to hold off treatment until Monday. Like Leslie has mentioned our furbabies are very intuned into our energy and Princess will be able to sense if you are nervous, and we want calm energy, right!;):) So I think you made a good judgement call.

Love and hugs.
Lori

[MiniSchnauzerMom]

I decided to delay her treatment until this coming Monday. I was not very happy to make this decision since I was pretty anxious to begin, however, I truly wanted her specialist to perform the stim based on the fact that she knows Princesses history, and I just feel more comfortable with her carrying through this process. I feel terrible for holding her off a couple more days, but at the same time I thought it made more sense to stick with the Dr. I feel more comfortable with.

Hi Jeanette,

I'm sorry you were feeling terrible for holding off treatment for Princess a couple of days and hope that feeling has passed. Delaying a couple of days poses no problem and I'd be doing the same thing you have chosen to do. Trust yourself! This is not an emergency situation and I agree with your thinking to stick with the doctor you are feeling more comfortable with.

For sure, I'll will "tune back in" on Monday. :D Give Princess a little hug from me and I'm sending a "comforting cyber hug" especially for you just in case you have any remnants of those terrible feelings left. Relax, you're doing a good job.

Louise

[gpgscott]

Jeanette,

Holding off is not an issue when you are doing it to further inform the treament.

Seven is a pup and Princess deserves the best of care.

Thanks very much for letting us to be part of this treatment.

Scott

[littleone1]

Hi Jeanette,

I feel the same way that the others feel. It's important that if you're comfortable with your IMS, and you know that she knows Princess, it won't hurt waiting a few days to start the treatment. I would do the same thing with Corky.

I'll keep in touch. Take care and give Princess kisses from Corky.

[mypuppy]

Hi Leslie,
Always, so nice to hear from you. Oh my gosh! I don't know what to say to you and everyone here, you are all one of a kind, caring and special individuals to me. I know I tend to say "thank you" quite often throughout my posts, but that's merely because I am EXTREMELY appreciative to each of you during these last several weeks. There are no words to truly express how deeply touched I am for having you all in my life, even though it's behind words, but they are precious. Thanks again. Princess and I love each of you SOOOOOOOOOo much....xo Regards, Licks, Jeanette and Princess

[mypuppy]

Thanks again for every kind word Louise and that "comforting cyber hug" sure was comforting to me and Princess. Thanks a million and the same to you....Luv, Jeanette

[mypuppy]

ps: hi again Leslie, I meant to ask, is there a way we can view close ups of Squirt. I love your avatar pic with his belly up position. I have so many of those of Princess. I just love when they lay that way, it's so adorable to watch, but I would love to see little Squirt's face soon. xo Jeanette pps: and i love the name Squirt, that's what I call my 5 year old at times...lol

[mypuppy]

Hey Lori, you are absolutely right about our furbabies sensing our stress, it's the same with babies, and I am pretty sure Princess has sensed my stress level's been way up there last few weeks, but if all goes well tomorrow and the rest of the week while she begins her initial treatment, I will feel so much more at ease and she will know it also...Gosh, I am truly scared for tomorrow. I guess my former gp traumatized when he initially told me "trilostane is deadly" that I am somewhat dreading tomorrow, but at the same time I think all will be fine....Keep those prayers going for us tomorrow. Best regards, Jeanette

[mypuppy]

Scott, you are right, I feel 7 is young also, and that's why I didn't rush into anything and waited this long. Thank you for all your great support these past few weeks. Regards, Jeanette


Jeanette,

Holding off is not an issue when you are doing it to further inform the treament.

Seven is a pup and Princess deserves the best of care.

Thanks very much for letting us to be part of this treatment.

Scott

[mypuppy]

Love and hugs to you both too Terri. I will be reporting tomorrow. lol. Say some prayers for us tonight....xo Jeanette and Princess

[Squirt's Mom]

ps: hi again Leslie, I meant to ask, is there a way we can view close ups of Squirt.

Hey Jeannette,

You can see more pics of Squirt and our other girls in my album. Click on my user name above this post, then on 'view public profile', and when it opens you will see albums down on the right hand side. Just click to open. :)

I think she's just beautiful! they all are! And, noooo, I'm not prejudiced at allllll..... :D

Hugs,
Leslie and all her girls

[mypuppy]

Oh my gosh Leslie, you have a big family. They are all precious, and it's nice to finally see Squirt's "beautiful" face up close, and I must agree with you that all our pups are indeed beautiful, that's why we love them sooooo much. Thanks for teaching me how to view everyone's pics. I never knew how to. I'll have to upload some of my Princess soon for everyone to view her "beauty" - lol......Thanks for sharing your memorable pictures....Best regards to you and the girls.....Jeanette

[mypuppy]

Dear all,
just wanted to send a brief post to let everyone know princess has begun her treatment today, and fortunately no side effects to report. I know it's only day one, but we are getting through this day with flying colors so far. I promise not to bore each of you with nothing to report every day..lol.....luv you all.....xo jeanette

[Squirt's Mom]

Oh Jeanette! You can't bore us with details of your baby! We especially love to hear when things are going good! :D Never worry about things like that with us! ;)

Thanks for the compliments on my girls! :) Can't wait to see some of Princess!

Hugs,
Leslie and her girls