Annie (12 yr old Lab) PDH (Trilostane) - Annie passed on 5/7/11

[Annie's Mom]

This website and all you wonderfully caring people is a Godsend. My name is Barb, and my 12 yr old lab mix (Annie) was just diagnosed with pituitary dependent Cushings. She will start on Trilostane next week.

My first question: where can you purchase Trilostane for the least amount of $$?

Now the details: on Wed Annie had a low dose dex test (Cortisol serial 3 - DEX):
sample 1: 2.0 (ref range 1.0-5.0 ug/dl
sample 2: 0.8 (ref range 0.0 - 1.4) ug/dl
sample 3: 4.2 (HIGH) (ref range 0.0 - 1.4) ug/dl

What do these results mean? How bad is 4.2 for the last test result? What can I expect from using the Trilostane? The vet has made me aware of side effects to watch for (lethargy, lack of appetite, and to stop the meds immediately and give prednisone if the vet office is closed).

My vet wants to start her on 60 mg/day for 10 days, then do an ACTH test.

Annie's health history: Annie is a 64# lab/dalmation mix. She's always been slim and trim, ran like a race horse until 3-4 years ago when her arthritis started slowing her down. She has arthritis and bone spurs in her R elbow. For the past 7 years she's been on Metacam, Derramax and most recently Rimadyl, along with Tramadol for the pain. In the last 2 years her arthrititis has progressively gotten worse. In June, she had a UTI and was treated with Amox/Clav.

Sept 7, she had a severe pancreatitis attack. She spent 6 days in the hospital on IV fluids; her platelets dropped dangerously low; they did an U/S and noted a nodule on her R adrenal gland. The focus then was to resolve the pancreatitis. Her liver enzymes were normal. We retested urine and blood a few weeks later, and her liver enzyme was elevated. We stopped the Rimadyl, and retested her blood 2 weeks later. Her liver enzyme was elevated even more, and she has another UTI. She is on 2 weeks of Amox/Clav and the vet suggested the low dose dex test, which confirmed pituitary Cushings.

The past 9 months I've noted she is panting more than usual, excessive drinking, muscle loss and weakness in her back legs (minor trembling or muscle twitching after/during a walk). I associated the muscle loss with the lack of exercise since her arthritis has gotten worse. Her coat is BEAUTIFUL!! About 8 years ago she was diagnosed with struvite crystals and has been on Hillls Rx CD food. When she came home from the hospital from the pancreatitis, I have now switched her to Science Diet for seniors-large breed, at my vets advice. She shows no signs of struvite crystals.

To complicate matters, 24 hours after she came home from the hospital from the pancreatitis, she had an episode of Vestibular Disease. What more can my Annie be faced with?!!! (and me!). Enough already !!

It has been a slow recovery process, however Annie IS recovering from Vestibular and pancreatitis. She still stumbles and loses balance at times on uneven ground and on inclines, and can't walk down more than 3 stairs without falling sideways, but she is making great progress! Maybe some of the balance issues will resolve once she gets more strength. She lost 9 pounds during the 6 days in the hospital. Once she was able to get back to eating regular food, she has now regained all that weight and is eating normally now. She was finicky with food earlier this week for 1 1/2 days, but eventually she ate her normal amount (by adding some canned food to the dry kibble). She has never had the "pot bellied" look; and has always been muscular and strong and active.

I am concerned that being on the Trilostane may increase her arthritis pain. I give her injections of Adequan every 3-4 weeks to help with the arthritis. I am going to increase that frequency, considering she won't be back on Rimydl. My vet said we can increase her Tramadol if necessary. Since taking her off Rimadyl, I give her Tramadol in the morning and night; and Gabapentin mid-day. As Annie has recovered from the pancreatitis and vestibular disease, her activity level has increased, she seems happier most of the time, yet also has bouts of panting, and lethargy. She's been on Amox/Clav for a week now, and she is drinking less water, urinating less, and seems to be more energized. Her body has been through a TON. I have seen Annie age sooo much in the last 7 weeks.

To add insult to injury, Aug 26, my dearly beloved 8 yr old lab Molly lost her 1 month battle to Hemangiosarcoma cancer. I know the staff at the local vet hospital WAAAYYY too well. Annie was definitely grieving and depressed prior to her string of health problems. Molly and Annie were best buddies. When it rains, it pours.

Thank you in advance for your support and knowledge. I know I will be asking lots of questions!

[BestBuddy]

Hi Barb and welcome to you and Annie. I'm not great with interpreting results so I will leave that to the more capable ones. I just wanted to say hi.
Jenny

[Harley PoMMom]

Hi Barb,

Welcome to you and Annie from me and my boy Harley. My boy Harley has pancreatitis too, altho he does not suffer from any of the symptoms...yet, his IMS (Internal Medical Specialist) has told me that pancreatitis can skew the results of any ACTH test, so keeping that in mind, I'm thinking that pancreatitis can skew the results of the LDDS test as well, I am sure of it. Any stress or non-adrenal illness that a pup is under at that time will skew the results of the LDDS and ACTH tests. I strongly urge you to hold off on using the Trilostane and asking your vet about this first.

Also according to the UC Davis protocol your pup should be getting only 29mg per day of Trilostane...

To be frank, Barb, we need to know more about your Annie, so we tend to ask alot of questions, ok...are you ready :eek::)

Was there a Chemistry panel or CBC blood panel done on Annie, if so, could you post the abnormal results with the units and reference ranges. Is Annie on any other herbs or supplements? Has Annie had any other tests besides the LDDS to help confirm cushings (UC:CR.)

Your poor Annie definitely has been thru alot, and a proper diagnose for Cushings is vital for treatment, so if you could get back to us with some answers and I'm sure others will be along to ask more :eek:.

Don't worry too much Barb, you have definitely come to the right place for help and answers, these amazing and knowledgeable people have helped my Harley and me tremendously and I know they will do the same for you.

In the meantime here are some links for you to read, the more knowledge you have the better you are able to help Annie.

Links to Cushings Websites (especially helpful for new members!)
http://www.k9cushings.com/forum/showthread.php?t=180

Trilostane/Vetoryl Information and Resources
http://www.k9cushings.com/forum/showthread.php?t=185


Treatment and Monitoring Recommended by University of California at Davis
Based on their clinical experience with trilostane, the Veterinary School at the University of California at Davis ("UC Davis") has modified some of Dechra's specific treatment and monitoring guidelines. Since there are differences in the two approaches, we suggest you ask your vet whether he/she will be following the guidelines of Dechra, or those of UC Davis. If your vet is following UC Davis protocol, here is a summary of their recommendations.

These recommendations are found on page 3 of the following article:

http://veterinarynews.dvm360.com/dvm/article/articleDetail.jsp?id=460965&sk=&date=&pageID=1



Hugs.
Lori

[labblab]

Hi Barb and Annie!

First of all, I am so sorry to hear about the loss of your Molly. Combined with all of Annie's health issues, you have surely been through the wringer. And this takes such a toll, both emotionally and financially. You are a wonderful mom to be educating yourself so thoroughly now on Annie's behalf, and we will do everything we can to do help you.

Lori has already given you some really helpful links. In answer to your first question, you have two general options in terms of buying trilostane. Vetoryl (the licensed veterinary version manufactured in the U.K.) has been approved for sale in the U.S., and you can search internet pharmacies for the best available price. If your vet carries Vetoryl himself, you can compare the internet prices with the price he would be charging. Another alternative is to purchase compounded trilostane. Again, several internet pharmacies in the U.S. sell compounded versions of the medication (meaning, they make up the medication themselves). The price will undoubtedly be less than that for brandname Vetoryl. Several of our members obtain compounded products from an Arizona pharmacy, Diamondback Drugs (you can google them for contact info). Other members may chime in here with other recommendations. Regardless of your source, one suggestion is to make your initial purchase in a smaller dose than Annie's actual daily total (for instance, buying 30 mg. capsules even if her daily dose is 60 mg.). Buying in a smaller dosage will give you a lot more dosing flexibility in the event that you end up needing to raise or lower Annie's dose (which happens a lot, especially at the beginning of treatment).

Secondly, Annie's LDDS results are indeed consistent with a diagnosis of pituitary Cushing's. Her 8-hour result is elevated above normal, and her 4-hour result shows suppression below 50% of her baseline reading. Here's a link that will help you with the test interpretation:

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

However, as Lori has pointed out, other nonadrenal illnesses (such as pancreatitis) can also cause elevations in LDDS results. While Annie is missing some typical Cushing's symptoms, she definitely exhibits others. And Cushing's dogs are prone to pancreatitis attacks. In her case, the first thing I would have suggested in terms of additional diagnostics is an abdominal ultrasound. But I see she already had that done in the hospital. Of interest is the nodule on her right adrenal gland. Given her ultrasound results, I might have expected her LDDS to have indicated adrenal rather than pituitary Cushing's. It is rare but possible for dogs to have both forms of the disease. What did your vet have to say about the adrenal nodule?

Assuming that Annie does have pituitary Cushing's, I am very pleased to read your vet's instructions re: her trilostane. Everything is according to protocol: watching closely for side effects, stopping the medication and administering prednisone if there is a problem, ACTH testing at the 10-day mark. I personally would feel comfortable with the 60 mg. starting dose. But as Lori has pointed out, UC Davis does have a conservative dosing protocol. For a dog of Annie's weight, 60 mg. is indeed higher than UC Davis's recommendation, but it would be at the very bottom of the starting range recommended by Dechra (the manufacturers of Vetoryl). You can read more about Dechra's instructions at the "Trilostane/Vetoryl Info and Resources" link given by Lori above. And for your own peace of mind, you can certainly discuss UC Davis's dosing recommendations with your vet before actually starting treatment.

Our experience here is that dogs tend to feel better when the dosing is started low and then increased as needed, rather than vice versa. In this way, the cortisol level is lowered more gradually and side effects are minimized. However, if the dosing is started at a really low level, the trade-off is that an added number of dosing adjustments (with associated ACTH tests) may be required. Plus, as a parent, if the dose is too low, it may be worrisome to not see much symptom relief at the outset. So it helps if you are prepared for that possibility.

So after all that I have blabbed here, I guess my primary question is, what did your vet have to say about the adrenal nodule? And also, have diabetes and thyroid issues already been ruled out in Annie's case?

Thanks in advance for the additional info,
Marianne

[corgipallie]

Welcome Barb!
I know you're gonna get some great advice and support here! Hugs to Annie!

Steph

[Annie's Mom]

Thank you all for your positive thoughts and info. Since I last wrote, Annie started on 60 mg/day of Trilo on 10/28 (she is a 65# lab mix - 12 yrs old); her 10 day ACTH results were:
Pre: 2.2 (1.0-5.0 ug/dL)
post: 6.6 (8.0-17.0 ug/dL)

T4 .6 (low) 1.0-4.0 range (previously it was 1.3)
Alk Phos 1365 HIGH (5-131)
ALT 62 (12-118)
BUN 27 (4-27)
Amylase 1321 HIGH (290-1125)
Lipase 1367 HIGH (77-895)

Her cushing symptoms has subsided: she is drinking & peeing normal amounts; more energized, appetite normal. The 9 pounds she lost while in the hospital, she has put back on.

Negative: her arthritis is more bothersome. 4 days after starting Trilo, she started moaning/groaning on and off during the night (I associate it with arthritis pain?). I have increased her Tramadol and Gabapentin. The vet won't put her back on Rimydl until her Alk Phos is normal.

She is definitely feeling more her old self as she is always looking for attention (vs sleeping and being very lethargic prior to starting Trilo).

This past Wed (11/28 -- day 22 on Trilo) she began having bad diarrhea, but still a great appetite. I added rice and canned pumpkin to her diet. This helped slightly. Fri morning she still had a great appetite, but still diarrhea AND she was trembling. I associated the trembling with pain. I took her to the vet. We ran a blood test and the vet feels she has colitis; sent her home with Metronidazole to stop the diarrhea. It has helped slightly. Her Alk Phos has INCREASED (different range but she is at 2291 with range 20-150). Her BUN and Amylase are still high (from 2 weeks ago).

The concerns: why is her Alt Phos increasing, why are BUN, Amylase and Lipase high? Are we dealing with Kidney disease as well?

Initially after getting the 10 day ACTH test results, my vet felt we should stay with the current 60 mg dose (considering her arthritis and that she was now in the low end of normal cortisol level); now with the increased Alk Phos, the vet feels we may need to increase her Trilo dose, based on the 30 day ACTH (which is due 11/28).

Is the 30 day ACTH really necessary since we now know that her Alk phos is rising? Is it unsafe to increase the dose now, and then recheck with an ACTH in 30 days? Is the cortisol number more important than the Alk Phos number? I am concerned that her arthritis will be worse if we increase her Trilo dose. With her current numbers, how much would she be increased? It seems like I need to contact Diamondback for compounding drug pricing. I currently have the 60 mg caps. My vet charges MUCH more than getting the meds online. Will Annie's alk phos ever get to the level where we can put her back on Rimydl? Why are her Amylase and Lipase elevated? I thought those were associated with pancreatitis?

On 8/20, prior to her severe pancreatitis attack on 9/7, her test results were:
Amylase 1117 (290-1125)
Lipase 1286 (77-695)
BUN 28 (6-25)
Alk Phos 573 (5-131)
On 8/20 she had a UTI and was treated with antibiotics.

Is her diarrhea related to the Trilo, or is it colitis for some unknown reason as the vet thinks? Is trembling common with Cushings? (my friend's Cush dog trembles occasionally).

I feel my vet is a little weary of all my questions. I don't question her judgement, I just want to fully understand what is going on. Annie, like many others on this forum, is a complicated case. My vet and the other vet in the practice do not have experience with Trilo and have not treated cush pts. Should I seek out a vet that has experience with Cushings? I am going to call around tomorrow to other vet clinics to inquire about their exp with Trilo. I question myself every day if I need Annie to see an IM specialist. She has had so many major issues in a very short time, and honestly, she is doing reasonably good (except for the bad gas and diarrhea right now) considering where she was mid-late Sept. I want the best for her, and I also want to be reasonable about what tests I put her through. Managing her arthritis pain so she can enjoy her walks is important and challenging. I love reading the stories of dogs running to get their toys again! Annie's arthritis will always limit her in that regard, unfortunately. Thank you in advance for your interpretation of all this info. I feel I need to make a spreadsheet with test results!

[AlisonandMia]

Hi again!

Good to hear the Cushing's symptoms have abated.

I've only just skimmed you post and will read it more carefully later but what stands out to me is high amylase and lipase numbers. Those really worry me, especially combined with diarrhea and painful behavior (particularly the groaning). I'm really, really worried that she is on the verge of a pancreatitis attack (or is already actually having one). I think this has to be checked out urgently with more specific pancreatitis testing.

I've got no personal experience with pancreatitis (thank goodness!) but quite a few others here have and they will no doubt chime in with a bit more info about the testing. Your vet should know all about that testing too and be able to run the test.

You probably don't need to rush off anywhere tonight if she is still basically ok (ie not vomiting or really ill) but I'd get onto it first thing in the morning if I was in your position.

Make sure any food she has until you can get her seen is as fat-free as possible, too.

Alison

[Squirt's Mom]

Hi Annie,

One of our "rules" around here is never give Cushing's meds to a sick pup...that includes Trilo. If it were me, I would hold the Trilo until she is feeling better - no diarrhea, no shakes.

Alison has made a very valid point about the amylase and lypase - pancreatitis is a definite possibility and it needs to further investigated asap. Food and water will make this condition worse so you might want to fast her tonite and get her to the vet first thing in the morning. A pancreatic attack would make the liver enzymes rise as well, I do believe. If she starts vomiting tonite, I would go to an ER.

Having a cush savvy vet is important but for now she needs this other problem checked out then we can worry about another vet for the Cushing's.

Please keep in close contact and let us know how Annie is doing.

Hugs,
Leslie and the girls

[Harley PoMMom]

Hi Barb,

My boy Harley has pancreatitis, so I do know about this condition. As the others have posted to you and I do agree with them, it does sound like Annie is having pancreas issues...the groaning at night, I believe is because of pain from the pancreas not arthritis.

Her elevations in the ALP, and I see now the BUN is starting to creep up as well, these are very well likely due to pancreatitis, and from her elevated Amylase and Lipase numbers and the fact that she has had a prior pancreatitis attack, pancreatitis is a factor here.

Until you can get her pancreatitis under control, which will take alot of work and may not ever really happen but once you see a flare-up like I believe you are seeing now, you have to act fast. Pancreatitis can be a life threatening disease if not caught early. Since you are seeing the Lipase number climbing up, my first step, if I were you, would be to get a cPLI done. This test is for lipase enzyme that is specific for the pancreas.

IMO, Since Annie is having diarrhea, trembling and painful episodes I would get her seen by her vet ASAP. Then I would find an IMS who could either take your case or oversee your case with your vet. This is what I have for my boy, his IMS is like oncall, we go see her every 6 months or if Harley has a specific/complicated problem, all other general issues are handled by Harley's regular GP.

I have more to say and will get back to you...

Hang in there, ok.

Hugs.
Lori

[Annie's Mom]

Thanks Alison and Leslie, I appreciate your quick responses. I felt it very odd that on Friday when the lab tests came back that my vet thought it was not pancreatitis, and that she was fine with continuing with the Trilo. I will continue to keep a close watch on Annie, and although she is begging for her dinner, I am sticking to rice and pumpkin for now. We just went for a walk, and she is energized, and had a normal bowel movement. I was also concerned on 11/7 when her blood work came back with a high Amylase of 1321 (290-1125) and Lipase 1367 (77-695). From the little I have figured out, that pointed me to continued pancreatic issues.

Thanks again and I'll keep you posted.
Barb

[Annie's Mom]

Lori, I just read your post too. Thanks for the info. I have been concerned about these levels for the past several weeks. I will follow up with my vet.
Barb

[corgipallie]

Hi Barb,
Glad to see you back here but I wish the circumstances were better...

So just adding my 2 cents...
I have no experience with Trilo but I agree with Leslie about holding it until you have other symptoms under control.

Colitis: did your vet do a fecal or is she just assuming colitis? I am just getting through a round of the same antibiotic for colitis with one of mine, but my vet did a fecal and found white blood cells and inflammation in the sample. So I'm wondering about that. At least I know you have the right med! But you don't want to use antibiotics if you vet is just assuming colitis. Colitis can cause vomiting but only in severe cases. Diarrhea is much more common. It'll take a few days for the diarrhea to clear up. Mine was on 5 days 2x a day.

BUN: Did you vet run creatinine levels too? Or just BUN? BUN is kind of an indication of kidney function but moreso an indication of fluid levels. Creatinine is what you need to know to determine if you have kidney function in the mix. If you have that test result, it would be helpful. If you don't and you're wondering her kidneys (kidney failure could definitely cause vomiting and diarrhea), you need to know what her creatinine is (normal is less than 1.7). Her BUN is on the high end but it's not concerning to me on it's own.

Rimadyl: Rimadyl (and other NSAIDs) can cause liver damage and as Leslie mentioned can also affect the pancreas. Tramadol is much better but doesn't have as good of a result on arthritis. It's more of a muscle relaxant than an anti-inflammatory. You can use a heating pad to help Annie's arthritis too.

On another note, her lipase isn't extremely high but you don't want it to go up more. Pallie's got up to the 3000 range just by giving her hamburger meat when she wouldn't eat anything else. She never had a pancreatitis attack but we were darn close to having a problem.

I don't know what your vet thinks about the low T4. It's not an emergency to treat the hypothyroidism and it could be related to the rest of the off numbers too. If it comes back low again on a test, you may want to ask about that.

You absolutely need a vet who understands Cushings. If you have any doubts about her knowledge in treatment, you will never feel comfortable. Having a vet who knows Cushings, symptoms, related problems, etc is of utmost importance in long-term treatment.

Hope that helps a little and doesn't cause more confusion with everyone else's feedback.
Steph

[Harley PoMMom]

Hi Barb,

So sorry about the name mix-up on my last post...I did go back and change it :eek: my feeble mind :p

Here's a very good article on pancreatitis.

http://www.dogaware.com/wdjpancreatitis.html

There is a test from IDEXX called the Snap cPL: In 2007, IDEXX introduced the SNAP cPL, a version of the Spec cPL test that can be done in-house by your veterinarian and return results in 10 minutes.

http://www.idexx.com/pubwebresources/pdf/en_us/smallanimal/snap/cpl/snap-cpl-accuracy-white-paper.pdf


Now a few things I'd like to share with you about my boy Harley... his BUN is 31 (4-27); his ALP 1289 (5-131); his cPLI 528 (0-200). Harley is on a special diet that was formulated specifically for him...very low fat, and he is also fed 3-4 small meals throughout the day.

Harley is rx'd Tramadol for his pancreatitis but I don't need to use it hardly at all.

If there are anymore questions you have, please, please feel free to ask, we are here to help in anyway we can.

I hope this helps some. :o:)

Love and hugs.
Lori

[labblab]

Hi Barb,

Given Annie's complicated situation and the fact that your regular vet does not have Cushing's experience, I do think you would be well-served to seek a consultation with an IMS. There are multiple factors at play here, and I think you need an expert to help you sort them out properly, as well as her medication. I am relieved to hear that Annie has improved this evening with good energy, normal appetite and a normal bowel movement. Just to further confuse things for you, given her improvement, I'm personally not so sure that it is necessarily a good idea to stop her trilostane. Since she has improved while still taking the trilostane, it makes it seem less likely to me that it is the "culprit." (And just as a warning, you may already know this, but too much pumpkin can actually cause the "runs" rather than stopping them. Unlike almost everybody else here, I've never had good success with pumpkin :o).

My vet routinely prescribes Metronidazole for my dogs when they have diarrhea. Metronidazole does have an anti-inflammatory effect, and it may be the case that Annie could have some sort of inflammatory bowel issue that is being unmasked by the lowering of cortisol associated with the trilostane treatment. But there could be other causes for the diarrhea, as well. And it sounds as if there is plenty of reason to feel concerned about the possibility of pancreatitis. However, I don't know whether you might actually be risking making that condition worse by stopping the trilostane.

And that brings me back full circle: I do think it would be helpful to consult at least once with an IMS in order to thoroughly evaluate all of these issues. The previous pancreatitis attack and the currently elevated labs, the worsening thyroid level, the long history of arthritis and need for pain control, and now, possible colitis. I think it would be good to talk with someone who is experienced with trilostane treatment and has a good understanding of the ramifications of giving it or withholding it in any given situation.

Just a couple more cents' worth to muddy the water even further!
Marianne

[Annie's Mom]

Thank you all for your feedback. Annie is doing ok. The Flagyl has gotten her bowels very close to normal (just a tad soft still--I'm probably too observant!); She still has a great appetite, energy level is good. I stopped giving her the pumpkin. Thanks for the reminder that it can do the reverse, although she was only getting it for a couple days.

In answer to questions: the vet assumed colitis; no tests were done besides a basic blood test. Annie had a cPLI done while in the hospital for the severe pancreatitis in Sept. She has not had one done since. On Nov 7 (during the 10 day post Trilo ACTH test)her BUN/Creat ratio was done on Nov 7 and it was 27 (range 4-27). Her creatinine has always been in normal ranges. Her BUN was normal in Oct, and high in November. Will Trilo increase her BUN? The vet hasn't pinpointed why she thinks Annie's T4 is low. My notes state that it could be related to a variety of conditions.

I scheduled an appt. for next week with another vet that came highly recommended to me, who has experience with Cushings and Trilo. Unfortunately today she had a family emergency and will be out of the office for at least a week. I am going to go ahead with Annie's 30 day ACTH at my current vet for this Fri or next Mon and will assess from there, and get an appt with the new vet as soon as she is back in the office.

Question: how much food should be given with the Trilo on the morning of the ACTH 30-day test? My instructions for the 10 day was "a small amount but not a full meal", so I gave Annie 1/2 of her morning feeding. Now, the vet tech says I should only give her enough food to give her the Trilo (meatball size). Now I question if Annie's 10 day test skewed because I gave her 1/2C food? (she normally gets 1C in the morning and 1C in the evening)? See why I want to find a vet that has experience with Cushings!! The staff and vets are really nice, but I need the expertise!

Also, thanks for the recommendation of Diamondback Drugs. OMG - the price is less than half the cost that I just paid. I can't wait to get my next Rx from them. Annie of course still has discomfort from the arthritis, but I am adjusting the Gabapentin and Tramadol to try to find a dosage that gives her adequate relief. Happy Thanksgiving to you all

[labblab]

Hi again, Barb.

I would have thought that the 1/2 feeding that you gave Annie would have been perfect for her ACTH testing. Some time ago, I emailed Dechra (the manufacturers of Vetoryl) and asked them what their feeding recommendations were for the day of testing. The response I received back was "a small, nonfatty meal." I understand the reason for the "nonfatty" part: if too much dietary fat is consumed prior to the testing, the blood sample cannot be analyzed properly. But like you, I would have thought that half a normal meal would have "filled" the bill. Since trilostane is metabolized most efficiently when it is consumed with food, I would think that you would want ENOUGH food to provide maximal absorption on the day of testing.

One suggestion...you can always call Dechra's U.S. office directly and ask them what their recommendation is. I've had good luck calling them in the past. They have vets on staff who are available to "field" general questions from pet-owners. Of course, they will not give you specific advice re: your dog's treatment. But I would think they'd be happy to answer a general question such as this. Here's a link to their contact info:

http://www.dechra-us.com/page/contact-us

Once armed with their response, you can talk about the feeding instructions more knowledgeably with your vet's office. Sometimes I worry that vets who are primarily experienced with Lysodren treatment and testing may not be as aware of the testing protocol for trilostane. I don't know whether this may be the case with your vet, but it can't hurt to be armed with Dechra's own recommendations. And who knows, maybe they'll confirm what your vet tech has told you. In that case, it'll be good for all of us to know that!

Marianne

[Annie's Mom]

Thanks Marianne for your useful info. I will try calling on Friday. Annie is scheduled for her 30 day stim test on Mon 11/30. I spoke to my vet today. She recommended feeding 1/4 of her breakfast the morning of her stim test. Remember, my vet doesn't have much experience with Trilo so don't take that as the official recommendation. One thing I'm really frustrated with now is my vet will not write a Rx for Trilo through a compounding pharmacy. She says that the FDA issued a warning that a compound of Trilostane could be unstable/unsafe and should not be used, so my vet clinic will not write an Rx unless the appropriate dosage is not available from the drug co. Has anyone else come upon this, now that Trilo is approved in the US? The vet won't even write the Rx if I sign a waiver. So much for saving some money.... I am still considering seeing a IM specialist, which my vet is not opposed to. Thanks again for all your input.

[labblab]

Barb, it is true that the FDA recently issued a letter to veterinarians warning against the use of compounded trilostane unless brandname Vetoryl is used as the basis for the preparation. It is also the case that compounded products cannot be sold in the same dosage as the Vetoryl capsules that are currently on the market. Here is a copy of the letter:

http://www.fda.gov/AnimalVeterinary/SafetyHealth/ProductSafetyInformation/ucm182038.htm

However, there is currently controversy in the compounding industry regarding these directives, with differing interpretations of what they mean as well as the force behind them. Also, it appears that some veterinarians remain comfortable with writing prescriptions for compounded trilostane, while others do not.

If you go to this thread on our "Resources" forum and scroll down to the bottom reply, you'll find additional information about the status of compounded veterinary drugs in the U.S. Hopefully this will help to explain the situation further.

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

Marianne

[lulusmom]

Hi Barbara,

I don't know what your vet is charging you for 60mg Vetoryl but you can purchase 30 ct on line for $72.95 or if you buy 60 ct, it is $69.95. Shipping is free. I have provided a link below.

Now that Vetoryl has been approved and the FDA has warned vets and compounding pharmacies about compounding with anything but Vetoryl as a base, I'm afraid the cost has gone up significantly. I found after a quick check that if my dogs were still being treated with Trilostane/Vetoryl, I would be paying a minimum of $180 for 100 ct of 30mg Vetoryl as opposed to the $70 I used to pay for 100 ct compounded Trilostane at Diamondback Drugs. Let me just say that having two cushdogs, I am thankful that we switched back to mitotane (Lysodren).

http://www.valleyvet.com/ct_detail.html?pgguid=057ae20c-efea-490b-b89e-562663425dfe&ccd=INT002&utm_source=NextTag%20Feed&utm_medium=cpc&utm_content=977RX,976RX

[Annie's Mom]

Thanks for all the links to all this useful info. As others have posted, it is overwhelming, and I am so thankful that I have found this site (thanks to Steph). I purchased my initial 2 boxes of 60 mg Trilo from Petmeds. Moments after I ordered it, I found Entirelypets.com selling it for $78.99/box and Petmeds price-matched. Days later I found it at Valley Vet for $69.95 if you buy 2 boxes, so I will switch to Valley Vet later this month when I refill. Every dollar makes a difference these days. It appears Valley Vet is the least expensive. Annie has her 30 day ACTH on 11/30 at the regular vet. I am going to schedule a consult with the IMS in Ventura next weekend. It will give me peace of mind. Annie seems stable right now. She has intermittent increased thirst (but not extreme as b4 starting Trilo) and intermittent soft bowels. She will be off of Flagyl tomorrow. Again, thank you all for your wealth of information. Barb

[Harley PoMMom]

Hi Barb,

Another search engine for finding meds at their lowest cost that is helpful is called NexTag, I already typed in Trilostane and some Pharmacies/compounders came up.

http://www.nextag.com/trilostane/stores-html

One I would phone/contact is CenterPetPharmacy.com, here is a post from another member who talked to the owner of CenterPetPharmacy.


Hi Glynda and Jeff –

Thanks for the information. We really appreciate your responses! Even though we have been reading and researching about Cushing’s, the more we learn we find the more we need to learn! While I had read that different delivery systems for the cortisone for the ACTH exist, I had no idea the gel was less effective! I have been reading so much that maybe I read it and it just failed to sink in, but it did this time…so, thank you, Glynda, we will be sure to ask the vet when we go to see her before we adopt Bree exactly what cortisone delivery method her terrific price includes.

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.

Glynda, we commend you for taking care of 2 Cushpups! It is obvious why God sent JoJo to you. We are thankful he found such a caring, loving, and knowledgeable home!

Thank you again, Glynda and Jeff, for sharing your experience and advice with us. Roger and I are so thankful we found this forum and are very appreciative of the support, advice, and warm welcome we are receiving from everyone.

Myrna

Hope this helps.

Love and hugs.
Lori

[lucygoo]

Hi...

Just wanted to share my experience with Center Pet Pharmacy...they are the best!!! When Trilo was approved here in the US, I looked all around for the cheapest price, and they were definitely the cheapest. They were also super nice, and Fed-Exed me the pills overnight. I would recommend them to anyone.

Gina

[mypuppy]

Hi Barb, I'm Jeanette, Princesses mommy. She's a 7 year old choco lab and was diagnosed with pituitary cushings in October and is on her 2nd week of treatment with trilo. She is currently on 2 (60mg) tablets once a day. I paid $200.00 for a one month's supply from my veterinarian pharmacy. It is amazingly expensive, I agree. In the process, I read a lot on this forum and found they charge $68.95 for 30 tabs at Centerpet. Being that Princess is still in the initial process of treatment and not sure if we will need to adjust her dosage, I have not purchased the next batch of meds, but I will most definitely consider centerpet next time I need to purchase once I know we can confirm the correct dose. And I agree with you once again, every dollar does count. Let me know how you make out, and I will let you know also once I proceed. Take care, and I am curious to know how Annie is doing with the trilo? Have you noticed any side effects? Princess has been doing great since she began. Her water consumption decreased from 6 liters of water per day to 2 liters now. She's not panting anymore, and she's finally sleeping in her own bed next to my bed through the night instead of sleeping in the dining room with the hardwood floors to cool off. It's a nice feeling to see her by my side again and hearing her sighs and snoring at night...lol....Licks to Annie and best regards to you....xo Jeanette

Thanks for all the links to all this useful info. As others have posted, it is overwhelming, and I am so thankful that I have found this site (thanks to Steph). I purchased my initial 2 boxes of 60 mg Trilo from Petmeds. Moments after I ordered it, I found Entirelypets.com selling it for $78.99/box and Petmeds price-matched. Days later I found it at Valley Vet for $69.95 if you buy 2 boxes, so I will switch to Valley Vet later this month when I refill. Every dollar makes a difference these days. It appears Valley Vet is the least expensive. Annie has her 30 day ACTH on 11/30 at the regular vet. I am going to schedule a consult with the IMS in Ventura next weekend. It will give me peace of mind. Annie seems stable right now. She has intermittent increased thirst (but not extreme as b4 starting Trilo) and intermittent soft bowels. She will be off of Flagyl tomorrow. Again, thank you all for your wealth of information. Barb

[Annie's Mom]

Today I received Annie's 30-day ACTH test results.
Pre sample: 2.8 (1.0-5.0 range) (10 day test Nov 7 = 2.2)
Post sample: 8.5 (8.0-17.0 range) (10 day test Nov 7 = 6.6)

Alk Phos 1356 (5-131) (Nov 7 = 1365)
BUN 37 (6-31) (Nov 7 = 40)
Creatinine 1.9 (.5-1.6) (Nov 7 = 1.5)
BUN/Creatinine Ratio 19 (4-27) (Nov 7 = 27)
Amylase 1019 (290-1125) (Nov 7 = 1321)
Lipase 803 (77-695) (Nov 7 = 1321)
CPK 55 (59-895) -- What is this?? (Nov 7 = 56)
AST 8 (15-66) -- what is this?? (Nov 7 = 10)

So, Annie is making slow progress to decrease her Alk Phos, Amylase, Lipase, BUN. My vet wants to keep Annie at the 60 mg dosage and retest in 2 months, unless I see clinical changes (thirst, etc). My vet said we want her post test to be between 5-9. She is on the high end of needing to increase her Trilo, but given her severe arthritis, we'll watch her closely and retest sooner than 60 days if I see clinical changes. Her soft stools have cleared up (yippee!). I am concerned about increasing her Trilo and the affect it will have on her arthritis. Your thoughts?

The latest health change is that she has lost most of her hearing in the past couple weeks. She hears a clap but that's about all. Now it makes sense why she started barking in the house (while I am in another room) a couple weeks ago. Her world went very quiet. She has more energy than pre-Trilostane and is getting stronger and is wagging her tail, so I continue to give her lots and lots of love, and pats and scratches and belly rubs.

Thanks again to everyone for your expertise and guidance. Barb
PS - one of these days I'll figure out how to post Annie's picture here!:)

[BestBuddy]

Hi Barb,

The ACTH numbers are pretty good but you wouldn't want them to get any higher.

Annie is not following the rules (like any of them do) because a lot of us found that even at the same dosage of trilo the numbers kept dropping for the first month or more.

Annie's numbers have actually gone up from the day 10 test.:confused: I think with the seniors especially with arthritic tendencies that keeping the number in the range of 5-9 for the post is a good plan.

I'll let the others weigh in on the other results.

Jenny

[haf549]

My vet said we want her post test to be between 5-9. She is on the high end of needing to increase her Trilo, but given her severe arthritis, we'll watch her closely and retest sooner than 60 days if I see clinical changes. Her soft stools have cleared up (yippee!). I am concerned about increasing her Trilo and the affect it will have on her arthritis. Your thoughts?

Hi Barb:

If Annie's symptoms have cleared up and she isn't having any sides effects, I'd be happy with the 'high normal' result. Kira has been 'high normal' for almost a year now. Whenever she has her ACTH, she's usually in the 'high normal' range. My vet told me that we are 'treating the symptoms, not the numbers'. Specially, given that Annie has arthritis, lowering those numbers might have an adverse affect on that. Are you giving her anything for the arthritis?
Kira has been on 900mg glucosomine/chondroiten. When we first started the trilostane, I noticed that her arthritis seemed much worse. But this past year, she's definitely become more active again. So, I'm not sure if she's just getting used to the arthritis pain or if it's actually gotten better.

Heidi

[labblab]

So, Annie is making slow progress to decrease her Alk Phos, Amylase, Lipase, BUN. My vet wants to keep Annie at the 60 mg dosage and retest in 2 months, unless I see clinical changes (thirst, etc). My vet said we want her post test to be between 5-9. She is on the high end of needing to increase her Trilo, but given her severe arthritis, we'll watch her closely and retest sooner than 60 days if I see clinical changes. Her soft stools have cleared up (yippee!). I am concerned about increasing her Trilo and the affect it will have on her arthritis. Your thoughts?

Barb, I think your vet's approach seems very reasonable given Annie's severe arthritis. It may be the case that she will end up needing a small increase in a month or two, but given her whole "picture," I can understand why your vet wants to give her some more time to stabilize on the 60 mg. before making a change. I am sorry to read about her hearing loss, but otherwise so glad to hear about her improvements since beginning the trilostane. Please don't be a stranger, and keep checking in with us over these next couple of months, OK? ;)

Hugs and best wishes to both you and Annie, :) :)
Marianne

[labblab]

Thanks again to everyone for your expertise and guidance. Barb
PS - one of these days I'll figure out how to post Annie's picture here!:)
Hi again! :)

Barb, when you have a chance, take a look at this link -- it will help you to set up Annie's picture as your "avatar":

http://www.k9cushings.com/forum/faq.php?faq=vb3_user_profile#faq_vb3_signatures_av atars

Also, if you want to set up a personal photo album, check out this link:

http://www.k9cushings.com/forum/faq.php?faq=vb3_user_profile#faq_vb3_albums

Lookin' forward to seeing some pictures of your special girl!! ;)

Marianne

[Annie's Mom]

I'm overdue for an update on Annie. I have been reading many updates here on the forum and learning alot. Annie has been stable with her cushings symptoms - normal eating, drinking, etc. Now she has another issue and we are not certain what is the cause. I wonder if anyone has had a similar experience. Her Right eye is not open completely. It's open about 3/4. I noticed it Sat evening 12/5. There is no tearing, no rubbing of the eye. It doesn't seem to bother her. I finally recalled that during the day on Sat she tripped in the yard on a tree root and fell hard to the ground (keep in mind, she had a vestibular episode in Sept and has balance issues but usually catches herself -- she hasn't fallen in over a month). I questioned if she injured her eye in the fall? Her eye wasn't better on Monday so I took her to the vet (I was going to be out of town 12/18-21 and didn't want to "wait and see" if it got better). The vet stained her eye and found no abraisions, nothing unusual. The only thing the vet could figure is a degeneration of nerves/muscles around the eye. I was sent home with antibiotic ointment to use 3/day for 7 days and pain drops for 3 days (as precautionary, I guess? I should have asked "why" but I didn't). By Thursday, it seemed that she had been rubbing her eye (irritation from that ointment in her eye), and her 3rd eyelid was popping up at times. I decided to stop using the ointment and see if it improved. I had a dog sitter staying at my house this past weekend while I was out of town, and felt it would be better to just leave her eye alone, since there still is no tearing or "goobers". I got home tonight, and I'd say it looks the same as a week ago. Sometimes it is closed 1/2 to 3/4, and sometimes it is open 3/4. Any thoughts? On another subject, I read on someones post about the side effects of SamE and Tramadol, that it can cause shivering and stiff muscles. Annie is not on SamE, but she is on Tram (200 mg spread throughout the day) and 150 mg Gabapentin for her arthritis/bone spurs in her elbow. She has periodic short episodes of shivering (mainly in her front legs) and now I wonder if it is from the meds, or from pain, or side effect of cushings? When it occurs, I either get her up walking around or I cover her with a blanket to get her warmer. I am also giving her NaturVet's ArthriSoothe Gold twice a day for a total of 1000mg glucosamine, 1000 mg MSM, 400 mg Chondroitin, 400 mg green lipid mussel, 180 mg bosweila, 180 mg Yucca, 120 mg Vit C, 10 mg Hyalronic acid. I also give her Adequan. Prior to Cushings Dx and while she was on Rimydl, I was giving her the injection once per month; since she's been on Trilostane, and no longer able to take Rimydl, her limbing has gotten worse, so I am giving her Adequan every 2-3 weeks. I can't really say if it is helping, but I feel it can't hurt. Is every 2-3 weeks too often, considering her condition? I give it subQ, as I have been told by several different vet techs that in their clinics they give it subQ. In trials it is has been shown to be equally as effective subQ, as IM. Adequan Users: your thoughts?

As others have stated over and over, I am so grateful that I have found this forum. Many days I feel so overwhelmed and alone in this frustrating and complicated life of caring for an elderly dog with many health issues. I come to this forum, and I no longer feel quite so alone. I have been in tears several times tonight, reading of Ruby's struggles, and Zoe's. My heart goes out to each of you who are reading this, and thank you for your support. Know that I am keeping you and your furbabies in my prayers, even if I don't post a remark on your page.

[Annie's Mom]

I tried to post a message last night and my computer timed out and I lost all that I wrote ! So, Annie is having an ACTH tomorrow. I call it the $350-400 "peace of mind" test. Just before Christmas I noticed she was drinking more water than normal and "asking" for more food. She's not drinking HUGE quantities, but it is definitely more than normal. It's been 35 days since her last ACTH (30 days since starting Trilo) and she was at 8.5 (high end of normal). It's a new credit card billing cycle and I figure I'll help stimulate the economy! LOL We are also doing urinalysis (since she had several UTI's last summer and showed no symptoms of a UTI), and a super chem blood panel. I'll post results when I receive them. She has had intermittent soft poop and I can't attribute this to anything, as I don't vary her food at all. Interestingly, she has the soft stool in the evening, after she has had a normal poop, while on our evening walk. Her morning bowel movement is generally normal. She gets her Trilo in the morning and I feed her am and pm. Any thoughts? Barb

[Casey's Mom]

Hi Barb, I give Casey the Adequan and have since Sept. The vet said some dogs need it every 2 weeks and some dogs once a month. I give it once a month but I don't know how bad Annie's arthritis is - Casey just has it in one hip from an old injury - probably a horse kick.

I have to get the shot from my vet tech because my vet won't sell the Adequan - the vet tech gives it IM in her back leg muscle.

Also as far as the soft poop goes I would not worry if that happens after a normal poop. Casey has always done this - she will quite often poop twice on our walk at the park the first one is normal and the second one a little softer. She has done that for as long as I can remember.

We all know about those credit card bills believe me! Your Annie is very lucky to have you for a mom,

Love and hugs,

[Annie's Mom]

Hi Ellen,
Thanks so much for all the info. I feel better now about the poop issue! Prior to Sept 2009, Annie didn't have problems other than darn arthritis! Now I'm on alert to any changes. Lately on our walk, she goes twice too. Never did that until recently. Something new to keep her mom on her toes and paying attention to her!! Bummer that your vet won't sell you Adequan. Annie's arthritis is bad in her R elbow. Probably caused by an injury years ago with rough-housing with her playmates. She always limps, but she still wants her daily walks. I tried accupuncture this past summer, but I didn't see any improvement. Since Annie can't have NSAIDs anymore, I feel every 2 weeks of Adequan is worth the effort. All the best to Casey and Desi.
hugs,
Barb (Annie's mom)

[Franklin'sMum]

Hi Barb,
My boy Franklin used to have 2 poops on our walks, sometimes only 50 metres or so apart. Very handy when you've just used the last baggie on the first poop :rolleyes:. That was even before the Cushings diagnosis.
Hoping Annie is well, BTW the "remember me" box when you log in? If you tick the box, you don't seem to get timed out.
Jane and the gang xxx
________
SIKHISM FORUMS (http://www.religionboard.org/sikhism/)

[Harley PoMMom]

Hi Barb,

Re; Annie's soft poops in the evening: As long as they aren't very foul smelling, don't have an unusual color in them and have some kind of form to them, I don't think I would be too concerned...but I would keep watching them...poop patrol!!!

I do believe Scott uses Adequan on Moria, altho my memory ain't what it used to be!!

And Jane is correct about the "remember me" box, one needs to check it before signing in so one doesn't get timed out...I had that happen to me too!!

We will be looking for your update for the results of the stim. :) Wishing you and Annie the best of luck on your stim test.

Love and hugs,
Lori

[Annie's Mom]

I just received Annie's test results from yesterday Jan. 7 (urinalysis and ACTH). She has a raging UTI, again. Drat! The vet called it a ROD infection. We will start her on Baytril today, and recheck urine in about 2 weeks, just as she is finishing the Baytril so that we can see if the Baytril is working. I am opting not to do a urine culture today (that would give more details of the type of Rx to use), and rather treat the UTI with Baytril and cross my fingers that Baytril is the right Rx. The last time she was on antibiotics was Clav/Amox and Baytril in September, when she had the severe pancreatitis, hospitalized for 7 days, etc.

ACTH results from Jan 7:
Pre 2.0 (1.0-5.0 range)
Post 4.9 (8.0-17.0 range)

If Annie didn't have the raging UTI, the vet would be very impressed with these results, but due to the UTI infection, these numbers could be (most likely) skewed. Annie has been getting 60 mg Trilo since Oct 28.

The SuperChem blood panel has not been run by the lab yet, so I won't have those results until Tuesday (when my vet returns to the office).

Below are Annie's previous test results:
30-day ACTH test results from 12/1.
Pre sample: 2.8 (1.0-5.0 range) (10 day test Nov 7 = 2.2)
Post sample: 8.5 (8.0-17.0 range) (10 day test Nov 7 = 6.6)

Alk Phos 1356 (5-131) (Nov 7 = 1365)
BUN 37 (6-31) (Nov 7 = 40)
Creatinine 1.9 (.5-1.6) (Nov 7 = 1.5)
BUN/Creatinine Ratio 19 (4-27) (Nov 7 = 27)
Amylase 1019 (290-1125) (Nov 7 = 1321)
Lipase 803 (77-695) (Nov 7 = 1321)
CPK 55 (59-895) -- What is this?? (Nov 7 = 56)
AST 8 (15-66) -- what is this?? (Nov 7 = 10)

I was soooo hoping for more positive test results, and being able to get a clearer picture of how she is responding to the Trilo, after being on it for 2 months. I am suspecting that her increase in thirst has been due to the UTI. Interestingly, Annie's peeing habits don't change tremendously when she has these raging UTI's. She doesn't have accidents and she "holds it" for a long time. On a walk, she'll squat a few times, but in the evening she does her business at like 6 pm, and again at 10 pm, so symptomatically it is difficult for me to recognize that she has an infection. Her weight is staying consistant (63# yesterday). I welcome anyone's feedback and direction to take with timing of the next ACTH. Thanks Lori, Jane and Sue for your recent feedback. I hope you and your babies have a great weekend. hugs, Barb (and Annie)

[Squirt's Mom]

Hi Barb,

Those numbers look great! For a Trilo pup the range is 1-7 which puts Annie's post of 4.9 right in the middle - a great place to be! :D FYI, the normal post range posted looks more like those for an untreated, non-cush pup. :confused: The goal isn't to get the number closer to the lowest, but to keep it in the middle of the range. So, to me, this looks like a pup who is doing quite well on Trilo. ;)

I hope the UTI clears up soon. When Ruby had one, I didn't notice anything either. :( The vet told me to watch the stream; if it comes in spurts, a UTI can be suspected. Also, smelling the pee (I know! :eek: ) can let you know. If it has a strong odor, a UTI can be suspected. The color, too, will give a clue; dark (orange or brownish) is suspect, especially in a cush pup as their urine is typically quite dilute. This can be checked by using a white paper towel to sop up some of the pee. Ain't being a cush mom FUN! Who knew we get to do all these exciting things with our babies! :p

Hugs,
Leslie and the girls - always

[Harley PoMMom]

I would definitely wait until her raging UTI is over and the reference ranges for a Trilo pup for ACTH pre (1.0-5.0 range) and post (8.0-17.0 range) these seem off to me?? According to Dechras Product Insert they want a post between 1.45 - 5.4 and it can go up to 9.1 as long as the clinical signs are controlled. These ranges you are giving seem to me are for a healthy pup??

Here is a link to the U.S. Dechra Product Insert:
http://www.dechra-us.com/File/prod_vetyrol.pdf


CPK 55 (59-895) -- What is this?? (Nov 7 = 56)
AST 8 (15-66) -- what is this?? (Nov 7 = 10)


The Creatine Phosphokinase (CPK) level is low. Low levels are not significant. This is a sensitive muscle enzyme test that shows high levels when there is damage to muscle tissue.

The AST, or Aspartate Transferase, is low. This is an enzyme found in liver and muscle cells, as well as red blood cells. Elevations are of significance, but a low level is not important. Metronidazole medication is known to cause a low level.

When I want details about lab reports I go to this web page:
http://www.broadwayvh.com/site/view/83223_AssessmentDescriptions.pml

I know this is probably a long shot but I only give Harley distilled water to drink and I only cook his food in distilled water also, he has never had an UTI...knock on wood (hitting my head) :p:) Just thought I'd throw that out there...FWIW!

Keeping you and Annie in my thoughts and prayers and sending healing and soothing energy and vibes for Annie to get over her UTI very soon.

Love and hugs,
Lori

[gpgscott]

Hi Barb, and Annie, and a belated welcome to you both.

The numbers look encouraging, especially since members with specific expericene have posted so.

It may take a bit for Annie's system to understand that it is not being bombarded by cortisol.

You are a wonderful mom and Annie is lucky to have you.

Scott

[Annie's Mom]

I am a little confused (and probably confused you guys as well!). Let me clarify a bit more on Annie's ACTH test results. BTW, the lab that my vet used is Antech Diagnostics in Irvine, CA. The reference range noted on the lab results is based on a Lysodren dog. Noted on the test results: "Post-Lysodren: Pre and Post Cortisol levels after Lysodren loading or while on maintenance Lysodren should be between 1-5 ug/dL." If I recall correctly, my vet has told me that we want Annie's Post # to be between 5-9, since she is on Trilo (not Lysodren). The reference range on the lab work for "Post sample" states 8.0-17.0 ug/DL (but this is for a Lysodren dog). Annie is currently at 4.9; which I would be happy with EXCEPT that from what I understood my vet telling me yesterday, her current raging UTI could be/mostly like is skewing her ACTH numbers. Do you all agree? I guess it gets back to what some of you have stated: "treat the symptoms not the numbers" ?? I felt Annie was doing well this past month, until she started drinking a bit more. It appears now that that increased drinking was due to the UTI, not Cushings. Her Post numbers have been: 10-day: 6.6; 30 day: 8.5; 60 day:4.9 (with a raging UTI). I'll post her blood work results next week. Thanks Leslie, Lori and Scott for your feedback, and encouragement. Good points Leslie; Annie's urine has been very dilute since summer 2009 (low gravity and dilute in color); it hasn't always had a bad smell, but this week I did notice a strong odor and it is darker in color. Thanks for the link for the lab test interpretation. Very helpful! The learning never ends! Annie is in good spirits and good energy so we are heading out to enjoy beautiful sunshine and a warm day in So. Calif. Wish all of you could be soaking in this Cailf sunshine right now. I don't dare call my family and friends back east.... thanks for all your encouraging words and healing energy.

hugs, :)

Barb and Annie

[Harley PoMMom]

On my Anitech results for Harley done 9/10/09 it states: The ACTH pre and post for a Lysodren pup are between 1-5 ug/dl, the post for a normal response canine are between 5.5-20.0 ug/dl.

The Lysodren pre and post statement is way down on the bottom of my page.

You are correct for a Trilo pup a post between 5-9ug/dl would be great!!

Most definitely in the diagnostic stage, any stress a pup is under can skew an ACTH test, whether this stress is from an illness or from being very nervous at the time of the test...and I believe stress can factor in for a pup being treated with Trilostane, but I'm not sure bc Trilostane is supposed to block the cortisol pathway....On the other hand with Lysodren...Lysodren shaves the adrenals away therefore a pup can only make so much cortisol.

I've got the cold, snowy weather here in York, PA. :eek: but Harley and Bear love it. :)

Still sending healing and soothing thoughts your way.

Love and hugs,
Lori

[zoesmom]

Hey Barb -

Those are respectable results altho' as I mentioned in the PM, it might be better for Annie to be a little higher on the post # - simply because of the arthritis. What is her current dosage of trilo? Since she's so early in treatment, those acth numbers could still drop a little more (re: that post number range of 8 - 17 . . . as the other mentioned, that is the normal range for a normal dog. Cush pups on lyso are shooting for the 1- 5 range; for a trilo pup, the goal is 2.0 - 7.2 and up to 9-ish if symptoms are under control. ) Certainly, no increase would be needed for Annie - if anything, she might beneffit from a very slight reduction in dosage. But with the uti, it's probably best to wait until that's cleared.

Zoe has been prone to uti's her entire life - several per year. I know she must have had some of them at the same time as some of her acth tests. Whether they affected her results, who knows? But I would think that if the stress of a bad uti did skew acth results, the effect would be to raise the cortisol levels (i.e, if NO uti, then Annie's results might have even been slightly lower.)

So much of treating cushings is making educated guesses and making slight tweaks here and there. It does get easier. In time, you will be able to better judge what's going on with Annie. After a couple years, I felt comfortable making some slight tweaks on my own - and sometimes stretching out the time between the testing. But if in doubt, and definitely in the beginning of tx, it's always best to test to confirm. One thing I do nowadays . . . if everything seems fine w/Zo, we will only do the post # on the acth. That saves a few bucks.

Zoe is one of those mixed-up girls. When her cortisol goes up, her appetite goes down. But for most dogs, it is the opposite. So watch Annie's appetite closely. Also, for a couple of years, I would measure Zoe's daily water intake. That provided the best clues for me. When the drinking went up, I knew that either her cortisol was creeping up OR she had another uti. The one time her cortisol went really low, she was extremely listless and her legs got quite weak. She was just downright PUNY.

For the uti's, I had Zo on d-mannose for awhile. That helped slow them down a bit, but I now think that just plain old cranberry extract capsules work best for her. Abut a year and a half ago, we tested her pancreatic enzymes and folate - to see why she had such bad gas. The enzymes were ok, but the folate was off. End result - we started her on something called tylan (or tylosin). The very next day her water consumption fell to half and since that time, she's only had about two uti's (that's an utter miracle for Zoe who averaged 5 - 8 uti's per year.) Her urine is also more concentrated now. USG was consistently low before and while it's still not up to normal, her pee has gotten more yellowish. AND most importantly . . . ever since starting the tylan, her acth results have stayed pretty steady too. Our vet has no explanation, but the tylan must be connected to all of this somehow!! (We still use the cran extract, too) I'm not saying that Annie's got the same problem but if she's had uti's all her life, maybe it's something to discuss with the vet.

On the liver enzyme #'s, especially the AlkPh, Zoe's has never gone back down to a normal range. But that's fairly standard in cush pups - to run higher. Some of those #'s can be affected by other meds, too. Zo's lipase level runs high because of her anti-seizure med. So unless a number is real high, not too worry too much. Your vet should know what to watch for. You and Annie enjoy your day. Northern CA is foggy and cool - we've had a really cold fall - with several nighttimes below freezing and lots of dreary weather. I'm missing So Cal this winter. Sue

PS - We're a ways inland, andn south, from Oakland, where you're going to visit. Probably further than you care to travel. Would have been fun to meet Annie tho'. Should be warmer for you in Oakland.:)

[Annie's Mom]

Annie is not feeling good today and I don't know why. :confused: I am concerned. She has been fine (eating, drinking, walks almost every day--when it's not raining). I came home at noon and she had vomitted her breakfast. This morning she was very slow to eat her breakfast, but eventually she ate it (Innova Seniors dry kibble 1C am and 1 C pm). She didn't want her usual treat that I give her when I leave for work so I sensed she was a little under the weather. At noon she did eat 1/2 c food (was a bit reluctant but did eat the dry kibble). This evening she doesn't want the dry kibble, but she is eating the canned food (Innova for seniors). She's very quiet tonight; resting, not interested in chewing on her usual bone. She's gone outside to potty, but definitely not feeling good. She's a lab.... she has never been fussy about her food until Sept 2009 when she had her life threatening pancreatitis attack. I don't know what time she threw up, so I don't know if her 60 mg Trilo stayed in her system or not. She's been on Baytril since January 9th for a UTI. On January 9th she had urinalysis, ACTH and blood work. We did a urine culture on Tues 1/20 to see if the UTI is clearing up; I don't have any results yet. She has 4 more doses of Baytril. I haven't given it to her tonight. Her test results from 1/9/10 are below. Changes from a month ago: good news: Alk phos has come down, ACTH post has come down, Bad news: going up and in high range: phosphorus, magnesium, sodium, Amalyse going higher; Lipase was low (55) and now is 1238. Some of these can be because of the UTI, right? Her ACTH could be skewed because of the UTI, right? Without the UTI, would it be higher or lower? I'm confused!

January 9, 2010:
ACTH:
Pre: 2.0
Post: 4.9(December 1, 2009 her post was 8.5)

AST: 13 (low; range 15-66) Dec 1 2009 was 8
ALT: 31 (range 12-118); Dec was 41
Alk Phos: 1187 (high; range 5-131); Dec was 1365
BUN: 33 (6-31); Dec was 37
Creatinine: 1.7 (High; range .5-1.6) Dec was 1.9 (high)
BUN/Creatine ratio: 19 (4-27); Dec was 19
Phosphorus: 6.2 (High; range 2.5-6.0); Dec was 5.9
Magnesium: 2.6 (high; range 1.5-2.5); Dec was 2.5
sodium: 156 (high; 139-154) Dec was 149
Amalyse: 1419 (high, range 290-1125) Dec was 1019
Lipase: 1238 (high, range 77-695); Dec was 55 (low)

This morning she was limping more than normal. We have had cold weather and it's been raining non-stop all week (cold for Santa Barbara, CA).

Do I need to give her a Pred? I am guessing no, since she ate food at noon and tonight and is keeping it down. I worry about my girl, ever since she was soooo sick and almost died from the pancreatitis. Her stools have been normal. Our 24 hr. emergency hospital closed a month ago, but fortunately another clinic came to the rescue and contracted with the ER vets so I do have an ER to take her if I get more worried.

Your feedback is greatly appreciated.
Sue: thanks so much for your feedback on the UTI's and supplements. I meant to email you much sooner than now. Annie and I are suppose to drive up to Oakland on Saturday. I hope she is feeling better by Fri morning..

Barb (Annie's mom)

[AlisonandMia]

Hi,

The golden rule with Cushing's meds (especially trilostane with its rapid action) is to not give it if the dog is even the slightest bit off color. Often it probably wouldn't be an issue but there is always the very strong possibility that the illness you are seeting could be low cortisol and also a sick dog needs a bit of extra cortisol to deal with the stress of illness so letting the cortisol rise a bit when they are sick is usually no bad thing.

Judging from the way her cortisol had come down from December to January I wonder if it is possible that it has continued to drop since the 9th and if this couldn't be the problem. It would be best to stop the trilostane and and contact your vet. He may want to do a stim test or at least stop the trilostane until Cushing's symptoms begin to appear again and then restart at a lower dose. There is also the worry that it could be the pancreatitis returning so a consult with the vet would be a very good idea.

It is also possible that it is the Baytril upsetting her. There were only two things that ever got my Mia down and they were low cortisol and Baytril. Baytril never made her that sick but it definitely made her distinctly off in the tummy and a bit depressed so it is possible that that could be the culprit

Good luck and keep us posted.

Alison

[Franklin'sMum]

Hi Barb,

I'm so sorry that Annie isn't feeling well :( but also very relieved you still have access to an ER just in case. I can't help with any of your questions :(. My idea is (please correct me if this is the wrong thing to do) but if my boy doesn't eat his food, no trilo. If he throws up anything more than spitbubbles, no trilo, lethargy- no trilo. Smushy poop, no trilo. I give him a couple of hours (or less) and if he's still not quite right, then I give some cortate. I don't think a dose here and there will do him any harm.
One of the zillion things I have learned here is : if in doubt, go without. Hoping Annie feels better soon, and that your questions are answered.

Jane and Franklin xx
________
Home made vaporizer (http://homemadevaporizers.info/)

[StarDeb55]

Barb, I just took a look at Annie's latest batch of labs & with both an elevated lipase & amylase, my concern is that pancreatitis is trying to rear its ugly head, again. Did your vet say anything about these elevations? Also, I know that there is a test called a cPLI, I believe that is the definitive test for pancreatitis. Has Annie ever had this test done? With one attack of pancreatitis, it might be worth it to have this test done.

Debbie

[Annie's Mom]

Thank you Allison, Jane and Debbie for your quick replies. It's now 11:30 pm and Annie is doing better. An hour ago she was begging for more food, so I gave her a little more canned food with her Tramadol for her arthritis pain. I hadn't yet read your posts and I went ahead and gave her Baytril tonight. I wish I hadn't, as I am suspecting the Baytril might be playing a part in her tummy upset. I am going to take Allison's advice and I am not going to give her Trilo tomorrow. Considering she was at 4.5 a few weeks ago, I question if she has dropped lower and that is why she is feeling punky today. also, with her severe arthritis, I don't want her to drop too low. I should get the urine culture results tomorrow and will talk with my vet about Annie's behavior today.

Debbie, Annie has not had that test done. I do feel she may be having some pancreatitis issues again. Thanks again and I'll update tomorrow.

Barb (Annie's mom)

[gpgscott]

Hi Barb,

I have always found it useful to give plain yogurt or acidophilus also with antibiotics, it can help with the tummy upset.

Scott

[zoesmom]

Barb - I agree with the others. Dog not acting right - hold up on the trilo. Sounds like she's been on the baytril for the uti for a while so you'd think that would have caused tummy trouble sooner, if it was gonna.

My thought is that maybe her cortisol has dropped too low, or close to it. That might also explain the limping. Arthritis flaring up because the cortisol isn't higher. The cortisol drop can happen - who knows why - at any time. Zoe's did that a year ago, after 3.5 years on tx and for no apparent reason. Since Annie's not been on the trilo for that long, it's an even stronger possibility, IMO. But the pancreatitis is also a big concern. Zoe has had bouts of that, too. And as you already know, it is nothing to fool around with. Let us know what the vet has to say. Hugs to Annie. Sue/Zoe

[Harley PoMMom]

Hi Barb,

If I were you I would definitely get either the cPLI or the cPL test done on Annie to determine how high the lipase really is.

When one gets the lipase results from their pups Chemistry report back the Lipase is non-specific because there are digestive lipases, intestinal lipases, lipoprotein lipase and heptic lipase, hormone-sensitive lipase, and lysosomal acidic lipase. But the cPLI and the cPL test for the lipase that is for the pancreas only.

Here is a quote from and a link to IDEXX Laboratories web page about the cPLI and the cPL tests:


Serum cPLI is highly sensitive and specific for pancreatitis in dogs. Serum cPLI concentration demonstrates greater than 80% sensitivity for pancreatitis in the dog (based upon histologically confirmed cases of pancreatitis). In contrast to serum lipase activity, serum cPLI concentration is not affected by renal failure or administration of prednisone, and can therefore be used to diagnose pancreatitis in patients with acute or chronic renal failure, and those patients treated with prednisone.
Due to the promising performances of the cPLI assay, IDEXX has
collaborated with Drs. Steiner and Williams to further refine the cPLI assay and create the new Spec cPL™ (canine pancreas-specific lipase) assay.

http://www.idexx.co.uk/animalhealth/laboratory/speccpl/diagupdate_0406.pdf
http://www.idexx.co.uk/animalhealth/laboratory/speccpl/

I will also add that my boy Harley has pancreatitis, his Nov. cPLI was 464 (0-200), on his Nov. Chemistry panel his lipase was 403 (77-695) and his amylase was 515 (290-1125). This just goes to show me that my boy's pancreatitis has to be monitored with the cPLI test. His chemistry panel and cPLI were done on the same day.

I am so hoping Annie is feeling much better now and will be keeping you and Annie in my thoughts and prayers.

Love and hugs,
Lori

[Annie's Mom]

Thanks Scott, Sue and Lori for all the info. Very interesting info on the cPLI and cPL tests. My vet has never mentioned those tests, and I forgot to ask today.... I will definitely ask about that test. I did not give Annie Trilo or Baytril this morning. She was eager for food this morning, so I gave her 1/2 her normal kibble and some brown rice. She was more energetic this morning than last night. She did have a lot of gas during the night (time for the air freshner or burn scented candles!), and she had very very loose stools at 3 am, 8 am and 11 am today. My vet has prescribed Flagyl which I will start tonight. My vet wants to continue with the same dose of Trilo. (I didn't tell her that I did not give today's dose. I think she already thinks I take matters into my own hands!) The vet commented that Annie's symptoms can be a side effect of Trilo but she isn't concerned that her Cortisol is too low. I DO question if her cortisol is too low (for her with arthritis) or if today's problems are pancreas related. On the other hand, we have had 6 days of cold and constant rain and people are complaining of more aches due to the bad weather. The vet recommends another blood panel, now that the UTI is cleared up. It does make sense to do the cPLI test. Is this an expensive test? The vet also mentioned we could try putting her back on a NSAID, as long as her amylase and lipase don't rise. I am concerned about starting the NSAIDs again, due to her blood test results. When should I start the Trilo again? Good news: her urine culture came back negative so the Baytril killed off her UTI. When Harley is in crisis mode, what do you feed him? I have been giving Annie probiotics for almost a month (it is a brand recommended by a friend who is a retired veterinarian). I forgot about fedding her yogurt. Long ramble...... thanks again for all the info. We are taking a little road trip tomorrow and I hope her belly is feeling better. Sue - bummer that you aren't closer to Oakland! It would be wonderful to meet you ! I'll be heading up the 101. Hugs to all of you -- Barb and Annie

[gpgscott]

Barb,

I gotta tell you, I think , you have it all down.

Twelve ain't old.

I would not be giving this dog Trilo.

Scott

[Harley PoMMom]

Hi Barb,

I have never seen Harley have a pancreatitis attack and hopefully I never will. When he had his first u/s done in April it showed up that he had prior bouts of pancreatitis :eek: I said WHAT!!! WHEN!!! His GP then ordered a cPLI test to see exactly what we were dealing with and his results came back 528 (0-200), this test cost me $132.50.

We have put Harley on L-Glutamine 2X a week and I have him now on a diet formulated for his pancreatitis and cushings.

His 2nd cPLI test results were 464 and Harley has no symptoms of pancreatitis...Thank God. ;):)

Hope this helps...

Love and hugs,
Lori

[zoesmom]

Barb - Haven't heard from you and Annie in awhile. Just wondering how she is doing. Was it pancreatitis? And how's it going with the CVS? Zoe has some days where she's more wobbly than others. Also, days where she does a lot of head shaking. But overall, she's doing ok. Sue/Zoe

[Annie's Mom]

I haven't been on here in a while.... Sue, I've been checking your posts and thinking about Zoe and your upcoming travels. Sending lots of positive energy your way! Annie's been doing ok.... She just got off of 3 weeks on Baytril for another UTI (culture showed e-coli -- same as previous test results). Annie has been off Baytril for 6 days and I think she has another UTI. She's been drinking alot more water again. I will get a UA done tomorrow or Wed and see what's going on. A couple days after finishing the Baytril, she had loose stools again and gas. I increased her probiotics to twice a day (wish I'd thought to do that while on the Baytril) and now her bowels are back to normal. Vicious cycle -- the Baytril kills off the bad and good bacteria and I think that's what has been causing her intermittent diahrrea/soft stools/gas. Her urine is dilute so she's susceptible to UTI's. Rats!! Good news: I finally switched to a new vet - one that has lots of experience with Cushings and Trilo! This vet is now responsible for the Cushings pts that were being seen by the IMS at the emergency hospital in town that closed in December. My new vet consults with the IMS on a regular basis, so I feel extremely confident in Annie's care. With this new vet, I have now been able to switch to the compound Trilo which helps the pocket book a bit. I wish I could figure out a remedy for the UTI's. I started the cranberry pills again, but probably not soon enough to avert another UTI. I will ask the vet about Tylan. Any other suggestions out there? Her CVS is stabilized. I don't expect her to ever be able to navigate going down more than a couple stairs at a time; she loves her daily walks and being outdoors in the fresh air. We only walk about 6 blocks --the cold and wet weather has not been good for her arthritis this winter so I am cautious to not walk too far. She lets me know when she wants to stop and rest. I haven't done an ACTH since the beginning of January. I feel it's a waste of money to do an ACTH if she has a UTI (skewed results); I feel she is stable on 60 mg of Trilo, and I haven't seen a change since swithing to the compound Trilo so overall good news (except for the darn UTI's...). Hope this finds everyone "weathering the storm" and looking forward to spring!!!! I'll try to check in more frequently. Hugs to you all.
Barb and Annie

[Annie's Mom]

Does anyone know what range of Ph dogs urine should be? Since Annie is getting recurring UTI's I thought it wouldn't hurt to test her urine Ph on a regular basis with those test paper strips (technical term!) to see if I see a change. First catch of the day she has stayed steady at 6.0; evening is between 6.0 and 6.5. I started giving her cranberry capsules and milk thistle a month ago, hoping these might help keep her clean of bacteria. I haven't seen a change in Ph. She finished another round of 3 weeks on Baytril on 3/31 and interestingly, her thirst increased a couple days before ending the Baytril (day 18 or 21). This morning her urine was really potent smelling and darker color than the past . I'm going to get her in this week for urinalysis. The bacteria in the UA is always e-coli. She continues to have dilute urine; it's a continuous battle of UTI's. Any suggestions? I'm giving her 3 cranberry pills 2x per day, 1 milk thistle 2x per day, and probiotics 2x per day. Hope everyone is enjoying springtime :)

Hugs from Barb and Annie

[Harley PoMMom]

On Harley's Urinalysis report from Antech Diagnostics the PH range is 5.5-7.0.

When Annie urinates does she squat very low to the ground? If so, I am just wondering if she is picking up something when she is peeing. Maybe try wiping her off with a non-irrating babywipe after she is done going potty...Just a thought. :eek::)

I have read that giving them more baths is recommended when UTI's are a problem.

Hope this helps.

Love and hugs,
Lori

[zoesmom]

Hi Barb -

Like Annie, Zo was constantly battling the e-coli urinary infections. Barely off a/b's sometimes, and they'd come right back. Don't remember if you said.....did they do a c & s on her urine for this last one. Because I'm wondering if the baytril wasn't the right drug, or maybe it 'turned loose' a different bacteria which took over. Guess I see another urine test in your future, regardless.

When you ask your vet about the tylan, I'm pretty sure he/she will never have heard of using it for this type of urinary problem. It's usually prescribed for small intestinal bacterial overgrowth. (IMO, all the many months that Zo spent on a/b's for uti's probably contributed to her SIBO!!!) The thing is, the tylan (prescribed only to treat Zo's SIBO) had that totally unexpected and fantastic consequence of virtually curing her of life-long uti's and excess drinking. Even her USG began to creep up into the low to mid-teens, once she got on tylan,. It had been in the 1.004 - 1.012 range most of her life. But the best thing was that she only had ONE more uti after starting the tylan - that is, in her last year and half of life. I finally stopped measuring her water intake, when I realized her drinking wasn't going back up. It fell from 12 - 14 c./day average (on the trilo, but higher with uti's) to 3 - 7 c./day - in one single night. Gave her the first tylan on a Friday and on Saturday, everything turned around. Drastically!!! You can't convince me that that was a fluke!!

Not even her IMS had an explanation for the unexpected urinary benefits, so I'm guessing your vet won't know about them either. I'm dying to know if other dogs would have the same positive effect. It IS a pretty safe drug, from what I've read. After selling me their overpriced version at our vet clinic, my IMS told me to just order the powder online (no rx needed) and just fill the gel capsules myself. SO MUCH cheaper and no rx needed. I wish more vets would find out about that side effect of tylan, if indeed it helps in other uti-prone dogs. If so, I would think there'd be a whole new use for tylan in the canine population - in all those poor pups who suffer from freq. uti's and/or excess drinking. I've wanted to tell some 'research' vet about it - but have no idea which one to tell!!!

Also have no idea if it would help with central DI, but I'm thinking maybe in dogs with nephrogenic DI (I think those are the ones for which desmosuppressin doesn't usually work.) Not saying that Zo had either kind of DI - 'cause we never tested her and simply don't know. But it's like which came first - the chicken or the egg. For Zo - from puppyhood on - she always drank excessively AND suffered several uti's/year. Not sure which caused which, but the two seemingly were tied together. (Actually, the big thirst was all the time and increased with uti's.)

Give Annie a big hug for me. Her sweet face always reminds me of my Zo. Sue

[Annie's Mom]

Lori: Thanks for the Ph info. From my home testing, she's in range. That's good. Annie doesn't squat real low--she has long legs! It is very easy for me to slip a short specimen collection container under her, without touching her.

Sue: I mentioned the Tylan to my new vet last month and she wasn't familiar with using it with UTI's. I didn't pursue it, but I will definitely talk to her now. Her thought was maybe Annie wasn't on antibiotics long enough the last time to kill all the bacteria. I think you are right on the money - definitely worth trying. We did a urine culture these last 2 times and both showed e-coli. Looking back in Annie's records from July 2009, that culture also showed e-coli and Baytril as the drug. Last summer she was put Clauv/Amox and she continued with recurring UTI's. She's now had 3 rounds of Baytril since January. She was on Clauv/Amox AND Baytril when she was in the hospital with the pancreatitis Sept 2009. Just like Zoe, Annie is barely off a/b's and it appears she has another UTI. Interestingly, in the last several days

Do you recall where you bought it? Do you buy the capsules from the same place? Interesting that you don't need an rx? I'll do some research where to buy the tylan online. Do you recall the dosage? Annie is 65#. Thank you for all the info. I think of you sooo often. All that you went through in the last year with Zo helps give me strength. Wish we had had a chance to meet before you left CA. Ditto -- seeing Zo's sweet gray face is like looking at sweet Annie! Big hugs to you, Barb

[zoesmom]

Barb- Annie's uti saga so sounds much like what we went thru with for almost 12 years!!! The tylan (also called tylosin) is sold for use in bee and chicken populations - hence the reason you can get it w/o an rx. In canines, it's prescribed for the SIBO and for dogs who have constant staining around the eyes. But if you try to order thru a pet pharmacy, that apparently requires a prescription. I didn't need one, as I ordered from the agric. supply places. I have never found anything online about its use in uti-prone dogs. Tho' there's quite a bit online about it's use for soft stools/diarrhea resulting from canine intestinal issues. Like I say, the uti/drinking benefit was a pure accidental discovery. But a notable one, IMO, given Zo's long history and her absolute turnaround.

Because it's apparently so safe, the IMS never seemed concerned about the exact dose so I did some calculations and decided to buy two sizes of gel caps (0 and 00). You can get them at most health food stores. The '0' size holds 400-500 mg of powder and the '00' holds 700-900 mg. I forget Zo's original dose (filled at the clinic) but think it was at the upper end of that lower range. However, it's hard to fill the capsules completely full when doing by hand, so the larger caps could be filled like 1/2 - 2/3 full and would probably hold about the same amt. as the smaller caps, filled really full. The smaller ones, of course, are easier to sneak down their throats!!

I bought the tylan powder online. It was a place in Alabama with the word 'Marketing' in its name. Think I found it at e-Bay. Just do a google search. Think I've also seen it thru Amazon. (I'd check for the exact name but my office/files are still not unpacked!) There were a number of sources, actually, and a good price would be $40-50 for a 100 gm jar. That lasted us about 7 or 8 mos. It's a pain to fill the caps, one by one by hand, but I'd sit down and do it about every 3 weeks. About 40 caps took about 1/2 hour. Gave twice a day, at first, but later, there were many days when I'd only give her only one/day - simply because she took so darn many other meds. Has Annie had this problem her whole life, too??? The cost of a/b's for all those uti's can mount up fast!!!! Sue

[frijole]

I have never used it but this is where I work! We are a large ag supply company so we have these types of things and sell them worldwide.

Here's a link to it on our website:

http://www.qcsupply.com/qcsupply/browse/subcategory.jsp?categoryId=12372&addFacet=9004%3A12372&cm_guid=1-_-100000000000000001607-_-523484355&cm_mmc=Google-_-Pharmaceutical+and+Vaccines_Tylan-_-Exact_search_523484355-_-tylan%20powder|-|100000000000000001607

[sunimist]

Sue, that's very interesting about the Tylan powder and UTI's.
I use Angels Eyes, which contains Tylosin, for tear staining in Suni and the improvements are remarkable after only a few days. However, I am a little concerned about giving an antibiotic long term, so I am using less than recommended and not as frequently.
Perhaps the Tylan had just enough antibiotic in it to keep Zo from having UTI's?? Very interesting to say the least, huh?

Barb, I have been following your journey with Annie and hoping you get it all worked out for your little Annie girl.

Shelba and Suni

[zoesmom]

Yep, Kim. That's the one I used - the powder in the jar with the blue label - by Elanco. I did see that same 100 gm jar once for $36 or $37 somewhere. But then couldn't find it again when I needed to reorder. Some places sell it for much more - like 60 or 70 dollars. And in pricey, smaller quantities for use with the tear staining. Sue

[lulusmom]

I've used Tylan for my Buster's tear staining for well over a year. It's a lot cheaper than Angel Eyes and I use a minute amount in Buster's food. I have provided a link to reviews on Amazon by pet owners that love the stuff for tear staining as well as IBD:

http://www.amazon.com/Tylan-Soluble-Powder-100-gram/product-reviews/B00061MQIC/ref=dp_top_cm_cr_acr_txt?ie=UTF8&showViewpoints=1

[sunimist]

The folks on the Poodle forum recommended it to me. I had never heard of it before. Good to know someone I love and trust also uses it. :D

Sorry to hijack Annie's thread.

[zoesmom]

Sue, that's very interesting about the Tylan powder and UTI's.

Perhaps the Tylan had just enough antibiotic in it to keep Zo from having UTI's?? Very interesting to say the least, huh?


Shelba and Suni

The strange thing is . . . . it also cut her drinking by way more than half. And that was an immediate and obvious benefit. Then as time went on, I realized she also wasn't getting the usual uti's. A full year went by before she had just that one more. Her drinking had come down a bit when we started treating the cushings, but it was still running above average - even after 2 or 3 years on trilo and always went higher when she was in the throes of one of her countless uti's. She'd had PD her whole life so I kinda felt like the tylan 'fixed' that first, and as a consequence, the uti's then stopped. But who knows. Maybe it was the other way around, like you said. It was the best side effect ever, with a drug!!!!!!! I could've taken a really long tropical vacation with all the money we dropped on a/b's for her uti's over the years. Poor baby . . . wish tylan had come into her/our life sooner!!!! ;):p;)

PS - yes, sorry Barb. Every now and then we just have to hijack somebody's thread!

[Annie's Mom]

Keep up the hijacking! I don't mind at all -- I'm learning alot!!! I know I've hijacked in the past. It's all about educating and supporting each other! Annie had maybe 4 UTI's in her first 10 years. She was diagnosed with struvite crystals about age 5, and was on Hills Rx C/D until Sept '09. The only UTI with some blood was Nov 2007. July '09 she had a raging UTI, unbeknownst to me. All her lab tests were excellent for her age in Dec '08, so it appears to me that big health changes started to occur early 2009 (around age 11) (liver, kidney, cushings, arthritis getting worse). Very interesting comment about the Tylan maybe having just enough antibiotic to keep the bacteria from growing. Annie has been on heavy doses of a/b due to recurring UTI's since Sept 2009, so if a daily dose Tylan can prevent an outbreak, it's worth it. Thank you all for your comments and concerns. We sure learn alot from each other's experiences. PS - my first dog was a cocker spaniel and I never knew there was a product to help with the tear staining!

[zoesmom]

Barb - sent you a PM here. Sue

[Annie's Mom]

A quick update on Annie. I had an ACTH done on 4/30 and her numbers were:
pre 1.1
post 2.9

The vet is pleased with these #'s and stated the ideal "post" number is between 1-5. Annie has been on 61 mg (compounded) once a day. I am concerned with the low 2.9 number, but the vet is not concerned. We discussed switching to twice a day dosing (29 mg morning and 29 mg night) to even out the dosing. The vet also has a cushpup, and recommends we try 29 mg every morning, and add 29 mg evenings M, W, F. Does this make sense?

I chose to do an ACTH because the last one was January 2010 (4.9 post and it turned out she had a raging UTI at the time so probably not an accurate #); currently she is "infection free", as she is finishing another round of Baytril for another UTI; and she seems happy and feeling pretty good. She gets anxious in the evenings and wants more food, and sleeping less, so I expected her numbers to be high (is she hyped up in the evenings and looking for attention because she's been home alone sleeping all day or thyroid issue or ?). Her arthritis is definitely not improving but she loves her short walks every day, sitting outside (especially in the evenings)It's time to reorder her Trilo so timing was right to retest. Good news is she's energized and normal poops!

I am doing a total body function blood test tomorrow (for the same reasons as above - she's infection free at the moment, it's been 4 months since last testing, and I want to know where her kidney/liver/throid levels are at, now that I know the ACTH results). Annie had blood drawn yesterday to do the TBF but I just got a call from the vet -- the lab messed up and we need to get another fasting blood sample. Argh.

I'd appreciate input regarding the Trilo dosing. I'm a bit confused about the reasoning for only 29 mg Tues, Thur, Sat, Sun. (or every other day, whichever schedule I choose) . Thank you! Sending lots of healing thoughts and energy to all of you and your furbabies. Barb

[labblab]

Boy, those ACTH numbers look great to me!! :) :)

It seems like a shame to "mess with success" in terms of altering the trilostane dosing, but perhaps it's because Annie seems to be getting symptomatic again in the evening? You've mentioned that she seems to be more hungry and restless in the P.M. If so, maybe your vet is thinking that the trilostane is losing its effectiveness a little too quickly during the course of the day, and that her symptoms would remain better controlled if she got a second dose daily.

However, I really can't explain the logic of the every-other evening dosing. The only thing I can think is that more recent reports indicate that dogs who receive trilostane twice daily often end up needing a smaller overall daily dose than those who are dosed once daily. So if all that you have on hand are 29 mg. capsules, maybe your vet is thinking that spacing out the evening doses would lower the overall dosage a bit. But I'm not aware of any standard protocol that suggests dosing that way...

Marianne

[Annie's Mom]

Thanks Marianne, for your response. Hmmmm. Maybe I shouldn't "mess with success" ?! My concern is just as you note-- is Annie getting symptomatic again in the evening becasue the trilostane is losing its effectiveness late in the day? My vet mentioned that the IMS recommended the every-other-evening dosing for her own cushpup. I am going to wait to see what the TBF blood test results show before making any changes. Since this is all still new to me, I'm having a mental block at times on how the half dose, twice a day will keep her at the cortisol level she is currently at with a full dose once a day. I have 23 pills of 61 mg. Barb

[labblab]

Barb, sorry about my confusion over the 29 mg. pills. If I had read your reply more carefully, I would have seen that what you have on hand are 61 mg. pills. So you'd have to order more, no matter what twice-daily dose you settled on.

For what it's worth, take a look at this video on trilostane dosing presented by Dr. David Bruyette. He's a well-known veterinary endocrinologist in Los Angeles, and he discusses once vs. twice-daily dosing in this video:

http://www.k9cushings.com/forum/showthread.php?t=231

Marianne

[BestBuddy]

Hi,

Just going to jump in with both feet here.:D

Buddy never tried alternate day trilo dosing but his specialist had two dogs that were on strange dosing, one I think was every 36 hours and the other every 48 hours.

He said that he had tried many combinations with these dogs and this seemed to be the way to keep them in good (and safe) levels without symptoms. So although unconventional it worked for those dogs so there may be a lot of different ways trilo can be dosed that works for individual dogs.

Now after all that I also agree with Marianne, everything is looking so good at the moment so why mess with it. Maybe Annie can do even better and I suppose if things start going a little askew then you can revert back to your original dosing.:confused:

Jenny

[Annie's Mom]

Thanks again Marianne and Jenny. I'm just trying to figure out why Annie pants and is hyper in the evenings, even when it's cool temps. Twice a day dosing seemed like maybe a good option to consider, yet I understand your thoughts. As I write this, she is mellow tonight! I will definitely watch Dr. B's video tonight. Annie has bad arthritis and bone spurs in her R elbow, so the low cortisol doesn't help her arthritis, yet it helps her overall body health. Catch 22! I won't have the TBF test results until Monday cuz we are going out of town for the weekend. Thanks again for your insight and knowledge. Barb

[Annie's Mom]

I have received all the blood test results for Annie's "total body function tests" from May 7th. I'll list only the high numbers, and I'll list where she was in January 2010 (with a raging UTI and a post ACTH of 4.9).

AST 10 (low -15-66) was 13
Alk Phos 1419 (5-131) was 1187 (Nov 2009 she was 2291)
BUN 37 (6-31) was 33
Creatinine 1.7(.5-1.6) was 1.7
BUN/Creat ratio 22 (4-27) was 19
Calcium 11.5 (8.9-11.4) was ??
Amylase 1215 (290-1125) was 1419
Lipase 960 (77-695) was 1238
T4 .2 (1.0-4.0) was .6
Free T4 11 (8-40)

ACTH pre 1.1
post 2.9


Her T4 has been low since Nov 2009 (.4) and this current result is even lower (.2 ), so we did the Free T4 Equilibrium Dialysis test. Based on the Free T4 results, my vet said it does not indicate a need for Thyroid medication, but we will need to monitor her T4, and that the low T4 reading is a result of all her other issues. Down the road she may need thyroid meds for hypothyroid. Whew. Another "condition" for me to read up on and try to understand! My vet recommends I give Annie 20 mg Pepcid AC every day to help her belly feel better (due to the high Amylase and Lipase).

Good news is her phosphorus has been high since November and is now in normal range.; her Amylase and Lipase are slowly getting lower; symptom-wise, she appears to be feeling better. Poops are normal (yippee!), she sleeps less, and wants my attention more often!; I am trying the Tylan to see if it keeps her UTI-free.

I still haven't decided what to do about switching to a twice-a-day dosing of Trilo. I am going out of town for Memorial Day (Annie is staying home with my housemate), so it doesn't give me much time to "test" a change in Annie's schedule. I think I will wait til after the holiday to test any dosing change. Yesterday I spoke with the vet partner at my new vet clinic, and she suggested trying to switch to 1 full evening dose and see if her "hyperness" changes from evening to morning. I have refilled her Trilo at half dose capsules so I am prepared either way. I am fortunate that it is so easy to give Annie her pills, so giving her 2 small capsules vs. 1 capsule is not a problem for me (and the cost is the same).

We spent last weekend in Yosemite and I think Annie had a great weekend, as well as I! She loves road trips as much as I do. My goal 8 months ago was to bike around Yosemite with Annie. With all her major health issues, I really didn't think with day would ever happen. This spring I slowly got her used to the Burley wagon for dogs, by walking/biking her around my city. On Saturday in Yosemite, we biked 18 miles around the Valley, stopping frequently to walk a bit and smell "new scents"! I think she loved it! I don't have to entice her to step back into the trailer -- she steps in all on her own! Unfortunately it rained all day Sunday and I was not prepared to bike in the rain! I'll post some pictures tomorrow!

As I read other threads, I now join the ranks of multiple multiple pills/supplements!

I am now giving Annie:
Glucosamine/condroitin, etc (Arthrisoothe Gold)
Milk Thistle
Cranberry Extract
FortiFlora
L-Glutamine
Pepcid AC
Trilostane
Tramadol/Gabapentin
Tylan

Did I miss anything?! And.... lots of TLC! The result is I think she is feeling better.

HUGE thanks to all of you who are reading this for your encouragement and advice and expertise. I couldn't make it without all of you! I've never been good at remembering what all the results mean. It is overwhelming. I just want the best for my girl, I want to do all I can to make her feel as good as she can, given all her health issues. I welcome your thoughts and opinions.
Hugs to you and yours, Barb and Annie

[Annie's Mom]

Ah, the ups and downs of a senior dog. You all can relate.... Another new situation for Annie. Annie now as swollen hocks/ankles; her R is much worse than the left, and has a marble size bump on the inside of the foot. The vet aspirated it today, and determined it is joint fluid causing the swelling. Somehow last weekend she injured her hocks. She definitely has discomfort and is walking with a limp. We are trying 4 days of Rimydl (in addition to her pain meds) to see if the swelling goes down. She definitely has arthritis in her back legs and feet, in addition to her front R elbow. Today for the first time I heard her joints crackling, like someone cracking their knuckles. My poor girlie. She is so full of energy and alert, if only her joints and muscles were strong and healthy. She wants to be on the move, but the joints don't cooperate. I am going to try cold compresses tomorrow night. She is also back on Baytril for another UTI (she was off Baytril for less than 2 weeks when I noticed a strong urine odor and more frequent urination). Crossing my fingers and toes that the swelling goes down so she can be relieved of some discomfort.
Barb (Annie's mom)

[zoesmom]

She is also back on Baytril for another UTI (she was off Baytril for less than 2 weeks when I noticed a strong urine odor and more frequent urination). Crossing my fingers and toes that the swelling goes down so she can be relieved of some discomfort.
Barb (Annie's mom)

Awww, crummy. So the tylan didn't have any effect, I guess? Or maybe the original uti never fully cleared? Are they sure that baytril is the right a/b (based on a urine culture?

What you are describing with the leg sounds exactly like what Zoe developed in '08 - on the inside of her rear leg "knee". It was quite swollen. I forget what they said caused it, but it had fluid in it which didn't clear on a/b's. So they had to go in and clean it out surgically. That did the trick. And yes, I can relate to their spunky spirit saddled with a funky body. Zoe always wanted to keep going and going (the energizer doggy thing), but her legs and mobility became so fragile during her last two years. I was constantly stifling her fun by not letting her walk in places or do things that I just knew was going to injure a leg and cause limping. She still wanted to frolic with other dogs at the park or chase little furry creatures or jump up on trees to get at the squirrels. But one wrong move, and I knew that would set her back for a week or more, with her legs and movement. It's so hard to watch them going from graceful and strong, to gimpy and awkward. :(:( I understand completely. Sue

[Annie's Mom]

"No news is good news" from me and Annie! Annie is "stable". Her arthritis continues to get worse, but she loves her daily walks and wants to move faster than her creaky bones will allow. I started accupunture treatments to see if that will help with her mobility and overall health. She's had 4 treatments (1 per week) of "aqua-accupuncture" (B12 injections) and 1 treatment of electro-stim. I haven't seen any real outward signs of improvement but I figure it can only help her. She continues to get UTI's. I'm not surprised... Fortunately for Annie, our summer has been extremely cool; I'm yearning for warm/hot weather! Thinking positive thoughts for everyone and their furry friends. hugs to all, Barb and Annie

[Annie's Mom]

It is with great sadness and tears continuing to flow down my cheeks that I let you all know that I had to help Annie cross the Rainbow Bridge on May 7th. In the last 2 weeks of her life it became more evident that her kidney disease was progressing quickly and her time was very limited. You all know first hand how difficult this time is. I know she had the best mom and the best life a dog could ask for. We travelled near and far, camping, hiking, swimming in lakes and streams... she was a sweetie, everyone who met her, adored her. She was like a cat with nine lives - she pulled through many times in the past 1 1/2 years. I lost my younger black lab, Molly, to hemangiosarcoma cancer of the spleen in Aug 2009; the house is very quiet and I'm not liking it. I will welcome another dog (or 2!) into my home again soon; for now I need to take a little time this summer to visit my family back in the midwest. A huge thank you to each and every one of you on this forum for all the advice and support you have provided. I've learned so much in the past 2 years, and made some good friends along the way. I will continue to keep a watch on this message board and help others as I have been so greatly helped with all of Annie's health conditions. I try to keep focussing on the fact that Annie is now painfree, but I still miss her terribly. Hugs, Barb

[frijole]

Barb, I am so sorry. I know you have a big void to fill but you gave Annie a great life. Thanks for letting us know. RIP dear Annie. Run wild and free of pain. Kim

[Squirt's Mom]

Dear Barb,

Thank you so much for coming back to let us know about Annie. I know that wasn't easy to do. :(

Annie's name has been added to our remembering list in In Loving Memory where she will always be remembered by her family here.

http://www.k9cushings.com/forum/showthread.php?t=2865

When you are ready, we would love to share in the memories you wish to share of your time together and help you celebrate her life. You can do this at:

http://www.k9cushings.com/forum/forumdisplay.php?f=8

My thoughts and prayers are with you.

Our deepest sympathies,
Leslie, Squirt, Trinket, Brick and our Angels, Ruby and Crystal

[lulusmom]

Barb, I am so very sorry for your loss. My thoughts and prayers are with you.

Godspeed sweet Annie.

Glynda

[Harley PoMMom]

Oh Barb,

I am so, so sorry for your loss of sweet Annie. I really do understand the pain you are feeling having just lost my boy, Harley, a little over a month ago.

You were definitely a wonderful and loving mom, the best. Please know we are here for you and know how hard this time is.

Sending loving and huge hugs.

With Heartfelt Sympathy,
Lori

[Cindy Thoman]

Barb, I am so sorry for your loss. My thoughts and prayers are with you.

xoxo
Cindy, Alex and Bear

[littleone1]

I'm sorry for your loss, Barb. My thoughts and prayers are also with you.

Terri

[marie adams]

Barb,

So sorry for your loss. So many of us know all to well how you feel. I will look out at Maddie's star to night and say a prayer for you!!:o

[addy]

This is sad news and I am so very, very sorry. Words are never enough to express our sorrow and we always wish we could make the pain go away but we can't.

We are always here whenever you need us for whatever you need. We reach out to you in your time of sorrow and share your tears.

God Bless Annie.

Sending very large hugs and hope you can feel them.

Love,
Addy

[Casey's Mom]

Barb, I am so very sorry to hear about Annie. Words cannot do justice so just know that I am sending you a huge hug.

Love and hugs,

[bgdavis]

Barb,

I'm so very sorry that Annie has departed this earth. She was a fighter and well loved. She will always be in your heart and mind.

Bonnie and Angel Criss

[k9diabetes]

I'm so sorry to learn that Annie passed away... The pictures of her as a senior dog with a lot of life experience are very moving. She obviously brought you a great deal of joy and I know you did the same for her.

Natalie

[jrepac]

Rest in peace Annie.

Jeff & Angel Mandy

[mypuppy]

Dear Barb,

I'm so saddened for your deep loss and pain. Your sweet Annie will forever remain in your heart and know beautiful memories of her will help sustain you during this very difficult time. God Bless you Annie, and you as well Barb.

Very tight hugs and much love, xo Jeanette

[Eva Cicmirko]

Hi Barb
I know that your dog has since passed away but how long did it take for Annie to recover from Vestibular? Max is now in his 7th week of recovery but still circles a bit, is uncoordinated and doesn't know where he is going and stumbles around. He is much better on rough surfaces. Thanks Eva