New member/Arwen/ 6 y/o GSD/ Hypothyroidism/ skin issues/maybe Cushings

[Bubbagump]

Hi my name is Susie, I live in Scotland. I have 2 gsd.
Arwen 6yrs Blue sable longcoat, diagnosed with Hyperthyroidism 3yrs ago. Spayed at 17 mnths.Panosteitis, behaviour problems, and Papular rash, black areas on ventrum, unable to gain weight as a puppy. Then later put too much weight on.Pyoderma, coat poor and dry. Tested T4 very low 2006, normal TSH-?.Started on 0.8mg Soloxine and 0.2mg Soloxine once daily,morning.Pruritis bad,dec 2006,re test T4 arrange referral to vet college for skin.Referral,history of Pruritus and alopecia, Hypo diagnosed, hair regrowth,lost 4kg ,Pruritus worse, severe hyper pigmentation in the ventral areas has resolved which is suggestive of bacterial overgrowth after antibiotics. Tested positive Atopic dermatitis with strong reactions to 4 species of dust/forage mites. Cytology confirmed superficial pyoderma in the feet and groin. Controlling the pyoderma is going to be difficult in this case as the atopy results is high levels of staph on skin which has poor barrier function and the hypo results in a poor immune response to pyoderma.april 2007 started 4 week course rilexine.Tried immunotherapy which failed. Since then had numerous T4 tests to change dosage, Hair has grown in ,very puppy like hair ,told it grow back but would never be same again.Pirton stopped working,given ucerax 25mg twice daily for nearly 2 yrs,took her off them 4 wks ago ,her temperament is a lot better off them, I use cortavance spray when needed, she has had urine tests the last year ,drinking alot,eating alot,looking for food all the time,hyper,weight gain ,drinks immense amount of water and is always wanting more, her stomach feels fatter than normal, could this be cushings ?,urine came back ok.
Suz x

[Harley PoMMom]

Hi Susie,

Welcome to you and Arwen from me and my boy Harley. German Shepherd's are beautiful dogs, and I grew up with a few of them when I was a child. I am so sorry for the circumstances that brought you here but I am very glad you found this forum with these amazing and knowledgeable people.

Your baby does seem to have alot of issues going on, and you said in your post that her urine came back ok; was this a UC:CR test? I was also wondering if Arwen had a CBC/Chemistry Panel done recently, and if she did could you post anything on there that is marked abnormal with the reference ranges and the units of measurements.

Cushings is a slow progessing disease so one does have the time to get a proper diagnosis for their pup. Cushings can be very hard to diagnose and not one test can diagnose it 100%. Other non-adrenal illnesses, such as Diabetes and Hypothyroidism share some of the same symptoms of Cushings and should be ruled out first. Also, non-adrenal illnesses can create false positives on Cushings tests.

The one diagnostic test I do recommend is an ultrasound but this has to be done on a well-equipped machine, and usually not found in your local vets office.

Please remember you are not alone on this journey anymore, we are here to help you in any way we can, so ask all the questions you want and we will try to answer them the best we can.

Love and hugs,
Lori

[Bubbagump]

Hi Lori, thankyou for your reply.These are the only results i have,my vet ...well im the owner and let them do their job,say no more.
30.11.06 idexx lab report
endocrinology
canine serum TSH 0.43 < 0.5
Basal T4/ TSH Ratio 4.7
Thyroxine * <2.0 17.0 - 54.0
Comment

Low basal T4 and ratio consistent with hypothyroidism however cTSH is normal rather than increased.Low basal T4 may however be affected by steroid theraphy and ideally glucocorticoid theraphy would be withdrawn for 4-6 weeks prior to evaluation of thyroid function
04.01.07
ALB 24 23-40
ALKP 42 23-212
ALT 47 10-100
UREA 3.3 2.5-9.6
CREA 108 44-159
GLU 5.52 4.11-7.94
TP 61 52 -82
GLOB 37 25-45
05.01.07 VET TEST ADULT CANINE at 1020
T4 = 88.00 nmo1/L

16.02.07 T4 > 90 reduce soloxine to 0.5 mg once daily

20.03.07 T4 levels normal

I dont have any results since then apart from the vet saying that her urine is ok .They done T4 last year and her soloxine was increased too much and then retested and now she is on 2x 0.5mg soloxine in the morning.Im goin to make appointment because ive already told the vet about her symptoms.She was given antibiotics because she had a discharge from her vulva,shes been spayed and they thought it might be a pyometra on her stump that is left.She had a temperature ,but the other vet said that it isnt unusual for a dog like Arwen and her excitability to have one this high.I told them all the symptoms and she is due in to get her thyroid checked.What should i ask for and what reasons should i give without upsetting the vet.
Suz x

[Bubbagump]

Hi Lori,did you get my reply ,only its not on the board and it took me ages to type it all out.

Suz

[Nathalie]

Hello Susie and Welcome! :)

Am I reading this correctly you are giving a total of 0.10mg of Soloxine per day? What is Arwen’s weight?
Soloxine should be given 2x daily – 1h before or 2h after feeding to ensure proper absorbtion.
- Dividing the daily dose q 12 hrs avoids “peak and valley” effect
- Achieves better steady state over 24 hrs; half life 12-16 hrs
- Dosing once daily results in undesirable cardiovascular stress

It sounds like you never where able to get a good therapeutic response to the Soloxine which would explain some of the derm issues and perhaps contribute to behavior problems as well.

“Tested T4 very low 2006, normal TSH-?.”

From Dr. Jean Dodds:
“What is the diagnostic importance of measuring canine endogenous TSH ?
A. The cTSH test gives relatively poor predictability for primary hypothyroidism in dogs [~ 70%] vs people [95%], because the dog has another pathway to regulate the pituitary-thyroid-hypothalamic axis via growth hormone. False negatives and false positives (i.e. discordant results) occur in ~ 30% of cases. New research just published has shown that unlike humans where growth hormone has minimal influence on thyroid regulatory control, the dog uses this additional important regulatory pathway along with endogenous TSH.”

When you retested the thyroid function did the vet send the blood sample to the lab to have them run a Free T4 or did they only a T4?

A lot of the symptoms could be due to Cushings but ‘hyper’ is not usually one of them so without specific testing for cushings there is no way of knowing. Hyper and increased intake of water could be a sign of Hyperthyroidism. What was Arwen’s last Free T4 level?

Cheers,
Nathalie

[Harley PoMMom]

Hi Susie,

Please bear with us, until the forum team can approve your status, a moderator or administrator has to approve your post individually.


I use cortavance spray when needed, she has had urine tests the last year ,drinking alot,eating alot,looking for food all the time,hyper,weight gain ,drinks immense amount of water and is always wanting more, her stomach feels fatter than normal, could this be cushings ?,urine came back ok.
Suz x

About the cortavance spray, how much and how often? Cortavance spray contains a solution of the active substance hydrocortisone aceponate...hydrocortisone aceponate is a corticosteroid...Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex, like cortisol.

Did Arwen take prednisone at anytime ever?

If you are using this spray often and for a while then Arwen might have what is known as Iatrogenic Cushings: steroid induced cushing's in dogs. Iatrogenic Cushings will generate the same symptoms as Conventional Cushings in our pups but the treatment is very different. You just slowly remove the source of steroid induced cushings.

Usually in our cush pups their liver enzymes levels (ALP and ALT) are elevated and their cholesterol. From what I see on Arwen's lab results there is nothing there that is making me think Cushings...but all dogs are different.

Hang in there Susie, I am sure the others will be along to share their opinions too.

Love and hugs,
Lori

[Bubbagump]

Hello everyone,thanks for replying.Ok hopefully i can remember both posts .Arwen was on steroids 2006/07 for her skin problems.The diagnosis of Hypo was because i pushed for it,saying that im not allowed to tell the vet what tests i want done.So im not sure if the full thyroid test was done,i asked for it .Basically they have treated the symptoms but not the actual cause for years.Arwen has never been well since having her first innoculation and the vet pointing at me as to the problem.I was even asked if i was actually giving her her soloxine.Just because they hadnt read the results and worked it out properly what to give her.The best she has been was from july 2008 up to july 2009.Ive asked for results before and the ones i put on the forum is all i have got because the vet ...well i dont know what the problem is.I m not trying to undermine him,but i think hes wrong and i have to find a way to get him to listen.

Suz xx

[Harley PoMMom]

Hi Susie,

Oh my dear...are there any other vets or an IMS you can take Arwen to? The one important factor with my boys health is the relationship I have with his vet...We are a TEAM. She, Dr Owings, Harley's vet, listens to everything I have to say because if she would not I would take my boy else where. Now, that does not mean she DOES everything I say, :p:) She listens to me and we discuss everything about my boys health. She also has written in his file that I get copies of ALL tests done on him...I adore her and Harley does too.

When it comes to thyroid issues, I am no expert there. Nathalie, who posted to you earlier is very knowledgeable in thyroid issues. She has communicated with Dr Dodds, who is a reknowed Thyroid expert, many times about her Phillip. I am sure Nathalie and others will be along shortly to give you more advice.

Please do not let a vet make you think that you are at fault, they are the experts, remember that, ok.

Love and hugs,
Lori

[Bubbagump]

Hi again ,sorry i forgot to say about Arwen's weight.She was 43kg then went down to 39kg,but its increased now,i dont know by how much but she has put weight on.She pants alot ,seems really unsettled when food is around,wether it be the other dogs food or human .She is always whining to be fed,she gets fed in the morning at 8 am and at 5pm.She gulps her food down in seconds.

Suz xx

[Roxee's Dad]

Hi Susie,
A belated welcome from me. Arwen seems to have many issues going on along with various medications. Have you considered taking Arwen to an Internal Medicine Specialist? I think it could save you alot of money and heartache in the long run.


I was even asked if i was actually giving her her soloxine

I wouldn't blame your vet too much for asking, as a groomer, I see so many pups with skin conditions and other problems and when I ask the owner if the pup is being treated, they tell me yes, but can't find the medication. That tells me that although they have been to the vet and recieved the prescription, they haven't really treated the poor pup. So I think the vet's see so much of this, they need to ask.

Belly rubs to Arwen.

[Nathalie]

Hi Suzie,

I am so sorry for what you and your dog are going through! There is no excuse for making you feel bad and to boot make your dog Hyperthyroid.:mad:
In my experience, you can work with a less experienced vet if they are willing to work with you and open to learn and you are willing to do a LOT of foot work yourself but yours does not seem to fit that personality profile.;)
If at all possible, the best suggestion I have for you is fire him/her, get copies of ALL records – you paid for it hence you are entitled to it. You are your dogs only advocate and by the information you provided so far you need someone that is knowledgeable and compassionate and treats you like a partner in the care of your pet.
1.5 years ago my previous vet threw her hands in the air and left me standing in the hallway after I told her I think we need to test for Hyperthyroid and Cushings – she basically told me I am off my rocker and my Phillip is just getting old. Fast forward – I went to a different vet – asked for test a and b and blood to be drawn to be send to Dr. Jean Dodd’s – it’s your money and if there is no harm to the animal by doing a test you are entitled to request these.

“2x 0.5mg soloxine in the morning”

Suzie – are you saying you are giving 0.10mg in the morning or did you mean to write 0.5mg in the morning as well as in evening which makes a total of 0.10mg?
Are you giving it with or away from food?
When you did the last T4 (I am going to assume it was not a free T4 correct?) how many hours after you administered the Soloxine was the blood sample drawn?

It’s really hard to comment on Awren’s thyroid issue without knowing what the result of the last test and without running a full thyroid panel.

Basel thyroid levels can be affected by the following:
• Basal levels affected by certain drugs
• Basal levels lowered by estrogen; raised by progesterone
[sex hormonal cycle effects]. Test during anestrus
• Thyroid levels are suppressed slightly (up to 25%) by corticosteroids, sulfonamides, overdosing iodine (kelp), and phenobarbital
• Rabies vaccination within previous 45 days can elevate TgAA by ~ 25%

When monitoring a dog on Soloxine running a T4 test is not enough - because the body can increase thyroxine turnover rate and excrete it faster to
avoid thyrotoxicosis.

This maybe confusing but diagnosing, treating and monitoring is not rocket science as long the appropriate test is run to diagnose, protocol is followed when monitoring and dosing is done appropriately – your vet should know this.
Do you think getting yourself a better vet would be an option?

Nathalie

[Harley PoMMom]

Hi Susie,

This is just a thought on my part, but maybe you could have a thyroid panel sent to Dr. Dodds. Here is alittle about her:


The main reason for sending Dr. Jean Dodds / HEMOPET the serum samples instead of having the testing done locally, is that HEMOPET is the only group routinely offering expert clinical interpretive diagnostic comments that take into account the age, sex, and breed type of the animal. This often means an expected normal reference range for an individual pet that differs from the test lab's generic broad reference range. Practitioners usually are unaware of these differences, which have been established by published research and Dr. Dodds' many years (46 years this year - 2010) of clinical and research experience.
http://www.itsfortheanimals.com/HEMOPET.HTM

If you would decide to ship Arwen samples to her:
INSTRUCTIONS ON SHIPPING SERUM SAMPLES FROM OUTSIDE THE UNITED STATES OF AMERICA
http://www.hemopet.org/files/International_Shipping_Instructions_rev_09.28.2009 .pdf

Love and hugs,
Lori

[AlisonandMia]

Hi and welcome from me too.

Like Lori I'm wondering how much of cortovance spray you are needing to use - and does Arwen lick the areas you've put it on after you've applied it?

Another issue that I wonder about her possibly having is something called Color Dilution Alopecia. This is a skin/coat condition that can happen with blue and fawn dogs. Here's a couple of links to info on this condition: http://www.tapestrychihuahuas.com/ColorDilutionAlopecia.html

http://www.upei.ca/~cidd/Diseases/dermatology/colour%20dilution%20alopecia.htm


Hi Susie,

Please bear with us, until the forum team can approve your status, a moderator or administrator has to approve your post individually.



About the cortavance spray, how much and how often? Cortavance spray contains a solution of the active substance hydrocortisone aceponate...hydrocortisone aceponate is a corticosteroid...Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex, like cortisol.

Did Arwen take prednisone at anytime ever?

If you are using this spray often and for a while then Arwen might have what is known as Iatrogenic Cushings: steroid induced cushing's in dogs. Iatrogenic Cushings will generate the same symptoms as Conventional Cushings in our pups but the treatment is very different. You just slowly remove the source of steroid induced cushings.

Usually in our cush pups their liver enzymes levels (ALP and ALT) are elevated and their cholesterol. From what I see on Arwen's lab results there is nothing there that is making me think Cushings...but all dogs are different.

Hang in there Susie, I am sure the others will be along to share their opinions too.

Love and hugs,
Lori

[Bubbagump]

Hi everyone,the practise has 10 vets ,the one vet that Arwen seen till she was sent to The Royal dick Vetinary University specialist was ok .He didnt test for Hypo because she was so young.To watch her lose all her hair and not be able to sleep for 2 years is alot for any owner to cope with.It was CIMDA that helped me push for the other tests .I stopped asking for him and Arwen has seen 3 other vets from the same practise that all have different thoughts,which is confusing and doesnt get results.The last vet is a new one and she seems a bit more open to explaining things,which is what is needed for Arwen.Arwen's litter mate is at the same vets and there is nothing wrong with him,he is so laid back and the opposite of Arwen which i hear all the time.She has been socialised,puppy classes,around other dogs and all different enviroments .When she goes to the vets i feel really bad because her mood changes and im to blame.This doesnt help it causes me stress and then Arwen.I can't take her anywhere else .The specialist wrote to my vets and said that she would be a very hard case to deal with and i believe they where giving up on her.Ive read about Jean Dodds ,and asked my vet if he would read what ive been looking into and he said theres alot on the internet sometimes too much.I have asked for results but the reception i get for even asking for those isnt very good.Other people are trying to help Arwen and if i can get the results it would help.My vet doesnt have the time to spend hours and hours a day on one case so the least they can do is let me help.We have a saying in Scotland "dont tar me with the same brush"it means just because one person has done it doesnt mean to say everyone else has.It's an insult to be quite honest to be blamed or accused of not doing something.Not everything is by the book,i wish it was for her sake.So what im going to do is call on Monday,ask for their advice ,results and book her in for another Thyroid and full blood .See how we get on.If they give me results i will post them on the forum.

With thanks again

Suz xx

[Harley PoMMom]

Hi Susie,


To watch her lose all her hair and not be able to sleep for 2 years is alot for any owner to cope with.

Yes my dear it is, and my heart goes out to you and I wish that I could do more for you.

When she goes to the vets i feel really bad because her mood changes and im to blame.This doesnt help it causes me stress and then Arwen.

Oh Susie, you are not to blame for this, Arwen is like many pups when they go to the vets...fearful. Some pups are just like that.

Ive read about Jean Dodds ,and asked my vet if he would read what ive been looking into and he said theres alot on the internet sometimes too much.

Altho there is alot of info on the internet, there is also alot of very good informative resources on the internet. The first link I pasted in your post for Dr Dodds (HEMOPET), you can email her too...just a thought.

I have asked for results but the reception i get for even asking for those isnt very good.Other people are trying to help Arwen and if i can get the results it would help.

According to the AVMA policy here: Principles of Veterinary Medical Ethics of the AVMA; MEDICAL RECORDS
Veterinarians are obligated to provide copies or summaries of medical records when requested by the client. Veterinarians should secure a written release to document that request.
http://www.avma.org/issues/policy/ethics.asp#VIII

Maybe you can check and see if something like this applies there too.

My vet doesnt have the time to spend hours and hours a day on one case so the least they can do is let me help.

You are so right, and I do hope and pray that they do.

Not everything is by the book,i wish it was for her sake.

None of our cush pups read the directions and go by the book either! UGH!! They have us pulling our hair out and shaking our heads...Thank GOD for this forum!


So what im going to do is call on Monday,ask for their advice ,results and book her in for another Thyroid and full blood .See how we get on.If they give me results i will post them on the forum.

Sounds like a plan and the very best of luck to you and Arwen.

With thanks again

Suz xx

Will be looking for your updates.

Love and hugs,
Lori

[Bubbagump]

Thank you Lori for all your help and advice.I must go to bed ,be up in less than 5hours.

Suz xx:)

[Nathalie]

“When she goes to the vets i feel really bad because her mood changes and im to blame. This doesn’t help it causes me stress and then Arwen.I can't take her anywhere else .The specialist wrote to my vets and said that she would be a very hard case to deal with and i believe they where giving up on her.”

A lot of animals freak out when fearful which can be due to a number of things and does not have to be anything you have done or not done. The whole clinical setting is stressful – 10 vets – there must be a lot of commotion going on, being roughly handled and having a previous bad experience, illness such as hypothyroidism or damage from vaccines can bring on over the top responses.

I have one of those vaccine damaged pups laying right beside me – my little Sophie is a real tough cookie but when it comes to having anything done to her body she will completely fall apart. I am not talking being a bit afraid but working herself in a state that she appears to be afraid of her life and when pushed will have a seizure. This all started after her only and last rabies booster.
She also has developed a very large lipoma on the site of injection. She will be going in on Monday to have dental work done and if doable have the lipoma removed. To make things easier on her the vet is coming in on her day off – Sophie will be the only one we have to worry about and I will be with her throughout the entire time. The point I am trying to make is that there are vets out there that care and do take extra time and go the extra mile and it is not all about money but they are not easy to find and it took me quite some time to build this relationship.

“Ive read about Jean Dodds ,and asked my vet if he would read what ive been looking into and he said theres alot on the internet sometimes too much.”

That’s just ignorant. Jean lectures all over the world – why don’t you just drop her a line – she might be even able to recommend a vet in your area or at least point you in the right direction.
She is VERY approachable and CARES – she reviewed my Phillip’s blood tests even so some where run by another lab and helped me in Phillips cushings diagnosis at no charge.
Just in case, here is her email address: hemopet@hotmail.com
Or, you could book a consultation with her.

My thoughts will be with you. Wishing you the best and I am looking forward to your updates.
Nathalie

BTW: nice pictures!:D

[Bubbagump]

Hi Lori,Alison
Arwen is really good when i used the spray,i havent used it since summer last year,in house she has to wear a buster collar if im not around,she wiill start chewing herself.The ucerax tablets have helped,except theres quite a few side affects to them.She cant tell me verbally but i can observe her on them and lond term isnt good.I started weaning her off then ,shes alot more responsive.I have read about the blue gene and i actually spoke to my vet a long time ago about this.That there was studies going ahead into this blue gene and the affects it was having breeding with this gene.To me it makes sense,other people dont seem to have the time to bother.What can you say to that?

Suz xx

[Bubbagump]

Hi Nathalie

Thanks for your advice,i have read alot about Jean and im not a vet but i have alot common sense.I think what she does is fantastic and find the Uk very behind in times to new research wether it be for animals or humans,or maybe they are aware of it but too ignorant to listen to a simple pet owner
Thanks for the comment about my pics,hope they give a little insight into my little world in bonny Scotland.

Suz x

[Nathalie]

Suzie - you probably know this already but just in case ...

"So what im going to do is call on Monday,ask for their advice ,results and book her in for another Thyroid and full blood .See how we get on.If they give me results i will post them on the forum."

When you take Arwen in for the Thyroid test give the Soloxine 1h before or 2h after breakfast and make the test so the blood is drawn within 4-6h after the morning pill (this is when the Soloxine peaks) to get the most accurate result and don't waist your money.

I am still curious about your dosing schedule :confused:

I am also very curious to see the result of the full blood panel, especailly the the liver values, ALT and ALP. Most dogs that have cushings do have a siginificant increase in ALP.

Looks like nice country where you live. :)

Nathalie

[Harley PoMMom]

Hi Susie,

Very beautiful pictures you took, I absolutely loved them, and you definitely have an eye for the camera.

Like I had mentioned before, Nathalie is very knowledgeable about thyroid issues, and here is some reading material for you about Hypothyroidism if your interested.

Hypothyroidism
http://www.lbah.com/canine/hypot4.htm

Now, about diagnosing the cushings, the first test I would have done is the UC:CR test, but Arwen would have to have some of these issues taken care of. You see UC:CR test checks the level of cortisol in the pups body and if the pup is really stressed or ill their cortisol level will be elevated.

Here is a link about the UC:CR test.
Canine Cushing’s Syndrome: Diagnosis and Treatment (Rhett Nichols)
http://www.michvma.org/documents/MVC%20Proceedings/Nichols2.pdf

Also here is a quote from Dr Bruyette, Dr. David Bruyette is a nationally known veterinary endocrinologist and the medical director of VCA West Los Angeles Animal Hospital. He is also a member here.


Yes. The same would apply when looking at urine cortisols in the initial diagnosis of Cushings. Ideally 3 morning pooled urine samples collected by the owner at home and refrigerated.

Dave

I hope this helps.

Love and hugs,
Lori

[Bubbagump]

Hi Lori, Yes ive read those links and found them very interesting.What tests are actually taken when Arwen gets her Thyroid levels checked.What should be checked? If her Soloxine needs to be lowered or increased can she still be checked for Cushings at the same time,or will her thyroid count affect the results of her having or not having Cushings.Do you know what i mean.If her thyroid is not right can that result give a false idea of her having Cushings.If they sort her thyroid then test for Cushings will the results be more reliable?

Suz x

[Harley PoMMom]

Hi Lori, Yes ive read those links and found them very interesting.What tests are actually taken when Arwen gets her Thyroid levels checked.What should be checked?

I will let the "thyroid knowledgable" people answer your questions, because I am not one of them, and I am so sorry.

If her Soloxine needs to be lowered or increased can she still be checked for Cushings at the same time,or will her thyroid count affect the results of her having or not having Cushings.Do you know what i mean.If her thyroid is not right can that result give a false idea of her having Cushings

Until Arwen's hypothyroidism is controlled, at least somewhat, the UC:CR test and the LDDS test can create false positives for Cushings in dogs. Now there is another test...ACTH test, but this also can create false positives with dogs that have non-adrenal illnesses; however they do use this test to diagnose for cushings in dogs that have diabetes.

If they sort her thyroid then test for Cushings will the results be more reliable?

Yes.

Suz x

You are doing a great job Suz, keep the questions coming! ;):D

Love and hugs,
Loti

[littleone1]

Hi Susie,

Corky and I would like to say hi and welcome you and Arwen.

Corky has been on Soloxine since 2003 for his hypothyroisim. If I were you, I would have a full thyroid panel done. Corky just recently had the T4 and the FT4 done, after his dosage was increased. His levels were in the normal range, but he was experiencing other problems with the medication. By having the full panel done, you can find out if it truly is hypothyroidism or if Arwen has a sick thyroid. I wish you the best.

Terri

[Harley PoMMom]

Hi Susie,

In the meantime, here is a post from Nathalie's thread that has some very good information about thyroid testing.



I previously had emailed Dr. Jean Doods with some questions and thought I post my questions and Jeans responses here as well for anybody who might be interested.

“Optimal therapeutic response levels should be in the upper 1/3 to 25% above the upper limits of the resting optimal ranges at 4-6 hours post-BID thyroid medication.”
Explanation:
Geriatric Therapeutic Optimal Levels:
T4 2.20 – 4.50 ug/dL
FT4 0.70 - 2.00 ug/dL
T3 40 – 70 ug/dL
FT3 1.6 - 3.5 ug/mL

Question: How often should I have his thyroid function tested and what tests should be done?
Answer: Every 6-12 months; test T4 and freeT4.
Question: I have read that we should test not only for T4 but also Free T4 – is this correct and what does the Free T4 value in conjunction with the T4 value supposed to tell me?
Answer: Definitely, because freeT4 is the biologically active tiny fraction [0.1 %] of total T4 .
Question: How to convert T4 value from nmol/L to ug/dL
Answer: you must divide the nmol/L by 12.87 to convert it to ug/dL

Nathalie

Hope this helps.

Love and hugs,
Lori

[Bubbagump]

Hi Terri, thanks for the info,it gets a little confusing what to ask for sometimes.


Suz x

[Harley PoMMom]

Hi Susie,

Here is another link :eek: to really good article by Dr. Dodds about:

Thyroid Disease, Diagnostic and Treatment Misunderstandings (Dodds)

http://www.k9cushings.com/forum/showthread.php?t=1627

Love and hugs,
Lori

[Bubbagump]

Lori i did ask for a full panel ,i remember now,they wouldnt do one ,infact it was the specialist when Arwen went for her referral that tested her.Ive got some of Arwens file here .Its says this,mind it was a while ago , that her urine was very dilute.Her urine has come back a couple of times like this,some protein in the urine also.Arwen was spayed due to extended season and found to have ovaries slightly cystic.All these symptoms..... are they all factors of her thyroid and maybe more underlying health problems. For years owners where told "your dog has this and we will treat the symptoms" and no one questioned this.My parents dog had diabetes,but he could have had other health issues that was never investigated.My parents were never told ,they just accepted it. Maybe he would have been around alot longer,and maybe if we dont just accept things ,then dogs would live alot longer.

Thanks Lori

Suz x

[Harley PoMMom]

Hi Susie,

In our cush pups, dilute urine is common. The excess cortisol in their body stimulates the kidneys to go into overdrive, and thus our pups urinate more. To keep up with the increasing urination our cush pups HAVE to drink more water. Cushingnoid pups usually have a very low urine specific gravity (USG), a normally hydrated dog is 1.015 - 1.050. In July, Harley, my boy, his USG was 1.006. When did Arwen start drinking alot more water?

Harley has protein loss in his urine also, and his vet and I, along with the help of these wonderful people on this forum, have figured out that his protein loss is because he has high blood pressure. Have you ever gotten Arwen's blood pressure checked?

For me, symptoms are a sign of an underlying illness that has to be dealt with. But one cannot do that alone, Susie, you need a vet/IMS who will work with you.

Love and hugs,
Lori

[Nathalie]

Hi Suzie,

Like Lori said – we are no vets – you need a good compassionate vet!!! Your dog is so young and has not been well in a long time ……

With the information provided, here is what I would do … Let’s regroup and start from scratch ..

1. Find new vet – speak to friends, people at the dog park etc. people are usually more then happy to speak about their vet experience
2. Have a complete blood panel done. It should include a Free T4. If not, have a Free T4 test done and make sure the blood is drawn 4-6h in the am after pilling.
OR, send blood sample to Jean. If you are having a full thyroid panel done by Jean you may as well have her run the full blood panel as well since you are already having to pay for shipping.
If you do deceide to send blood to Jean - I would email her first to tell her that you are planning to send blood to her, giving her a condensed overview of what is going on to find out if there is anything that she highly recommends in light of the history/symptoms that she can run at the same time.

Once you get these tests back let’s take a look at the result. Cushings is a slow, progressive disease so there is no harm done in waiting a bit to have cushings specific testing done.

You never confirmed when and how much Soloxine you give on a daily basis nor if any previous T4 test where done in the am 4-6h post pill. Could you please confirm? This is important and can affect therapeutic response and test results.
Let’s take it one step at the time.

I was also thinking .. Are you giving any supplements such as Kelp? What are you feeding?

Even if the hypothyroidism is poorly controlled you still can test for cushings. Having said that, I don’t think that an UC:CR would be my first choice with everything else that might be going on. I opted to do the LDDS test but you can cross that bridge until after you get the full blood panel/Free T4 test results back.

Nathalie

[Bubbagump]

Hi Nathalie & Lori

Im going to get Arwen in for all those tests this week and if my vet doesnt feel the need to do them i will have to find another practise that will.
Im going to start from the day i bought her.
7 wks old,the owner was going into hospital thats the reason why she came home at 7 wks which normally i would have preferred 8wks.
4th Dec 2003 vaccination ,panacur
19th dec 2003 Diarrhoea and very demanding for food,urine test results sg 1.008,leukocytes++,rest - ve
delay 2nd vac not well sg very dilute,not putting weight on
29th dec 2003 Still the same only put 2kg on
This carried on to 27th Jan 2004 2nd vaccine ,no diarr
5th march 2004 eating faeces,intermittent lameness weight 23kg,no diarr.
4th sept 2004 Papular rash also affecting nipples.This continued with weekly vet visits right up till 18 march 2005 ,not well ,extended season,spayed and skin complaints got worse,hair falling out drinking lots of water,weight loss,weight gain,continuos use of antibiotics,steriods ,creams,shampoo,skin scrapes.
On the 9th november 2006 they decided to take blood for thyroid.
28 november 2006 sample sent to Idexx T4 /TSH V LOW T4,NORMAL TSH-?low T4 due to steroids wean off and retest
1st results TSH 0.43 < 0.5
BASAL T4/TSH RATIO 4.7
THYROXINE * <2.0 17.0-54.0
Retested results normal.i dnt have a copy of them 4 Jan 2007 T4 test .
she was started on 0.8mg once in morning.
15 feb 2007 T4 sample taken ,results T4 >90 reduce soloxine to o.5mg once daily in morning,retested 30 march 2007 T4 normal.
31 march 2007 referral to specialist in edinburgh,dust mite allergies.
Thats about it.She has had another blood test to check her kidney function all ok ,with this infection she had in summer last year,shes been back about 4 times for that.She has had very little blood done .
They told me the vet has carried out all the tests that we feel required and only options as discussed before re referral or low dose steroids.The reason for that reply,i had asked for yeast tests,i had said the black areas on ventrum were needed checked again ,the vet said its pigment and is permanent change.Arwen has no more black on her ventrum after referral vet gave her Rilexine but my vet said it was unchangable.

I hope this helps a bit .soloxine 0.5mg twice in morning,vet wont allow splitting dose.She was on 0.8mg twice in morning that was reduced to the dose she is on now but as you can see in the pics her condition is goin down hill slowly.Drinking alot water 4-6months vet didnt want to mess about with her soloxine in summer 09 as her coat was really good.All she has had a few times since then is antibiotics for her discharge in vulva and her high temperature.

Suz xx

[Nathalie]

Suzie - I just send you a Private Message.
On the right upper hand corner there is a link from where you can retrieve PM's.
Nathalie

[Bubbagump]

Hi Nathalie,yes ive sent you message back

Suz x

[Nathalie]

".soloxine 0.5mg twice in morning,vet wont allow splitting dose."

There is no other way of saying this but the vet is WRONG! If it was my dog I would split the dose against the vets recommendation for the good of the dog.

Q. Should thyroxine be given twice daily or will once daily suffice ?
A. Dividing the daily dose q 12 hrs avoids “peak and valley” effect
• Achieves better steady state over 24 hrs; half life 12-16 hrs
• Dosing once daily results in undesirable cardiovascular stress
• Dosing should be given directly by mouth

Q. Should thyroxine be given with or away from food ?
A. Because thyroxine binds to calcium and soy, it should be given at least an hour before or three hours after each meal, to ensure proper absorption.

There is no way you can get an optimal therapeutic response the way the Soloxine is administered.

- the dog may not be able to absorb the Soloxine properly or if he does absorb most of the 'double' dose it might explain why he is hyper - it's like eating a whole bag of candies at once - you get a sugar rush and then you crash - over time this is very hard on the body. eg cardiovascular stress

Not splitting the the daily dose between am and pm may also scew your thyroid test results but you would not even know about it because ...

Q. Why do some dogs over-supplemented with thyroxine still test hypothyroid ?
A. Because the body can increase thyroxine turnover rate and excrete it faster to avoid thyrotoxicosis.

A dose of 0.5mg IF devided daily seems to be approbriate for a 34kg dog but 0.1mg per 15 lbs twice daily is only a suggested dose and needs to be properly monitored via blood test and adjusted if needed.

In one of your earlier posts you menitoned that you feel that they had given up on your dog - one more good reason to go somewhere else.

Nathalie

[Bubbagump]

".soloxine 0.5mg twice in morning,vet wont allow splitting dose."

There is no other way of saying this but the vet is WRONG! If it was my dog I would split the dose against the vets recommendation for the good of the dog.

Q. Should thyroxine be given twice daily or will once daily suffice ?
A. Dividing the daily dose q 12 hrs avoids “peak and valley” effect
• Achieves better steady state over 24 hrs; half life 12-16 hrs
• Dosing once daily results in undesirable cardiovascular stress
• Dosing should be given directly by mouth

Q. Should thyroxine be given with or away from food ?
A. Because thyroxine binds to calcium and soy, it should be given at least an hour before or three hours after each meal, to ensure proper absorption.

There is no way you can get an optimal therapeutic response the way the Soloxine is administered.

- the dog may not be able to absorb the Soloxine properly or if he does absorb most of the 'double' dose it might explain why he is hyper - it's like eating a whole bag of candies at once - you get a sugar rush and then you crash - over time this is very hard on the body. eg cardiovascular stress

Not splitting the the daily dose between am and pm may also scew your thyroid test results but you would not even know about it because ...

Q. Why do some dogs over-supplemented with thyroxine still test hypothyroid ?
A. Because the body can increase thyroxine turnover rate and excrete it faster to avoid thyrotoxicosis.

A dose of 0.5mg IF devided daily seems to be approbriate for a 34kg dog but 0.1mg per 15 lbs twice daily is only a suggested dose and needs to be properly monitored via blood test and adjusted if needed.

In one of your earlier posts you menitoned that you feel that they had given up on your dog - one more good reason to go somewhere else.

Nathalie
Hi Nathalie,

Yes i think your right ,you see what the problem is ,its mind destroying .

Suz xx

[Nathalie]

Hey Suzie,

this morning in my PM to you I said “Since Arwen was never given the Soloxine 2x per day and away from food I would wait at least wait one week before doing the thyroid test to give the body a chance to get used to the every 12h dosing and start converting the Soloxine propperly.”

I kept on thinking about this and frankly I don’t like to suggest anything when I am not really sure and was never in the same situation with one of my dogs.

Anyhow, I picked my vets brain for you a bit while we where waiting for little Sophie to wake up after her dental to make sure we got our ducks in a row.

1. She confirmed that there is no way you can get good therapeutic control by the way the dosing has been done so far. You must switch to 0.5mg 2x daily (every12h) 1h prior or 2h after feeding.

2. Once you make the change it is like giving a new dose all together and the body needs time to get the benefit and absorb and convert this ‘new’ dose. Hence you need to wait not only 1 week but just like when you would increase the total daily dose you need to wait 4-6 weeks before you can a thyroid test to ensure you are getting a accurate readings and the dog may also improve quite a bit clinically.

3. She too would start off with a full blood panel – paying special attention to liver values (ALT and ALP) and a full Thyroid Panel in 4-6 weeks after you changed to giving Soloxine 2x daily.

4. If the symptoms that are indicative of Cushings are still present and the Thyroid Panel shows optimal therapeutic control she would opt to do an LDDS test over the less expensive urine screening test because it might come back showing elevated Cortisol because issues other then cushings. The LDDS result can be effected by issues other the cushings but since the LDDS is not only screening the cortisol level but also if the dog can suppress, when and how much it still give you a pretty good idea, combined with symptoms whether or not the dog has cushings.

I just got your PM …
Again – there is no point testing at this point in time unless you switch to 0.5mg 2x daily (every12h) 1h prior or 2h after feeding (away from food).
Also you must draw blood within the 4-6 h window and try to do any subsequent blood draws the same time after pilling eg. post 5h so you can compare apples with apples ….

If you feel your Arwen needs medical attention right now, take him into the vets and have them run a full blood panel for now and looked at.

Nathalie

[Nathalie]

Hello Suzie,

Just wanted to wish you luck for tomorrows vet appointment! You can do it!!! ;)
It’s unfortunate that you can’t just find someone else without losing the medical coverage from the program Arwen is enrolled in.
But who knows – the guy may surprise you and even if you have to jump up and down a view times to get heard – you just have to do whatever it takes. Maybe you want to practice jumping right now???;):D OK - bad joke. ;)
Keeping my fingers crossed.

Nathalie

[Bubbagump]

Hi everyone, thats me and Arwen getting ready for the vet appointment for today at 3.10pm .She will cause absolute chaos in the vets today she is so hyper lol .So i probably will be jumping up and down a few times today to get what Arwen needs.Wish me luck lol:D
I will let you know how it all goes, thank you for all the replies,sorry ive been a bit absent ,just exhausted.


Suz & Arwen xxxxxx:)

[Harley PoMMom]

Hi Suz,

Wishing you and Arwen the best of luck today with your vet appt. I'm also sending very calming and soothing energy your way. ;):) Will be looking for your updates!

Love and hugs,
Lori

[Harley PoMMom]

Hi Suz,

Was just wondering how you and Arwen were doing, and how the vet appt. went. When you get a chance we would love to hear from you.

Love and hugs,
Lori

[Bubbagump]

Hi everyone,

Sorry its been a while,thankyou for all your posts .
Ok these are Arwen's results.



ALB = 35 g/L 23 - 40

ALKP = 68 U/L 23 - 212

ALT = 32 U/L 10 - 100

UREA = 4.8 mmol/L 2.5 -9.6

CREA = 112 umol/L 44 - 159

GLOB = 29 g/L 25 - 45

GLU = 5.38 mmol/L 4.11 - 7.94

TP = 64 g/L 52 - 82



ENDOCRINOLOGY
THYROID

CANINE TSH

CANINE SERUM TSH <0.03 ng/ml <= 0.50

BASAL T4/TSH ratio 2430.0


THYROXINE 72.9 HIGH nmol/L 18.0 -58.0

(MICROGENICS)

For hypothyroid dogs on L-thyroxine theraphy,the recommended interval for peak level (4-6 hours post pill) is 37.4 to 72.5 nmol/L.

HEAD OF CLINICAL PATHOLOGY UK .

Arwen has now had her Soloxine reduced, she has to take one and a half tablets a day (0.5mg) instead of two tablets at 0.5mg a day.

Her blood results this week compaired to 2007 have all increased ,the 2007 results are on my previous posts.


What do you all think?

Suz xxx

[Harley PoMMom]

30.11.06 idexx lab report
endocrinology
canine serum TSH 0.43 < 0.5
Basal T4/ TSH Ratio 4.7
Thyroxine * <2.0 17.0 - 54.0
Comment

Low basal T4 and ratio consistent with hypothyroidism however cTSH is normal rather than increased.Low basal T4 may however be affected by steroid theraphy and ideally glucocorticoid theraphy would be withdrawn for 4-6 weeks prior to evaluation of thyroid function
04.01.07
ALB 24 23-40
ALKP 42 23-212
ALT 47 10-100
UREA 3.3 2.5-9.6
CREA 108 44-159
GLU 5.52 4.11-7.94
TP 61 52 -82
GLOB 37 25-45
05.01.07 VET TEST ADULT CANINE at 1020
T4 = 88.00 nmo1/L

16.02.07 T4 > 90 reduce soloxine to 0.5 mg once daily

20.03.07 T4 levels normal

I dont have any results since then apart from the vet saying that her urine is ok .They done T4 last year and her soloxine was increased too much and then retested and now she is on 2x 0.5mg soloxine in the morning.Im goin to make appointment because ive already told the vet about her symptoms.She was given antibiotics because she had a discharge from her vulva,shes been spayed and they thought it might be a pyometra on her stump that is left.She had a temperature ,but the other vet said that it isnt unusual for a dog like Arwen and her excitability to have one this high.I told them all the symptoms and she is due in to get her thyroid checked.What should i ask for and what reasons should i give without upsetting the vet.
Suz x


Hi everyone,

Sorry its been a while,thankyou for all your posts .
Ok these are Arwen's results.



ALB = 35 g/L 23 - 40

ALKP = 68 U/L 23 - 212

ALT = 32 U/L 10 - 100

UREA = 4.8 mmol/L 2.5 -9.6

CREA = 112 umol/L 44 - 159

GLOB = 29 g/L 25 - 45

GLU = 5.38 mmol/L 4.11 - 7.94

TP = 64 g/L 52 - 82



ENDOCRINOLOGY
THYROID

CANINE TSH

CANINE SERUM TSH <0.03 ng/ml <= 0.50

BASAL T4/TSH ratio 2430.0


THYROXINE 72.9 HIGH nmol/L 18.0 -58.0

(MICROGENICS)

For hypothyroid dogs on L-thyroxine theraphy,the recommended interval for peak level (4-6 hours post pill) is 37.4 to 72.5 nmol/L.

HEAD OF CLINICAL PATHOLOGY UK .

Arwen has now had her Soloxine reduced, she has to take one and a half tablets a day (0.5mg) instead of two tablets at 0.5mg a day.

Her blood results this week compaired to 2007 have all increased ,the 2007 results are on my previous posts.


What do you all think?

Suz xxx

Hi Suz,

First let me point out that I am no vet and have no training in the medical background but looking at some of Arwen's lab values and seeing many diagnosed cushingnoid pups lab values on this forum, well, Arwen's are not consistent with Cushings.

Particularly the liver enzyme values (ALT, ALKP) typically the ALKP will be elevated and this will tip the vet off to test for cushings. When my boy was first dx'd his ALKP was 416 (5-131), it is now 2514. :eek: I really do not believe you are dealing with cushings at all, but are struggling with a vet who does not know how to treat Hypothyroidism correctly.

I truly think if you can find a vet who can treat Arwen's Hypothroidism in the correct manner...ie; her dosage 2X a day, then I believe this roller coaster ride you and Arwen were on would slow down, altho I am no expert and this is JMO. :)

Hopefully the others will share their opinions as well.

Love and hugs,
Lori

[Nathalie]

Hi Suzie,

I am at work – so I have to keep this short ...


This thyroid test was taken while you administered 1mg of Soloxine in am.
If I am reading this correctly the desired therapeutic range is 37.4 to 72.5 nmol/L for a dog on Soloxine.
At 72.9 nmol that is just slightly above the therapeutic range. Obviously you can’t look at the numbers alone and Arwen may do better with a lower dose.

BUT, I would not put too much meaning into these numbers as Arwen was not pilled correctly and you did confirm that information with Dr. Jean Dodds.
Also, Arwen may have responded differently if the daily dose would have been split into am and pm dose, given away from food.

“Arwen has now had her Soloxine reduced, she has to take one and a half tablets a day (0.5mg) instead of two tablets at 0.5mg a day.”

IMO – unless you follow protocol when it comes to administering the Soloxine and stick with it for 4-6 weeks and then retest, you are not giving your dog a proper chance to improve clinically and get optimal therapeutic response.
Nathalie

[Bubbagump]

Hi ,

Arwen has to start her new dosage tomorrow,im going to give her half the dose at 6am then feed her at 8am .Then feed her at 4pm and then give her the second dose at 6 pm. I have to make appointment for 4 - 6wks for thyroid test and the vet will be informed about me splitting the dose and times ,and its the vets job to do the calculations given the changes that im making.We just have to wait and see how it all turns out.

Ok ,now we have the ball moving in the right direction for Arwen ,how about helping Bubba ?


Suz xx:D

[Nathalie]

Good for you!

I hate to be a stickler about this but the am and pm dose should be the same. Your vet asked you to cut down the Soloxine to a total daily dose of 0.75 mg …..
If I where you I would give 0.4 mg in am and pm = total daily dose of 0.8 mg. The 0.05 mg won’t make much of an overall difference but will add consistency/accuracy to your next test and helps get a nice curve.

Also, when it comes time for re-testing I would ask them to run a Free T4 as well as this is a more reliable test.

"vets job to do the calculations given the changes that im making'

There are no calculations that need to be made - the test result combined with Arwens symptoms or lack of will tell you whether or not an increase/decrease is needed or if the new dose is right on the ball.

Is Bubba’s vet the cooperative kind? ;)

Nathalie

[Bubbagump]

Hi Nathalie,

The vet said all the syptoms that Arwen is displaying is because of her Thyroid dose needing adjusted,which we are doing .Like i said im splitting the dose and administering the tabs without food.

I have a question. Does Arwens coat change when she is given too much Soloxine?

When she wasnt getting enough Soloxine her hair went brittle and sparse and a tail what we call (a rat tail) She sought heat sources because she was cold . Now if she is receiving too much why is her hair the way it is then?

The vet said the panting,hyperness,drinking loads of water and being hungry should all improve ,i understand this ,but its the hair condition that i dont understand .Could someone explain it please.

I asked for a full thyroid panel test,so i take it the test i had done wasnt a full panel thyroid one ?


Suz xx

[Nathalie]

Hi Nathalie,

The vet said all the syptoms that Arwen is displaying is because of her Thyroid dose needing adjusted,which we are doing .Like i said im splitting the dose and administering the tabs without food.

Call me anal ;) – but I just wanted to make sure that the am and pm dose are equal since you wrote that the total daily dose was reduced to one and a half tabs of 0.5 Soloxine and I can’t imagine how this could be split into 2 equal doses. My thinking on this was it would be easier and more accurate to get 0.4 mg tabs and pill 2x per day.

I have a question. Does Arwens coat change when she is given too much Soloxine?

When she wasnt getting enough Soloxine her hair went brittle and sparse and a tail what we call (a rat tail) She sought heat sources because she was cold . Now if she is receiving too much why is her hair the way it is then?

The vet said the panting,hyperness,drinking loads of water and being hungry should all improve ,i understand this ,but its the hair condition that i dont understand .Could someone explain it please.

I could not find coat issues listed specifically as a symptom of Hyperthyroidism but since Hyperthyroidism can affect all the organs is would make only sense that it can manifest itself among other things into a poor coat if it has been going on over an extended period of time.

Keep in mind that Arwens test result was only slightly above the therapeutic range so you can’t really rule out that the symptoms are not from ‘double’ dosing in am – your next test should be more meaningful.
Another thing to look at would be what you are feeding.

I asked for a full thyroid panel test,so i take it the test i had done wasnt a full panel thyroid one ?

Not what we would consider a full thyroid panel. Check the document Dr. Dodds emailed you it lists the min tests that should be included in a full panel.

Suz xx

You must be relieved that nothing in the test results points towards cushings.

Nathalie

[Bubbagump]

Hi Nathalie,

No your not anal lol,see my vet wasnt thinking of me splitting the dose ,but no its ok ,i have plenty tabs in all sizes that Arwen can take,so i have evened the dose out which wont cause any problems. Its a puzzle about her hair because her food is the same as its always been,her tablets at some point where working otherwise her condition of her coat wouldnt have been so good if they wasnt working.Yes maybe too much soloxine could have caused the change,something isnt right.Theres always been an issue about testing Arwen fully by the vet,so i will need to phone her tomorrow.If she wont do the full thyroid which is meant to be more reliable then i will take her to another clinic and pay for the test.Im not getting messed around anymore.


There was an issue about her T4 being low but Tsh ? ok they blamed it on steroids but did not investigate that result any further. She hasnt had steroids for years now and when they retested her they didnt feel the need for full thyroid to be done,surely the full thyroid test results could have the answers .



Suz xx

[Nathalie]

I think all you can do at this point is wait an see how Arwen does over the next few weeks and what the blood test result will tell you.

I am not surprised that her coat is not as nice as it could be - her thyroid treatment has been quite a mess up until now which does affect her body.

As for testing all I personnaly would ask for in your situation would be a Free T4 and perhaps a Basal T4. But it is the Free T4 that is a must.

"Its a puzzle about her hair because her food is the same as its always been"

Don't dismiss the power of food - health starts in the gut and if you been giving the same kibble over and over for a prolonged time you may see ill effects no matter what the name of the kibble is.

IMO - there is nothing better than a homemode fresh diet, that consists of human grade ingredients, is grain/soy free and has variety

If you must feed kibble - choose a high grade kibble and switch between different types to avoid food sensitivity.

It does not have to be all or nothing - you can feed kibble for breakfast and a nice cooked stew with sweet potatos and veggies for supper. How about some eggs or fish ...

Anyhow - I think you get the idea where I am coming from :) You may want to take a second look at what you are feeding.

Nathalie

[Nathalie]

Hey Suz - how about an update? :)

How is Arwen doing? Have you noticed any changes since you changed the Soloxine protocol?

Cheers,
Nathalie