Toby, 9 y/o Yorkie - From Trilostane to Lysodren [Archive] - Canine Cushing's Information and Support Forums

Harley PoMMom

03-12-2010, 10:47 PM

Hi Linda,

Welcome to you and your precious fella from me and my boy Harley. I am so sorry for the circumstances that brought you here but so glad that you found this forum with these amazing and knowledgeable people.

I was wondering if you could provide us with some more information about your boy so we can give you better feedback to any questions you might have. How much does your boy weigh? What dose of Vetoryl did the vet prescribe for him? Is the dosage going to be once a day or twice? What symptoms did your boy display that led you or your vet to test for cushings in the first place? Do you have copies of any of the tests? If you do, could you post the results here. Did your boy have a CBC and or Chemistry blood panel done? If so, could you post anything on there that is marked abnormal with the reference ranges and the units of measurements. Is your boy taking any herbs or supplements? Does he have any non-adrenal illnesses like diabetes or hypothyroidism? Did your vet give you prednisone?

I am sorry for all these questions, but the more we know about your furbaby, the better our advice will be. Hang in there Linda, you are not alone, we are here for you and your boy and we will help you in any way we can.

Cushings is a slow progressing disease so one has the time to get a proper diagnose. A proper diagnose is the key to a proper treatement plan. Both Trilostane/Vetoryl and Lysodren/Mitotane are life-saving drugs for our cush pups, but there is a protocol to follow when giving these drugs, and one has to follow that protocol.

Here are some links for you to read from our Resource Section, and if you have any questions, please do not hestitate to ask, ok.

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

Love and hugs,
Lori

Tobias

03-12-2010, 11:37 PM

Hi all: Wow! what great responses...I never thought about having the prednisone on hand--a safety net--I will surely ask the vet. To answer these very good questions: I do not have copies of any of the tests. But I am sure I could get them...but probably not until next week. I was given values over the phone but the numbers really meant nothing to me at the time I was so overwhelmed by the diagnosis. I would be happy to ask for them! As far as the bloodwork he had quite a bit...it was a long printout and the gist of it was it could indicate cushings when stacked up against the clinical picture...nothing really out of wack, some very minor elevations here and there but nothing alarming a/t the vet. Toby originally went in for evaluation of excess drinking (it has gradually increased to about 3 cups per day starting towards end of last summer) also constant food seeking also gradual. A lot of energy and very hyperactive--this is toning down now, I think....but he has always been hyper so it took me a while to identify he was overly so. ..he is just beginning to the get the pot belly. Hair is fine, regrowth is fine...I keep him in a terrier cut so I take him every 6 weeks and he needs the grooming at that time. No panting. Screening test was done for the urine first, indicated need for further testing. ACTH stim test was done and the results were strongly positive a/t the vet but again I do not have them. He asked for an Ultrasound which was done this morning and the vet who did that said the adrenals are definitely enlarged, both of them and the findings are absolutely consistent with pituitary dependent cushings. The vet today on the phone said it is really all pretty straightforward and he is ready to dispense the Vetoryl. Toby weighs just over 9 pounds--I think 9.6. I did read on this site about the UC Davis recommendations versus the manufacturer's recommendations and I was going to ask the vet for the lowest range to start--at 1 mg per kg that would be about 5 mg for a dog close to 10 pounds? I told the vet on the phone today I want to start SUPER low and work up. Does this sound about right? I see the smallest pill is 10 mg? and it is a capsule so I was wondering how it would be split. Again I thank you for your help. Many blessings to all Linda and Toby.

frijole

03-12-2010, 11:50 PM

Linda, Wow you are a quick study! :p Good going reading like you have. Absolutely smart to start low and work your way up. Dogs react differently and better safe. My understanding is that you are NOT to open up a capsule. There are companies that will compound the medicine so they can be available in smaller dosages. I'll let those that have done it speak to that.

You asked about the drug choices and really it is trilo or lysodren in 90% of the cases. They are equally effective but work in different ways. There are pros and cons to each. I can only speak to lysodren and I have been very happy with it.

It is written in protocols that prednisone should be prescribed for both trilo and lysodren users. The reason is that both drugs lower the cortisol levels to lessen the symptoms caused by excess cortisol. If the dogs get too much of either drug they go into a form of shock. In extreme cases they can die. The prednisone mimics cortisol and within a few hours they feel normal again. That is why this is important.

There is ton of this in reference material located here:
http://www.k9cushings.com/forum/forumdisplay.php?f=10

If you have any concerns please know that there is no rush to treat the cushings. So you have time to gather your facts and get up to speed before starting. It isn't life threatening in an immediate way. If untreated it can result in organ failure but it takes years... so take your time and make sure you are content with the overall plan. You will do fine. Kim

StarDeb55

03-13-2010, 12:19 AM

Linda, I can't really address much about trilostane usage but I did want to let you know that a lot of us use diamonback drugs, a vet compounding pharmacy. They can compound any dose of trilo you might need for your little guy. I use them as I have a Shih Tzu who weighs not quite 12 lbs., on lysodren, & there is no way I'm going to be able to cut those 500 mg. pills to get an accurate dose. I'm assuming you are in the US. so I know that Diamondback will ship anywhere in the country for a flat fee. They have terrific customer service.

http://www.diamondbackdrugs.com/

By the way, welcome to you & your little guy from me & Harley.

Debbie

Franklin'sMum

03-13-2010, 06:25 AM

Hi Linda and welcome to you and Toby,

You're doing really well so far, with the reading and learning :) Great job! The smallest dose of the branded trilostane is 30mg, so you may well be better off getting Toby's trilo compounded.

You've probably noticed, but this is an amazing group of people, very knowledgeable, caring and supportive. Welcome aboard!

Jane, Franklin and Bailey xxx
________
Whole foods gift cards (http://bestfreegiftcard.com/whole-foods-gift-cards/)

labblab

03-13-2010, 08:07 AM

Hi Linda,

Welcome from me, too! Nosy people that we are, we will be very glad once you are able to post Toby's actual test results :p ;). But from what you have described, it sounds as if his testing was conducted in a logical progression with results that support this diagnosis. So on to the treatment...

As has already been said, we have lots of members who are using Vetoryl (trilostane). When you have time to read through other threads, you'll find lots of companions in your journey! As you have already discovered, the 10 mg. capsule of Vetoryl is the size that has been approved most recently by the FDA. (previously, Jane is correct that 30 mg. had been the smallest size).

I see that you are already familiar with the two different protocols: Dechra and UC Davis, and that you are leaning towards the Davis dosing schedule. If, by chance, your vet is considering Dechra's recommendations, we are aware of a "modification" to their printed dosing chart that also lowers their starting dose. Through conversations with one of their U.S. technical reps, we have discovered that Dechra is recommending that all dogs be started at the lowest end of their published dosing range: at 1 mg. per pound. So in Tobias' case, they would recommend beginning at approx. 10 mg. If your or your vet have any interest in talking directly with Dechra with questions about Vetoryl, you can contact their rep., Dr. Allen, at their Overland Park, KS office: http://www.dechra-us.com/page/contact-us. Whichever protocol you and your vet decide upon, our general recommendation here is that dogs do seem to experience less side effects when they are started at lower doses and work upward if necessary, rather than vice versa.

Also, as Debbie has said, many of our members do rely upon Diamondback Drugs for compounded trilostane. If your vet feels comfortable with prescribing a compounded product, then you can get virtually any dosage strength prepared that you would wish. However, some vets prefer that their patients be treated with brandname Vetoryl. If that is the case with your vet and you need a dose smaller than 10 mg., then it may still be possible to identify a compounding pharmacy in your area that will take the 10 mg. Vetoryl capsules and "break them down" into smaller capsule units. Hopefully your vet can give you suggestions in this regard if he wants you to treat with brandname Vetoryl. You should never try to open and divide the capsules yourself!

Once again, welcome, and we look forward to hearing much more about your Toby.

Marianne

Tobias

03-13-2010, 11:46 AM

Wow! again I must say, what a group! I feel better already:) I am learning to navigate the site and it is pretty easy, even for a technoklutz like me....Thank you again for the community of concern. Here is what I am going to do, based on the gracious replies to my post and also because of studying all the posts on "Augie's" (Bulldog) thread. (Thank you Augie for your awesome capacity to bring out love and concern of all these lovely humans, and for the learning that has come to me because of your life journey....) Anyway... I am firstly going to wait another week, maybe two....I am not on the page where I can check the name of person who reminded me I do not have to start right away if I don't want to; and I am afraid if I go back I will lose my post here, but thank you for reminding me I have time! ITM I will get the values etc and post. Also even though it was a board certified (diplomate?) who did the ultrasound and concurred entirely with my own home vet's diagnosis, I will ask for the measurements etc of ultrasound and post that. I will continue to study on the site for the next 1-2 weeks, thoroughly familiarize myself with the navigation, etc. Reading about dear Augie's initial reaction to the trilostane I realize that my Toby will need my absolute focus and availability. Our Horsefield tortoise is coming out of hibernation today and will require a lot of monitoring, bathing, etc, until up and running--this is his most vulnerable time all year. Also, for Valetines day ( about 2 weeks prior to the vet's decision to do the cushing's work-up--my husband presented me with a gorgeous shih tzu puppy, black and white--the housetraining, time committment to a puppy, etc. is quite considerable. Needless to say we wouldn't have planned for all this to converge at once! I know my vet will understand and concur. Most significant, my 12.5 year old shih tzu, my spiritual teacher and guide, was euthanized December 18 with really advanced cancer. We had no clue--he was eating, guarding his home, playing, etc. and just a little "off" until it was way to late to do anything about it. Emotionally I am really close to the death of this other dog, still. I just cannot bring myself to give my Yorkie something that has the potential to down him so quickly. I do feel in a few weeks I will be more positive....my own mental attitude is a big part, I think, of how my dogs handle things. So does this sound okay to all, as far as waiting another week or so, studying, healing a little bit more from losing my Zorro (and I thank all of you, right now, for helping me to clarify this, even though it was never brought up until right now!. Many blessings to all. I must run the vacuum--it's my Toby's favorite game! He just doesn't understand why I release the horrible contraption from the tiny room I managed to confine it too last week. To him the light that shines on the floor as I vacuum is the glow of an evil monster, to be subdued at all costs with barking and chasing! He is such a part of my life....he makes a game of everything (even housework!)....I just need time with him as he is now for a few more weeks. Many blessings to all Linda and Toby

labblab

03-13-2010, 01:20 PM

Dear Linda,

I think your decision to give yourself some additional time is very, very reasonable. I am so sorry to hear about your loss of Zorro. And I am fascinated to learn more about your tortoise. And many welcomes, of course, to your new baby! With so many conflicting responsibilities and emotions, I think it makes perfect sense to take a bit more time out before launching into the commitments associated with treatment.

Just so you'll know, we reserve a special part of our forums for remembering and honoring those whom we have lost: "In Loving Memory." (http://www.k9cushings.com/forum/forumdisplay.php?f=8). If, by chance, you should wish to begin a thread there in honor of Zorro, we would feel privileged to read anything that you might care to share with us.

Please continue to ask any questions that come to mind. It is clear that Toby is in very good hands, and that you are a wonderful advocate for all of your companions...

Marianne

Harley PoMMom

03-13-2010, 01:55 PM

Wow! again I must say, what a group! I feel better already:) I am learning to navigate the site and it is pretty easy, even for a technoklutz like me....Thank you again for the community of concern.

If you do have any questions about how to navigate around the forum, please feel free to ask, there is also a "FAQ" on top of the page you can click on that will answer alot of your questions. Here is the link just incase I'm not making sense! http://www.k9cushings.com/forum/faq.php

Here is what I am going to do, based on the gracious replies to my post and also because of studying all the posts on "Augie's" (Bulldog) thread. (Thank you Augie for your awesome capacity to bring out love and concern of all these lovely humans, and for the learning that has come to me because of your life journey....)

I think that's great that you are reading other member's threads to gain knowledge, so I am including some others that use Trilostane for their pups. :)

The Corkster, updates
http://www.k9cushings.com/forum/showthread.php?t=392

Franklin, 4½ yo maltese, trilostane (is loss of pigment anything serious?)
http://www.k9cushings.com/forum/showthread.php?t=1327

Update on Kira (trilostane treatment)
http://www.k9cushings.com/forum/showthread.php?t=394&page=7

Mypuppy: Update on Princess (7 yr. old Lab on Trilostane)
http://www.k9cushings.com/forum/showthread.php?t=1324

Anyway... I am firstly going to wait another week, maybe two....I am not on the page where I can check the name of person who reminded me I do not have to start right away if I don't want to; and I am afraid if I go back I will lose my post here, but thank you for reminding me I have time!

My boy Harley was first dx'd for cushings in April 2009 by a LDDS test, he had the trademark symptoms and some of the results on his Chemistry lab report was why his vet tested him for cushings in the first place. That vet wanted to start treatment then with Trilostane, and thankfully I found this forum. After further testing it was revealed that my boy has elevations in all his intermediate/sex hormones as well as high cortisol. Trilostane is not the drug of choice for him because Trilostane elevates some of the intermediate/sex hormones. My boy is on Lysodren along with melatonin and flax hulls with lignans. This diagnostic phase took 4-5 months, but he was a bugger to figure out. :eek:

ITM I will get the values etc and post. Also even though it was a board certified (diplomate?) who did the ultrasound and concurred entirely with my own home vet's diagnosis, I will ask for the measurements etc of ultrasound and post that. I will continue to study on the site for the next 1-2 weeks, thoroughly familiarize myself with the navigation, etc. Reading about dear Augie's initial reaction to the trilostane I realize that my Toby will need my absolute focus and availability. Our Horsefield tortoise is coming out of hibernation today and will require a lot of monitoring, bathing, etc, until up and running--this is his most vulnerable time all year. Also, for Valetines day ( about 2 weeks prior to the vet's decision to do the cushing's work-up--my husband presented me with a gorgeous shih tzu puppy, black and white--the housetraining, time committment to a puppy, etc. is quite considerable. Needless to say we wouldn't have planned for all this to converge at once!

Horsefield tortoise! Shih tzu puppy! Oh my!!! and how we would love to see pics!

I know my vet will understand and concur. Most significant, my 12.5 year old shih tzu, my spiritual teacher and guide, was euthanized December 18 with really advanced cancer. We had no clue--he was eating, guarding his home, playing, etc. and just a little "off" until it was way to late to do anything about it. Emotionally I am really close to the death of this other dog, still.

Oh Linda, I am so sorry about your beloved Zorro, and my heart goes out to you at this time. You do need time to grieve for your best friend, please take that time, and know we are here for you.

I just cannot bring myself to give my Yorkie something that has the potential to down him so quickly. I do feel in a few weeks I will be more positive....my own mental attitude is a big part, I think, of how my dogs handle things.

Very, very true, they are so intune to us. They know if we are happy, sad, or mad, without us making a sound.

So does this sound okay to all, as far as waiting another week or so, studying, healing a little bit more from losing my Zorro (and I thank all of you, right now, for helping me to clarify this, even though it was never brought up until right now!.

Sounds like a plan to me, and remember we are here for you, ok.

Many blessings to all. I must run the vacuum--it's my Toby's favorite game! He just doesn't understand why I release the horrible contraption from the tiny room I managed to confine it too last week. To him the light that shines on the floor as I vacuum is the glow of an evil monster, to be subdued at all costs with barking and chasing! He is such a part of my life....he makes a game of everything (even housework!)....I just need time with him as he is now for a few more weeks. Many blessings to all Linda and Toby

Love and hugs,
Lori

haf549

03-13-2010, 02:34 PM

Hi Linda:

Welcome to you and your baby from Kira and myself. Great idea about giving yourself more time. Trilostane is really quite simple to use once you get the dosage right. Good about starting low too. Better a few extra stim tests than the worry of overdose. Another thing you might want to do is start measuring your baby's water intake. Once he starts the trilo, you'll be able to get a feel for how things are working out. You're in good hands here on this forum. It saved my sanity when Kira was diagnosed. She's now going on 1 1/2 years on trilostane and though she's slowing down (she's turning 13 in May) she's once again the dog a always know.

Heidi

frijole

03-13-2010, 02:41 PM

:o I'm the one that told you could wait... learned that firsthand. My first vet did testing for cushings and I went home thinking my dog was gonna die. Before the tests were in she was telling me about the drug we were gonna use etc. I found this find groups of people thank GOD.

The treatment this vet was recommending was not even close to what is recommended. I was torn. So I wrote up a page of questions to ask the vet so I could determine whether to trust the vet or this group on the internet. :D Uhm... these people won and I found a vet that had more experience. I'll never forget - they had the lysodren all packaged up and a huge bill waiting for me. I told the gal at the counter "I'll get back to you on those". Never looked back.

Toby will be just fine and you must tell us about all your other creatures! Kim

Tobias

03-13-2010, 05:29 PM

Hi to Kim, Heidi, Lori, Jenny, Jane and Marianne and all other helpful people! I will on Monday call my vet and announce my intent to delay for a week or so and to study to be a better partner for the vet ITM. I will ask for copies of all test results and post. Now I
thank you all for your validation of my plan for Toby’s Cushing diagnosis and treatment. Also thank you for your understanding about my Zorro’s passing and how that has affected me in terms of taking any risk with Toby at all. As all of you have been kind enough to encourage questions, as part of my initial Cushing’s education I have several! Firstly, is there a consensus about when treatment should begin? Do people usually start as soon as possible after the diagnosis is made, even if the symptoms are not particularly bothersome, or do people wait until the symptoms are more problematic. For instance; Toby is able to go all night without needing to go out. My husband is home all day and I am home all morning so Toby can go out whenever he wants. I do fill the water bowl more but I would willingly fill it 50+ times per day rather than give him medicine with the potential to do harm (although admittedly the potential to do great good, also). Right now his symptoms don’t seem to bother him or me that much; just that I worry about the damage that will happen to his organs from all the cortisone, day after day. Also I read the really serious side effects of trilostane are not at all dose related but entirely random. It really scares me that life threatening Addisonian reactions can occur, I have read, although in theory destruction of the adrenal cortex should not be possible. I am so flummoxed! Having the prednisone on hand is going to help with this, bc the minute I see undue lethargy, bloody diarrhea, complete lack of appetite, I give it, right? Then somewhere I read that with or without treatment the expected life span is +2-3 years from diagnosis. Yet my own vet said with treatment Cushing’s dogs can live a normal life span, in terms of number of years, as does seem true from the initial posts I have received from this list (thank you thank you thank you!) . Without doubt I want to do the best for Toby. But what is the best for Toby? To wait until the symptoms are more of an issue for either one of us (thus delaying the total time on such systemically challenging medications) or treat now to try to prevent the worsening of symptoms I see at this time? Also, about the initial dose—The UC Davis protocol recommends 1 mg/kg once daily. So if toby weighs 9.6 pounds or 4.35448 kg he would get 1 x 4.7 (say 5 kg) which would mean 5 mg to start—am I correct about this? Does anyone on the list dose their dog with such a small dose? Do I understand correctly that the diamonback(?) mentioned in the previous post would be able to do this? Will my vet likely go along with this (as it is not "brand name" Vetoryl, right??) I do like this UC-Davis protocol because it seems most conservative. Also as mentioned in a previous post, I would rather do a few extra stim tests than overdose. Thanking all for continued support. Linda and Toby. Once I get the hang of things I would love to post pics of everyone--I do see there is a good explanation in the FAQs...thank you all for your very warm welcome and sympathy for loss, for understanding. I, too, seem to be a "magnet for medically needy animals" (thank you for that laugh!) So far I have survived (or my sweet animal companions have) the pet food recall with IV hydration and hospitalization times 2), insulin requiring diabetes with my cocker (passed away in October of 2007 at age 15) liver shunt surgery for my middle shih tzu at age 6 months (age3 at this time and doing fantastic), and now Cushings for the Yorkie! It is really great to know I am not alone in all this. TC all and thanks again Linda and Toby

frijole

03-13-2010, 07:03 PM

Linda, You have been one busy lady reading I can tell. ;) I will not respond to the trilo questions because I use lysodren.

Re starting - It is wise to take time to confirm diagnosis is correct, get up to speed on what cushings is and how the drug works prior to dosing. Regarding waiting to treat - that is so hard to answer because we don't know what "symptoms aren't that bad" means. Most of us discovered cushings by accident. In my case it was from a blood panel prior to a dental cleaning. After I knew what the symptoms were I felt so horrible because she had that round tummy, appetite, and a few other symptoms for years! I suspect I am not alone.

The thing is that no one knows when an organ will fail and there isn't alot of warning with diabetes, heart failure etc. So it becomes a gamble. I think that once you start treatment you will change your opinion on the drug. At first I thought I was killing my dog with each dose. Once I saw improvement I realised that the drug was truly a miracle - and a very good thing.

Like any drug, including aspirin - too much is harmful. So look at it like that. The chances of addisons occuring are not great so long as you are giving a dose within recommended guidelines, keep a close eye on any changes that happen, and have an experienced vet on the case.

Where we see problems is when people don't take the time to learn and they hook up with a vet that isn't experienced. You are getting there and obviously are involved and will be a great advocate for Toby. So I am sure all will go smoothly.

Hope I answered a few questions you had. And ignore that rubbish about 2-3 yr life expectency after dx. Total baloney. I'm at almost 4 yrs and my dog is over 16. She won't live long but she won't die of cushings. We have people whose dogs have lived 8 yrs after treating. It is totally a treatable disease. So know that Toby can lead a very normal life. Its just that the drug will be given forever and you will do periodic testing to make sure cortisol is at desired levels.

Kim

StarDeb55

03-13-2010, 07:10 PM

Linda, my 1st boy, Barkley, was one of the 8 year survivors. He was successfully treated with lysodren for nearly 8 years, crossing the bridge at 15. As Kim said, the 1-2 year survival range that you see quoted, is HOGWASH!

Debbie

Harley PoMMom

03-13-2010, 07:20 PM

As all of you have been kind enough to encourage questions, as part of my initial Cushing’s education I have several!

Good for you!!

Firstly, is there a consensus about when treatment should begin? Do people usually start as soon as possible after the diagnosis is made, even if the symptoms are not particularly bothersome, or do people wait until the symptoms are more problematic.

Strong symptoms are a huge part of making the diagnosis, and treatment should never begin until a proper diagnosis is made. Even though none of us are vets, trust us on this, you have the time to get Toby a proper diagnosis for cushings.

Right now his symptoms don’t seem to bother him or me that much; just that I worry about the damage that will happen to his organs from all the cortisone, day after day.

It takes a long time for the excess cortisol to do the damage to the internal organs, but giving a non-cush pup Trilostane or Lysodren is lethal.

Also I read the really serious side effects of trilostane are not at all dose related but entirely random. It really scares me that life threatening Addisonian reactions can occur, I have read, although in theory destruction of the adrenal cortex should not be possible. I am so flummoxed!

The serious side effects are because the dose is too high for that particular pup and Trilostane can cause adrenal necrosis:This is from Dechra's U.S. Product Insert

ADVERSE REACTIONS:
The most common adverse reactions reported are poor/reduced appetite, vomiting, lethargy/dullness, diarrhea, and weakness. Occasionally, more serious reactions, including severe depression, hemorrhagic diarrhea, collapse, hypoadrenocortical crisis or adrenal necrosis/rupture may occur, and may result in death.

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

Having the prednisone on hand is going to help with this, bc the minute I see undue lethargy, bloody diarrhea, complete lack of appetite, I give it, right?

We have a saying here: Anything that would make you go "hmmm," meaning Toby's really just not acting himself.

Then somewhere I read that with or without treatment the expected life span is +2-3 years from diagnosis. Yet my own vet said with treatment Cushing’s dogs can live a normal life span, in terms of number of years, as does seem true from the initial posts I have received from this list (thank you thank you thank you!) .

Your vet is right on, a cush pup being treated and controlled can live out a normal life.

Without doubt I want to do the best for Toby. But what is the best for Toby? To wait until the symptoms are more of an issue for either one of us (thus delaying the total time on such systemically challenging medications) or treat now to try to prevent the worsening of symptoms I see at this time? Also, about the initial dose—The UC Davis protocol recommends 1 mg/kg once daily. So if toby weighs 9.6 pounds or 4.35448 kg he would get 1 x 4.7 (say 5 kg) which would mean 5 mg to start—am I correct about this?

Yes, this is correct for UC Davis protocol.

Does anyone on the list dose their dog with such a small dose? Do I understand correctly that the diamonback(?) mentioned in the previous post would be able to do this?

I would believe that they would be able to do this, you would have to check with them tho.

Will my vet likely go along with this (as it is not "brand name" Vetoryl, right??) I do like this UC-Davis protocol because it seems most conservative.

What some members do is find a happy medium between UC Davis and Dechra's. So if UC Davis's protocol for Toby is 5mg and Dechra's is 10mg, then you could go with 7mg...just a thought.

Also as mentioned in a previous post, I would rather do a few extra stim tests than overdose. Thanking all for continued support. Linda and Toby. Once I get the hang of things I would love to post pics of everyone--I do see there is a good explanation in the FAQs...thank you all for your very warm welcome and sympathy for loss, for understanding. I, too, seem to be a "magnet for medically needy animals" (thank you for that laugh!) So far I have survived (or my sweet animal companions have) the pet food recall with IV hydration and hospitalization times 2), insulin requiring diabetes with my cocker (passed away in October of 2007 at age 15) liver shunt surgery for my middle shih tzu at age 6 months (age3 at this time and doing fantastic), and now Cushings for the Yorkie! It is really great to know I am not alone in all this. TC all and thanks again Linda and Toby

Oh Linda, you are never alone, we are here for you always, keep the questions coming. I am sure the "others" will share their opinions as well.

Love and hugs,
Lori

Tobias

03-13-2010, 07:34 PM

OK Ladies! I needed that! Because I want my Toby around 5 years from now....I'm going to come out swinging! I live in a rural area and I do trust my vet--actually it is a practice. It is a very close professional relationship of greater than 20 years and 3 generations of dogs. He is the senior guy, the "go to" guy for the "doogie housers" coming up through the ranks. His "gut feelings" I have learned to really trust, and he will be conservative with me, I feel sure. He is always open to my suggestions and totally supports my advocacy for my dogs...so on Monday I will be honest and tell him I want to delay a week or so, and what I think I will want to do at that point (the extreme low range of anything published I can find). I will tell him as part of my studying I want the labs, etc.. You will hear from me then! I am glad my vet was right about the life span issue of them being able to live a long time. Hearing it from others is very gratifying. Thank you! Now I know I will not be putting him through all the testing, etc, for no gain...there will be a gain...we will fight to stay together as long as possible, he and I. Many blessings and more later. Linda and Toby

labblab

03-13-2010, 09:20 PM

Linda, your vet sounds like a "keeper," and I am so glad that you have him onboard ;). From what you have described re: Toby's testing progression, the diagnosis of PDH does sound appropriate (suspicious symptom pattern, "postive" UCCR, "positive" ACTH, and bilaterally enlarged adrenals). We remain anxious to see the actual numbers, but the testing process appears to be sound.

A couple of random thoughts from me... First, you've asked about the time frame for treatment. This is just my personal opinion, but given Toby's age, I believe I would begin treatment sooner rather than later. For an older dog nearing the end of his natural lifespan, I would be more inclined to base a treatment decision on the dog's comfort. If the overt symptoms do not seem to be bothering the dog to any great degree, then I would be more conservative and less worried about the cumulative organ damage occuring over time from a chronic disease process. But for a dog of Toby's age, I would be more concerned about halting the "hidden" damage caused by untreated Cushing's. It does sound as if Toby is exhibiting enough overt symptomology by which to judge the effectiveness of the treatment (excessive thirst and hunger). So if your vet thinks it's time to start treatment, I'd tend to agree.

I surely understand your anxiety about any potential harm from the medication. And you are right, it is true that there have been rare cases where dogs being treated with trilostane have suffered unexplained adrenal necrosis. But the far more common side effects do appear to be dose-related, and can be reversed by reducing or temporarily halting the treatment.

As to whether or not your vet will feel comfortable prescribing a compounded version of trilostane, that is a conversation that you must have together. But once again, even if he does not, it should still be possible for a local pharmacy to alter the dosage of Vetoryl capsules so as to accommodate your dosing needs.

Once again, I think you are being very wise in taking the time that you need to feel comfortable with your decisions. When I spoke earlier about treating sooner rather than later, I'm not referring to any immediate urgency. Once again, I am so glad that you have found us!

Marianne

StarDeb55

03-13-2010, 09:23 PM

unexplained renal necrosis

Marianne, I think you may have meant adrenal necrosis?

Debbie

labblab

03-13-2010, 09:24 PM

I did. Thanks for the "heads up," and I'll go back and edit my reply accordingly. ;)

Marianne

Franklin'sMum

03-14-2010, 07:18 AM

Thanks, Marianne for correcting me on the smallest dosages available
Jane and Franklin xx

Tobias

03-14-2010, 09:11 PM

StarDeb55

03-14-2010, 09:38 PM

Linda, unfortunately anipryl has a very limited benefit to treating cushing's. The lesion has to be in a specific location of the pituitary called the pars intermedia, I believe, for the drug to be effective. I believe that the percentage of pups who have a lesion in this location is only about 15%. The other problem with anipryl is that when the pup's body metabolizes the drug, it basically breaks down into something similar to "speed' in humans.

I know you want to be very cautious with Toby, but you really need to use the medication that gives Toby the best chance at living his full life span with a good quality of life.

Debbie

frijole

03-14-2010, 09:45 PM

recruiter

03-14-2010, 09:51 PM

Linda, my minature schnauzer Mackie and I are coming to the end of our first month on Vetoryl and I've been very pleased with the results. The side effects sheet is scary, and I gave some thought to not treating, but over the past five days, the old Mackie is back. I'm glad we started.

jrepac

03-14-2010, 10:11 PM

Hi all: this is me, Linda (Toby's mom) --I'm cramming a few more Cushings study sessions in as the weekend draws to a close. On one of the links under cushing resources on this site it was mentioned that Anipryl would be a good first try for pituitary dependent cushings, d/t the least side effects of any drugs. I think it was a vet hospital site in California???Anyway, it said many dogs do respond. Yet I thought I read somewhere else that it was considered fairly unreliable???? Does anyone have any experience with this drug? I may not get Toby's labs posted till next weekend--It's rush rush rush all week--but something tells me you all know what that's about! Tc and thanks for all the help and support.--Linda and Toby. (9 year old Yorkie)

Anipryl is a good drug to try under certain conditions....it has very few side effects and is low risk. If an older dog cannot tolerate other meds, it is an option. Or perhaps, the Cushings symptoms are mild; the anipryl may provide sufficient relief. The professional opinions on anipryl are very mixed; there are different POVs and different tests/trials out there on its efficacy. Essentially, if you try it and it works out great; if it doesn't you try something else.

I've been using it for my Aussie Terrier for 18 months now, in tandem with melatonin & lignans (her cortisol, plus other hormones are elevated). She will soon be 13; I was concerned w/side effects and her symptoms were mild, so I decided to try it as a first step. I have been very satisfied with the results. So, I may be one of the lucky ones.

But, if you are ready to start vetoryl, really no need to shift gears. Many people have been quite satisfied with that drug...there are many users here; a former colleague of mine also found great success with it.

Good luck

Jeff

Tobias

03-15-2010, 11:58 AM

Hi to all new friends and my Cushings panel of experts! After my crash course in Cushings this weekend (although it strikes me this will be ongoing study) I feel much more positive and ready to start the trilostane. I did, upon further study, read the problem with Anipryl and the results being dependent upon the location of the tumor. My vet called this morning and is in total accord with a 5 mg starting dose (which at Toby's wt of 4.6 kg/9.6 pounds is the lowest therapeutic range for the trilostane. It will be compounded by the compounding pharmacy our clinic uses. Karl (my vet) will have them gather all the results of all the tests so I can keep copies of them at home as reference for all issues (although there will certainly be more along the way). I am taking about a 2-3% risk with Toby's actually having an idiosyncratic, irreversible life-threatening addisonian reaction versus the possible very great benefits of treatment. Fortunately the vet, too, is proceeding with great caution..he has been working with me for the greater part of his professional life and knows how I react to things! He also seems to understand that Toby's diagnosis coming so soon after Zorro's euthanasia is not exactly "optimum" emotionally. I am going on ebay and buy a scale to really closely monitor Toby's weight (just like my tortoise, lol) to be vigilant about any weight loss esp at the beginning that would impact the dose. We will be using the UC Davis protocol for monitoring and interpreting results etc. So this is where we are, and thanks to all the support from this list, which will prove an invaluable resource as we start out with the medication/monitoring etc. I hope everyone has a great week! Many thanks, I cannot say it enough. Linda and Toby

labblab

03-15-2010, 12:13 PM

Linda, your gameplan sounds excellent! :)

And for what it's worth, here's some reassurance that even in those rare cases, dogs who DO experience irreversible Addison's can still lead happy, healthy lives as long as their condition is identified and treated appropriately. As luck would have it, one of our long-term members returned to us over the weekend to tell us how well her dog, Wally P, is doing. His Addisonian condition resulted from Lysodren treatment, but the management of Addison's is the same regardless of the cause. Here's a link to Wally P's thread:

http://www.k9cushings.com/forum/showthread.php?t=1861

The trick is to be vigilant in monitoring your dog's behavior and labwork. And from everything you've told us, there is absolutely no doubt in my mind that Toby is in excellent hands -- both yours and your vet's. ;)

Marianne

Tobias

03-15-2010, 12:49 PM

Hi Marianne and thank you. Just to be sure I understand about the labs and behavior checks. I want to start the med during the work week so I am dealing with Karl and not the on call. If I give the medicine at 9 a.m. (I work evenings 1:30 p.m. to 10:30 p.m. including drive time) is there a time frame within which side effects would be most likely? I think I read 4 hours somewhere? Should I take the first couple of days off work, do you think, to monitor? I could use personal time. Am I likely to see side effects the first day or as the med gets in his system and begins to decrease the cortisol--say within the first week? Also for monitoring what is the safest time frame for the first check after med initiation. UC Davis says one week--I was thinking 5 days (Mon and Friday as Karl is in the clinic both those days). Karl said the concept of prednisone for cushings is not something he had considered--Prednisone he gives to owners of Addisons dogs. I think he would if I insisted, if only for my own psychological benefit. Also is the consensus that a UCCR should be done on the morning of the ACTH test as described in the UC Davis protocol? This is what I am going to propose to Karl. Many thanks for the thread on the Addison's dog. I must start exercising the dogs now before going into work but I will surely be reading it tomorrow before work. With profound gratitude. Linda

labblab

03-15-2010, 01:43 PM

Linda, these are all great questions. I'll go ahead and give you some of my own thoughts. But I'm certain you'll hear from others, as well. And that is the great value of belonging to a message board like this -- so that you can gather a number of different perspectives!

Hi Marianne and thank you. Just to be sure I understand about the labs and behavior checks. I want to start the med during the work week so I am dealing with Karl and not the on call. If I give the medicine at 9 a.m. (I work evenings 1:30 p.m. to 10:30 p.m. including drive time) is there a time frame within which side effects would be most likely? I think I read 4 hours somewhere? Should I take the first couple of days off work, do you think, to monitor? I could use personal time.

It is true that trilostane's peak effectiveness is generally reached within the first few hours after administration, and thus, cortisol levels should be at their lowest during that time. It stands to reason that cortisol-related side effects would also be most likely then. However, every dog does metabolize the drug on an individual basis, so there can be variations.

Do be sure to give Toby his trilostane along with a meal, since that allows for peak absorption and also buffers the tummy. Since you are starting at such a conservative dose and will be home with him during those first hours after dosing, I don't know that you actually need to take time off from work -- unless you will otherwise feel really anxious about him. Is there anybody who could just stop in and briefly check on him once daily while you're gone during those first few days?

Am I likely to see side effects the first day or as the med gets in his system and begins to decrease the cortisol--say within the first week?

I haven't seen any research to back this up, but anecdotal reports from our members seem to point to side effects starting to pick up around the third day or so of dosing. Mind you -- many dogs don't experience any significant side effects at all. And by starting at a low dose as you are intending, you will really minimize the risk of side effects.

Also for monitoring what is the safest time frame for the first check after med initiation. UC Davis says one week--I was thinking 5 days (Mon and Friday as Karl is in the clinic both those days).

Unless Toby experiences worrisome problems, I would hold off for at least one week. Dechra recommends a time frame of 10-14 days. You want to allow enough time for Toby's system to "adjust" to the dose at which he is being tested, so that you will really get an accurate picture as to how the dose is suiting him. ACTH tests are not inexpensive, so you want to get maximum bang for your buck :o.

Karl said the concept of prednisone for cushings is not something he had considered--Prednisone he gives to owners of Addisons dogs. I think he would if I insisted, if only for my own psychological benefit.

We do think it is wise for every owner to keep prednisone on hand, regardless of whether they are treating with Lysodren or trilostane. Many vets do not think of prednisone as being as necessary for "trilostane dogs," because the effect of the drug is theoretically so short-lived. The notion is that if a dog is exhibiting an worrisome side effect, you just discontinue the trilostane and allow the dog's system to normalize. However, our experience here has been that every owner should have prednisone available, so that if their dog is acting visibly "off," they can have an immediate aid at hand should they need it.

Also is the consensus that a UCCR should be done on the morning of the ACTH test as described in the UC Davis protocol? This is what I am going to propose to Karl.

It is not that common for vets to routinely perform a UCCR on the day of testing. I personally would not "push" for a UCCR unless I was seeing a rebound of late-day symptoms in my dog even after his monitoring ACTH indicated that his morning cortisol was within the desired therapeutic zone. At that point, I would want to consider shifting to twice-daily dosing, and the UCCR would be a tool to use in making that decision.

DO ask that Toby's electrolytes be checked along with every ACTH, however. This is standard protocol with both Dechra and UC Davis. Also, you may or may not want to stick with Davis' ACTH testing time frame of 2-3 hours post-dosing. Dechra's protocol advises a testing window of 4-6 hours post-dosing, and that is the time frame that is more commonly followed by members here and worldwide. If you do decide to consult Dechra's monitoring guidelines for help with dosing adjustments, their recommendations will be most meaningful if Toby is tested within the 4-6 hour time frame. However, if you do decide that you prefer to follow Davis' protocol, then just make sure that every ACTH is performed within that same time frame, so that you are comparing apples-to-apples with each test.

Many thanks for the thread on the Addison's dog. I must start exercising the dogs now before going into work but I will surely be reading it tomorrow before work. With profound gratitude. Linda

Linda, please keep on asking your questions. They are excellent ones!

Marianne

haf549

03-15-2010, 03:05 PM

Linda;

Karl said the concept of prednisone for cushings is not something he had considered--Prednisone he gives to owners of Addisons dogs. I think he would if I insisted, if only for my own psychological benefit.

I just want to comment on your statement regarding trilostane. Kira gets trilostane and at the beginning of her dosing, I needed to use the predisone 3 times. That said, I think all those times it was just panic on my part, and not really a crisis with the trilostane, but I'm glad I had it on hand, just for my own peace of mind. All 3 times it was because of irregular breathing and as it turned out, that was due to a respiratory infection. Each time I only had to give Kira 1 tablet and she perked right up again within a couple of hours. Of course this always happened at night (again why I think it was over-reaction on my part) but I took her in the next day to have her checked out and I discontinued the trilostane for a couple of days. She was on a pretty high dosage at the start (120mg for an 80lb dog) and that is why I am now a big supporter of starting low and working up. Kira is on 40mg twice a day since January 2009 and things have been running smoothly since then.

Heidi

Tobias

03-16-2010, 12:44 AM

Hi Heidi: Thank you for that reassurance on the prednisone; after reading your post I will really press him on that; I have to be really prepared mentally for this and having the prednisone will make me feel more in control. Actually I am more the type that would rush him to the vet but there might always be that issue on a weekend morning, holiday, etc., that it would really come in handy.TC and thanks again Linda

haf549

03-16-2010, 09:29 AM

It really does provide that peace of mind you're talking about and these issues always seem to happen in the middle of the night. Or may-be we're just more attuned to something being off in the middle of the night.

Take care and good luck with the trilo.

Heidi

labblab

03-16-2010, 09:53 AM

Hi again, Linda.

I just wanted to come back and add a couple of links to "flesh out" some of the info that I posted to you in my reply yesterday afternoon. Even though you are proceeding with the UC Davis protocol, I'm thinking it will be helpful for you to have the chance to review some of Dechra's product info, as well. There is nothing wrong with combining the "best of both worlds," after all. ;)

You may have viewed these links already, but if not, I think they both can be very helpful. The first is the U.S. Product Information sheet for Vetoryl. And the second is Dechra's Treatment and Monitoring Flowchart.

U.S. Product Information (http://www.dechra-us.com/File/prod_vetyrol.pdf)
Treatment and Monitoring Flowchart (http://www.dechra-us.com/File/vetoryl_Treatment_and_Monitoring_Flowchart.pdf)

As I mentioned yesterday, you'll see that Dechra (as well as UC Davis) stresses the importance of having electrolytes checked along with each ACTH. You'll also get a better idea as to the specific side effects to watch out for, and also what actions to take in the event that you see anything worrisome. You'll also get a sense of Dechra's recommended testing "milestones" as you proceed in time.

Hope all this additional info will help you to feel well-armed when you are ready to launch into treatment with Toby! And if there is anything that I said yesterday that has left you feeling even more confused, don't hesitate to ask for clarification or for additional feedback from others.

Marianne

BestBuddy

03-16-2010, 06:51 PM

Hi Linda,

I just wanted to comment on the prednisone. I wasn't given any when Buddy started Trilo because at the time the specialist didn't think I needed it. As it happened Buddy had a serious crash with low cortisol and we rushed to the local vet who didn't know what to do. It was a nerve wracking few hours, on a Saturday of course, and it was only that I knew pred could help that I begged the vet to give him some. The vet tried to contact the specialist and couldn't get hold of him so finally gave him the injection of dex, just to shut me up I think.

The specialist gave us some pred the next Monday but luckily we never had to use it. It was just our safety net and gave me a bit more peace of mind.

Please don't think these sort of crashes happen often because Buddy had many issues going on and was a bit of a complicated case. I just believe if we had the pred at home that morning I would have given him some and we wouldn't have had the awful hours waiting.

Jenny

Tobias

03-17-2010, 12:18 AM

Hi all: I am going to put my case to the vet really strongly about the prednisone after reading these posts. On reading the Vetroyl protocol flow sheet included in a link from a previous post I see under the right hand side of the chart if there are symptoms of hypoadrenocorticism to evaluate the dog, do a stim test and then if the dog is determined by the labwork to be in this state, then administer prednisone. From reading these posts that would be "Plan A"--work week, full clinic staff etc." Plan B (weekends, late night etc) is give the prednisone myself. I have cardiac issues myself--I need the security on hand. I will be posting the lab work which Karl immediately sent out--there is quite a bit ....is it ok to post stim test results, urine results and the abnormals on the rest (blood count and serum profiles) Ultrasound showed bilateral enlargement of the adrenals consistent with pituitary dependent cushings. Thanks I am in quite the rush--this is my quiet time with my ragdoll cat upstairs away from the new puppy--TC and many blessings to all Linda and Toby

StarDeb55

03-17-2010, 12:25 AM

Linda, if you have easy access to emergency vet care, you might not need to administer the pred in an emergency, but there is the old saying, "better safe than sorry". A couple of other things about pred usage; a rescue dose is very small, .25 mg/kg body weight, & pred will read as cortisol on any stim done within 24 hours after administration. Pred, also, will act very quickly with the pup showing signs of improvement in about an hour. If you do have easy access to ER vet care, they can give any injection of dexamethasone which will act to replace the cortisol, but will not read as a false positive on any stim, if one needs to be done. Always remember that it is just as important to have the electrolytes checked on a pup who has a suspected low cortisol emergency.

Debbie

Tobias

03-17-2010, 11:49 AM

Hi all: Here are Toby's labs: Stim test: Pre ACTH: 7.51 ug/dl Ref 1.8-4. Post ACTH 47.3. ref 6-16. Creatinine for UCCR: 33.6 (ref not established) . UCCR: 17.6 Ref 1.2-5) CBC with diff: 57.5% Hemoglobin 20.4. Platelets 550. Electrolytes and chemistry profile: Phosophorous 6.9 mg/dl Alk phos 265 U/L. GGT:24 U/L. Cholesterol 381 mg/dl. Sodium 163mmol/L. None of the other values were low; all the rest were within normal limits. Upon review of these does the Vetroyl seem safe for toby? Also I do see the need to repeat the electrolytes very soon after initiation to verify that the Vetoryl is not making matters worse with the liver--although Karl did not seem unduly concerned about these moderate elevations in terms of giving the med. As mentioned earlier the ultrasound done by a Board certified diplomate confirmed bilaterally enlarged adrenals. Once I have given the Vetoryl for a while are the liver enzymes likely to return to normal? That is, by giving the Vetroyl is the chemistry corrected? Also I was wondering, as far as giving the prednisone rescue dose--if the dog is showing signs of corticosteroid withdrawal (lethargy, anorexia, stiff gait, fever) are there any "tricks" for administering the oral dose? Also, say we gave the prednisone on a Sunday, for instance, the electrolyte imbalances (hyperkalemia?) that could accompany the hypoadrenocorticism also have to be addressed, according to the chart, possibly with IV 9% sodium chloride. So is the plan then just to get the prednisone into the system and take the dog in for the stim test, IVs etc the next day? Also, when taking the dog's temperature at home can I use a regular rectal human thermometer or is there a less stressful way? Thanks to all (Toby really thanks you too..woof!) Linda

labblab

03-17-2010, 12:10 PM

OK, Linda. Here's some more thoughts from me.

Hi all: Here are Toby's labs: Stim test: Pre ACTH: 7.51 ug/dl Ref 1.8-4. Post ACTH 47.3. ref 6-16. Creatinine for UCCR: 33.6 (ref not established) . UCCR: 17.6 Ref 1.2-5) CBC with diff: 57.5% Hemoglobin 20.4. Platelets 550. Electrolytes and chemistry profile: Phosophorous 6.9 mg/dl Alk phos 265 U/L. GGT:24 U/L. Cholesterol 381 mg/dl. Sodium 163mmol/L. None of the other values were low; all the rest were within normal limits. Upon review of these does the Vetroyl seem safe for toby?

I think the test results you have posted are indeed consistent with Cushing's. Taken in conjunction with the ultrasound which showed bilaterally enlarged adrenals, if Toby were my dog, I would proceed with treatment.

Also I do see the need to repeat the electrolytes very soon after initiation to verify that the Vetoryl is not making matters worse with the liver--although Karl did not seem unduly concerned about these moderate elevations in terms of giving the med.

The electrolyte checks are not to monitor liver health, per se. Rather, they are to insure that Toby's cortisol and aldosterone levels are not dropping so low as to alter the balance of his blood chemistries. That is why they are to be performed in conjunction with every stim test.

As mentioned earlier the ultrasound done by a Board certified diplomate confirmed bilaterally enlarged adrenals. Once I have given the Vetoryl for a while are the liver enzymes likely to return to normal? That is, by giving the Vetroyl is the chemistry corrected?

Sometimes the liver values normalize; sometimes they do not. But minor elevations should not be a big concern, even if they persist.

Also I was wondering, as far as giving the prednisone rescue dose--if the dog is showing signs of corticosteroid withdrawal (lethargy, anorexia, stiff gait, fever) are there any "tricks" for administering the oral dose? Also, say we gave the prednisone on a Sunday, for instance, the electrolyte imbalances (hyperkalemia?) that could accompany the hypoadrenocorticism also have to be addressed, according to the chart, possibly with IV 9% sodium chloride. So is the plan then just to get the prednisone into the system and take the dog in for the stim test, IVs etc the next day?

Linda, given the low dosage with which you plan to start Toby, it is really unlikely that you will need to give him prednisone at all, even orally. And it is far more unlikely that he would suffer a crash sufficient to require IV support. If he ends up with some mild signs of corticosteroid withdrawal, your first approach may be simply to hold his trilostane dose for a day or so. If you do decide he needs some prednisone, say on a weekend, you will need to wait for at least a day before performing the stim test because the results will be skewed by the prednisone in his system.

Also, when taking the dog's temperature at home can I use a regular rectal human thermometer or is there a less stressful way?

I'm afraid I can't be any help at all in that regard. I've never taken any of my pups' temperatures at home...:o

Thanks to all (Toby really thanks you too..woof!) Linda

Linda, I think you and Toby are going to do just fine!

Marianne

StarDeb55

03-17-2010, 12:36 PM

Linda, to expand on what electrolytes are they include sodium, potassium, & chloride. The most important being sodium & potassium. These 2 are what helps control how well muscles function, & also the fluid balance within body tissue vs. the blood stream. The most important is the muscle function as this includes how well the heart is functioning. When using either of the 2 cushing's meds, you are not only lowering the cortisol but you are also lowering the other 5 associated hormones produced in the adrenal glands, one of which is aldosterone. Aldosterone is the hormone that controls the sodium/potassium levels within the body. When a low cortisol emergency is severe enough, the aldosterone may also be affected which in turn can have serious affects on sodium/potassium levels. I will say that a low cortisol emergency has to be fairly severe, I believe, before the aldosterone is affected. This is why Toby's electrolytes need to be checked whenever a stim is done, after he starts the trilo.

Liver function is completely separate from the above. There are 3 tests which are usually looked in conjunction with Cushing's to get an idea of how the liver has been affected, alk phos, ALT, & cholesterol. Liver function tests are elevated with Cushing's because the liver is having to work overtime to process the excess cortisol that the adrenals are producing. With treatment & the lowering of the cortisol, the hope is that the liver function may at least stabilize, if not show some improvement. There is no guarantee that treatment will ever get these liver values totally back to normal. There are several liver support supplements that a lot of members in this forum use with their pups including milk thistle, vitamin E, & I think the 3rd is Sam-E, but I don't remember for sure on the 3rd. Harley is given milk thistle daily. To use Harley as an example, he has been treated for 2 years now for his Cushing's along with the liver support supplements. His ALT & alk phos have shown slow but steady improvement in these 2 years, perhaps in the neighborhood of a 20% decrease, but his liver function tests have never returned to normal. I don't expect they ever will, but I am satisfied with the steady improvement.

I agree with Marianne that if you suspect that Toby may be showing the initial signs of a low cortisol problem, simply hold his trilo for 24-48 hours. He should perk up fairly quickly as trilo stays in the system for something like 12 hours only. Of course, please notify your vet that Toby is not feeling well, & you are stopping his trilo for a day or two. If he doesn't improve fairly quickly, then by all means get him to your vet or an ER clinic. If a low cortisol emergency is severe enough, IV fluid support may be required to make sure that the electrolytes are ok, & this would not be something that could wait overnight to be addressed.

Hope this helps.

debbie

Tobias

03-17-2010, 12:53 PM

Wow! you guys really have your act together. I have run off copies of both emails to study at work in my spare time--Thanks forever! I am planning on one more week of study after this week. Tortoise is coming round quite well after hibernation this year, etc...he should be out of his critical period by then for sure. TC...I'm sure I will be posting as questions arise. Since we do have 24 hour back up at the clinic, I guess, and since the dose we are starting with is so low, I suss it will be okay to not worry about the prednisone, as I would really want the lytes checked if there are any questions at all; this would be more in touch with the flowsheet from manufacturer and probably that is why Karl is more comfortable doing things that way; I do understand that, as the coverage is available 24/7 if I should require (although its gonna cost me lol) Blessings to all Linda and Toby

labblab

03-17-2010, 12:55 PM

As usual, Debbie has done a great job of explaining more about the meaning and significance of these lab tests. One additional note about the electrolytes and the importance of monitoring them alongside the ACTH tests. Per Dechra's Product Insert link that I gave you previously, trilostane should be temporarily discontinued either if the ACTH is too low OR if electrolyte abnormalities are exhibited:

If the ACTH stimulation test is <1.45 μg/dL (<40 nmol/L) and/or if electrolyte imbalances characteristic of hypoadrenocorticism (hyperkalemia and hyponatremia) are found, VETORYL Capsules should be temporarily discontinued until recurrence of clinical signs consistent with hyperadrenocorticism and test results return to normal (1.45-9.1 μg/dL or 40-250 nmol/L). VETORYL Capsules may then be re-introduced at a lower dose.

Marianne

Tobias

03-18-2010, 12:01 PM

Hi: Yes the lytes will be done with the stim test as I do understand thanks to the explanation. When the cortisol is lowered so is the aldosterone. The aldosterone will affect the sodium and pottasium levels which if allowed to fall outside of normal limits could cause muscle (heart) and fluid distribution issues. So even if the stim test is normal the lytes must also be normal or the medicine should be stopped until signs of Cushings resume. About the liver supplements. I have a liver supplement by VetriScience that includes milk thistle among other liver supports. Does anyone have experience with this? Vetri Science products are used by a Holistic vet I consult with from time to time in conjunction with my "mainstream" vets...that is how I learned about them. Would this supplement be compatible with the Vetoryl? Toby also gets Glycoflex III for his arthritis. Also is weight loss common with cushings? I have read about weight gain but not weight loss. Toby seems to be losing weight and I can feel his ribs but I'm not sure if the pot belly is getting worse and the weight is shifting to his belly from his rib cage area? When getting belly rubs his belly looks quite big! Yet his liver was not enlarged on the ultrasound. Has anyone with a cushing's dog experienced this? He has had a very thorough physical work up including ultrasound and nothing indicates any underlying illness. thank you Linda

StarDeb55

03-18-2010, 12:19 PM

You will need to discuss with your vets any supplement usage. We can simply make suggestions as to things to take a look at with your vets. The pot belly is usually due to the redistribution of fat, along with the muscle wasting associated with Cushing's. Lack of appetite is unusual in a cushpup, but not unheard of as not all of our babies have "read the book" about the symptoms they are supposed to have. My Harley is one of the pups who has a poor appetite when his cortisol is too high, his appetite definitely improves when we get his cortisol down to a more acceptable level.

Debbie

labblab

03-18-2010, 12:26 PM

Linda, my Cushpup was one of those who "didn't read the book" as far as weight goes :o. Even though he had the classic Cushing's ravenous appetite prior to diagnosis, he was losing weight (and he did not develop a pot belly). Once started on trilostane, his weight began to rebound back to a normal level. In retrospect, I can only figure that his weight loss stemmed from the fact that even though his metabolism was altered by his surging cortisol, he never was allowed any extra treats or access to extra food. His diagnostic ACTH post-stim result was about as high as Toby's, if I remember correctly -- perhaps even higher.

We've had a few other dogs here who also lost weight prior to diagnosis and treatment.

Marianne

Tobias

03-18-2010, 02:31 PM

Great! thank you for letting me know about the other dogs that seemed to be losing weight in spite of ravenous appetites bc that does describe toby. I have just increased his feeding amount slightly. I want to be really careful with undue wt gain bc of the stress on joints, etc...just have to find that happy medium. I am still waiting for the med to arrive from the compounding pharmacy. I will check with the vet about the Vetri Science supplements. Thanks again and with much gratitude and great respect for your advice. Linda and Toby

jrepac

03-18-2010, 06:13 PM

loss of appetite is unusual, but possible, with many of the cushings treatments...I would not worry too much; just keep an eye on things.

I went thru a few months when my Mandy suddenly was eating a lot less...but, that did not last....now she is back to her "munchy" self

Tobias

03-23-2010, 02:34 PM

Hi: Just wanted to make sure my Cushings angels are still fluttering about the computer--I took toby today for his final vet visit before starting medication on Monday, March 29 at 9:00 a.m. I made a copy of the UC Davis outline and also the Vetoryl chart--we disscussed how we would cover any potential problem that would arrive. I have told them I will be expecting the manufacturers recommendations for monitoring from any vet that might deal with Toby if his regular vet is off. I told my vet of the need for the lyte checks with the stim test and why. He did give me 10 rescue doses of prednisone for any emergencies bc he felt after talking to me I totally understood how this drug would work, necessary monitoring, etc. WE disscussed the reasons I would give it, etc. I did tell my vet of all I had learned on this list and he said I know more about Cushings than many vet grad students! That's when I told him of K9 cushings. So thanks to all. Toby is beginning to show the effects of fat redistribution but actual wt has not changed for one month and is at just under 9 pounds. Toby will be starting at 5 mg. I will post Monday a.m.---I am excited to help toby but also nervous!. Thanks to all. Linda

frijole

03-23-2010, 02:50 PM

Linda - fantastic update! You are a great pupil. Toby is in great hand so all will go well... meanwhile I was laughing so hard at this:

"Just wanted to make sure my Cushings angels are still fluttering about the computer" :D

Oh the visual. We are glad to be here for everyone as angels helped us too. Keep us posted! Kim

lulusmom

03-23-2010, 03:13 PM

Hi Linda,

You are a quick study and it sounds like you have given your vet adequate instructions on how things are going to go down. :D I love it!!! Honestly, I am glad that your vet appreciates the fact that you took the time to learn and understand what is happening to Toby and how his medication works. You are way ahead of the curve at this point and Toby is one lucky guy to have such a great advocate. You go, girl!

Glynda

labblab

03-23-2010, 03:16 PM

Great job, Linda! We'll be flapping our angel wings like crazy come Monday morning...;) :p :)

Seriously, I know you and Toby will do just fine. Try to have as relaxed a weekend as possible.

Marianne

Tobias

03-24-2010, 12:02 AM

Just a quick note as I am really tired after work. It means so much to me to know I have such incredible back up, thanks again to all of you and I will be posting monday morning after the deed is done....Linda and Toby

labblab

03-29-2010, 08:19 AM

Linda, good luck to you and Toby today as you begin his trilostane!!!

We'll be awaiting updates...

Marianne

Tobias

03-29-2010, 11:04 AM

Hi to all and thanks for the good wishes! My little guy had his first dose of trilostane at 9:12 this morning. It is now 9:52. He is resting comfortably right next to me on the computer desk at this time....this is our one-on-one time. I type away and talk to him as my special boy....He is not even a foot away and at the same level as the keyboard. Yesterday he was so hungry he grabbed my toast when I turned away for a minute--this is the first time ever he has done something like this--I think the whole being hungry/ hyper thing has really been more difficult for him and I knew it was definitely time to start treatment today. He didn't jump up and bark at the recycling guy like usual this morning but is definitely alert and breathing normally with his eyes open. When dog spends their entire past 6-9 months "reved up" on cortisol is there a tendency just to go back to normal level of activity which might in fact seem abnormal to the guardian because before the dog was in a "hyper" state? Thank you all for your support. Honestly I do not think I could have done this on my own; I am in uncharted waters as far as my personal experience with Cushings--great to be with a crew who "knows these waters..." Blessings to all Linda and Toby

lulusmom

03-29-2010, 01:26 PM

Hi Linda,

Trilostane is a really fast acting drug and cortisol can drop drastically in the first day or two. I just listened to a lecture given by a well respected expert on cushing's and he mentioned that studies showed that Trilostane can drop cortisol dramatically within 20 minutes of a dose. Because cortisol can drop so rapidly, some dogs feel pretty yucky due to cortisol withdrawal. This is more likely to happen at larger doses and since you've opted to start low, chances are that Toby may not experience this problem. A lot of pet owners report improvements in the first week so let us know when you start to notice any difference in symptoms.

Keep up the excellent work!!!

Glynda

Tobias

03-29-2010, 01:37 PM

Hi and thank you: It is now 12:31 p.m.and I have noticed no symptoms of withdrawal whatsoever. He may be drinking slightly less. But just slightly. Very slightly. Playtime today quite vigorous and nothing different. Appetite still excellent. We are all walking around on egg shells, rearranging schedules, etc. This is the time at which the medicine would be starting to peak, right? I will be leaving for work at 1:30 and hubby will be checking on him after that as he works at home. Fingers crossed. I think I will be edgy until day 3 or 4 although I know things can change well into treatment, it is so nerve wracking. About posting--I for sure will! Will just keep communicating regularly as it is helping me to feel more in control and positive about the experience--good for Toby when I am feeling strong. TC and blessings to all Linda and Toby

lulusmom

03-29-2010, 01:56 PM

Feeling edgy the first couple of days is normal but honestly, I would be a lot edgier if Toby were on a higher dose. A good number of dogs that start on doses much higher than Toby do require an increased dose within the first 30 days so that may help ease your edginess a bit.

I have the worst memory but I think we either started my Lulu on 20mg but we may have started at 30mg and she weighed less than 5 lbs. That was at a time I wasn't aware of the UC Davis protocol so I'm glad I was ignorant; otherwise, I would have been a total basketcase. Lulu stayed at 30mg for almost two years.

Glynda

littleone1

03-29-2010, 03:07 PM

Hi Linda,

I was also on edge when Corky started taking his Trilostane. He was fine after the first dose. After the second dose, he did seem to be much quieter. I called his specialist and she told me to see how he was the next morning before I gave him his next dosage. He was fine. The effect had been similar to being on a high and coming down from it, as his cortisol level had dropped. After that there were no other effects. I know this can be very stressful.

I hope everything goes well with Toby's treatment.

Terri

Tobias

03-30-2010, 11:26 AM

Hi all: Toby received his 2nd dose of trilostane at 9:22 this morning. It is now 10:13. Again he seems perfectly ok. But I do think I see a slight decrease in drinking--by about 1/8 to 1/4--I monitor his drinking quite closely. I usually have to fill the kitchen bowl upon coming home at night (He has a "back up bowl" in the living room) Last night his kitchen bowl still had some water in it when I got home. Also the urgency for treats last night when I got home from work seemed slightly less intense.. . he did not "paw" at my feet when I was in the kitchen as usual (his way of begging) but he did readily accept treats when offered. These are very subtle changes...so subtle that I could be imagining them. Thanking all who have taken the time to read and respond to the posts with such concern; it is such a loving thing you are all doing, for animals and people. I will post daily and more if necessary! Linda and Toby

labblab

03-30-2010, 12:42 PM

Linda, what a good report! And "subtle" changes sound excellent to me. Gradually increasing improvement without any negative side effects is hard to beat...;)

Marianne

mypuppy

03-30-2010, 08:00 PM

Hi there Linda,
Welcome to you and your little Toby. With all that is going on for you at the present moment and so much info. to digest, I am not sure if had a chance to go on my thread. Nevertheless, I will summarize my story for you. My Princess (7 year old chocolate lab) was diagnosed with PDH (pituitary dependent cushings), in October '09. As you, I was completely scared to death of the treatment with trilostane. In fact, her gp, who was not Cushings knowledgable in the least told me it was fatal. At that point, I contemplated not treating my pup at all, until I started doing some research and joined this wonderful forum, and well, these great, experienced, caring individuals sustained me and my precious Princess and lead me every step of the way to date. Princess initially started at 2 (60mg) pills once a day, and at her 14 day stim we learned it was too high of a dose for her, so we stopped the trilo. I am happy to report she has now been in remission for almost 5 months now, is symptom free, is energetic, engaging and happy. I am so glad you chose to start your Toby on the lower dose, and glad to hear you are seeing instant results the way I did when Princess began her treatment. Please know that I wish you well and even maybe the same outcome I had with Princess's treatment. It's such a great feeling to have our pups back even knowing they have this condition. And so, I wish your Toby the very same. Please stay on board and learn as much as you can, ask a lot of questions. We have so many educated people here with this condition. For now, I am sending you my best regards and lots of belly rubs to your Toby. Tight hugs. xo luv, Jeanette

Tobias

03-31-2010, 01:12 AM

Why thank you for that very nice post; I feel your goodwill and I am so grateful, as for all the stellar advice from, as you say, these lovely caring people. I am checking in after work so must sign off quickly and get some sleep. Toby had another good day of eating usual amounts but drinking a little less and perhaps showing a little more withdrawal at this late hour (it is 12:02 a.m. and he gets medicine at 9 a.m.) He does seem quieter tonight but is 100% alert and accepting of treats I give when I get home from my shift at the hospital. Today I set up the appointment for Toby's stim test, lytes, etc for day 11 of therapy as day 10 would be the day Karl, his vet is at a satellite clinic. Manufacturers recs are for 10 to 14 days but both Karl and I want to be very conservative. I do see fewer trips outside tonight. I do sense about him that he feels different in some way but all physical functions of appetite, interest in exercise, voiding and bowels seem at baseline. It is nerve wracking to anticipate a possible "crash" but I do feel after reading the wise opinions of the many who have been thoughtful enough to post that at this very low dose perhaps we will not see this. Many blesssings to all and good night from New York, USA Linda and Toby

mypuppy

03-31-2010, 01:14 PM

Thanks Linda. Everyone here has your Toby's best interest at heart and we willingly and wholeheartedly offer you our knowledge and our love. We are very happy to help in any possible way. Linda, I understand your feelings of uncertainty with the treatment, but with your close supervision and very open lines of communication with your IMS this process should go smoothly for both of you. Do not fret Linda, remain positive, watch little Toby closely and you will get there just like the rest of us. Looking forward to reading more on his progress, and I can only hope and pray it will all be good. Take care of you and Toby. Luv ya bunches. xo Jeanette

Casey's Mom

04-01-2010, 12:53 AM

Wonderful news Linda and Toby. You are keeping a very close eye on Toby and noticing all of the subtle changes :o:o Keep posting and asking questions - everyone is here to help.

Love and hugs,

Tobias

04-01-2010, 12:58 AM

Hi again: End of day III on trilostane. Toby was a lot more active today; I see now that on day I and II he was, in fact somewhat quieter at intervals throughout the day although all activity levels were definitely within normal limits. Appetite has shown no change overall but with less persistence with food begging activities--although he still does beg lol.... He is definitely drinking less. We took our walk today and he showed great interest in being out. Also he spent a while barking at the squirrels, crows, etc. n our fenced yard. He is resting comfortably now on the couch as we watch Jay Leno, our unwinding time before bed. This is just about the best I could hope for in terms of an uneventful initiation of therapy. I do not think I will fully relax until end of the first week, though. I was wondering, in the event that the dose would need to be increased (I just like to plan ahead so all ducks are in a row) is there a way of calculating how much to increase it? I was thinking just 2.5 mg--adding 1/2 of his 5 mg capsule to the current dose--of course it would have to be recompounded. Is this just something the vet calculates according to some formula or is it based on the results of how much the cortisol has decreased from the initial result following the initiation of the medication? I want to be ready with my plan if this would happen and know how to talk to the vet. I certainly wish everyone a wonderful spring! Many blessing to all Linda and Toby

StarDeb55

04-01-2010, 01:14 AM

Linda, I think if you will take a look at the "treatment & monitoring" flowchart on the following link from the important information section of the forum, it may answer some of your questions.

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

Debbie

littleone1

04-01-2010, 08:03 AM

Hi Linda,

I'm glad Toby is doing good with the treatment. He's in very good hands.

Just an FYI - Corky was on the same dosage of Trilo for over 5 months. His dosage was just recently increased 5mg a day. If Toby's dosage would have to be adjusted, you're vet would take care of that.

Terri

labblab

04-01-2010, 09:14 AM

Is this just something the vet calculates according to some formula or is it based on the results of how much the cortisol has decreased from the initial result following the initiation of the medication?
I'm so glad that Toby continues to do well! And no, although each individual vet may have a general dosing "schedule" in their own minds, there is no set formula as to specific percentages when dosing changes are indicated. However, the results of Toby's ACTH test will be the best indicator as to whether, or how much, change should be made at any given time.

Per the link to Dechra's monitoring chart that Deb gave you above, you'll see that they do not recommend any dosing change at all within the first 30 days, as long as Toby is feeling well and his cortisol has not dropped too low (below 1.45 ug/dl). This is because his cortisol will likely continue to drop during the first month of treatment. It is at that point -- the 30 day test mark -- that adjustments are first recommended, depending upon the cortisol level at that time. And those adjustments really will depend upon both his symptom resolution and also how far afield his cortisol level is from the desired therapeutic range.

So for the time being, I think you can sit tight and feel good about the positive changes that you are seeing in Toby!

Marianne

Tobias

04-01-2010, 10:28 AM

Wow! all of this is so helpful. I will go to the link this morning and study after my coffee--not much use trying to learn anything before that lol. Seriously this is so empowering. Thank you light-keepers and
Cushing's angels--Toby and I can feel the breeze created by the fluttering of your wings! Our darkness is not so great because of the lanterns you all carry. Many blessings to all--time for daily "yard duty" TC all and thanks again. Linda and Toby

Tobias

04-01-2010, 11:11 AM

Hi--it's me again. I do see on the protocol sheet from Dechra that all the steps are outlined--I was so focused on the beginning of the therapy-section for testing etc....I did not go any further! Thank you for the reminder, though, to keep referring to the chart....TC all and have a great day! Thanks again from Linda and Toby

mypuppy

04-01-2010, 06:25 PM

Hi Linda,
Awesome to know you are seeing subtle great results with his symptoms... Embrace it, and enjoy Toby and each other and tomorrow will work itself out. So happy to read good stuff. Luv ya, xo Jeanette and Princess
ps: would you be able to upload a pic of Toby. I can't wait to see his precious face. We have a lot of those here on the forum.

Tobias

04-02-2010, 10:40 AM

Hi all: Just a quick post/update on Toby--This is my work at home weekend/moonlighting job so I am swamped. Toby continues to do well. Appetite, etc still quite good. All patterns of behavior seem normal--maybe just a tad slower and less restless during the main hours of the day. But still yesterday he engaged in his favorite game of chasing the vacuum cleaner lol...actually one of my favorite games, too...even running the vacuum is fun with Toby!Toby is my very first terrier--they are so much fun! Very intelligent guys with a lot of independence. We keep him in a terrier cut. Next weekend I will try to figure out how to post a picture as I do enjoy the pictures of your dogs so much--it does enrich the learning experience. Well, more later ....I will update just a few lines daily...many thanks to all and have a wonderful Holiday weekend from Linda and Toby

Tobias

04-08-2010, 12:02 AM

Hi all: Toby goes for his first stim test tomorrow, day 11 of therapy initiation with Vetoryl. We will not have the results until Friday, I don't think, as they are sent to Cornell....Toby has had a very good beginning of therapy, it would seem, in spite of all my anxiety. I see less drinking for sure but really no appetite changes. Everything else clinically seems 100% baseline so we will see about the actual lab data on Friday....Many blessings and gratitude to all who have been so helpful....you will hear from me Friday! We are following the Dechra chart for monitoring. ....Linda and Toby

BestBuddy

04-08-2010, 04:38 AM

Linda,
Wishing you and Toby luck for the test.
We would also love to see a pic of Toby.:D
Jenny

Tobias

04-08-2010, 10:26 AM

labblab

04-08-2010, 10:44 AM

Yes, I would love to send a picture but I cannot figure out how. I click the links and follow the directions. I copied toby's pic from my documents but I cannot paste it in the box that comes up under "add album"??? I have no clue. I have a really old computer and when I right click on Toby's picture it only shows me option to send to e-mail recipient, but I do not know how to transfer that to the blank box on the cushings page at this site. I am so sorry as I would really like to share with you his picture; you have all been so giving to us. Linda and Toby
Hi Linda,

I don't know whether this "hint" will help, but you have to first create your photo album before you can actually upload pictures to it. So when you first click on the prompts to "Add Album," you will just be typing in the words for a title and any verbal description that you might want to have associated with your set of photos (you don't have to have a description, though). Once you've typed and entered that info, your album will be created, and THEN you'll have the opportunity to actually upload photos from your computer. Here's another link that might be helpful:

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

If that works, we can also coach you as to how to add Toby's photo as an avatar alongside your Username, if you'd like. :)

If you continue to have problems uploading, though, let us know and we can tell you how to email a photo to us for one of the staffmembers to upload on your behalf. :)

Marianne

Harley PoMMom

04-08-2010, 11:02 AM

Hi Linda,

Your pics have to be a certain size to be uploaded too...no larger than 600 X 600 pixels. I use a program called Hot Shots to resize my pics.

Like Marianne has said if you are having problems, please let us know and we will gladly help you through this. ;):)

Love and hugs,
Lori

Tobias

04-13-2010, 11:08 PM

Hi all: I finally have Toby's stim test results. On the message phone tonight when I got home from work. Test was last Thursday, which was day 11 of vetoryl therapy initiation. His initial level was 5.07. Then his "post" level was 15.8. He receives 5 mg daily. Vet is happy with these numbers. He says keep Toby at the same dose of 5 mg for 30 days and then retest. I checked the Dechra chart and I see toby is well above the 1.45 for continuing the med at present dose. But there is no "less than" parameter given. Clinically Toby is fine. Appetite still excellent. Still very active as usual. Not as thirst, definitely. Do I have to worry about Toby dropping down too low before the next test as I have read that the levels continue to drop. My other question is about administering the prednisone rescue dose in an emergency (which I would like to be prepared for now, ahead of time)---if I usually put his medicine in food, and if he would not be eating food d/t lethargy, weakness, etc,--is there a safe way to give it when the dog is not his usual self? Thank you all for your most expert opinions. It is late for me and I have bird cages to clean so I will sign off. With much gratitude Linda and Toby

frijole

04-13-2010, 11:18 PM

Linda, It sounds like you are doing great and Toby is comfortable so that is even better. At 15 you probably won't need the prednisone but just to be safe - if you were to need it, it would be very obvious.

I never had to use it for emergency but dogs that are low are so lethargic owners sometimes think they are gone. They often can't stand up. If it is an emergency I would grab the pill/pills and shove them down the throat and hold the mouth shut so I knew they went safely down into the tummy. :D No time for hiding it in food or mixing it up.

That is just me though. The pills are tiny little things and easily hidden in cheese, peanut butter, cream cheese.

Glad to hear the update! Keep up the good work. Kim

BestBuddy

04-14-2010, 01:28 AM

Hi Linda,

I like what I read.:D
It looks like the cortisol is coming down (did you give us the numbers when he was dx) and I like that it seems to be slow. Slow is good because it gives Toby's body time to adjust to the decreasing levels of cortisol. A lot of us noticed that the cortisol continued decreasing after a month or more at the same dosage. The ideal is to got the cortisol post number at 9 or below and the actual number will differ in all dogs. Some do better with it up closer to 9 and others much lower. You will have to work that out when the time comes but all in all a great report.

Jenny

Tobias

04-14-2010, 09:34 AM

Ok experts, thanks for the feedback which is once again really good information to have, both for the prednisone, should the need arise to give it, and the target number of 9 for post acth result. Many thanks for all you do for so many dogs and humans everywhere. Linda and Toby

lulusmom

04-14-2010, 10:29 AM

Linda, as Jennie has said, a post acth stim number of 9 is okay but only if all symptoms have resolved. This is the upper limit reflected in the Dechra monitoring guidelines; however, many experts here in the states use the same targed post stim as Lysodren, which is 1.5 to 5.5 ug/dl. This is standard treatment monitoring protocol for UC Davis. Dr. David Bruyette, a venerable member here, prescribes Vetoryl for the vast majority of his patients and he lectures that a post stim of 9 ug/dl is acceptable but only if the acth stim test is done outside of the optimum 4 to 6 hour after dosing timeframe.

It is important to monitor the clinical and biochemical effects of therapy and to adjust the trilostane dose to achieve optimal control. Dogs are re-examined and an ACTH stimulation test is performed at 10 to 14 days, 30 days and 90 days after starting therapy. It is important that all ACTH stimulation tests are performed 4 to 6 hours after trilostane administration and interpreted in the light of the history and the findings of a thorough physical examination. If the post ACTH cortisol concentration is less than 20 nmol/l (0.7 μg/dl) the trilostane is stopped for 48 hours and then re-introduced at a lower dose. If the post ACTH cortisol concentration is more than 120 nmol/l (4.3 μg/dl) then the dose of trilostane is increased. If the post ACTH cortisol concentration is between these two values and the patient appears to be clinically well controlled then the dose is unaltered. If however the post ACTH cortisol concentration is between these two values and the patient appears not to be clinically well controlled then the trilostane may need to be given twice daily. If an ACTH stimulation test is performed at times other than 4 to 6 hours after trilostane then the post ACTH cortisol concentration should be more than 20 nmol/l (0.7 μg/dl) and less than 250 nmol/l (9 μg/dl)

Dr. Mark Peterson, another reknown expert on endocrine disorders, includes the following in his lectures on monitoring Vetoryl treatment:

There is a lot of controversy about the target post ACTH stim cortisol concentration. The manufacturers recommend a result between 1.5 and 9 ug/dl. However, many clinicians feel that a post-stim cortisol over 5.5 ug/dl indicates sub-optimal control.

The following table describes my personal preferences:

POST-ACTH STIM CORTISOL DOSE ADJUSTMENT

< 0.7 ug/dl Stop trilostane. Do not restart unless patient
shows signs of HAC

0.7 – 1.5 ug/dl Stop trilostane for 48 hours
Restart at 50% of previous dose

1.5 – 5.5 ug/dl Continue present dose

5.5 – 9.0 ug/dl Consider a 50% increase in dose if patient
shows signs of HAC

> 9.0 ug/dl Increase the dose by 50 – 100%

Recent studies in Europe have suggested a simpler dosing plan, in which both the pre and post cortisol should be between 2 and 7 ug/dl. I think this idea has some merit, and have used this rule lately in my clinical practice.

When my dogs were on Trilostane (Vetoryl), their symptoms didn't improve until their post stims were less than 5 ug/dl. As I recall, both Lulu and Jojo had consistent post stims between 2 ug/dl to 3 ug/dl range. Others members' dogs have done very well with post stims higher than 5 ug/dl so you won't know where Toby's post stim needs to be until you get there.

Sorry for the long post but I wanted to share Dr. Peterson's and Dr Bruyette's approach to monitoring Vetoryl with you and other members.

Glynda

Tobias

04-14-2010, 11:13 PM

OK Glynda and Jennie and all my other really on top of it helpers. According to what I just read in these last few posts (thank you--I love having a referral chart and the credentials do seem impeccable) Toby's dose should be increased by 50 to 100%. But the vet is comfortable leaving the dose right at 5 till the next test, which would be about mid May if counted 30 days from April 11)and I am too, since it has been posted that level does continue to drop for the first 30 days. Is this okay to do? I am so happy with the gradual changes I see and would rather not step outside the comfort zone for another few weeks. He's still getting some benefit, isn't he? And we are following the Dechra chart. Is this satisfactory? Thanks again Linda and Toby

BestBuddy

04-14-2010, 11:36 PM

Did you have an ACTH done before starting the trilo and if so what were the numbers?

If the numbers are coming down at your current dose I would leave it as is until the next months ACTH test. Remember this is only my opinion. You are getting benefit from the lowering of the cortisol and I think it makes is much easier for the dog to go slow and let their body get used to the changes. If the next ACTH hasn't come down then I would consider increasing the dose.

Hope this helps but just remember I am only speaking from "my" experience and as we all know our dogs are all different.

Jenny

Tobias

04-15-2010, 10:00 AM

Hi again: The first stim test 2/16 pre was 7.51 ref 1.8-4. Post was 47.3 ref 6 to 16. His pre test day 11 of therapy initiation is 5.0. His Post is 15.8. So comparing the numbers like this is quite a good idea--I had not thought of it. Looking at the numbers I do see he is making quite good progress lab wise, it seems. Clinically I could not feel better about him. Less restlessness, less drinking. Appetite super and activity level fine. Because of my nervousness about giving him this medicine, I think it good psychologically to stabilize for a few weeks...does this make sense? All opinions, comments etc most welcome. Thanking all again, I can never thank you enough...Linda

Tobias

04-15-2010, 11:47 AM

Hi again all: I forgot to mention in the posts about the stim test that toby's lytes were also done and were normal acc/t the vet, who did not mail me the values yet. But he said they were fine. He is off till Saturday now. I have just read the thread about the Lab, pepper, and my heart is so sad for her and her guardian. I sent them light, I have no knowledge, really, to offer compared to all of you. I hope the fluttering of the Cushing Angels wings of K9 cushings revive sweet Pepper, God bless and many prayers for her from Linda and Toby

lulusmom

04-15-2010, 02:36 PM

Hi Linda,

If you are seeing steady improvements in Toby and given that his post stimulated cortisol has dropped dramatically in a short period of time, I think your plan to leave things the way the are until the next stim test is an excellent one. Slow and easy is a great way to approach things. You're doing a great job!!!

Glynda

Tobias

04-18-2010, 08:55 PM

Hi alll: There may be a little blip on the radar screen regarding how Toby is handling the Vetoryl. He started therapy 03/29. First stim test 04/11 with results posted and signed off on by the list members/thank you! Lytes were also good on 04/11.

Over the weekend I have begun to notice loose stools. Not diarrhea but not really formed. No straining, no urgency, no increased numbers of trips outside. Of course I will call the vet tomorrow morning but I am wondering if this should be a cause for concern/ reason to stop the med a day or so just to be sure, etc. That is question #1.

Question #2 regards something really gross. My puppy (the shih tzu my husband gave me for Valentines day just before toby was diagnosed with Cushings) is throwing up lately with no diet changes etc. I noticed today he was going after Toby's poops (as it was coming out....excuse this disgusting graphic) as there are none in the yard for him--I scoop every day. Now that I realize it is happening of course it will not happen again but I am afraid puppy might have gotten the "processed" Vetoryl and I was wondering if it might be affecting him. Puppy is also on amoxicillin for a UTI so that might be making him throw up, too--of course I will call the vet about this tomorrow also. But my question is: Would the digested vetoryl pose a threat to the puppy? He might have done this before, I am not sure, but I am just trying to rule out any cause for the vomiting.

Thanking anyone for the opinion on either issue. :eek:Linda and Toby

Spiceysmum

04-19-2010, 12:11 PM

Hi Linda,

We are going through a similar thing with Spicey at the minute after just one dose of Vetoryl. Spiceys diarrhea was quite bad but not watery and we have been told not to give any more for a week then start again on a lower dose. What did your vet say today?

Regarding your 2nd question I remember 3 years ago when Spicey first started on Vetoryl my other dog (before he was castrated) used to lick her pee when she had been on the garden.:eek: I too was worried that he might be ingesting some of the remains of the Vetoryl but most people agreed that he wouldn't. Can't remember the explanation they gave, too technical for me!! Hope that helps you feel better.

Linda and Spicey

Tobias

06-29-2010, 11:08 AM

labblab

06-29-2010, 12:23 PM

Welcome back Linda and Toby!

I'm afraid I can't be helpful re: Toby's gassiness, but I'm betting some other folks will be by before long because we've heard some similar complaints lately by other members.

As far as needing to adjust his trilostane dosage over time, I can reassure you that it is not uncommon at all. We've seen many dogs who have needed to make shifts in both directions. That's why it's such a good idea to continue to perform the periodic ACTH tests, even when a dog is outwardly looking well. But once you get back the results of Toby's ACTH testing, hopefully you'll have a clear idea as to what a new optimal dose may be. The only other question that I'd ask is, have you shifted to a different source for your compounded trilostane or have you started a new batch during this time period? If so, I suppose there's always the chance that there is a difference in the effectiveness of the medication itself. But that seems pretty unlikely.

Definitely check back with us when you receive the ACTH results. And as I say, hopefully you'll soon get more feedback re: the gas issues.

Marianne

Harley PoMMom

06-29-2010, 12:51 PM

Re; the gas...ask your vet about Pepcid AC, it has really helped my boys tummy out with the gas. ;):)

lulusmom

06-29-2010, 03:38 PM

Hi Linda,

I just went back through your thread and see that the last stim result you gave us was done 11 days after treatment. That was done on 4/11. If you are following Dechra protocol to the letter, you should have had another stim test done 30 days after treatment. Was this done and if so, can you please post the results? To bring everybody current, here are the only two stim test results for Toby:

2/16 (Diagnostic ACTH Stim) Pre 7.51 ug/dl Post 47.3 ug/dl
4/11 (11 days post treatment) Pre 5.00 ig/dl Post 15.8 ig/dl

Considering the small dose Toby is getting, there was a dramatic drop in cortisol in just 11 days; however, at this point it is still not within the desired range. As Marianne already mentioned, it is not uncommon for dogs to require an increase or decrease in dose, especially within the first 30 to 90 days. In my opinion, however, it would be a little odd to have a dog whose stim results are within the desired range at 30 days then have a big jump in cortisol in the following two to three weeks. The question mark in my head can be eliminated once you let us know if there were any stim tests done after 4/11.

FYI, my cushdog, Lulu, weighs less than 5 lbs and she was taking 30mg Trilostane so you just never know what dose a dog is going to stabilize on.

Glynda

P.S. If Toby's gassiness appeared about the same time you noticed an increase in his drinking and eating , I would tend to agree with your vet that gulping air is probably the culprit.

Tobias

06-29-2010, 10:06 PM

Hi all: Thank you for your answers--I will ask the vet about the Pepcid, too--We did in fact do a stim test and lytes on 04/27--I don't have the copies of results but I will surely call to see. My work schedule changed and now Gary (hubby) has to pick toby up at the assigned hour. The vet told Gary the results could not be any more satisfactory --they were within ideal range, I think he said, and the agreement was to continue on the same dose. But I will call tommorrow for the exact number--I may have to wait till Thursday when Karl works again. I did take Toby up today for some emesis overnight, the night following the 3 month mark test done a little early yesterday. Also the gas thing is really starting to bother me. Karl spent a lot of time palpating his belly and he feels the abdomen is benign. But he does think that maybe the administration of the dexamethasone for the test pushed him up a little high, which may have caused the overnight and a.m. vomiting last night and today, and that the baseline value may have in fact risen (which would in fact correlate with the clinical presentation) and that he is most anxious to get the results back and that he will call me ASAP upon getting them from Cornell--it will probably be Thursday, maybe Friday a.m. . So actually I might wait until then to clarify that 04/27 value to post on, now that I am thinking about it. So we did definitely test on April 27th and I probably did not post bc Karl verbally told Gary it was optimal and had in fact decreased from the values on the 11th. Also we got new software at the hospital where I work and we are all just about ready to self destruct. I probably thought "Good Lord, thank goodness everything is good with Toby" and went on to study the technical manual for my job. My heart really palpitated when I read about possibly missing a test, which it turns out we did not, thankfully, as I would have never forgiven myself. So I will post with the 04/27 values asap, and also we will know about the 90 day test then, too. I did see the blood work results today and the only thing at low end of elevated was hemoglobin and rdw...red cell distribution width, but just shaded in at the very beginning of the abnormal range..Karl said he was not concerned about this and that it was clinically insignificant. Thank you again for all your help. I feel so blessed to have such a resource. It is so satisfying to connect with people who want to nourish and sustain all the life forms great and small. It is a drop of kindness in the oil filled ocean that surrounds our gulf, it makes the pain less. Thank you so much. Blessings to all from Linda and Toby

SavingSimon

07-01-2010, 12:17 AM

Hi all Cushing's angels! In April I began the thread of Toby's odyssey with Vetoryl. After being helped tremendously by this wonderful list things settled in quite comfortably and without incident. Blood work has been optimal, lytes, liver enzymes, etc...according to the vet...although I do not have yesterdays values in front of me right now. We are using the Dechra protocol and Toby just had his last complete round of blood work yesterday(the big long one that shows everything--for humans it would be a comprehensive profile or an SMA 18-22 in old terminology). Vet says the liver values have actually improved slightly that were off. The actual stim test results must go to Cornell and we will not know till probably thurs. My question is this--Toby's drinking began to increase dramatically within the last few weeks...we actually moved the scheduled 3 month from therapy onset date up one week bc of this. His appetite seems greater. His levels had been in optimum range with the 2nd test according to the vet--again, we are using the manufacturer's protocol and doing things by their exact schedule. Everything has been going so smoothly. But Toby is so gassy--his belly is bloated so much of the time...this actually started before the Vetoryl and it was worked up thoroughly via bloodwork and ultrasound. No one can find any reason as all the blood work is normal and the sonogram showed absolutely no findings other than the bilaterally enlarged adrenals consistent with Pituitary dependent hyperadrenocorticism. Vet seems to think it is all the air gulping with excitement about eating and drinking. I think this gas makes him so uncomfortable. We can give him Reglan/metaclopromide as needed but I am so squeamish about this as it is a drug of course not without possible side effects. The vet does not seem thrilled about simethicone and would prefer the metaclopromide be used. So one question is any recommendations for the gas that I could recommend to the vet? Also. is it common 3 months into the therapy to see a drop in the effectiveness of the trilostane? We use a 5 mg compounded preparation for Toby bc of his small size. Of course we will wait for the stim test results to increase doseage if necessary, but I just wondered if anyone had the similar experience of the dog needing more of the trilostane this far into treatment (which commenced March 29). Thanking anyone who can offer any insights about the gas or the possible decrease in effectiveness of the trilostane as far as input to the vet. God bless. Linda and Toby

Hi Linda,
I'm pretty new to this, but could a side effect of the trilostane be the gas and bloating? What is Toby's diet? I can say (and I am afraid of a lot of drugs if you see my thread, it will confirm that) that reglan and metaclopramide are really minor drugs with minimal side effects if any. I have taken them myself and they work great for any nausea or indigestion - I am not really sure about gas, but the mechanics of how the drugs work make me think it's worth a try. Reglan is NOT a drug that I would be any more afraid of than the pepcid. That's just my two cents on that. Also, tagamet is a drug that works for some dogs if pepcid doesn't. My dogs have had reglan for other times when their stomachs were bothering them that had nothing to do with Cushings with only good - no bad effects whatsoever. I do realize a Yorkie is a delicate breed, but honestly would give the reglan a try if I were you.
I hate how scary that this is for all of us, and I will keep you and Toby in my prayers. I also think that Vetoryl is a wise choice the more I read, and see that once you were afraid of it but looks like you are okay with it now. Comparing reglan to Vetoryl is like comparing tums to gastro-bypass surgery in my opinion. Be brave for Toby, and you can hunt me down if I am wrong - I'm that confident the reglan is okay .. BUT I would want to get to the bottom of what is causing the gas and stomach pain. If it is the panting, then the cortisol needs to come down, maybe the dose of Vetoryl needs to be adjusted?
Like I said I'm new here, but if you read Simon's thread you will see what a chicken I am when it comes to medications, so I just wanted you to know that reglan is one I have used often in non-Cushings related stomach issues for both me and my Jack Russells, and have never, ever, ever, had a single side effect at all - it just does what it is supposed to do and settles an upset stomach within a half an hour, and kind of speeds up digestion - so maybe a Cushings dog would seem more hungry from it but that is the only side effect I think it could give Toby.
You and Toby will be in our prayers.
Love,
Dena, Simon and pack

frijole

07-01-2010, 12:37 AM

Hi! I use lysodren but was loading my 2nd cush dog on lysodren when it all of a sudden was no longer working (decreasing cortisol) and she quit eating. After many tests we found out she has SIBO which is small intestinal bacterial overgrowth.

I have been giving her a med to get her to eat (anti nausea) along with pepcid ac. I am using tylan (a non FDA approved antibiotic typically used with poultry) and so far it is working. I did a TON of research. While not FDA approved, vets can and do recommend it.

It has been interesting that there have been a fair number of dogs with similar problems lately. SIBO, IBD and pancreatitus to name a few.

Certainly an upset stomach can affect test results. Also if the digestive tract is upset Toby might not be getting the full benefit of the drug which might also be why you are seeing a change and symptoms returning. I certainly am not an expert in this area but am just sharing my experience and what I have read here with other's experiences.

Hoping you figure it out quickly... i know it is stressful. Kim

Tobias

07-01-2010, 10:25 AM

Hi again all: Thank you for these very thoughtful replies. The thing is, Toby had the gas prior to Vetoryl/trilostane administration. The level of bloating is pretty much unchanged although there are days, recently, when he seems to remain bloated for longer. We came out of a very hot muggy period recently--it is very hard to separate out actual physiological need for water versus the "drive" generated by the Cushings in this weather. And increased water intake would lead to increased bloating bc he really slurps it down with gusto! But interestingly, we have been in cooler weather past few days here with no humidity and he seems to be stabilizing again with more normal water level consumption. Summer really complicates things in assessing the clinical picture as we do not have air conditioning! (But bring it on anyway, lol) But he does seem to be engaged in food seeking activities with more persistence lately. So we will see. I do thank you for the remarks about being timid with medication-it is a good reminder. Tues I did break down and give it to him and he was zipping all over the place, pawing at me and never still--while waiting for the appointment at the clinic I had to take him out of the exam room and walk him about outside till the vet was ready as he was just wired! It was like I had given him amphetamines! But his tummy sure "deflated" nicely by the end of the day. Thank goodness he tolerates the Vetoryl so well...I really see nothing but good coming from that, in spite of the "angst" that led up to administration of it...I never could have done it without knowing I had such fantastic back up from the list! Thanks again, many blessings and gratitude from Linda and Toby--I will post asap with results of stim tests.

apollo6

07-01-2010, 11:46 PM

Hi Linda and Toby
Apollo had the bloating and gas over the past months, this is before I started his diagnosis. He gulps his food always has, but I think his little intestines and stomach could not digest it fast enough. His bloating is a little better. I am on day 6 of Vetoryl, too soon to say.
You both are in my prayers.

Tobias

07-05-2010, 06:09 PM

Hi all: This is Linda again, Toby's "mum." I posted a few days back about the gradual increase in Toby's symptoms of excess drinking and also voiding (although not as definite and obvious as the increase in drinking, but still seemed to be an increase) that possibly could be related to our recent heat wave of temps in the upper 80 and now 93 F or could be related to Toby's Cushings.

Toby started 03/28.

On 2/16 His initial level 11 days into therapy was 5.07. Then his "post" level was 15.8. He receives 5 mg daily. Vet continued same dose.

On 4/27 his pre ACTH was 4.38. His post ACTH was 13.7. Same dose continued.

On 6/28 his pre ACTH was 5.77. His post was 11.0.

Electrolytes have been done with every test and are within normal limits. Comprehensive profile done at therapy outset of therapy and also 06/28 showed very little change—the alkaline phosphatase and GGT(?) actually showed a minor improvement this draw.

We are seeing an increase in drinking over the last 2 weeks --my impression is as the day goes on. The only thing I notice (certainly being oblivious to what I would be looking for) about the numbers is that although there is steady improvement in the “Post” level the “Pre” level was actually higher after 3 months of therapy than on the 11 day test. Although the 5 mg dose was never changed, (and he is still on that dose) his “pre” level initially went down but as drug therapy progressed it went back up. Is that “pre” level value significant when correlated with the recent increase in drinking? Or is it the “post” that is significant.

I spoke with Karl, his vet, quite a while this morning. I am wondering about trying to correlate the UCCR urine ratio with the serum levels of cortisone, which is not mentioned at all in the Dechra protocol, but is advised in the UC Davis protocol if it is felt that twice a day dosing might be in order. Karl is really reluctant to increase the dose at this point, which I am too. Toby does seem to be “processing” something from about ½ hour to 4 hours after administering his dose in the a.m….I can tell there is something different about him—he is aware of something happening and is coping with it..he slows down slightly, walks a little slower, etc and seems mentally just a bit “off”---I really would not want to go over this threshold of where I am seeing him now post dose in the a.m. It is very subtle, but we are so tuned into each other and I just “feel” that something is affecting him. . I feel he is handling it, but just short of his limits. Then within a matter of 5 hours or so he just seems normal again.

Can any one advise as to 1) interpretation of these results 2) assessing need for twice daily dosing, safety of doing this, etc.

We administer trilo 5 mg compounded by Wedgewood Pharmacy (Our vets compounder) at 9 a.m. The blood is drawn at 2 p.m.

Thanking anyone who can help….Linda and Toby

labblab

07-05-2010, 08:43 PM

Hi Linda,

Well, now that we have all of Toby's ACTH results, I can offer out a very simple thought as to why his Cushing's symptoms remain unresolved: his post-ACTH results have never fallen within the desired therapeutic range :o. I believe you can ignore his pre-ACTH results; there really are no significant differences among them. Plus, as long as they are all above 1.45 ug/dl, I don't believe that Dechra (the manufacturer of Vetoryl) has any concerns about them -- or any real interest in them from a monitoring standpoint.

However, at a maximum, the "post" result should be no greater than 9.1 ug/dl. And that level is really only acceptable as long as clinical symptoms are resolved. If not, the target treatment goal is below 5.4 ug/dl. So as you see, Toby has never been within that range. Without lowering his cortisol further, I'm afraid you may never see additional improvement in his symptoms. And instead, they may continue to worsen. Here is a link to Dechra's "Treatment and Monitoring Brochure" where you can find the target ACTH goals:

http://www.dechra-us.com/files//dechraUSA/downloads/Client%20Literature/47902_VETORYL_10mg_Treatment_and_Monitoring_Brochu re_Update_3_2_ps.pdf

Under these circumstances, typically the first step would be to increase the once-daily dose. A switch to twice-daily dosing would only be considered if the 4-6 hour ACTH test was in the desired range (which Toby's is not), but symptoms recur later in the day. However, if you are reluctant to increase his daily dose, I suppose you could try splitting Toby's dose in half, and administering it twice-daily. I say this only because we have been told by one of our members (Dr. David Bruyette, a veterinary endocrinologist) that dogs being dosed twice-daily tend to require a lower overall daily dose than those who receive their medication only once a day. Here's a link to Dr. Bruyette's thread where his comments can be found:

http://www.k9cushings.com/forum/showthread.php?t=543

Sorry to be the bearer of bad tidings in this regard :(. But unfortunately, Toby's cortisol level does not yet seem to be well-controlled.

Marianne

Tobias

07-05-2010, 09:39 PM

Hi Marianne: I really thank you for such a prompt response!:eek:How did we miss this? Good Lord. I have rechecked the sheet and yes, you are absolutely correct! I was going by the reference range on the printout from Cornell thinking everything was fine...So we are going down, which is good. But we are at 11 and we need to be at 9 or even lower, it seems. How hard is it, to go down to 9 and not send him below the 1.45 lower parameter? I cannot see in the manufacturer literature how the increase in dose would be calculated. Would we go up 2.5 mg or another 5 mg (sounds somewhat scarey). Also, when I walk Toby (about 1 hour after giving him the trilo, I see muscle tremor in his right front leg, which I worry about--again, this may or may not be d/t the trilo--I am not sure. But it's funny that's the only time of day I see it. But of course that is the only time of day I walk him--at night we just play in the house or out in the yard sine I don't get home from work till late. Well let me tell you I am very appreciative of your recommendation but also I don't understand why the vet has been satisfied with the results--was he going by the Cornell reference range? :confused: I will call first thing tomorrow. Many thanks Marianne...I do feel like quite an idiot...I do not see a symbol for this so I will use :o. TC Linda and Toby

labblab

07-05-2010, 09:59 PM

Linda, believe me -- you have PLENTY of company when it comes to confusion over interpreting ACTH results!!! So do not be hard on yourself. The big problem is that the "normal" reference range that is typically given on a lab sheet is the range for a dog that does NOT have Cushing's. The desired range for a Cushpup taking medication is significantly lower, and is often not detailed on a standard lab page. So this type of confusion is not uncommon.

And I do understand your worry about increasing Toby's dosage. However, you've got a lot of leeway between his current level of 11+ and the lower limit of 1.45. Just to remind you, Dechra's recommendation re: initial dosing is to use a formula of 1 mg. per pound. So the 5 mg. that Toby is currently taking is only half of what Dechra would have recommended as their starting dose for a dog of his size. So if you do decide to increase and want to limit it only to another 2.5 mg., Toby would still be taking a conservative dose according to Dechra's formula. Just some more food for thought to talk over with your vet.

Once again, don't kick yourself over this, and definitely don't despair. Trilostane "tweaking" is a very common activity around here! ;)

Marianne

Tobias

07-05-2010, 10:34 PM

Thank you again Marianne: I will definitely call the vet tomorrow a.m. He may not call back till I am work, so I may not find out anything tomorrow. Also, so I am better prepared to talk to the vet, is there a rationale he would understand for the values needing to be lower for a Cushing's dog than a dog without Cushings? (although I do admit that in the normal range for normal dog he is still drinking quite a bit). Also--would we test again in 2 weeks and then a month, as if starting all over again? TC Linda

frijole

07-05-2010, 10:41 PM

I'm not Marianne but I stayed at a Holiday Inn last night! :D;):D

The reason why Cush dogs have a lower "NORMAL" is because they need to maintain lower levels of cortisol and for some reason the magical number is between a 1 and a 5. It is written in all of the instructions for using lysodren and is the protocol they are supposed to follow. So you shouldn't have to explain it to your vet. (unless your vet is new to cushings)

Dogs that stop loading at an 8 for example almost always are not able to maintain that "8" and cortisol production increases and symptoms return. You want to get to that point where you don't ever have to load again. Right?! ha. Hope this helps. Kim

StarDeb55

07-05-2010, 10:55 PM

Linda , to expand on what Kim has said, with pit Cushing's the lesion in the pit gland is constantly making the adrenocorticotropic hormone (ACTH) which is what stimulates the adrenals to produce cortisol. Both medications do not affect the production of this hormone in the pit gland, so the only way to treat is to stop the production of cortisol by the adrenals. In trilostane's case, it blocks some of the enzymatic pathways in the adrenals that produce cortisol. In lysodren's case, it cause necrosis of the adrenal cortex tissue which is where cortisol is made. Since the adrenals are constantly being told to make cortisol, the medicine is decreasing but not eliminating the production of cortisol, this is why the normal range for our kids is different than the normal range for a healthy pup.

Hope this helps.

Debbie

AlisonandMia

07-06-2010, 03:30 AM

Hi,

My take on the need for lower numbers for a treated Cushing's dog (versus a normal dog) is as follows:

In a normal dog (or human or any animal for that matter), the pituitary gland "tells" the adrenals to produce cortisol and adrenals then produce the right amount. The right "dose" of Cortisol is necessary for the metabolism to work properly. The pituitary gland does this by producing a hormone called ACTH (Adrenocorticotrophic Hormone) which stimulates the cells in the adrenal cortex to produce cortisol - when the level of cortisol reaches a certain point the pituitary gland temporarily switches off its production of ACTH which in turn stops the adrenal cortex from making more cortisol for a while. When the cortisol level begins to drop towards being too low the pituitary gland will then switch on the production of ACTH which turns on the cortisol again.

This goes on all the time and it is the normal, healthy process by which cortisol production is kept "just right" (a lot of other mechanisms in the body operate in a similar way – it is called a feedback loop). In humans, more or less cortisol is produced at various times of the day (most at about 9am and least at around midnight typically). Whether this daily rhythm happens with dogs is controversial – but the main thing is that in a normal dog, ACTH and therefore cortisol, is not being produced in large amounts constantly through the 24 hours – in a Cushing’s dog this is what is happening. (When an animal is under stress (could be extreme physical exertion, cold weather, illness, injury, psychological stress or whatever) the need for cortisol is greater (to fuel an increased metabolism) and then the pituitary will stimulate the adrenals to produce a little more cortisol - but the production will go back to normal when the stress goes away.)

However, when an animal develops an ACTH-producing pituitary tumor this neat little feedback loop no longer works. The cells in the pituitary tumor have very little or no ability to "switch off" temporarily when the cortisol level is high enough (or even too high) - those ACTH-producing cells just go on and on pumping out vast quantities of ACTH - which in turn stimulates the adrenals to pump out vast quantities of cortisol. This large amount of cortisol is what produces the signs and symptoms of Cushing's disease in our dogs – and the hyperstimulation of the adrenals is why many dogs with pituitary Cushing’s have enlarged adrenals.

When an ACTH stim test is done a relatively large dose of (synthetic) ACTH is put into the dog's blood stream with the aim of getting the adrenal cortext to make and dump into the bloodstream as much cortisol as possible - this allows us to see what the maximum cortisol-producing capacity of the adrenals is. It is rather like giving a sponge a good squeeze to measure how much water it can hold.

A normal, healthy dog’s maximum cortisol-producing capacity as measured by an ACTH stim is usually around 8 – 15 ug/dl. An untreated dog with pituitary Cushing’s can have a max cortisol-producing capacity of anything from around 20 to >50 ug/dl. (Many pituitary Cushing’s dogs tend to have be around 30-ish at diagnosis – but there can be quite a variation.)

Because the pituitary tumor is constantly “on” in the Cushing’s dog the daily dose of cortisol that is produced by the adrenal glands capable of producing the normal amount when stimulated by an ACTH stim test ( 8 – 15 ug/dl) will still likely be too high – remember in a normal dog the production of cortisol is switching on and off according to need.

That is the reason that we need to artificially reduce the adrenal glands’ capacity to produce cortisol to a lower level than in a normal, healthy dog. It is all about keeping that daily dose of cortisol at a healthy level – not too much and not too little. For a dog treated with Lysodren the correct level is usually between 1 – 5 (individuals vary as to what is their best number) and with dogs treated with trilostane the level can be up to 9 – as long as clinical symptoms are resolved. Some trilostane dogs will do fine with a stim level of 9 – while others really need to be kept lower. Many trilostane dogs seem to do very well around 4 - 6. The reason the desired numbers can be different for Lysodren -v- trilostane treated dogs is though to be because of the way the different medications affect the adrenal cortex’s cortisol-producing capacity and this can, in turn, affect the test results.

Hope this helps!:)

Alison

AlisonandMia

07-06-2010, 03:37 AM

Toby does seem to be “processing” something from about ½ hour to 4 hours after administering his dose in the a.m….I can tell there is something different about him—he is aware of something happening and is coping with it..he slows down slightly, walks a little slower, etc and seems mentally just a bit “off”---I really would not want to go over this threshold of where I am seeing him now post dose in the a.m. It is very subtle, but we are so tuned into each other and I just “feel” that something is affecting him. . I feel he is handling it, but just short of his limits. Then within a matter of 5 hours or so he just seems normal again.

We administer trilo 5 mg compounded by Wedgewood Pharmacy (Our vets compounder) at 9 a.m. The blood is drawn at 2 p.m.

I'm wondering, from what you are saying here, if Toby isn't having the trilostane peak quite early on - maybe around 2 - 4 hours post dose. I see you are starting 5 hours after the dose (which is within the guidelines). Is the draw at 2pm the first or second draw? If it is the first then when is the second? Is it at 3 or 4pm? (Whether there is 1 or 2 hours between draws can depend on what stimulating agent is used). Maybe, given the signs you are seeing, you need to be starting the test by, say, 11.30 am if you are dosing at 9 rather than waiting until 2pm.

If you were to test earlier in the day and his numbers were in range - then maybe going to 2X a day dosing would help. But I think it would really be of value to see what is going on around the time that Toby himself seems to be feeling the dose the most. Not all dogs have read the guidelines and Toby maybe needs his test run a little closer to the dose.

Alison

labblab

07-06-2010, 07:52 AM

Hi again, Linda.

I see you've gotten some really helpful info from the others. So the only thing I'll add is that yes, you're correct, if you do alter Toby's Vetoryl dose -- you'll go back to the original ACTH monitoring schedule and begin testing again after approx. two weeks.

Also, if you or your vet have any questions about all this, I know that Dechra's technical rep would be happy to talk. His name is Dr. Tim Allen, and he is also a vet. I've spoken with him myself, and he is very nice and very helpful :). Here's Dechra's U.S. contact info (if you or your vet call, you can just ask to talk to Dr. Allen):

http://www.dechra-us.com/Default.aspx?ID=365

Good luck!
Marianne

Tobias

07-06-2010, 11:22 PM

Hi all: Thank you for your very thoughtful responses to my questions about Toby’s plan. I did ask Karl today about using 1.45 ug/dec for the reference range. He said he as always used the reference range (which I now know is for normal dogs)—that this is just how he has always done it. I do totally understand now the rationale for keeping the range lower, as suggested by the manufacturer, thanks to the explanations provided on this wonderful list.. To summarize: (I am checking here, just to make sure I understand): The reason for keeping a cushings dog lower is as follows. They lack the normal feedback/regulatory mechanisms that would enable the pituitary to decrease the level of cortisol when it does increase, say due to physiological, emotional or any other form of stress that might provoke the body to produce more for “fight or flight: response. The dog is in perpetual “fight or flight” mode and lacks the ability to lower the level again naturally in response to the decreased level of stress that would naturally happen when the stress abates. So we keep the overall level of cortisol, the baseline level, lower, so that when the cortisol continues to be pumped through the body, the level of it is is lower (qnd less harmful to the dog) because the adequate amount of trilo is blocking the enzymatic pathways that would contribute to the constant, unrelenting production of cortisol. We know that we need to lower it in Toby’s case because he is still drinking and eating quite obsessively. Do I understand this part correctly?

Also, Karl would like to the UCCR test and recommended by the UCD protocol, to confirm whether or not twice a day dosing is in order. He wants to run another stim test in a couple of weeks and also test the urine as described on the information from this site. Does this seem a good idea? Should we just up the dosage before doing this? Will this still be a valid test even though Toby is on a dose that is more than likely too low? We have scheduled the test for July 19th, about 3 weeks from his test of June 28. Will it be harmful to Toby to have another dose of dexamethasone so soon? I do think that if it turns out by the test that twice a day dosing is not in order, he would consider increasing the dose.

I am going to talk with Karl again about the dosing. This morning when he called I had not read your e-mails yet; I did not have the confidence to really push the matter; now I do. I am also going to call the Dechra vet as provided in the link, thank you. I will ask him to put it in terms that Karl will understand, if possible, vet to vet or if not, I will relay to Karl. Why he has not used the Dechra guidelines I still do not know. He is being extremely conservative, I believe….I am not sure exactly why.. .possibly because my Shih Tzu was euthanized just a short while ago and there is an underlying desire not to take any risks at all with my Toby—it would be so shattering on top of just losing what felt to me like losing a child. But in spite of this, I know he has Toby’s and my best interests at heart, absolutely. If I need to find another vet, a specialist because of this, I will do that. But our nearest specialist would be a 45 minute drive, stressful for Toby, stressful for me, requiring time off from work, etc. Honestly the information on this list is so intense and complete, the level of expertise so elevated, that I think Karl and I should be able to handle it with me getting guidance here. But I will have to show him the science, and you have all given me the science to show him, and I thank you.

So, to summarize, my questions: Does a UCCR test before increasing the dose make any sense to at least confirm it is not twice a day dosing that is needed, but an increase in dose? I think my vet would consider increasing the dose if the test demonstrated twice a day dosing was not in order.

Should I “push” harder for a modest dose increase before doing the UCCR test along with the stim test?

Will an “inadequate” dose of trilo in any way invalidate/skew the ability of the UCCR test and the stim test, given together, to determine whether or not twice a day dosing is in order?

In other words, should the plan be UCCR/stim test and then increase the dose depending on the outcome of the test..or…

Should we increase the dose modestly first and then do the tests together.

Will another dose of dexamethasone be harmful to Toby just 3 weeks distant from his dose on the 28th given for his most recent stim test?

Also, I will definitely ask for an earlier test—that was brilliant—why it did not occru to me I do not know…it would give me much greater security with increasing the dose.

Is Toby’s Cushings “really bad”/severe given that his untreated cushings first stim test (before medication) 47.3? Are there degrees of Cushings?

Finally, I am so in awe of the collective wisdom you share as a group. Your e-mails are such an incredible gift of light and hope for so many dogs and people. Many, many blessings and with extreme gratitude. Linda and Toby

AlisonandMia

07-07-2010, 12:03 AM

To summarize: (I am checking here, just to make sure I understand): The reason for keeping a cushings dog lower is as follows. They lack the normal feedback/regulatory mechanisms that would enable the pituitary to decrease the level of cortisol when it does increase, say due to physiological, emotional or any other form of stress that might provoke the body to produce more for “fight or flight: response. The dog is in perpetual “fight or flight” mode and lacks the ability to lower the level again naturally in response to the decreased level of stress that would naturally happen when the stress abates. So we keep the overall level of cortisol, the baseline level, lower, so that when the cortisol continues to be pumped through the body, the level of it is is lower (qnd less harmful to the dog) because the adequate amount of trilo is blocking the enzymatic pathways that would contribute to the constant, unrelenting production of cortisol. We know that we need to lower it in Toby’s case because he is still drinking and eating quite obsessively. Do I understand this part correctly?

Yes you've got it! I'd only add that only part of the "flight or fight" thing is going on with Cushing's dogs - they have high cortisol levels (cortisol is a stress hormone) but they don't have high adrenaline levels (produced by another part of the adrenal gland) so they don't feel awfully stressed in that way. They can act restless and somewhat hyped up in the evenings particularly - presumably because cortisol is a "wake-up" hormone - thus high level that is normal in humans first thing in the morning. People on corticosteroid medication (or who have Cushing's) typically suffer pretty awful insomnia. Dogs don't seem to be quite so affected in this way but a lot of them still get that restlessness in the evening.

I think doing an earlier stim would be my first move in your position - it is possible that his cortisol is dipping low enough but just not for long enough - maybe not for very long at all. If this is the case then increasing the dose (1 X per day) could send him too low for those few hours and possibly lead problems and certainly make him feel pretty bad for a while. If he is going low enough for a few hours but is still pretty symptomatic a lot of the time then going to twice daily dosing would be your next step. When you get the UC:CR you would be wanting to get an early morning sample of urine - this indicates what the overnight cortisol production has been. This is how UCDavis recommends the UC:CR be used.

Here's a quote from and a link to info on the UC-Davis recommendations:

http://veterinarynews.dvm360.com/dvm...date=&pageID=1

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

Owners are instructed to collect a small urine sample from their dog before leaving home the morning of the scheduled re-check prior to trilostane administration. Trilostane should then be given and the dog should be seen by the veterinarian two to three hours later.

The goal of therapy is an owner who is completely pleased with the response. As aids in achieving this goal, both urine and blood tests are indicated. The urine should be checked, at a minimum, for specific gravity, glucose and urine cortisol-to-creatinine ratio (UCCR). An ACTH stimulation test should be started at the time the dog is seen, again about two to three hours after trilostane administration.

The UCCR result should be within the reference interval and the post-ACTH serum cortisol concentration should be between 1.5 and 5.5 mcg/dl.

If the serum-cortisol concentration is within that goal and the UCCR is abnormal, the medication should be given BID. If the serum-cortisol concentration is too high, the trilostane dose should be increased. But if the serum-cortisol concentration is too low, the dose should be decreased.

This approach should be used at each re-check until the dog is doing well.

(Interesting that they are saying the dog should be seen by the vet and have the ACTH stim 2 or 3 hours post morning dose. UC-Davis also goes for the 1.5 - 5.5 post reading too - in line with the original guidelines for Lysodren dogs. You may find that he doesn't need to be quite this low - but maybe he does.)

When you go to twice daily dosing it is worth remembering that a little "tail" of the previous dose is often still in the system, even if the level is so low that it is having no effect that you can see. When a subsequent dose is added that little bit remaining in the system is added to the dose. So if the post-dosing stim is ok (especially if it is on the lower side) then it is sometimes preferred to give two smaller doses rather than to simply add another dose of the same size i.e. you might go from 30mg once a day to 20 (or even 15mg) twice a day, particularly at first, just to check what the response will be.

We have seen a couple of dogs that ended up doing best on 3 X a day dosing - and one that was even on 4X day dosing. So you can see that there can be a big variation in how they process the drug - and this can even change over time with the same dog too, just to make things a little more interesting! Most dogs do fine one once or twice a day dosing though.

Alison

labblab

07-07-2010, 12:56 AM

So, to summarize, my questions: Does a UCCR test before increasing the dose make any sense to at least confirm it is not twice a day dosing that is needed, but an increase in dose? I think my vet would consider increasing the dose if the test demonstrated twice a day dosing was not in order.

First off, I hope that you will follow through and call Dr. Allen at Dechra. I think it will be very good for you to have the opportunity to talk over your questions and concerns with a vet who is well-versed in Dechra's monitoring protocol. This would also be a good chance to ask him about Alison's suggestion re: shifting the timing of Toby's future testing a bit. Given Toby's behavior, what she's said about moving up the timing of his test makes sense to me, as well, and I'd be curious to know Dr. Allen's reaction.

However, I'll honestly be surprised if Toby's cortisol has actually dropped "too" low at any point in time if it has already rebounded to 11 ug/dl by the five-hour mark and he is still obsessively eating and drinking. My guess is that he will indeed need a dosage increase. Regarding your question above, I admit I am confused by your vet's strategy to try to first rule out twice daily dosing prior to increasing the once daily dose. Until Toby's cortisol has dropped within therapeutic range and his symptoms show resolution for at least the early portion of a 24-hour time period, there really is no basis for judging whether the effectiveness of the medication is wearing off too quickly so as to make a second dose necessary. It will be a certainty that the cortisol is not being controlled properly during the latter part of the day if the therapeutic range is never reached at any point in time.

So I agree with Alison that I think the first step revolves around ACTH testing. Depending upon what Dr. Allen says, however, I'd probably go ahead and try increasing Toby's single daily dose at least a bit prior to re-testing. If he reacts poorly to the increase, you can always discontinue it. But I'd leave the question of twice-daily dosing on the back burner until you see whether Toby's symptoms resolve satisfactorily once his cortisol is within therapeutic range on the ACTH test. At this point, worrying about twice-daily dosing seems like putting the cart ahead of the horse.

Marianne

labblab

07-07-2010, 09:51 AM

Hi Linda,

I'm back again this morning with one more thought to add (or really, to try to clarify what I said earlier). Upon talking to Dr. Allen, he may actually think that twice-daily dosing might make sense for Toby based upon his small size and the physical problems that you're describing within the first hours of dosing -- he might think that Toby would tolerate the trilostane better if it were split into two smaller doses rather than giving it in one larger dose. But this is a separate issue from performing a UC:CR test. What I was trying to say earlier is that without a dosage change, right now a UC:CR is not going to tell you anything that you don't already know -- that Toby's cortisol level is too elevated for too much of the day.

Marianne

Tobias

07-07-2010, 11:20 AM

Hi all--just to check in and thank you all once again for your help. I did call the Dechra number and spoke with someone named "Shelly" --she was able to really help with some issues. She feels 100% that with a compounded drug (less rigorous quality assurance than even a generic) the first step given the fact that he did so well initially symptom wise, is to get him on the Brand name...more potent, more consistent, rules out any possibility of drug inconsistency. She does not feel an increase is in order before ruling this out. She feels the vet instincts about not wanting to increase, even given the reference range he is using is for normal dogs (whereas theirs it for treatment) is sound. She thinks he may need a divided dose, but first change to the brand name. The issue of the leg tremor after administration is not to be ignored...but that the stim test without a doubt--should be done 4-6 hours ...with the brand name it absolutely peaks in this time frame. The uccr test can be done with the stim test when he is on the brand name--she said to get two urines early a.m. and after the second one, do the stim test in the prescribed interval. She relayed several anecdotes about dogs switching from generic to Brand and actually needing to reduce the dose--so no way, until he is on brand name, should he be increased. As far as the difference in protocols with UCD and Dechra, she emphasized we are still very much in the learning phase about Cushings and dogs and there are many issues to be yet settled and many very educated differences of thought....we are still learning. She seemed to be keying in on the clinical picture being very satisfactory on the 5 mg dose for over 2 months (regardless of the range being used as target) and the sudden change somewhat late in the monitoring period. This seemed to direct her thinking in the direction of drug inconsistency. I have already called the vet clinic to tell them I want to switch to the brand. The local pharmacy (because they like me lol) is going to "professionally" split it and will be sent and MSDS by Dechra. The vet must order the actual product through a rep???? So the ball is now in their court--if they will not give me the brand name I will head up to Rochester to the endocrinologist (Poor wallet, ouch ouch ouch) and switch vets. I just wanted to let you all know her insights, and in many ways they all clarified what you each have been trying to tell me....again I thank you! Especially for the encouragement to call Dechra, as now the plan is very straightforward. She did feel I was the type of person that would administer the drug very consistently and the problem may very well be the "batch" received from the compounding pharmacy. It makes complete sense to me to pursue this lead. Many blessings to all from Linda and Toby:)

labblab

07-07-2010, 12:02 PM

Linda, I had temporarily forgotten that you were using compounded trilostane when I suggested that you call Dechra. It is not surprising to me that they would encourage you to switch to their branded product. Whether or not that will actually make a difference will be very interesting to see. If drug inconsistency/ineffectiveness was the reason for Toby's recent increase in symptoms, I would have thought that his June ACTH results would have been higher than the previous tests -- not lower... But at the dose that Toby is taking, the shift to brandname Vetoryl shouldn't be that big an issue from a cost standpoint. And I will definitely be curious to see whether or not that makes a difference in symptom resolution and test results.

Out of curiosity, did "Shelly" also identify herself as a vet and a technical rep?

Marianne

Tobias

07-07-2010, 12:40 PM

Hi again: On my way to work so will be brief (what a relief, eh???)Yes I do understand the reason she would encourage brand name use, yet what she was saying made a great deal of sense but as you say--we will see! But I think this would answer any bottom line questions before cautiously increasing the dose. On a risk taking profile if 10 was a compulsive gambler/sky diver/bungee cord jumper and 1 was a tortoise (who only sticks his neck out when he has to, to move--usually to eat) I would fall below the tortoise. Then when/if we do have to increase, there will be no doubt in my mind-- I need no doubt about the baseline of the program. This is just me--I really wanted the brand name at the outset but it was not offered. Now, I'm going to really ask nicely. Well I gotta go! Many thanks Miss Marianne for all your help. You are so dedicated, I tip my hat to you. Linda

Tobias

07-23-2010, 09:30 PM

Hi my Cushing's friends and fellow dog lovers: Just an update on Toby: It took about a week to obtain the brand name, locate a local pharmacist to split into 5 mg doses. Toby started Tuesday7/20 on the brand name Vetoryl. I do not think I see much change and do think, based on what I have seen so far, and based on your advice about the target values, that an increase will be needed. So next Thursday when the vet examines Toby I will lay all this out. Because of recent expense with paying the fee to the druggist to split, very recent stim test that was within normal but not target range by the manufacturer's protocol, because of the cost of switching to the brand name of the drug after just buying the compounded, as long as Toby is showing no clinical problems would it be safe to wait a few weeks for the test and run it a month (allowing for my moonlighting check to come in) after starting the Vetoryl--toby's dose was not changed from 5 mg, just that we switched from 5 mg generic to 5 mg brand name vetoryl. So he has been on the same dose since March 28 and is really showing no change in his clinical presentation. The finances are getting so difficult and I need a break, if possible. Also about Toby's gas--we started the Pepcid AC today--we have to divide a 20 mg pill into 1.7 mg doses-- Vet said okay to try this as the metoclopromide was making him really hyper and bizzare--the last time is was quite frightening--I have not given it to him since then. Any ideas on how to separate a pill down this far? It is giving us fits. Thanks and blessings to all...Linda and Toby

frijole

07-23-2010, 09:45 PM

Wow. I had to split it into 8 pcs and it was a bear. Once you get to a certain point it all crumbles. If yours are shaped liked mine they aren't perfectly square so it makes them a bit harder to cut too. I guess I would do my best and if you end up with crumbs then so be it. Hopefully someone can give you better advice than I did! :p;):D

labblab

07-23-2010, 10:15 PM

Linda, my honest opinion is that you will not see any improvement in Toby until you have increased his Vetoryl dose. Since he remains symptomatic (i.e., it is unlikely that his cortisol level could possibly be too low), I also don't see any point in performing another ACTH test until he HAS been increased. At that point, Dechra recommends an ACTH test approx. 10-14 days after any dosing increase.

Marianne

acushdogsmom

07-23-2010, 10:40 PM

Also about Toby's gas--we started the Pepcid AC today--we have to divide a 20 mg pill into 1.7 mg doses-- Vet said okay to try this as the metoclopromide was making him really hyper and bizzare--the last time is was quite frightening--I have not given it to him since then. Any ideas on how to separate a pill down this far? It is giving us fits. Thanks and blessings to all...Linda and TobyRe: the Pepcid, I'm not sure why you're trying to split 20 mg pills. Pepcid AC is available in 10 mg pills, at least I know that it used to be. I used to buy 10 mg Pepcid AC (famotidine) for my little dog and then cut the pills with a pill splitter - into halves (5 mg each half). He weighed about 16 lbs

I'm not sure how much Toby weighs exactly, but according to the following link, the dosage of famotidine (Pepcid AC) for a dog would be 0.25 to 0.5 mg per pound (0.5 to 1.0 mg/kg)

http://www.petplace.com/drug-library/famotidine-pepcid/page1.aspx

How Famotidine is Supplied:
Famotidine is supplied in 10 mg, 20 mg and 40 mg tablets.

Famotidine oral powder for suspension is supplied at 50 mg/5 ml.

Dosing Information:
Medication should never be administered without first consulting your veterinarian.

The typical dose administered is 0.25 to 0.5 mg per pound (0.5 to 1.0 mg/kg) every 12 to 24 hours.

According to the dosing information above, 5 mg (half of a 10 mg Pepcid AC pill) wouldn't be too much for a 10 lb dog. How much does Toby weigh?

Why is your Vet recommending such a small dose of only 1.7 mg? And why are you being asked to split 20 mg pills when there are 10 mg pills available?

Famotidine can also be formulated into a liquid suspension for dogs if the required dose is too difficult to get by splitting pills.

littleone1

07-23-2010, 10:46 PM

Hi Linda,

I buy the 10mg Pepcid AC, which splitting might be easier to do than with the 20mg. I'm glad I only have to cut it in half for Corky, as he gets 5mg a day. I don't know if you would be able to crush it and then somehow measure it.

Terri

acushdogsmom

07-23-2010, 10:49 PM

Hi Linda,

I buy the 10mg Pepcid AC, which splitting might be easier to do than with the 20mg. I'm glad I only have to cut it in half for Corky, as he gets 5mg a day.Aha. So the 10 mg pills are still available. :)

sunimist

07-23-2010, 11:38 PM

Yes mam they are. I take them daily myself. :)

Tobias

07-23-2010, 11:59 PM

Hi again all: The vet figured the dose for famotadine at 1/2 mg per kg if I understood correctly.--Toby weight 7.6 pounds or 3.4 kg x .5 equals 1.7 mg. When we went to Wal Mart tonight all I could find was 20 mg??? But if there is a 10 out there I will go hunting and find it...I really did not know if it came smaller than 20 as this is all I saw at wonderful Wal Mart! :D Thanks again Linda.

acushdogsmom

07-24-2010, 12:02 AM

I think that 20 mg might be the "Extra strength" size.

I called my pharmacy and asked and they said that most pharmacies should carry regular Pepcid AC in the 10 mg tablets.

(That's the regular Pepcid AC, not the Pepcid Complete and not the Pepcid Extra Strength)

littleone1

07-24-2010, 12:42 AM

I don't even get Corky's at a pharmacy. I can buy it at any of our grocery stores.

Tobias

07-25-2010, 05:47 PM

Hi all: I am going up Thursday to the vet with my dog to lay out the case for an increase, per Marianne's post, I do feel this is in order having observed him now almost a week on the brand name. Honestly I do see a more even rhythm on the brand name but I also see that still, even when the brand name is peaking in the 5-6 hour range, there is some restlessness, need to drink (although quite decreased from when he was on the generic), persistent food seeking activities, etc. So, with my dog I am going to take the Dechra guidelines (which I understand, as the parameters are given in the same form as the Cornell sheet my vet is using for normal dog reference i.e., ug/dl). To reinforce, I want to show him also the UC Davis guidelines. This is my problem. The serum cortisol concentration per UC Davis post stim s/b between 1.5 and 5.5 mcg/dl. Can someone please tell me how this translates into "ug/dl" which is used on the Cornell sheets my vet is going by. I am going to say that as an owner I am not satisfied with the clinical picture or resolution of symptoms and that I would like to try a modest increase (being the nervous nelly I am) since both the Dechra and uc davis protocol give a lower post acth stim target than is given on the Cornell lab report as normal. Also I will point out the pot belly is really not resolving and the coat pigmentation is lightening further--showing us clinically that the levels are still too high. I will correlate the clinical picture with the science to achieve this goal of increasing the dose. So could someone fill me in on this, so that I can present my case for my boy. Thank you and many blessings to all. Linda and Toby. That is, specifically how does 1.5-5.5 mcg/dl equate with "ug/dl" (Toby's most recent post stim being 11 "ug/dl" Thanks again Linda...PS. He is doing good on the pepcid and I am still looking for that smaller dose pill.

lulusmom

07-25-2010, 05:54 PM

Hi Linda,

I don't have a lot of time but wanted to let you know that ug is the symbol for mcg so they are one in the same. I asked the same questions once so I know how confusing all of this stuff is. I hope that helps.

Glynda

labblab

07-25-2010, 06:06 PM

To reinforce, I want to show him also the UC Davis guidelines. This is my problem. The serum cortisol concentration per UC Davis post stim s/b between 1.5 and 5.5 mcg/dl. Can someone please tell me how this translates into "ug/dl" which is used on the Cornell sheets my vet is going by...

That is, specifically how does 1.5-5.5 mcg/dl equate with "ug/dl" (Toby's most recent post stim being 11 "ug/dl"
Hi Linda,

The two abbreviations "mcg/dl" and "ug/dl" actually mean exactly the same thing: "micrograms per deciliter." The "u" stands for the Greek letter "mu" which is commonly used in place of "micro." So the units of measurement are the same among all three sources: Dechra, UC Davis, and Cornell. And the ideal treatment ranges for Dechra and UC Davis are almost identical:

Dechra: 1.45 - 5.4 ug/dl
UC Davis: 1.5 - 5.5 ug/dl

I will also add that of the different Cushing's symptoms, the pot belly (along with coat issues) may be one of the slower symptoms to show resolution. Ravenous appetite, thirst, and urination are among the earlier symptoms to show improvement once therapeutic levels of medication are reached. So no matter what, it may take some time before Toby's pot belly goes away...

Marianne

Tobias

07-25-2010, 07:13 PM

Hi again: I am just posting to thank you all for your answers to further my understanding of the units used to identify the reference intervals for the post stim results. It is true, I think, that "It takes a Village" (to care for a Cushing's dog). Toby says thank you too. Well, have to go--I hear a "woof" at the door....Linda

Tobias

10-22-2010, 11:15 PM

Hi all: It's been a while since I posted but I really need to check in about my little Yorkie, Toby. We have just started (past Monday) an increase in Vetoryl from 7.5 to 10 mg. We have gradually been working the dosage up since last March, when therapy was instituted. We started really low at 2.5. Toby's post stim values, it seems, were never in the therapeutic range per Dechra. Our vet was going with the values on the Cornell diagnostic sheet, it seems! Toby's most recent values are in the 11 range--I don't have them in front of me right now. But we have gradually been inching him up after it was pointed out to me on the list that he needs to be lower in post stim value for actual treatment. I called Dechra at number provided in a post on this wonderful list and talked with the vet. When I then talked with my vet he was on board and we are now trying to get Toby down to the 9 range and lower if symptoms do not resolve.My HUGE concern as we struggle with this is #1) Toby's weight loss and wasting appearance which is becoming more pronounced lately. This definitely tells me we have not had the post stim levels low enough. He is still constantly hungry and his coat is so light. Drinking really is not as bad as it was but of course the weather is cooler, too. All his blood work including the complete profiles and the lytes done with the most recent stim test is unchanged from relatively normal values at onset of therapy. The vet commented that Toby should be fed more so we have started doing this but the #2 problem is bloating...he has a horrendous problem with this. I hand feed him slowly and have divided the the larger portion into 3 to 4 times per day and also give him simethicone, which helps. He cannot handle metoclopramide mentally-- it makes him really agitated. But within 10 minutes of his meals he always wants to drink, and he slurps down the water right after the food and turns into a balloon! I did read the posts on another thread about never withholding water from a Cushing's dog bc of the need to regulate as well as possible at all times, an am in agreement. But would it be okay to pick up his water for just a half an hour after he eats so he won't balloon out like he does? Or would this be dangerous? Also are there any supplements to bulk up to address the symptoms of muscle wasting? I do try to give him extra protein but of course I worry about his kidneys, too, as he ages. Lastly, I worry that the Vetoryl is just not working for him...if the values are gradually lowering into the target range per Dechra by the laboratory work, shouldn't I have seen some improvement in his appearance by now, (we are in 7th month of dose-tinkering) or do we just keep giving it and assume it will work when the post stim level is low enough? (i.e,, in the Dechra recommended range) Is it possible to have acceptable values by the laboratory work but have the symptoms never resolve ? Or do people change to another modality because the values are not coming down in spite of dose increases? Also, in what increments do we increase the dosage when test indicates a need? My vet wants to be very cautious at about 2.5 mg per increase and I have been comfortable with this. Toby was at 11.6 last test about a month ago for post stim value on 7.5 mg, so we decided to increase to 10. he is due for testing on this new dose next Thurs. I hate to keep dragging this out as I want to see the muscle wasting addressed asap. Yet I want to be safe! Also, is there any way the Vetoryl itself could be causing the gas? I give him FortiFlora, probiotics and Prozyme...still the gas persists. Thanking anyone who can comment on
1) The continued weight loss and wasting, and how long does he have to be in the Dechra therapeutic range before the Cushings starts to resolve?
2) Is is okay to withhold the water in the immediate post meal period to reduce bloating. I would put it back down in approximately 1/2 hour to 45 minutes.
3) How do we establish that Vetoryl is the effective treatment and that it is not time to try a new treatment?
4) IN what increments is the dosage to be increased if the stim values indicate an increase is indicated? Are their guidelines somewhere I missed?
5) Any hints for increasing muscle mass and addressing the wasting of muscle tissue that goes along with Cushings. I do not think muscle wasting occurs without consequent kidney damage; I am very anxious to prevent this.
Phew! Thanking anyone who has the fortitude to read all this and comment. Toby and I sincerely thank you! Blessings to all from both of us. Linda

labblab

10-23-2010, 10:09 AM

Hi Linda!

It's so good to see you and Toby again! But I wish that your report was a bit different :o.

First, I have a few questions for you. Can you please list for us the approximate dates and amounts of his dosing changes, as well as the actual associated ACTH results?

Secondly, how much does Toby weigh now? I know he was around ten pounds when you started treatment. Has he actually lost weight since then, or does he just look less bulky due to the muscle wasting? Actual weight loss is uncommon in Cushpups (but not unheard of as my own Cushpup also lost weight prior to treatment).

Last but not least, I'm assuming that Toby's glucose and thyroid levels are remaining in the normal range? I just want to make sure that we're still confident that there is nothing else "at play" with Toby other than the Cushing's.

OK, now on to YOUR questions. Given Toby's initial weight of approx. ten pounds, starting him off at 2.5 mg. was REALLY low (only half the dose of the already conservative UC Davis protocol). I know you and your vet have wanted to remain cautious, but after seven months, you are only now reaching the starting dose that Dechra would have intially recommended for Toby (1 mg. per pound). With your most recent ACTH coming in at 11.6 -- I don't think you have any basis yet for considering shifting treatment modalities. Unfortunately, Toby's Cushing's has essentially remained uncontrolled during these past seven months. That has allowed his muscle wasting to progress, which is unfortunate since along with skin/coat issues and a pot belly, muscle wasting is one of the slowest symptoms to rebound once cortisol finally does fall within therapeutic range.

Since Cushpups are bombarded with excessive cortisol at all times (not just transitory spikes like normal dogs), it really is necessary to lower their circulating cortisol down into the desired therapeutic range before expecting to see any improvement in overt symptoms (ideally 1.45 - 5.4 ug/dl for pups on trilostane; up to 9 if symptoms are well-controlled). So for example, just because the ACTH has been lowered from 30+ to 15, you can't expect to see "half" of an improvement in symptoms. The pup may need to be consistently maintained in that target therapeutic range before you will see any symptom improvement whatsoever. Typically, excessive thirst and hunger may improve in a matter of weeks -- even days. Other symptoms such as muscle wasting can take considerably longer. Here's a link to a Dechra publication containing info regarding reasonable expectations as to symptom resolution:

Dechra Technical Brochure (http://www.dechra-us.com/files//dechraUSA/downloads/Client%20Literature/38965_Technical_Brochure.pdf)

As far as guidelines as to dosing increases, different specialists may have their own protocols based on the experiences they have had in treating Cushpups. But overall, I think the most important guideline is each dog's individual pattern of ACTH results. That's why it will be helpful for us to see Toby's. But I will say that seven months is a terribly long time for your vet to have kept tinkering with tiny dosing changes. I know you consulted directly with Dechra at one time, and perhaps your vet would be willing to talk to them now, as well, if Toby doesn't show some significant improvement on this next ACTH. That may give your vet the confidence to actually move forward with effective treatment for Toby before he worsens even more.

As far as withholding water for just a half-hour after feeding, I wouldn't think that short amount of time should be an issue. We have had folks who have planned to withhold water all day while they were at work, for instance. And THAT would definitely be an issue. And as far as suggestions for improving his muscle mass, I will let others address that issue. But by far the biggest help would be getting Toby's cortisol under control!

Marianne

Tobias

10-23-2010, 11:05 AM

Hi Marianne: Thank you so much! I have requested past 3 stim test results from July, August and September and will pick them up by 4:00 today this afternoon. Also when I called the clinic I asked for weights he has not lost weight at all. In fact he gained a little bit from past June. I know I must have posted somewhere that he weighed 10 pounds at the beginning, but I must have been estimating bc per their computer today upon checking , actually at therapy onset he weighed 8.2 pounds. He maintained that weight until June, when he dropped to 7.6. As we have slowly increased the dose he has maintained at 8.2, just about breed standard actually a little over but he is large for a Yorkie. I am going to study your post today, and will post his stim results tonight. thank you for pressing me on the "science" to get everything precise. I will talk top Karl and I know he will work with me and call the vet at Dechra if this is what is necessary which I do agree, before any further dose adjustments, we must do so he is confident about getting a little more agressive with the management. But I am squeamish too, there is no doubt about that. More later and many many thanks to you from Linda and Toby

labblab

10-23-2010, 11:53 AM

Linda, that will be great to have the ACTH results for July, August and September. I went ahead myself and backtracked in your thread to see if you had posted results for earlier months. And here's what I found. Just want to clarify one thing, though. In re-reading your thread, it looks as though Toby started out in March on 5 mg. (not 2.5 mg.?), and 5 mg. is where he remained until at least July. Is that correct? If so, all these prior ACTH results reflect an unchanged dose of 5 mg.:

Pre-treatment diagnostic ACTH: Pre: 7.51, Post: 47.3
(5 mg. of trilostane started on 3-29-10)
4/16 ACTH results: Pre: 5.07 Post: 15.08
4/27 ACTH results: Pre: 4.38 Post: 13.7
6/28 ACTH results: Pre: 5.77 Post: 11.0

At what point did you increase his dose to 7.5 mg.?

Marianne

Tobias

10-23-2010, 05:07 PM

OK Helpers, here is where we are. I just picked up his last three stim test results. Toby did start on 2.5 and work up to 5 within a couple of months, I think--I really am not sure on that one. But he was at 5 for quite a while...I have it marked on our calander that he went to 7.5 on August 19..It was actually supposed to be earlier than that but I had a tooth extraction and developed dry socket so I put off raising the dose until I could focus on him..I was quite drugged for pain and feeling quite un-sharp, shall we say. 6/28 stim test was 11.0. Anyway, when I came off the codeine myself and started to feel better, on 8/19 he was increased to 7.5. 8/27 stim test was 10.6. 9/27 stim test on the same dose was 11.0. After a month, I did not think the level was going to drop any further on 7.5 So I asked for an increase at that time and Karl was in total agreement. But we just went to 10, hoping that would work because I am giving him brand name Vetoryl and I pay a local pharmacy to compound the in between doses. They waste 1/3 of it and charge me 40.00 a month to compound it. I hae to pay for the waste, too! Anyway, then my husband tore his biceps tendon and required surgery and Trips to Rochester for surgery, etc. Again I waited until after Gary's surgery to increase the dose of Vetoryl because I want my full attention on the dog when I do an increase....So on October 18--after I had used up the previous compounded refill of 7.5 mg I had paid for ahead of time and could not afford to throw out--I gave him the 10 mg dose....he has been absolutely fine. He is due for stimtest 10/28, now. The big question looming, as I do not want to keep up at this snail's pace of regulation any longer....is how much we can increase it after this next test. Should I go to 15? Should I go to 20? Toby shows absolutely no side effects and his blood work has remained unchanged basically throughout all this time. Thanking all again for guidance and light. We have had a rough summer but now my focus is back on Toby. I am wondering if I should ask Karl to call the Dechra vet to establish safe parameters for increase, based on lab work, stim tests etc. Blessings to all, Linda

littleone1

10-23-2010, 07:11 PM

Hi Linda,

Corky's dosage has had to be increased 3 times since he started taking Trilostane. His IMS started him on the lower dose, which helped at first. Then his cortisol level kept rising. Corky's dosage was increased from 20mg to 25mg once a day. He then went to 31mg a day, BID. He's now at 40mg a day BID. This really helped reduce his cortisol level. His last stim test was 3.0.

I would definitely get your vet's input about any dosage increase. I know the dosage does need to be adjusted depending on the stim test results. Many furbabies can be stabilized once they are on the dosage that controls their cortisol levels.

Terri

Tobias

10-23-2010, 07:27 PM

Hi Terri and thank you! It really helps to know what experience others have had; especially to feel more comfortable about dosing smaller dogs such as your Corky and my Yorkie, based on the increases you have safely made! . TC Linda and Toby.

labblab

10-23-2010, 09:54 PM

Linda, thanks so much for your additional info. I'll go ahead and add it to what I had posted earlier, in order to have Toby's complete ACTH history all in one spot. For what it's worth, according to what you posted on your thread back in March, it really does look as though you started out on 5 mg. rather than 2.5 mg. You reference 5 mg. as a starting dose on several occasions, without ever mentioning 2.5 mg. Regardless, it appears as though Toby was on 5 mg. for an extended period of time.

Pre-treatment diagnostic ACTH: Pre: 7.51, Post: 47.3
(Trilostane started on 3-29-10; either 2.5 or 5 mg.)
4/16 ACTH results: Pre: 5.07, Post: 15.08
4/27 ACTH results: Pre: 4.38, Post: 13.7
6/28 ACTH results: Pre: 5.77, Post: 11.0

(Trilostane increased to 7.5 mg. on 8-19-10)
8/27 ACTH result: Post: 10.6
9/27 ACTH result: Post: 11.0

(Trilostane increased to 10 mg. on 10-18-10)
Awaiting first ACTH test at that dose.

Linda, I honestly don't think there is any point in speculating about a dosing increase until you see the results of the next ACTH test. If Toby does show a decline after approx. 10-14 days on that dose, you may want to leave it alone until for a few weeks longer. If there is no significant decline, your dosing decision may be different.

I do agree that it is unfortunate that so many months have passed without Toby receiving a therapeutic dose of the medication. But that is now water under the bridge. And you don't want to err in the opposite direction and abruptly increase his dose prematurely in order to try and make up for the time that has been lost. So let's see how his next ACTH results turn out, and then take things from there.

Marianne

Tobias

10-24-2010, 12:16 AM

Wow Marianne: I just feel so much better after reading your post. You are right--I had the same thought today ( I have thought about this quite a bit today) that it is water over the dam in terms of not moving faster. I did the best I could with the knowledge I had--when I got more knowledge I tried to increase the dose--(this was after the post in which you emphasized it so strongly) Then my tooth issue and Gary's injury, plus the need not to waste any more medicine because the finances are so tight, plus my grieving over Zorro for many months and just not taking hold of Toby's treatment like I could have--all of this contributed to how it is today. All I can do is go on from here. I am so grateful that you put this into words that really echoed thoughts I was having today. I just can't tell you now much it means to me to have you just an e-mail away to help oversee this. We really cannot afford an Endocrinologist right now and anyway--I think you know more than any I might locate. But I have a vet who is greatly concerned for the welfare of my dogs and willing to partner up and learn. He is a very intelligent and compassionate man and whatever he lacks in knowledge is outweighed by his genuine desire to see me through this while keeping my dog safe--he was the vet who euthanized Zorro the week before last Christmas and I know he understands how this affected me and how careful we are both being because of this. I am just starting to heal and really focus on my boy after being on auto pilot for so long. I know you understand this because after reading your memorial posts I know how profoundly you grasp the human animal bond. To have someone like you to understand and help is just so awesome. Thank you for putting every thing in the post about the dates and results. It is so important to stay precise with the values. It is not a strong area for me...Blessings to you and all your wonderful helpers. I will post more than likely early next week (going into the first week of November) as the draw will be this coming Thursday and as you say, we will take it from there. More blessings to you from Linda and Toby

apollo6

10-24-2010, 12:37 AM

Dear Linda and Toby
Can't remember if I posted on your thread or not. I read about Toby bloating. Before I realized Apollo had cushings after eating and drinking he would just balloon up. He is on Vetoryl, 12.5 mg compounded weighs 10 lbs and just turned 12.
All I can say is it took me a long time before I decided on medication, lots of tests, lots of reading and getting input from this wonderful supportive forum. I was frightened to start Apollo on medication. If you have the time you will see from my postings. I don't regret finally making the decision. But you don't have to jump into it.
We are hear to help and support you through the roller coaster ride called cushing.
Welcome.
Hugs Sonja and Apollo.

Tobias

10-24-2010, 10:53 AM

Hi: Thank you!. Does this mean that there is possibility all this gas is related to the cushings disease process itself and will resolve when the medication is high enough? Did your dog's "ballooning" resolve when he got into the lower acth stim results. Thanks again and take care, Linda and Toby

Harley PoMMom

10-24-2010, 12:03 PM

Hi Linda,

I don't think that only our cush-pups are prone to this "gas" problem. I believe any pup that will drink/eat very fast will swallow air and this can create the issue.

Some members give their pups Gas-X and it seems to really help. Here are links to a couple posts from members about Gas-X:
http://www.k9cushings.com/forum/showpost.php?p=21818&postcount=48
http://www.k9cushings.com/forum/showpost.php?p=21926&postcount=51

Link to Gas-X: http://www.gas-x.com/products-infantdrops.shtml

As always, it is best to get the approval from your vet before giving anything new.

Hope this helps.

Love and hugs,
Lori

Squirt's Mom

10-24-2010, 12:24 PM

Hi Linda,

When you say Toby has a problem with bloating, do you mean his tummy swells after eating and drinking, or are you talking about GDV - Gastric Dilatation and Volvus? GDV is a very serious condition and can be fatal very quickly. One of our babies had the dilatation but luckily we got her to the vet before there was any twisting...still it was very scary, especially after learning about this condition.

Here are some links on GDV:

http://www.peteducation.com/article.cfm?c=2+1677&aid=402

http://www.addl.purdue.edu/newsletters/2005/Summer/canine-acd.htm

http://www.vetinfo.com/symptoms-of-gdv-in-dogs-canine-gastric-dilatation.html

http://www.vetsurgerycentral.com/gdv.htm

Hugs,
Leslie and the girls :D - always

Tobias

10-24-2010, 03:13 PM

HI Lori and Leslie

I am giving Toby simethicone liquid at dose given by the vet. Gas X is I think, simethicone? This does help Toby but I worry about the time between when I give it and when it works....he gets so round...I don't know how he breathes. But really his breathing does not seem labored (he has always had a bit of a collapsing trachea). But he seems normal in all other respects. I do not mean volvulus or gastric dilatation/torsion.. I do worry that with the bloating he could develop volvulus and I keep him super quiet for at least 2 hours after eating. I know he does not have a deep chest and is not a breed prone to torsion, but I worry about it anyway and don't do playtime in the morning till he has had time to digest. I honestly think it might be related to the cushing's, because it makes sense that if his skeletal muscles are atrophying that maybe the muscles that affect peristalsis, etc, are not as forceful? I am not sure, though. TC and thank you for your input and concern for Toby. I am just in a funk about it at the moment.....will talk to Karl tomorrow about the plan and post when I have the stim test results for guidance before deciding what for sure I want to ask for. Blessings and have a great week to all..Linda and Toby

apollo6

10-24-2010, 03:43 PM

Dear Linda
to answer your questions

Does this mean that there is possibility all this gas is related to the cushings disease process itself and will resolve when the medication is high enough? Did your dog's "ballooning" resolve when he got into the lower acth stim results. Thanks again and take care, Linda and Toby

Apollo was bloated after eating. He ate too fast and the extra water consumption only aggravated the situation. But it did start around the time of his cushing diagnose. I have not seen it since. Maybe the combination of lowering the cortisone, a reduction in water intake and eating not so fast helped.
Hugs Sonja and Apollo
P.s if possible in your profile, we'd love to see you download a picture of Toby.

Harley PoMMom

10-24-2010, 05:14 PM

Hi Linda,

You are correct, the active ingredient in Gas-X is simethicone.

Does Toby's abdomen resemble a pot-belly appearance? Does his roundness go down or does it seem to stay?

The reason for the "pot-belly" appearance in our cush-pups: Cushing's does cause the liver to enlarge because the liver is working harder. Excessive cortisol can cause muscle atrophy and one of the places this is usually seen is in the abdomen.

If you think the excessive gas is coming from how fast Toby eats they do make special bowls for dogs that are supposed to help with that.

Love and hugs,
Lori

Tobias

10-24-2010, 08:08 PM

Hi again: The exaggerated roundness of toby's belly goes away as the hours between meals pass. It is food and drink related, without question...I will try to send a picture. He is so adorable. The face of a Yorkie is so appealing. I have had him since puppyhood. We went to obedience together when he was 1 and he charmed everybody including the instructor. He won the "most progress" award because with each class he became more outgoing and joyful. Let me go and see if I can figure out how to do a picture--I tried many months ago and gave up. Here I go. TC and blessings and gratitude to all. Linda and Toby

Tobias

10-24-2010, 08:24 PM

Hi sorry to bother everyone again but I think I uploaded a picture of Toby. It is about 4 years old....his coat is quite lighter now almost white. I need to send a more updated one but I was afraid I would run out of time. I am going to try again with a more recent one. Thanks from Linda and Toby PS did the picture make it in the album? I am not sure.

addy

10-24-2010, 09:50 PM

Yes, the photo is there and what a darling photo it is:)

I was curious, you mentioned his coat color is changing to almost white. Did that just start? I ask because my Zoe is about the same age and all her honey colored markings are turning white. Since she has skin/coat issues, I figured it is the Cushings.

Anyway, your Toby is really cute. I can't really comment on the bloating. Zoe has colitis and sometimes her stomach does get bloated. Since her colitis has been under control and I cut back a tiny bit on her food, it has been much better, for awhile her tummy was tight as a drum. She is also on melatonin and lignans for now. That could be helping too as it seemed to help her colitis.:) We are on wait and hold for a retest in late November or December, depending on the holidays.

Glad you found us,
Addy

Tobias

10-25-2010, 09:54 AM

Hi Addy: Thank you for letting me know about the picture making it! I am asking hubby for a recent photo with our new camera to upload. You will see there is quite a difference. The coat whitening has been dramatic in the past year, I think he actually had cushings for a while before it was diagnosed; I think that is why his ACL ruptured a few years back--at the time the orthopedist stated it was an unusual injury for a small dog....Also there have been episodes with his bowels but fortiflora has really helped that...It isn't cheap but worth my sacrifice to buy it, for sure. I thank you again, many blessings from Toby and LInda; we are very appreciative of everyone's help.

addy

10-25-2010, 02:38 PM

I was using the Fortiflora for awhile with Zoe. I then switched to Culturelle (human probiotic) You have to play around with the dose, Zoe is 18 pounds and gets 1/2 capsule every evening. Some are able to cut back to 2 or 3 times a week but Zoe needs it every night. I purchase it from Walgreens. I think it is cheaper than the Fortiflora. We stock up when it is on sale $18.00 or $19.00 for 30 capsules so that is 2 months worth for me. It seems to be pretty consistant for Zoe. I just open up the capsule and sprinkle some on her food.

Hugs,
Addy

labblab

10-25-2010, 04:12 PM

Linda, I've still been thinking more about you and Toby -- and considering what I might be doing, testing-wise, if I were in your situation. You've already had so many ACTHs performed that I hate to think of one at this ten-day mark at the new dose -- and yet another one at the 30-day mark. Because if Toby ends up showing some downward movement on the ten-day test, you'd probably still want to give him the 20 additional days to stabilize and be retested on this same dose before upping it even further.

Given the fact that Toby has been on the trilostane now since March without any ill effects, I'm going to throw out a suggestion that you and/or your vet might want to discuss further with Dechra. And that would be to forego the full ACTH test on Thursday, and instead only test Toby's baseline cortisol within that same 4-6 hour "window" after his morning dose of medication. In other words, hold off on the full ACTH test until Toby has reached the 30-day mark on the new 10 mg. dose. And then, based on those results, you could decide to stay put at the 10 mgs. or increase the dose further.

This is what I'm thinking... From a safety standpoint, your big concern is to make sure that Toby has not dropped too low on the new dose. I believe that is really the main reason for the initial ten-day cortisol check after a dosing change. And one new research study has recently been published suggesting that as long as a dog's baseline cortisol (or "pre" number) is higher than 1.3 ug/dl, the likelihood is great that the dog is not being oversuppressed by the trilostane. The single baseline draw should be far less expensive than the full ACTH, plus Toby wouldn't have to remain at the vet's office for any longer than the initial blood draw. And then if he continues to look and act normally -- and his baseline cortisol is greater than 1.3 ug/dl -- perhaps you could just sit tight until performing the full ACTH at that 30-day mark. And then, if Toby's "post" ACTH cortisol level is still too high, increase the dose and repeat the same process during the next 30 days.

I am just conjecturing here and I don't know what Dechra would have to say about such an approach, especially based upon just one research study. But I believe that a researcher from Dechra's U.S. office participated in this study. Even if not, I'm certain that they are aware of this new data. So you might consider calling them in order to see whether, given Toby's previous dosing/testing history, his situation could merit some type of revised testing approach. Once again, here's Dechra's U.S. contact info:

http://www.dechra-us.com/Default.aspx?ID=365

Marianne

Tobias

10-25-2010, 11:56 PM

Hi Addy and Marianne--thank you for your wonderful ideas. I have tried Toby on so many different probiotics and always end up back at the fortiflora--it just seems to work so well for him. But you never know. At any rate, I just ordered a 3 pack so I'll probably just carry on with that for a while. But you are right about the expense--it is a killer. I thank you Addy for taking the time to fill me in about this; it was very nice of you! I hope someday I can help others, too, when I have learned more.

Now, about the "partial" test; I understand the logic and it makes sense to me. Marianne, I think I will sleep on this, as it is quite late for us and my night time blood pressure medicine is really starting to kick in and my brain feels like mush right now. I may just call them/Dechra in the a.m. and "give this a go" and then call Karl thurs a.m. Many thanks for the money saving tip--it comes at a good time. I'll let you know what they say. TC and thanks for the brain power. Toby certainly thanks you to. Blessings to you and yours from Linda and Toby.

Tobias

10-26-2010, 10:07 PM

HI again all: Just quick post as I have quite a bit going on ATM. But I did talk to a very nice vet at Dechra...actually everyone was so friendly and helpful, even the office people/receptionists were super. He does not seem to think it so bad that we are going slowly. The medication has a very wide range of effectiveness for any given dog..a dose that would be fine and control symptoms for one dog may not control symptoms for another dog. This was the gist of what he said. If we go very slowly we will find the lowest possible effective dose ...this is my interpretation of what he said. He said from what I am describing (as Marianne surmised) he has never been controlled. I am going to call him with the results of the Thursday test. From the sounds of it to him Toby is heading for twice a day dosing, from my descriptions. He has no doubt Toby will be brought under control and that we can help him. We had a super bad phone problem (my end...call waiting disconnected me...Time Warner..I am so disgusted but nevermind) and had to resume talking after I tried several times to get him back so I never did get round to the question of the "partial" test study. My regular vet also thinks we are heading for two doses per day and we will see what results are Thursday. Also he would rather do the UCCR and testing as we have because he does not want to change anything from the manufacturers protocol for the testing, even though a UCCR will more than likely be predictably positive...he seems to want to know how positive. So anyway this is what I know for now and I will post more later when there is a bit more time. I do feel reassured after talking to Dr. Allen. Blessings to all from Toby and LInda.:)

Tobias

10-28-2010, 09:00 PM

Hi Cushing's caretakers and love and blessings to each and every one! Toby went today for his 10 day stim test after dose increase. The results are not back yet..it could be Monday or tues, I think. But today we also did the UCCR test as per the UC Davis protocol to prepare for possible twice a day dosing and I am seeing so much rebound in the evening and into next morning pre dose time in terms of drinking and food seeking..... I asked them to do a urinalysis also as just a general screen for any possible kidney issues etc in addition to the blood work. Alas I am at somewhat of a loss to understand the significance of the abnormalities in the urine as written on Toby's discharge sheet. The science is not my strong point. Vet writes that Urinalysis showed a dilute urine with specific gravity of 1.008--it is written on the paper hubby brought home as I was at work. Also proteinuria ++, normal sediment no inflammation???.Urine sent for uccr ( I understand what that test is for) and also protein creatinine ratio tp better assess why he is losing protein in the urine?I wasn't so sure about the protein creatinine ratio? The vet also wrote that pending the results of the protein creatinine ratio further diagnostic might be in order i.e., ultrasound of abdomen or kidneys. I am giving Toby extra ground beef in his meals --maybe a tablespoon twice a day??? just to help him keep weight and energy up...Maybe I should not do this. Also if we do go to twice a day dosing I thought I read somewhere on this forum (the only one I post on...you all seem so darn smart) the dose should be lowered a little and I wondered if anyone had an opinion about that. Thanking my helpers with all my heart ...Linda and Toby.

lulusmom

10-29-2010, 12:30 AM

Hi Linda,

To answer your question about twice daily dosing, it is recommended that you up the daily dose a bit and divide by two. For instance, if Toby is getting 20mg once a daily, you would up that to 30mg, divided into two daily doses of 15mg. However, you first need to see if his current daily dose is adequate. If the post cortisol is still high, his current dose is too low and you may need to up the dose a bit more.

With respect to the urinalysis, dilute urine, low specific gravity and protein in the urine are very common in cushing's. Since Toby's cortisol has never been under control, these results are not surprising at all. These abnormalities, as well as others, such as elevated liver enzymes, usually normalize once a dog is stabilized on the correct dose. If creatinine and bun are normal, I personally would not pursue further testing for possible kidney dysfunction until Toby's cortisol is within the therapeutic range and his symptoms have resolved.

Looking forward to the results of the acth stim and the UCCR.

Tobias

10-29-2010, 10:05 AM

HI: Thank you! I have his bloodwork from 09/27/10 in front of me right now and it says BUN 24 Creatinine 0.7, BUN/CREA 34. On the sheet is shows 25 as normal value for BUN/creatinine. Is that significantly high above the normal and should I worry about that/does it mean we should investigate it now or just wait? Many thanks. Linda and Toby

labblab

10-29-2010, 11:57 AM

Also if we do go to twice a day dosing I thought I read somewhere on this forum (the only one I post on...you all seem so darn smart) the dose should be lowered a little and I wondered if anyone had an opinion about that.
Linda, I'll leave the kidney questions to those who are better informed than I. But I think I can clear up possible confusion about twice daily dosing. Glynda is absolutely right regarding Dechra's published recommendation: if a switch is made to twice daily dosing, increase the daily total by a small amount and then divide into two doses given 12 hours apart.

However, one of our members -- Dr. David Bruyette, a veterinary endocrinologist -- posted this reply last year when some questions were asked about twice daily dosing:

With regards to once vs twice a day dosing if we look at all the studies throughout the world you will see that about 80% of dogs do well with once daily dosing. One huge advantage of once daily dosing is owner compliance which goes up substantially when owners only have to dose once a day. While twice a day dosing may result in a lower amount of trilostane being used per day it will require closer monitoring as the ACTH stimulation tests tend to be lower so we have to look for both hypocortisolemia and electrolyte abnormalities.

This quote has been posted here at various times, so it is probably what you are referring to. I can only speculate, but perhaps Dr. Bruyette's comment reflects a trend over time -- that as dogs become stabilized on a twice daily dose, their dosing needs tend to decrease somewhat, and the longterm trend is for a lower daily total than for dogs being dosed only once daily.

I also want to "second" another comment of Glynda's -- that if Toby's ACTH result is still outside of the desired therapeutic range, a reasonable treatment plan might be to increase his once daily dose before deciding to shift to twice daily dosing. According to the UC Davis protocol, the results of the UCCR really only become relevant if the morning ACTH results are where you want them to be. Otherwise, an elevated UCCR only confirms something that you already know -- that Toby's cortisol is not being controlled sufficiently at any time of the day. Here's that quote from the Davis protocol:

The UCCR result should be within the reference interval and the post-ACTH serum cortisol concentration should be between 1.5 and 5.5 mcg/dl.

If the serum-cortisol concentration is within that goal and the UCCR is abnormal, the medication should be given BID [twice daily]. If the serum-cortisol concentration is too high, the trilostane dose should be increased. But if the serum-cortisol concentration is too low, the dose should be decreased.

There may be additional reasons why the Dechra rep. is thinking that twice daily dosing may benefit Toby. One might be his size -- for small dogs, Dechra may feel that it is better to split the dose rather than to keep increasing a single daily dose to a high level. But in general, the published literature that we have seen coming from both Dechra and UC Davis recommend holding off on a shift to twice daily dosing unless symptoms (and UCCR) are rebounding too quickly for a dog who demonstrates a therapeutic morning ACTH result. And thus far, Toby has never had a monitoring ACTH result within that desired range.

Marianne

lulusmom

10-29-2010, 12:26 PM

Hi Linda,

Normal bun should be below 25, which Toby's is high normal, and creatinine should stay below 1.6 and I believe Toby's would be considered low normal. This is very good as creatinine is a much better indicator of true kidney dysfunction so if this is elevated, I would be worried. A high normal bun and a low normal creatinine will cause a high bun/creatinine ratio, which is not uncommon in cushing's or even diabetes mellitus. Basically, any condition that interferes with the metabolism of protein, including dehydration and a recent high protein meal, can cause a high ratio.

I believe that the abnormal lab results you are seeing, including the high bun/creatinine ratio, can be attributed to the lack of control of Toby's cortisol. In my laywoman's opinion, it would premature to launch full blown kidney function testing until such time as the cushing's is under control.

Glynda

Tobias

10-29-2010, 08:13 PM

Hi Glynda and Marianne: Thank you Glynda, for relieving my worries about Toby's kidneys. I am going to quote you to the vet when I speak with him I hope Monday. I will tell him that I have learned from the forum that dilute urine and low specific gravity with moderate amts of protein are to be expected because his symptoms are not resolved. This does correlate with what the vet said from Dechra, Dr. Allen. He said he could predict without even seeing the dog, from what I was describing, that the UCCR would be positive. Thank you for reinforcing this for me; I have read it over and over and I think I understand it now...when humans drink lots of fluids our urine becomes more dilute also...this is why they tell us if we are plagued by frequent UTIs to drink...it dilutes the urine and there is less bacterial concentration, etc...is this a correct understanding? And I ESPECIALLY understand and agree with the plan of getting the post stim value to the therapeutic range between 1.5 and 5.5 on once daily dosing before going to twice daily dosing. It is safer, too, in my opinion (just my opinion) because if you don't know how to dose the dog once a day to get a satisfactory post stim value, there is not a solid base for increasing it and then dividing it to something else--you could increase it too much or too little, because you really haven't established what his once daily dose requirement is. Do I have that right? :eek: I am going to run copies of your explanations and review them before I go to sleep so they will sink into my subconscious mind and I will be ready to advocate for my boy with my vet. I will post the stim results asap after talking to my vet. Toby and I are so blessed to have your collective understanding. Kindest regards from Linda and Toby

littleone1

10-29-2010, 08:39 PM

Hi Linda,

I know there has been discussion on once a day dosing with Trilostane vs BID. In Corky's case, BID is actually better for him. Each furbaby is different, and the dosing requirements are also different. There are some dogs that actually do better on BID, and Corky is one of them. Corky's dosage didn't decrease. Instead, it was increased. I believe that this is something you need to discuss thoroughly with your vet.

Terri

Tobias

11-02-2010, 10:41 AM

HI all: I have news about Toby and it sounds concerning. Is there hope for him? The vet called early this morning and said (I wake up late d/t working second shift and I felt it important to take the call but I was barely awake and writing without my glasses so I hope this makes sense). Toby's acth is not back but the protein/creatinine ratio he sent is. Toby is loosing much protein through urine.His protein creatinine ratio is 7.7. Vet said normal is less than 5. Abnormal greater than 1. He said Toby could have kidney degeneration. Still the BUN and creatinine are okay. Is the protein loss causing the muscle wasting or is the muscle wasting causing the protein loss? He said his glomerular protein is very high but his BUN/creatinine ratio is okay. His UCCR is 52! His first one for diagnosis was only 17.6. He wants to put Toby on something called benazepril, a vasodilator, to decrease protein loss in the kidneys. Also fish oil to decrease inflammation. He wanted to go to 7.5 twice a day pending ACTH stim test result not yet back. But I told him I want the once a day dose correct for bringing him down into the 1-5 range (I don't remember the exact range and don't have time to find it ATM) before going to twice a day and also of course, we have to get the stim test back. Can someone tell me what these values mean for Toby. Thanking you all--I do hope there is some hope. Blessings from Linda and my sweet Toby

Harley PoMMom

11-02-2010, 11:11 AM

Have you ever had Toby's blood pressure checked? High blood pressure can cause protein loss in a pup. My boy Harley has high blood pressure which is being controlled by Amlodipine and Benazepril. Harley gets 2.5mg Amlodipine BID and 2.5mg Benazepril SID.

Harley also has proteinuria, his last UPC results were 5.0 (>=.5) he was also dx'd with kidney disease/glomerular disease.

There definitely is hope for Toby!! Harley is doing great, so think positive, ok!

Anything I can do to help, just ask. ;):)

Love and hugs,
Lori

Tobias

11-02-2010, 12:22 PM

HI Lori--thank you! The vet did mention something about possible glomerular disease, too. Also his blood pressure was high on visiting the vet specialists last year...I am not sure if they regularly check it at our vets locally? I will ask about thisMy concern about adding the benazepril now is that we are going to be increasing the vetoryl, more than likely, and I worry about sorting out the side effects with an increase in dose and the addition of a new med which will possibly impact appetite, lethargy, drinking and urination. How will I know what is what at the outset with new dose of Vetoryl and new dose of benazepril? Maybe I should start the benazepril and then wait about 10 days before increasing the vetoryl?? Does that make sense? Thanks again for your input. I'm glad your Harley is doing so well..it gives me hope, too. TC Linda

Harley PoMMom

11-02-2010, 01:32 PM

If it were me, I would definitely want to know if Toby's blood pressure was high and if so, then your vet would make the correct blood pressure medication dosage based on Toby's blood pressure reading.

Also with Harley giving him the pepcid ac BID is vital for the nausea that the blood pressure medicines sometimes give to him.

With glomerular disease, I give Harley wild salmon oil too.

Here is a link to an article about glomerular disease in dogs: http://www.marvistavet.com/html/body_glomerulonephritis.html

Hope this helps.

Love and hugs,
Lori

apollo6

11-02-2010, 03:39 PM

Dear Linda
Will be praying for you and Toby.
Apollo is 10lbs and was on 10mg. now is up to 12.5mg. compounded liquid. He gets it once a day. I am going for the ACHT STIM to see how the increase is. Please note when doing twice daily , does not mean doubling up the dosage.
It would mean increasing dosage by only an additional 1/3 or 1/2.
eg . 5 mg +1/2 would be 2.5mg. so 5mg and 2.5 mg or 7.5 mg. once a day.
Please see actual quote from Decha/Trilostane.
1. Individual dose adjustments and close monitoring are essential. Re-examine and conduct an ACTH stimulation test 10-14 days after every dose alteration. Care must be taken during dose increases to monitor the dog's clinical signs and serum electrolyte concentrations. Once daily administration is recommended. However, if clinical signs are not controlled for the full day, twice daily dosing may be needed. To switch from once daily to twice daily dosing, increase the total daily dose by 1/3 to 1/2 and divide the total amount into two doses given 12 hours apart.

Apollo has been doing okay with the increase so far. But still the hind leg weakness. My concern for Toby is that his dosage is not increased too much. Apollo is not a strong little guy, has stomach issues, so I have been extremely conservative with dosage. Hope this helps.
Hugs Sonja and Apollo

lulusmom

11-02-2010, 03:49 PM

Hi Linda,

Please see my comments below in blue.

Toby's acth is not back but the protein/creatinine ratio he sent is. Toby is loosing much protein through urine.His protein creatinine ratio is 7.7. Vet said normal is less than 5. Abnormal greater than 1.

Toby's protein:creatinine ratio is just a tad higher than my Lulu's was in the past. She was at 7 with 2+ protein. As I mentioned before, dogs with cushing's commonly have proteinuria which usually resolves once cortisol is adequately controlled. Not all dogs will see resolution, however, and my Lulu is one that is consistent with the 2+ protein. Because all of her other bloodwork and urine is normal, her specialist is not concerned with it and says that it is secondary to the disease.

He said Toby could have kidney degeneration. Still the BUN and creatinine are okay.

BUN and creatinine at normal levels is a good thing as it is an indication that Toby has no remarkable kidney dysfunction. As I mentioned in previous posts, I personally believe that testing or treating for possible kidney dysfunction should be deferred until Toby's cushing's is under control. I have a real concern that your vet wants to put Toby on drugs for kidney dysfunction before he has even ruled out high cortisol as the cause of the proteinuria. I predict that the results of the acth stimulation test will give your vet the answer he should be looking for.

It appears that your vet has failed to get Toby's cushing's stabilized after all these months and his apparent lack of understanding that the blood and urine abnormalities he is seeing are most probably due to high cortisol levels, are red flags that his experience with cushing's is extremely limited. I think you mentioned a specialist in one of your posts. Do you still have access to that specialist? If so, you may want to consider consider having the specialist direct treatment.

Is the protein loss causing the muscle wasting or is the muscle wasting causing the protein loss?

High cortisol levels cause both symptoms. It increases the blood flow in the kidneys which affects the glomerular filtration and as a catabolic steroid, it chews through protein and causes the muscle wasting you see.

He said his glomerular protein is very high but his BUN/creatinine ratio is okay.

These are not uncommon findings in cushing's.

His UCCR is 52! His first one for diagnosis was only 17.6.

It is not uncommon to see variable high UCCR results as many factors can impact how much cortisol is in the urine on any specific day, at any specific time. Factors as simple as there is more circulating cortisol now or how and when the respective specimens were collected.

He wants to put Toby on something called benazepril, a vasodilator, to decrease protein loss in the kidneys. Also fish oil to decrease inflammation.

Lots of our members, including me, give fish oil to their dogs. As far as the benazepril and vasodilator, I wholeheartedly agree with Lori. I would think that before your vet prescribed a drug that is contraindicated with Vetoryl, he would make absolutely certain that 1) the drug is necessary and 2) the dose is appropriate. The only way he can determine either is to obtain a blood pressure measurement. I don't mean to sound like a broken record but if the blood pressure is high, it's probably due to the fact that Toby's cortisol has gone uncontrolled for months and months. It could be that you won't have to worry about blood pressure meds at all once you get the cushing's under control.

He wanted to go to 7.5 twice a day pending ACTH stim test result not yet back. But I told him I want the once a day dose correct for bringing him down into the 1-5 range (I don't remember the exact range and don't have time to find it ATM) before going to twice a day and also of course, we have to get the stim test back. Can someone tell me what these values mean for Toby.

Through decades of experience in treating cushingoid dogs, it was determined that for a dog with cushing's to become "normal", meaning resolution of all clinical signs and improvements in blood and urine values, you must strive to get the dog's post stimulated cortisol within the therapeutic range of 1 to 5 ug/dl. That is the therapeutic range for dogs treating with Lysodren, however, the manufacturer of Vetoryl indicates that if all symptoms have resolved, a post stimulated cortisol of up to 7 ug/dl is the therapeutic range; however a post stim of 9 ug/dl is also acceptable as long symptoms have resolved.

Thanking you all--I do hope there is some hope.

I think there is a lot of hope that once you get Toby's cortisol down where it needs to be, a lot of your concerns will be eliminated.

P.S. Marianne has graciously provided me with the most current recommendations from Dechra relative the therapeutic ranges. Apparently, Dechra has simplified their dosing protocol a bit, and now they only discuss two acceptable ranges (they've eliminated that middle cutoff point of 7-something). The ideal range is 1.45 - 5.4. The second range is from 5.4 - 9.1, where the instructions are either to "continue with the current dose if symptoms are well controlled, OR increase dose if clinical signs are still evident." Linda, please share this with your vet as this is very important information for purposes of assessing acth stimulation test results.

Harley PoMMom

11-02-2010, 05:50 PM

Hi Linda,

I totally agree with what Glynda has said, Harley's vet was very hopeful that once we could get Harley's elevated cortisol adequately controlled that his high blood pressure and proteinuria would resolve.

Dogs can get what's called a "white coat syndrome" it is a phenomenon in which patients exhibit elevated blood pressure in a clinical setting but not in other settings. Does Toby get really stressed at the vets office?

We are here for you and Toby, ok?

Love and hugs,
Lori

Tobias

11-02-2010, 10:24 PM

Hi everyone; Well I have been busy all day from work reading the posts when I thought I could get away with it although I cannot post until at my home computer...Anyway I mulled things over quite a while and at the end of the day I called the specialists office and made an appointment for next Tuedsay the 9th at 10 a.m. actually I have been thinking about this for several days. This morning I thought about it really strongly after finding out about the lab work and the request to medicate. So all I needed was a shove...thank you! She is board certified, a diplomate in internal medicine. Her desk people seemed quite knowledgeable and agreed to fax a referral request to Karl. I just poured out my story and they were so nice! Then I called the home clinic and explained and My vet was just fine with everything. He said there is a really good guy at Cornell, too..I can't remember his name. Another pair of eyes is welcome and encouraged and he is filling out the referral. He is anxious to see what she has to say...he appreciates and highly endorses my idea. He knows of the vet we are going to and a former vet at our clinic actually worked with her and highly recommended her...this makes me feel quite peaceful about things. I told Toby tonight when I got home he would be going to the specialist because he is special. He said "I know!" Anyway the pre value on the stim test Friday was 5.08. and the post was 10. So this is where we are. I will keep him on his current dose more than likely until next Tuesday...this way I can use up the med and then see if the specialist wants to increase at that time and retest, or whatever. At any rate this is where we are. I will start the fish oil but not the benazepril. Thanking everyone for all the positive thoughts. Linda and Toby

labblab

11-03-2010, 08:49 AM

Oh Linda, I think this is a great plan! And I'm especially glad to hear that Karl is on board, too. This way you won't be losing anything -- you'll simply be gaining an expert consultant! :) :)

We'll all be anxiously awaiting your visit next week. In the meantime, please give our very special Toby some extra hugs and pats from his k9cushings family. ;)

Marianne

Squirt's Mom

11-03-2010, 03:06 PM

Hi Linda,

It sounds like you have a good plan in place for sweet Toby! I hope the IMS is able to give you some answers and get things under control so he will feel better. Let us know what she has to say!

Hugs,
Leslie and the girls :D - always

Tobias

11-09-2010, 07:42 PM

Hi all: Just a quick update on Toby. He did see his specialist today. She was not unduly alarmed about Toby's kidney blood work but asked to do a culture and sensitivity. So I agreed, and Toby got cathed. I told her he just had a urinalysis at the home clinic which was negative for any bacteria but she said with Cushing's dogs UTIs can go undetected by urinalysis because the urine is so dilute....I think she meant it would not concentrate the bacteria, etc., enough for detection? She said the changes in his values (the proteinuria...not sure about the glomerular changes??? could mean a uti--she would rule this out and lower the post stim first before trying to look at other kidney issues. She said that she has started dogs in his range at 30 mg! ...it took us7 months to get to 10! I just about fell out of my chair--3 times the manufacturers guidelines???? but anyway she has awesome credentials...but for Toby (I am not sure why) upon review of everything she would suggest going from the current dose of 10 to 15. That is actually what I planned to ask Karl for...so I am comfortable with that. She said she does not feel anything serious or life threatening is imminent. She said his liver is enlarged exactly in the manner of cushing's process. It feels (it sounds as if she was saying something like this--I certainly hope not to misrepresent her statement) as if it is a benign feeling liver to her but not a mass-type of thing. She mentioned it and went on. She really did not go off the wall about the benazepril (which I did, after someone here posted it was contraindicated and I reread the package insert) but said that in some cases it could benefit the kidneys but it would not be something she would start now. So she has her "people" looking for a compounded version of 15 mg for him and they will call first and then mail to me. We are going back to generic as the cost of wasting Vetoryl plus the compounding fee is just way beyond my means financially. She did get his blood pressure and said it is okay....she did not say what it was. If we can afford it (the charges there are super high IMO--55.00 for a blood pressure. 40.00 for a catheter and 40.00 to insert it. 175.00 for the exam and her assessment/input. Working in a hospital I know that is phenomenal mark up on a catheter but I realize this is part of their profit margin...groan....so I am not faulting them for that. She will not interpret stim tests results when her clinic does not draw them--again I understand this. They are vague about future charges as it depends what she wants to do.....again I understand this. I will probably try very hard to keep her on board till he is stable if we can swing it financially. Otherwise Karl and I could follow her current plan and then take him up again if we get stymied. ...I am not sure how it will go actually, at this point. She does not want to test him for a month after the change to a new dose of 15 mg. I did tell her I have a prednisone rescue dose and that seemed to please her. She said if he is to the point that he is so out of it he can't swallow (I asked her how to give it) he should be seen anyway and otherwise just put it in his mouth and let him swallow it. One interesting thing is that they wanted him fasting for possible diagnostics. When I told them the Vetoryl was always given with food and a meal she said it was okay to give it on an empty stomach...did anyone ever hear this? I thought the directions said give with a meal...So I said I would just hold it because I did not want to get into any struggles with him because he was so sick last night--he vomited about 12 times in 2 hours because my husband gave him celery for fiber (bless us and save us). :( Any way first the celery came up and then the rest...I will not relay anymore disgusting details) He finally stopped throwing up about 11:00 p.m. for good. He was so hungry this morning and I really had a hard time holding food and almost called the whole thing off but then the appointment got moved up to 9 so he wouldn't have to wait so long...I liked that she offered me the option. It is an hour drive and I left the house 1/2 hour after getting up basically:eek:No make up 3 minute shower no hair set, Tea and bagel in the car and bewildered Yorkie looking out from his crate towards the front seat wondering what happened to breakfast, I am sure.... Just wanted to share with you all as you have been SO helpful to me and I know being such a loving group of people you would wonder. Blessings...I certainly will post about the urine results...did anyone ever hear this before...she said she really things cushing's dogs should be checked twice a year for latent UTIs.....with great gratitude and respect to all. Linda and toby

Tobias

11-09-2010, 07:52 PM

Hey friends--me again. I also wanted to share that she really did not want to consider twice a day dosing until once a day dosing was adequate. This inspired confidence as it is the same way I felt. This would be a really good reason to stay with her until the plan is worked out if we can...twice a day dosing is really not something I would want to blunder through...she feels, as I know someone posted here...that he may not have what seems to be a rebound of symptoms when he is adequately controlled.... just wanted to mention this one last thing. Blessings and bye for now from Linda and Toby

labblab

11-10-2010, 08:52 AM

Hi Linda,

Thanks so much for your report! For the most part, it sounds as though things went well :), although they were definitely pretty darn expensive :eek:! As you say, hopefully Toby will soon be stabilized on an increased dose of trilostane and you will be able to cut back on the specialty costs.

The gameplan for the once-daily increase sounds good to me. Regarding giving the Vetoryl on an empty stomach -- as far as I know, it is not harmful, per se (although pups with sensitive tummies may generally do better if they've eaten something). But according to Dechra, the main reason for giving the medication with food is because it is metabolized more efficiently that way. As an isolated occurence, it does makes sense to me that the IMS would tell you it's OK for Toby to skip his breakfast on a day when other diagnostic testing (that requires fasting) might be performed. But hopefully she will instruct you to give his Vetoryl along WITH a small meal on a morning when an ACTH is to be performed. If not, I think you'll just have to assume that the result might have been lower had he eaten, and base your comparisons with previous tests accordingly...

I'll keep my fingers crossed that this new dosage will do the trick!

Marianne

Tobias

11-14-2010, 11:01 AM

Hi all: I just have one quick question to be 100% prepared and confident about my Toby's dose increase. Toby was increased to 10 mg on 10/18 and acth on 10/28 was 10.00 He saw the specialist November 9th and she is increasing him to 15 with no further testing until 30 days post initiation on that dose. My question: If the worst happens (which I need to be prepared for so that I know my plan and relax) and Toby needs to be evaluated, is there a time frame involved. Here is the scenario (a disaster drill, they would call it at work): Vet Specialist wants to do her own stim tests. Vet Specialist is a one hour drive. Linda needs her hubby with her, it's city, difficult driving. Linda works 5 days a week 12 noon to 8 p.m....they are tolerant to a degree about time off but I have to play it by ear, workload etc. Linda gives toby medicine at 8:30 a.m. At noon Toby is wobbly and staggering. He goes out back and has watery diarrhea. I bring him in, my heart is beating about 200+ per minute (and I am on 3 cardiac meds) I offer him a rescue dose in a very tiny piece of turkey frankfurter low fat, and he turns away and throws up again. He needs to see his vet! Now! What do I do? My local vet is 5 minutes away and will see him in a heartbeat, knows me, knows my dog, can at least figure out what is going on and give me further instructions to proceed to vet specialists when stable. But to assess my dog, won't my local vet have to do a stim test at the time, not 3-4 hours later by the time I've made arrangements to go to Rochester, found my husband at his job site, called work hoping I can come in late? My home vet when I asked him about this asked if there would be anything he could change about his procedures --even sending it to a different lab, using same cortisyn (?), same dose, etc., she would use, so that she would be comfortable with him doing the test on an emergent basis. So my question for all you brainey people is...am I just imagining that there would be a time constraint such as this? If I could take Toby locally couldn't they just give him an injection, and then do the acth the next day? But if I have to give him an oral dose the test will not be valid the next day, am I correct.

I guess a summary of my question would be: A crisis:eek:. The time frame for resolution of the crisis, the time frame for the diagnostics, should it in fact turn out to be a cushing's related crisis. The dog has been overdosed to the point of stupor. In this worst case scenario what would the plan be for rescuing the dog. If I can get some feedback I will be more prepared to talk this week to the specialist and verify everything before starting Toby on the higher dose:confused:. Blessings and gratitude to all from Linda and toby

labblab

11-14-2010, 11:48 AM

What do I do? My local vet is 5 minutes away and will see him in a heartbeat, knows me, knows my dog, can at least figure out what is going on and give me further instructions to proceed to vet specialists when stable.

Linda, I think you've provided your own best answer. And the good news is that it is really the simplest answer. If Toby were to have a reaction severe enough to warrant attention, then I think you should take him directly to Karl. Karl can then personally consult with the specialist in terms of what to do and when to do it. These are not decisions that you will have to make. The important thing is for Toby to be professionally assessed and stabilized. The vets will be the ones to decide the appropriate venue and time frame for testing, given Toby's specific condition right at that time. It is true that oral prednisone will skew an ACTH result for at a day or so. But if Toby was ill enough to be taken in, Karl (or any vet) would be able to draw blood in order to check his basic chemistries (those "electrolytes" that we keep harping about). And on an emergency basis, that information would probably be the most valuable and necessary in terms of deciding on appropriate immediate treatment such as IV support.

I know this will probably give you little peace of mind, but I think it is beyond unlikely that, without prior warning, Toby would have a reaction severe enough to warrant emergency attention. He has been taking the trilostane for seven months now without any ill effects whatsoever. You do such a good job of monitoring him that I do believe you would first see and notice nonemergency changes in his behavior that would signal that his dose is too high (for example, loss of appetite, less active, some diarrhea).

Since I am a huge worrier, I do understand and appreciate your desire to have a gameplan in place. But I don't think there is a set "time frame" that I can offer out to you. Because it will all depend on your vet's assessment of Toby's condition. You are so lucky that Karl is just five minutes away!

Marianne

Tobias

11-14-2010, 12:43 PM

Hi Marianne: Thank you! Ah yes common sense....the least common of the senses (or so my husband reminds me). Clarity is a breath of fresh air! I will be speaking to the vet specialist Monday about her protocols for the stim test and how Karl can comply, so that she would be comfortable with this should the need arise. Because it is possible that if there were a crisis and they did draw the lytes here and give him prednisone by injection, I might not be able to get him to the specialist clinic the very next day for the stim test; Karl would be willing to do the test per her guidelines (he has told me this) to satisfy any reservations she might have. But I guess part of me thinks this might annoy the specialist and that she might not want to tell us her protocol, that perhaps it relates somehow to her expertise and she would prefer not to share it? Is that ridiculous? I want to be so careful about hurting her feelings as I feel she has already been so helpful. So, does anyone think I would offend her by asking this? Thank you for your input. Linda and Toby

lulusmom

11-14-2010, 06:13 PM

Hi Linda,

I think your specialist would not only understand but should commend you for being a great advocate for Toby. I cannot imagine any vet or specialist who would be offended by a conscientious and educated pet owner who has taken the time to map out a sound plan in the event of an emergency. If your specialist were to be offended, knowing that you are an hour away, you should probably look for a new specialist who doesn't put their ego above their patient's welfare. Don't ever be afraid or embarrassed to discuss anything that could possibly affect Toby's well being with your vet or your specialist. You are Toby's only voice so make it heard loud and clear.

Glynda

Tobias

11-14-2010, 06:28 PM

Hi Glynda: Thank you! Your voice is very strong and convincing on this matter--it gives me a fresh perspective. Thank you for giving me confidence to ask for this. I do agree with you but do not think I could have put it quite so succinctly. You are right! So here I go! P.S. I too was "Lulu's Mom"--Lulu was my forever dog, an American Cocker Spaniel (aka "Queen Lu"). Lulu died on October 21, 2006. She had insulin requiring diabetes and lived 6 years post diagnosis to just short of 16. So whenever I get a post and see "lulu's mom" I think of my big, bossy boots girl and my heart sings. (I hope she hears). Thanks again for your input...you have empowered me! TC and have a great week...I will post upon finding out what she has to say. Linda and Toby

Squirt's Mom

11-14-2010, 07:00 PM

Hi Linda,

So whenever I get a post and see "lulu's mom" I think of my big, bossy boots girl and my heart sings. (I hope she hears).

She hears you, sweetie, and sings in unison each time.

Hugs,
Leslie and the girls - always

Tobias

11-15-2010, 10:22 PM

Hi again all: Just wanted to post that I did call the specialist to ask about the guidelines for the stim test for my home vet to follow in the event of an emergency and the girl at the desk talked to her and came back and said that the doctor said the injectable they use at the specialist clinic is more expensive and costs more, she thinks, than our local clinic would want to pay. Our local clinic uses something called cortisyn (spelling?) for the stim test. the specialist seemed to indicate that whatever she used was more expensive and "better" Did anyone ever hear of some tests using more expensive versions of of the cortisol to inject to stimulate the response and if so, what would the difference be in terms of accuracy. I did notice the cost at the specialist clinic is twice the cost at my home vet...The vet further said that she still does not want to interpret any specimens she does not draw at her clinic because she wants consistency???? I suppose of technique. But it is interesting to me that she is raising the dose 5 mg based on the tests I took her that were all done at our local clinic...and she is not requiring any further tests before upping the dose double the amount it has been increased before. And She does not want to test for 30 days. So she must have found the results somewhat acceptable. Also at that time she has no intention, apparently, of doing lytes or any other profile with the stim test in 30 days. ...which does rather shock me but I am (quite obviously) not a board certified diplomat. Well there you have it. Also she said if my home vet wants to know how to do the test in my home clinic the way it is done at the specialist clinic, he should call her and she will talk to him. So when I told my home vet that he said he will call her this week...he is very interested in whatever she is doing differently, I think. Just wondered what anyone would think about #1) upping the dose without the 30 day test of 10 mg every having been done (only the 10 day test which showed value of 10) and then going 30 days on the 5 mg increase (which would mean Toby at 15 mg now) with no further testing for 30 days. I guess because she is so qualified she does not have to go by the procedures recommended by the manufacturer. But I really would at least like to get a set of lytes before we increase the dose, just to make sure nothing looks abnormal before stirring the pot with an increase. Would that make sense? My home vet could just do that this week..it wouldn't be a big deal. Thanking anyone who has an opinion:confused: Linda and Toby

BestBuddy

11-16-2010, 03:03 AM

Hi Linda,

Buddy's specialist was always happy to either do the ACTH or take the results from our local vet. There are two types of injections (Synacthen aka Tetracosactide or Cortrosyn aka Cosyntropin) but I think (haven't had the heart to go back through Buddys records) they both used the same. I do know one is more expensive than the other but I believe the results should still be comparable.

Jenny

labblab

11-16-2010, 08:31 AM

Our local clinic uses something called cortisyn (spelling?) for the stim test. the specialist seemed to indicate that whatever she used was more expensive and "better" Did anyone ever hear of some tests using more expensive versions of of the cortisol to inject to stimulate the response and if so, what would the difference be in terms of accuracy. I did notice the cost at the specialist clinic is twice the cost at my home vet...The vet further said that she still does not want to interpret any specimens she does not draw at her clinic because she wants consistency????
I will be very interested to find out what your specialist is using that is even more expensive than cortrosyn. Because I've always thought it to be the priciest of the stimulating agents. When I started to read your reply, I first guessed that maybe your home clinic uses acthar gel. But now I'm really curious as to what your specialist uses and why she'd have a problem with cortrosyn. Here's a quote from another one of our administrators ("acushdogsmom"):

"Cortrosyn" and "ACTHAR gel" and another agent called "Synacthen" are actually synthetic forms of ACTH that when injected, stimulate the adrenal glands to release their reserves of cortisol into the blood stream.

There are many vets who use the gel, but the Cortrosyn or Synacthen do seem to be the stimulatory agents preferred by Internal Med Specialists, many of whom find the ACTHAR gel to be less reliable as far as getting consistent results is concerned.

Cortrosyn is very expensive though. And Synacthen, although less expensive than and considered just as reliable as Cortrosyn, seems to be used more in countries other than the USA. (My Internist here in Canada does use Synacthen).

As for "technique," maybe she's only referring to being totally consistent and punctual as to the timing of the injections. Or maybe she has some special method for calming the dog? Who knows? Please let us know what your vet finds out when he calls her, because your specialist does seem to be particularly rigid and protective re: the monitoring testing...

As for increasing Toby's dose without performing another ACTH beforehand -- I personally would not worry about that given Toby's most recent post-stim level and the resistance of his response to the previous increases over these past seven months. As long as he is looking and acting normally, I would not worry if he were my dog. I wouldn't bother having the electrolytes checked right now, either. But it's a simple and relatively cheap test. So if it would give you more peace of mind to have it done, I think that's your decision and not hers. Am I understanding correctly, however, that she's not going to check electrolytes at the 30-day ACTH testing mark? I would simply ask her "why not?" in order to understand her rationale.

Marianne

Tobias

11-16-2010, 10:26 AM

Hi to Jenny and Marianne: Thank you for your responses! They are both extremely helpful. My home vet just called and said she (specialist) is out until thursday and he (home vet) is on the call list for Thursday. So we will see. Also, I really appreciate the input on the lytes and lack of stim test before starting the new dose. Specialist did put us in touch with Diamondback and his medicine of new 15 mg dose) arrived yesterday. But because this week is so frantic I am going to probably wait until next Monday to start it and I may still do the lytes ahead of time...I think as Marianne said for peace of mind. But I will certainly post when I hear from Karl about his talk with her. I do think "rigid and overprotective" is the vibe I got from her but I really have only met with her one time and of course the main issue is how well is she doing with Toby....which remains to be seen. So far from the feedback on the list her decisions have been sound but there is a question about the lack of faith in any other vet to do a test she can interpret. Blessings to all....Off to work! Linda and Toby

Tobias

11-19-2010, 11:23 PM

Hi all: Just to let everyone know that my home vet has spoken with the specialist vet. There is really no difference in how they are doing the testing. The results are processed at the specialists in house but my home clinic sends to Cornell. There is a difference in the reference range for normal. (Which really shouldn’t impact treatment as we are looking for a treatment reference range). So far everything good. But then we lost her. Karl told her we want the ability to do the tests down here and ask for her help with interpretation when necessary. No she does not want to do it that way. She wants to do everything or nothing. She wants to do the test (160-180), examine the dog (extra, I’m not sure how much) and speak with me all at the same time. Electrolytes 60.00. Profiles 80.00. I am not getting out of there for less than 300 per visit. I just can’t do that, I have to be realistic.

She told my vet that she always starts dogs in Tobys range (less than 10 pounds) at 30. If they develop Addisons she really does not care, because treating Addisons is easier and cheaper than treating Cushings. This just made me sick. Did all the dogs “sacrificed moribund” in the clinical trials die for nothing? Is this how we honor their laying down their lives to create safety standards so that other dogs would not have to suffer further illness? It creeps me out big time…I know this is how some vets feel (as far as treating the addisons) but to me, it is practicing medicine with your brain, not your heart. I want a vet who has more regard for my dog than this.

So Karl and I have a plan: 1) Start 15 mg Monday. Test 10-15 days. Increase by 25% or greater if drinking and eating have not slowed and post stim results not in therapeutic range for treatment (9 or lower). 2) When #1 has been accomplished, determine need for twice a day dosing. 3) Delay any kidney work up or concern about current values until cortisol levels are controlled. 4) Consult with K9cushings forum as needed and with a different IMS when needed—One who will accept our testing and my need to keep my home vet in the loop.

Toby and I are much more relaxed now. Toby soaks up my stress. I need to keep his stress/cortisol levels as low as possible. Dogs are predators. They observe every nuance, every blink of an eye, every change in scent that emanates from their humans. They listen to the pitch of our voices and study our faces and our body language all day long. Toby reads me like a book, and my little guy has had quite the worried look on his face that past few days. He picked up my concern about this specialist from the get-go. I couldn’t put my finger on it…I just remember saying to by home vet that I trusted her (specialist’s brain and her academic credentials but I was not sure she had the welfare of my dog foremost in her mind, as I know my home vet does (has cared for my dogs 20+ years).

So there we are. Blessings to all…I’m off to clean the finch cages! I am so grateful for each and every one of you. Linda and Toby

Harley PoMMom

11-20-2010, 12:38 AM

Hi Linda,

IMO, I wouldn't let that specialist vet even look at my furbaby. :mad: I wonder what the deal is with her???

Also, IMO!! when increasing the dose to 15mg, I wouldn't do an ACTH test until 1 month, unless Toby is showing signs of adverse reactions.

I'm sure the others will be along to share their opinions as well.

And you are right, our furbabies are so attuned to the behavior and mood of us.

Love and hugs,
Lori

Tobias

12-05-2010, 05:19 PM

Hello dear cushing friends. Just posting with a question about vomiting with cushings...I do not think related to hypoadrenocorticism d/t to normal activity and appetite. Toby is on the new 15 mg dose as advised by the specialist and is to be tested thursday for stim test at our local clinic. He seems very normal activity wise, etc. but the bloating is really getting worse and causing nausea...this morning when we went downstairs we were greeted by a relatively normal appearing dog with normal appetite who had "pooped" or so we thought, in small areas all over the kitchen. The stink was absolutely horrendous. but hubby *(who cleaned it up before I got there) said it was poop...we steam cleaned the floor and since he seemed normal I fed him this morning, gave him his vetoryl etc. everything seemed normal. But just now (about 7 hours after eating and vetoryl) he has started vomiting large amounts 2-3 times of what really smells like poop (and just like what we smelled this morning). I know because he is always so hungry he gets to the poop even though I clean up constantly immediately...he is always sniffing for it etc.... I wonder if he has something really serious wrong and of course I will call the vet tommorrow but the bloating is occuring so much more frequently and the vomiting (which seems to relieve the bloat) is happening at least once a week to every 10 days for the last month or so. He just seems to right himself quickly after vomiting and then appetite etc plus activity are normal...he has been fine all day, playing, etc....does anyone have any idea what this could be? Many thanks Linda and toby

labblab

12-06-2010, 02:41 PM

Hi Linda,

Sorry that I didn't see your question until now. And I'm guessing that you will already have talked to your vet by the time you are reading this. But if Toby is truly vomiting stool, then I would have to guess that he's suffering from at least a partial intestinal blockage of some sort that will require additional diagnostics :(. Thank goodness he doesn't seem to be acutely ill which I believe could signal a more complete obstruction. But I don't think that vomiting stool is ever considered to be normal...

Please keep us updated, OK?
Marianne

addy

12-06-2010, 08:47 PM

I don't know if this will help or not but when I first brought my Koko home from Animal Control he ate poop any chance he could and then he would vomit it up and the smell was unreal.

He was not vomiting stool, he was vomiting the poop he ate. Any chance he is having accident in the house and eating it?

Addy

Squirt's Mom

12-06-2010, 08:51 PM

Hi Linda,

How is Toby tonite?

Hugs,
Leslie and the girls :D - always

Tobias

12-06-2010, 11:48 PM

Hi again dear Cushing's friends...thank you for your concern for Toby and for taking the time to ask about him...he is doing quite well tonight. I called the vet first thing this morning and they told me just bring him up they would work him in. The fecal smelling vomit is most likely from the pica Toby is developing...as the appetite continues to be voracious he has in the past few weeks begun to eat poop...seek poop to eat...etc etc. Also he tries to eat the pine nuggets from cat litter....also bird seed. I have to keep every thing immaculate...but even with going out in the morning for playtime and yard duty (I look for poops even in the snow because you can bet toby does...:eek. So my vet thinks this is what it was. He said they can obstruct and this can happen (fecal emesis) but usually they present in very poor condition. He thinks because of the pica and poop eating it just came up. Also he I did forget to give toby his simethicone yesterday a.m. and he was REALLY bloated..Karl thinks if the bad day was the day I forgot to give him the simethicone and he got really bloated this is a tip off that we have to really keep ahead of the gas. The gas causes bloating. The bloating causes nausea. The nausea causes the vomiting. The vomiting relieves the bloat and Toby normalizes within hours of this happpening. He did bloodwork just to be sure nothing is different. The kidney values have actually improved. No other major changes in anything in the health profile. So I think we are okay for now. He will have his stim test thursday and we will immediately raise the dose if indicated. Also I decided to restart Toby on a very small (1/2 of the lowest dose recommended for his weight) dose of Reglan. Last time I gave him this he got really agitated and hyper. But on this lower than therapeutic dose (per the prescribing guidelines) Toby has "slimmed down" nicely and is very comfortable but without agitation. Also Karl said I can increase the simethicone to 3-4 times a day and give it with the Reglan mini mini dose.....So just wanted to let you all know what is "up" and will post with Toby's stim test results. next week if not sooner. Also we are feeding toby 4 1/2 cup meals spaced about 2.5 to 3 hours apart. This is where we are with Toby's care plan! He is very comfortable and in his "computer bed" at my feet right now, all cuddled and cozy...I feel so peaceful looking down at him as I work. Blessings to all from Linda and Toby.

Tobias

12-06-2010, 11:58 PM

Thank you dear Addy: Yes, we do think this is what is happening upon talking with the vet! This is exactly what the vet surmises. Toby's appetite is ravenous and a sign that his Cushing's is not under control. We are doing this as quickly/safely as possible. He has a stim test thursday and I feel certain there will be a dose increase coming. Many thanks for your input and I wish you a wonderful holiday season. Hugs from Linda and Toby.

Squirt's Mom

12-07-2010, 11:43 AM

Hi Linda,

Man, I can sympathize with the Pica! Crys would eat anything and everything she could get hold of and it was really scary at times to see what was in her poop. She passed a whole toothpick once! :eek: My favorite poops were the technicolor piles - they were pretty as poop goes, and not near as scary as the ones with metal, plastic, wood and other assorted hard items. She came in one day, walked up to me and puked up a pink pile that scared the crap out of me until I recognized Azalea blooms in the mess - along with stems, leaves, and rocks. That was when I started using a muzzle with her.

It broke my heart and made me feel about 1 inch tall to put one on her, but I had to protect her from herself. She was part Pitty and people treated her accordingly anyway and with the muzzle on, she really looked mean - and she wasn't at all.

We went through several different types of muzzles - mesh, cloth, vinyl - and she ate all them off her face! ATE THEM! So I went to heavy plastic muzzles - three different kinds. She ate them as well! She would eat the muzzles then eat all the things I was trying to keep her from eating like a crazy thing who was starved! I finally resorted to a metal and leather muzzle, made to order for her. This one she couldn't get off and couldn't get any part of in her mouth to start eating it off. Crys really did look like Lector Hannibal wearing his face mask in that muzzle. :(:(

Crys didn't have Cushing's, she did have Pica, tho. I really, really hope that once Toby's cortisol is under control, this will change for him and not become a problem separate from the Cushing's. It can be a sad and scary thing to deal with Pica. We were blessed that she never ate anything that caused problems requiring surgery.

Hang in there and keep up the good work!
Hugs,
Leslie and the girls :D - always

Tobias

12-07-2010, 10:38 PM

Hi Leslie: What an interesting post and reading it makes me realized what I am going through is so minor! But nevertheless I must be vigilant. Pink poop! That has to be a first!. Funny you mention about the muzzle because just last night my husband was joking about it...and at first I just laughed it off but then I read your post and thought hey...on a leash with me very close it might be a darn good solution! I do think you did it in entirely the right frame of mind and with great llove--for the health and safety of your dog 100% to protect and avert impending catastrophe! For now I am now just going out with Toby (and the 2 shih tzu's) and keeping an eye on what is going on. Our property is fenced and towards the borders partially wooded and we all meander around twice in the morning and once at night after work...I get all bundled up and pretend to be a pioneer with only my dogs in the wilderness...we let the wind blow all around us and they smoosh through the new snow with noses to the ground like little snow plows.,..we have little trails that don't go far but are surrounded by very tall pine trees, (ancient, like our house). and we pretend we are on an adventure. Also finally things are beginning to freeze quickly now and all vegetation is long since dead and buried. But this spring will be another story and we may have to really think this through if, as you say, the pica doesn't resolve with the cushings. Because his life could depend on it. Thank you again for this most interesting solution and for sharing it. Toby says "Don't forget to take off the muzzle at supper time!" ha ha ha. I feel good about things right now. The increased simethicone and mini mini mini reglan dose have made him so much more comfortable. Blessings to you from LInda and Toby

Tobias

12-07-2010, 10:41 PM

PS: can someone tell me how to put Toby's picture at the front of the posts like everyone else does. I cannot find where the explanation is! I am really a dunce about computers. Thanking anyone. I do love the idea of the pictures of the sweet doggies at the beginning of the post. LInda

frijole

12-07-2010, 10:58 PM

Linda - trust me, we all needed help with this the first time. :D Can't wait to see Toby's photo! Kim

http://www.k9cushings.com/forum/showthread.php?t=2018

Tobias

12-08-2010, 10:21 AM

Oh my gosh...it was really so easy! Thank you! I love seeing my little guy on my posts....now we really feel a part of the action! Blessings to all and thanks for the instructions ....also thanks for making them so easy to apply. Linda and Toby

addy

12-08-2010, 10:36 AM

We love seeing Toby, he is so darn cute!!!!!!!!

So glad he is feeling better. I worked hard with Koko on drop it and leave it with lots of soft chicken as a reward. Also went out on leash and every time he pooped Koko got chicken. Focus on me when walking and not eat stuff in the street and you get CHICKEN.

The only problem is it takes a long time and dedication. There were plenty of times I was ready to go get the muzzle. Koko's pica is not severe but I would resort to muzzle if I have to.

Also, when he had alot of grain in his food, he was always more interested in his poo. I think it was the smell.

It's a long road :rolleyes:

Hugs,
Addy

Squirt's Mom

12-08-2010, 11:54 AM

Toby is a doll!! :D How precious is he?!?

Tobias

12-08-2010, 12:29 PM

HI Addy and Anne: Thank you! Of course toby is 10 now and coat has faded quite a bit. (picture was about 3 years ago, I think... But he still moves well (I know, the cortisone masks the possible underlying arthritis issues at age 10--but it is nice to know that he is getting at least some benefit from the cushings until we get the levels down asap...I try to enjoy it now because it is positive and I have to guard against seeing Toby as "sick"--there is such a fine line between focusing 100% + on your dog's care for an illness such as this and identifying the soul and spirit within the dog TOO closely with it...this not being healthy IMO for either of us.) He is very loved at the vet clinic even by the "big dog" people....his disposition is so benign and he tolerates so sweetly the necessary testing and probing with dignity and grace. But WHOA!...what's that odor coming from under the computer desk where my boy naps? A cloud of toxic gas emanating from his bed tells me the gas movers are doing their job...definitely gotta find a new spot for a few minutes. Thanks again for everything. Linda and Toby

lulusmom

12-08-2010, 05:00 PM

C'mon Linda, a tiny thing as cute as Toby couldn't possibly be guilty of passing deadly gas. :D:p:D

Tobias

12-09-2010, 10:44 AM

Oh my! Too funny! Toby goes today for his stim test....he started the increased dose 18 days ago. I really did not feel comfortable waiting the 30 days as per the specialist (the one who "didn't really care") if he developed Addison's) and also I want to waste no more time dilly dallying if a dose increase is indicated....Toby looks good lately and seems better mentally, somehow...not as distracted by the food seeking. I see him more frequently just lying about the house and watching us like he used to rather than sniffing the floors and corners for food. You know how when you might be doing dishes, or just any little thing, and you have the thought to eyeball them to see what they are up to, and turning away from your chores you find them looking at you intently, eyes focused like a laser beam on your head. I love that about dogs!...will post soon about the stim test results. Linda and Toby

apollo6

12-12-2010, 03:47 PM

Dear Lindy and Toby
Sorry never got to read your thread. Apollo is 12 and has been on Trilostane since June. I went through the same about the medication. Let us know the test results.
The trick with any of these medications is to keep the cortisone under control, not to low and not to high. It is an ongoing task.
As far as the odor. Apollo can stink up a storm since he was diagnosed. I am worried that he will let loose in public and every one will be looking at me not him.:eek::p
If you have any questions ask. You Toby is so cute, I want to reach into the computer and hug him.
Hugs Sonja and Apollo

Tobias

12-14-2010, 10:08 PM

Hi all (and thank you for your sweet words about Toby, Sonja. It's good to know I'm not the only "mum" of a lil stinky.)

I have Toby's stim test results back: Pre 5.96 and post 6.62. I hope this e mail makes sense as I am posting after work..not much left in the brain department. My vet called at work with the above results. He wants to increase from 15 to 20 per day trilo and go right into twice a day dosing. Impressionistically this makes sense to me.Both Dechra vet and vet specialist emphasized that the decision to go to twice a day dosing should be based on observation of symptom rebound more than the UCCR value pre stim test. Here is what I see with Toby: Toby gets trilo at 8 to 9 a.m. By time I come home about 8:30 p.m. he is cranking up on the food seeking (less so on the drinking) although from about noon to 8:00 p.m. he does not drink or food seek excessively. Right now (8:52 p.m.) he is snuffing everywhere looking for birdseed and anything left on the flloor. By the time I come down in the morning (about 7:30 p.m) I can see that he has usually emptied 1/4 to 1/3 of the water bowl overnight. . As I write this mail he is looking for food obsessively, trying to eat the birdseed on the floor and anything else he can scrounge. He will be excessively food occupied, looking for poop in the backyard, etc from now until about 12 noon tommorrow when the 8 a.m.-9 a.m. dose kicks in. I KNOW he needs twice per day dosing. So I figure that we are in the treatment range for the post stim but we could go a little lower for better control based on what I am seeing in terms of eating and drinking. Also going from 15 to 20 does not seem unreasonable based on how he has handled this last increase. Bloodwork done last week showed no flags and slight improvement over last profiles for kidney values. Just when toby is cranking up, (like this time of day, around 9 p.m.) I will be able to give him another dose to see him through the night. It will carry him over to the noon hour the following day when the daytime dose kicks in. At that time the nightime dose will be dropping and I feel like this will work. I would really feel so much more confident to get "my panel of experts" take on this, too. Thanking anyone who can help. My vet said, and I tend to agree with him, that it really does not seem the medicine is staying with him much longer than 12 hours and that during that time the adrenals are continually pumping out the cortisol...this is one reason, IMO, toby looks so "wasted" We have to get a handle on this quickly but safely...Thanking anyone who can give an opinion...Toby and linda

Tobias

12-14-2010, 10:14 PM

Hi--me again. Just to point out that Toby's last UCCR...a few posts back....I do not have time to seek out the exact value as I have to do the bird cages and Toby is now BARKING at me to get out of this chair.RIGHT NOW..was very high...so actually we would be considering that in going to twice a day dosing but also it would be based on my observations of toby's food seeking and water drinking activities. Just to make that clear...I think we have all the criteria in place per the UC davis protocol to move to twice a day increase. Thanking all for so much help, again Linda and Toby

jrepac

12-14-2010, 10:42 PM

got to think you are right Linda; you'll see the food seeking & water drinking behaviors change as the cortisol is under better control....quite a few people have had success w/twice a day dosing. Sometimes you have to modify the protocols slightly based on observed behaviors. Same with the dosages; some have done well w/low doses while others require more. Each case is unique.

as far as the gas is concerned...LOL! My Mandy used to stink up a room...not sure if it is just age, the food, or the cushings condition....but whoa! little dogs, big stinkies! Ah, I miss that too!

LOL! I am sure it will work out well for you and toby....

Jeff & Angel Mandy

labblab

12-15-2010, 08:23 AM

Hi Linda!

I think your proposed gameplan makes a lot of sense. I'm really pleased to see that Toby's ACTH results have come down into a more reasonable range, but agree that the small dosing increase -- broken into two 10 mg. doses -- might finally be the perfect solution. So count me as having jumped onboard your train... WOO WOO!! <emoticon for pulling that whistle> :p :p

Marianne

Tobias

12-15-2010, 10:56 AM

HI Marianne and Jeff: I sincerely thank you for your guidance as it does give me the extra shot of confidence I need to proceed in a very positive frame of mind with the planned changes. I do have one tiny fear left about being asleep and not able to monitor Toby at 2 a.m. as the second dose peaks. If he were to go too low I would not see it---it could be completely resolved by 8:00 a.m. the next morning. Because of husband allergies we need to have one room (the room we sleep in) designated as "allergy free"--the dogs sleep downstairs on the first floor. We do leave the door to the upstairs open to hear anything unusual, etc..but of course any type of reaction would be quiet and completely missed in the event administration of a rescue dose would be necessary. On the other hand....isn't it true that if there were a reaction severe enough to merit intervention there would be "evidence" in the morning (say vomit or diarrhea on the floor for us to notice) even if Toby did look completely normal? Should I worry about being asleep when I do this for the first few nights? If I started on the weekend I could set the alarm and check on him but I do take VERY powerful drugs for blood pressure at 8 p.m. and I am well, let's say not comatose but close to it as the night, early morning progresses. Thanking anyone who can advise about the potential lack of monitoring for the full 24 hour period...is it something to worry about or not, etc....I bless each and everyone of you for your input. Linda and Toby

labblab

12-15-2010, 02:25 PM

Linda, I really don't think you need to worry about monitoring Toby during the night. If he does fine with his morning 10 mg. dose, then I wouldn't expect any problems with the evening dose. I'd encourage you to just continue with your normal night-time schedule and pattern. I'm betting he'll be just fine. And if he actually were to experience a transitory episode whereby he was sick during the night but fine again by morning, you wouldn't need to be giving him prednisone, anyway. You'd only need prednisone in the event that he was having problems that don't resolve quickly. So when you check him in the morning, you'll know then if there's an issue that needs to be addressed.

Marianne

Tobias

12-15-2010, 10:41 PM

Okay Marianne: I am going to call the clinic tomorrow and get the medication ordered....off we go...I will probably start Monday if I can get the medicine that quick...I will keep everyone posted! Thanks over and over. Linda and Toby

Tobias

12-16-2010, 10:09 PM

Hi all. Today I called the vet to okay the med increase to trilo 10 mg bid as described in previous posts. The receptionist took the message. I thought it was all a done deal, but the vet called me back at work in the afternoon with what I thought was most unusual news! Diamondback filled my prescription from the vet specialist in 15 mg capsules. Our vet's purchasing person called diamondback to order the new 10 mg dose at twice per day as discussed. But the purchasing person relayed to the vet that 10 mg would come in a tablet and that it would be 11 mg because they did not compound 10 mg tablets???? I know the brand name is 10 mg. So if we extend that out to 2 doses Toby would be getting 22 mg per day, not 20 as the vet ordered (to be split into 2 doses 12 hours apart). I told the vet this made no sense to me and also I did not understand why I could not get capsules, as they gave me capsules for 15 mg, and Toby has been tested etc all along on capsule form. Will the fact that the new dose of trilo is a tablet make any difference in stability or absorption. Also, why would there not be a 10 mg dose available from Diamondback? Did anyone else ever hear of this? The vet is calling Diamondback himself tomorrow, to clarify...he will get back to me. Did anyone else ever hear of 1) trilo in a tablet and is there is difference I should be concerned about and 2) Trilo 10 mg that had to be given in a tablet as 11 mg because 10 mg doses not available. I would surely appreciate any input from the group if possible and I thank you sincerely. Blessings to all from Linda and Toby

StarDeb55

12-16-2010, 10:56 PM

Linda, the only thing I can offer is that since the brand name is available in 10 mg., compounding pharmacies are no longer allowed to offer any dosage that is available in the brand name. Thus, the "oddball" dosage of 11 mg.

Debbie

Tobias

12-16-2010, 11:31 PM

Hi Deb...thank you! I guess now we will have to go for 11 and 9 total 20 or else two 5 mg tablets morning and two 5 mg tablets evening...probably this would be the best for uniformity. But at least I understand the reason now. TC and thanks again Linda and toby

Tobias

12-28-2010, 10:29 PM

Hi all and hope everyone's holidays have been bright! I have a concern about Toby I was wondering if anyone would have an opinion on. Toby is developing very loose stools on the vetoryl. At times his poops just squirt out....Stools are more frequent, though not usually occurring constantly, through the night, all day long, etc. It does not seem to be illness as such but rather a marked change in his bowel habits. I do think this is worse since the vetoryl was increased and put in divided doses...he is now on 10 a.m. and 10 p.m. His last stim test before dose change was 4 something if I recall, and he was still with full blown symptoms of excessive drinking and eating but all blood work looking normal or unchanged. He was on 15 once a day prior to this dose increase and change to twice daily, which really seemed necessary as his symptoms seemed to rebound sharply in the afternoon and evening. He still continues to eat and drink heartily and certainly is not lethargic so I really do think this is an indication he is at risk of hypoadrenocorticism....he seems really normal other than this change in bowel consistency and frequency of episodes. My question is...did anyone ever experience this as being a side effect of Vetoryl (apart from representing his cortisol levels are too low) Or is a sign of uncontrolled cushing's itself diarrhea...is it that once we get his cushing's controlled the loose runny stools will firm up again? The only supplement Toby gets now is Proden plaque off which is a "seaweed only" product but it is rich in iodine and I wonder if that might be throwing things off somehow although he has been on it for quite a while.I am going to try holding that for a while to see. I think I will ask for lytes before the next scheduled stim test next week, probably Thursday, just to make sure even though he acts fine...would anyone have an opinion on Toby's situation; if so I would appreciate hearing from you and I am very thankful. Blessings to all from Linda and Toby

apollo6

12-29-2010, 12:39 AM

Dear Linda and Toby
Sorry have not kept up with you. The stools can be loose. With cushing the stools can be watery, sometimes firm, sometimes pellets.
Watch for any major changes , contact the vet if you are concerned. You know what is best for your Toby. Listen to your gut feeling. I have done so since Apollo started Trilostane. Watch for any hind leg weakness. If Toby is happy, skin and coat improving and has a good appetite reduced thirst and peeing, then you are doing good. The ACht stim test will let you know how Toby is doing,mention the loose stool to the vet . He/She may want to do a blood panel. If Toby is lethargic and looses his appetite, contact the Vet immediately to stop the Vetoryl. Apollo has improved on the Vetoryl, but I stopped it for awhile, under Vet instructions to see if his hind leg weakness may be due to the medication. We are hear to support you.
Sonja and Apollo.

Tobias

12-29-2010, 11:12 AM

Thank you Sonja: An update on my boy--last night Toby did get quite ill, throwing up and squirty stools, bloating, not exactly staggering but tail tucked and hesitant with movement. He went as if to drink by the dish but stood over it several times without drinking or took a sip..as if just sticking his tongue in it but not swallowing. Then by the time we went to bed (about 11:00, when the early day dose was probably pretty much metabolized) he was taking sips and holding it down. This all began at about the 3 hour point after administration of 10 mg p.m. dose which was given at 7:30 p.m. exactly 12 hours after the a.m. dose, also 10. I have stopped everything now until he can see the vet Friday morning...our appointment is at 10. He is out of clinic wednesday and thursday nothing is open....I do not consider this emergent as he is absolutely fine at the moment but it is urgent because he is not now under treatment. Actually when I look back I think the looser stools, bloating, really smelly farts etc have become worse as the doseage has increased and has just come to a head with the twice a day dosing. I really begin to wonder, as the eating and water drinking are every bit as voracious at post stim level of 4-something as it was at the higher post stim levels, if this drug is for him. I see troublesome side effects as it is increased and really no obvious changes for the better. I am wondering if there dogs that just don't handle the Vetoryl/it isn't effective for, and if he may be one of those dogs. It will be interesting to see if by Friday (even though he will be accelerated as far as the disease symptoms) the poops are improved. Would anyone have any opinions about this? I am so grateful that as you say Sonja, the list is here for Toby and I. Blessings to all Linda and Toby

Harley PoMMom

12-29-2010, 11:33 AM

Hi Linda,

Throwing up, diarrhea, lethargy are all adverse reactions to Trilostane/Vetoryl. If Toby is not drinking water this would really concern me as this could cause some dehydration issues since Toby is throwing up and is having diarrhea.

If Toby were my pup, I would stop the Vetoryl and give him some prednisone. He probably should have his electrolytes and an ACTH stim test done ASAP...but if you give him any prednisone now the ACTH test will be skewed. Prednisone will stay in his system for at least 12 hours.

Squirt's Mom

12-29-2010, 11:49 AM

Hi Linda,

Yes, there are pups who simply don't do well with Trilo and those who don't do well with Lyso. If Toby improves being off the Trilo, then the dose may be too high or it may be that he needs to switch. I would want to be sure that any other cause for his recent behaviors were ruled out first, tho.

I am sure some of our Trilo parents will be along to share their experience with you and Toby.

Just to be on the safe side, I would not give any more Trilo until an ACTH can be done and his electrolytes checked...I would have this done asap. ;)

Hang in there!
Hugs,
Leslie and the girls - always

labblab

12-29-2010, 12:25 PM

Hi Linda,

I only have a moment to post, but am so sorry to hear that Toby is not responding well to his dosing change. You're right, it may well be the case that a medication change is in order. I'm glad you've got an appointment scheduled for Friday, and certainly glad that Toby has improved since discontinuing the trilostane. If he remains improved, I believe I would personally hold off on giving prednisone in order to avoid any possibility of skewing the Friday testing. If he has already rebounded since stopping the trilostane, I'm guessing he doesn't need the supplemental steroid. We'll definitely be interested in hearing how his testing turns out.

Marianne

Tobias

12-29-2010, 09:28 PM

Hello dear friends: I have a good report about Toby...Tonight he pooped a beautiful normal poop...the first normal one I've seen in weeks. I would do the lytes tommorrow, thursday, but I simply cannot get him to the vet. We are down a transcriptionist at the hospital where I work and we are BONKERS with overload. I have to work days to cover the woman who is on medical leave and the clinic is closed when I get back. So Friday at 10 (we are off for that day) a.m. I will take Toby to vet. I feel quite certain and am trusting my gut feeling that we are barking up the wrong tree with the Vetoryl. Symptoms have never abated even as the dose has been raised and the stim test has fallen to 4. Just more farts, vomiting, etc. I do think he is much less bloated upon my arriving home also. I was rereading the Marvista vet site about treatment options. Lysodren seems much like Vetoryl as far as monitoring...I wonder what the odds are of that working for a dog that did not handle vetoryl. Anipryl requires that it be a particular type of pituitary tumor that most dogs do not have (in the central part of the gland??--not sure about that). Ketaconazole was mentioned yet I know the liver must be in good shape...not sure if Toby would be a candidate with his liver values...I guess the vet would decide this. Anyway...I will certainly keep up with the updates. Friday a.m. is his appointment. He seems so 100% now with eating, drinking, pooping, peeing I do think he has managed to turn things round in his system as far as being permanently damaged. It has now been 24+ hours since the reaction. Blessings to all from Linda and Toby

StarDeb55

12-29-2010, 09:49 PM

Linda, IMO, lysodren needs much less monitoring than trilo. This is after successfully treating 2 pups with lyso. The normal schedule is you do what is termed a loading or induction period with a dosage of lyso that is 25-50 mg/kg. The little guys like Toby, usually need close to 50 mg/kg. I have forgotten Toby's current weight, so let's use 8 lbs, so you can see an example. 8 lbs. would be 3.6 kg., (divide lb by 2.2), so 50 mg would work out to be a daily dose of 182 mg. During loading, you split the daily dose in half, so Toby would get 91 mg, morning & evening. You watch for signs that loading is complete such as a decrease in appetite or water consumption. Sometimes the signs can be very subtle, such as the dog who licks their bowl spotlessly clean in 1 min, now, stops after taking a couple of bites to look at you. Something as simple as this can be a clear sign of loading. At this point, you would schedule a stim for 48 hours after the last dose of lyso is given. Timing is important with lysodren as it's a long acting drug that reaches its peak about 48 hours after the last dose.

Now, you want a cortisol between 1-5 mg/dl, so let's assume that Toby's numbers are within this range, for example, a pre of 2.0 & a post of 4.0. (As a reminder, the post is always the most important). Toby would, now, go to maintenance dosing which means that the daily dose of 181 mg is split into 2-3 doses during the week, usually no fewer than 2 doses. Let's say that Toby goes to maintenance of 60 mg. given 3x per week. At the end of 1 month, you repeat the stim to confirm that the maintenance dosing is keeping the cortisol where you want it. The number of stims then drop way off. Some vets will only stim every 6 months as long as the pup is stable, some vets prefer every 3-4 months. My vet was very careful with Harley & would not let him go any longer than 4 months between stims. Harley always did better with his numbers running around 7. Anytime he started creeping up over 7, his symptoms would come roaring back.

Last couple of points, with these little guys you will have to get compounded lysodren. The lyso only comes in 500 mg. tablets, & it's extremely difficult to cut those big pills into a small, accurate dose. I had Harley's lyso compounded at Diamondback & kept a supply of 75 & 100 mg. capsules available so I could adjust his dose. The other thing that is even more important is that when considering a switch from trilostane to lysodren, it's usually recommended that there be a 30 day washout period with no meds, a return of symptoms, &, I believe, a stim of >9. It will be really important to have a stim done prior to making the switch to make sure that Toby's cortisol level has come up enough to make the switch.

Hope this helps & I haven't confused you too much.

Debbie

Tobias

12-30-2010, 09:19 PM

Hi to all and thank you Debbie, for the most informative lesson on Lysodren. I really like the idea of one month "off" for sure...I feel so free now of worry because Toby seems so much healthier two days after stopping the Vetoryl...Continues to have formed stools and no farting and drastically reduced bloating.. at the same time I feel guilty because I did not figure this out sooner. The lysodren as described does not sound too scary per your post, Debbie. I think I could do that. Also there would be the added plus of my vet (a baby boomer, like me lol) being probably more experienced with lysodren as I assume the protocols would be more familiar to him as this is all that was available for a long time. Anyway, it is encouraging that you have had success with two dogs doing this. I wonder if Toby might just have the same reaction to it as he did the Vetoryl but at least now I will know right away if I see the symptoms as I did on Vetoryl and that it must be stopped. Thanks again to everyone and I will post over the weekend about our vet visit tomorrow . Blessings and hugs to all from Toby and Linda

StarDeb55

12-30-2010, 09:26 PM

Linda, my GP vet actually offered to use vetoryl with Harley since it had just been made available by the FDA which was 2 1/2 years ago. I told him no thanks, I would just as soon stick with lysodren as it was the drug I was comfortable using. I think he was just as happy I made that decision, because, I think, Harley would have been his first trilo pup. He had years of experience with lysodren, so everyone was happy all around.

Debbie

PS- I wanted to add that, referencing your comment about success, my first boy, Barkley was successfully treated with lysodren for nearly 8 years. He crossed the bridge at 15 due to medical causes unrelated to his Cushing's.

Tobias

12-30-2010, 10:44 PM

"He crossed the bridge at 15 due to medical causes unrelated to his Cushing's."...thank you, this is so reassuring. I really appreciate you letting me know that. To have Toby for 4-5 more years would just be so awesome. I pray for wisdom every day on how to manage him. I know God answers me through all these thoughtful, knowledgeable posts:) I will post following our appointment to let everyone know the next step... I REALLY look forward to a month off. Toby seems to be enjoying it, too! Hugs and Blessings to all the Cushing's angels. Linda and Toby

frijole

12-30-2010, 10:57 PM

Linda, My gal Haley used lysodren for over 4 yrs.. passed away at age of 16 1/2 earlier this year.. not related to cushing's. Lots of positive stories here so keep the faith. Kim

Casey's Mom

12-30-2010, 11:09 PM

I know that there are not that many on this board that use Lysodren but I just wanted to tell you about my success using Lysodren for my girl Casey - it will be two years this February since her diagnosis and treatment with Lysodren began. She is almost 15 and is doing very well, daily walks at the park with days like today where we came home from our hour walk and she ran around the inside of the house like a lunatic after we got home!

She was prescribed Lysodren and a month later Trilostane became available here in Canada - I initially thought about switching but I became more comfortable with Lysodren thanks to the help I received on this forum.

Love and hugs,

lulusmom

12-30-2010, 11:21 PM

There are actually more than a few of us who are familiar with Lysodren. My two cushdogs have been treating with Lysodren for a few years. They were originally on Lysodren, then switched to Trilostane and switched back to Lysodren. They actually do well on both drugs but I chose to go back to Lysodren to see if it would help Lulu regrow her coat and help Jojo with his diabetes insipidus. Unfortunately, it didn't help either dog but hey, that's what sweaters and washable waterproof pee pads are for. :D

Tobias

12-31-2010, 08:36 PM

Hi to my wonderful Cushing's advisory board! I am so grateful for all the input about Lysodren. First I wish a Happy New Year to all:D. Just wanted to let everyone who has been so kind to contribute to this thread that I did take Toby (curled up at my feet in his special "computer bed" and looking very comfortable) to his vet this morning. He is agreeable to starting Lysodren. We did Toby's lytes and there was nothing changed from the last set (i.e., within normal limits) done not too long ago) The minor difference was that the sodium bicarbonate was was just a tad low. Gary has the car with the paper in it. But there was a shaded bar area for sodium bicarbonate from low to high. Toby's shaded area was just edging over a wee tiny bit to the left (the size of a toothpick, maybe) of the low normal value. The vet said nothing to be concerned about. He does not feel Toby should be off treatment for a month...he wants to do a stim test and pending that, get going on the lysodren. I am to observe Toby for symptomatology and give the vet the go ahead as soon as I am ready...he said he would calculate the dose...at first he seemed not to talk about loading but then when I questioned it he seemed to say something about being very conservative. He would do a stim test in 10 days or when appetite/drinking decreased which would indicate the need for sooner stim test. This WILL affect Toby, he feels, in terms of appetite changes. But he feels I will observe Toby very closely and that if anyone will observe the slightest change in his condition, it will be me! He trusts me 100% to observe Toby and notice if he needs testing before 10 days once the drug is started. I was wondering if there is a book, or any resource on line (maybe this one-- I will look at the articles section) that would familiarize me with the lysodren protocols so that I would understand and be able to advocate for Toby. The visit to the vets wasn't too bad--he got quite a bit of fussing over and also a low fat biscuit (just a tiny piece). Blessings to all for the New year from Linda and Toby

Harley PoMMom

12-31-2010, 08:41 PM

This will come in very handy! ;):)

Lysodren loading Instructions and related tips
http://www.k9cushings.com/forum/showthread.php?t=181

Love and hugs,
Lori

Tobias

12-31-2010, 08:58 PM

HI Lori: I went to the articles section on this site and found the info on Lyso. Toby weighs 7.6 pounds and when he goes less than 210 ml or 7 ounces of h20 I should stop the Lysodren and call the vet. Measuring Toby's exact water intake (CRITICALLY important so that we do not go further down on the list to vomiting and diarrhea) is going to be pretty darn tricky. I have two other dogs. Water dishes are in Kitchen, Living room and on Front Porch. Unless I remove all the water other than the kitchen water and sit in the kitchen each day he is loading and monitor which dog is at the dish (blocking the other two dogs out of the kitchen if I had to leave for some reason) ...how will I know which dog is drinking the water.... I am very worried about this. Would I have to completely separate Toby from the other dogs for the loading phase? Am I supposed to measure the water in the dish? Thanking anyone who may have had to load the dog in a multipet household who may have some tips....Linda and Toby

StarDeb55

12-31-2010, 09:22 PM

Linda, a change in appetite is going to be a better indicator & will probably occur faster than a change in water intake. When I was dealing with this with my first boy, (I had 2 pups in the house), the vet said to keep only one bowl of water available for both dogs. I did that anyway, Measure the amount of water you put out, & make sure you measure what has been consumed at approximately the same time every day. The vet said we will have to make the assumption that any change is coming from my boy being loaded. She was right. On day 8, there had been no change in appetite or water, so I took him in for a stim. The vet calls me the next afternoon, wants to know if I had checked water yet, I had not. She said she would wait while I did. There had been a 40% drop in water intake between day 8 & day 9. The stim numbers reflected that, & Barkley had to be put on prednisone for the next few days as his numbers were quite low. He never got sick from it. This is just to illustrate that no matter how watchful & careful you are, none of our pups read the book, & may not display textbook changes in symptoms. Glynda has gone through the same thing with JoJo more than once, where he is eating & drinking like a pig, but his stim numbers come back super low. Just remember, none of our pups read the book, so if Toby shows signs of loading, don't let your vet tell you there's no way.

I am concerned about using a conservative dose of lysodren, closer to the 25 mg/kg level. This may cause you to end up with a very protracted period for loading, if Toby would ever load on a low dose. Most dogs will load in 5-8 days, some can load in as little as 3, some may take a month or more. We have seen both extremes for loading timeframes on these boards.

Debbie

Tobias

01-01-2011, 12:56 AM

HI Debbie: OKay, I understand what you are saying about the loading dose; I get that. Let's see what he suggests starting at. If it is lower than the recommended as specified in guidelines I will bring that up. Let's put that on hold for now..he may come up with what we see in the IM veterinary guide as shown on this site. I understand about the food/appetite, too being probably the first indicator as I studied the guide more. Actually according to what I read (if I understand correctly) the drinking might not decrease for 30+ days. I am going to start practicing the water measurement tommorrow when I change and wash their water dishes out daily. I will take all the water up except that kitchen dish...the one in the puppy pen will be locked shut when he is not in there and also when he is--to prevent any confusion there. This is an extremely good tip you gave me...thank you! Also I am going to practice calling his name after I put the food down to see if he will stop eating...if he does not....then I will know that once he starts the lyso if I call his name after putting food dish down and he looks at me that he is loaded and I will stop med and call the vet for stim test, right? I do wonder about the appetite though, because eating seems so "compulsive" with Toby that he might just keep eating because he is so "fixated" on it. Terriers are very into "controlling" their environment, and one way Toby amuses himself all day is finding food, notifying Linda there is food, begging/asking Linda for the food...getting Linda up to get the food, sniffing the floor for food--pawing at the furniture in case a piece of kibble has rolled under it...etc, etc...it goes on all day long! So I do understand how something like what you are describing could happen.....anyway it is quite late and I am signing off for now. Happy new year to you and may 2011 be filled with blessings and light. Linda and Toby:)

Tobias

01-01-2011, 07:52 PM

Hi again everyone...I have been reading the post's by Lulu's mom and also the reread several times the lysodren induction guidelines from the IM veterinary handbook. I have several questions. #1) How many hours must be between the doses during the induction phase and how much food must accompany the dose? I ask because we go to bed around 11:30 p.m. and we do not like to feed later than 6:30 p.m. so that everyone has a chance to do their business before the overnight period. Yet I do not usually get up till 7:30 and feeding is usually by 8:30 a.m. 2) In Lulu's mom posts it mentioned her dog was switched to Vetoryl because of the increased side effects of lysodren. I was wondering how bad these side effects are and if there is anything I can do to prevent them.#3) During the induction period how do we know if the vomiting, diarrhea and lethargy are because Toby is just too sensitive to the drug or a sign that he is loaded (actually overloaded, I guess) and to stop the med. 4) Say it is time for the p.m. dose. but because of how the dog is acting you decide to hold it...say it is Friday night...is it okay to just hold the dose till you talk to the vet Monday morning and...will the dog be expected to improve and get his appetite back or should you give him the prednisone? Will the cortisol levels "rebound" as they do as the vetoryl is eiliminated from the body or in the case of lysodren, because the adrenal cortex has been destroyed, does the dog just not revive on his own as he would with Vetoryl? Thank you to all for all your help. Linda and Toby.

StarDeb55

01-01-2011, 08:37 PM

1) About 12 hours, but it doesn't have to be exactly on the dot.

2) There should be few side effects, unless you keep dosing until you are reaching the point of an overload. This is why, if there is no change by day 8 during loading, you go in for a stim. If you see anything in Toby's behavior that makes you stop & go "Hmmm, that's new or different." That is probably your sign that loading has occurred.

3) Without a stim being done, you don't know. It's also called, when in doubt, give the pred. You just need to remember that you want to try to avoid scheduling a a stim within 24 hours of giving pred, or the pred will read like cortisol on the test.

4) Compared to trilostane, lysodren is a long-acting drug, reaching it's peak in the body about 48 hours after the dose was given. This is why you alwaya wait until meals are completed before giving the lyso during loading, because once you give it, you can't take it back since it doesn't clear the system as rapidly as trilo. Depending on how quickly the adrenal cortex regenerates, will determine how fast the cortisol levels come up. This varies from pup to pup. I think Alison has always said that Mia's adrenals would regenerate almost in the blink of an eye. Some pups may take days or weeks. This is why using lysodren is kind of like walking a tightrope. You want to destroy just enough of the adrenal cortex to get the cortisol down to a healthy range, without pushing the pup into Addison's.

I know all of this sounds scary, Linda, but as careful as you are with Toby, I seriously do not think you will have much of a problem. The lysodren parents on the board, including me, will be here to help you every step of the way. Once last tip, you always want to start loading on a weekend, preferably Saturday, that way, if Toby should load within the 5-8 day timeframe, loading will occur on a weekday & there shouldn't be too much of a problem getting him stimmed. The other thing is once you go in for the stim to confirm loading, you hold the lyso until you get the results. Assuming the results are ok, & the last dose was given on Weds. Toby's vet wants him on maintenance dosing 3x per week, you just give the first maintenance dose on Friday.

I got to the point where I could read Harley like a book when it came to what his cortisol levels were doing. He would start drinking water like a fish, I would call the vet & ask to adjust his lyso dose up. The vet & I would calculate the change, & the agreement alway was that if his symptoms did not resolve within a couple of weeks, I would get him in for a stim. Harley was one of the pups who did not read the book about symptoms as he was always a very picky eater, & he would actually eat better when his cortisol was at a more healthy level.

Debbie

frijole

01-01-2011, 09:56 PM

Deb gave you some wonderful tips. I am including a link that I used to help me thru the loading phase. It is helpful.

Give lysodren AFTER they eat because that way you can tell if they have a change in eating pattern (an if so you do NOT give the lysodren) ... you can't take the pill back so you want to be sure before you give it that they aren't loaded.

Most people wrap the pill in cheese as it helps coat the tummy.

Don't try any new foods or snacks during the loading phase because if your dog vomits you won't know if its due to loading or the snack.

Keep an eye on the poops. If they start getting less firm, it can be a sign you are getting close. Diarrhea is a sign of too much lysodren.

Lysodren continues to work in their system for up to 48 hrs AFTER giving the pill.

Never give lysodren to a dog who is sick.

Hope these tips help! Kim
http://www.k9cushings.com/forum/showthread.php?t=181

Tobias

01-01-2011, 10:28 PM

Okay Debbie and Kim: I have read your posts each several times now. If I start to feed the meal and he hesitates with eating-- I do not give the lysodren. I understand that part of it. Do I also at this time give the prednisone? Will giving him the prednisone at the first sign of hesitation during meal time prevent him from a dangerous free-fall? I assume this is just a one time dose--or is the vet supposed to give me a time interval in which to repeat the dose (say he showed signs of loading on a Saturday). I understand about not giving anything new either treats or meds during the loading. But say he has not shown any signs of hesitation during meals, but drinking is slowing down...then do I hold the lysodren until a stim test can be done? Also, if eating and drinking are the usually excessive amount, and he gets diarrhea, should I stop the lysodren based on the bowel movements only? I worry about the eating as the sign because I really have felt that Toby has an almost obsessive compulsion regarding food...he could eat as normal and still be loaded...something in my intuition is telling me it could happen this way. I do not think he would do this with the water....he has never been as compulsive about drinking. So if the water is slowing down drastically but he is still eating, should I stop the lyso and give the prednisone? I measured his water today....he drank between 8 a.m. and 8 p.m. 5 1/2 cups of water (meaning that is what disappeared from the dish with all 3 dogs drinking out of it) So if only 2 cups disappeared one day during loading, should I stop the lyso? When I stop lyso, do I ALWAYS give prednisone? Sorry for all the questions but I feel so responsible to be a good caretaker for Toby and not let him down and miss a chance to stop the medication if I should. Thanks again...I can never thank you enough, all of you!

frijole

01-01-2011, 10:38 PM

You are smart to ask the questions now!

Prednisone is only to be used in case of an emergency. So you probably will not need it. I never had to. But what others have described - when their dog has too much lysodren (overdose) the dog looks close to death... they say you will 'know' if you need to give the lysodren. Dog can't get up, beyond lethargic - can't lift up head. This is a result of the cortisol going too low. Their bodies need some cortisol. Prednisone mimics cortisol and within an hour or two brings them back to normal.

Back to your other questions... withold lysodren if you notice any changes in water consumption or food intake. It could be something as minute as your dog pausing between bites when normally she is inhaling food.

If your dog vomits or has diarrhea - that means she has had too much lysodren and to stop. Pay attention and if the dog is distressed you can give the prednisone... normally you would be phoning your vet for advice. We have found that emergencies happen over the weekend and at night so we have helped others thru the process. ;)

So - when you notice changes it is time to stop the lysodren (no prednisone) and call your vet to schedule an acth test. This test will determine the cortisol level. Your goal is for the 2nd number to be between a one and a five. If it is then you will be giving the same amount of lysodren weekly that you were giving on a daily basis. This amount will should the desired cortisol level. If your test comes back high you simply go back to daily loading and repeat test at next sign of change.

I hope this helps.
Kim

StarDeb55

01-02-2011, 12:29 AM

Just to emphasize what Kim has already said, pred is for an emergency only. It's only used if you get into an possible overload situation, not because Toby has simply paused while eating. If you think you are coming close to an overload, always try to contact the vet first to get instructions as to whether the pred should be given. If you can't track down the vet in a reasonable amount of time, give the pred. An emergency consists of one or more of the following symptoms; nausea, vomiting, diarrhea, lethargy to the point that Toby can't get up or stand.

It's good that Toby is very food motivated. My first boy Barkley would have eaten until he popped if I had let him. The one time he had a possible overload, several years after diagnosis, he refused to eat or drink one night, & absolutely refused to get up from where he was laying. I knew immediately something was very wrong.

The other thing I wanted to mention is you want to try to give the lyso with something fatty. I use to give Harley's lyso in a dollop of peanut butter. Lyso will absorb better when given with something fatty. Don't get cute like I did a couple of month after Harley initially loaded. He was getting a tsp. of sunflower oil mixed in with his evening meal to make sure there was enough fat present for the lysodren. Harley had a pre-existing gall bladder condition, so I decided that he didn't need the extra fat in his diet from the oil & stopped giving it. The little twerp promptly unloaded. I learned a big lesson on that one.

I missed your question about a change in water. The change has to be significant. We're not talking 10%. On Harley's initial load, his water consumption had dropped 20%, I insisted he had to have a stim as I felt he was probably loaded. The cortisol had come down to something like 12, initially, it was >25. He was not loaded. Based on my experience with Barkley, years ago, I would think anything >30% drop would probably be significant. I know you feel that food is not going to be a good indicator for Toby, so, certainly watch both food & water. I will bet you right now, though, that the first thing you see is going to be a change in Toby's eating. Remember, the cortisol that is pumping out into their system is making them feel hungry 24/7, to the point they feel like they're starving. Once that cortisol starts coming down to a healthy level, that insatiable hunger is going to decrease.

Debbie

Tobias

01-02-2011, 11:14 AM

Hi again: I am really trying to get a grip on this over the weekend bc my week is always so frantic and I may not have time to post...I have reread the entire thread several times this morning--both Toby's thread and the one provided by Kim--I made copies to review at work in spare minutes. Yesterday I measured Toby's water consumption through 24 hour period. His bowel holds 6 cups. It was 5.5 cups during the day and 3.5 cups last night. If I round that up to 6 (Oh dear God, help me with the decimal points) --the point at which the bowel approaches the half way mark for days is a HOT TIP! In the morning when I measure the night time water if it approaches the 1/4 empty point this is a hot tip....does this sound right to everyone? The other thing I was wondering was, do the extremely squeamish ever schedule a stim test say....4 days into treatment? I would feel so much more confident. I could start on Saturday and test on Tuesday...I would keep giving it until the 8 day point when another test could be done? It would be an "extra check" for an "extra neurotic highly excitable unstable owner" lol...would something like this be unreasonable? Also is there any leeway in the timeframe of one month of drug abstinence following discontinuation of the Vetoryl before administering the lyso? Can we go shorter than a month as long as the lytes (look ok now) and stim results (could maybe schedule in 2 weeks?) Also I want to get a complete profile again with of course the lytes prior to initiation of lyso, but I was just wondering if we could "bump it up" any from one month as I do see my boy suffering so from the constant hunger.. the Vetoryl at least took the edge off it...Also: I started him yesterday with vet okay on something called Marin for his liver...milk thistle....as I read many of you give milk thistle to your dogs. In one week I have new glucosamine supplement to introduce by vetri science the vet also signed off on..this will give me a chance to make sure the supplements would not cause any changes in bowel, appetite, nausea etc and he would be stable on these meds to cont with the lysodren. Many thanks to all of you...back to work Monday and I will no longer be able to pester you kind, thoughtful, compassionate and extremely focused people any longer.....Hugs and gratitude forever from Linda and Toby

Squirt's Mom

01-02-2011, 12:12 PM

Hi Linda,

I have been reading along on your thread and am so very pleased to see how involved you are! Getting all these questions out up front, getting your head wrapped around all the little nuances of Lyso use before you start is just wonderful AND a clear sign to me that Toby is in GREAT hands.

When my Squirt was first diagnosed, Lyso scared the crap out of me! But the more I learned the less fear I had, and as time has passed Trilo scares me much more than Lyso. Of course, I am a bit of an oddball! :p

Squirt will be starting Lyso in the next week or so as a maintenance dose only, tho. Squirt is Atypical, not true Cushing's like Toby, so the loading phase isn't needed. Her Cushing's is caused by intermediate hormones VS cortisol - tho her cortisol has been rising. I am very calm about starting her on the Lyso because - 1) I understand why she needs it, 2) I understand what it is supposed to do for her, 3) I know what to look for in case of a problem, and most of all 4) I know we have 100's of good folks supporting us all the way who have experience and first-hand knowledge they are happy to share.

There is no doubt in my old mind that Toby is going to do just fine because his mom is so devoted and so determined to do the best she can for him.

Hang in there! You are doing a fine job, Mom!
Hugs,
Leslie and the girls - always

frijole

01-02-2011, 12:19 PM

:D I do believe I found someone who worries even more than I do! LOL ... will do my best to answer questions...

1. I measured water once a day. I marked the bowls so I could quickly fill them. So if I had 5 bowls and put 1 cup in each that is 5 cups to start with. 24 hrs later I would measure the content of all 3. Say there was 1/2 cup left total. Water consumption for that day is 4 1/2 cups.

I would fill all 5 bowls up for the next day and repeat 24 hrs later. I wouldn't bother checking twice a day. Too complicated.

2. Vets are following instructions/protocol when they say: give lysodren for "x" number of days and then come in for an acth test. What they should say is to give lysodren until you see any change in water intake or food consumption. (see notes from yesterdays' posts)

If after 7 to 10 days you do not see any changes then doing an acth test gives you peace of mind. Doing one 4 days into the process will slow things down (typically). Here is why: Remember the drug keeps working for up to 48 hrs after the last pill. So you give lysodren for 4 days and you WAIT 2 days for that appointment/acth test. Then you WAIT another day or 2 for the test results to come back. Then you find out that you are not 'loaded'... you start all over with the loading process.

For this reason I truly believe the best thing you can do is watch like a hawk for changes and I have every bit of faith that you will do that! From what we have seen for some reason dogs that are large tend to load faster. They are the ones that can load in a couple days. Smaller dogs take longer. This said... we have NO way of knowing because every dog is different. So the best thing you can do is monitor.

That is why I am a proponent of the "Poop Patrol". I too was worried about my gal loading because water intake was never an issue I could only monitor food. She was such a little piggy I too worried I wouldn't know when it was time. I went out and watched her poop and poked it with a stick. (Not fun in the winter but I did it) and I watched her movements go from quite firm to slowly softer. Knowing that diarrhea meant too much lysodren, I scheduled her acth when I felt it was pretty soft but not runny. AND it paid off as she was at 1.8 (on that scale of 1 to 5)

3. I can't really answer your question about the vetoryl and waiting period since I never used it. I would however tend to take their advice and wait if I could.

Hope I answered everything. Hang in there. Oh and keeping a daily diary will help you. Watch how Toby eats now so you can notice changes. You will be fine. Kim

Tobias

01-02-2011, 01:00 PM

Okay Kim and Leslie, thank you SO MUCH. The encouragement and approval of a list member mean everything to me! It gives me more confidence...my dear Toby is teaching me to believe in myself..I must not let him down. I will use 1 bowel and measure twice daily. The puppy would have 5 bowls all over the kitchen..he likes to play duck/duck and turn bowls over..sometimes I worry about the soundness of his mind...I had to buy a special superheavy ceramic one. Anyway. I have talked to hubby over and over about the water and food consumption monitoring for when I am at work. I will give both doses at 9 and 9...we will put pads down and if he poops in the kitchen I really don't care. But I do think I will mark the bowel for easier observation...I never thought of that...thank you! I am really into poop monitoring ...I watch his butt from the porch when he goes and what comes out of it. I go around twice a day and clean. The really hard part is that it is dark by 5 or so and the reach of our yard lites does not extend always to toby's pooping range. I take a flashlight but I need to get a brighter one. I may get a special helmet with a light beam on the front....like in "Honey I shrunk the kids!" lol...but seriously, I do understand that I must really watch every single poop. The glitch will be the hours I am at work and my husband is on duty. He is not as vigilant as I am. After dark I will need a much better flashlight because I will have to thoroughly inspect the yard upon coming home...it will take a few weeks, I think, to get this part organized. I do understand now about the timing of the test, thank you...would it be okay to ask him for 7 or 8 days...or sooner for any changes in eating and pooping...he said 10...that kind of seemed to long to me. I really think he would go for 8 if I asked, though...he so wants to calm me down, I think. Anyway it is so reassuring to know that other people love their dogs so. Blessings and happy Sunday to all from Linda and Toby

Tobias

01-02-2011, 01:01 PM

OH my, me again...I see upon re reading my post that I said I would mark Toby's bowel...I meant the bowl, of course. Hugs Linda and Toby

StarDeb55

01-02-2011, 01:29 PM

Linda, I alway measured the water in ozs., makes the math a little easier since there's no decimal. If I remember, I alway put out 40 ozs. of water for both dogs, so if 10 ozs. have been drunk, you know that's 25%. The other thing is that I measured water for about 5 days before starting loading, so I could have a good average for normal, daily consumption.

We have seen it time & again on these boards, where a vet will say to bring the dog in for a stim at day 10 of loading with no real mention of watching for signs of earlier loading. This really is not protocol, & as both Kim & I have said, each pup is different. The most important thing is to watch for those loading signs. Remember, when you think Toby may be loaded, you have stopped the lysodren. If you want that stim on day 4 for your piece of mind & you started on Saturday, you have now stopped the lyso on Tuesday. You can't get into the vet until Thursday, & the results aren't back until Friday or Sat. Toby has now gone close to a week without meds, & you have probably lost a lot of ground, & will be starting the load all over again. The important point is that the lysodren is completely stopped until you get the results of that first stim back. I will say that if running stim on day 4 give you piece of mind, I won't argue against it. I just want you to be aware of the possible consequences, if Toby should be nowhere close to loaded.

Debbie

frijole

01-02-2011, 01:57 PM

Yep Deb is right. Vets will say "take them and on the 10th day we will test" but I guarantee you - they never had a dog with cushings and had to give the drug! :) So take his/her instruction to give for 10 days as "guideline". You give it til you see the changes and then you stop, call the vet and DEMAND an acth in 48 hrs. :p;):D

The visual of you walking around with a hard hat and light is terrific. I will officially dub you the Poop Patrol Queen!

StarDeb55

01-02-2011, 02:05 PM

The one thing I wanted to mention on one of Harley's reloads, we had hit day 6. I had a worse time than usual getting him to eat, so I threw up my hands, decided I was calling the IMS in the morning to get him in for a stim. I get a call back for one of the techs that the IMS feels that there is no way he is loaded, wants me to see if he'll eat that night. If he eats, he gets the lyso. Well, he ate barely, & I gave him the meds against my better judgement. At this point, I was fed up with my IMS, fired her, & took the little twerp back to his GP. I told him I had had it with the IMS, that I pilled him the night before against my better judgement, & I wanted him stimmed. He agreed that he needed to be stimmed, & that continuing with the lyso had been a risk. Well, guess what, I was right. The cortisol came back in range, & if I had continued the meds per the IMS instructions, both of us would have been in a world of hurt. My GP vet has had a lot of experience treating Cushpups with lysodren, & if I ever have another Cushpup, I'm sticking with my GP vet. I will never use this specific IMS ever, again. 2 1/2 years later & I'm still pis--d off, as you can tell.

Debbie

Squirt's Mom

01-02-2011, 02:28 PM

POOP PATROL!!! :p I never thought of a hat with a head-lamp! Funny! :p

One day a year or so ago, I was out doing poop patrol when this voice asked, "Did you lose a diamond, lady?" Surprised, I looked around and finally found a guy on a ladder next door who had been watching me study poop piles. :p

Then one of my babies developed a penchant for UTI's so along with poop patrol, the neighbors would see me squat and sniff piddle puddles! At that point, they stopped asking questions. :p

Hugs,
Leslie and the girls - always

Tobias

01-02-2011, 03:13 PM

OMG LESLIE: That is so funny! Thank you for that laugh....I really needed it. OK helpers, I will be the poop queen, all for the higher good....Yes I DO understand about waiting it out past 4 days for the first stim as it would be for my good, not Toby's. I will not call for stim test before 8 days unless I see water decrease of 30% or more, lack of appetite or loosening poops. Then I stop the lyso. Then I call the vet for stim test. It has to be in 48 hours. I hold the med until after the stim test is called back to me. I got the plan, I think. I am ready now except for establishing the starting date. I would like to have a more flexible work schedule in order to cover emergency vet apts, but that may not be possible. We are "down a man" at my job and that makes things more difficult...usually there is no problem with making up time, etc. So we will see. It sounds as if the advice is to start in one month anyway....only one more question for now (I have finally run out)...about the diabetes insipidus someone's dog got tested for to explain the thirst and appetite that did not abate with treatment on either vetory or lysodren...could that be an issue for Toby? all of his glucoses have been normal....just don't want to overlook anything. Blessings to all from Linda and Toby