Before prescribing Trilostane...(Discussion of UTK adrenal panel)

[O'Riley]

This has been bothering me for the past several days because I have read of several recent accounts of dogs that are testing positive on either the ACTH and/or the LDDS, are started on trilostane without knowing whether a dog also has Atypical Cushing's Syndrome.

Is it possible to have both Atypical and regular Cushing's at the same time?

If it is possible, then before starting a dog on trilostane, shouldn't it be standard operating procedure to do the University of Tennessee full adrenal panel? It is my understanding that a serious side effect of trilostane is that it can adversely affect levels of intermediate sex hormones in dogs that have Atypical Cushing's.

Doesn't it stand to reason that a vet could not prescribe trilostane without first knowing what's going on with the intermediate hormones?

[zoesmom]

You are right. That is possible and many owners are now taking that route before starting their pups on trilo. It's like a preemptive strike. But there are also many here who haven't done that but over the last couple of years, we've gotten wiser, thanks to all of the members who have consulted with Dr. Oliver. So I've noticed several here are now suggesting that kind of testing to new members. But for those dogs already on trilo who haven't had the UT panel would continue to have symptoms after a few months on the drug, then of course, it's still not too late to get the testing of intermediate hormones done. But I believe that then, the question arises: Do you take the dog off of trilo for a month or so and have UT do the combo panel as if starting from scratch (I think that's what Dr. O recommends.) Or do you just test the intermediate hormones, and assume that any out of range hormones are a result of the trilostane?. 'Cause really . . . those intermediates could have been out of whack even before the trilo was started or could be MORE messed up because of the trilo. We had a big discussion on this in Zoe's thread a couple of years ago - on the 'old' cushings forum. I might still be able to get it, if I kept the links to her recovered thread. Sue

PS - this is not to say that trilostane has that effect on every patient who is taking it. In fact, I think it's not that common, although I did suspect it might have been the case with Zoe. Never went ahead and tested her thru UT though. She'd been on trilo for at least two years at the time I considered it. And eventually, a drug she was given for something else (tylan for SIBO) finally brought her drinking and peeing under good control. She had improved somewhat after starting trilo but was still above the norm with the PU/PD - until the tylan.

[Squirt's Mom]

Good questions, and I feel the same as you about prescribing Trilo without the UTK panel first.

One problem is that many GP vets aren't even aware of Atypical Cushing's. Several of us here have had the pleasure of educating our vets on the topic. Me included. ;)

Another problem is that Lyso is going to be phased out in the US, making Trilo the only real option for Canine Cushing's so vets are being introduced to Trilo and encouraged to use it.

This is one area where I believe educating yourself before starting treatment is so important.

As for whether a pup can have both true and Atypical Cushing's, the answer is technically no. True Cushing's means that only the cortisol is elevated while Atypical means only intermediate hormones are elevated with normal cortisol levels. If a pup has both elevated cortisol and intermediate hormones, then that pup is considered to have true Cushing's with concurrent elevated intermediate hormones. For true Cushing's the treatment is either Lyso or Trilo (sometimes Ketochonazole). For Atypical the treatment is lignans and melatonin, sometimes along with a maintenance dose of Lyso. For both elevations, the best approach is Lyso, including the loading phase plus maintenance, along with the lignans and melatonin.

The UTK panel and abdominal ultrasound are, to me, the most important tests in diagnosing Cushing's and determining which form the pup has.

Hugs,
Leslie and the girls

[zoesmom]

:p:p:p

OK, funny. Your first two answers and you get a yes and a no. I will defer to Leslie on this one, since she's actually had the panel done. It sounds like more a matter of semantics - i.e. what to call the concurrent conditions??? But I did e-mail back and forth with Dr. O about Zoe and he suggested we stop the trilo before doing the full panel on her. However, she was complicated and had had the PU/PD all her life So I was questioning whether she could have had DI (diabetes insipidus) OR atypical cushings long before the regular cushings manifested and also trying to figure out why her PU/PD didn't totally resolve after starting trilo. Like I said . . . . complicated.

[labblab]

This is a question that has been "chewed over" quite a bit by our staff here in recent months. For a period of time, I was one of those who recommended UTK testing to most "newbies" since it is true that trilostane does inevitably increase some of the intermediates. But now my own impression has shifted: I don't think there is yet consensus among veterinary clinicians as to whether or not the elevations in intermediate hormones caused by trilostane necessarily result in any problematic symptoms for the majority of treated dogs, nor is it clear which dogs will actually exhibit symptoms as a result of naturally-occuring intermediate elevations.

I'm one who likes to know as much about the "big picture" as I possibly can. So in terms of testing, if it were my own dog, I would like to have a full adrenal panel performed as part of the initial diagnostic Cushing's work-up. That way -- especially if both the ACTH and an LDDS came out "negative" for my dog with Cushing's symptoms -- I would already have an indication as to whether it may instead be the intermediate hormones that are creating the problems. So for folks who come to us and have not yet had an ACTH performed, I do often suggest that they consider the combined ACTH/full adrenal panel instead. That way, they wouldn't have to backtrack and repeat any part of the testing in the event that the "stand-alone" ACTH (and/or LDDS) turn out "negative."

But for members who have already had "positive" diagnostic ACTH or LDDS tests performed, I am backing away from encouraging them to incur the expense of having a repeat ACTH/full adrenal panel done upfront, prior to beginning trilostane treatment. Presumably, they are going to go ahead and treat the elevated cortisol, regardless. And the status of the intermediates, even if elevated, may not end up actually causing any clinical problems for their dogs. Plus, for members not living in the U.S., it is not anywhere near as easy to ship the blood samples to Tennessee for analysis.

If, however, a member consults us about a pup who had originally been well-treated with trilostane but who starts exhibiting worrisome symptoms again even though the cortisol is well-controlled (or for whom symptoms never fully resolve) -- then I definitely do encourage them to consult with Dr. Oliver about the advisability and timing of performing the full adrenal panel. When being performed for diagnostic purposes, he does generally recommend that the trilostane be suspended for at least a couple of weeks before performing the test.

So those are some of my thoughts to throw into the mix!

Marianne

[jrepac]

I'm dealing with the concurrent situation as well....elevated cortisol AND elevated intermediate hormones....I tend to think of it as having both typical and atypical Cushings. But, I think it tends to get classified simply as cushings.

Still, knowing that the other hormones were elevated led me to a very different treatment path....bless the UTK and their test!

[I'm the oddball owner using anirpyl + lignans + melatonin, which seems to work pretty well...at least so far]

Jeff

[Roxee's Dad]

I am now in the throws of having Rozee going through diagnostics for cushing's (probably Atypical) Met with the vet earlier this week to discuss further testing and he wanted to do the ACTH stim test. I disagreed and asked him to do the full UTK adreanal panel. One vet visit, one blood draw, and a full page of answers in return. My Roxee (Rozee's littermate sister) had PDH and was on Trilo, I wish I had done the full UTK with her but I just didn't know enough about it at the time. :(

But I did get a great education here. :)

[lulusmom]

After doing quite a bit of research in the last year on this subject, I've changed my position even more so than Marianne. I personally will no longer encourage members to have a UTK panel at all, unless conventional tests such as ACTH stim and LDDS are negative. Dr. Oliver himself states in his paper entitled "Steroid Profiles in the Diagnosis of Canine Adrenal Disorders" that steroid hormone profiles are indicated when other routine tests of adrenal function are negative (ACTH stim; LDDS; combined dexamethasone suppression/ACTH stim) and the dog still exhibits signs of cushing's syndrome, indicating the likelihood of atypical cushing's disease being present. Dr. David Bruyette prescribes Trilostane to the vast majority of his patients and has all but abandoned Lysodren, reserving it for those dogs that cannot handle Trilostane. He also lectures that you should not jump at having a UTK panel done unless all other tests are negative for cushing's.

At no time has Dr. Oliver ever suggested that pet owners should always have a UTK panel before starting treatment with Trilostane. I think the rationale behind that is that if a dog has been properly diagnosed with cushing's, it is pretty safe to say that a number of the intermediate steroids are also elevated. So with that being the case, Trilostane would rarely, if ever, be prescribed.

Some of you may recall that we asked Dr. David Bruyette if he had any concerns about prescribing Trilostane for dogs that have significant elevations in intermediate steroid/sex hormone levels and in those instances, did he recommend an alternative treatment? He answered; "Any adrenolytic agent or enzyme blocker can raise steroid intermediates to some degree. Whether this is an issue clinically depends on the given dog, the dose of medication used, the duration of treatment and concurrent diseases and/or medications." When talking about Trilostane, even Dr. Oliver admits that the long-term effects of elevated intermediate steroids remain ill-defined. Add on top of those opinions that we've never had a member treating their dog with Trilostane report a return of symptoms, despite having perfect 24 hour control of the cortisol.

I switched my own dogs from Trilostane to Lysodren because Lulu's coat and skin never got better and Jojo's PU/PD never resolved on Trilostane. Well guess what??? It's been a year or better since then and neither one has improved. Lulu is still bald and Jojo is still a drinking fool and a great big pee bucket.

The veterinary community at large has come a long way in accepting the fact that there are dogs out there with atypical cushing's but I think it's going to take a lot more convincing evidence before the endocrinologists, world reknown or otherwise, will subscribe to the theory that you need to know if intermediates are elevated before prescribing Trilostane. I'd like to see some of that evidence myself.

[Harley PoMMom]

My boy Harley dx'd positive for Cushings in April 09 with a LDDS test. His former vet wanted to start him on Trilostane immediately. At the gentle urging of these wonderful and knowledgeable people I had the UTK full adrenal panel ran first. The UTK panel showed that Harley's estradiol hormone was very elevated but his cortisol was within the normal range. His treatment, at that time, was melatonin and flax hulls with lignans. Harley also suffers from high blood pressure which Dr Oliver says the elevated estradiol is the reason.

Harley has since had another UTK full adrenal panel done in Nov. 09 and now all his intermediate/sex hormones and his cortisol are elevated. His treatment still consist the melatonin and flax hulls with lignans plus a maintenance dose of Lysodren 3X a week.

Love and hugs,
Lori

[labblab]

Add on top of those opinions that we've never had a member treating their dog with Trilostane report a return of symptoms, despite having perfect 24 hour control of the cortisol.

Glynda, for the most part, I do think you and I hold similar views about the advisability of UTK testing. But we diverge here, because I do believe that we've had a few occasions of "unexplained" symptom rebound. And I think that it happened with at least one member fairly recently (although of course I can't remember who :o), because I know that I recommended UTK testing -- and that is since I've adopted my new strategy of recommending it more selectively. What I am talking about are not instances where the symptoms were reappearing only later in the day, which would instead point to less than 24-hour control and the need for twice daily dosing. This doesn't happen very often, but Dr. Oliver has spoken of a subset of dogs who may start out fine on trilostane, but who potentially end up experiencing problems down-the-road from the inevitable elevations.


Trilostane reportedly offers effective control of Cushing’s syndrome, but the long-term effects of the elevated intermediate steroids remain ill-defined. Some dogs do have return of clinical signs of Cushing’s syndrome while on trilostane.

So I do think that obtaining the UTK profile for that subset of dogs may be enlightening. And maybe in those instances, the testing could occur without suspending the trilostane treatment? For people whose dogs are already being treated with trilostane, I always encourage people to have their vets consult with Dr. O in advance of testing to make sure what his recommendations are re: advisability and timing.

Marianne

[labblab]

Me again, with one more thought. :o

Perhaps another situation where dogs might be tested while actively being treated is when an adrenal tumor is present? In an email, I asked Dr. O about using the UTK panel for "monitoring" rather than strictly diagnostic purposes, and this is what he said:


I shouldn't totally dismiss the idea, since very few veterinarians are doing this yet. With experience, it may turn out to be very useful. I just know that trilostane increases the intermediates, and it makes it difficult to know if it's due to disease or the drug. It probably would be of value to do it with ADH maybe one time, just to see what's going on with the ADH condition. Trilostane has mostly been used for PDH, as I understand it.

So it seems as though there may always be situations where an individual vet thinks that UTK testing may be of special value in the treatment of a specific dog.

Marianne

[lulusmom]

Marianne, this is probably no surprise to you but I can't remember any members who have reported return of symptoms, despite twice daily dosing and a current acth stim showing effective control of cortisol. I am aware that Dr. Oliver reports that some dogs do fine initially on Trilostane but may have problems down the road because of increasing intermediate hormones but where is the documentation by UTK or anybody else for that matter? You would think that with the UK and a number of European countries that have a lot more history with Trilostane and who have conducted a number of studies on the drug, there would be something out there mentioning this phenomenon.

On the flip side, however, there is research showing that the majority of dogs treated with Trilostane, particularly for Alopecia X, demonstrated improvement despite no change, and in some cases, an actual increase in 17OHP concentration. So where do you go with that bit of information? I went back to Lulu's medical records to see if she fit the pattern.

Some folks may recall that Lulu started treatment with Lysodren but I switched her to Trilostane about a year later after my pharmacist said it had less side effects. All was well and good until her new IM and I discovered that a UTK panel was part of testing done for her original diagosis two years earlier, which reflected elevated intermediates. We thought the Trilostane could have been the reason why she never regained her coat. After a 30 day washout we did another UTK panel which showed intermediates were now off the chart in comparison to the original.

08/22/08 Post ACTH:
Cortisol = 202.3 (66.7 - 174.8 ng/ml)
Androstenedione = >100 (3.8 - 42.1 ng/ml)
Estradiol = 84.8 (31.8 - 63.1 pg/ml)
Progesterone = 7.9 (.33 - 4.33 ng/ml)
17 OH Progresterone >25 (.68 - 4.44 ng/ml)
Aldosterone 507.1 (72.9 - 398.5 pg/ml)

You would think that with those huge elevations, she would have had raging symptoms but she was totally asymptomatic for three months after the UTK panel. We started Lysodren at the end of November, 2008 after return of symptoms were apparent and an acth stim showed post cortisol at 25.2 ug/dl. So for Lulu it wasn't the intermediates that were driving the symptoms, it was the cortisol.

Lulu's baldness and Jojo's continued PU/PD, plus their breed being predisposed to hormonal imbalances, have been huge motivating factors in my drive to know more about elevated sex hormones. I was convinced that Trilostane was responsible for both of their unresolved symptoms but they've been on Lysodren for a very long time and it too has failed to resolve Lulu's coat issues or Jojo's PU/PD. For clarification purposes, Jojo did not respond to desmopressin eye drops on two different occasions so central diabetes insipidus was ruled out.

Lulu was on melatonin and lignans for over a year and her skin and coat were no better. The only improvement we've ever achieved with her skin was after I put her on a great fish oil I got from the vet. She's a couch potato anyway but with the melatonin, she was comatose most days. Lulu's IM and I discussed the efficacy of meltatonin and lignans and we decided to discontinue treatment with these supplements. Since then, Lulu has become more alert, more active and a lot more affectionate.

Without credible research, the effects of Trilostane on intermediate hormones will remain ill-defined, which means I can only rely on what I read and my own experience with Lulu and Jojo, including treatment with Trilostane and Lysodren. Based on that, I am no longer convinced, beyond a shadow of a doubt, that long term treatment with Trilostane is an imminent problem.

[littleone1]

Hi and welcome from Corky and me.

Corky had the stim test and the LDDS tests done, along with ultrasounds, which showed that he has adrenal Cushings. He has a tumor on his right adrenal gland. Corky is being treated with Trilo. After 10 days of being on Trilo, he had the full adrenal panel done.

Due to anxiety issues that Corky is currently having, his IMS did the full adrenal panel, in addition to a complete blood work-up, and another U/S. I am now waiting for the results of the adrenal panel. Dr. Oliver did e-mail be back regarding the intermediate hormones being elevated because of his being treated with Trilo. Since he had the adrenal panel done before after being on Trilo, at least I will be able to make a comparison between the two tests.

I know that this can all be very confusing. Hopefully, after there have been more studies done on the effects of Trilo, we will all be able to get clearer answers to our questions.

Terri

[lulusmom]

Me again, with one more thought. :o

Perhaps another situation where dogs might be tested while actively being treated is when an adrenal tumor is present? In an email, I asked Dr. O about using the UTK panel for "monitoring" rather than strictly diagnostic purposes, and this is what he said:


I shouldn't totally dismiss the idea, since very few veterinarians are doing this yet. With experience, it may turn out to be very useful. I just know that trilostane increases the intermediates, and it makes it difficult to know if it's due to disease or the drug. It probably would be of value to do it with ADH maybe one time, just to see what's going on with the ADH condition. Trilostane has mostly been used for PDH, as I understand it.


So it seems as though there may always be situations where an individual vet thinks that UTK testing may be of special value in the treatment of a specific dog.

Marianne

I totally agree but I think a before and after UTK panels of an ADH dog on Trilostane would be more valuable. The likelihood of elevated intermediates with an adrenal tumor is great and with Trilostane being known to enlarge the adrenals and elevate intermediates, I'd be really curious to see if the intermediates are markedly higher after treating and if so, did symptoms correlate with these increases. Do we have any volunteers? Is that Terri I see with her hand up? :D:p:D

[littleone1]

LOL!:D I volunteer.

I don't know how much of a difference there will be, since Corky was only on Trilo 10 days before he had the first adrenal panel done. I know that his adrenal gland had increased in size before, but his U/S last week did show that there was no increase in size of the right adrenal gland. There was actually a slight decrease in size. When he had the U/S done last month, the adrenal gland was 1.9x3.3. This time is was 2x3.

[labblab]

I thought I would "bump up" this thread since there are so many active discussions going on right now re: trilostane/Atypical Cushing's/the UTK adrenal panel.

For anyone who is considering requesting the UTK panel for their dog at any point in their treatment, I strongly encourage you or your vet to first correspond with Dr. Oliver at UTK in advance. Thus far, Dr. Oliver has always been very willing to talk directly to pet owners in addition to vets. There can be so many variables involved in each dog's situation. Dr. Oliver can best tell you whether the UTK panel might be helpful to you, and if so, what the best timing would be (e.g., must the trilostane treatment be suspended, and if so, for how long a time).

Here's a link providing general contact information for Dr. Oliver:

http://www.vet.utk.edu/faculty/oliver.php

Dr. Oliver's email address is: joliver@utk.edu

Marianne

[Harley PoMMom]

Variability of estradiol concentration in normal dogs

Abstract

Estradiol concentrations are evaluated in canine serum as part of an adrenal panel used to diagnose atypical Cushing’s syndrome and other endocrine abnormalities. Estradiol concentrations are often elevated in dogs without clinical signs of hyperestrogenism, and the significance of this elevation is unknown. The purpose of this study was to estimate the variation in estradiol concentrations in normal dogs. Ten neutered male and female dogs were enrolled in the study. Blood was collected from each dog at 2 h intervals, four times during a given day. This was repeated approximately 1 (week 2) and 5 weeks later (week 6). There was no attempt for a given dog to be started at the exact time or day each week. Results showed that estradiol concentrations ranged from 44.6 to 120.3 pg/mL with a mean of 70.4 pg/mL, which is greater than the upper limit of normal for our laboratory (69 pg/mL). The mean difference between the highest and lowest concentrations for each dog was 28.8 pg/mL, with a range of 12.5–53.5 pg/mL. Mean estradiol concentrations from week 6 (63.2 pg/mL) were significantly lower than those from week 1 (71.4 pg/mL; P = 0.015) and week 2 (76.5 pg/mL; P = 0.0004). These data show a wide range of variability in estradiol concentration both within and between dogs and that these measurements often exceed the normal ranges established by the laboratory. Therefore, diagnosis of hyperestrogenism or atypical Cushing’s syndrome based on increased estradiol concentrations should require compatible clinical presentation of hyperestrogenism together with elevated serum estradiol.
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-3164.2010.00896.x/abstract


Since the topic of estradiol is becoming relevant I've been doing some "googling" and found this abstract. I found this to be very interesting that the "normal" dogs have elevated estradiol.

[AlisonandMia]

I see these researchers are working out of UTK itself: http://lib.bioinfo.pl/auid:1659036

(above link shows same abstract but with info as to where researchers work happens to be included.)

[Harley PoMMom]

UTK college is pretty big:
The Veterinary Medical Center and the Agriculture/Veterinary Medicine Library are also contained within this modern structure of 246,000 gross square feet.

The College has research facilities on Cherokee Farm adjacent to the UT Medical Center at Knoxville. Satellite teaching/research facilities are located in Middle and West Tennessee.
http://www.vet.utk.edu/about/facilities.php

I looked up the researchers:

Linda A. Frank, DVM, Professor, Dermatology
http://www.vet.utk.edu/faculty/frank.php

Barton W. Rohrbach, VMD, MPH, Associate Professor, Department of Comparative Medicine
http://www.vet.utk.edu/faculty/rohrbach.php

Could not find much on Rebekah Mullins, maybe a student?

[SavingSimon]

Interesting. I will definitely have more to say about this, once I am in a mental place where I can say more. Simon has had the UTK test done before he was on trilostane, and then recently. I will say this, the IMS said to disregard the first test, and Dr. Oliver's opinion and put Simon on Trilostane (making me wonder why I spent money on the test in the first place) and since then his hormones went up, (they were high before his cortisol was high enough thus he was diagnosed with atypical cushings, or right when his cortisol went up the first time - I can't remember now, numbers for that should be on his thread) anyway, he has since had another UTK test, which does show Oliver is right, in that it makes the hormones off the chart, but that he does not know what this means is news to me. He told me that high estradiol causes the same symptoms as Cushings. If he has nothing to back that up, no wonder people don't get second tests, and even throw out the results of the first one!


After doing quite a bit of research in the last year on this subject, I've changed my position even more so than Marianne. I personally will no longer encourage members to have a UTK panel at all, unless conventional tests such as ACTH stim and LDDS are negative. Dr. Oliver himself states in his paper entitled "Steroid Profiles in the Diagnosis of Canine Adrenal Disorders" that steroid hormone profiles are indicated when other routine tests of adrenal function are negative (ACTH stim; LDDS; combined dexamethasone suppression/ACTH stim) and the dog still exhibits signs of cushing's syndrome, indicating the likelihood of atypical cushing's disease being present. Dr. David Bruyette prescribes Trilostane to the vast majority of his patients and has all but abandoned Lysodren, reserving it for those dogs that cannot handle Trilostane. He also lectures that you should not jump at having a UTK panel done unless all other tests are negative for cushing's.

At no time has Dr. Oliver ever suggested that pet owners should always have a UTK panel before starting treatment with Trilostane. I think the rationale behind that is that if a dog has been properly diagnosed with cushing's, it is pretty safe to say that a number of the intermediate steroids are also elevated. So with that being the case, Trilostane would rarely, if ever, be prescribed.

Some of you may recall that we asked Dr. David Bruyette if he had any concerns about prescribing Trilostane for dogs that have significant elevations in intermediate steroid/sex hormone levels and in those instances, did he recommend an alternative treatment? He answered; "Any adrenolytic agent or enzyme blocker can raise steroid intermediates to some degree. Whether this is an issue clinically depends on the given dog, the dose of medication used, the duration of treatment and concurrent diseases and/or medications." When talking about Trilostane, even Dr. Oliver admits that the long-term effects of elevated intermediate steroids remain ill-defined. Add on top of those opinions that we've never had a member treating their dog with Trilostane report a return of symptoms, despite having perfect 24 hour control of the cortisol.

I switched my own dogs from Trilostane to Lysodren because Lulu's coat and skin never got better and Jojo's PU/PD never resolved on Trilostane. Well guess what??? It's been a year or better since then and neither one has improved. Lulu is still bald and Jojo is still a drinking fool and a great big pee bucket.

The veterinary community at large has come a long way in accepting the fact that there are dogs out there with atypical cushing's but I think it's going to take a lot more convincing evidence before the endocrinologists, world reknown or otherwise, will subscribe to the theory that you need to know if intermediates are elevated before prescribing Trilostane. I'd like to see some of that evidence myself.

[addy]

I just returned from IMS visit with Zoe. She suggested the UTK panel before I did along with an ultrasound when she first was trying to diagnose Zoe. She said she uses it to "see where I am at" with a dog and also as a reference point. Zoe has high estradiol along with 4 other hormones as well as elevated cortisol. I was told Dr. Oliver did not recomment Trilostane for Zoe because of that reason. It would further elevate the estradiol and 17 something progesteran. I don't have it in front of me. Zoe's main complaint is skin coat issues. Her blood work looks pretty good with alk elevated but not nearly where you would expect it to be. In fact when her regular vet read her test results last week, his comment was "but there is not much here, not what I would expect to see. " IMS said we will retest in 3 months the EXACT same test, UTK panel, to see where we are. I think how well the trilostane works may depend which intermediates are elevated and if one is estradiol, well who knows? This is why I wanted to do the poll about who has a dog with elevated estradiol and is treating with trilostane and what where the results? I also want to know what part a non adrenal disease plays with the intermediates. We know stress and illness can falsely elevate cortisol but do they also elevate the other hormones?

However, if Glynda is saying we have never seen a repeat of symptoms with a pup on Trilo and elevated intermediates, then I guess I have my answer. That is not what I thought Dr. Oliver's studies showed but I don't have the papers here, they are at work.

On a side note, Dr. Bruyette also recommended that if a dog has mild symptoms, start with Anipryl. Then if that does not work, go to Trilostane, leaving Lysodren for the last option. If the U.S. is going to stop using Lysodren, that would explain the increase in new members being put on Trilostane.

What I did not know is that not many members had the UTK panel done.

I think I am too tired to digest now, long day at work, followed by long vet visit with IMS

Glad we had the discussion and I will have to reread it but I still have a feeling that it is the estradiol that is the problem and we just don't know enough about it yet.

Addy

[addy]

switched my own dogs from Trilostane to Lysodren because Lulu's coat and skin never got better and Jojo's PU/PD never resolved on Trilostane. Well guess what??? It's been a year or better since then and neither one has improved. Lulu is still bald and Jojo is still a drinking fool and a great big pee bucket

If Trilostane elevates the Estradiol and Lysodren does not always decrease the estradiol can this be because of the estradiol being elevated?

That is my questions, I guess, what part does the estradiol play in all of this?

Thanks,

Addy

[apollo6]

I don't have much input this discussion.
All I know is started Apollo even lower then recommended. He has improved but would like to know if anyone else is having hind leg weakness like Apollo.