Jay Gatsby has passed away [Archive] - Canine Cushing's Information and Support Forums

Derekvof

03-29-2010, 05:15 PM

Hello all -

Thank you guys for this forum. I've been trying to read as many posts as I can to help my dog, Jay Gatsby - it's been very beneficial when speaking with his vets. However, things have not been going well. We initially started treatment for Cushing's with Trilostane (15mg/2x -38-40lb dog) 17 days ago. Within three days, he started to show some inappetence. As he was just coming off some GI upset the previous few weeks, we assumed that he was just having a flare up of IBD, but in an abundance of caution, our vet had us take him off the medication for a day to do the ACTH stim test. Results came back that he's still WAY high on steroid (not even close from what she said), so we're not over corrected. We restarted the medication and a week later, did another ACTH stim test. This time he was closer to normal range (I don't have the numbers in front of me - I've got to talk to his vet and get them). However, during the time and still, he is having food issues - big time. We decided that rather than use the compounded dosage, we'd move to the Vetoryl and drop the dose a little to see if we could let the GI calm down a little. We thought maybe the chewable version we were using could have been causing some issues. Between the switch, we took him off the med entirely for 3 days, but his appetite never really came back all the way.

Both my wife and I have been very happy with the Trilostane treatment in all regards (alertness, muscle strength, etc.) EXCEPT the inappetence which is becoming a big issue. Gatsby has become SO picky about what he eats - we're literally putting together buffets for him to pick from - beef, turkey, baby food, bread, bagels, home-made dog treats, w/d, etc. However, it has become increasingly hard. One time he'll eat something, the next time shy away from it. Stools are good & firm, no vomiting or diarrhea. Gatsby is on a literal pharmacy of medications (as outlined below), but I'm not sure what to do because he really needs all those medications according to the vets. We got him a B-12 injection today to try and stimulate some appetite, but so far, nothing.

I did see from some links and comments that anorexia could be a side-effect. I'm just wondering if anyone has had any good luck with trying anything that would allow us to keep him on the Trilostane rather than either take him off entire or move to Lysodren (rather the devil you know, than the one you don't). Any suggestions would be appreciated as his eating is getting more and more difficult.

Derek (Indianapolis, Indiana)
Jay Gatsby, Bassett Hound/German Shepherd mix, 16 yo, M/N, 40lb, Kidney disease (dx 2/09), Hypertension (dx 2/09), Liver Disease (dx 10/08), Gall Bladder (dx 11/09), Pancreatitis/IBD (dx 6/09), Cushings (dx 1/10), Cervical issues (dx 2005), Arthritis/weak back (dx 2008), hypothyroidism (dx 2006), Thyrosyn (5mg/2x), Enalapril (5mg/2x), Amlodipine (1.25mg/2x), Pepcid AC (10mg/2x), Doxycycline (100mg/2x), Metoclopramide (7.5mg/3x), Tramadol (12.5mg/2x), Ursodiol (250mg/1x), Denamarin (1x), Trilostane (10mg/2x) Diet currently whatever he'll eat - beef, turkey, baby food, bread, pasta, Prescription Diet w/d, etc.

BestBuddy

03-29-2010, 05:46 PM

Hi Derek and welcome to you and Jay Gatsby.

Getting those ACTH numbers from the vet will really help understand what the cortisol is doing and maybe give an understanding on what is causing the lack of appetite.

Even the "right" dose of trilo can give Jay Gatsby the yukkies (technical term:p) as the body takes time to adjust to the lowering of the cortisol.

Some of the tricks I have used to tempt the appetite are a little Parmesan cheese sprinkled over the food, the water (not oil) from a can of tuna poured over the food and sometimes just warming the food a little will give it a better smell. The dogs nose is what tells him he is hungry so if you can trick that a little then maybe that is all that is needed.

Jenny

Derekvof

03-29-2010, 06:13 PM

Hi Jenny,

Thanks for the welcome, and the note. Yeah, we've been trying everything:
- We tried the parmesan - that worked for one meal.
- We've been trying to heat up the food - that only works some times.
- Tried pouring the water I cooked the meat in over the dry food
- Tried home-made dog biscuits.
- I've cooked ground lean beef & turkey - sometimes he'll eat them, but not today
- 3 different types of dry dog food
- His old home cooked diet (salmon, potato & yam)
- Boiled egg whites
- We've tried a variety of baby foods - some he'll eat, some no way
- Tried breads & bagels - those will work a meal or two, and then forget it
- Honey didn't work, neither did chicken broth (without onion or garlic of course)

He's really preferring the crunchy/dry food, but even of that, he won't eat much and gets turned off of the food quickly. I'm going to try some liquid diet (like DogSure or ClinicCare) to try to get some more into him. Problem is he's losing weight and we can't have that. He's already done a couple pounds over the last 2 months.

I'll call the internist in the morning about the ACTH stim numbers for the two tests.

Thanks,
Derek

lulusmom

03-29-2010, 06:35 PM

Hi Derek and welcome to the forum.

First let me say that with JG being 16 years young, you've done a magnificent job of rearing. :D:D:D We'll do all we can to help you continue on and see JG through this rough patch.

First it would be very helpful if you would round up all of JG's testing, to include those done to confirm the cushing's diagnosis and the subsequent acth stim tests that were done after initiating treatment.

You mentioned that JG had some GI issues shortly before starting the Trilostane. Was the GI problem totally resolved before starting Trilostane? Were the diagnostic tests for cushing's done while the IBD was being treated? Was the Doxycline and Metoclopramide prescribed for the IBD? Was the Ursadiol prescribed for liver and gall bladder problem? Was JG diagnosed with primary liver disease and if so, was a liver biopsy done? What is the formal gall bladder diagnosis? Sorry for the twenty questions but the more we know, the better feedback we can provide. With so many prescriptions that are known to cause inappetance, it's not going to be an easy task to figure out the root of the problem.

FYI, it is not advisable to administer Trilostane to any dog that is not eating normally. If either one of my cushdogs did not eat, vomitted or had soft stool, they were automatically off the Trilostane for several days and until they were completely back to themselves.

Looking forward to hearing a lot more about Jay Gatsby.

Glynda

P.S. Forgot to mention that it is not advisable to prescribe Trilostane to a dog that is on ace inhibitors and JG is on two of them, Enalapril and Amlodipine. If you are treating with an internal medicine specialist, I am sure that s/he is aware of this but just in case, you may want to mention it.

Derekvof

03-29-2010, 06:58 PM

Hi Glynda,

Wow - lots of questions. I'll try to answer to the best of my ability. First off, I'll just say that several of Gatsby's illness have been "diagnosed" based on symptoms and non-invasive testing alone (IBD, liver, gall bladder, spleen, etc.) - my wife and I have lost 2 of our dogs in the last decade to post-surgical complications, so at 16 years old, we absolutely refuse to put Gatsby through surgery or sedation. I know our vets would prefer to have a definite diagnosis, but we just can't put him through that risk. If we had, in the last 2 years alone, Gatsby would have had 4 surgeries in which he would have lost his spleen & gall bladder along with 2 surgical biopsies. He's still here with us, so at least for now, we've made the right decisions to avoid surgery.

That being said, let me try to answer your questions:

- In terms of testing, we've done it all - all except surgery or things requiring sedation. So plenty of blood, urine, x-rays, and ultrasounds (as our vet said, Gatsby has probably had more ultrasounds & tests than any dog in the state of Indiana). Diagnosis of Cushing's was originally made last October. Pre-ACTH was 2.1 (2-6 normal) Post-ACTH was 49.6 (6-18 normal). However, the internist asked us to repeat testing with urine catches because Gatsby get very stressed at vet's offices. Tested in November - 58 urine cortisol/creat ratio (less than 13.5 rules out Cushings). Again, asked to do it again. Tested in December - 114 cortisol/creat ratio. Tested with LDDS in January - Pre-Dex 5.0 (range 1-6), 4 hr Post-Dex 4.3 (greater than 1.5 or 50% is Cushings), 8 hr Post-Dex 4.1. We were very reluctant to start based on all the feedback from the internist (e.g., no impact on longevity - which we completely disagree with now), but at the end of Feb/early Mar we were watching such muscle wasting and reduction in QoL, that we felt we had no choice but to try.

- GI issues were due to too much fat in the diet (trying to put on some weight) and a Chinese herb that really shot his GI. He was back on his normal diet before starting and seemed to be completely resolved. All test for Cushing's were prior to the IBD flare up, but all post IBD diagnosis (last year). Meto was for the IBD. Doxy was IBD and persistent bladder infections. Yes, Denamarin & Ursodiol were for liver (high Alk-Phos & ALT) & gall bladder (looking sludgy on ultrasound). No biopsies were performed, however, as they'd require sedation (he's not a calm dog on the ultrasound table).

- I know that all the prescriptions make it tough. Every time we've tried to ween him off of any of the meds, he seems to do worse. Very frustrating, but I guess to be expected dealing with a 16 year old dog.

- As for the Trilostane, prior to the GI debacle, Gatsby was eating like a horse - literally almost 2.5-3lbs of food a day (potato, salmon & yam - plus a little w/d to keep things moving). Post GI debacle, we had just got him back onto his normal diet, but we felt we needed to get started on the Cushing's treatment ASAP before we lost any more ground. As for the meds, Gatsby has had firm, solid stools the entire time on the med and no vomiting. He's not even gurgling or shivering as he had been during GI flare ups. He just doesn't want to eat. He jumps up looking for food, stares at it and walks away. I end up having to try to coax him to eat his food which is disheartening & very frustrating.

Any thoughts would be appreciated. Thanks,

Derek

Harley PoMMom

03-29-2010, 07:18 PM

Hi Derek,

Welcome to you and Jay Gatsby from me and my boy Harley! My 13 y/o boy Harley has PDH cushings, pancreatitis, and elevated blood pressure. His high blood pressure is being controlled with Amlodipine. I am treating him with Lysodren.

About Jay Gatsby pancreatitis, was this confirmed with a cPLI or cPL test? If so, could you post the results of that test. Harley's pancreatitis was found on his first ultrasound :eek: and confirmed by a cPLI test. His results on his first cPLI test was 528 (0-200). His last one done in Feb. was 303. The cPLI/cPL test will test for the lipase enzyme that is specific for the pancreas only. I do urge you to have this test done to see if pancreatitis could be the reason Jay Gatsby is not eating or if it is the IBD, although these two can go hand-in-hand.

Another food you may want to try is tilapia (white fish), my Harley loves this. He does have a diet formulated for him, it does not include tilapia, but I am allowed to give this to him when he is being a fussy eater. I also give my boy L-Glutamine, which is very good for the GI tract.

Please know we are here for you and Jay Gatsby, and we will help you in any way we can.

Love and hugs,
Lori

Derekvof

03-29-2010, 07:42 PM

Hi Lori (and Harley) -

Actually, Gatsby had a full-blown pancreatic episode almost 1 year ago that had him hospitalized for 3 days vomiting. A few months later (after I got onto some of the K9 Kidney boards), I find out about the Spec cPL test which came back positive (I've got the results from last May/June somewhere). We also reran it in October of last year (about the time Gatsby was having some additional issues) - came in at a 755 (>400 is consistent with pancreatitis). I'm not sure any more what's going on - IBD flare-up, pancreatitis, reaction to the Trilostane, reaction to the lower cortisol levels. All I know is I'm sure having a hard time getting him to eat regularly which is just very stressful.

Thanks again,

Derek

P.S. Photo of Jay Gatsby below
http://www.indiana-paw.com/melanie/gatsby-small2.jpg

Harley PoMMom

03-29-2010, 07:54 PM

IBD/Pancreatitis can go hand-in-hand, and usually do. If the Trilostane is the last medicine given, then IMO, this is the culprit of JG's GI upset.

With my boy, his vet and I decided since Harley does have pancreatitis that instead of doing a "loading phase" of Lysodren that we would do just a maintenance dose instead, and start at a low-dosage too. Harley's has great success with this so far, as you can tell by his cPLI numbers. I believe if I were you and JG were my pup, I would start him at a lower dose and try to work your way up. Let his GI and pancreas get used to the Trilostane...slowly.

Love and hugs,
Lori

Squirt's Mom

03-29-2010, 08:11 PM

Hi Derek and welcome to you and Gatsby! :)

He is a handsome fellow, BTW!

At 16 it is entirely possible that Gatsby just doesn't have the capacity to smell or taste that he did. That happens with geriatric pups sometimes. But we don't want him losing weight.

Glynda's suggestion of stopping the Trilo for a few days is quite pertinent. Even if the cause isn't the Trilo, it could be making whatever has him off, worse. So give him a few days break and see if that helps any. You won't lose any ground with the Cushing's since Trilo is in the system for such a short time anyway.

Have you tried adding any green tripe? It has a strong smell so just a teeny bit may be enough for him to smell and stimulate appetite. With the IBD/pancreas issues, don't give him much, tho. Eggs have a smell they like, too. Try frying an egg (no butter/oil) over medium...make sure the white is done but leave the yellow runny. Some other things you might try are sweet potato (not yams), turkey/chicken meat both dark and white but not the ground variety - regular people bird, or perhaps a novel protein like ostrich, bison, or venison but not lamb - too much fat.

There is a product called Nutrical that is a complete mineral and vitamin supplement you can give him to make sure those are being met while he is having difficulty eating. It comes in a tube as a paste and most pups like it well enough to lick it off your fingers.

It can drive you absolutely batty, but give him whatever it is he will eat each time. Keep trying until you hit his "sweet spot" for that meal, so to say, and don't expect to repeat it for the next meal. He may need variety to keep his interest up.

One of mine is so finicky she drives me nuts! I always have numerous kinds of feed - kibble and canned - plus a variety of home made meals in the freezer for her that she liked one day and refused from then on. I even went so far one day, just being goofy, that I put different things in each section of a divided plate. She ate each one...but now won't eat out of her bowl! She wants that stupid divided plate! :rolleyes: Even if the same food is in each section...go figure! She's my little psycho. :p

Hugs,
Leslie and the girls - always

Harley PoMMom

03-29-2010, 08:16 PM

Another thought came to my mind :eek:

How are JG's teeth/mouth? Have you checked in his mouth lately?

Love and hugs,
Lori

labblab

03-29-2010, 09:04 PM

Were Jay Gatsby's electrolytes checked at the same time that the ACTH tests were performed? Glynda has already mentioned a cautionary note re: the combination of trilostane and ace inihibitors. Here's a quote from Dechra that elaborates on the danger:

Angiotensin-converting enzyme (ACE) inhibitors should be used with caution with VETORYL Capsules, as both drugs have aldosterone-lowering effects which may be additive, impairing the patient’s ability to maintain normal electrolytes, blood volume and renal perfusion. Potassium sparing diuretics (e.g. spironolactone) should not be used with VETORYL Capsules, as both drugs have the potential to inhibit aldosterone, increasing the likelihood of hyperkalemia.

It's just a thought...but even though JG's cortisol level may not have dropped too low, perhaps it's possible that his blood chemistries are out-of-whack as a result of the drug combination that he is taking?

Also (and this is a questions unrelated to the appetite issue), JG's LDDS results could be consistent with Cushing's caused by an adrenal tumor. You have mentioned multiple ultrasounds...have any visualized his adrenal glands?

Marianne

Derekvof

03-29-2010, 11:08 PM

Lori - Thanks for the info about how you and your vet are treating Harley. That's helpful to know. As to his teeth & mouth, that was one of my first questions to the vets - they took and look at Gatsby's mouth and said everything looks really good, especially for a 16 year old.

Leslie - Thanks for the info about the green tripe. I have heard that mentioned before, so I think I'll get some ordered up and see if that helps Gatsby. I have noticed that when I'm cooking him ostrich or making him dog bones, he seems really interested, and is eating - but really only when fresh so the problem may be his sense of smell plus the lower cortisol. Not sure, but if stinky works, I'll give it a shot. Thing is, this is all weird for me because Gatsby has been for his entire life an eater - he'll eat anything and everything. I actually picked up some DogSure tonight (which he seems to be drinking some of) to get him some nutrients.

Marianne - Thanks for the note about the medicine combination. I've heard that also. I made sure when we ran the ACTH stim last Friday that my vet double-checked the electrolytes as well - everything was in the normal range. Regarding the ultrasounds, they have looked at his adrenals (which was part of the reason we were so slow to diagnose - they looked fine until recently). As of the last ultrasound, they were according to the radiologist both slightly enlarged (no visible tumors) which would indicate it was most likely pituitary instead of adrenal Cushing's. We did let it go on for quite some time, apparently, because the vets believed it unlikely that Gatsby had Cushing's (I was asking about it almost a year before it was diagnosed finally).

Off to buy some green tripe! Keep firing away - anything & everything is helpful!

Derek & Gatsby

Derekvof

03-30-2010, 09:01 AM

Hi again,

Another question - could Gatsby be overcorrected even though the tests show that he's not? I thought I saw several people on the boards indicating that treatment should really be to see improvement of the signs (over drinking, muscle wasting, etc.) as opposed to the numeric results of the ACTH stim test, correct? And there's a 7-10 day window in which the systems cortisol levels drop, right? Well, Gatsby seems to do really well the first 3-4 days on the Trilostane and then about day 5 or so, seems to feel really exhausted. I know that sounds weird in a 40lb dog on 10mg/2x, but is that possible?

I'm just wondering because in addition to the inappetence, the last two days he's seemed really exhausted again. It's a total 180 from the weekend when he seemed to be coming back to his normal self.

Any thoughts?

Derek & Gatsby

AlisonandMia

03-30-2010, 09:19 AM

Has he had an ACTH stim test done since starting the trilostane? If so, how long after the morning dose of trilostane was the test done? Trilostane's cortisol-lowering effects peak 2 - 6 hours after dosing and for the results to be reliable as possible the test needs to be started and completed within that time period.

Sometimes a dog can suffer from what is called "cortisol withdrawal" when the levels drop rapidly from very high to what is actually a more healthy level. They adjust to it in time but can feel pretty yukky for a while - in fact the symptoms can be very similar to low cortisol. The answer is often to back off on the treatment slightly to give them time to adjust. JG's levels at diagnosis were very high which could possibly make this more likely in his case.

With regards to poor appetite, some people have had luck with cultured butter milk.

Alison

labblab

03-30-2010, 09:29 AM

Derek, it looks as though he's had two ACTH tests since starting the trilostane? If you could post the actual test results, that will help us as we sort through possible explanations for JG's issues. Otherwise, it is difficult to know how "high" or "low" his cortisol level actually is.

If his cortisol levels and electrolyte checks truly do not identify any obvious problems, then I have one other suggestion to make -- one that you probably won't like :o. But that is to discontinue the trilostane for a longer period of time in order to see whether JG's appetite rebounds normally. In rereading your thread, I see that he went without trilostane for a three-day time period when you made the dosing switch, and his appetite improved but not back to his baseline prior to beginning treatment (or prior to his GI upset). I know it may feel like a "set-back" to stop the medication again, but at this point, a more extended break may be the easiest way to determine whether it's the trilostane that is causing the problem or whether it is something else altogether.

I know you don't need me to tell you that ongoing inappetence is a major concern -- you are living with the daily (make that hourly!) stress of trying to tempt JG to eat. So even though it will be hard to see a rebound of Cushing's symptoms during a medication break, I think it may be worth it to conduct this simple experiment. If he DOES improve after being off the trilostane for a week or so, but then exhibits the same problems once you start back -- then you'll know that it is truly the trilostane which is in some way the culprit. But since you've not had the opportunity to see his appetite ever normalize for an extended period since the GI episode, there may still be some other underlying issue going on that the trilostane is somehow aggravating.

Marianne

Derekvof

03-30-2010, 10:20 AM

Hi Alison - Actually, he's had 2 test (I'm going to get the numbers today from Gatsby's internist). First test was only 3 days after starting because he seemed to be feeling kind of lousy & shying away from his food. Vet at that time said he "wasn't close to being corrected". After restarting, we reran a week later and was told he was "close to normal" - again, going to get those numbers today. First test was done after (purposefully) skipping the morning dose (which would have put it about 15 hours after the previous dose). Second test was done exactly 4 hours after the Trilostane morning dose (as directed by the internist). Thanks for the info on the "cortisol withdrawal".

Marianne - Definitely going to get those numbers today. Going to be speaking with Gatsby's internist this afternoon to try to get that info and discuss the cortisol withdrawal. I actually found your post on the K9Diabetes board discussing it, and it's very helpful - http://www.k9diabetes.com/forum/showpost.php?p=14933&postcount=82 As for the suggestion of moving him off of it entirely, although I see the benefits of doing that, that's a difficult decision. We started treatment in many respects because we felt he was going downhill. I'm concerned that taking him off would allow that to progress and us lose our window of opportunity, as it was.

Will definitely discuss with our vets today and see what we can do. May be time to take him off for a few days and restart lower (like 10mg/1x or even 10mg every other day). I hate to move so slow, but I guess it's better to have him feeling good then feeling like he is today :-(

Derek & Gatsby

sunimist

03-30-2010, 10:24 AM

I don't have anything else to offer except having the same problem with my girl, it sounds like Gatsby might be nauseated...acting interested, but not really tasting. Could some of the meds combination be causing nausea? Kidney disease is notorious for causing nausea also. We found that Cerenia and Ondansetron as nausea meds worked well for my girl, since she could not take Metoclopramide. Just something to run by your vet, but sounds like all bases have been covered already.

Keeping you in my thoughts and prayers.

Shelba and Suni

labblab

03-30-2010, 10:44 AM

As for the suggestion of moving him off of it entirely, although I see the benefits of doing that, that's a difficult decision. We started treatment in many respects because we felt he was going downhill. I'm concerned that taking him off would allow that to progress and us lose our window of opportunity, as it was.

Derek & Gatsby
Derek, I totally feel your pain in terms of a decision to suspend treatment for longer than a couple of days. But I'm making the suggestion from my experience with my own Cushpup (so bear in mind, my suggestion is "biased" by what I wish I could go back and change for my own boy :o).

My 9 y/o Lab was diagnosed at a time when he was horribly uncomfortable from Cushing's symptoms -- excessive panting, muscle wasting, excessive thirst and hunger, etc. We treated him with trilostane, and had several months in which he rebounded (for which I will be forever thankful). But then he started losing his appetite... To make a long story short, although it was not definitively diagnosed, we believe that his pituitary tumor was enlarging and placing pressure elsewhere in his brain (inappetence is a common symptom). Because his cortisol level and electrolytes were always "OK," we never discontinued his trilostane for an extended period of time (just for a few days, and then lowered the dosage). We ended up in crisis, with him refusing to eat and drink entirely, and he never rebounded.

In retrospect, the one thing that I really wish we had done was to leave him off his trilostane for a longer period of time in order to see whether his appetite would ever return and whether the trilostane was playing a bigger role than we thought. It was so difficult to watch his Cushing's symptoms re-emerge, and that is why we chickened out ourselves. But it was a stone that we did NOT turn over, and it would have been the easiest thing to try, diagnostically (although the definitive diagnosis for enlarging macrotumors is imaging of the head via CT or MRI).

Marianne

Derekvof

03-30-2010, 04:28 PM

OK - finally got the test results after speaking with our internist. The first test was done after being on Trilostane (15mg/2x) for only 3 days. Pre was 9.5, Post was 31.6. Second test was done after being on Trilostane for 7 full days. Pre was 3.6. Post was 16.9. Not sure how that falls into everything, but as I understand it, the second test was within a tenth of a point of the high end of normal.

Hi Shelba & Suni - Not sure about nausea. It could be. Thing is when he's had GI issues and felt sick before, he'd shiver uncomfortably, lick his chops, etc. He's doing none of the above and is having very solid, well-formed stools as well. So not sure.

Marianne - I totally understand the reasoning behind your suggestion. Thing is, if it is something else, there's nothing we can do to treat it really. Trilostane really is our last chance for Gatsby. We can't do surgery, we can't do further diagnostics other than what we've done, so if it (godforbid) is something else, we're out of options. :-( I do appreciate the input, it's just not somewhere that I think we can go...

Derek & Gatsby

labblab

03-30-2010, 05:39 PM

Derek, you're right that both ACTH tests indicate that JG's cortisol level was far from being too low at those times. Actually, the ideal therapeutic range for a dog being treated with trilostane is a post-stim result of approx. 1.45 - 5.4 ug/dl. The goal is to consistently maintain the cortisol level at a significantly lower range than what is considered normal for a non-Cushpup. Dechra, the manufacturers of Vetoryl, will "allow" treated dogs to range up as high as 9.1 ug/dl, as long as Cushing's symptoms remain under control. But JG's second "post" result of 16.9 remains quite a ways outside the recommended therapeutic range -- and certainly far from being too low. Here's a link to Dechra's U.S. Vetoryl Treatment and Monitoring Flowchart:

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

This is not to say that JG isn't suffering from "cortisol withdrawal" as has already been discussed. I do think that remains a possibility. But the longer that the inappetence continues at such low doses of trilostane, the more I would question that as being the sole cause. If I am understanding you correctly, you are now 18 days into treatment and have lowered the trilostane dose, but he is doing worse instead of better in terms of the appetite issues.

Given JG's age, I totally get it as far as not wishing to consider any invasive diagnostics or treatment options. But if for whatever reason JG is unable to tolerate trilostane because of issues specific to the medication itself, I do think you still have Lysodren as a Cushing's treatment option. So that is one of the reasons why I'm thinking it would be of interest to find out whether his appetite would rebound if given a total temporary break from the trilostane. But I promise to quit harping on that suggestion (well, at least for the moment!).

Marianne

Harley PoMMom

03-30-2010, 06:23 PM

May be time to take him off for a few days and restart lower (like 10mg/1x or even 10mg every other day). I hate to move so slow, but I guess it's better to have him feeling good then feeling like he is today :-(

Derek & Gatsby

IMO, I think this is a great idea. Derek, Cushings is a slow progressing disease, and some dogs do not get diagnosed correctly for years. The fact that you are treating Jay Gatsby, even if it would be a small dose of Trilostane, will still help him. But Jay Gatsby should be eating properly before anymore Trilostane is given.

So I do agree with Marianne here, stopping the Trilostane to see if Jay Gatsby regains his appetite. And then if so, restarting the Trilostane at a much lower dose. Please talk to your vet about this.

Love and hugs,
Lori

Derekvof

03-30-2010, 07:04 PM

Hi Marianne - Thanks again. I know - our vets are frustrated as well. They'd really like to get to the bottom of the issue and do more invasive diagnostics, but as I may have mentioned, in addition to his age, 2 of the 3 dogs my wife and I have lost in the last decade have been due to post-surgical complications (bleed out after a spay and blood clot following a GI biopsy). Both should have been "simple" operations but both ended in tragedy for our family. We just can't do that again. As for the treatment, although it's been 18 days, we haven't been treating that long - 3 days on, 1 day off, 8 days on, 2 days off, and now 5 days back on. Kind of a roller coaster ride here...

Hi Lori - Yup, that's the plan - take him off for the next three days and see if his appetite rebounds (at least some of the way) and then look at restarting on Friday or Saturday, depending how it goes. Just frustrating because for the first three days of each treatment cycle, we can visibly see the improvement in his demeanor, strength, etc., but as soon as Day 4-5 hits, he starts to go down hill...

<sigh> Just frustrating... why can't it be easy?

But when I start to get frustrated, I have to remember my wife and I are planning some special events for Gatsby (like we always do) to keep us focused and help make special memories with him - going to take him around the Indianapolis Motor Speedway for Mutt Strut for the local humane society here in a few weeks, and then my wife has decided to throw him a "Sweet 16 Party" at a local roller skating rink. You'd be surprised how many people say "yes" to letting a dog into their businesses :-D

Derek & Gatsby

Harley PoMMom

03-30-2010, 07:16 PM

Derek,

When you are doing this, can I ask you to do me a favor...and this is a little gross...sorry :o but take a look at Jay Gatsby's poop: the color; does it have a orange tint to it? any color? texture; is it firm, or like a cow pile, or not formed, runny...etc. You get the picture! :p:) Poop can tell alot!

Another question I wanted to ask you, does Jay Gatsby's tummy rumble or make noises when he is having GI issues?

The sweet 16th party for him sounds awesome and going to Indianapolis Motor Speedway for Mutt Strut!!! Man, my boy is jealous! You really love your Jay Gatsby and it shows, you are both such wonderful parents.

Love and hugs,
Lori

Derekvof

03-30-2010, 07:25 PM

Not gross at all - sad thing is, I've been doing it regularly :-) As of today (and consistently since we started treating for Cushings at least), they've been solid, well formed and a nice, rich brown. Not watery, not mucous coated, not orange - actually he's going in my office right now (oops) so let me check - they look good, just as I've described. Do we need photos? ;-)

Gotta clean up now...

Derek & Gatsby

P.S. Forgot to mention - last week, Gatsby was at our family vet and dropped one almost into his hand during an exam. He took a look and thought it looked good too. Also did a fecal exam just to rule out any sort of worms or parasites - all came back good.

Harley PoMMom

03-30-2010, 07:30 PM

Does Jay Gatsby's tummy rumble or make noises when he is having GI issues?

Derekvof

03-30-2010, 07:37 PM

When he has really bad GI issues (like he had about 4-6 weeks ago), yes - like a whole party in his stomach. Recently, maybe once every day or two I'll hear a gurgle. Not bad considering he sits just 5 feet from me throughout the work day. We had serious issues with borborygmus last year when we tried to move him to Prescription Diet k/d - too fatty for him...

Derek & Gatsby

labblab

03-30-2010, 07:39 PM

Is it unusual for Gatsby to be defecating in the house (and at the vet's office)? Is it something that has also started recently?

Marianne

Derekvof

03-30-2010, 07:42 PM

Unfortunately, not in the last several years. It has become more pronounced in the last 6 months, however. Our vets have both indicated that the severe muscle wasting in his back-end (which is causing him to walk like a drunk sailor) is causing problems in that respect, but he's had accidents in the house for years. He can be kind of stubborn and when he needs to go, he doesn't communicate it very well. We have been trying to help the muscles and issues in the back-end with some chiro from a local holistic vet - he does a great job at getting Gatsby's feet back under him when he throws his back out.

Derek & Gatsby

frijole

03-30-2010, 08:40 PM

:p Hi from me! I haven't posted on your thread yet as I use lysodren but I do have a dog that turned 16 in December and.. mmm... the defecation thing does come with old age.

:D;):D;)

We are cheering you and Gatsby on!
Kim

sunimist

03-30-2010, 08:57 PM

I too am cheering you guys on and I would just like to say..."What an exceptional and loving dad you are!" You certainly bring inspiration to me!

Many (((HUGS))) to the Gatsby boy! :D

Shelba and Suni

Also just a quick note...I too lost a baby post surgery following a simple spay. She was only 6 months old. Heartbreaking. Absolutely devastated us, so I can personally relate to your reasoning without question.

Derekvof

03-30-2010, 09:37 PM

Thanks Kim, Shelba and Suni - we really appreciate the kind words and support. And thanks to every one else that's responded. I can't tell you how much I appreciate the help & support. It's nice to know there's somewhere I can ask my "bone-head" questions (I think my vets are getting tired of hearing from me) ;)

Derek & Gatsby
P.S. Ok - I know it's a shameless plug, but if you want to see our family's website (and all of Gatsby's special events and photos and videos), you can visit http://web.me.com/derekf

lulusmom

03-30-2010, 11:02 PM

OMG, Derek, thank you so much for sharing your website with us. I am sitting here crying my eyes out. I can't even tell you how touched I am. You and Amy are absolutely awesome and how incredibly lucky all of your kids, past and present, are to have been given the opportunity to share your lives. God bless you both.

Glynda

sunimist

03-31-2010, 10:31 AM

That's the most beautiful, touching and awesome thing I have ever seen! What a tribute and testimony to your beloved pets and all the pets around the world. Thank you so much for sharing and giving us all such a feeling of love and inspiration. May God richly bless you.
Just speechless!

Love and ((((hugs)))) to your family.

Shelba and Suni

BTW, there is no such thing as a "bone-head" question to us! :D

Roxee's Dad

03-31-2010, 12:56 PM

Hi Derek,
A very belated welcome from me too. :) I haven't posted but I have been following along. I visited your wonderful website, love it, and I know I ran across it some months ago. Don't know why or remember how but thought it was really wonderful then too.:)

Our Roxee was on Trilo and when she lost her appetite, we would stop the trilo for a few days until her appetite returned. We sadly lost her due to neurological issues, most probably a macro.

Keeping fingers and paws crossed that Gatsby is doing better.

labblab

03-31-2010, 01:17 PM

Derek, your family's website is wonderful! :o

And maybe it is truly the case that Gatsby just hasn't yet been able to get past the yuckkies caused by cortisol withdrawal:

As for the treatment, although it's been 18 days, we haven't been treating that long - 3 days on, 1 day off, 8 days on, 2 days off, and now 5 days back on. Kind of a roller coaster ride here...

Derek & Gatsby
I've got my fingers crossed, too, that he'll start eating again for you during these next few days of his trilostane "break"!

Marianne

Squirt's Mom

03-31-2010, 01:21 PM

Hi Derek,

Ok, well, I've had my morning cry...your site is just so touching and uplifting. Thank you for sharing with us.

I hope Gatsby is feeling a bit better today!

Hugs,
Leslie and the girls - always

Derekvof

03-31-2010, 02:04 PM

Wow - thank you Glynda, Shelba & Suni, John, Marianne and Leslie for your kind words. We do appreciate it. Been a very difficult two years for our family.

So far, so good. Gatsby is eating much better today. Not back to his normal ravenous self, but very much improved over yesterday. Hopefully a little break will be just what he needs and then see if we can start him on a low low dose every day or every other day with the Trilostane and try to get him used to the cortisol withdrawal a little slower. I'll let you know how it goes.

Derek

labblab

03-31-2010, 02:40 PM

Derek, at whatever time you decide to start back with the trilostane, I support your suggestion of giving once-daily dosing a try. I know you've been dosing Gatsby two times each day thus far, but it might be worth it to try cutting back. Even though several research studies have endorsed twice daily dosing, the two "active" dosing protocols with which we are most famliar -- that of Dechra and UC Davis -- still recommend starting dogs off with once daily doses, and moving to twice-daily dosing only if symptoms rebound later in the day. (Additionally, there may be specific reasons why diabetic dogs may benefit from twice-daily dosing.) One of our members is a veterinary endocrinologist, and he has told us that dogs who are dosed twice-daily do run a greater risk for having their cortisol levels drop too low during treatment, and thus should be monitored even more closely.

Perhaps Gatsby would do better with allowing his cortisol to rise back up a bit more within each 24-hour dosing period. Just one more thought...

Marianne

Derekvof

04-01-2010, 02:12 PM

Hi Marianne - Thanks for the suggestion about the once a day dosing. It was actually our suggestion to dose twice a day to our vet because we were concerned about GI upset. I guess another question along those lines would then be "when should we be dosing?" I know the suggestion is first of the morning, but I'm kind of tempted to do it about 9-10pm after his last dinner of the day. That way by morning, the levels are up a little better so he's "down" overnight and maybe feels more like eating in the morning. Not sure if that messes up the circadian rhythms though.

Gatsby's been off now for the last two days, and his eating has improved (with a little help from some tripe) - but he's still not gorging himself like I'm used to. Of course, I'm also no longer having to hand feed him part of his meals, so I think that's progress. Hopefully he'll feel more like eating this afternoon and tomorrow.

Derek

labblab

04-01-2010, 02:58 PM

I guess another question along those lines would then be "when should we be dosing?" I know the suggestion is first of the morning, but I'm kind of tempted to do it about 9-10pm after his last dinner of the day. That way by morning, the levels are up a little better so he's "down" overnight and maybe feels more like eating in the morning. Not sure if that messes up the circadian rhythms though.
Derek
Unfortunately, once-daily dosing during the evening would mess up the usefulness of the ACTH monitoring tests. The testing really needs to be performed during those first few hours after ingestion when the trilostane is maximally effective. Otherwise, you have no way of knowing how low Gatsby's cortisol is dropping at that time, which is a safety issue. Plus, all the published monitoring guidelines are based upon comparisons of tests performed during that specific post-ingestion "window." Trilostane does need to be given with food, though. So Gatsby should be getting it along with breakfast in the morning.

Marianne

Derekvof

04-02-2010, 09:15 AM

Thanks Marianne - I thought that might be the case.

Another question for you - Gatsby has gotten back to eating more regularly (not perfect, but much better). However, he is still being REALLY picky and wanting a whole buffet of food to select from. I'm wondering if I'm just making things worse by giving him options. I'm afraid with him eating whatever he wants, he's going to increase his BUN from his kidney disease and then not feel like eating and put us into a vicious cycle. Should I just try some "tough love" and try to just leave out his usually dog food until he eats it or is it more important to try to keep him eating, even if it messes up his system?

Derek & Gatsby

Harley PoMMom

04-02-2010, 10:28 AM

What's does Gatsby's Creatinine number look like, this is more specific to the kidneys than the BUN.

Love and hugs,
Lori

Derekvof

04-02-2010, 10:43 AM

Last I have in my records (from 3/2) was 14.9. However, that was before Gatsby's GI upset which caused us to start throwing everything at him (fast, then just potato, then potato & eggs for a week, then back onto his potato & salmon, and then starting Trilostane which caused us to be changing food left and right). I know the internist mentioned when we did the blood panel with his ACTH Stim a week or so ago that his BUN was going up which she attributed to all the cooked meat we'd been feeding him to keep him eating (turkey, ostrich, etc.).

Thanks,

Derek

StarDeb55

04-02-2010, 11:32 AM

Derek, I have not posted to you & Gatsby previously, but have been following his story. To let you know, I'm a medical lab technologist with 30 years experience, so I'm kind of use to reading lab results.

Your vet is correct, high protein diets will most definitely cause the BUN to rise. Very simple things can cause a rise in the BUN including dehydration. As Lori has already mentioned, the creatinine is the most important of the 2 values when it comes to monitoring kidney function. Do you happen to know what Gatsby's last creat value was?

Debbie

Squirt's Mom

04-02-2010, 12:42 PM

Hi Derek,

Here are some links pertaining to protein and kidney disease. It has become generally accepted, based on studies such as these, that it is the mineral content of diets, not protein content, that is more likely to damage the kidneys. Minerals like phosphorus, calcium and magnesium....phosphorus in particular.

Links to abstracts of studies that have been done on the effect of protein and phosphorous on renal functions in dogs.*

Influence of dietary protein on renal functions in dogs - School of Vet Med, University of Penn.http://www.ncbi.nlm.nih.gov/pubmed/1...?dopt=Abstract

High dietary protein intake does not cause progressive renal failure in dogs after 75% nephrectomy or aging. - School of Vet Med, Univ of Penn
http://jn.nutrition.org/cgi/reprint/...Suppl/S128.pdf

Dietary Protein Intake and the Glomerular Adapations to Partial Nephrectomy in Dogs - Univ of Georgia, Tulane Univ, New Orleanshttp://jn.nutrition.org/cgi/reprint/...Suppl/S125.pdf

Effects of dietary polyunsaturated fatty acid supplementation in early renal insufficiency in dogs. University of Georgea, Athens
http://www.ncbi.nlm.nih.gov/pubmed/1...?dopt=Abstract

Here is an excellent website that deals with canine kidney disease:*
http://www.dogaware.com/kidney.html

Dietary Management of Dogs With Renal Disease*
http://www.vetprof.com/clientinfo/KidneyDiseaseInDogs/diet.htm

Hugs,
Leslie and the girls - always

Harley PoMMom

04-02-2010, 12:48 PM

The dogaware link Leslie gave you is a very good web site, and here is a link to their Table of Nutritional Information on Selected Foods you may want to feed JG.

http://www.dogaware.com/health/kidneytable.html

Love and hugs,
Lori

StarDeb55

04-02-2010, 12:56 PM

Derek, to clarify what I said earlier, there are a number of very simple things that can cause a transient elevation in the BUN including dehydration, & high protein diets. Blood urea nitrogen (BUN) is a breakdown product of protein, so a high protein diet will most definitely will cause an increase in the BUN. I was not trying to indicate that an increase in BUN is directly related to permanent impairment of kidney function. Again, the creatinine is the more important of the 2 values.

Debbie

lulusmom

04-02-2010, 01:07 PM

Last I have in my records (from 3/2) was 14.9.

Is this the creatinine? I seem to recall that normal creatine is less than 1.6 so 14.9 is is really, really high. I also wanted to point out that elevated BUN is very common with cushing's and most often is not an indicator of loss of kidney function; however, with creatinine levels so high, it looks like Gatsby's elevated BUN is certainly more likely to be due to loss of kidney function.

StarDeb55

04-02-2010, 01:18 PM

Glynda, great catch! Derek, if Glynda is correct that the 14.9 is the creatinine, this is extremely elevated, & does indicate loss of kidney function. Can you clarify this for us?

Debbie

Derekvof

04-02-2010, 03:17 PM

Actually, the values are from the UPC test we ran in March. Values from IDEXX were:

U PROT 67.4 mg/dL
U CREA 14.9 mg/dL
U PRO/CREA 4.5

I know that doesn't sound good, but it's significantly better than the 7.4 we had at this time last year when he was first diagnosed with kidney disease and hypertension (first visit to the internist, he registered a BP of 290! Just a little high-strung at the vets office).

As for the diet, up until his GI debacle at the beginning of the month, Gatsby was eating a home-cooked diet of salmon, potato & yam plus Balance-IT put together by Dr. Remillard, a certified veterinary nutritionalist out of Boston. Prior to that, he was mostly on Prescription Diet w/d (we tried k/d which was too fatty for his system with the pancreatitis issues he's had). We only started throwing everything at him after he started shying from his food. I know it's not the protein, per se, that's the issue, but that meats are higher in phosphorous which I understand is the issue with kidney disease.

However, the good news is today I decided to just take the risk and play some "hard ball" and just giving him his normal w/d (no meats, no baby food, no breads, etc.), and he's been eating it. Not with the enthusiasm he's had in the past, but without coaxing or encouragement by me. So, good news by and large. Now I just need to try to move him back on the Trilostane at a ridiculously low dose in the next few days and try to let his little old body adjust to the steroid reduction slowly.

Keep your fingers crossed... Thanks again Debbie, Lori, Leslie, Glynda and Marianne. I appreciate all the input!

Derek & Gatsby

Squirt's Mom

04-02-2010, 03:29 PM

Hi Derek,

Sounds like some improvement today, which is great news! And it sounds like you have a good plan for the diet and restarting the Trilo. IMHO, whatever Gatsby will eat and tolerate, let him have. Take it very slow and easy, giving his system ample time to adjust to every tiny change from here on out. He's had a lot to deal with lately and we older folks often don't take well to change. ;)

You are doing a wonderful job and I know Gatsby is full of gratitude and love for all you do for him, and the rest of his family.

Hugs,
Leslie and the girls - always

labblab

04-02-2010, 04:31 PM

lulusmom

04-02-2010, 05:25 PM

Hi Derek,

Wow, that is some high creatinine and like Marianne, I am wondering if your vet mentioned anything about the risks of treating a dog in kidney failure with Trilostane. It could very well be that your vet suspects that the high blood pressure is a bigger threat to the kidneys than the Trilostane. The Trilostane will lower cortisol which should lower the blood pressure so I do understand that way of thinking; however, if not for the blood pressure issue, the decision to stop the Trilostane permanently would be a no brainer for me.

Glynda

P.S. On second thought, I think that even if cortisol were lowered, the kidney problems are severe enough to keep the BP elevated. Can you let us know why your vet wants to treat the cushing's given Gatsby's age and multiple issues?

StarDeb55

04-02-2010, 05:39 PM

Derek, I'm 95% sure that the "U" preceding these results that you've posted indicate that all 3 results are from a urine sample. What I'm specifically looking for is blood chemistry results that would have a serum creatinine & BUN. The serum results are much more significant than urine.

Debbie

lulusmom

04-02-2010, 05:43 PM

Debbie, good catch!!! I am so hoping that the blood chemistry values look a lot better.

Derekvof

04-02-2010, 07:50 PM

Yes, it is from the urine for the UPC. That's my fault - I wasn't sure which one you were looking for, Debbie. Just pulled up the bloodwork from early March which was, as mentioned, prior to the GI issues we've been dealing with - CREA 0.6 mg/dL (range 0.4-1.8) - so actually pretty good. BUN/UREA was 17 mg/dL (range 7-27). Sorry for the confusion. I know our vets have mentioned that even thought the UPC is fairly up there, it's still not showing in the bloodwork which is a blessing. By the way, Gatsby's BP is actually well managed currently. I measure it at home as about 140-145 on a typical day (we gave up measuring at the vet - he has SEVERE white-coat syndrome and will throw a number up around 210-230 in the office which I've verified with my meter).

Regarding the question of giving Trilostane, my wife and I saw some significant decrease in QoL in February and March which appeared to be very much due to the Cushings (severe muscle wasting, making it increasingly difficult to walk - the Walking Wheels arrive tomorrow). We actually decided, with our family vet's blessing, that we really wanted to treat it because of the impact we were seeing. Our internist suggested very strongly (and our family vet ultimately agreed with her) that we should try Trilostane because of the ability to get it out of the system faster, and started on what both of them believed was a very low dose to start (30mg starting with both believing he'd need around 60mg). We know and knew it was a risk to treat, but we felt that we were out of options and our window of opportunity was closing.

I'm glad to say that Gatsby is eating better today (now 3 days off the Trilostane). Still not back to his old "I'll eat shoes I'm so hungry" attitude, but going over and gobbling up some dry food without coaxing. Much improved. I feel confident that given enough time, his eating would come back up to normal.

Thanks again, Leslie, Marianne, Glynda, & Debbie!

Derek & Gatsby

lulusmom

04-02-2010, 08:02 PM

Hi Derek,

Those kidney values are great!!! I feel so much better now, especially knowing that the BP is well controlled. This is all great news.

StarDeb55

04-02-2010, 08:12 PM

Yes, indeed, those 2 values are beautiful for such a senior fellow!

Debbie

Squirt's Mom

04-03-2010, 10:37 AM

~~whew~~ good to know those kidney results via blood are good! :D One less thing to worry about right now. :cool:

It looks to me as if the Trilo could be playing a significant role in his loss of appetite. Per Dechra's 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,...

...Additional adverse reactions were
observed in 93 dogs. The most
common of these included diarrhea (31
dogs), lethargy (30 dogs), inappetence/
anorexia (27 dogs), vomiting (28 dogs),
musculoskeletal signs (lameness,
worsening of degenerative joint
disease) (25 dogs), urinary tract
infection (UTI)/hematuria (17 dogs),
shaking/shivering (10 dogs), otitis
externa (8 dogs), respiratory signs
(coughing, congestion) (7 dogs), and
skin/coat abnormality (seborrhea,
pruritus) (8 dogs).

Hope Gatsby has a wonderful day!
Hugs,
Leslie and the girls - always

Derekvof

04-06-2010, 05:52 PM

Thanks again, Debbie, Leslie & Glynda. So far, things are going fairly well. I've actually been dosing Gatsby with only 10mg every other day starting on Saturday. He's continued to eat regularly with a pretty good appetite (not voracious, but good). He's had a really good last several days (alert, mobile, happy, bouncy), so I'm very encouraged. Hopefully he'll continue on this path and I'll be able to increase the dosage by this weekend to 10mg every day.

I did have one question, however. Gatsby has, in the past and again the last few weeks, been breathing rather heavily at bed time (our vets have referred to it as "forceful breathing") but up until now, we've assumed it was discomfort from GI and/or arthritis. However, now I'm wondering if it's panting due to the temperature raising to a more normal level (been in the 70s here this week) along with the Cushing's. During the day, I don't notice it, but he's also sleeping on a cool bed (water cooled) that we got for him a year or so ago. At night, we put him in bed with us, but lately, I'm having to put him down on the floor in the bedroom on his cool bed so that he can sleep comfortably and quietly. He has done this on and off for the last two years, but when he hadn't for the past few months, I thought we'd licked the issue, perhaps with the tramadol we've been giving him at bedtime.

I read that panting is a side-effect of Cushing's. Could this heavy breathing/panting be due to Cushings + temperature? If so, will this resolve once we manage the Cushing's (like the polyuria and polydipsia)?

Thanks for the info,
Derek & Gatsby

sunimist

04-06-2010, 06:42 PM

So glad to hear Gatsby is doing better! Way to go little buddy!

I read that panting is a side-effect of Cushing's
It was with my girl, but once we got her adequately controlled, it subsided. The only other times she panted excessively was when she was in pain from something else.

Shelba and Suni

Derekvof

04-23-2010, 06:07 PM

Thank you all once again. I just wanted to drop a quick note to thank everyone again for their comments. It's been a few weeks, and Gatsby is doing really well on his Trilostane now. As I discussed before, I restarted him using a low low dose of only 10mg every other day for about 10 days, and then moved him to 10 mg every day for the last 10 days or so. We're now moving him up to 20mg one day and 10mg the next day so we can continue the s-l-o-o-w-w-w move upward in dosage.

And it's worked! He's eating well (gobbling up a good 3-4 bowls of food a day) which has helped him put back on about a 1/4 lb in the last couple of weeks. His energy is good, he's alert - he's much more himself than he has been in a good 2 months. His fur is growing back and his muscle wasting seems to have subsided. He's even getting around better with less slips. And I really do owe it to the advice and discussions from this forum.

So again, thank you. :D
Derek & Gatsby

lulusmom

04-23-2010, 06:22 PM

Hi Derek,

This is no lie but I was thinking of you only a few hours ago when I saw a snippit of one of your posts while I was googling something. I was planning on posting to your thread to see how the Great Gatsby was doing and you beat me to it.

Let me say that I am elated that your boy is doing so well on the Trilostane. I literally breathed a sigh of relief when I read that his appetite is back. Whew!!! Thanks for the great update. You just made my weekend.

Glynda

Harley PoMMom

04-23-2010, 06:25 PM

Oh Derek, I am so very happy for you and Gatsby!! You must be smiling ear-to-ear to see Gatsby feeling and looking so much better again. I just love these kind of updates, thank you so much for letting us know.

Give Gatsby some special hugs from my boy Harley and me, and give some to yourself too! You are doing a wonderful job taking care of Gatsby and should be very proud of yourself.

Love and hugs,
Lori

sunimist

04-23-2010, 06:33 PM

What a great update on the Gatsby!! Love it!!!
Keep the good news coming!!

Shelba and Suni

Derekvof

05-03-2010, 03:00 PM

Thanks Glynda, Lori & Shelba & Suni for your kind thoughts. We really appreciate it. Gatsby has continued to do well. He is more alert, rebuilding muscle, and feeling pretty good. We recently picked up a large dog "stroller" so that we can take him on extended walks through our neighborhood which he absolutely loves. He's even taken to barking at the other dogs from his stroller which is just hilarious. We did the ACTH stim test a week or so ago when he was at 10mg once a day, and he was 4.3 pre and 21 post, so we're moving him SLOWLY up to 20mg (right now 20mg one day, 10mg the next so we can slowly increase him).

However, the one bad thing is that his liver values continue to rise. Latest bloodwork has his ALT up at 2,000 and his ALKP at over 5,400 (up from 781 & 4009 in early March and 394 & 1956 last October). As I mentioned before, we've opted to not do anything in terms of exploratory surgery or even procedures requiring anesthesia due to his age (16). I know these numbers are bad, but I guess my questions are - 1) how bad?, 2) could these be Cushings related?, 3) will they come down with continued treatment of the Cushings?, and 4) any idea how long that would take to see any impact?

Any input/thoughts would be appreciate.
Derek & Gatsby

P.S. We had Gatsby's 16th Birthday Party a few weeks ago at a skating rink here in Indiana - it was a ball and he loved it - photos are here - http://tinyurl.com/gatsbyroller

Harley PoMMom

05-03-2010, 03:57 PM

Thanks so much for sharing Gatsby's 16th Birthday Party pictures with us, I absolutely adored them.

Cushings most definitely elevates the liver enzymes and in most cases these levels, when the cortisol in under control, do return to their normal levels in time. Are you giving Gatsby any liver support supplements like milk thistle or denamarin?

Love and hugs,
Lori

Derekvof

05-03-2010, 04:01 PM

Hi Lori - glad you liked the photos. We had such a good time.

Actually, Gatsby is on Denamarin for the liver and Actigal/Ursodiol for the gall bladder (which has been sludgy/problematic for a long time). Is there anything else that could be helpful?

Derek & Gatsby

Harley PoMMom

05-03-2010, 04:40 PM

My boy Harley is on Denamarin also, and altho I think that this is a very good product I am looking into switching to using milk thistle. It seems, at least to me, many members have better results with milk thistle, have to do more reasearch tho.

Derekvof

05-03-2010, 04:44 PM

I know this may be overkill, but is there any reason milk thistle couldn't be added to the medications in addition to the denamarin? Any risk of excessive milk thistle?

Harley PoMMom

05-03-2010, 05:04 PM

jrepac

05-03-2010, 05:13 PM

I do know that there is a recommended dosage for milk thistle and denamarin. I believe any herb can be harmful/toxic if given too much. I'd ask your vet about giving them together...I give Harley marin in the morning and denamarin in the evening, making sure that they are given 12 hours apart...per their packet instructions and Harley's vets approval.

marin and denamarin both contain the active ingredient from milk thistle (silymarin, I believe)...denamarin does not contain all that much silymarin in it, tho' they claim it is more readily absorbed from their product vs. milk thistle, which is usually at 70% active silymarin. Net, net, you could probably give a milk thistle cap in addition to denamarin, but I would double check w/the vet

BestBuddy

05-03-2010, 05:59 PM

I take Milk Thistle myself for liver protection. There are some details and also dosages for dogs on the link below.

http://www.lowchensaustralia.com/health/thistle.htm

Jenny

Derekvof

05-04-2010, 02:00 PM

Thanks for all the information, Jeff, Jenny & Lori. Does anyone know if milk thistle by itself is better than denamarin? Also, any comment on those liver values? Is there anything else I can do to help bring those numbers down? Also, I read somewhere it can take up to 6 months to see an impact on the liver values - does that sound right?

Thanks,
Derek & Gatsby

Harley PoMMom

05-04-2010, 03:00 PM

Hi Derek,

With the denamarin, you are getting the benefits of 2 liver protecting supplements; S-Aldenosylmethionine (SAM-e) and Silybin (milk thistle). The reason I choose to use the marin also, is because it contains Vit. E which helps with the liver.

There is another herb called Burdock that is supposed to help support the liver, I don't know much about this herb tho.

The only other thing I can suggest would be to get a diet formulated for Gatsby's health issues, mainly his liver.

With our cush pups the high ALP levels do not alarm us, and other things can attribute to the elevated ALP levels. The ALT levels are more liver specific than the ALP, so we do like to see the ALT number slowly come down...but it does take time. Harley's ALT number is still high -- 195 (5-107). What are Gatsby's AST and GGTP levels?

You did say Gatsby's eating good, right? Is he eating a variety of foods? What exactly is he eating?

Love and hugs,
Lori

Derekvof

05-04-2010, 03:19 PM

Thanks Lori. I don't have all the latest blood work (need to get a copy when I'm at the vets this week), but I do have the numbers from early March - ALT 781 (5-107), ALKP 4009 (10-150), AST 81 (5-55), and GGT 113 (0-14).

As for his eating, Gatsby is doing well. He's eating mostly Prescription Diet w/d dry (his old standby which he's eaten for years) with a couple spoonfuls of ostrich, salmon & turkey breast (all meats cooked). I put down three bowls - all with a cup of w/d and one of each meat in a bowl. From meal to meal, he'll pick something different. Last night it was ostrich & w/d, this morning ostrich & w/d and salmon & w/d. However, he is eating this way about 3-4 cups of food a day. He was previously (Nov 09-Mar 10) on a home-cooked diet of potato, salmon, and yam (with some BalanceIT), but had a bit of a GI debacle in March and now really won't touch the potatoes regularly, and won't touch salmon for every meal :-(

In the last year, we went through a ton of different foods due to his GI issues (pancreatitis, gall bladder sludge, etc.), including canned and dry versions of Hills Prescription Diets k/d, i/d, d/d, and w/d, along with Iams Low Residue. And of course, the home-cooked diet.

Thanks,
Derek & Gatsby

Harley PoMMom

05-04-2010, 04:36 PM

I would try either tilapia or cod with the other foods and feeding him several small meals a day. Pups that have pancreatitis, GI issues or liver disease do better with several small meals spread out during the day; for one thing their tummy's aren't so full, and sometimes they can just feel nauseated because of the disease that they have and they just don't feel like eating alot.

With GI issues and pancreatitis in our pups it is really hard to get the ALT and ALP levels considerably lowered...but we do the best we can for our furbabies because we love them so very much.

Derek, you are doing such a wonderful job taking care of Gatsby. ;):)

Love and hugs,
Lori

Derekvof

05-04-2010, 05:40 PM

Thanks again, Lori. Right now, Gatsby is eating about 4-6 times a day - anywhere from a few bites to a cup of food at a time... we're trying to keep him from eating too much at once (due to our fears of bloat), but at the same time wanting him to eat whenever he's actually hungry. Crazy balancing act, but so far, so good...

Thanks Lori,
Derek & Gatsby

Rebelsmom

05-04-2010, 06:51 PM

Derekvof

05-04-2010, 07:12 PM

LOL - yeah, I couldn't imagine putting down three bowls either just a couple months ago. However, when we started on the Trilostane, it really messed with Gatsby's appetite. But between the really, REALLY slow dose increases and the food alternatives, I'm able to keep him eating and keep his weight steady, while treating the Cushing's.

BTW, I also had to put in a plug for something that has made a HUGE impact for Gatsby. The reason my wife and I started really treating Gatsby's Cushing's was the muscle wasting. He was having such a hard time getting around. Well, I saw someone post on a K9 diet board about taking their lab to chemo in a stroller. Every dog stroller I have seen has been for a little dog - like under 20 lbs - but I've NEVER heard of one big enough for a lab - or even a 40lb dog like Gatsby. And then someone pointed me to the HoundAbout (aka his trike or the chopper - sounds better than "stroller"). Gatsby LOVES it. We can take him out for long walks through the neighborhood where he loves to experience the sights, smells and sounds of other areas that he hasn't seen in years (if ever). It has made a HUGE impact in his quality of life - he just loves his adventures now. It's like a dog kennel on wheels and I'm sure we're going to be using it a TON this spring and summer. Shot below with mom :-)

http://www.indiana-paw.com/images/chopper.jpg

Anyways, thought I'd throw that out there for anyone else who's a large dog with muscle wasting.

Thanks again,
Derek & Gatsby

Derekvof

05-13-2010, 10:02 PM

Thank you all, again, for your input and support. I come again, asking questions and asking for support.

Today, as part of our routine, we took Gatsby over to the specialty vet to do an ultrasound. We've been doing these on a fairly regular basis for the last few years with Gatsby after losing two of our dogs within just a few months. Long story short, we seem to have at least a partial answer to the elevated liver enzymes - the ultrasound is showing a mass on his liver. No idea at this point if it's malignant or benign. And no idea if it's spread (we'll probably be doing a CT scan and chest x-rays next week). The internist seems confident about going in and removing his liver (and his spleen which has several nodules of various sizes on it). I guess the question is - any thoughts on if we should do this?

He is 16 years old, but his issues are fairly well managed - kidney disease is good, hypertension is controlled, Cushing's is becoming managed - is it reckless to consider surgery? I would really appreciate anyone and everyone's thoughts on this. It's a very difficult decision for us, as my wife and I have lost two dogs due to post surgical complications.

Thoughts? Oh and some prayers would also be helpful as well...

Derek & Gatsby

zoesmom

05-13-2010, 10:51 PM

Hi Derek -

Don't think I've posted to you before. Jay G is certainly a lucky fellow (not to mention a handsome one) to have made it to the ripe old age of 16. I suspect it's because you've been a fantastic parent and advocate for him and have given him the very best care possible.

I can't tell you what you should do, obviously. But is it something they can aspirate and test for malignancy? Don't know enough about that kind of surgery to know if that is an option. But with his advanced age, I would be extremely concerned about subjecting him to surgery of any kind. If they could do that and it was benign, then I'd be inclined to let well enough alone. I guess I'd do the same, either way.

We just had to release our 13 yr old black lab mix Zoe in March. She'd had so many health issues and tests and treatments over the years - she also took a ton of meds for various issues. But she was a fighter so, for years, we chose to deal with them. But after a bad go around with severe vestibular syndrome in December that landed her in the hospital for a week, I decided that if anything else came up, that I would not put her through any more tests or treatments, regardless. In March, when her health again took a turn for the worse, I felt that enough was enough. I could've pursued a diagnosis but I could see that she had grown weary of it all. And so we made the decision to let her go, as hard as it was. Wish I could offer something more definitive, but only you know your boy best. If he's doing ok, then simply enjoying the time that you have left with him may the fairest thing for him. And as we say around here, when his life is no longer 'dogworthy, then you will know what to do. Keeping you and JG in my thoughts and prayers. Sue

acushdogsmom

05-14-2010, 12:48 AM

I can't tell you what you should do, obviously. But is it something they can aspirate and test for malignancy? Don't know enough about that kind of surgery to know if that is an option.That would be my question, too.

I'm not saying that your Gatsby's situation is the same as my dog's situation was, but we did have a liver issue at one point, where the Internist found what she thought to be a mass on his liver via ultrasound too. Before recommending any treatment plan at all for that liver "mass", she wanted to at least do an ultrasound-guided fine needle aspirate biopsy of the affected area of the liver, which is not a very invasive procedure (it can be done with the dog just sedated) and which could give us some detailed information about the "mass" tissue at the cellular level. They insert a very, very fine needle through the abdomen and right into the area of the liver (guided by ultrasound, so they know that they are getting to the exact right spot) and take a bunch of tiny tissue samples from the area by aspiration. Then they can send the samples out to the pathology Lab for evaluation.

Well, we decided to do the ultrasound-guided fine needle aspirate biopsy procedure and it turned out that the area that had initially looked very much like a "mass" on the original ultrasound exam was actually just an area of the liver which had apparently been affected by the high steroid levels that he'd had before we his Cushing's treatment started. The pathology report said clearly that it was only "steroid hepatopathy" and possibly also some degeneration of the liver associated with aging! So there was no need to treat his liver "condition" with anything more than some supplements.

We were all very glad that we decided to do the ultrasound-guided fine needle aspirate biopsy before considering anything like a more invasive surgery.

So can you maybe ask the Internist if there's a way to do something like an ultrasound-guided fine needle aspirate biopsy to find out if the area on his liver is really what they think it might be before going in and doing a full on surgery?

P.S. I don't think the Vet meant that they want to remove Jay's liver - probably just the "affected" part, right?

Derekvof

05-14-2010, 10:48 AM

Thanks for the input, Sue & acushdogsmom. I knew I didn't provide enough info, so let me get some more out there.

First off, Gatsby has been having elevated liver enzymes for about 20 months now. We have been watching with regular ultrasounds and bloodwork, but up until this time, nothing had shown up on the ultrasound. His recent bloodwork (from just 2 weeks ago) showed a definite jump in his ALT and ALKP, which is why I posted asking about it a few weeks ago.

His last ultrasound was just 10 weeks ago and there was nothing there on his liver. Now there is a 5x5cm mass on his liver. It's only on one lobe and our internist said it's VERY small and that only being proactive has found it this early on. Also, just a note that the last ultrasound was just a few weeks BEFORE we started to treat for Cushing's (e.g., no mass prior to starting Cushing's, mass now), so I'd guess steroid hepatopathy wouldn't be likely.

In terms of what the mass is, there's not a good way to tell. Based on Gatsby's history, our internist believes it to be (I THINK) primary to the liver (not secondary), but we'll probably need to do a CT scan and x-rays to verify. She also believes it likely benign, but believes its growth will lead to the destruction of the liver. We did also discuss the possibility of a needle biopsy, but in our discussions, our internist has indicated that they are very inaccurate for diagnosis of something like this - a section would really be required for an accurate diagnosis. Not something we've taken off the table yet, but seems like a long shot for anything definite.

We've still got a lot of talking to do with our family vet, our internist, the surgeon, our holistic vet and our oncologist to get their feedback. And we'll probably take him up to Purdue for a second opinion from their vets.

Thanks again - I appreciate all the thoughts, good wishes, and feedback. I really do - it's already made a world of difference for Gatsby's Cushing's treatment.

Best,
Derek & Gatsby

clydetheboosmom

05-14-2010, 02:58 PM

Hi -

I can't add much in the way of advice, but I can add that I think you are doing a wonderful job and hopefully, everything will work out. Please keep us posted.

My best to you -

Lynne, Clyde & Bailey

acushdogsmom

05-14-2010, 04:08 PM

We did also discuss the possibility of a needle biopsy, but in our discussions, our internist has indicated that they are very inaccurate for diagnosis of something like this - a section would really be required for an accurate diagnosis. Not something we've taken off the table yet, but seems like a long shot for anything definite.

We've still got a lot of talking to do with our family vet, our internist, the surgeon, our holistic vet and our oncologist to get their feedback. And we'll probably take him up to Purdue for a second opinion from their vets.Aha. Thanks for the additional information. I think that your Internist is probably right regarding the reliability of a fine needle aspirate biopsy vs a true biopsy and we may have just been lucky to have been able to get the results that we did via just a fine needle aspirate.

It sure sound like a fine team of Vets that you've got working with you on Gatsby's case! And with their expertise and advice, you will hopefully be able to come to a clear decision regarding what's best for Gatsby.

Of course, you've got to do what you think is best for Gatsby - and whatever you decide, that will certainly be the best thing for him. I know he's not a young dog, but I don't think that your team of Vets would agree that you should go ahead with a surgery that they don't think will help him, so if they agree that he is a candidate for surgical intervention and that there's a good chance to have a good outcome, then that's certainly going to help you to decide.

Please let us know what your Vets all think and what they say at Purdue if you do take him there for a consult. (Purdue is great veterinary school, btw!)

Harley PoMMom

05-14-2010, 06:22 PM

Hi Derek,

Altho I am sorry that I do not have any words of wisdom to share with you, I did want to let you know that you all are in my thoughts and prayers.

Love and (((hugs)))
Lori

Derekvof

05-25-2010, 04:30 PM

Thanks again, Lynne, Lori & acushdogsmom.

Well, we met with the surgeon on Wednesday. He's a great guy that we've seen about possible surgeries on Gatsby before. Yet again, he gave us the facts (20% chance he never makes it off the operating table, another 20% chance he never leaves the hospital after surgery, etc.), and we yet again decided not to do surgery on Gatsby. So, we are in wait and see mode. We did recheck Gatsby's liver via ultrasound a week later and the mass is unchanged, which I guess is good that it's not growing noticeably within a week. Nothing is showing up elsewhere and x-ray of the lungs came back clear. So, we're just going day-by-day and see where it leads us.

He is doing really well lately which is the ironic thing. He goes nuts for his stroller rides every evening, and we've started doing a little hydrotherapy to try to bring back some muscle tone. He seems to be enjoying that as well, although he does look like "what have you gotten me into this time???"

I did post on some liver boards and had some recommendations - wondering if any of you have heard of them:

- Azodyl: supposed to help stop uremic build-up in kidney/liver disease
- VSL3: probiotic supposed to help with IBS
- Royal Canin Hepatic LS 14: special dog food for liver disease

Any thoughts would be appreciate. And any suggestions on holistic treatment for liver issues and/or cancer issues would be appreciated.

Thanks again,
Derek & Gatsby

P.S. We put up a video about Gatsby's 16th birthday party - http://tinyurl.com/jgskate

Harley PoMMom

05-26-2010, 10:34 AM

Oh Derek,

I sure enjoyed Gatsby's video and it really looks like he had himself a real good time with all his friends and family there to celebrate his 16th birthday!

I don't know anything about the things you posted but I googled some...

The Azodyl: link to an article from DVM newsmagazine "Azodyl to target uremic toxins, reduce azotemia associated with chronic kidney disease":
http://veterinarynews.dvm360.com/dvm/Renaldisease/article/detail/338568

The Royal Canin Hepatic LS 14: The one thing that worries me with this food is the fat content, Crude Fat (min) 14%. With Gatsby having pancreatitis this might be too much fat but all dogs are different.

I found the food analysis information here:

http://www.dogfoodanalysis.com/dog_food_reviews/showproduct.php/product/1510

So happy to hear that Gatsby's doing so well, and I think the hydrotherapy will be good for him. Also very glad to hear that he loves his stroller!!! Please keep us updated and best wishes to you all.

Love and hugs,
Lori

Nathalie

05-26-2010, 11:41 AM

Hi Derik,

Royal Canine Hepatic LS 14

Rice, ground corn, chicken fat, soy protein isolate, natural flavors, dried beet pulp……

Nothing in that bag I personally would feed my dogs. They spray chicken fat on the kibble so dogs will eat it and like Lori I would be worried about the fat content.

You may want to look into Dr. Dodds Liver Cleansing Diet (http://www.canine-epilepsy-guardian-angels.com/liver_diet.htm) , adding any supplements that Gatsby is on.
For liver issues I would also put him on Milk Thistle.

I am not familiar with this particular probiotic but I have used others. When I did use it I always bought a good brand name (sorry, can’t remember the name). But it was one of those that can be found in the refrigerator section of the health food store.

Slippery Elm might also be something you could look into http://www.littlebigcat.com/?action=library&act=show&item=slipperyelm

Sorry, that’s all that comes to mind right now.
Nathalie

PS: Love the stroller:)
How does it handle off-road?

Rebelsmom

05-26-2010, 12:13 PM

Derek, love the stroller and the video. Gatsby is a very lucky dog to have you guys. I don't have much exp with with liver disease, but I have heard very good things about milk thistle. I currently have Rebel on it. I also agree with Lori and Nathalie I would stay away from that food. Full of grains and fat.

Melissa

Derekvof

10-02-2010, 06:54 PM

Hi everyone -

Sorry it has been so long since my last post. Gatsby is still here and still doing pretty well. We've worked him up to 60mg of Trilostane (30mg/2x) and he's on a homecooked diet that he's doing pretty good on. I just wanted to thank all of you for your help and input - it has been amazingly helpful.

And I wanted to quickly share so photos we had taken with Gatsby just last weekend - http://www.brandphotodesign.com/?p=3965

Thanks again for all your help!

Derek & Gatsby

frijole

10-02-2010, 07:02 PM

Great update and even greater photos. That photographer is awesome and those are the nicest dog photos ever! And you guys look good in the photos too. ;) Seriously captures the spirit and love. Thanks for sharing those. Kim

Derekvof

10-02-2010, 10:53 PM

Thanks, Kim. They were really good natured about humoring us with Gatsby and his stroller :-) Thanks again for all your help! Derek

lulusmom

10-02-2010, 11:09 PM

Hi Derek,

I am delighted that you came back to give us an update on Gatsby and I hope you continue to keep us posted. You, Amy and Gatsby make a beautiful family. I would have to agree with Kim....the photographer did an awesome job. Beautiful!! You and Amy have done a remarkable job with Gatsby and I'm sure he knows that he is one lucky boy.

Hugs,
Glynda

Franklin'sMum

10-03-2010, 09:32 AM

Absolutely gorgeous photos :), thank you for sharing them with us :)
Jane, Franklin and Bailey xxx

mytil

10-03-2010, 12:54 PM

I am so very happy you have checked in and updated us!!!

Those photos are incredible and I agree the photographer did a nice job capturing a beautiful family!!!!

Please do not be a stranger here :D

((((hugs))))
Terry

Derekvof

10-18-2010, 06:19 PM

Thank you all for your notes of support. I can't tell you how much they mean. We've kind of reached a juncture and I could use some input. Over the last several months, we've worked Gatsby up to 60mg of trilostane (30mg, 2x). However, the last few increases in medication have not shown any increase in correction and our internist has indicated that Gatsby had "plateaued" on the Trilostane. He’s not getting any better correction when we increase the medication dosage. However, as she pointed out, the goal isn't necessarily to be in the perfect “range”, but to see improvement in clinical signs (e.g., decrease in ravenous hunger, decrease in overdrinking, etc.).

Although Gatsby is doing better, his liver values are still elevated (quite a lot - we're doing bloodwork this week to see where we're at) and his back-end weakness is continuing, although I'm not sure if it's worsening. Question is - do we just try to keep him on trilostane at the current dosage and recheck in a month or so to see if there is any improvement or do we consider switching to lysodren? I'd be interested in any pro/cons considering Gatsby is 16 years old with, as indicated, several concurrent health issues (e.g., hypertension, kidney disease, elevated liver values, back-end weakness, etc.) in addition to his Cushings.

Thanks again,
Derek & Gatsby

lulusmom

10-18-2010, 07:30 PM

Hi Derek,

It would really help a lot if you could post the results of the last few acth stim tests that were done and please do post the results of the one you are about to have done. I'm not sure what your vet means by plateaued. It is very common for a dog on Trilostane to end up at two to ten times the starting dose and with Gatsby being at 40 lbs, his current dose may simply be inadequate and should be increased slowly until you see resolution of symptoms.

To give you a frame of reference, my 4 1/2 lb Pomeranian treated with Trilostane and stabilized on 30mg a day and my other 6 1/2 lb Pom stabilized on 15 mg twice daily. Gatsby is a giant in comparison and with all things being relative, his current dose is pretty light. I personally would not contemplate switching to Lysodren unless Gatsby is simply not tolerating Trilostane and is experiencing side effects. Is he tolerating the current dose well?

Can you tell us if any of Gatsby's symptoms ever improved. What symptoms are you seeing now? Looking forward to seeing the test results.

Glynda

Derekvof

10-19-2010, 04:48 PM

Hi Glynda,

Thanks for your note - I called over and got the last three ACTH stim test results:

9/10 - Pre 8.2 (range 1-5) Post 13.4 (range 8-17) (dosage - 40mg, 20mg/2x)
9/27 - Pre 10.0 Post 14.9 (dosage - 50mg, 30mg/20mg)
10/14 - Pre 11.1 Post 16.1 (dosage - 60mg, 30mg/2x)

The internist who we go to has indicated that she thinks that Gatsby isn't getting corrected as much as she'd like to see and the increase in dosage (although I agree, it appears slight) isn't increasing the correction (as I understand it). We've been increasing for the last 6 weeks or so. We had stopped at 30mg a day after we discovered the tumor on his liver, but after almost three full months without any significant growth (only 1-3mm per month on average), we restarted the Cushing's correction.

In terms of tolerating the trilostane, he seems to be tolerating it just fine. We're on a home cooked diet, and he seems to be doing well. In terms of the symptoms, the overeating and overdrinking definitely seem to be better managed. He's still getting plenty of fluids, but doesn't seem to be crazy drinking and no voracious appetite. I think there are two symptoms which we're most concerned about - 1) the continued increase in liver enzyme values (which have been going up for 2 years now, although not steadily - they've bounced up and down at times) and 2) the muscle wasting (which appears to be continuing). I know both are long term effects and will take a long time to correct (if they do correct), but those are probably our biggest concerns right now.

Thanks again,
Derek & Gatsby

Harley PoMMom

10-19-2010, 04:59 PM

How is Gatsby's kidneys tolerating the Trilostane? What were the creatinine, BUN, and phosphorus levels?

Derekvof

10-19-2010, 05:02 PM

As far as I know, fine. We're having bloodwork done this Thursday, but the last bloodwork we had done (August), only concern was the increasing elevation of the liver enzymes. I'll have to grab the numbers when I'm over this week.

Derek & Gatsby

lulusmom

10-19-2010, 06:02 PM

Hi Derek,

Thanks for posting the results of the last three stim tests so quickly. Clearly, Gatsby's cortisol is not within the desired therapeutic range so I am not surprised that you are not seeing any improvements in the liver enzymes. FYI, most of the time you will see improvement in liver enzymes once a dog is stabilized at the right dose; however, it is very possible that they will never return to normal. As I mentioned previously, a lot of dogs require more than a little dose tweaking before you find the right mg, so I don't find Gatsby's results to be surprising or uncommon. Can I assume that tests were completed with 3 to 6 hours after Gatsby's morning dose?

Treatment goal is to see an improvement in clinical signs and a post stimulated cortisol within a range of 1 - 7 ug/dl. The normal range you posted of 8 - 17 ug/dl is for a normal dog. Cushdogs are not normal and you want the pre and the post cortisol to be within the pre (basal/resting) range. Depending on the lab that range is usually 1 - 5 or 1 - 6 ug/dl.

Based on my own experience with Trilostane, as well as my observation of the many dogs here being treating with Trilostane, I think the next logical step would be to increase the dose to 40mg twice daily. If your internist is not sure what the logical progression should be, you may want to suggest that she contact Dr. Tim Allen at the U.S. Dechra office. Dr. Allen is one of the veterinarians on staff that serves as a consultant. One of our Administrators, Marianne, has spoken with Dr. Allen a number of times and has found him to be extremely helpful.

Here's the contact info for Dechra:

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

You can read up a bit on Vetoryl (Trilostane) dosing protocols in our Important Resources forum:

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

Derekvof

10-19-2010, 06:17 PM

Thanks for the info, Glynda. Pre was taken approximately 4 hours post dosage with post and hour late per our internist. I will definitely discuss with her increasing the dosage, and will look to see what the results are from the blood work that we're doing on Thursday. I'll see what she says.

Thanks again,
Derek & Gatsby

apollo6

10-19-2010, 07:23 PM

Dear Derek and Gatsby
Love the photos, beautiful.
I noticed you have a stroller for Gatsby.
I am Apollo's mom. Apollo has a stroller also. His hind leg weakness and stiff gait started around the time he started Trilostane. He is 10 lbs, started on 10 mg. now on 12.5 liquid compounded, still no improvement in legs. I am going to email Decha to see if there is a correlation. Other symptoms have improved.
Does Gatsby also have weakness in his hind legs. He is a sweetie.
Hugs Sonja and Apollo

Derekvof

10-19-2010, 07:54 PM

Hi Sonja,

Yes, Gatsby does have weakness in his hind legs. He loves his stroller - he goes everywhere with it. We've done some hydrotherapy to help support the back-end strength, but it really saps him of energy, so we don't do it often. We've been hoping the management of the Cushings would stop or maybe even reverse some of the weakness. I definitely think its slowed down...

Thanks,
Derek & Gatsby

apollo6

10-19-2010, 07:59 PM

I know what you mean.
Apollo has a harder time walking also. Was told it can take some time to get better with the hind leg muscle wasting. He gets tired very easily. But he still has joy. He enjoys his fire engine red stroller.

Derekvof

10-19-2010, 08:46 PM

Yeah, Gatsby loves his stroller more than anything. Going to be tough taking him out into a Midwest winter every day for a walk, but we're going to do our best to try. It's the happiest part of his day - he just yelps his head of when he's riding in his stroller. :-)

apollo6

10-19-2010, 09:06 PM

They still have joy despite this awful disease. I do little walks with Apollo now. You do the best that you can just like them.

Derekvof

03-07-2011, 10:45 PM

All -

Thanks again for all the support you've given regarding my dog, Gatsby. After almost a year on Trilostane, Gatsby is still here at almost 17 years old and corrected per his last STIM test. However, we now have another challenge that I could use some advice on.

Gatsby has developed a drug resistant UTI. Our vet has done a urine culture, and based on the results that have come back, he and our internist believe that chloramphenicol is the best of the limited drugs that they know will treat it. My wife, however, was concerned when I told her that the medication is fine for Gatsby, but risky for me as even touching the medication can cause bone marrow issues and anemia, and she's confused that could be possible for us, yet be safe for Gatsby. Anyone here use chloramphenicol? How successful were you with treating using it? Any bad side effects I should know about?

I'd appreciate your thoughts.

Thanks,
Derek & Gatsby

AlisonandMia

03-07-2011, 11:57 PM

Hi Derek,

I just looked this up and found this: http://www.petplace.com/drug-library/chloramphenicol-chloromycetin/page1.aspx

It says (bolding is mine):

The most serious adverse effect in people is an irreversible suppression of the blood-forming cells (aplastic anemia). For this reason, chloramphenicol exposure in humans should be limited as much as possible.
This reaction (aplastic anemia) is not possible in animals, however chloramphenicol may suppress the blood-forming cells in a reversible manner if administered for prolonged periods at high doses. In cats, for example, this reaction may be observed after two weeks of continuous treatment.

It doesn't say why it is not possible in animals but I guess the reason is known and it is more than the fact that it hasn't been reported in animals. In the Wikipedia article it says that this rare reaction in humans seems to be the result of genetic predisposition. Maybe animals don't and can't have this genetic glitch(???)

I guess it is similar to the way we can eat certain foods and tolerate certain drugs that can be harmful or even deadly for dogs and cats.

The possible bone-marrow suppression looks like it is not necessarily that serious as it is reversible and dose related - and more of an issue with cats.

There is a risk (however small) with any medication but it is a matter of whether the risks outweigh the benefits. I'd think in this case having the poor fellow free of this nasty UTI is worth the very small risk of a transitory problem. It looks like the most likely side effect will be nausea/lack of appetite - as is the case with many antibiotics.

Are they looking to use a smallish dose considering his advanced age?

Alison

Derekvof

03-08-2011, 11:46 AM

Hi Alison - Thanks for your response. I was told safe dosing is 40-50mg/kg per day typically. With 250mg/3x, we're right dead center in the dosing for it. I did see an article on overdosing and they were talking 150-275mg/kg per day at which they saw the adverse results.

I'm just hoping that his system tolerates it with everything else going on. At his age, we definitely have to think two and three time about every change we make unless we want some debacle that causes him to spin out of control. We'll keep our fingers crossed.

Thanks again,
Derek & Gatsby

Derekvof

04-17-2011, 09:25 PM

All -

Our beloved Jay Gatsby passed away today just shy of his 17th birthday.

I wanted to thank all of you for the support, encouragement, and information that you provided to all of my questions about Gatsby's health. I can not tell you enough how helpful your information was and how we used that info to keep Gatsby feeling good and healthy as long as possible. We often amazed vets with the list of illnesses that Gatsby was some how managing.

My wife asked me to share this link & photo with everyone - http://tinyurl.com/jayg2011

To all those newcomers - don't give up hope. To all of you wonderful supportive board members - all our thanks.

Derek & Amy

apollo6

04-17-2011, 10:42 PM

I am so sorry for your loss. Gatsby had a wonderful life and the best parents ever. May he be looking down from heaven at you .
Hugs Sonja and Apollo

Derekvof

04-17-2011, 10:50 PM

Thanks for your note, Sonja and Apollo. We really appreciate it.

frijole

04-17-2011, 11:13 PM

The photo says it all....your dog was deeply loved. 17 wonderful years. RIP Jay Gatsby. Run free of pain and know we will miss you. Kim

lulusmom

04-17-2011, 11:18 PM

Derek and Amy, I am so terribly sorry for your loss. All of our cushdogs should be so lucky to live a full life like your Gatsby. He was an amazing dog, not to mention a really lucky one to have been able to share his live with such loving parents. My thoughts and prayers are with you.

Godspeed, Sweet Gatsby.

Glynda

BestBuddy

04-17-2011, 11:33 PM

What a beautiful photo.

Jay Gatsby was obviously very much loved and because of that care had many more years to share with you.

Godspeed Jay Gatsby

Jenny

k9diabetes

04-18-2011, 02:03 AM

Oh... I'm so sorry to learn of Jay Gatsby's passing. He was a beloved member of a wonderful family, which is the important thing in the end.

With great sympathy,

Natalie

Franklin'sMum

04-18-2011, 05:43 AM

Dear Derek and Amy,

I am so sorry to learn of the passing of the Great Gatsby. He was so incredibly loved and adored.
My thoughts and prayers are with you and your family at this very sad time.

My deepest condolences,
Jane, Franklin and Angel Bailey xxx

addy

04-18-2011, 09:01 AM

Dear Derek and Amy,

I was so sad to see the news of Jay Gatsby. Your love for your boy ran so deeply, he was truly blessed as were you. We share our lives with them for such a short time. We are all better people, I think, to have been able to love and be loved by our dogs.

Love,
Addy

bgdavis

04-18-2011, 09:31 AM

I'm so sorry for the loss of your wonderful, Jay Gatsby! He will always be loved by many and serve as a true inspiration to others facing aging and a multitude of problems.

Your video and pictures show how much he was a part of your lives and I know the hole in your heart will take a long time to heal.

Hugs,
Bonnie and Angel Criss Ann

Derekvof

04-18-2011, 11:27 AM

Thank you all for your lovely notes. They mean so much to our family at this time. Again to all of you wonderful people who give advice & support for those of us trying to fight the good fight on behalf of our pets, a HUGE thank you. You DO make a difference in people and pets' lives.

Derek & Amy

Squirt's Mom

04-18-2011, 12:44 PM

Dear Derek and Amy,

I am so sorry to learn of Jay Gatsby's passing. There is no doubt he was deeply loved or that he returned that love ten-fold. He had the best team possible on his side always - his Mom and Dad.

It is my personal belief that you will one day be reunited with Jay and you will find him as he was in his youth...strong and healthy, still loving you as much as ever. Til then, he will watch over you both, sending his love as only he can.

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

hfurlotte

04-18-2011, 02:29 PM

Derek and Amy,
Our thoughts and prayers go out to you on the loss of Jay Gatsby....he will be with you always.

Heather and Zoe Claire

marie adams

04-18-2011, 04:22 PM

Derek and Amy,

My thoughts and prayers for the loss of your sweet boy. I never knew how hard it could be--I always told Maddie she couldn't get old...:(

We all fought the good fight with our buddies and we will always have those silly wonderful stories to share and remember.

The pain is worth it for all the joy, but it still hurts and is lonely. You will work though it and it get less painful.:o

Take care!!:)

Casey's Mom

04-18-2011, 09:57 PM

Derek and Amy,

I am so sorry to hear of Jay Gatsby, 17 wonderful years. He was certainly blessed to have such loving parents. My heart goes out to you in sorrow, please stay with us. You are family now.

Love and many hugs,

jrepac

04-19-2011, 11:33 PM

So sorry to read of Gatsby's passing...:(

Such a wonderful life of 17years! We all know the time goes all too fast. The photo is really sweet.

My condolences to you both.

Jeff & Angel Mandy

Bichonluver3

04-20-2011, 05:21 PM

Beautiful, beautiful picture. What a treasure and what a treasure he was to you. it is so obvious he was loved and given an incredibly long wonderful life with you.
Sleep well, sweet prince. Godspeed and God bless,
Carrol & Chloe

Derekvof

05-17-2011, 10:27 PM

Thank you all for your wonderful notes of encouragement and support. It has been (and continues to be) a difficult period of adjustment here without the Great Gatsby who was the center of our lives, and your notes have been a source of comfort throughout. Some of the warmest notes we received were from people that had just followed Gatsby's adventures from afar. It really touched us how many people actually knew of him and the battles he was waging.

The weekends following Gatsby passing were intended to be two parties to celebrate his 17th birthday. We did have the parties but they became rather celebrations of his life. My wife has spent the last two weeks working feverishly on a video encapsulating his final journey, and asked that I share it with all of you - http://tinyurl.com/jaygatsby

Thank you again for the support and well-wishes, and we hope that you enjoy our send-off for Gatsby. And we hope that everyone that is dealing with Cushings and other health issues (such as Gatsby had) may take some encouragement that you can manage these issues and still enjoy some wonderful moments with your loved ones.

Best,
Derek & Amy