Big Mack's progress and current change

[Mackey's Mom]

Hi all...Big Mack (Max) and I are back after having "lost" you last year. I'm so glad we "found" you because I trust you all more than the vet's we've seen!
Have a question regarding Max's recent ACTH test last week. We have a new vet who has little experience with Cushing's and no experience with Trilostane. Max takes 120mg of Trilo 2x a day (he was 125 lbs). The day of his test he had his meds at 6:30am; the blood draw and injection was at 8:35am. I told the vet that the test should be done 4-6 hours post pill, but he felt that 2 hours was sufficient. We waited for 2 hours at the vet, and then had his second blood drawn. Our vet called the next day and said that Max's pre injection was 1.3 and his post was .08. He told me Max should come off the Trilo for a day and then restart at a lower dose. I suggested cutting it in half (from what I've read, and what we've done before).

Max weighed 118 lbs the day of the test. He has been losing weight, and panting an awful lot (it has been hot and humid here, but he pants all of the time -- still). He also had a CBC and panel done and the vet said everything else was fine. What do you all think of the spacing of the meds and the test? Could the lower post # be a result of doing the test too soon after meds? What else would be making his #'s drop like that, instead of his post # going up? He's had some back end weakness which I attributed to age (he's 9-1/2), but now wonder about Addison's.

Thank you for your help...he's looking a bit tired out lately, allergies acting up, and he's achy; want to make sure I'm doing everything I can for him. :(

Lori

[Franklin'sMum]

Hi Lori and Max :)

The trilo info says that the drug is at it's most potent at 4-6 hours after dosing, as you know, so I don't understand why the vet would say that 2 hours is sufficient if he freely admits to not having the experience or knowledge of both cushings and trilo. I don't know if that would explain the non stimulatory result though. With Max losing weight, I wonder about stopping the trilo for just one day, and if that one day would be enough to help Max feel better, especially if this result is legitimate (and due to fear factor alone, I wouln't second guess it)
When was his last stim test, and what were those results? Has Max been himself lately (eating, drinking, pooping, energy levels)? Keeping in mind the heat obviously.
Just thinking out loud here, but maybe with the allergies playing up he might feel better with his cortisol level a little higher than usual.
Have you phoned/emailed Dechra to find out if they know what effect timing the stim v dosage may have with regards to a non stim result? The details are in the helpful resources section.
Was Max difficult to settle into trilo dosing? Wondering if it might be worthwhile to stop trilo until symptoms resume. The electrolytes were ok, yes?
Sorry I can't be more help, but someone else will be along shortly I'm sure.
Jane, Franklin and Bailey xxx

[labblab]

Hi Lori and welcome back to you and Big Mack, but I'm so sorry that he isn't feeling well right now! Just wanted to comment on a couple of things. First off, even though it is true that Dechra recommends that all monitoring ACTH tests be performed 4-6 hours post-dosing (and therefore that is the most common testing window worldwide), UC Davis has instead adopted a testing schedule of 2-3 hours post-dosing. So your new vet may be choosing to follow recommendations similiar to those of Davis. If you take a look at this link, you'll see the Davis protocol discussed at the bottom of the first post:

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

According to Dechra's most recent U.S. Product Insert:

Trilostane absorption is enhanced by administration with food. In healthy dogs, maximal plasma levels of trilostane occur within 1.5 hours, returning to baseline levels within twelve hours, although large inter-dog variation occurs.
So according to Dechra's own pharmacological info, we can assume that Max's trilostane dose was likely reflecting its maximal effect at the two-hour testing mark. If all of his previous ACTH tests were performed 4-6 hours post-dosing, then you can account for a bit of variation among earlier results and this one (for instance if he metabolizes the drug quickly, then you may have been testing "post-peak" previously and his cortisol may already have been starting to rise somewhat). But that doesn't change the fact that these most recent results are TOO LOW, and probably do reflect his cortisol at its very lowest daily level.

Given this result, Dechra recommends withholding the trilostane for longer than one day:


A post-ACTH stimulation test resulting in a cortisol of <1.45 μg/dL (<40 nmol/L), with or without electrolyte abnormalities, may precede the development of clinical signs of hypoadrenocorticism. Good control is indicated by favorable clinical signs as well as post-ACTH serum cortisol of 1.45-9.1 μg/dL (40-250 nmol/L). If the ACTH stimulation test is <1.45 μg/dL (<40 nmol/L) and/or if electrolyte imbalances characteristic of hypoadrenocorticism (hyperkalemia and hyponatremia) are found, VETORYL Capsules should be temporarily discontinued until recurrence of clinical signs consistent with hyperadrenocorticism and test results return to normal (1.45-9.1 μg/dL or 40-250 nmol/L). VETORYL Capsules may then be re-introduced at a lower dose.

It sounds as though Big Mack's electrolytes were also checked at the time of the ACTH testing and were OK -- so that is a good thing. But given his recent behavioral changes, I would definitely heed Dechra's recommendation that a more extended medication break be taken before starting back on a decreased dose of trilostane. All this info is contained here in the U.S. Product Insert:

http://www.dechra-us.com/files/dechraUSA/downloads/Product%20inserts/Vetoryl.pdf

Do keep us updated, OK?
Marianne

[labblab]

Me again, with one more question/thought...can you remind us as to why Big Mack is being dosed twice daily? Is it because he was having a rebound in symptoms later in the day? The reason why I ask is because one of our members here who is a veterinary endocrinologist has warned us that dogs being dosed twice daily may run a higher risk of suffering from incidents of too-low cortisol and therefore need to be monitored even more closely than those who are receiving only single daily doses of trilostane.

Some dogs do seem to need twice-daily doses to maintain effective cortisol/symptom control (and diabetic dogs may also do better with twice-daily doses so as to keep their medication and endocrine systems more consistently balanced throughout a 24-hour time period). But otherwise, apparently the majority of dogs do well on only a single dose a day and that remains the standard initial dosing recommendation of both Dechra and UC Davis. So unless there is a specific reason why Big Mack is being dosed twice daily, once his cortisol rebounds you might want to consider cutting him back to just dosing once each morning...

Marianne

[Mackey's Mom]

Thank you all...this is why I am so happy to have found you again!!! :D

Because of his size, the distributor recommended dosing twice a day, based on information they had from the manufacturer. Plus his symptoms were worst during the night. Max's symptoms have always remained, except for the hunger....without meds he wakes me up during the night to eat, and will constantly cry for food. With meds, he still pants constantly, is stiff, gets tired easily.

Max's previous tests were done between 3-4 in the afternoon (at the internist). This vet recommended doing them first thing in the morning (which I see recommended elsewhere).

I am going to withhold his medication for a week, and see what happens. He has other issues, like the allergies (he is allergic to just about everything). Will read all the information you gave me, and do some more research, and talk to his new vet. Will let you know what happens.

I'm off now to do a transport run of 2 white german shepherds, coming from IN and going to foster homes in MA and CT.

Thank you all for pointing me in the right direction.

Lori and Big Mack

[labblab]

Hi again, Lori!

I sure hope your transport run went well -- what a pair of lucky pups to have you shepherding them along the way to their foster homes!

And thanks for this additional info about Max. That's interesting that the Dechra distributor recommended twice-daily dosing on the basis of Max's weight. I had known that Dechra had made that recommendation in the past for some of the tiny ones (splitting the daily dose if it had to be increased above a certain point). But this is the first that I have heard of them making the same suggestion for the big'uns strictly on the basis of weight. So that's some new info to throw into the mix.

When you have the chance, will you please give us a quick recap of Max's dosing and ACTH test result history?



Max's previous tests were done between 3-4 in the afternoon (at the internist). This vet recommended doing them first thing in the morning (which I see recommended elsewhere).

When Max was being tested that late in the afternoon, what time was he getting his two daily trilostane doses? And was he getting them along with some food? You may already know this, but trilostane is metabolized most efficiently when given along with a meal. So I'm just trying to wrap my head around that afternoon testing in conjunction with his dosing and also his meals..:confused: If this recent test was done after dosing along with breakfast (whereas the previous tests were not), that might also account for some differences in the test results, as well.

Any additional history that you can give us will be super helpful, so thanks very much in advance!

Marianne

[Mackey's Mom]

Hi all,
Wanted to update you on Mack's progress. The big guy has been off of all Trilostane since September. He has been asymptomatic as far as I can see (except for the panting...that's always there). Yesterday he had his ACTH Stim test done at 8:30 a.m., no breakfast, no meds. Pre-test he was 5.3, and post-test (2 hours later) he was 12.2. His vet is considering this to be well within the normal range, and is mystified as to why Max is doing so well without medication. I'm shocked, but happy. We are going to re-test in 3 months.
Hope all is well with everyone! :)

Lori and Maxwell Joseph (aka Big Mackey)

[lulusmom]

Hi Lori and thanks for the update.

I am glad that Mack's symptoms have not returned yet but I'm afraid they will at some point. Mack's post stim of 12.2 ug/dl is within the normal range for a normal (healthy) dog but that is not the therapeutic range for a cushingoid dog. However, I'm glad to see that you are not contemplating putting him back on Trilostane until he becomes symptomatic. When I took my little one off of Trilostane, it took her five months before her cortisol was high enough to make her symptomatic again. At that point, her post stim cortisol was over 25 ug/dl. The time before that her post stim was 20 ug/dl and she still was still asymptomatic. You just never know how long it'll take with these guys. Enjoy your Trilostane vacation.

Glynda

[Mackey's Mom]

Hi Glynda,
Thanks for the information. I'm mystified...does this happen often? I did a lot of reading last night and couldn't find much information. My vet said he's never seen it, but said because Max seems to be doing well in other areas, to keep him off of the meds for now and just keep re-testing. He'll be 10 in March, and a big boy (125 lbs), and is hiking with me and his canine family and keeping up just fine. He's even been playing with his brother, which is unusual for him. He's become a wild man in his old age! :D
We'll hang in there and retest in February, or earlier if symptoms come back.
Lori and Max

[lulusmom]

Hi Lori,

Yes it happens more than you think. We've had a number of members who have reported that their dogs were off Trilostane for months and months. Even though Trilostane has a short half life, it seems to have some kind of long lasting effect on the adrenals.

[Mackey's Mom]

Spoke again to our vet today. He feels that we should re-test in February and if his #'s are still within normal range, that we not re-test again unless he becomes symptomatic. I said I would feel best if we re-tested, symptoms or not, in February and then again in June.

No meds...no ear infections...shiny coat...renewed energy and playfulness. Who would've thunk it? For however long this lasts, I'm going to enjoy watching him feel better for a while. :)

[Franklin'sMum]

Hi Lori and a big Woo Hoo to you both!! :D:D:D:D:D

Absolutely, enjoy the break, and rejoice in Mackey's feeling great and peppy! I really hope things continue to run smoothly for you :)

Jane, Franklin and Bailey xxx

[Mackey's Mom]

Max had his ACTH test on Wednesday at 8:30 a.m. -- he had had no breakfast and no medication (he isn't on Trilostane as his last test was in the normal range).

His pre was 6.7 and post, 2 hours later, he was at 10.1

The vets at this practice consider this "well within normal range" and said he should not take any medication for his Cushing's.

I would appreciate your feelings/comments about this...he seems to be fine, has been panting some, not begging for food other than what he normally does.

Thanks from me and the big guy!!! :D

[Mackey's Mom]

Forgot to add...his weight was up: 132 lbs. if that makes a difference.

We've been using grain-free dry food, specialty canned food, and pasta/meat in attempts to get Sophie to eat. She has been picking at food. Problem is, while I'm trying to hand feed her (and the Dingo who "feeds" off of her nervousness) Mr. Chunky Monkey Maxwell sneaks in and eats the food. He also gains weight on dry food, and it is like "puppy crack" to him. No more after yesterday...back to cooking.

Thanks again...

Lori and Max

[lulusmom]

I don't have time to respond but am bumping up in the hopes others do.

[lulusmom]

Hi Lori,

Looks like I bumped your thread up for myself to respond. :D Since Mack remains asymptomatic and his post cortisol has actually gone down a few points since the last stim, you can continue your indefinite vacation away from cushing's. You lucky girl! :D

[Mackey's Mom]

Thank you!:D We can use the break...now that his sister is diagnosed as well, and not responding well to our attempts to treat her. I still think something else is going on with her, not just Cushing's Disease.

I love my boy and I'm blessed that I still have him. His birthday is Friday, he will be 10, and we're having a party with his friends and his Auntie, and his brother and sister. Pot roast, sweet potatoes, and green beans...and Frosty Paws!

Thank you again, everyone.

Maxwell Joseph (Big Mackey) and his mom, Lori

[Mackey's Mom]

Hi all...wanted to give an update on Max (Big Mackey). According to his most recent LDDS test (done by his new vet) he is still in remission from Cushing's. The test was "inconclusive" so the vet called the lab and spoke at length with them about it, and they said they would consider his test results "normal." Max is having problems with his rear legs/weakness/etc. The vet thinks it is due to a spinal issue, because he turned his left (and weaker) foot under (knuckling)and Max did nothing to correct it. Vet called me yesterday and now thinks it might be degenerative myelitis or myesthenia gravis, and def has laryngeal paralysis (still moving air so no surgery). Not happy at all about that...would rather be dealing with Cushing's, hate to say it.

Would love to hear from anyone having experience with either DM or MG. I went through DM with my Old English Sheepdog many years ago and don't want to see another dog go through that (for their sake and for mine). Reading a lot and looking into diet changes, swim therapy, supplements. He is sleeping well at night with the cooler weather, and the LP doesn't seem to be bothering him too much.

Thank you all for your support and help!

Hugs,
Lori and Maxwell Joseph (aka Big Mackey) :)

[addy]

Hi Lori,

I don't have an experience with DM or MG, though I did find a website that talked in great lengths about it. Wish I would have book marked it.

I am hoping others will come by to give you their experiences. So many of us are dealing with hind leg weakness, sometimes caused by Cushing myopathy (not sure of the spelling) or back problems, etc, the list seems to be endless.

Hang in there,
Addy

[frijole]

Lori - I do not have experience with DM but have recently stumbled onto some info on it because my Annie is losing the use of one her hind legs. I elected to seek help from the people at Eddie's Wheels (thanks to John and Glynda's experiences). Not only have they provided help to tons of dogs with DM they are a wealth of information on the illness. I read that most vets know nothing about it because they are taught nothing about it because there is no treatment. If you google Eddie's Wheels you can read their site but also google first time Eddies Wheels and you will get a slew of videos. They link you to stories with a ton of people whose dogs have DM. I hope this helps! Kim

[Cyn719]

Hi Lori - I dont much about what Max has but Penny has the hind leg weakness and weak back - like Addy has mentioned - from the Cushings - Love and prayers for Max and you -

[Mackey's Mom]

Thank you for the information and support everyone. Max is on Dasoquin and Deramax and doing a bit better. He is still weak in his rear left leg, but was able to do a short hike with me and his canine family. But his laryngeal paralysis has been a bit worse, and he gave me quite a scare again. I thought he was suffocating, he had fear on his face...got him to the lake so he could get into the cold lake water and relax. It just never ends...I felt so good about the remission from Cushing's and now I wish I could switch disorders: LP is not what I want him to have. Considering surgery, but I've read as much bad as good. The warmer weather we've had recently has taken a toll on his breathing, and (gulp, can't believe I'm saying this) I can't wait for it to get cold out.

His weight is down to help with his legs, back and his breathing; but tonight he had an apple cider donut with yogurt on it, and he is one happy and content boy right now :D

Thank you again for all your support...nice to know you're not alone.

Lori and Max

[Cyn719]

Lori Penny is on the Dasaquin twice a day - Rimadyl twice a day and starting Adequan Shots this week also - alot of members on this forum say the shots have helped alot - Prayers and hugs going out to you and Max

[Mackey's Mom]

Thank you for the thoughts and prayers. The vet today said he wants him to remain on the Dasaquin and the Deramax. It seems to be working because Max got into my SUV today with no boost-up help from me...YAY! He was slow doing it, but he did it on his own. I know it doesn't sound like much but to me it's huge...he hasn't done that in some time.
It's cool tonight and he's breathing easily...:)

[Cyn719]

Good job Max!!!

Believe me - the littlest things are such big things to us!! When Penny gets in my SUV on her own I do a happy dance!!!:D If I find her on my sons bed I do a happy dance!:D So I understand for sure!! Hope the good days continue!! xo

[Squirt's Mom]

Hi Lori,

Good to hear from you! It's really amazing how the little things our babies do can mean so very much to us. Especially when we know the journey they have taken to make that little step. ;)

Keep up the good work and stay in touch!
Hugs,
Leslie and the gang