Otis - 12 y/o Dachshund Borderline Symptoms - Otis has passed

[Oatsiedog]

Hi all!

My dog Otis is suspected of having Cushings. He has had some of the symptoms -- increased water intake, hypothyroid (he's already on Soloxine 1mg twice a day) and alopecia.

The Cushings question came up last week when he developed a wicked case of diarrhea that went on for 4 days without any relief (did the white rice, chicken yogurt thing with no impact), so we ended up at the vet to treat that. They ran a blood panel and did an xray to rule out tumors etc. The results were that his liver function was off, his heart looked enlarged and they wanted to do more tests. So today he went back in and had the ACTH stim test as well as an ultrasound of his heart and his abdomen.

The vet who did the ultrasound made the following observations:

1.) "definite adrenal disease"
2.) slight thickening of the heart walls as well as a slight murmur, but no significant leakage
3.) His liver looked "brighter" than normal
4.) sections of his large bowel looked inflamed (not surprising considering he just got over a multi-day bout of diarrhea!)

The vet just called and said his ACTH test came back "borderline" and that if he wasn't exhibiting any more significant symptoms, she's inclined to just monitor for now. She's treating his bowel inflammation with a course of Baytril and a switch in food to Purina EN. She wants to start doing regular urinalysis to see how he's processing hormones. She's also put him on Melatonin to help with the hair loss.

So, while I'm relieved he's not critically ill, I am curious to hear the thoughts of others. My initial Cushings research has me thoroughly confused, as it seems there's not a lot of agreement on diagnosis and treatment, and I'll admit that i still don't totally understand the biology of it all!!!

But my last dog, Fargo, was diabetic, and we got great support and insight from the Canine Diabetes forum, so I'm hoping the same kind of wisdom lives here in this forum -- from those who live with this all the time!

Is my vet's "monitor, but don't treat unless symptoms worsen" approach a reasonable one, or should we be seeking a more aggressive approach? My understanding is that the various treatment options also have their share of side effects and risks, so I'm not inclined to jump into anything too quickly, since he's still a happy, active dog.

Are there specific recommendations in terms of diet with Cushings? Before he went on the Purina EN to stop the diarrhea, he was eating California Naturals grain free venison

What are the top 3 things i should be concerned about at this point, with such a vague (non)diagnosis?

Any and all thoughts apreciated!!
Sarah and Otis

[apollo6]

welcome Sara and Otis
Mu Apollo is a 12 year old dachie.
I am attaching an easy to read link on cushing.
http://www.kateconnick.com/library/cushingsdisease.html

near the bottom it even shows pictures of a dog with cushing.
I am puzzled by the remark -cushing sign? First off an ultrasound would show if one or both adrenal glands are enlarged as well as other organs such as the kidney, liver, and pancreas.
Please take your time before you even jump into any type of treatment. You first need to know does Otis have cushing, and what kind is it. It can mask other symptoms.
Apollo probably had cushing for over a year before I got to the point of tests, treatment. For him symptoms were: loss of hair on ears, tail, both sides, skin liaisons over belly and back, extreme thirst, dark underbelly skin, pot belly.
Other will be along soon. Remember we are here to help and support you. You don't have to make any hasty decisions.
Hugs Sonja and Apollo
P.S. Otis is a cutie.:p

[Harley PoMMom]

Hi Sara and Otis,

Welcome to you both from me and my boy Harley. We are so sorry for the circumstances that brought you here but very happy that you've joined our forum and thus our family. :)

Cushing's can be so very hard to diagnose especially since other non-adrenal illnesses like diabetes and hyperthyroidism share some of the same symptoms.

Strong symptoms are a huge part of making the diagnosis, and a Cushing's savvy vet will not initiate any treatment without strong symptoms and a proper diagnosis.

Cortisol is a stress hormone, one of the "fight or flight" hormones. Stress and illness can cause a pup's cortisol to be elevated.

IMO, I believe your vet's approach to monitor Otis is the proper thing to do. If Otis were my pup I would have his CBC/Chemistry blood panel rechecked in 6 months. Also if you want to retest Otis for cushing's I would check that using the UC:CR test instead of the ACTH stim test. The UC:CR is the least stressful on the pup and its high negative predictive value suggests that cushing's is unlikely if the UC:CR is within the reference range but that further investigation for cushing's is warranted if it is elevated.

Almost all of our cush-pup have very elevated ALP values (liver enzyme) and many of us are giving them some type of liver supplement like milk thistle or denamarin. I would ask your vet about this.

Also on the ultrasound does it only say adrenal disease and nothing else about the adrenal glands?

The melatonin should be the regular melatonin and not the rapid-releasing or fast-acting kind.

Again, welcome to you and Otis, and if you have any questions please ask away. I've provided a link for you with info about cushing's below.

Love and hugs,
Lori

Links to Cushings Websites (especially helpful for new members!)
http://www.k9cushings.com/forum/showthread.php?t=180

[StarDeb55]

Sarah, welcome to you & Otis! I'm sorry to hear that Otis has not been feeling well lately, but we can help you understand what's going on with Cushing's & getting a confirmed diagnosis. I do warn you that we tend to ask a lot of questions of new members. You have given us a great start by telling us about his symptoms, & what testing has been done. I do have some concerns, & hopefully you can clarify some of these.



1.) "definite adrenal disease"
3.) His liver looked "brighter" than normal
Could you clarify #1? This sounds like at least one or probably both of his adrenal glands were enlarged. Bilateral enlargement of both adrenals is common in pituitary Cushing's which is the type that 85% of pups have. In cases of adrenal Cushing's, one gland may be enlarged, the other normal or even shrunken. If there is an adrenal tumor present, surgery offers the hope of a permanent cure. The comment about the liver is very common for our pups, I believe term is "hyperechoic". This is because the liver is working overtime to process all the excess cortisol that the adrenals are producing.


The vet just called and said his ACTH test came back "borderline" and that if he wasn't exhibiting any more significant symptoms, she's inclined to just monitor for now.

I am very glad to hear this as most Cushing's savy vets will not treat until there are strong symptoms present which can include a voracious appetite, drinking buckets, & peeing gallons (polyurina/polydypsia), as a change in symptoms is the main way to monitor the effectiveness of either of the 2 drugs. This is especially important when using lysodren as a decrease in appetite is frequently the telltale sign that a lysodren loading is complete. Without strong symptoms, it would be extremely difficult to determine whether or not either medication is working. Does Otis have any other symptoms which can also include skin/coat issues, muscle wasting especially in the rear end?

How soon was the ACTH done after this round of GI upset? Was Otis on any medication when the ACTH was done? Non-adrenal illness can increase cortisol levels as the elevated cortisol helps the pup fight the stress of the illness. A recent round of GI upset could easily explain the liver function tests being elevated. Could you get the actual results of these tests & post just the abnormals along with reporting units & normal ranges? I would be interested to see if the alkaling phosphatase was the result that was "off the charts" as a badly elevated alk phos is frequently what will tip a vet off to look at Cushing's. We would also like to see the actual numbers of the ACTH. Your vet should be happy to give you copies. Most members do keep files on their babies at home as you never know when that file might come in handy, especially if you end up at a strange vet in the middle of the night.

IMHO, if the GI upset is the only thing going on with Otis right now, your vet is "spot on" about just monitoring for the next 6 months.

Hope this helps.
Debbie

I see that Lori was posting at the same time, so my apologies for any duplication.

[Oatsiedog]

Thank you all! THis is very reassuring to hear that the cautious approach seems to be appropriate given his ambiguous testing and marginal symptoms.

I too was confused by the ultrasound vets assessment of "definite" adrenal disease, and his regular vets test results of "borderline" cushings. I'll follow that up in my next round of questions for them.

The progression of things has been:

4 straight days of diarrhea ( on the 4th day he had blood in his stool, so that's when we went to the vet and got him started on meds

1 day marginal improvement in the diarrhea

then no pooping at all for 48 hours

then MASSIVE but solid poop

2 days of normal pooping

then the ACTH test and ultrasound

So there were really only a handful of days between the resolution of the diarrhea and the testing, which is why I'm not too surprised that his bowel looked "angry" !! He was on his regular Soloxine dose throughout the ordeal.

He does look a little skinny right now, and is down to 14 pounds -- his usual weight is between 14.5 - 17-5 pounds, but again, the diarrhea may be the cause of the weight loss. He still is his little chowhound self!

Sorry for all the poop talk, but you know how it is with dogs -- you're always monitoring what's going in or what's coming out!!!!

I'll get the actual test results and post here.

Thanks so much -- I feel much less worried! And he is snoring happily by my side!

Sarah and Otis

[Harley PoMMom]

Sorry for all the poop talk, but you know how it is with dogs -- you're always monitoring what's going in or what's coming out!!!!


Thanks so much -- I feel much less worried! And he is snoring happily by my side!

Sarah and Otis

We love details! Heck we even have a poop chart! :eek::D I am happy that his diarrhea has subsided, he sure is a cutie.

Love and hugs,
Lori

[gpgscott]

Heck we even have a poop chart! :eek::D Love and hugs, Lori

Opps!, I been callin that thing a poop LIST:rolleyes:

Welcome Sarah and Otis,

Keep a close eye on him and let us know, we will help you keep watch.

Scott

[apollo6]

Will be waiting for results.
First addressing the diarrhea was important.
We all have poop control to mointer how the fur balls are doing. Never thought my life would end up being poop monitor.:D
Will be waiting on you and Otis.
Hugs Sonja and Apollo.

[addy]

Hi and Welcome

I'll share my expereince so far, perhaps that will give you some insight:

My Zoe has colitis and had a flare up when we tested her. Her UTK adrenal panel showed high cortisol and 4 other steroid hormones were elevated and ultra sound showed enlarged adrenal glands but her main symptoms were thin coat, rats tail and thin skin. So she was not borderline.

I had to fix the diarrhea before anything, which took me 2 months. We then went on melatonin and lignans which took me another month to get her touchy system up to the correct doses. We are now on melatonin and lignans while we wait for a recheck end of November, early December so you can see your vet seems to be right on with her approach.

I started Zoe on 1mg of melatonin at night and then added 1 mg a week until we go to 3 mgs. Then did the same thing in the am. Each time she would be tired and spacey but she adjusted. Some pups get tired from it, most do just fine.

I can't say her coat is as before but it is growing faster but still not thick. I am told that could take 3-4 months and might not ever get back to normal, depends on the pup. We've only been at full dose for about five weeks.

Let us know how things go,

Addy

[Oatsiedog]

Hi all,

back in October I had posted that my 13 year old dachshund Otis had just been tested for Cushings and all his results came back "borderline". My vet recommended monitoring and watching for clearer symptoms. Well. I think we're at that point. In the last two days his water intake has increased dramatically and he's peeing buckets all over the house. He also has some additional stuff going on that confuses me:

1.) His gait has become pretty "stumbly" -- he seems to be tripping over his front feet and his back end seems a little less stable.
2.) When he pees, it's either a gusher of a urine stream, or intermittent small squirts that go on for a while.

I'm going to take him in on Monday to get checked out, but in the meantime I'm wondering if anyone has any onsights -- are these common symptoms? Might he have a UTI going on? Is the stumbling gait a common symptom?

He's in a great mood, eating well (NEVER a problem) and playing happily with his toys.

Thanks!
Sarah

[Oatsiedog]

Well, we spent a long and expensive day at the vets to discover that not only did his ACTH stim test come back at "greater than 30". but his blood glucose was at 648, so he is officially diagnosed with Cushings AND Diabetes. The diabetes end of things doesn't freak me out too much, as my last dog was diabetic, and I learned that routine. He was very well-regulated and lived three long and great years with the disease until he died from a spleen tumor. I am a bit freaked out by the potential complications of Cushings and Diabetes, as I know this can make for difficult regulation and hard-to-interpret test results.

For now, the vet wants to get the BG under control, so we've started insulin, and in 2 weeks we'll take a look at how he's doing before we start the Cushings treatment.

Any suggestions or helpful hints? What questions should I be asking?

Thanks so much for any and all input!
Sarah and Otis

[frijole]

Hi Sarah - Glad you found us! Getting that kind of dx is a tough one but I can tell you are already up on things which is always good. Your vet is right to work on the diabetes first. Sometimes there are false readings for cushing's so you might retest for it prior to treating it. I would probably have an ultrasound to look at the adrenal glands to see what is going on.

Should Otis have both then yes you are right... in some cases the cushing's can make getting the BG under control. I only have experience with cushing's so I am not much help but I did want to welcome you. No doubt those with experience treating both will chime in.

All the best to you and Otis. Kim

[k9diabetes]

Hi Sarah,

We would love to have you over at the sister forum to this one on diabetes - www.k9diabetes.com/forum (http://www.k9diabetes.com/forum).

I think it's good to get started with the insulin first. Cushing's causes problems only over the long-term while very high blood sugar can have devastating consequences very quickly.

Otis' blood sugar is pretty high. Any problems for him with ketones?

How much does he weigh and how much insulin and what kind of insulin was he started on?

Natalie

[Oatsiedog]

Thanks Natalie! I've actually been on the diabetes board for years, because if you can believe it -- my last dog, Fargo was diabetic too! So I'm pretty familiar with that routine and just hopeful that it goes as smoothly with Otis. Are you the same Natalie who had Chris?

He weighs 14 pounds and they're starting him on 3 units of Humulin twice a day. I started him on the purina DCO diet at the vet's suggestion -- still need to do some research on what will ultimately work best for him, but want to see how the BG regulation goes first, then work on the Cushing's stuff, then see if I can make diet improvements for him.

Thanks!

[Oatsiedog]

Oops! Just realized i've been a member of the "other" diabetes board for years, so I went ahead and signed up for this one too -- knowledge is power!

and only trace ketones in his urine, thankfully!

[apollo6]

JUST A WELCOME.
I do not have experience with diabetes, only cushings.
I have attached an easy update on cushing and the signs. You are wise to address the diabetes first. Before you jump into any treatment find out which one Otis has, there are three types.
http://www.kateconnick.com/library/cushingsdisease.html
you should get a full blood panel and an abdominal ultrasound. Also read if Otis has many of the symptoms of cushings.
HUgs Sonja and Apollo

[k9diabetes]

Hi Sarah,

Yup, that's me. :) I wasn't sure if you were the same one or not. I had concerns about the long-term future of the other forum since the administrator wasn't doing much with it so I decided in 2008 to create one of my own in case the other one disappeared someday.

I have many many fond memories of Fargo and recall some pretty hilarious stories! Chris passed just two months after Fargo - two great dogs who are greatly missed.

Otis is in great hands with an experienced diabetes parent like you! Glad he doesn't have any ketones.

Natalie

[Oatsiedog]

Well, it's been a frustrating week. Otis was diagnosed last Monday with both Cushings and Diabetes. Our vet wanted to start treating the diabetes first, then move on to to addressing the cushings issues. The first few days of getting him started on insulin and new food went fine -- no major issues, but he kept drinking a ton of water and peeing like a hydrant. But he was happy and still playing with his toys.We were going to do his first curve next Monday, but over the weekend he started getting very wobbly on his feet and really started looking acutely ill. This morning I had to help him eat, and about half an hour after eating he tried to throw up and got so staggery on his feet I thought he might be having a hypo, so I gave him some honey on his gums and took him sraight to the vet. His BG was over 500 (forgot to write it down), so I probably made it worse with the honey -- Aaargh! They're keeping him for the day, giving him IV fluids, and doing a curve, so hopefully we should know more later in the day. His vet says once she sees the results of his bloodwork, she may start him on the cushings meds today.

I'll check in again when I have more information (I'm trying not to call the vet's every hour like a neurotic mother!), but in th emeantime, if anyone has any suggestions about what questions I should be asking, I'd appreciate it.

Update, 10 pm: Well they finally got his BG under 300 by 5 pm, so they let me bring him home for the night, but he's going back tomorrow for another curve and to start the Lysodren, in hopes that it will enable him to get a better response to the insulin.

He looks better -- still wobbly, but not drinking as much water. He ate his dinner, but about an hour later was retching -- didn't actually vomit. He's pretty tired and quiet, but I do get some tail wagging whn I talk to him, which is a big improvement.

I'm worried that the BG being so high for so long is going to leave permanent kidney and neurologcal damage, but what should I be worrying about now that the Cushings has apparently kicked in?

Thanks for any and all input!
Sarah and Otis

[AlisonandMia]

What dose of what insulin is he on?

Do you have some ketodiastix on hand? It sounds like with him running so high that having those to test his urine with might be a good idea - that way you can keep an eye out for ketones which seems to be the biggest risk at the moment. Did the vet say he had ketones this morning?

Alison

[Oatsiedog]

He's on 3 units twice a day. Still only trace ketones in his urine -- that's no change since last week.

He had a pretty good night at home, definitely drank less water and his urine is back to being yellow (easy to tell up here in the snow!), but I'm not sure what kind of an indicator that is.
He woke me up to eat, and ate 85% of his breakfast. I have a feeling that the DCO, which I soak in warm water, bulks up so much that he may actually be getting too full, and he's just too tired to "power through" . He's always been a good eater, but he's a little less eager about it these days.

We're back to the vet in an hour, so fingers crossed for a productiev day there!

[frijole]

Wow you have had a couple of rough days. Do you know what the vet's thoughts are on lysodren? Are they wanting to go with a full loading dose or just enough to lower the cortisol a bit?

It would be helpful when/if you are instructed to give lysodren - post the dosage prescribed. I just want us to double check it. I would think with all you have going on they will go with a lower dose just to get the BG under control and then you can worry about the cushings later.

BTW a loading dose is between 25 and 50 mgs/kg of weight per day. So I would think they'd go 25 or lower and maybe not daily.

Also, never give lysodren to a dog who is sick (vomit/diarrhea) as those are signs of overdose. It is a strong drug and can upset and already upset tummy.

In the event you go that route here is a link of lysodren for your reference. Thinking of you. Kim

http://www.k9cushings.com/forum/showthread.php?t=181

[Oatsiedog]

Hi Kim -- Thanks for the info! We haven't yet discussed the Lysodren dosage. I dropped him off at 8 am for another day of IV fluids and a blood glucose curve. The plan is to see if he can maintain a decent BG level for the day, then he'll start the Lysodren. I'll have a phone chat with his vet later in the day and see what her plan is. In the meantime, I'm researching...wow, this is a complex disease!

I'm lucky in that I work from home, so he can be with me while he "loads" and I can keep a very close eye on him. The vet is just 10 minutes away, so we can get there quickly if there's a problem.

At least this morning he was feeling well enough to be a bit annoyed that he had to go back to the vet! Yesterday he was so sich he just didn't care!

[Oatsiedog]

They actually decided to start him on Trilosane today, not Lysodren. The vet felt like he was just a little too fragile to handle the Lysodren at this point. So, they've prescribed 30 mg twice a day. He had his first dose this morning and did vomit a bit afterward, so they gave him some Pepcid. I just gave him his second dose at 6 pm.

Foodwise, he was having a hard time getting through the DCO dry food -- the kibble chunks were pretty big and he's missing a bunch of teeth, so it was tough going for him. So I started soaking the kibble in warm water, which made it bulk up so much I think that may have been the cause of his retching over the last 2 days -- literally he was stuffed to the brim. With all the water he's been drinking he's pretty full up for a little guy. So we switched him to Purino OM canned tonight, which he wolfed down without a problem and licked the plate!
They suggested I feed him a small amount, give him the Trilostane, wait 15 minutes, give him the rest of the food and then his insulin. It's been almost an hour and so far he seems to be tolerating it all pretty well.

His blood sugar was high again this morning (over 600), but they got it down to 209 this afternoon. He goes in again tomorrow for another day of fluids and a BG curve, then hopefully we will be well on the road to stabilization. His vet says she is pleased with his progress, but wants to proceed with caution, so she'd like to have him do another day of in-clinic observation.

He was pretty perky on the ride home --wanted to stand in my lap and look out the window, which he hasn't wanted to do for about a week, his tail started wagging a lot when we pulled in the driveway. He was happy to get home, sniff around the house, and inspect his toy basket for theft of squeakies (it's a ritual!). Now he's sleeping happily on his favorite blanket.

Obviously the Trilostane is going to be expensive -- I haven't settled my bill yet, but the receptionist mentioned that it was something like $100 for a bottle of 30 pills. So if he gets 1 pill a day, that's going to be roughly $100 a month. OUCH! Is it possible to mail order it for less anywhere? If we're going to embark on this regimen, I have to start doing some serious financial planning. so any thoughts on how to manage costs are much apreciated!!! With the Trilosane, insulin, special food, syringes, not to mention all the regular bloodwork, it's a major committment. Of course it will be a top priority, but I will admit that I'm a bit freaked out by it all! One day a time...one day at a time....
Best to you all and your pups!
Sarah and Otis

[labblab]

Hello, and I'm afraid I only have a moment to post right now. But are you sure about the trilostane dosage for Otis -- 30 mg. twice daily for a total of 60 mg.? According to your "signature," he only weighs 14 pounds, and if so, a total of 60 mg. is a massively high dose!! Way, way higher than any initial dosing protocol with which I am familiar.

Even though their published U.S. Product Insert lists an intial dosing range of 1-3 mg. per pound and a total daily dose of 30 mg. for a dog of Otis' weight, Dechra (manufacturers of brandname Vetoryl) are now verbally recommending a starting dose of only 1 mg. per pound (per the technical representatives in their Kansas office). And for a dog being dosed twice daily, this total amount would be increased only incrementally and then split IN HALF for each dose, rather than doubled. So for a dog of Otis' weight, the starting recommendation might be for 10 mg. twice daily (for a daily total of 20 mg.). Here is a link to Dechra's product insert:

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

Do you know whether your vets are experienced with using trilostane? I don't mean to alarm you unduly, but truly this is a massively large total daily dose. I encourage you to double-check the dosing with your vets as soon as you are able! And if they have any questions, to contact Dechra directly regarding their most current intial dosing recommendations.

Marianne

[Oatsiedog]

Uh Oh.... now that I've read that through, I'm concerned. Maybe I'm reading the label incorrectly. I will hold off on his morning dose until I bring him in and I will bring the article as well.

It's a pretty large and experienced practice, and his vet and the vet techs seemed very knowledgeable and experienced in using Trilostane.

He's as spunky as he's been in over a week -- he just woke up from a nap and played with his toys and climbed the steps back onto the bed all by himself, which he hasn't been doing lately, so clearly something is improving.

I'll keep a very close eye on him overnight -- what should I be looking for if he's had too high a dose?

Thanks -- I'll check back in here tomorrow.

[frijole]

You should have been given prednisone to have on hand in case of overdose. You simply give whatever dose is prescribed. I am assuming because you asked that your vet didn't give you any??

Vets that aren't that experienced will sometimes ASSume that there are no risks with trilostane (vs lysodren) and they are wrong. Dogs can and do overdose on trilo. I don't mean to scare you but that dose was way out of line as you probably know. Mistakes happen.

So keep a very close eye on Otis. Signs of overdose will be very apparent. He will quit eating, and often they get to the point where they are lethargic to the point of not being able to even stand. It can be scary. Please know that prednisone will give relief fairly quickly.

If you start to see any signs call and ER vet and take your dog in asap. Do not wait. They will give prednisone, make sure they check the electrolytes. Depending on the results they might keep overnight for observation and/or give fluids intraveniously.

I hope this does not happen but just wanted to prepare you. Hugs, Kim

[labblab]

I'm hoping that Otis did well overnight. Just wanted to add the "Contact Us" link for Dechra in the event that you or your vets want to speak directly with one of their technical reps:

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

Our experience has been that they are really helpful and willing to speak with both owners and vets over the phone or via email.

Marianne

[Oatsiedog]

Thanks guys! He did fine overnight and seems good this morning -- much less water consumption, appropriate peeing and all around happier.

I, of course, spent the night up researching dosage. It does seem that there are variations in recommendations, but I agree that 60 mg a day is very high for a 14 pound dog.

I've printed out a folder of studies, the Dechra info, and the input from this board, and when I take him in to the vet in an hour I'll review it all with them and see what their rationale is for the dose, and if we need to reconsider. I didn't give him his scheduled 6 am dose, figuring the risks of him getting it late are less severe thatn an accidental overdose.

I'll check in later.

Thanks!

[labblab]

I am so sorry for your sleepless night, but that is terrific that you have compiled so much useful information. You are surely right that there are a lot of different dosing regimens to be found, and also that recommendations are continually evolving. When I started treating my dog with trilostane back in 2003, the recommendation at that time WAS to simply double the dose if a shift was made to dosing twice daily. So according to today's revised recommendations, I was also giving a huge daily dose. As it turned out, my boy actually did well at that level for several months. But we ultimately had to lower the dose. And the trend now is to start dogs "lower" and to go "slower" in terms of initial dosing -- so as to lessen the risk of side effects or adverse events associated with overdosing.

Having said all this, perhaps there is a reason why your vets are recommending this particular dose for Otis. But it will be very reassuring for you to have the chance to talk it over in greater detail. I also wanted to add that our experience here is that diabetic dogs are frequently started out with twice daily dosing right from the get-go (rather than the once daily dosing initially recommended by Dechra) in order to keep their endocrine systems more evenly balanced throughout a 24-hour time period. So the notion of dosing Otis twice daily makes sense to me -- it's just the size of the dose that has me concerned.

I'll be really anxious to read your updates. Good luck at the vet's!
Marianne

[Oatsiedog]

Thank you all for your vigilance and insights. I am certainly rocketing up the learning curve on this stupid disease!!!

After some thought this morning, I caved in and gave him his morning Trilostane dose, since I knew we were on our way to the vets and I didn't want to delay the impact of the meds any further, since I have already seen a remarkable change in his water intake and his wobbliness. I also read a few other case studies of 13 and 15 pound dogs being started on the same dose without adverse reaction, so that made me a little less panicky.

Wednesdays are procedure days at my vet's, so she wasn't available when I dropped him off, but I had a long talk with the tech, who listened to all my concerns very carefully, took notes and reviewed the articles I had printed out with me. She made a list of my questions for the vet and will have her review them before I pick him up.

Basically I just said that I needed to understand the rationale behind the dose, given that everything I've researched and been told by experienced and knowledgeable people indicates that he should have been started on a lower dose.

If I don't get a well-thought out answer that I feel comfortable with, I will certainly insist that the dose be dropped back to the manufacturers guidelines until we see how he's doing on it. His stomach was very "gurgly" about 45 minutes after taking it this morning, but he pooped fine -- no diarrhea and no vomiting. I was going to give him a small dose of Pepcid, but all had in the house was the chewable fruit-flavored kind, and it had no measurement on the label (!)and I was worried it might have sugar in it.

In terms of the Prednisone, the tech said that yes, they do recommend using that if he has a bad reaction, and if he stays on the Trilostane they'll give me a supply for home, but in these earliest days, they wanted me to bring him immediately to the emergency vet if he had any issues.

So, the issue is not resolved yet, but I do feel like they are taking my concerns seriously, and I will have a much better sense of things after I speak with the vet directly this afternoon.

Thank you all again!!

[Oatsiedog]

OK, we're home with lots to report!

First if all -- he looks better than he has in 2 weeks -- tail wagging, interested in toys and food, and much less wobbly on his feet.

I had a long phone chat with the vet this afternoon, and we discussed the Trilostane dose among other things. Her rationale for the high dose was that she has seen it be effective in quickly stabilizing dogs who have both Cushings and Diabetes and are as acutely ill with such consistently high BG readings as Otis. She reviewed all the studies I had brought with me, and we agreed that we would lower the dosage to 15 mg twice a day, and watch carefully to see if it impacts his BG. I thought she had a very responsible perspective which is that she went with what she has seen be effective in dogs with similar symptoms, but she was not at all resistant to reading through the literature and acknowledging that she is always open to new information. She emphasized that she wanted to make sure that I felt secure and confident in the treatment plan and she had no objection to lowering the dose and watching to see if it continues to have the beneficial effect on the BG it appears to be having.

Then, as if to illustrate my concern, Otis leaned over and barfed all over the floor! So we both took that as a good indicator that he wasn't tolerating the high dose very well and it reinforced the decision to lower it. So he got a dose of Prednisone, and she sent us home with more. We're going to skip tonight's Trilostane and start again in the morning with a 15 mg dose. He had two completely normal poops today, so no diarrhea.

His BG curve today was pretty good, so wile I'd like to see the numbers come down overall, he didn't have any dramatic spikes and drops over the course of the day. Here are his curve results for the last 3 days:

3/7: (from 6 pm on 4/6 - 6 am on 4/7 he drank 2 and 2/3 cups of water)

6am: 3 Units Humulin N
3/4 cup DCO dry
11 am: 605
12:30 pm: 538
2 pm: 486
4 pm: 356
5 pm: 230
What these numbers don't really capture is that they were tweaking his insulin throughout the day, but it didn't have much of an effect. I don't know exactly when they gave him insulin and hw much
6 pm: 3 Units Humulin N, 3/4 cup DCO dry

3/8: from 6 pm on 3/7 - 6 am on 3/8 he drank 1 1/3 cups of water

6am: 3 Units Humulin N, 3/4 cup DCO dry
8:30 am: 652, first dose of 30 mg Trilostane
10:15: 538
11:30: 356
12:30: 317
2pm: 308
3 pm: 170
4 pm: 206
6 pm: 3 Units Humulin N, 3/4 cup OM canned, 30 mg Trilostane

3/9: From 6 pm 3/8 to 6am 3/9 he drank 1/3 cup of water

6 am: 3 Units Humulin N, 3/4 cup OM canned, 30 mg Trilostane
8:30 am: 327
10 am: 208
11 am: 222
12pm: 247
2 pm: 279
4:30 pm: 307

So, while the dosage issue was a bit frustrating, I do feel that she responded appropriately to my concerns, was not at all resistant to considering another option, and most importantly, I feel like I have a real partner in this battle. She and her staff are always very responsive, take plenty of time to answer questions and are very supportive of me doing independent research and educating myself.

She shared with me that she had 3 dogs in today with the dual diagnosis of Cushings and Diabetes, and that she sees it pretty frequently, but she also said " we are all always learning here!"

So Otis is begging for his dinner (great sign!) so off i go to empty cans, fill up syringes and do the nightly routine!

Overall, I feel like this was a good day -- my boy's tail is wagging and he is slightly annoyed that I'm not feeding him -- in other words, he is acting VERY NORMAL!!!

Thank you all!!!

[labblab]

Thank you so much for your update! I've been thinking about you guys all day, and wondering how things were going. I absolutely agree with you that the quality of the partnership with your vet is so valuable. I was wondering myself whether a desire to rapidly lower Otis' cortisol in the face of his diabetic issues was the basis for the initial dosing decision. But I must confess that I will rest much easier knowing that the dose has been lowered!

My own Cushpup was actually the first trilostane patient for my IMS back when we started our journey in 2003. And so there was a lot for us all to learn. But I, too, really appreciated the fact that my vet was so open to my feedback and my questions, and did not hesitate to consult with others on matters about which there was uncertainty. So all in all -- aside from Otis' barfing :o -- it sounds as though it has been a valuable day for you guys.

Definitely keep us updated, OK?
Marianne

[frijole]

Whew... I was worried too... and I will sleep better tonight given the lower dose and the prednisone on hand. Like I said, alot of vets don't worry so much about cortisol dropping low with trilo but it does and it can be fatal. We have had owners drop in with emergencies wondering what to do and no prednisone on hand... the ER vet and the IV fluids cost up to $1000 so prednisone is cheap life insurance. ;)

Glad Otis is doing OK and thanks for updating us... we are worry warts. :D Kim

[Oatsiedog]

We're having a good day!! He woke up a little on the thirsty side, but hasn't been hoovering water since then. I gave him the 15 mg of the Trilostane and about 45 minutes later his stomach was gurgling pretty loudly, and I could tell it was bugging him. He threw up a tiny amount -- no solid food, just about 2 Tbs of liquid, and no pill fragments in it. I gave him the Prednisone just in case. Went to the pharmacy and picked up some Pepcid, and will give that to him with his evening dose.

He was definitely sleepy after his morning dose, but we went for a visit to the toy store, which perked him right up! He's been alternately napping and playing with toys all afetrnoon -- oh, yeah, and begging for my sandwich too!! He's been pretty steady on his feet -- definitely an improvement!

I'm really pleased with his progress and keeping my fingers crossed that things continue like this.

I can't thank you all enough for all your insights and good thoughts. 2 days ago, I really thought we were at the end of the line and was preparing myself for the worst, but the more I understand how this disease works, and how it corresponds to the diabetes, the more empowered i feel to help him.

best to you all and smooches to your pups!
Sarah and Otis

[Oatsiedog]

Oh yes -- and he's pooping just fine -- no diarrhea! I know we all are always worried about the poopin'!

[Oatsiedog]

Hi all!

Otis had a good day, but I'm concerned that his Trilostane dose may still be too high.

This morning about 45 minutes after he had eaten, gotten his 15 mg of Trilostane and his 3 Units of insulin, his stomach was very gurgly and loud, then he got up and started retching. He vomited a very small amount of fluid (about 2 Tbs), so I gave him a Prednisone just in case. He took a nap, then woke up and had a great day.

Tonight at 6 , I fed him about a quarter of his food and 10 mg of Pepcid, then waited 15 minuted before giving him the rest of his food and another 15 mg of Trilostanne and his insulin. At about 6:40 he got up and started retching again, but this time no vomiting. He sat on his blankie looking like he was going to vomit for about 10 minutes, then it seemd to pass and now he is happily napping again.

He's been pooping fine -- tonight's BM was maybe a little bit soft, but he's also on new food that is very high in fiber (Purina OM canned), so that may be the cause of that.

If he has the same reaction tomorrow morning, I'm inclined to call the vet and suggest that we drop the dose to 10 mg twice a day. Does that sound like a reasonable strategy?
Thanks all!!

Moderator's Note: I have moved your update on Otis into his existing thread. We normally like to keep all posts on a pup in a single thread as it makes it easier for other members to refer back to the pup's history, if needed.

[apollo6]

Please call your vet. Don't wait. Stop the Trilostane now. He should not be vomiting.
HUgs Sonja and Apollo

[StarDeb55]

This may not be the trilo. Do you have the sticks that you can check for the presence of ketones in Otis' urine? If he has ketones in his urine, this could indicate that his BG is extremely high, & he needs to be seen by a vet tonight.

Debbie

[labblab]

Hi Sarah,

I'm hoping that Otis did not have any further issues throughout the night and appears to be doing well this morning. I do agree with you that I would lower his trilostane dosage due to the gastric issues. You can always increase the dose later on, but hopefully he will better tolerate a lower initial dosing regimen if it is the trilostane that is causing the problem.

Keep us updated!
Marianne

[Oatsiedog]

He was fine all night, but then this morning refused the canned OM, so I fed him some plain chicken breast (no skin no fat) and some cottage cheese so he's have something in his system to work with the insulin, but he threw that up about half an hour later. I did not give him any Trilostane.

I took him into the vet at 8 and they've put him on IV fluids and are running bloodwork this morning to see how his electrolytes are doing. I'm worried about pancreatitis as well, so they're checking for that too.

It's a roller coaster for sure -- yesterday was mostly a great day for him...

[Oatsiedog]

...and still no ketones in his urine

[labblab]

Oh, I'm so sorry for this setback!! Please do let us know as soon as you find out anything.

Marianne

[frijole]

I just want to make sure you know that if a dog is sick and vomiting, NEVER give trilo. I don't care what the vet says. ;) Seriously. The most important thing right now is to figure out if the dose was too high and cortisol has gone low or if something else is amiss. Hang in there. Did you have another acth test done? Kim

[Oatsiedog]

Hi all -- I'm sorry to report that Otis didn't make it. I took him in to the vets and they immediately got him on IV fluids and tried to get him stabilized, but he continued to vomit uncontrollably and was unable to sustain any hydration. They gave me the option of taking him to the emergency specialist, but that's about an hour away and they weren't sure he would make it.

The minute I saw him, I knew what I had to do. Others may have made a different choice, but I know my boy well and I had always promised him that I would give him a good life and not allow him to suffer when it was time to go. So with him wrapped in his favorite blankie and with one of his favorite toys tucked under his chin, we said our goodbyes and I let him go.

I realize that others may have made a different choice and that there has been lots of concern about the level of Trilostane he was put on, but his labwork this morning didn't show any concerns about his cortisol level and there was nothing else remarkable about his other results. Please know that while I apreciate all the expertise that's been offered her, at this moment I don't think it will help me to hear opinions about what went wrong. I am horribly sad about this, but I am not blaming his vet team, and I am OK with the decision made.

Thank you all and big smooches to your pups.
Sarah

[lulusmom]

Oh Sarah, I am so incredibly sorry for your loss. There are no words at times like this so just know that my thoughts and prayers are with you.

Godspeed sweet Otis
Glynda

[apollo6]

i am so sorry for your loss. May your sweet angel Otis now be at peace.
sending you loving prayers
Sonja and Apollo

[BestBuddy]

Sarah,

I am so sorry for your loss. Otis will be sadly missed.

Jenny

[SachiMom]

Sarah,

I am so sorry. You have done what is right for Otis. We cannot, nor would not, second guess your decision. You were with him and you love him, so only you could make the hard decision that gave him peace and relief from pain.

Godspeed Otis.

Hugs ~ Mary Ann

[labblab]

Dear Sarah,

I am so terribly sad to learn that Otis has passed. But thank you so much for telling us what has happened, so that we can join you in honoring his life and his spirit. Otis has now been added to our special memorial thread:

http://www.k9cushings.com/forum/showthread.php?p=46185#post46185

Please know that we are here to give you our support, now and always. Not one of us has the right nor basis to judge any decisions that were made on his behalf. No one knew Otis better than you, and no one loved him more than you. You are the one who shared his life, witnessed his struggles, saw the entire big picture, and had Otis' very best interest at heart ~ always.

Sarah, I hope you will feel as though you will want to return to us. Because it will be our privilege to read about any special stories or memories that you might wish to share. We cannot lessen the pain of your loss, but we can walk alongside you in these coming days.

Many hugs to you on this sad evening, in loving memory of your brave boy.
Marianne

[k9diabetes]

I'm so very sorry to learn that Otis has passed...

Natalie

[Casey's Mom]

Dear Sarah, I am so sorry to hear about Otis. You were a great mom to him and he is now looking after you from above,

Love and many hugs,

[Squirt's Mom]

Dear Sarah,

I have just read Otis's journey and am so very touched by the devotion you showed to him. It is apparent the two of you were fighters who took advantage of every opportunity given you - whether medically or just to enjoy a good day together. My heart was crushed when I read that he had lost the final battle, he was such a valiant little guy.

You kept your promise to your sweet boy, that is the most any of us can hope to do when that "time" comes. That is all Otis could have asked of you that day if he could have spoken. We understand the courage and depth of love that takes.

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


May I Go

Do you think the time is right?
May I say goodbye to pain filled days and endless lonely nights?
I've lived my life and done my best, an example tried to be.
So can I take that step beyond, and set my spirit free?
I didn't want to go at first, I fought with all my might.
But something seems to draw me now to a warm and living light.
I want to go, I really do; it's difficult to stay.
But I will try as best I can to live just one more day.
To give you time to care for me and share your love and fears.
I know you're sad and afraid, because I see your tears.
I'll not be far, I promise that, and hope you'll always know,
That my spirit will be close to you wherever you may go.
Thank you so for loving me. You know I love you too,
And that's why it's hard to say goodbye and end this life with you.
So hold me now just one more time and let me hear you say,
Because you care so much for me, you'll let me go today.

by Susan A. Jackson

[mytil]

((((hugs))))) Sarah. I know these anniversaries are very tough.

Terry