Kira, 14 y/o Husky - Successful adrenal surgery (Kira has passed)

[Altira]

Administrative Note: Janis also has a companion thread about her dog, Mira, who is suffering from liver cancer (link to Mira's thread (http://www.k9cushings.com/forum/showthread.php?t=2651)). After beginning that thread, Janis has discovered that her other husky, Kira, appears to have an adrenal tumor. We are today beginning a new thread for Kira that leads off with copies of some replies earlier posted on Mira's thread. This first post by Janis was in response to another member's request to see Kira's diagnostic Cushing's test results as soon as they are available.
________________________________________________

Of course I will pass along all the test results. But I can tell you right now Kira fits all the symptoms to the letter. She has for years. The desperation for food, drinking enormous amounts of water and peeing huge puddles. Lakes! The distended belly. She also said it explained the failure oh her knee legaments. And why the fur on her back never grew back after the last surgery. It's been seven months and still it looks like they shaved her yesterday. The other side done two years ago was slow to come in was back to normal in six months. I have so many questions for you all.

[Altira]

KIRA
Siberian Husky
10.5 yrs
10/29/10

ALK - 354 (10-150) high
ALT - 117 (5-107) high

LIP - 1474 (100-750) high

CHOL - 378 (112-328) high

MCV - 59 (60-77) low

That is the initial blood work.
We have an ultrasound behind us too. I cant recall the specifics right now but there is a tumor. Not giant like Miras.
Now we wait a week for her urine track infection to clear up. Then on to the next test.

[Altira]

Because of the ultrasound is why ACC doctor is heading us that way.


Hi Janis,

Can you tell us why you think Kira may have cushing's? Cushing's is not a death sentence and with effective treatment, dogs can live out their natural life expectancy with a really good quality of life. My first cushdog is a rarity and was diagnosed at 3 years old. She is now 9 years old and still going strong. We think she had cushing's for at least before being diagnosed. My 2nd cushdog was a foster dog who we adopted because we knew he had cushing's. He had had the disease for a very, very long time and was a walking infection from head to tail, had very little fur and could hardly stand up due to severe muscle wasting. I've gotten estimates on his age of anywhere from 8 to 15 years old. He's been on treatment for three years and you'd never know he was the same pathetic dog that walked through our door in August, 2007. Whether a dog is diagnosed early or later in the disease, treatment can work miracles. I saw it happen twice. FYI, the object of treatment is to improve/resolve the symptoms so it is not recommended to treat a dog until the dog has overt symptoms.

Now that Kira may be cushingoid, please remember to get her records as well and post test results here.

Glynda

[missbeagle]

Janis -

You can put Kira on milk thistle if you want to. The milk thistle is the cheap and that will help with the elevated liver enzymes. If you Google it a bit you will find information on milk thistle to help you get the right one. You can get some at the health food store. I'm not a vet tech, but although her liver enzynes are elevated, they are not super duper elevated.

Remember to give the antibiotics for the urinary tract infection with some food. Antibiotics are always absorbed better with food. :) I would assume they gave you Clavamox, which is an excellent broad spectrum antiobiotic. Also urinary tract infections are common in spayed females. My lab always gets Clavamox for her urinary tract infections.

Gretchen and Rusty in NC

[Altira]

"It seems you have found a great new vet clinic that can handle Kira's health. Overt cushing's symptoms would be extreme water drinking and urinating in the house, losing& hair/skin irritations, back leg weakness to name a few."

She drinks tons of water always has. Every now and then she pees in the house. More often she is wanting to go out every half hour and always seems real desperate! She had to have knee surgery on both back legs. ACC doctor said cushings can effect knee ligamants which is what happened to kira. She has never lost fur in an unnatural way. BUT she had knee surgery just 7 months ago and the fur on her back has not grown back at all!

[Altira]

Gretchen -

Kira:
is taking Baytril 60s for her infection. The regular vet gave those to her. $$$$ expensive!!! ACC doctor was ok with that I guess. There hasn't been any giant water drinking since taking those.

[Altira]

New blood test for Cushing's:

Kira
Siberian Husky
10.5 yrs
11/11/10

ALK - 386 (10-150) high
ALT - 178 (5-107) high

CK - 209 (10-200) high

CHOL - 402 (112-328) high

Not sure why they did this one. But everything is a bit higher then it was two weeks ago. And "CK" is in there now. Any comments?

[Squirt's Mom]

Hi Janis,

Those values are often elevated in cush pups but Kira's are not near as high as many we have seen. It isn't unusual to see ALKP values in the 1000's. CK is creatine kinase. Why is has elevated since the last test, I can't say. Hopefully someone has more info on this for you and I will be happy to do some research into it with you.

Has the vet mentioned doing any cushing's specific testing on Kira such as the UC:CR, LDDS, HDDS, abdominal ultrasound, or ACTH? While the CBC can give some indicators that there may be a problem like Cushing's, this test (the CBC) cannot diagnose it.

How is our Mira doing today?

Hugs,
Leslie and the girls - always

[Altira]

Kiras ultra sound and spot on symptoms has made them pretty certain. They will do more tests four days after we finish Kiras meds for the infection. They have me set for a Cushings consultation at the same time.

[Altira]

A CUSHING'S REPORT:

I listened to the recording of the ACC doctor telling me about Kiras ultrasound. Here is some of what I'm hearing this time:

She has a very small mass in one of her adrenal glands. Some dogs aren't effected by this. There is a mass off the back side of it. It can be cancer. It usually is cancer but it doesn't appear to be evading anything right now. They usually grow very slowly and could take a year to get twice this size. If it's producing ???? then you get the symptoms of Cushings. (Kira has all the symptoms) It can be removed but she needs to be tested. If it were her dog she would not remove it knowing it may never be a problem. It should be watched via ultrasound. If it changes then you remove it. It's not real bad but she would need treatment for it. And we could see the symptoms of cushings reversed including her fur growing back.

Other concerns:
(1)There is a heart murmur that on a scale of 1 to 6 in loudness its about a 2. One side maybe slightly enlarged. (she said a little more on that but I'll move on)

(2) The liver looks ok. There are no masses there. But it appears to be braking down. We may need to find out what is going on with that too.

My thoughts:
I'm just glad that I don't have another terminally ill dog that's going to die soon and there is nothing we can do. Kira has a chance. Hopefully she will respond well. But I am very concerned that her most resent blood test shows even more elevated numbers. It looks like a big increase to me in the span of just two weeks.

My other concern:
How is she going to handle the loss of Mira. She will be effected in some way. They always are. She lost Kodi when she was three. And carefree Kira left with him. A sadness that never left her. When I took both dogs for a walk. Kira was very good about walking slow bless het heart. She looked over at Mira a bunch of times with great interest seeming concerned. What's wrong Mira?

[Altira]

Kira is acting oddly. It could be sadness or maybe she's tired. Thats what it looks like. Normally anytime I go into the kitchen she comes right in behind me looking all hopeful. Now she doesnt bother to even get up! I'm worried about her. I haven't seen those bright eyes in days. Is she upset that Mira is getting so much attention? Is she upset that I put her outside when Mira eats? Does she know something is wrong with Mira? Or god forbid is it Cushings kicking in? Or worse?

Sorry I was going to try to be brave today but it didn't work...

[Squirt's Mom]

Hi sweetie,

If Mira and Kira are close or bonded, then it is possible that Kira is picking up on Mira's distress and the changes in Mira caused by her illness. Since you are with them both all the time, Kira could be picking up on your distress as well if she is bonded to you as I'm sure she is.

One of the signs of Cushing's is lethargy and a loss of interest in things, a kind of pulling away, at times. Squirt had started sleeping more and she would go "hide" under furniture to spend her time. She wouldn't show the connection and need to be with me like she used to as much. If cortisol is running wild in their systems it can throw off the circadian rhythms keeping them from resting well at nite. Cortisol is normally released in quantity in the early part of the day and as the day passed, that level drops allowing other chemicals to step up causing our bodies to relax and sleep. In Cushing's, the cortisol level doesn't drop like it normally would but is continually released, making a restful nite difficult to achieve.

Keep an eye on her, as I know you do like a hawk, and let us know if you see anything else that is disturbing for you.

Hugs,
Leslie and the girls - always

[Altira]

Hi sweetie,

If Mira and Kira are close or bonded, then it is possible that Kira is picking up on Mira's distress and the changes in Mira caused by her illness. Since you are with them both all the time, Kira could be picking up on your distress as well if she is bonded to you as I'm sure she is.

One of the signs of Cushing's is lethargy and a loss of interest in things, a kind of pulling away, at times. Squirt had started sleeping more and she would go "hide" under furniture to spend her time. She wouldn't show the connection and need to be with me like she used to as much. If cortisol is running wild in their systems it can throw off the circadian rhythms keeping them from resting well at nite. Cortisol is normally released in quantity in the early part of the day and as the day passed, that level drops allowing other chemicals to step up causing our bodies to relax and sleep. In Cushing's, the cortisol level doesn't drop like it normally would but is continually released, making a restful nite difficult to achieve.

Keep an eye on her, as I know you do like a hawk, and let us know if you see anything else that is disturbing for you.

Hugs,
Leslie and the girls - always

Can anything be done for this? The ACC doctor spoke of medication. Does it work?

You know Kira just had TTA surgery done on her knee 7 months ago. Recovery is like 12 to 18 weeks long. Kira got ALL my attention for that time and well beyond it. Me and Mira slept on the floor by her confinment area for weeks! At first I was just walking Kira everyday and poor Mira had to stay behind. They cut a piece of bone off and reposition it and you have to wait for the bone to grow back. The leg is very fragile at first. Then finally I was able to handle both dogs on a walk. That was not so long ago. Kira was used to getting most all of the attention until about a month ago. If that is what she is reactating to then it took her long enough. I'm thinking it's something else. The twinkle has gone out of her eyes! Kira doesn't go into hiding much. She and Mira trade off for the spot beside me. Her sudden lack of interest in food worries me. Normally she hops around all excited. And what about the rise in her blood test?

Mira is getting all the peanut butter with her zillion pills. Kira is taking pills too but.... I don't know. I can easily see the light going out in Kira's eyes when Mira is gone. Hell I can see mine doing the same thing. I need Kira's bright eyes so much. Those bright blue/brown eyes. Those eyes told me she would make it thru that long surgery. Both dogs are laying behind me right now. Kira's breathing is very noise. She barks and runs in her sleep all the time.

Take a look at the first clip in this video and you'll see what I mean about her bright eyes.

http://www.youtube.com/watch?v=H-Rfcg7n_iY

Janis

[Altira]

Thank you!

Kira goes to ACC's Cushings specialist today. I think they will do more tests. I know this was ment to also be a consolation appointment. I wish i was in a better frame of mind for this. Bud is going this time. He needs to understand what's happening with Kira. Hopefully my brother will have a chance to look at Kiras detailed records and give us an opinion.

[Altira]

They are suggesting surgery for Kira. Any comments on that?

They are both staying here for at least eight hours. More when we get home.

[Altira]

Kira : dexamethasone suppress 1pre/2 post 1
Dexamethasone injection 2nd/ml
Urinalysis IDEXX
Urine culture and MIC (cal micro)

Whatever that means - this is what they did today.

I asked them to do whatever was the best tests and would give us the fastest results. She said one test had to go to michagin and would take a week. The other will take a couple days. I recorded our conversation. I'll listen to it soon but I'm pretty sure the opperation would be to remove the one gland over her left kidney. The right side looks fine.

[addy]

Are they talking about removing an adrenal gland? The moderators will be along soon to comment. I believe if it is a tumor on an adrenal gland and they are able to remove it the dog no longer has Cushings. We have members who have had that procedure.

Love,
Addy

[Altira]

Thank you Addy

I managed to do a search here on surgery and found there has been some success with adrenal surgery. That was encouraging since I read elsewhere where it said it was the most difficult surgery they do on dogs and the survival rate wasnt so great. Lots of horrible things could happen post surgery. They did say that the other side looked ok. And the Cushings specialist seemed very confident. But I can't help feeling that they are just out for their Ginny pigs. They get to test out new things on our pets and it doesn't cost them a thing. I can't tell you how greatful I am for this forum. I hate to think how I'd be feeling right now with out you guys.

[Squirt's Mom]

Mornin' Janis,

It sounds like tests are indicating adrenal dependent hyperadrenocortisim (ADH). In simple terms this means there is a tumor on one of Kira's adrenal glands that is causing the Cushing's. Removal of the tumor means a cure just about every time! ;):D

It is a serious surgery but one that has been performed many, many times with success. Some pups have had both glands removed and do just fine with meds. Make sure the surgeon is Board Certified and that he has done this type surgery many times before with positive results.

Leslie and the girls - always

[Altira]

ACC just called Kiras test got messed up. We need to take her back in pronto. I'm in great shape thank goodness Bud is here. One test result came thru they want to start her on something expecting that surgery will be done. The same doctor who did her two tta surgeries is being asked to do it. Im so glad. So I guess we are off to save our Kira. MirA she seems ok right now shell make the trip with us I'm sure of it. She would want this.

[frijole]

ACC just called Kiras test got messed up. We need to take her back in pronto. I'm in great shape thank goodness Bud is here. One test result came thru they want to start her on something expecting that surgery will be done. The same doctor who did her two tta surgeries is being asked to do it. Im so glad. So I guess we are off to save our Kira. MirA she seems ok right now shell make the trip with us I'm sure of it. She would want this.

Pls let us know what test got messed up. The surgery you are talking about is a serious one and needs to be done by a VERY VERY experienced surgeon that has done a LOT of this type of surgery. I would not rush into it. Is there a reason they want to do this so quickly? Have they even done an ultrasound? Every adrenal case I remember they did ultrasounds to determine the location and size of the tumor - plus to confirm that it is in fact an adrenal tumor. You really do not need any additional stress right now.

Please tell us more when you can. Others that have been thru this surgery can offer you advice as well. Hugs, Kim

[Altira]

Kim. We are still at ACC. But not much longer I think. Phenoxyhenzanine 10 mg they want her to take.

[frijole]

Kim. We are still at ACC. But not much longer I think. Phenoxyhenzanine 10 mg they want her to take.

Looks like it is for high blood pressure as a result of an adrenal tumor? When you get home and have time please let us know what they are telling you. Also find out as much as you can about the surgeons experience, specficially how many of these exact surgeries he/she has done. Thanks!

[Altira]

Kira - YES how many times has this doctor done this type of surgery and what has been his success rate? It's at the top of my list. Dr Sebestyen did Kiras first TTA surgery in 2008 and did the same thing to the other knee in May of this year. Except for the expected long recovery from this, Kira breezed through the first one. The second one at age ten was a bit harder on her. But god she was a champ about it, we both already new what to expect, and she was so good about it. They have to be confind for like 8 weeks! This is why we were out walking so much. I was out PROTECTING my investment! Nearly $7,500 invested in her back legs. She would not be walking today if we hadn't. They actually saw off a piece if the bottom leg bone, tilt it outward attach a metal cage at the top and screws at the bottom. Then you wait for the bone to fill in the gap. This takes the pressure off the knee ligaments that normally are always under stress in a dog. You know their knees are always bent unlike ours.

But! For some reason the fur on Kiras back this last time did not grow back! The doctor was very concerned about it and kept asking me to let him know about that. I wasn't concerned at all for some stupid reason. I thought when she blew her coat it would come in. Well neither has happen. Seven months have past and it still looks like they just shaved her yesterday. Except the skin has turned a bit dark. ACC thinks it's from Cushings. Would you agree on that?

Dr Sebestyen is located in the same complex as Advanced Cridical Care (ACC) in Tustin California. They have their own building called Veterinary Surgical Specialists (VSS).

I will now gather up what technical details on Kira I can get. I'm glad to have something to do and not be watching Mira constantly. She is drugged up and that always freaks me out.

[Altira]

We tried a picnic outside Lesile. I was armed with pocket filled with treats. Mira excepted a couple then went off by herself so did Kira the other way. It was a lonely picnic. Mira used to stay right by my side even when it was 100 degrees out shed be laying on the hot cement beside me. Shed never go in the house without me. Oh well I hope it's just the meds. We'll try again later.


Ok I got all the recent detailed results I emailed it to you but I'm not sure it's readable.

Pre Dexamethasone 5.1 1.0-6.0
Post 4 hour dex. 3.4 less then 1.5
Post 8 hour dex. 2.7 less then 1.5

There is a bunch of stuff after that too.

Collection cystocentesis
Color yellow
Clarity clear
Specific gravity 1.022
Glucose negative
Bilirbin neg
Ketones neg
Blood neg
Ph 7.0
Protein neg
WBC none
Rbc none
Bacteria none
Ept cell 1+(1-2)
mucus none
Casts none
Crystals none

Other:
Amorphous debris present
Urobiltnogen normal
(did I miss anything?)

Triostane 80mg is what they want to put her on right away with one blood results still pending and weither or not surgery is done. I think she said. They will send me this by mail.

Her bp was 220. I have a script for the bp meds. Should I go get that right way? She said it wasn't as important as the above. She also said to watch for dizzyness or weekness and if so to discontinue it. To me that sounds like thier not sure she needs it. What do you think should I do it or not?

[Altira]

PETER SEBESTYEN, DMV, DIPLOMATE ACVS

Doctor of Veterinary Medicine - University of Veterinary Sciences, Budapest 1989
Internship - Sonora Veterinary Surgery and Oncology, Arizona 1995
Residency - North Carolina State University 2000

Dr. Sebestyen graduated from the University of Veterinary Sciences in Budapest, Hungary in 1989. Following his graduation, he underwent two years of post-graduate training in anatomical pathology. In 1991, he moved to British Columbia and joined a general small animal practice. Early in his career as a veterinarian in clinical practice, he developed a strong interest in surgery and decided to pursue further academic training in this field.

In 1995 he joined Sonora Veterinary Surgery and Oncology in Scottsdale, Arizona and completed a rotating small animal internship. He enrolled in a 3-year residency program in small animal surgery at the NCSU College of Veterinary Medicine. After completing his residency, he joined the faculty of the CVM as a clinical assistant professor from 2000-2001. He also held a research position at the Department of Anesthesia at Duke University Medical Center in Durham NC and participated in microvascular surgical research. Dr. Sebestyen became board certified by the American College of Veterinary Surgeons in 2001. Prior to his relocation to California, he has been in a small animal surgical referral practice in North Carolina.

During his residency and his academic and referral surgery positions, he completed several research projects, gave numerous seminars, and participated in advanced surgical courses. His research interests include total hip replacement, spinal biomechanics and tibial plateau leveling osteotomy. Dr. Sebestyen has a wide range of clinical experience in veterinary surgery from academic and private practice settings. His clinical interests are surgical oncology, reconstructive and microvascular surgery

[frijole]

Ok I got all the recent detailed results I emailed it to you but I'm not sure it's readable.

Pre Dexamethasone 5.1 1.0-6.0
Post 4 hour dex. 3.4 less then 1.5
Post 8 hour dex. 2.7 less then 1.5

There is a bunch of stuff after that too.

Collection cystocentesis
Color yellow
Clarity clear
Specific gravity 1.022
Glucose negative
Bilirbin neg
Ketones neg
Blood neg
Ph 7.0
Protein neg
WBC none
Rbc none
Bacteria none
Ept cell 1+(1-2)
mucus none
Casts none
Crystals none

Other:
Amorphous debris present
Urobiltnogen normal
(did I miss anything?)

Triostane 80mg is what they want to put her on right away with one blood results still pending and weither or not surgery is done. I think she said. They will send me this by mail.

Her bp was 220. I have a script for the bp meds. Should I go get that right way? She said it wasn't as important as the above. She also said to watch for dizzyness or weekness and if so to discontinue it. To me that sounds like thier not sure she needs it. What do you think should I do it or not?

Thanks for these numbers on Kira. Like I said, they are probably concerned about the high blood pressure coming from an adrenal tumor. Yes that bp reading is HIGH. I wouldn't hold off on getting her the meds for that. The dizziness and weakness she described to you are POSSIBLE SIDE EFFECTS from the drug they are recommending. I know this because I googled it.

Couple other questions -

1. Has Kira had an ultrasound to take a look at the size and location of that adrenal tumor? IMHO this absolutely should be done prior to any surgery because it gives the surgeon a better idea of how to approach the surgery and frankly the likelihood of success. If too risky then you could opt for treating with lysodren or trilostane. I am not sure why they are recommending trilo right now unless it is to give her some relief while you decide on surgery?

What are the docs telling you? Without this info we don't have the full picture and so it is hard to help.

2. The vet seems experienced at surgery from the bio you posted. I did not see anything specific to this type of surgery and you will probably only get the answer by having discussions with him directly. It is OK to ask him - he will understand. Just like if you were having heart surgery you would want to know that your surgeon has done a lot of them successfully..

Sorry you are dealing with alot at the same time. Hugs, Kim

[Buffaloe]

I see that Dr. Sebestyen did his internship at Sonora Veterinary Surgery and Oncology in Phoenix, AZ. It is now called Sonora Veterinary Specialists and there are two locations in the Phoenix area. It is a wonderful facility and has a great reputation here. The owner is a fantastic surgeon and performed my Shiloh's adrenalectomy in 2006. I have to believe that Dr. Sebestyen received some great training while at Sonora.

Ken

[Squirt's Mom]

Hi Janis,

How is Mira this morning? How are you?

The results on Kira aren't clear to me, but that's not surprising! :rolleyes: It might help you could post all the info given with these numbers:


Pre Dexamethasone 5.1 1.0-6.0
Post 4 hour dex. 3.4 less then 1.5
Post 8 hour dex. 2.7 less then 1.5

There is a bunch of stuff after that too.

That "other stuff" might help. ;) And, of course, I am sure others will be along who can tell you much more about what all that will mean than I. :)

Her specific gravity of 1.022 appears to be normal to me. According to the Merck Veterinary Manual, 9th Edition, the normal range for canine specific gravity is 1.001-1.070. Did they do a blood panel, what is often called a CBC, on Kira? There are several values from this test that are also used as indicators for Cushing's.

I'm not sure I agree with the vet concerning which is the most important to focus on for Kira. In my simple mind, the BP needs attention now. But what do I know?! :p

The vet is right in that the Trilo can cause some of the signs mentioned to watch for, but that is just part of the treatment with either drug, Trilo or Lyso. INSIST they give you some prednisone to have on hand just in case Kira needs it. This is not an option - it is a necessity but some vets are loath to give it when pups are on Trilo because they hold to the false belief that Trilo is so much safer than Lyso that the pred isn't needed. The fact is, both drugs can have serious consequences if the diagnosis isn't right, the dose isn't right, and/or the pup isn't properly monitored. So pred is something a parent needs to have on hand with either treatment. ;)

I am curious...are they wanting to treat Kira's adrenal tumor until it is removed or are they going to try the treatment path instead of surgery?

Big hugs,
Leslie and the girls - always

[Altira]

The vet said that Dr Sebastian at VSS is wonderful at tumor removal. He said that he has been successful at many cases that seemed hopeless. not the adrinal type but another very touchy one. He said ten years ago this type of surgery for dogs was unheard of. He said if anyone can get Kira through it Sabastian can. And he amited that adrenal removal is the most dangerous surgery in dogs right now. His confidence in Sebastion is encouraging. And we know Sebastian. He did both of Kiras legs. He knows Kira. Her other leg was just done in May. And a big thank you to who ever noted that place where he studied (or worked?) as being a great place. That sure helps alot. Anyone know how much this might cost me? I will get you all the missing pieces I swear I will. And little by little I will read these posts better.

Ok I will get Kiras bp meds right away. Thank you for that input.

[Altira]

Hey labblab (sorry I'm horrible with names)
Nice job at reconstructing a seperate thread for Kira. Thank you!

[labblab]

Janis, you are very welcome!!

Has Kira already started taking the trilostane? If so, does she seem to be doing OK with it?

Marianne

[Altira]

Janis, you are very welcome!!

Has Kira already started taking the Trilostane ? If so, does she seem to be doing OK with it?

Marianne

I just now got the Trilostane.

It's iiquid. Wonderful:mad:!

We started the bp meds last night. It said to watch for legathery, all Kira does is sleep I doubt if I could tell a differance. I'm just being difficult she's fine with that. Sure wish I could take her bp myself though.

Anyway, I'm waiting to get the go ahead from you guys on the Trilostane. What should I watch for? What if she spits some out? What if I miss her mouth? I'm not expecting that Kira is a good girl but what if? Should I give her food with it? What if I forget to give it to her? I'm already using my iPhone alarm to remind about Miras pills four times a day. I'll add Kira to that I guess.

Anyone?

[frijole]

I have never used trilo so I can't answer that question but am curious... what dosage did he tell you to give and how often? Also what is Kira's weight?

Also, were you given prednisone to give in case of emergency? Did they give you any instructions for the trilo?

Hopefully an experienced trilo user will give you some feedback soon. Kim

[Altira]

I have never used trilo so I can't answer that question but am curious... what dosage did he tell you to give and how often? Also what is Kira's weight?

Also, were you given prednisone to give in case of emergency? Did they give you any instructions for the trilo?

Hopefully an experienced trilo user will give you some feedback soon. Kim

60 CP TRILOSTANE 80MG/ML SUSP CPCRX

Dose is 1mg twice a day

Kira weighs about 74 pounds probably more than that with all the treats flouting around here with sick Mira.

There was no mention of prednisone.

Really no instructions at all. I cant even find it mentioned on the paperwork they gave me. Just on the records i insisted they give me. They make this seem like it's a sinch. That's rather disturbing.

[missbeagle]

Janis -

My dog is currently not on anything for Cushing's yet, but I thought you might want to check this link out.

I would be leery if my vet gave me meds without detailed instructions.

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

Gretchen & Rusty near the beach in NC

[frijole]

Janis - Please don't give any trilo yet. I'd really like for a trilo user to give you their thoughts and check the dosage. We see more capsules then liquid so hold on... holiday weekends are a little slower.... Thanks! Kim

[Altira]

Ok Kim. I'd like to hear from them too.

Good greif I followed that link. I have no idea what they are talking about. There certainly was never any mention of doing tests right away. It said 1mg a day too. Course Kira is pretty big. She is well over standard for a husky.

[Altira]

Hi sweetie,

If Mira and Kira are close or bonded, then it is possible that Kira is picking up on Mira's distress and the changes in Mira caused by her illness. Since you are with them both all the time, Kira could be picking up on your distress as well if she is bonded to you as I'm sure she is.

One of the signs of Cushing's is lethargy and a loss of interest in things, a kind of pulling away, at times. Squirt had started sleeping more and she would go "hide" under furniture to spend her time. She wouldn't show the connection and need to be with me like she used to as much. If cortisol is running wild in their systems it can throw off the circadian rhythms keeping them from resting well at nite. Cortisol is normally released in quantity in the early part of the day and as the day passed, that level drops allowing other chemicals to step up causing our bodies to relax and sleep. In Cushing's, the cortisol level doesn't drop like it normally would but is continually released, making a restful nite difficult to achieve.

Keep an eye on her, as I know you do like a hawk, and let us know if you see anything else that is disturbing for you.

Hugs,
Leslie and the girls - always

Kira will go off by herself sometimes but not often. She is more like mira and stays within view or just as often at our feet. She likes to be my foot rest a lot. And she has no problem at all sleeping ever. I can feel her twitching under my feet. She likes to lay at Buds feet and paw at him so he will pet her. It works too. She sleeps belly up all the time. She does a lot of running and barking in her sleep. She also snores when she's wake. Does anyone elses dog do that? It's always sort of worried me...

I am worried about her. Like it was with Mira. Something is wrong but I can't really put my finger on it. She looks a lot heavier them 73 pounds and when she walks it's a bit labored. She looks like she's carrying too much weight. I want her slimmed down and well excersized before doing any surgery. There is no way I'd send her to surgery as she is today. Bud can just barely pick her up to weigh her.

They said I think... That the tril will reverse her food and water problem and her fur will grow back. Does anyone agree with that?

I think I need to get in touch with the woman handling her case too. Errrr maybe I should replay play the recording of our conversation first. I was worried sick about Mira (who was being examined at the same time).

[frijole]

Janis, I am really glad you recorded the conversations. It is why I am asking you to tell us what they said - as specific as you can. Treating cushing's with chemo drug requires we help get you up to speed on the disease so you can be Kira's voice in this. With everything going on with Mira it is understandable that you might not have heard it all... but regardless - it is very important.

Cushing's is a result of overproduction of cortisol. In your case it is coming from that adrenal tumor. Cortisol in excess usually results in dogs having an insatiable appetite. They also have round tummies. It affects the liver, the heart and often cush dogs have shaky hind legs which weaken over time. Treatment of an adrenal tumor can be by removal of the tumor (depending on the size and the location) which results in a cushing's free dog OR by using a chemo drug (typically trilostane or lysodren). The chemo drugs are strong and you want them to be so they work.

For this reason you want to be sure that the dosage amount is appropriate for your dog's size (which is why I asked). You would see results fairly quickly. I am not sure if the dosage is increased for dogs with adrenal tumors. (it is with lysodren but it works differently)

If you think of anything they said that might help us help you, just post it! Kim

[Altira]

I can email the recording to anyone who wants to hear it.

[AlisonandMia]

Yes, Lysodren and trilostane are called "chemo" drugs because they are or have been used in cancer treatment - Lysodren in adrenal cancer and trilostane, briefly and not anymore, in treatment of some breast cancers (because it blocks the production of progesterone). But don't let this term frighten you - chemotherapy really just means treating disease with chemicals so taking an aspirin for a headache is, strictly speaking, a form of chemotherapy.

However trilostane is a powerful drug that lowers cortisol (which is what you want to do in treating Cushing's) and lowering it too far can result in a sick dog - which is why the dosing has to be correct for the dog.

Are you going forward with surgery for Kira's adrenal tumor? It is usual (but not always done) to treat the Cushing's medically first to lower the cortisol to a more healthy level before going in and doing surgery. This makes for better recovery and healing and helps get the dog into better physical condition. It sounds like this is what the trilostane is being used for now with Kira.

It sounds like you have some sort of compounded trilostane liquid which is 80mg per ml and you have been instructed to give one ml per day - is that right?

Alison

[Altira]

No it's twice a day!

[AlisonandMia]

So is it 80mg per ml - is that what it says on the label?

Just off the top of my head I would think that 80mg 2 X a day would be quite a hefty starting dose....

Alison

[Altira]

We were just looking into the surgery. They never said anything about checking the levels. All she said was to make a consolation appointment with dr stebastian. She didn't say anything about were being any rush for that. What she did stress was that the trilosane was important. Like don't hold back on that. They are open 24 hours I can call and ask anytime. I need to better understand what to ask. The side effects are written in words I don't understand I really need to talk to someone who has used this. I was just asumming most poeple here had.

Thanksgiving is tomorrow? My Mira isnt looking well. Great timing.

[Altira]

60 CP TRILOSTANE 80MG/ML SUSP CPCRX
Give 1ml by mouth two times daily

Kira weighs about 74 pounds probably more than that with all the treats flouting around here with sick Mira.

[AlisonandMia]

Side effects of trilostane (and Lysodren for that matter) have largely to do with the cortisol level going too low - so you will see these "side effects" if the dose is too high for the particular dog. Common symptoms of low cortisol are: lack of appetite, nausea, vomiting, diarrhea, weakness, lethargy.

If you see anything like that you need to not give any more and consult the vet ASAP. If the dog has severe symptoms then they need to be seen urgently as they may need immediate treatment.

It is usual to start treating with trilostane using a single daily dose (in the morning) and then the decision to try adding a second dose if symptoms rebound in the evening may be made. This seems to be the simplest and safest way to start treatment. Twice daily dosing is more likely to lead to side effects.

The trilostane will make no difference to tumor itself but will reduce the Cushing's symptoms you are seeing like excessive urination and big appetite. How long it will take for coat growth to occur is anyone's guess, unfortunately. Skin/coat issues are usually the slowest to resolve.

Alison

[Altira]

CT scan before surgery.

[AlisonandMia]

Got to go out now (I'm in Australia and it is 2.50pm) but will be back later.

Usually just an ultrasound is done before surgery but in some cases a CT or MRI could be done if surgeon is unsure about degree of blood vessel involvement.

Alison

[frijole]

Janis - I haven't seen any trilo users on tonight but please know that there are plenty of them here... just not right now. I do agree with Alison that the recommended dosage seems HIGH. That is why I was wondering if recommended dosing is higher for dogs with adrenal tumors. On that high of a dose I am surprised they did not give you prednisone to have on hand in case of emergency.

As Alison indicated - trilo helps reduce the amount of cortisol the body is producing from the tumor. But a dog still needs cortisol to live so you don't want to go too low. That is why most start LOW and slowly increase to find the best dose. Prednisone mimics cortisol so if a dog's cortisol goes too low (overdose) you can give them prednisone. It is pretty important.

This is why I didn't want you to give any yet. I just want to make sure the amount isn't too high. Sorry but this is the best I can do since I used lysodren.

I am headed to bed now but will check in in the a.m. Hang in there! Kim

[Altira]

I called ACC and talked to the doctor on duty. She said she hadn't used Trilostane much. I expalained to her that I really didn't have anything anywhere that tells me anything about it, what to watch for, or rechecks or anything. She's looking at the chart and not finding much there either. She told me of the likely side effects which are the same as mentoned above. She knew nothing about keeping prednisone on hand or wheither that would be something that we would used in Kira's case. So her first impression was to tell me I should feel comfortable about it before starting it and to just wait until I can talk to Dr. Chung. But when I told her that Dr. Chung had told me that the Trilostane was more important then the bp meds, she started telling me differantly. Now she says I shouldnt be too worried about staring it, but to watch for the side effects and if i see that to stop the meds and call. Well it's rather hard to stop the meds if they were just recently swallowed! I told her that it was a liquid and she seemed to be a bit more confused about what's going on with Kira. She didn't have time to study the chart I'm sure. It's 11am and no doubt she's the only doctor working tonight.

Any comments ?

It's thanksgiving I know. Maybe I should just consentrate on Mira today. I'm not going anywhere. Mira doesn't seem well at all. I don't know if I have her too drugged up or if she's really going down. Or am I just panicing again. Anyway I'll keep watch incase someone happens by today.

[AlisonandMia]

The problem with stopping the meds is not as hard as it would seem. Usually it is pretty clear that you shouldn't give the med and the golden rule with Cushing's meds is "if in doubt, hold the dose". The consequences of missing a dose unnecessarily are always less, much less, than the consequences of giving a dose you shouldn't have given.

This is one really good reason for starting the trilostane with once daily dosing - it is much easier to see what is causing what and stop dosing if necessary. With twice daily dosing there is a degree of overlap between the two doses with subsequent doses being given on the "tail" of the previous dose and this can make things less clear as to how the dog reacts to the drug.

How much she will end up needing is anyone's guess - each dog is an individual and, from what I've seen here, each adrenal tumor is an individual too. This is the reason for "starting low and going slow".

Maybe you could say to the treating vet that you are hanging by your last nerve at the moment and that you really couldn't handle having Kira getting sick from too much trilostane and so would it be ok to start out with once-a-day dosing before moving to twice-a-day if it seems necessary?

We have one other dog here (Corky - cute little Boston) with an adrenal tumor who is being treated medically with trilostane and I believe his specialist started him on once-a-day dosing and then moved him to twice-a-day as symptoms rebounded later in the day. They started conservatively and he has done really well to date. Here is a link to his thread: http://www.k9cushings.com/forum/showthread.php?t=392

The rationale for twice daily dosing is that trilostane's cortisol-lowering effect only lasts for 8 - 12 hours which theoretically means that dosing at least twice a day would be optimum. But as with lots of things the theory doesn't necessarily reflect reality and a big proportion of dogs to very well on once-a-dosing - which is what the manufacturer of Vetoryl (brand-name trilostane) recommends at the outset.

Alison

PS: I've taken the liberty of editing the title of this thread to mention treatment with trilostane.

[labblab]

60 CP TRILOSTANE 80MG/ML SUSP CPCRX
Give 1mg by mouth two times daily

Kira weighs about 74 pounds probably more than that with all the treats flouting around here with sick Mira.
Hi Janis,

I am familiar with trilostane, and am glad for all the helpful advice you've already gotten. It is more common to give trilostane in the form of tablets or capsules. We've usually seen liquid trilostane given to little dogs who require doses that are too small to be purchased in "solid" form. However, I suppose that another advantage to the liquid is that dosing changes can be made more easily. So perhaps that's why Kira has been give the liquid.

I am confused by the instruction on the bottle, though. I am guessing that the "1 mg. by mouth" must be a misprint, and that it should instead read "1 ml. by mouth?" I would double-check that dosing instruction, because it is true that 160 mg. a day is a very large dose -- much larger than is recommended by the manufacturer. Dechra (the manufacturer) is currently verbally recommending that dogs be started on 1 mg. per pound per day. So as Alison has said, it would make more sense to us if you were to be giving Kira only 1 ml. (80 mg.) once a day rather than twice.

If you do switch to once daily dosing, you should give the trilostane in the morning rather than the evening. This is so that monitoring ACTH tests can be performed 4-6 hours after dosing. The first test should be scheduled in approx. two weeks. So there is not an immediate rush about this, but again -- something you'll want to clarify with the vet.

Since ACC is open 24/7, I'm not as concerned about them not giving you prednisone. If Kira were to look seriously sick (really lethargic, vomiting, diarrhea), it would probably be best for you to take her in to be seen by them immediately, anyway.

The one "wild card" for all of us is whether or not they are seriously considering recommending surgery. Because if so, they may be following a different dosing protocol from the one with which we are familiar. They may want to try to really aggressively lower Kira's cortisol in a very short time. But this is definitely something that should have been discussed with you, including careful warnings about what to watch out for in the event that the medication dosage does turn out to be way too high.

So given the fact that this is a long holiday weekend and you've already got so much on your plate with Mira, I endorse Alison's suggestion that you talk with them about temporarily cutting Kira's dosage back to one 80 mg. dose a day (given in the mornings). Also, trilostane should always be given along with food since it helps the body to metabolize the drug more efficiently.

You've probably already seen this link, but I'll give it you once again just for reference purposes. It is a link to Dechra's U.S. Product Insert for Vetoryl:

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

Marianne

[Altira]

Thank you!!!! I'm going to go study this.

[Squirt's Mom]

Hi Janis,

Just wanted to say what a good job you are doing with Kira. Keep asking those questions of us and your vets, and I am sure things will start to become easier and clearer as your understanding grows.

Hugs,
Leslie and the girls - always

[Altira]

CUSHINGS CONSOLATION REPORT

Below this a shortened version (using my own words) of the conversation I had with the Cushings lady. You might remember the one test got messed up and we had to go back the next day. At that time she said one of the tests had come back. That's when she gave me the script for the bp meds and told me that a compounding company would be calling me about the trilastine. She said regardless of weither we do the surgery or not, we need to get Kira started on it. She said the trilastane was more important then the bp meds. That was it! Nothing more was said about the triastane. The place was a mad house. A shortage of staff or something. *There was no charge for this visit because it was their error. So I didn't get any paperwork at all. I guess I should be asking for the test result that she said came back. Come to think of it I might find the explanation I'm looking for in their file and just wasn't given to me. I will call and find out.*


(I emailed a copy of the actual recording to the forum. Below is just notes at best.)

*****Need to check urine to make sure infection didn't come back. Asked if she'd had lots of cronic infections. And what type. Explains the causes of Cushings and what happens. Skin infections. The ultrasound showed a plump left gland. Question is is it a cortasol creating tumor. Need to get her blood pressure and a ATCH level test. Would do that today. If it is a tumor regardless of the type one option is to remove it. Need more screening before surgery. To see if there is any evasion. That helps the surgeon. Do a CT scan which is more sensitive then the ultrasound. If surgery is not an option we can try medical management. She would recommend doing the surgery if it is the cortasol type. We can try other drugs but sometimes there is none. ??? She would do the surgery if it were her dog and I noted that dr deihl said she would not. (if you haven't read my notes on what Dr Deihl said you might want to. Her assessment was quite differant. She also mentioned cancer.) Wish I had remembered why dr deihl said that at the time. There are risks. Bleeding and blood clots. Normally if one gland produces too much the other shuts down. Sometimes we need to use steroids for awhile. Medical management does work is some animals. Some need higher doses. We would use trilastine. It hasn't been proven that she has Cushings. Left gland is really big with some arcatexture. The right is normal size. It looks like a tumor but we aren't sure. It appears to be three times the size of the other. Normally Cushings effects both sides. She advises the two tests be done. I tell her I want to know for sure as soon as possible. ****

You must remember during our conversation my little Mira was in the next room getting the once over. Her gums had turned pailish! We had also heard a women having her dog put to sleep in the next room. I was upset and didn't ask hardly any questions I had.*

I did email her later and asked a few questions. And I told her about you guys and how I ended up there. I told her I would be conferring with you all on this. But I never heard back from her. I think they only work like three days a week. But those can easily be like eighteen hour days! Which makes sence if you have an emergency you don't pack up and go home in the middle of it!

[Squirt's Mom]

Hi Janis,

With adrenal tumors in Cushing's, we often see one adrenal gland much larger than the other, and sometimes one gland will be atrophied, or shriveled up. With the pituitary form, it is common to see both glands enlarged, but this also happens with adrenal form at times, too.

There are also adrenal tumors that are not associated with Cushing's but I am not very familiar with these. Blood and chemical assays along with ultrasounds, CTs and/or MRIs can tell more about what type of tumor is present, what all is involved with the tumor like major veins, and whether it can be removed or not.

By "cortisol type" of tumor, I am sure your vet was meaning the ones associated with Cushing's. If I understand this correctly, different type adrenal tumors produce or cause the release of different hormones, enzymes and other chemical responses that the assays will help pinpoint.

The Trilostane will help with the tumors associated with Cushing's but surgery, when possible, is usually the best bet for the adrenal form as it can effect a cure. Once the tumor and gland are removed, the Cushing's disappears. This is not always the case, but it is what is usually expected after surgical removal. Until it can be determined if Kira is a candidate for surgery, the Trilo will help disrupt the signals to her adrenals that tell it to release cortisol giving her some relief from the signs and helping stop the damage caused by the cortisol.

HOWEVER, until that dose is figured out and making sure she should have it twice a day VS once, your vet gives you some prednisone, and you are comfortable with her treatment protocol, I wouldn't rush giving her the Trilo...but that is me. Waiting a day or two to talk in more depth with the vet shouldn't hurt. It is very important for Kira that you understand the treatment, what to look for in case of an overdose, how to handle a possible overdose, and that you be as comfortable as possible with her treatment plan.

I have all the faith in the world in your ability to do this, Janis. It is scary and confusing and frustrating, I know, but you are stronger than you think and, once you are going on Kira's treatment, you will do just fine.

Hugs,
Leslie and the girls - always

[frijole]

Have you not had the acth test that she mentioned and the BP check? Also can you please explain who this lady was vs Dr Diehl? I'm getting confused between the two dog's cases and want to make sure I know who is who.

Without having measured the cortisol I am wondering why they wanted to rush the trilostane. Is this vet clinic the one with the internal med specialists (vs a regular vet)? If my dog had adrenal tumor I would want a specialist on the case. Comments like "not worth treating" tend to come from those who have little experience in treating the disease.

Do not let a busy office environment keep you from having the quality time conversing with the vet. You are paying them to help you and they need to take time in a quiet environment where you can think and ask questions. They also must give you copies of all tests if you ask for them and you WILL ;):D always ask for them from here on out.

When things are rushed, mistakes happen and I just want to make sure everything is being done right.

I would make sure there is an acth test done to see where the cortisol levels are. I would call them and ask WTH is up with that dosage. Surely it is meant to be once daily.

Make someone go and look and check. That someone needs to be a vet! It is OK to question this. Too much trilo could harm Kira and you do not need that right now.

Ask them what their thoughts are relative to surgery based upon the ultrasound.

You need a long term plan for treatment that you understand. As always we are here to help. Hope you had a good day. Kim

[Altira]

Have you not had the acth test that she mentioned and the BP check?

Bp was done, acth test results won't be in for a week.

Also can you please explain who this lady was vs Dr Diehl?

Dr Chung is there cushings person as ACC, Dr Diehl is the one that did the ultrasound and xrays and was the first to brake the news to me. She that that for Mira too. She had to tell me Mira has stage 4 lung and liver cancer.

I'm getting confused between the two dog's cases and want to make sure I know who is who.

Without having measured the cortisol I am wondering why they wanted to rush the trilostane. Is this vet clinic the one with the internal med specialists (vs a regular vet)? If my dog had adrenal tumor I would want a specialist on the case. Comments like "not worth treating" tend to come from those who have little experience in treating the disease.

Do not let a busy office environment keep you from having the quality time conversing with the vet.

It's not that they didn't give me the chance. My mind has a bad habit of going blank and I hadn't gone prepared. We just jumped in the car and went when they said they needed a new sample.

You are paying them to help you and they need to take time in a quiet environment where you can think and ask questions. They also must give you copies of all tests if you ask for them and you WILL ;):D always ask for them from here on out.

They do, I just forgot to ask. Hell I almost walked out the door without Kira! I can call and they will fax to me no problem.

When things are rushed, mistakes happen and I just want to make sure everything is being done right.

I would make sure there is an acth test done to see where the cortisol levels are. I would call them and ask WTH is up with that dosage. Surely it is meant to be once daily.

I'm currently writting a long letter to Dr. Chung (I write much better then I talk) she is due in in the morning. I'm sure she'll call after reading it.

Make someone go and look and check. That someone needs to be a vet! It is OK to question this. Too much trilo could harm Kira and you do not need that right now.

Ask them what their thoughts are relative to surgery based upon the ultrasound.

I think she explained that in the conseltation.

You need a long term plan for treatment that you understand. As always we are here to help. Hope you had a good day. Kim

See above in bold text

[Altira]

QUESTION!

When you first start giving cushing meds to they seem better right away? Worse? Does it take a long time to show any effect?
I suspect I'll be starting Kira's meds very soon this morning. Her doctor should call soon. If not I'll call her. I want Kira to feel better and not be so hungry all the time. Course that's the highlight of her day too. Eating. Maybe I don't want to loose that.

Will it give her more energy? Or less?

She's whinning behind me now. Not sure whats wrong. Kira is a talker. But only talks when SHE wants to.

[Squirt's Mom]

Hi Janis,

Trilostane is known for lowering the cortisol rather rapidly in most pups so it isn't uncommon to see some improvement fairly soon after starting treatment. Some issues, like the coat and muscle wasting, take a bit longer to resolve.

Please don't rush into treatment...

1) WAIT for those ACTH results to come in and be read by your vets, and posted here for us to read

2) Make ab-so-lutely sure the Trilo dosage and schedule for dosing is correct.

3) Make sure you have prednisone at home, especially if this big dose is what they want her to start on

4) Make sure you have detailed info on what to look for in case of an overdose and what to do if that happens

Excess hunger is something that can be lived with until you have all of these things under your belt. I know you want to help Kira feel better as soon as you can but rushing into treatment can be dangerous, much more dangerous than waiting and letting the Cushing's continue unchecked for a bit. These are very powerful drugs that are used to treat Cushing's and should not be used lightly.

Have you gotten the answers from Dr. Chung you were writing her about? If she is the one you are waiting to hear from, then before she calls, print out your questions and take the time to write her answers down while ya'll talk. That way you can be clear on what she is saying (even if you don't understand what she means, write it down and we will help), and have the answers there to refer back to without having to rely on memory.

Do you know if they are treating Kira while waiting to do the surgery, or have they decided she isn't a candidate and will treat instead of surgery? To repeat Marianne's comment:


The one "wild card" for all of us is whether or not they are seriously considering recommending surgery. Because if so, they may be following a different dosing protocol from the one with which we are familiar. They may want to try to really aggressively lower Kira's cortisol in a very short time. But this is definitely something that should have been discussed with you, including careful warnings about what to watch out for in the event that the medication dosage does turn out to be way too high.

Looking forward to hearing what Dr. Chung has to say and what the plan is.

Hugs,
Leslie and the girls - always

PS. Again, pleasepleaseplease don't rush into treatment.

[Altira]

Trash this one please ....I don't know how to cancel I want to quote instead

[Altira]

Hi Janis,

Trilostane is known for lowering the cortisol rather rapidly in most pups so it isn't uncommon to see some improvement fairly soon after starting treatment. Some issues, like the coat and muscle wasting, take a bit longer to resolve.

Please don't rush into treatment...

1) WAIT for those ACTH results to come in and be read by your vets, and posted here for us to read

2) Make ab-so-lutely sure the Trilo dosage and schedule for dosing is correct.

3) Make sure you have prednisone at home, especially if this big dose is what they want her to start on

4) Make sure you have detailed info on what to look for in case of an overdose and what to do if that happens

Excess hunger is something that can be lived with until you have all of these things under your belt. I know you want to help Kira feel better as soon as you can but rushing into treatment can be dangerous, much more dangerous than waiting and letting the Cushing's continue unchecked for a bit. These are very powerful drugs that are used to treat Cushing's and should not be used lightly.

Have you gotten the answers from Dr. Chung you were writing her about? If she is the one you are waiting to hear from, then before she calls, print out your questions and take the time to write her answers down while ya'll talk. That way you can be clear on what she is saying (even if you don't understand what she means, write it down and we will help), and have the answers there to refer back to without having to rely on memory.

IM GOING TO RECORD IT. IM DESLEXIC, I CAN'T WRITE AT ALL UNDER PRESSURE. CANT THINK. CANT SPELL. CANT REMEMBER.

Do you know if they are treating Kira while waiting to do the surgery,

YES THAT IS WHAT WE ARE CURRENTLY DOING

or have they decided she isn't a candidate and will treat instead of surgery?

IT IS NOT FOR CERTAIN YET

To repeat Marianne's comment:



Looking forward to hearing what Dr. Chung has to say and what the plan is.

Hugs,
Leslie and the girls - always

PS. Again, pleasepleaseplease don't rush into treatment.

please see notes in CAPS above. I'm with you on all things. All things on my list. Except I'm not wanting to wait. Please if you can stand by. If she doesn't call soon I will call her.

[frijole]

Janis - Your vet might be doing something different because it is adrenal cushings but I have been here for 4 yrs and that is ONE HIGH DOSAGE. Please read the links we provided on trilostane. Dogs can become very very ill if they get too much. You do not need that. We just want to be sure. No disrepect to your vet. Mistakes on labels happen often. Maybe they haven't used trilo much. Trust me, we have seen too many dogs here overdose due to vets who thought trilo was safe. And I agree with Leslie - make them give you prednisone. Emergencies only happen in the middle of the night or weekends and you need it just in case ---- especially on that dose.

Not trying to scare you but want you to totally understand that this drug is fantastic when used right but can be harmful if not. Thanks!!!!! Kim

[Altira]

The label says 1ml twice a day

I wrote that wrong earlier.

Is that better or what you aleady believed it to be?

I have prednisone on hand for Mira. 20 mg

[Altira]

Ok I have talked to Dr Chung Kira's Cushings doctor. She asured me that it will be ok. A ton of stuff was said (most of it over my muttled head) it would take me half the day to relay it all you. So I'm going to email my recording to you in a moment. I think you have access to that Leslie maybe you could listen to it? And relay your thoughts here? I know your having a hard time too. I understand if your busy. I need to go get meds for Mira. And I hope to have some approval on starting Kiras meds today. Thanks so much! Truly

[Altira]

I asked Dr. Chung for written instructions. This is what she just emailed to me:

Hi Janis -
Regarding medical managment for Cushing's disease using Trilostane;
Trilostane is an enzyme inhibitor. It is used to reduce the production of cortisol within the body. Unlike Lysodren, which is an adrenolytic drug, there is no destruction of adrenal gland tissue. Side effects of Trilostane include: lethargy, inappetane, vomiting, diarrhea and electrolyte abnormalities is cortisol and aldosterone levels are oversuppressed. There are a few documented cases of complete suppression of the hormones cortisol and cholesterol leading to hypoadrenocorticism(Addison's disease). There is a very large range of dosing for Trilostane. We usually start on the lower end and dose upward as needed. Monitoring of cortisol levels via ACTH stimulation tests and electrolyte levels are done weekly until adequate cortisol levels are acheived and then monthly to every 3 - 4 months.

Once you start giving Kira the Trilostane you will need to monitor her closely for any signs of lethargy, weakness, inappetance, vomiting or diarrhea. If any of these changes occur please stop the medication and call ACCIM. Trilostane should be given with food or on a full stomach. The drug is given once to twice per day. In Kira's case we have started twice per day because adrenal tumors produce higher levels of cortisol in the body and most often require higher doses of Trilostane. Kira should return to ACCIM approximately 1 week after starting Trilostane. An ACTH stimulation test and electrolyte levels will be performed 4 - 6 hours after she gets her AM dose of Trilostane. This test will be done weekly until her cortisol levels are in a range between 2 - 5micrograms/dL. After that we will recheck bloodwork in 1 month and then every 3 - 4 months.

Trilostane is available in 60mg and 120mg capsules. The drug can be compounded into a liquid and a capsule form. I usually use liquid to start because it is easier and cheaper to adjust. If liquid is too difficult to give we can definately get it made into capsule form.

Please feel free to email me at any time with any further questions or concerns. I check my email all the time and can be available for you.
Kerrie

[labblab]

Hi Janis,

For the most part, what your vet has written does correspond with the recommendations with which I am familiar. There are a couple of differences. By asking you to bring Kira in for weekly ACTH/electrolyte checks, she is recommending more frequent testing and dosing changes than does Dechra (whose published recommendation is for testing at the 10-14 day mark after any dosing change). Also, the starting dose of 80 mg. twice daily represents approx. 2 mg./lb, which does fall within the middle of Dechra's published initial dosing range (1-3 mg./lb). But as I wrote to you earlier, the technical representatives at Dechra are now verbally recommending that dogs be started at the very lowest end of the range -- at 1 mg./lb. Also, if dogs are shifted to twice-daily dosing, Dechra's recommendation is not to double the recommended once-daily dose, but instead to increase the daily total by only a small amount and then split that it half.

Having said that, though, it does sound as though Dr. Chung is advocating for a higher dose due to the fact that Kira's Cushing's is adrenal-based rather than pituitary-based. And since the vast majority of our members who use trilostane have dogs with pituitary Cushing's, I really don't have the experience to tell you whether the dose she is prescribing for Kira is unusually high for an "adrenal" dog.

I am very relieved, however, that she seems to be so open to your questions and so available to you. I'm also glad to know that ACC is open 24/7 with emergency services. So if you do feel as though Kira is having any problems with the medication, you can take her in to be seen immediately at any time. I know you will watch her like a hawk. Hopefully you will only see good changes after starting the medication (my own Cushpup cut back on his thirst and appetite within two days after beginning trilostane). But if not, do not hesitate to withhold the medication and contact Dr. Chung immediately for additional guidance.

Marianne

[Altira]

Thank you so much Marianne! Did you listen to the recording or just desifer all that from dr chungs email above? You certainly understood it better then me.

I'm going to make simplified notes for myself first, make sure I get it right. And probably one last conformation from Chung before I start.

I do want to mention that I read somewhere were it said that they are finding less problems with side effects when using two doses a day. I should have a link to that page somewhere.

I asked her what I should do if Kira spits some out and she said not to worry about it. Ha ha I'll worry about it every step of the way.

I wonder how long it takes for side effects to start. Or a bad reaction? With most meds I would say about an hour but I don't know with this stuff. I suppose it could take as long as a couple days or longer to show up.

Gosh wish us luck.

I should also mention that my Kira is a pretty strong girl. She isn't effected by very much. But then again possibly this treatment may change a lot of things. Chung said we may discover things we didn't know she had cus it could have been masked by the Cushings.

I wonder do the dogs personality change?

[Altira]

T-30 minutes (aprox) and counting to Trilostane. That means 6pm tonight. Everyday 6pm and 6am. Husband says to do it. Give with food or right after eating. All will be well... it has to be.

[missbeagle]

Janis -

Fingers and paws crossed here. :)

Gretchen and Rusty in NC

[Altira]

So far Kira seems fine. Except for moms crying. Mira I'm not so sure.

[frijole]

Hang in there Janis. Keep the faith and stay strong for your girls. Hug them lots - sending strength and love, Kim

PS Keep us posted and any questions - ASK!!!

[Altira]

My 7 year old Mira is gone. No more Kira and Mira.

Kira has had two doses so far. She seems unaffected. Either way. Her eyes are still sqinty. She just lies here beside me

[Squirt's Mom]

Hi sweetie,

Kira may well be depressed after losing Mira plus she will pick up on your sadness during these days to come. Just love her as you always do and she will adjust.

I'm glad you aren't seeing adverse effects from the Trilo and hope you don't!

Keep in touch and let us know how things are going with Kira.

Hugs,
Leslie and the girls - always

[Altira]

Kira seems very bad today. I don't know what it is. It could be any number of things. They advised me to stop the meds. I'm a basket case. I'm terrified I'm lossing her. I'm so bad at this.

Has anyone else had any side effects from trilo? What are the normal changes and when did they happen?

No one is telling me what to expect in a normal reaction to this. They said she might show signs of problems that have been masked fromthe over production of cortasal. Her legs seem week or like they hurt her. Is there past threads that might relate to us?

[Roxee's Dad]

Hi Janis,
Is Kira eating? How's her poop? Is she drinking any water?

[Roxee's Dad]

Has anyone else had any side effects from trilo? What are the normal changes and when did they happen?

Normal changes you may see, drinking less water...Not stopped completely though, May take her time eating rather than wolfing it down.

Could happen within 3 to 5 days but may take a bit longer. Not to say it couldn't happen within a day or 2.

[frijole]

Janis - first, off please be sure to answer Johns' questions as they are important. As you know, the dosage you are on is high. I'm glad your vet told you to stop. How many days/doses have you given so far? 2 days? Please tell us exactly what you are seeing with Kira.

So long as you stop the trilo you should be fine. That is why you have the prednisone - in case of emergency.

The leg thing could be that the dosage is too high, it could be that the dosage is working. Cortisol in the body masks pain from arthritis and other issues - like a natural pain pill made by the body. Its just that the adrenal tumor is shooting off too much of it. So you use the trilo to reduce that amount. When you do this, if Kira had arthritis issues they might now show up.

Since you are using the liquid form it would be easy for your vet to have you reduce the dosage and try starting low and easing your way up.

You never did get the acth test results did you? I think you said it took a week. I wish we had the number because that would tell us what your starting point (cortisol level) is.

Kim

[littleone1]

Hi Janis,

Check Corky's thread, which Alison gave you a link to, as Corky has an adrenal tumor and is being treated with Trilo. After his second dose of Trlo, he seemed to be lethargic, but that was due to the cortisol level being lowered. I equate it to someone coming down off of a high. The next morning he was fine and hasn't had any problems since. Some of his symptoms started to be resolved within a couple of days. Others do take longer. Corky was started at 1mg per pound.

Terri

[frijole]

Has anyone else had any side effects from trilo?
Yes and that is why we have been asking questions including whether or not you were given prednisone, your dog's weight etc. The good news is that once you stop giving it you should see her bounce back fast because the cortisol is being produced. If not, you give the prednisone.



What are the normal changes and when did they happen?
Sorry but there is no normal with cushings - it depends on the type of cushings, the size of the dog, the age and the dog itself. You should see improvements fairly quickly. Again - because your dog has adrenal cushings (which is less common) it could take longer to see changes. This is why they went with a higher dosage.


No one is telling me what to expect in a normal reaction to this. They said she might show signs of problems that have been masked fromthe over production of cortasal. Her legs seem week or like they hurt her. Is there past threads that might relate to us?As I mentioned, the leg issues could be caused by arthritis. Please tell me what you mean by her legs might be hurting her? Describe what is happening please. Thanks. Kim

[frijole]

Here is a link to Corky's thread. He too has an adrenal tumor and is using trilostane.

http://www.k9cushings.com/forum/showthread.php?t=392

[Altira]

Hi Janis,
Is Kira eating? How's her poop? Is she drinking any water?

Still eating TONS if I let her. Poop is totaly normal. She poops three and four times a day. We go for a walk for fortfive minutes and she poops twice! Come to think of it maybe it's only been twice today. Now drinking water has change drastically so much so I'm not sure she drank anything at all.

[Roxee's Dad]

Janis,

In what way does she seem bad???

[frijole]

Still eating TONS if I let her. Poop is totaly normal. She poops three and four times a day. We go for a walk for fortfive minutes and she poops twice! Come to think of it maybe it's only been twice today. Now drinking water has change drastically so much so I'm not sure she drank anything at all.

Monitoring food and water consumption is very important because a reduction in either (not both) is a sign that the drug is working. If the reduction is that drastic then you need to communicate this to your vet when you speak next - even if you weren't instructed to.

A drastic reduction in water and the legs could be signs that the dosage is too high.

Vomit or diarrhea is a sign of overdose or too high of a dose. You monitor poop to make sure it doesn't get runny...as that is a sign as well.

[Altira]

Here is a link to Corky's thread. He too has an adrenal tumor and is using trilostane.

http://www.k9cushings.com/forum/showthread.php?t=392

My god that gets way too technical for my pea brain. Talk about level headed. You all could easily be vets your self. I get so horrible emotional over it. All those illness and keeps on living. Makes me want to move to phenix. Maybe in time I'll learn this stuff. Or maybe I'll get lucky and Kira will convince me that she can do the surgery and save us all the greif you all live though. It's all toomuch for me right now. All I can see is Kira falling apart just like Mira and me falling right with her. I'm just not cut out for this, im going to fail her and hate myself for it forever. I almost gave Kira another dose of trilo six hours too soon. I was so used to giving Mira meds at noon I just started to do the same with Kira. Ok I'll give her her meds then well go for a walk. Thank god it dawned on me that that was wrong. I'm DESLEXIC I confuse easily. And even worse right now. I try so hard and still get it wrong. I'm the worst possible person to deal with this.

I failed Mira. I didn't know what to give her. Had I known what I was doing she would likely still be here. I'm so sorry little Mira. I tried so hard I agonized over what pills to give her. Id stand there forever trying to deside. What she needed when. I almost never got it right. I'm so sorry little Mira. My little 7 year old girl was being eaten alive by cancer. And they left it in my hands to keep her confortable. I failed her over and over. It's the crewest thing I've ever known.

[missbeagle]

Janis -

No honey, you did not fail Mira. You did everything in your power; you took her to the vet, you sought out help, you even found us. :D

It was the cancer that took her. YOU DID NOT FAIL HER! She left on her own terms and that wasn't something that you did. Her body wore out from the cancer, pure and simple. Just like people do.

She had seven wonderful years with her wonderful family and Kira. Your time with her was short and you will miss her for a long time.

I would keep looking for the dogs in the fog..........

Maybe you can write out a checklist for Kira's meds? So you know what time she got what. You are under a lot of stress right now and you need to take care of yourself.

Blessings and hugs to you tonight. All the way from North Carolina.

Gretchen and Rusty

[Roxee's Dad]

Hi Janis,

First, you did not fail Mira, you loved her and there was nothing you could really do about the cancer....Mira knew that you loved her right up to the end. I know it's hard to not blame yourself and see through the pain.

Now for Kira, we need to take care of Kira, I would start off with a chalk board or a white board, hang it on the wall in the kitchen and write down what time she should get her meds.

After you restart the trilostane.

Measure her water in the morning and at the end of the day or in the morning, pour the water back into the measuring cup. In Kira's case you may need a larger measuring cup. It will be very easy to see how much she drank. Write it down on the chalk board every day and in a few days you may see a trend of her drinking less.

Keep an eye out for any vomiting or diarrhea. Rule of thumb is to stop the trilo if any vomiting or diarrhea and call the vet for an ACTH and electrolyte check.

and please keep us posted :o

[Altira]

And what of the weekness? She gets up with great difficulty walks two steps and lays down again. Before you know it she's sleeping again. She snores even when she's awake. Is she having trouble breathing? I'm I to ignore all that? Just like with Mira I look at her and feel something is very wrong. Maybe I should take her que and just go to sleep.

[Roxee's Dad]

Hi Janis,

Is she off the trilo?? When did the weakness start or did it come on gradually??

It could be arthritis, it may be the effects of her cortisol running high for quite a while causing some muscle wasting. Until the ACTH results are in, we don't really know or really can't speculate on her rear end weakness.

She still has her appetite and her poop looks normal. Probably a very good idea for both of you to get some healing sleep. Sleep is a way of healing and rejuvenating.

[Altira]

Hi Janis,

Is she off the trilo?
YES

When did the weakness start or did it come on gradually??
IT SEEMS LIKE TODAY. BUT SHE'S BEEN HAVING TROUBLE GETTING UP FOR A LONG TIME. SINCE HER FIRST TTA SURGURY IN 2008.

It could be arthritis, it may be the effects of her cortisol running high for quite a while causing some muscle wasting.

MUSCLE WASTING KEEPS STICKING IN MY MIND. WHEN SHE HAD HER LAST TTA SURGERY THEY SHAVED HER WHOLE LEG AND WAY OVER HER BACK. I WAS STUND TO SEE THE DIFFERANCE FROM HOW SHE WAS TWO YEARS EARILER WHEN THEY DID THE OTHER LEG. THIS TIME SHE LOOKED LIKE SKIN AND BONES. EVEN WITH ALL THE WALKING WE DO SHE NEVER SEEMS TO GET ANY STRONGER. STILL SKIN AND BONES. HER REAR END BONES STICK OUT AT LEAST AN INCH. OTHER THINGS I DIDN'T MENTION. I THOUGHT HE BACK WAS ALWAYS STRAIGHT BUT IN THE LAST FEW YEARS THERE SEEMS TO BE A HUMP IN HER BACK ABOUT WHERE HER KIDNEYS MIGHT BE. I PET HER ALONG HER BACK AND THERE IS A HUMP THERE. AND ALSO FOR MANY MANY YEARS SOMETIME WHEN SHE BURPS THERE IS THIS REALLY STRONG SMELL. SORT OF LIKE VINIGAR. ITS REALLY STRONG. IM TOO SCARED TO MENTION THEM CUS THEY SEEM REALLY BAD. I JUST EXPECT THE VET TO FIGURE IT OUT. IF THEY DON'T SEE IT THEN IT MUST BE OK. IM SO STUPID. I FAIL THEM ALL THE TIME. BUT THE WORDS JUST WON'T COME OUT OF MY MOUTH. THEN THEY WILL FIND SOMETHING HORRIBLE AND IT WILL BE ALL OVER.
Until the ACTH results are in, we don't really know or really can't speculate on her rear end weakness.

YOU MEAN IT WILL TELL US THAT MUCH? THAT SHOULD HAVE GONE OUT ON THE 20th I THINK.

She still has her appetite and her poop looks normal. Probably a very good idea for both of you to get some healing sleep. Sleep is a way of healing and rejuvenating.

WELL KIRA HAS BEEN DOING PLENTY OF THAT. BUT I CAN'T. SHE LOOKS SO UNWELL.

TRILOSTANE WILL HELP WITH MUSLE WASTING?

IT WAS PROBABLY WRONG TO TAKE HER OFF IT. SHE HAD NONE OF THE BAD SIDE EFFECTS ALL THE REST COULD HAVEBEEN PREEXISTING. OR ARTHRITAS BEEN UNMASKED. (Sorry all these words I can't spell. I do all this from my iPhone. I cant see much of the screen, just three lines)

See caps above

[Altira]

Maybe it's Mira? Maybe she just figured out Mira isn't ever coming home? I just offered her peanut butter she wouldn't get up to get it. But she licked it when I held it for her. She's eating it on her own now. Certainly not with her normal gusto. It's been 18 hours since her last Trilostane dose. It could be that. My gosh Mira would always lick paws like crazy when eating peanut butter. I just saw Kira do that. I don't recall Kira ever do that. But I haven't been watching Kira over these past two peanut butter filled weeks. She just got to her feet with great difficulty in her rear legs. They looked all stiff then she laid down again. Now she's up and moved to the doggie pillows were I just was. I can't BELIEVE she didn't go get a drink!!! I don't think she has drank any water today. That would be bad wouldn't it? She has her back to me. No pep at all. What is it? Mira is gone? Or the Trilostane? Or the Cushings? Or arthritis? Moms upset but not crying right now? Well one thing is for certain the peanut butter is gone. At least we have that.

If I had to gage her quality of life right now I'd have to say it's very poor. I wish she would look at me. I think I'll try to pet her. She likes that.

[Altira]

Normal changes you may see, drinking less water...Not stopped completely though, May take her time eating rather than wolfing it down.

Could happen within 3 to 5 days but may take a bit longer. Not to say it couldn't happen within a day or 2.

Sorry I missed this one! Thank you that tells me a lot!!! Sometimes you have to bet me over my whimpering head to get my attention.

[labblab]

Janis, if and when you get the OK from the vets to restart the trilostane, I'd suggest you ask them if you can cut back to just the single morning dose of 1 ml. (80 mg.) until you perform the first ACTH monitoring test. I think Dr. Chung wanted to have that test done after about a week of treatment. With all you have going on right now, it would be so much simpler if you only had to dose Kira once in the morning. Plus, that would give her body a chance to adjust to the lowering cortisol more gradually. After that first ACTH monitoring test, you can always increase to the twice daily dose if it looks as though Kira would benefit from more medication. But once-daily dosing sure might ease things for you during these next few days...

Marianne

[frijole]

Janis, I agree with Marianne. You have alot going on and your vet surely knows this too. Kira will be just fine. One day at a time - take lots of deep breaths and know we are here to help. No - we aren't vets but we have been thru this and helping others for a very long time. Feel free to scream, vent, rant here.... we need you strong for Kira right now because you are her voice. And you will do just fine. Kim

[Altira]

Janis, if and when you get the OK from the vets to restart the trilostane, I'd suggest you ask them if you can cut back to just the single morning dose of 1 ml. (80 mg.) until you perform the first ACTH monitoring test. I think Dr. Chung wanted to have that test done after about a week of treatment. With all you have going on right now, it would be so much simpler if you only had to dose Kira once in the morning. Plus, that would give her body a chance to adjust to the lowering cortisol more gradually. After that first ACTH monitoring test, you can always increase to the twice daily dose if it looks as though Kira would benefit from more medication. But once-daily dosing sure might ease things for you during these next few days...


O
Marianne

Ok... I'm so scared. Nobody mentioned tremors

[Altira]

I want to take her for a walk. I want her to be ok. Sad songs of loss full my head. I just want to go with her. The nightmare lives on even as I wake. This day will be no better. Will she collapse and dye today? I want to go too. We go for short walk.

[frijole]

Ok... I'm so scared. Nobody mentioned tremors

Janis, I know you are scared but please when you post be sure to give us enough information to help you. I assume (?) that Kira is trembling? If so please let us know if it is back legs (very common with cushings) or whole body. Please be a specific as possible as it helps us help you better.

Remember you have the prednisone on hand. If you get real scared phone the vet, describe the situation and probably you will give the prednisone. It mimics the cortisol that you lowered so within a few hours Kira would feel normal.

Kim

[labblab]

Ok... I'm so scared. Nobody mentioned tremors
Janis, is Kira having temors? If so, can you try to describe them for us? And when did they start?

Tremors can mean different things. But tremoring is listed as a possible side effect of trilostane. My own Cushpup started having tremors across his shoulders shortly after starting trilostane. They really scared me, but didn't seem to bother him. We were never certain whether they were caused by the medicine itself, or were instead an effect of the sudden lowering of his cortisol (he was originally put on a high dose twice-daily, too). The tremors stopped entirely several weeks after we started treatment. But tremoring can have other causes, too. So if Kira is having tremoring episodes now, it will help if you'll tell us more about them (and also be sure and mention this to the vet, too).

Marianne

[Altira]

This day just gets worse. I just wrote this long post explaining. And I lost the whole thing! That's the first time. God I'm such a mess. I don't know if I have the strength to rewrite it. My Mira!!!!! My Kira...

[Altira]

http://www.k9cushings.com/forum/picture.php?albumid=274&pictureid=2096

My Kira a few moments ago. I keep running into pictures of Mira. I'm howling agian. All morning

[Altira]

As you can see Kira is fine this morning. I'm not. I don't remeber what I wrote just 15 minutes ago. I woke up and hugged Kira and she burped that horrible smell. (Bud is mad at me i can't stop crying. He says get over it.)

We went for a walk around the block. Kira did good. Great for her really. She still speeded up and slowed down. She loves the cold. She was very alert.. Intently watching people and dogs. Mira was everywhere on these streets. I let her do anything she wanted and she wanted to pee on everything. I think Kira smells her. Kira picks up odd things since Mira's gone. Maybe they smell like Mira. I'm a sobing mess. She's not limping. She didn't want to go home. I should be happy. She went into the bedroom earlier where Mira always slept with me. And she looks either way. No Mira. But she doesn't seem sad.

Tremors; When I put Kira in the warm bath tub yesterday her hind legs started to shake. It scared me. Kira never shakes. I couldn't get her out of there fast enough. I didn't know about tremors. Oh my Mira!!!!!!!!! I can't remember the rest.

Kira is well this morning. She was talking to us this right after our short walk... She groaned "oh you just dont understand" then got in the pillow and went to sleep. She sleeps all the time. Is playfull only rarely and short lived. She's a darn good catch. I never taught Mira to catch and she always looked so sad when Kira did. But I THOUGHT we'd have plenty of time to teach Mira!!!! After Kira was gone. This was Kira's thing right now. I'm SO sorry Mira!!! Kira spends 70% of her life happily laying belly up. If you pet her she will scoot closer to you. Her belly is shaved from the ultrasound and the fur IS growing back there. Still nothing on her back though.

[Roxee's Dad]

Hi Janis, I just wanted to summarize Kira's history to date in one post for ease of reference.

Kira:
Siberian Husky
10.5 yrs

Posted 11/12/2010
Kira fits all the symptoms to the letter. She has for years. The desperation for food, drinking enormous amounts of water and peeing huge puddles. Lakes! The distended belly. She also said it explained the failure oh her knee legaments. And why the fur on her back never grew back after the last surgery. It's been seven months and still it looks like they shaved her yesterday. The other side done two years ago was slow to come in was back to normal in six months.
ALK - 354 (10-150) high
ALT - 117 (5-107) high
LIP - 1474 (100-750) high
CHOL - 378 (112-328) high
MCV - 59 (60-77) low
That is the initial blood work.
We have an ultrasound behind us too. I cant recall the specifics right now but there is a tumor.

11-13-10
is taking Baytril 60s for her infection


11/11/10
ALK - 386 (10-150) high
ALT - 178 (5-107) high
CK - 209 (10-200) high
CHOL - 402 (112-328) high

Ultra Sound:
She has a very small mass in one of her adrenal glands. Some dogs aren't effected by this. There is a mass off the back side of it. It can be cancer. It usually is cancer but it doesn't appear to be evading anything right now. They usually grow very slowly and could take a year to get twice this size. If it's producing ???? then you get the symptoms of Cushings. (Kira has all the symptoms) It can be removed but she needs to be tested. If it were her dog she would not remove it knowing it may never be a problem. It should be watched via ultrasound. If it changes then you remove it. It's not real bad but she would need treatment for it. And we could see the symptoms of cushings reversed including her fur growing back.

Other concerns:
(1)There is a heart murmur that on a scale of 1 to 6 in loudness its about a 2. One side maybe slightly enlarged. (she said a little more on that but I'll move on)

(2) The liver looks ok. There are no masses there. But it appears to be braking down. We may need to find out what is going on with that too.


Posted 11/20
Phenoxyhenzanine 10 mg they want her to take.

Posted 11/21
Pre Dexamethasone 5.1 1.0-6.0
Post 4 hour dex. 3.4 less then 1.5
Post 8 hour dex. 2.7 less then 1.5

Triostane 80mg is what they want to put her on right away with one blood result still pending

Her bp was 220. I have a script for the bp meds. Should I go get that right way? She said it wasn't as important as the above. She also said to watch for dizzyness or weekness and if so to discontinue it.

Posted 11/24
60 CP TRILOSTANE 80MG/ML SUSP CPCRX
Dose is 1mg twice a day (Corrected 11/26 : The label says 1ml twice a day)
Kira weighs about 74 pounds

Posted 11/25
Copy of the recording between Janis and Vet:
Need to check urine to make sure infection didn't come back. Asked if she'd had lots of cronic infections. And what type. Explains the causes of Cushings and what happens. Skin infections. The ultrasound showed a plump left gland. Question is is it a cortasol creating tumor. Need to get her blood pressure and a ATCH level test. Would do that today. If it is a tumor regardless of the type one option is to remove it. Need more screening before surgery. To see if there is any evasion. That helps the surgeon. Do a CT scan which is more sensitive then the ultrasound. If surgery is not an option we can try medical management. She would recommend doing the surgery if it is the cortasol type. We can try other drugs but sometimes there is none. ??? She would do the surgery if it were her dog and I noted that dr deihl said she would not. (if you haven't read my notes on what Dr Deihl said you might want to. Her assessment was quite differant. She also mentioned cancer.) Wish I had remembered why dr deihl said that at the time. There are risks. Bleeding and blood clots. Normally if one gland produces too much the other shuts down. Sometimes we need to use steroids for awhile. Medical management does work is some animals. Some need higher doses. We would use trilastine. It hasn't been proven that she has Cushings. Left gland is really big with some arcatexture. The right is normal size. It looks like a tumor but we aren't sure. It appears to be three times the size of the other. Normally Cushings effects both sides. She advises the two tests be done. I tell her I want to know for sure as soon as possible.

[Altira]

Email from dr Chung just now. I'm not sure I like this women. I'm I to restart the Trilostane or not? I know this is her day off but she could have at least made that clear. I'll write her again.
(God the wind is blowing here again. Is Mira flying furiously around trying to get my attention. My furry (anger) is no less then hers. )


Janis
I would expect that Kira will have a decrease in appetite and water intake. *These are all positive things. *If she stops eating, has any vomiting or diarrhea that would be cause for concern. *I'm not sure if her recent depression is due to the loss of Mira. *Sometimes when the cortisol levels decrease with Trilostane it can unmask other problems. *For example, you may notice that her arthritis worsens. *Let me know how she does and we can check her at the end of the week. *Kerrie

[Altira]

Thanks John you are a sweetheart.

Marriane. I wrote dr Chung back. I didn't ask about changing the dose but I asked her once what happens if Kira spits some out and she said not to worry about it. Also the syringe fills with air bubbles that has to decrease the dose. I think for the moment I'll leave it in gods hands and give it to her twice a day and let the actual dose be whatever fills the thing. And try not to panic. If she does it again I'll just stop again and trust all will be well in 24 hours. Then I'll try it your way. It's just that I read twice a day has less side effects. I'll have to find that thing.

I will start again at 6pm. I don't want to change that time and get confussed.

[Altira]

Reply from dr Chung

Yes, restart trilostane. Let me know I she seems painful I can rx some pain meds

[Squirt's Mom]

Hi Janis,

Honey, I think your twitcher is stuck wide open, making a difficult situation 10X worse. It is unbelievable that you have been dealt such a bad hand recently and I am so sorry you are having to face so much all at once. :(

You did everything you could for Mira, and now it's time to turn that energy toward Kira. There is nothing more you can do for Mira other than hold her memory close and honor her life, but Kira is still here and needs you desperately. And she needs you to be a strong as you can for her.

Take time to grieve for your sweet Mira but also make time to put that grief aside so you can tend to Kira's needs. Take some time just for yourself, away from the medicine bottles and schedules, away from Kira and Bud, away from the familiar. Let yourself just be free from everything for a little bit. Go have lunch and see a movie with a friend; take the credit card and go shopping; go to a museum; something you enjoy that isn't connected to your babies. It's alright to do this, Janis, you deserve a break. You have earned this....and Kira needs this. Kira needs you be centered and as calm as you can be, so take some time to help yourself heal just a tiny bit.

We are all here for you, honey, and will do all we can to help you and Kira.

Hugs,
Leslie and the girls - always

[Roxee's Dad]

Hi Janis,


I think for the moment I'll leave it in gods hands and give it to her twice a day and let the actual dose be whatever fills the thing.

Dosing is very important. Please understand that to make any adjustments to the dose will depend on what the previous dose was.

Kira will be going back to the vet for another ACTH test (soon) to see how the dose of Trilostane has affected her cortisol control. This is an important step in the overall treatment of cushing's.

If the vet finds that her cortisol is not under control, meaning it's still too high, she will most likely increase the dose.

Treating cushings has to be controlled.

The amount of the dose is very very important to relieve her symptoms but at the same time, not be overdosed.

[Altira]

Kira wants to walk we are going to walk I'll read your posts when we get back. In the mean time can you tell me....

Is Kira going to change?
The high light of her day was eating. Are those bright eyes going away?

Is this just a temporary thing?
Does she take trilostane this forever?
Will it be for just a period of time?
How long maybe?
Considering if we don't do surgery...

[labblab]

Janis, if you decide against surgery, then Kira will always continue to take the trilostane to control her Cushing's (unless she were to switch for some reason to the alternative medication, Lysodren). Her trilostane dose may change over time, but she will not ever stop taking the medicine.

Once she is stabilized on an effective dose, it should make her feel better. She should return to eating and drinking normally, instead of overdoing. Hopefully she will also have more energy, and regain some of the muscle mass that she has lost. There may be some trade-offs as Dr. Chung has mentioned: for example, arthitis may bother her more as her cortisol is lowered. But overall, there should be more "pluses" than "minuses" for your girl.

Marianne

[Altira]

Hi Janis,

Honey, I think your twitcher is stuck wide open, making a difficult situation 10X worse. It is unbelievable that you have been dealt such a bad hand recently and I am so sorry you are having to face so much all at once. :(

You did everything you could for Mira, and now it's time to turn that energy toward Kira. There is nothing more you can do for Mira other than hold her memory close and honor her life, but Kira is still here and needs you desperately. And she needs you to be a strong as you can for her.

Take time to grieve for your sweet Mira but also make time to put that grief aside so you can tend to Kira's needs. Take some time just for yourself, away from the medicine bottles and schedules, away from Kira and Bud, away from the familiar. Let yourself just be free from everything for a little bit. Go have lunch and see a movie with a friend; take the credit card and go shopping; go to a museum; something you enjoy that isn't connected to your babies. It's alright to do this, Janis, you deserve a break. You have earned this....and Kira needs this. Kira needs you be centered and as calm as you can be, so take some time to help yourself heal just a tiny bit.

We are all here for you, honey, and will do all we can to help you and Kira.

Hugs,
Leslie and the girls - always

I can't leave Kira alone. She's never been alone. That's why we keep two doggies. Me and her are going shopping for a chalk board. She loves to go and I love to take her. She's talking to me right now. How is sqruit? (sp? Sorry)

[Altira]

Thank you. It's not 100% what I wanted to hear but it answered a lot.

What about the fur on her back any chance that might grow back?

If we don't do surgery what are her prospects? How many years could she have?
At best maybe. Im sure that question depends on many things.

Weither we do surgery or not I want a CT Scan done to see if there is anything else we don't know about. Do you think that's a good thing to do or not?

[Altira]

Here is that link.. Don't know if I agree with it either but here is where I read about the twice a day dose thing.

http://www.vetinfo.com/dog-cushings-treatment-with-trilostane.html


Side-Effects of Trilostane

Because it is such a new drug, not all side-effects are known. They can include:

Mild lethargy
Addisonian reactions
Vomiting
Loss of appetite
Diarrhea
Fatalities as a result of Trilostane are around 1% to 2%. Side-effects are less likely with twice-a-day doses as opposed to one.*

[Altira]

Help cold feet, to start Trilostane again. I think she's in pain. She can hardly get up. We walked 3 miles today a mile more than we normally would. Bud went after some doggie asprin. Maybe i should wait until tomorrow to start? I'd feel better if she wasn't in pain when we start incase we get side effects. He water drinking is still way down and she hasn't had any meds for a day and a half. Would that mean it's still in her system? She hasnt hardly moved in four hours.

[Altira]

I read Corkies thread. God how depressing is that? I didn't see a glimmer of hope. Just me failing and doing all the wrong things. We all know how well I did with Mira. I'm so scared.

Is it ok to give her etogesic?
Probably not. Should I ask for something else?

And what about these adrenal panels? You had corky do? Should we have done that first too?

I gave her the Trilostane 2 Dashqiun and the bp meds at 6. I want to take her to my mom and dads. They have two little dogs. Kira... I need to see her happy. She doesn't seem to miss Mira. I guess I do enough of that for all of us.

[labblab]

Is it ok to give her etogesic?
Probably not. Should I ask for something else?

Janis, I'd encourage you to email Dr. Chung and ask about appropriate pain relief for Kira. Certain pain relief meds are not recommended for dogs with Cushing's due to a higher associated risk of GI bleeding. Plus, rather than pain, it may just be that Kira is tired after taking a longer walk than usual. If it does turn out that she is feeling poorly enough to be needing pain relief, I think Dr. Chung would want to know so as to factor that in to her evaluation of the trilostane treatment.

I am so sorry to hear that you've found no hope in Corky's story. It suggests to me that you are in such a dark spot right now that it is hard to see light shining anywhere. I think if you were to read about Corky's treatment journey at another time in your life, you might see things that many others of us do: a journey that has held many challenges, but which has rewarded Corky and Terri with good days and quality time still to be shared. But right now, at this moment, you are exhausted and grieving. And facing what seems like the overwhelming task of taking care of Kira. So today is not the day when you are seeing or feeling anything hopeful.

I do believe that can change. But it can be hard to see or make changes like that on your own. Especially when you have the responsibility of Kira's treatment facing you square-on. So I'm glad you're going to see your mom and dad. I hope you will feel as though they are able to support you right now. Because even though it does not seem like it to you, I do think there are reasons to be hopeful for Kira and her treatment. And with some time and some support, I'm betting you'll come to feel that way, too.

Marianne

[lulusmom]

Mommies lost her fan club. No matter where I went a few minutes later in would wonder little Mira. I always knew where she was cus o only had to look behind me. Is it wrong to want another?it's another heart broken morning. I hugged bud goodbye as she slips from me. This hurts so damn much. Kira doesn't follow me. She is dying too. I don't think I can save her.

Janis,

I know this is a very difficult time for you and I also know that grief has a way of clouding our judgment and causing emotional paralysis. A lot of us have been there, done that and know the gut wrenching heart break of losing a baby that you love more than life itself. And the members here who lost a baby and had another baby fall ill on the heals of that loss understand your fears more than you know.

Kira has cushing's, which is not a death sentence. There are any number of reasons why she is acting so inert and I don't believe dying is one of them. Intolerance to exercise, cortisol withdrawal or cortisol too low and mourning the loss of her sister. Regardless of how you may perceive her behavior, Kira very well could be grieving over the loss of Mira every bit as much as you right now. I live full time with four dogs and usually one or two fosters. None of them really interact that much but if one is gone for more than day, they are all excited to see him/her return. Even my grumpy old Jojo, who could care less about anybody or anything, gets happy for the moment. You just never know what a dog is thinking or feeling.

I think the sweet girl who is still here with you is coping with a lot of physical and emotional stuff too and she needs you to reach deep down inside yourself to find the strength to accept the things you cannot change and the will to change the things you can. You are the only one that can change things for Kira but you don't have to do it alone. We are all here to share our strength with you in the hopes that you will come to accept that Mira is at peace and that she would not want you to torment yourself over the decisions you made for her. They were the right decisions and were made out of the immense love you feel for her. I believe with all my heart that Mira knows that and she would not want to be the reason why you now doubt your ability to help Kira. Please don't give up on yourself or Kira now. Whether you know it or not, you both need each other more than ever right now.

It's hard to believe but there really are better days to come for both you and Kira. If I can help make that happen sooner than later, then all you have to do is say the word. I am not that far away and my weekends are my own. I'd be happy to sit with you, cry with you, babysit for Kira, chauffer her or both of you to the vet, do your shopping, whatever you need.

Glynda

[Altira]

As the corksters mom would say "thank you I aprecaite your comments" (or something like that) it means a lot to me. All of you here are like a life line to me. My family is as supportive as anyone could be they get it just as badly form me as you do here. We had a very good doggie visit. 70pound Kira was a sweetheart to moms two Papiloins. And the Papilons were inertested in Kira. My sister showed up too. And wanted to know everything I could manage to tell them. My dad who is 93 sat there not saying a word, listened to every word I said. I talked a lot. My sister inspected Kira. Will go back again sometime.

The pain med I mentioned was given to me by Dr Chung. I looked it up and didn't like what it said about it at all. Tons of people complained about it. But dr Chung said it was safe. I dont trust her all that much. Then when reading corkies thread there was a lot of people talking about arthritis meds. Names like duralactin and adequans i think were mentioned as working reall well. So I wondered. Any comments?

I guess I did sort of asked indirectly what you thought about me getting another dog.

Glynda that is so sweet of you to offer to help. But what you are doing right now is all I could ever ask for.

I dont know that I will ever be able to face things the way corkies mom has. I read that and what I see is the same nightmare I just went thru with Mira. One that lasts years not a month. It's in my nature to fall apart easy and get confused and end up doing the wrong thing. I don't think my heart can take it. But that does not mean I wouldn't try. What it means is I'll be a gaint pain in the ass and likely ask the same questions more then once. And or just totaly forget to do things. You pretty much need to pin a note to my shirt before you let me go off anywhere.

It is for this reason surgery is still high on my list of possibilities. I still intend to look into it. Where I would ever have the courage to take that chance with Kira is slim. Well see.

[Altira]

Panicing again

[Altira]

My dog that was just running the streets with me a month ago is now tripping going up curbs and walks like she just aged a hundred years. Now I'm half scared shell have a heart attack on one of our walks. We get home and she lays down and does not move. She squeeks she doesnt follow me at all which is really heart braking. Somebody tell me I'm being silly please

[frijole]

Janis, A couple thoughts to ease your mind...remember that trilo is a chemo drug. This just means its strong and just like if you or I took a strong drug to get well.. it takes a while to get used to it. It is certainly fine to take her for walks but I would not be pushing it. She's just tired. If trilo is anything like lysodren (which is what my dog was on) - at first they tend to sleep more. If you read the trilo insert (if you got one) or go back to the link we provided early on regarding trilo you can see the side effects. I am sure she is just adjusting. Kim

[Altira]

Well ok she does look peaceful as hell. I just want her to be ok and stop scaring me. I lost Mira just five days ago. Talk about helpless. Nope all I got was a bottle of dog killer and a syringe to torment her with. Truly she hates me and I feel like I'm killing her. What would happen if I stopped giving the meds. It would be horrible huh? A horrible painful death. Why? She was fine. All she had was a minor urine infection that's long since gone. She seemed so strong. Damn all. She's twitching in her sleep now. She falls asleep so easy.

[Altira]

She keeps pawing at her eyes. Whatever it is it bothered her enough to wake her up and paw at her eyes. She has been squinting a lot. I put some eye wash in them but it doesn't seem to help.

[Roxee's Dad]

Hi Janis,

How is Kira doing today and how is it going with the Trilostane??

[Altira]

Awe thanks for asking. We had a pretty good day for awhile. I got he to pound her paws as a stuffed toy danced by. Been taking the trilostane since last Friday. We missed three doses in between until my panic attack passed. We see dr Chung at 11:30 tomorrow for a cortsal test I think. The only change I've seen is the water thing. Still not a spec of fur on her back. I spent a good part of the day making a list of questions and concerns. It's three pages long! I have comparison pictures too. Muscle wasting, lameness, shaking, fur growth, hump on her back, arthritis, itchy eyed, nasodigtal hyperkeratosis, noisy breathing, heart murmur, blood test results, Trilostane, high bp, surgery statistics, CT scan.

Actually I'm going to start with "grieving" cus the farther we get into this the more I think some of this is greif. Kira and Mira got along amazingly well. There was no alpha dog here. They each had there own things that they did and a whole lot of things they shared. Even when running they ran side by side. On walks where bud held one and me the other, if we split up Mira would get upset. And the car. I take Kira with me to the store and she looks so sad. Well duh! That was the last place she saw Mira.

Kira and Mira just as the names suggest it was an almost perfect match. God I hope this is greif cus if it's not we are in trouble.....

For awhile there was a Kira and a Mira. For the last two years we could leave them in the car for hours while we went in casinos or out to eat. The were prefect angels. Wed be driving to the desert and I'd say to bud we better go back I think we forgot the dogs!! They never made a sound. For six days now it's just been Kira. So tragic.

[Altira]

Big Question.

If Kira is grieving as bad as I think she might be, could that mess up the test they want to do today?

She's just given me more reason to think so.

[AlisonandMia]

God I hope this is greif cus if it's not we are in trouble.....



It could be grief. But it could also be low cortisol - which is my suspicion from what you are describing. Weakness and looking incredibly ancient all of a sudden was my Mia's first sign of low cortisol. (If things continued that way she would develop diarrhea and then lose her appetite - she never vomited).

I suspect either Kira's cortisol is absolutely too low or the sudden drop to a more healthy level from a long-term high level is knocking her around, especially when combined with stress (grief). This is called "cortisol withdrawal" and the signs are more or less identical to a slightly too low cortisol level and the only way to be sure whether it is low cortisol or this cortisol withdrawal is to do an ACTH stim test and electrolyte test.

In either case the solution would likely be (depending on the stim test results) cessation of the trilostane and then restarting at a lower dose or (if it is simply cortisol withdrawal) maybe lowering the trilostane dose to give her a chance to adjust.

But I want you to know this is not how a dog treated with trilostane (or Lysodren) lives its life - these are not symptoms you expect to see long term so don't worry that this is what her life is going to be like from now on - that she either has to have the Cushing's symptoms or be like this. The aim of treatment is to make the dog "normal" and healthy acting not debilitate it. Having said that it is not uncommon for a treated Cushing's dog to go low at least once in the course of the treatment - but it can and should be remedied pretty rapidly by adjustment of dose and maybe prednisone or another steroid med.

Grief (stress) shouldn't interfere with the results of a treatment-monitoring ACTH stim. It can affect diagnostic tests for sure but shouldn't skew monitoring tests because the cortisol-lowering effect of the medication will over ride any affect of stress. (Stress can cause false positives on diagnostic tests because stress increases cortisol output in a normal dog and can make it look like Cushing's when it is not.)

Alison

PS: I've suffered very mild "cortisol withdrawal" myself when I stopped a steroid asthma med suddenly (script ran out) - what I had was strangely weak-feeling legs, a great desire to just lie down and generally I felt pleasantly tired. And I did get a bit grumpy if I had to get up and do something - I'm not as sweet-natured as most dogs!;):p I felt more energetic and with it within a very short time of restarting the med (within the hour) and then I tapered it off and had no further problems.

[frijole]

Janis - this reminds me that we never did see the acth test results from the FIRST test that was done PRIOR to treating with trilo. Can you get the two numbers and post them? Important. THis way when we get the next set of numbers we can compare them. Thank you!

I agree with Alison. Janis - I think alot of us felt we were killing our dogs with the drugs when we first gave them. That is just our own fears and the unknown. Once you get the dosage amount corrected you will start to see your girl bounce back and will get more comfortable with her health as well as the trilo. Hugs, Kim

[labblab]

Janis, I also want to "second" the things that Alison has written. Also to let you know that even when the trilostane dose is right where it should be, it will take a while (weeks, not days) for some of Kira's Cushing's symptoms to improve such as the hair loss and muscle wasting. Changes such as a decrease in thirst and appetite are the first to be seen, and can occur within days of treatment. But other physical changes have taken a long time to build up, and so will take a longer time to reverse. But the improvements will come.

Also, Kim is right that it will help us if you can get the first ACTH results for comparison purposes. However, do not freak out if those first diagnostic ACTH results actually fall within the range expected for a normal dog rather than the elevated range for a dog with Cushing's. It is well known that the ACTH frequently does not register an "abnormal" reading for a dog who is suffering from the adrenal form of the disease as is the case with Kira. But the results will still be helpful in terms of judging the effectiveness of Kira's current dose of trilostane.

Good luck with the test today!

Marianne

[Altira]

Thank you. I'm so glad you were able to get back to me before I see the doctor. I tried looking up dr Chung on the Internet and all I could find was a name. At the ACC site they only mention her name and it's just Kerrie Chung DVM. Doesn't look like there is much experance or schooling there. I also looked up the sergeants name and although he is mentioned a lot there is no mention of anything other then hips and legs. Not very encouraging. Dr Deihl is at ACC though and she is wonder. She had a much differant take on the whole thing. I hope I can pick her brain sometime soon. Well we will see what Chung has to say. Surly that test they did on the 19th should be back and I'll get copies. I guess I should have asked if today's test will have immediate results.

I'm thinking about going to Phenex Arizona. To that wonderful place one of you spoke about. We could do it. There is nothing keeping us here.

And thank you for telling me that this isn't the way Kira will be from now on. That she should be happy again at some point. I just hope there isn't something else wrong.

It's going to be very hard to go back there today. Last time I was there I was holding my Mira.

[Altira]

It's all greek to me....

Kira-Beghtol
12/3/10

BARMETER 755.21

BLOOD GAS
ph 7.455 (7.350 - 7.550)
pc02 25.2 (35 - 45 ) <
p02 41.6 (83 - 108 ) <<
hct 46 (39 - 49)

COOX
thb 17.5 (12 - 17.8)
s02% 75.1 (0 - 100)
02hb 72.9 (94 - 97) <<
c0hb 1.7 (0 - 1.5) >
methb 1.2 (0 - 1.5)
hhb 24.2 (0 - 1.5) >>

CHEMISTRY
na+ 147.2 (142 - 150)
k+ 4.95 (3.5 - 5.10)
cl- 111.8 (100 - 106) >
ca++ 1.37 (1.12 - 1.4)
mg++ .61 (.45 - .60) >
glu 114 (75 - 120)
lac 2.1 (.07 - 2.5)
bun 23 ( 8 - 24)
creat 1.2 (.6 - 2)

CALCULATED
hc03- 17.8
beb -3.4

CALCULATED CHEMISTERY
tc02 18.6
gap 17.5
ca/mg 2.2
osm 297.4
bun/cre 18.9

[Squirt's Mom]

Hi Janis,

These values are not from an ACTH. An ACTH will have two values - one, a pre and the other, a post.

Is this the only test other than the ultrasound that was done prior to starting the Trilo? When you talk with Dr Chung, ask her specifically for the ACTH results.

I hope Kira is feeling and acting better this evening.

Hugs,
Leslie and the girls - always

[labblab]

Janis, it looks to me as though these results that you have posted represent the additional testing that was done today alongside the first monitoring ACTH. It is not surprising if the ACTH results are not yet available from today's testing.

I believe the "Blood Gas" and "COOX" tests both relate to pulmonary function and how well Kira's blood is being oxygenated. These may have been ordered as a result of her "noisy breathing?" I am clueless as to how to interpret these results, however.

For dogs on trilostane, it is recommended that the blood chemistries be checked each time that a monitoring ACTH is performed (the blood chemistries include the famous "electrolytes"). It doesn't look to me as though anything is greatly out of whack regarding the basic chemistries except for the chloride, and I don't know what significance that would have, if any. I also don't know what the norms would be for the "Calculated" results.

Janis, what did Dr. Chung tell you about these results?

Marianne

P.S. What we're wondering about now are the results of the first ACTH testing that was done in mid-November? Later this evening, I'll try to check back through your thread to get the dates straight about this...

[labblab]

OK, I've checked back through your thread, and I'm not certain whether or not another ACTH test was actually performed in mid-November. The recorded summary of the "Consolation Visit" talks about the need to take Kira's blood pressure and also to do an ACTH test. But I can't tell for certain whether or not that test was actually performed.

Janis, when you get the results back for today's ACTH test, definitely do ask them whether an earlier ACTH was performed in November. And if so, what the results were.

Marianne

[Altira]

Please delete the dup post sorry. I thought certain I had posted everything. I will go through it all and chech again. Maybe I emailed it.

[labblab]

Janis, I will go ahead and delete that duplicate post (for anybody who wants to see Kira's diagnostic LDDS results, go to p. 3 of this thread and look at reply #25).

And AHA! I think I've solved the mystery of the November ACTH test. I went back to look at your email (Janis has emailed some results to the k9cushing's emailbox), and per Dr. Chung's note, I believe it was an "Endogenous ACTH" test that was performed in mid-November. I know it is confusing, but this is a different test from the ACTH "stim" test that was performed today. The "endogenous" test helps to differentiate between the types of Cushing's -- pituitary vs. adrenal. Although the test results were not yet available to be included in the lab summary that you emailed, presumably they were consistent with adrenal Cushing's. And the bottom line is that they will not have relevance to the ACTH "stim" test that was performed today -- it is like comparing apples to oranges. So we will be starting fresh with today's ACTH test in terms of looking at Kira's cortisol level for the purpose of monitoring the progress of her trilostane treatment. I'm betting you'll have the results back by the first of next week.

Marianne

[Altira]

Well you did better then me I can't find the ACTH test for 11/19 any where but I was charged for it. The results I just posted I asked her what did we get from that and all she said is we use it to compare with other test results. Does that sound right to you?

Oh she said it confirmed a tumor. Well duh!!! We saw that in the pictures!

[Altira]

Janis, I will go ahead and delete that duplicate post (for anybody who wants to see Kira's diagnostic LDDS results, go to p. 3 of this thread and look at reply #25).

And AHA! I think I've solved the mystery of the November ACTH test. I went back to look at your email (Janis has emailed some results to the k9cushing's emailbox), and per Dr. Chung's note, I believe it was an "Endogenous ACTH" test that was performed in mid-November. It is very confusing, but this is a different test from the ACTH "stim" test that was performed today. The "endogenous" test helps to differentiate between the types of Cushing's -- pituitary vs. adrenal. Although the test results were not yet available to be included in the lab summary that you emailed, presumably they were consistent with adrenal Cushing's. And the bottom line is that they will not have relevance to the ACTH "stim" test that was performed today -- it is like comparing apples to oranges. So we will be starting fresh with today's ACTH test in terms of looking at Kira's cortisol level for the purpose of monitoring the progress of her trilostane treatment. I'm betting you'll have the results back by the first of next week.

Marianne

You mean the test results from today's test? Or is there another old one still pending? They said today's test should come back tomorrow. I would hope so. Could you clarify which one you expected to come next week? I hate to think we have to wait that long to make an adjustment. She is walking so poorly sometimes.

She confirmed muscle wasting in Kiras rear legs. I had pictures of right after her surgery in May and compared it to the one done two years earlier. It's disturbing I had been walking then briskly for two miles every night for four months and Kiras rear is still weak!!! She said maybe three weeks that might start to change.

Surgery:
She says that dr sebestian has done lots of these Adrinal surgeries and has been successful with all of them. Cost about $3000. Oh man.

Her bp was 160 down from 220 I think it was before. We are going to continue on with the meds with the thought that surgery is a possibility. Well see. My Kira is a strong girl. I just hope that wasn't just a cortasol high.

[labblab]

You mean the test results from today's test? Or is there another old one still pending? They said today's test should come back tomorrow. I would hope so. Could you clarify which one you expected to come next week? I hate to think we have to wait that long to make an adjustment. She is walking so poorly sometimes.

Yes, it was today's ACTH test that I was talking about. With the intervening weekend, I just figured that it would be at least Monday before you got the results (it always used to take a couple of days for me to get ACTH results back). But that's great if they'll already have them by tomorrow.

As for the blood chemistries, yes, it does make sense to say that they were done today for comparative purposes. If anything had been really abnormal today, of course that would have been important to know in its own right. But you're also watching for any trends upwards or downwards over time that would indicate a developing problem. I'm not so sure why the lung function tests were performed. They are not typically done in conjunction with routine trilostane monitoring, so Dr. Chung must have had a different reason for wanting to see those results. Maybe it was to rule out any lung problems that would be causing Kira any difficulty with breathing.

Marianne

[AlisonandMia]

As Marianne said, the "ACTH test" Kira had done in November (during the diagnosis) was a test called the "Endogenous ACTH test". In that test what is looked at is the amount of the hormone ACTH that is being produced by the pituitary gland. If the dog has pituitary Cushing's the level will be high (or maybe normal) but if the dog has an active (cortisol-producing) adrenal tumor then the level of ACTH being produced by the pituitary will be abnormally low. It sounds like Kira's was abnormally low which confirmed that the adrenal tumor they could see was actively producing cortisol.

The reason for doing this test, in addition to the ultrasound, is to make sure that lump that can be seen on the adrenal gland on the ultrasound is, in fact, producing cortisol. Sometimes a dog with pituitary Cushing's will simply have a lump or lumps on the adrenal gland(s) and the Endogenous ACTH test helps to conclusively tell if what is being seen on the ultrasound is actually what is causing the Cushing's. Sometimes it is clear from the ultrasound but not always and it sounds like in Kira's case it wasn't.

This test isn't always done but if the appearance of the adrenal mass is such that there could be some doubt as to whether it is a tumor or just some "lumpiness" then the Endogenous ACTH test can be very valuable.

The test she had today was completely different: She would have had an ACTH Stimulation Test - (ACTH stim). What they did was inject a dose of synthetic ACTH into her system to get her adrenal glands to release the maximum amount of cortisol they can. This test is the test routinely used to measure to what extent medication is suppressing cortisol production. It is a bit like squeezing a sponge to see how much water it is holding - except instead of squeezing with the hand as you would a sponge the adrenals are "squeezed" - that is stimulated - by the dose of ACTH. (This very rarely causes any ill effects from this but sometimes you can see some effects of elevated cortisol for a few hours after the test. This would be more common with dogs with pituitary Cushing's I'd think.)

Usually, with most labs, results of ACTH stimulation tests (like she had today) come back the next day.

It doesn't look like an ACTH stimulation test was done during diagnosis or before treatment - it looks like the diagnosis was done on the basis of clinical signs (important), LDDS test, ultrasound and the Endogenous ACTH test.

Alison

[Altira]

What happens if the cortasol levels drop and the blood values stay the same? I really should think happier thoughts huh?

We walked past a house, there was a doggie behind a fence near the side walk. I let Kira go over there and say hi. Kira wanted to play, she did all the normal I want to play things dogs do. Oh sweetheart.

[Altira]

Endognes (sp?) ATCH test
What dr Chung actually said:

We did this to find out if the tumor is producing cortasol. It came back low but not classically as low as a cortasol producing tumor comes back as. It's not as solid as I would expect with a cortasol secreating tumor. (is that good or bad?) it's still a tumor and I would not treat it any differently. We are looking to see if it is producing exess cortasol.

Any comments please. That's as clear as mud to me.

[Squirt's Mom]

Hi Janis,

Clear as mud to me as well. Personally, I would want to know what I was treating before I gave drugs. If the tumor is not producing cortisol, then I wouldn't want a cortisol reducing drug given to my dog. :confused:

Hugs,
Leslie and the girls - always

[Roxee's Dad]

Hi Janis,

I think it best that we actually see the results of the ACTH stim test before any meaningful comment can me made about treatment.

I would expect you should have the results on Monday. Just write them down and post them here.

ACTH Stim

Pre : ?

Post: ?

[lulusmom]

Hi Janis,

An endogenous acth test does not measure cortisol...it measures the amount of acth in the blood. Dogs with pituitary tumors will have normal to high amounts of acth in their blood because the lesion/tumor is causing the pituitary to continuously release acth into the bloodstream. Depending on the stage of disease, feedback between the pituitary and the adrenal glands may not be lost yet so the amount of acth in the blood is still normal. As the disease progresses, feedback is eventually lost between the pituitary and the adrenal glands and the pituitary just keeps on releasing acth and the adrenal glands respond by cranking out the cortisol. Dogs in this stage of the disease will usually have high acth levels in their blood as well as high levels of cortisol.

An adrenal tumor secretes excess cortisol independent of the pituitary gland. The adrenal tumor could care less about the pituitary gland or the acth it releases and pumps out the cortisol at will. The pituitary gland responds by saying, "hey, there's enough cortisol in the blood so I don't have to release any more acth." This is why dogs with adrenal tumors have low circulating acth and the gland that does not have a tumor will atrophy. It atrophies (shrivels up) because it eventually shuts down from lack of use because the pituitary gland is no longer releasing acth.

It's not an easy thing to explain but I hope I've helped you understand a bit more about the endogenous acth test.

Glynda

[Altira]

Glynda you are a scentist at heart aren't you? I can't even remember how many pills to give when. I just discovered the bp pills are twice a day not once. God you guys I'm so bad at this!

I guess my biggest question to you is this... Do you think Dr Chung knows what she's doing???? It doesn't sound like it.

[Altira]

Hi Janis,

I think it best that we actually see the results of the ACTH stim test before any meaningful comment can me made about treatment.

I would expect you should have the results on Monday. Just write them down and post them here.

ACTH Stim

Pre : ?

Post: ?

COOL a form to fill out what an excelent idea. Keep the place nice and neat!

Yup didn't hear anything today. I really wish they would just tell the truth. Do you know we NEVER did get the final results of Miras biopsy? She died! Makes you wonder. If it even got sent.

[lulusmom]

Hi Janis,

I checked Dr. Chung online and while she's not an internal medicine specialist, it appears that she works exclusively in the internal medicine department. I don't know if she knows what she is doing but I would give her the benefit of the doubt simply because Kira is not textbook. The results of her low dose dex test are more in keeping with pituitary dependent disease yet the ultrasound shows one adrenal gland much larger than the other, which is normal size. Usually that other gland is much smaller or atrophied which I think is why Dr. Chung rightfully wanted to validate by doing an endogenous acth test.

It is rare but a dog can have a pituitary and an adrenal tumor. Not all adrenal tumors are functional, meaning they secrete excess hormones. It is possible that Kira has a nonfunctional tumor or even a pheochromocytoma. The latter type of tumor does not secrete cortisol but rather something called catecholamines, which includes epinephrine and norepinephrine. Regardless of the type of tumor, if it is not secreting cortisol, then pituitary dependent disease would be the logical diagnosis. You mentioned that Dr. Chung said that the endogenous acth test results were not as low as you would normally see with an adrenal tumor. If so, the good doctor may be having a very difficult time trying to determine if the adrenal tumor is the source of the excess cortisol or if the culprit is a pituitary micro/macroadenoma. Personally, if I didn't know for sure, I'm not sure I would opt for surgery unless a CT scan or MRI ruled out a pituitary tumor.

Glynda

P.S. I barely passed science and chemistry classes by the skin of my teeth. I may look like a "mad" scientist though.

[Altira]

And so the terror continues. I think someone better pass me a brown paper bag. I will send those results to my doctor brother. He lead us in the right direction with Mira. I'm going to go cry now.

[Altira]

(me) what can a CT scan tell us?
(Chung) it helps to deturman if it's evading the blood vessels around it and mastastases I can't see around it.
(me)could we do it even if we don't do the surgury?
(Chung) there wouldn't be any point if your not going to do anything about it
(me) you can't do chemo
(Chung) we don't do chemo for adrenal tumors


She never mentions anything about a pituitary tumor. Why wouldn't she tell me?


(me) if we don't do surgery and just do the Trilostane what about the cancer?
(Chung) the tumor will start evading the blood vessels around it. It may take a awhile

(me) she's a niosie breather
(Chung) it could be normal, it's probably nothing.

(me) what about the heart murmur could she have a heart attack?
(Chung) we could do a echo cardiogram to make sure all is well. But normaly a murmur does not cause a heart attach. Arithmias do but none were heard.
(me) so when dr deihl checked heart she would have heard an irregular heart beat?
(Chung) yes

(me) the differences between the blood test on 10/29 and the one on 11/11 it was higher.
(Chung) it was actually better just minor elevations.
(me) what about the CK
(chung) that's nothing, dont worry about that

And my current biggest worry below...

(me) we walk about five miles a day not all at once though. I spent ten years trying to get this dog to stop pulling and I never could. Suddenly now she doesn't pull. She walks like she's aged a hundred years. Sometimes end up walking real slow. Her rear legs seem weak someones she trips. For four months straight I had been walking the dogs everynight she was doing fine. Now she seems stiff and her gant is labored. Shell walk fast then slow, speed up then slow down. It's worse in the day time. Somtimes there is an odd step that's so fast I'm not sure what I saw. She wants to go very much. Sometimes doesn't want to go home. She seems in pain when we get home. She has a lot of trouble getting up. When at home she just lays down and doesn't move for hours. (I show her some pictures from there to tta surgery) when they did the first one the leg was all nice and rounded healthy looking. But two years later the other one looks like this.
(Chung) yes muscle apathety
(me) and Cushings can do that?
(Chung) yes Cushings can do that
(me) what sbout arthritis?
(Chung) walking is the best thing five miles is fine.
(me) so the trilostane will fix the muscle wasting
(Chung) yes

[labblab]

Janis, I am not well-versed regarding the specifics of adrenal tumors, so you can take anything I say here with a grain of salt. But in general, the things that Dr. Chung has told you over time do make sense to me and sound reasonable. It also seems possible to me that you may end up considering surgery on the adrenal tumor regardless of whether or not it is producing cortisol. It seems to me that Dr. Chung may be recommending additional adrenal imaging in order to decide whether the tumor itself is imminently threatening Kira due to its size, location, or likelihood that it is cancerous. If so, the tumor may present a separate issue which takes priority over determining whether the Cushing's might actually instead be pituitary-based.

Marianne

[Altira]

Janis, I am not well-versed regarding the specifics of adrenal tumors, so you can take anything I say here with a grain of salt. But in general, the things that Dr. Chung has told you over time do make sense to me and sound reasonable. It also seems possible to me that you may end up considering surgery on the adrenal tumor regardless of whether or not it is producing cortisol. It seems to me that Dr. Chung may be recommending additional adrenal imaging in order to decide whether the tumor itself is imminently threatening Kira due to its size, location, or likelihood that it is cancerous. If so, the tumor may present a separate issue which takes priority over determining whether the Cushing's might actually instead be pituitary-based.

Marianne

Yes that makes since, I just wish, or hope that she is being honost with me. I think if Kira was a human there would be no question about getting that cancer out of there. IF it were reasonably safe to do so.

I'm sending everything I have to my brother this morning. Surely he'll have something to offer. He doesn't like telling me bad things though. I know he will avoid that. But he'll tell my mom. Or my mom will get it out of him. Wish us luck.

[Buffaloe]

Janis,

I have tried to keep up with your thread and have a few little tidbits to throw your way.

It sounds to me like Dr. Chang is doing a good job for you and Kira. And I believe your surgeon received some really good experience when he interned at Sonora. The owner and surgeon performed Shiloh's adrenalectomy and he is seriously top notch. I'm sure your surgeon interned under him.

Adrenal tumors are complicated. There are at least 6-8 different types. Some produce excess cortisol but many do not. Shiloh's cortical adrenal tumor did not produce escess cortisol but it was a very bad tumor and had to be removed. Generally speaking, the larger adrenal tumors have a higher likelihood of being malignant. I think Kira's is relatively small which is a positive. If Kira's tumor produces excess cortisol, then Trilostane treatment would probably be quite helpful. As Glynda mentioned, it is very rare for a dog to have both an adrenal and a pituitary tumor...but it is possible.

Corky's treatment with Trilostane has been very successful. The fact that Kira is still going on long walks with you is a huge positive sign.

If a dog has both adrenal and pituitary cushing's, that's a very difficult diagnosis for any veterinary professional to make with certainty. Apparently, Kira has an adrenal tumor. IMO, the likelihood of a pituitary tumor is small.

You are doing a very good job with Kira and I think Dr. Chang sounds excellent. Best wishes to both you and Kira.

Ken

[lulusmom]

Janis,

I forgot to mention that I have a tremendous amount of respect for Dr. Sebestyan. I think he is an incredibly talented surgeon; however, I have no idea how many adrenal surgeries he's done. Since he is being referred by the internal medicine department at ACC, I would think he is no stranger to adrenalectomies. He has performed amazing surgeries on three of our little rescues. The most amazing was a kitty whose back legs looked like they were put on backwards. His feet were up in the air and he was pulling himself around on his rear haunches. Nobody thought it was possible for that cat to walk normally but by golly, he looks like a regular cat and walks around just fine now on all four feet. No other surgeons would touch any of these babies and recommended euthanasia. Dr. Sebestyan saved their lives. When he says he can fix something, he means it.

[Altira]

Thank you ... I sure want to trust those in charge of Kiras life. After the misdiagnoses by the regular vet (it was even obvious to me it was wrong) you just don't know who to trust. So often people get second and third opinions and end up with three differant answers. We still have a long way to go understanding all this stuff. And with a pateint that doesn't talk or give the slightest clue. Some day...

KEN what did you mean that it is a good sign that she is walking?

[Altira]

That helps thank you.

QUESTIONS

Why would you not do a CT scan right away if you suspected a pituitary tumor?

Wouldn't this scan be good for seeing still unknown problems?

Why would you continue the Trilostane if the last test showed low levels? Or at least lower the dose.

Why does she not seen concerned about Kira trouble walking? I mean if she can't walk then what good is any of this?

She said the etogesic was the best thing for her lameness. But EVERYWHERE I look I read horror stories about this drug. Seriously, people left and right are complaining about problems with it. I'm terrified to use it! Should I trust Chung on this too? Kira defiantly needs something. I've asked this before and no one has answered. Does anyone know about it?

[frijole]

She said the etogesic was the best thing for her lameness. But EVERYWHERE I look I read horror stories about this drug. Seriously, people left and right are complaining about problems with it. I'm terrified to use it! Should I trust Chung on this too? Kira defiantly needs something. I've asked this before and no one has answered. Does anyone know about it?

Janis - My dog Annie may or may not have cushings... it is a story that started earlier this year. I ended up driving to Kansas State Univ because it is the closest place where I could go to a specialist. She has an adrenal tumor and they are not sure if it is emitting cortisol but they don't think it is. They did 3 ultrasounds, a CT scan ---- you name it.

Her hind legs are really bad - like barely any meat left, just bones and very weak. Despite the fact that they don't think she has traditional cushing's they do NOT want to give her any of these traditional pain meds. (just in case there is cushing's). They recommended I try a natural product called "Duralactin". I started her on it almost 2 months ago and while she still has some issues, she has vastly improved. They are vanilla tasting tablets.

My local vets had never heard of it and I don't think anyone else here had used it. Anyway... I am going to link you to the information I posted on it in case you'd like to try it. You can just order it online. It doesn't effect any other meds - its all natural. You just have to read the reviews from dog owners on this product. I hope it gives Kira some relief. Note that the guy who recommended it at K State is the Head of the Small Animal Sciences Department!

Kim

http://www.k9cushings.com/forum/showthread.php?t=2635

[Altira]

Could you link me to your thread please. I'd like to read it.

[lulusmom]

Here is a link to Annie's thread:

http://www.k9cushings.com/forum/showthread.php?t=933

[frijole]

Could you link me to your thread please. I'd like to read it.
Glynda gave you Annie's thread but this is the thread where I linked information to Duralactin. Feel free to read up on Annie but warning.. it is long:D

Here's the duralactin one just in case you just wanted to read about it:
http://www.k9cushings.com/forum/showthread.php?t=2635

[Buffaloe]

Janis,

In one of your recent posts you said Kira went for a 45 minute walk and in another you said she walked 3 miles. Those are substantial walks, at least compared to Shiloh before she had her adrenalectomy. Shi would walk a couple of hundred yards and want to come home. After her surgery, she'd walk a mile or two every day and loved it.

Ken

[Altira]

I see Kira walked for almost 2 hours a couple days ago but seemed hurting when we got home. How does shi do now?

[Altira]

THIS IS A TEXT CONVERSATION WITH "STEVE WELTON MD" MY BROTHER

Curious? Does she really drink that much fluid? Her urine specific gravity is 1.022 which is concentrated! Also her cortisol level before the blood test was normal (5.1)? Also in people these tumors are usually benign??

She was drinking like maybe 16 cups a day she's down to 5 now. That started right after starting the Trilostane*

Also why were the blood gases so bad and they are not concerned about that??? I mean the pO2 was 41.5 !!!!

So what do you think
It is?

Was the urine done on the trilostane? Because it shows concentrated urine?

I will ask about the p02 thing

Their values are similar to human and should be atleast 80

They just did a ACTH stimulation on Friday

Ok, good let me know how they are. Did they image the left adrenal gland?

They ultrasounded her whole belly both glands. Do you see a pituitary problem?

I see it now, mass is actually on the left kidney not the right (which is normal). This is adrenal not pituitary ,

Yes and normaly is cancer dr deihl said the other side is a normal size which is not
forum is a support group who have had experance with Cushings in there own dogs

I see, if she had cushing you would also expect her to be diabetic.

Never any mention of diabetic*

(I said something about doing a CT scan)

Yes but then when you find a problem you have to deal with it!

You mean it's better not to look?

Yes I know her sugar is norma? Run that by your forum,

That sugar is normal? They didn't mention that either*They are saying maybe both pituitary and adrenal based on where they are going with the tests

Depends on your outlook

That hard to read huh?

No don't think pituitary (brain) with the right adrenal normal

Why is she suddenly having so much trouble walking?bCould it be the Trilostane?
Her fur never grew back you know

That is a very good question!!! Like I said does't fit well!!

Where would you go from here?

Find out why they ignored the low oxygen! Because it looks like a believable test?

Ok And that would lead to?

Why would it be low in Kira?

Dr deihl offered to talk to you. You were the one that said to do the ultrasound on Mira

Well see what they say

I wrote a book on blood gases

[Altira]

Is he pointing to heart failure?

[Altira]

Glynda gave you Annie's thread but this is the thread where I linked information to Duralactin. Feel free to read up on Annie but warning.. it is long:D

Here's the duralactin one just in case you just wanted to read about it:
http://www.k9cushings.com/forum/showthread.php?t=2635

I just ordered some thank you!!!

[Altira]

I'm so worried about Kira. The heater came on and she almost jumped out of her skin. She jumped up all worried looking. She's been doing that pretty often for the last couple months.

Does anyones dog keep walking fast and slow? You know speed up then slow down. It's like she wants to go faster but then maybe something hurts so she slows down. Sometimes she slows down a lot.

Some times she starts to play then stops. Correction she almost always does that. We though a toy for her, she'll catch it twice then quit.

[Altira]

I'm going to stop all meds and wait and see what this last test says. She seems terrible to me. I want to see if this helps.

I'm going to see if we can speak with dr Sebastian too asap. I don't know if he can help but it's worth a try I guess.

[labblab]

Hi Janis,

Just a couple of quick thoughts after reading your summary of your conversation with your brother. I agree with him about asking Dr. Chung about the significance of the oxygen studies. I'm still not sure why she decided to run them in the first place, but if they are indeed abnormal, then you'll want to know what her thinking is about them.

Secondly, while some dogs do suffer from both Cushing's and diabetes, the majority of Cushpups are NOT diabetic. So the two diseases do not routinely go hand-in-hand with dogs.

And finally, you may already be aware of this, but in order to check for the existence or size of a pituitary tumor, Kira would have to have a CT or MRI of her head performed. Any imaging of her abdomen will not include her pituitary gland. The pituitary testing would have to be done separately.

Marianne

[Altira]

[QUOTE=Roxee's Dad;44708]Hi Janis,

I think it best that we actually see the results of the ACTH stim test before any meaningful comment can me made about treatment.

I would expect you should have the results on Monday. Just write them down and post them here.

ACTH Stim

Pre : 3.6. NORMAL?

Post: 5.6. LOW?

[Altira]

My brother says she doesn't have cushings! But we are still texting hes asking questions

Comments please.

[Altira]

Janis,

In one of your recent posts you said Kira went for a 45 minute walk and in another you said she walked 3 miles. Those are substantial walks, at least compared to Shiloh before she had her adrenalectomy. Shi would walk a couple of hundred yards and want to come home. After her surgery, she'd walk a mile or two every day and loved it.

Ken
Did she have cushings? Maybe the tumor is giving her pain? Cuz the one time I gave her a tiny 1/8 of tramadol it seemed to help! Oh crap she just looked up at me as I said this! She hasn't looked at me much all since Mira died. Dare I hope or is this just another big confusion. I think we better go for a walk. No we are going to do an 1/8 of tramadol wait 30 minutes when go. Please let this work.

[StarDeb55]

ACTH Stim

Pre : 3.6. NORMAL?

Post: 5.6. LOW

Janis, these results were Kira's 1st ACTH after starting trilostane, correct? If so, these are absolutely terrific results. You would expect the cortisol to have dropped because of the medication. Your brother is incorrect in his interpretation of these results. With trilostane, cortisol can continue to drop, & since Kira is on such a high dose, you will need to watch her very carefully which I know you are already doing.

Debbie

[labblab]

Janis, Deb is absolutely correct that these post-trilostane results are GOOD, and right at the treatment range that is hoped for in a dog being given trilostane. Please give your brother this link to read (it is the Product Insert for the medication):

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

He will see that the goal of the trilostane treatment is to lower Kira's cortisol into this range (which is lower than the range for a normal dog who doesn't have Cushing's). So the medication has done just what it is supposed to. She has to keep taking it, though, in order for her cortisol to remain within this range. The medication is only active in the body for approx. 18 hours.

Marianne

[labblab]

Also, you can give your brother this link regarding how to interpret the results of Kira's LDDS test:

http://veterinarymedicine.dvm360.com/vetmed/Medicine/ClinQuiz-Interpreting-low-dose-dexamethasone-suppr/ArticleStandard/Article/detail/580093

The LDDS demonstrates Cushing's on the basis of the 8-hour test result, and not the baseline cortisol. So the fact that Kira's baseline cortisol fell within the normal range on that test (5.1) does not mean that she does not have Cushing's.

Marianne

[Altira]

It's hard to get my brothers attention he's a 24hr doctor and is always very busy plus he doesn't like to deal with family stuff. The last thing he asked me was was she taking the trilostane before this test, I said yes but he never responded back. I don't know how closely he really looked at it. This test results would make cushings unlikely if she hadn't been taking the trilostane. I doubt that we could get him to read up on it.

On another note, we also have ignored the blood gas results. There are many things not normal there. Maybe that is a big concern.... Like there might be a bigger problem then this.

Kira's walk was no different still labored.

[lulusmom]

Hi Janis,

I just wanted to make a few comments about your brother's interpretation of things. My comments are in blue below.


THIS IS A TEXT CONVERSATION WITH "STEVE WELTON MD" MY BROTHER

Curious? Does she really drink that much fluid? Her urine specific gravity is 1.022 which is concentrated!

Depending on where the dog is in the progression of the disease, not all dogs that are diagnosed will have lost their ability to concentrate the urine. I do understand your brother's surprise because the vast majority (80% +)of cushdogs do have low specific gravity and very dilute urine.

Also her cortisol level before the blood test was normal (5.1)?

Marianne has already commented on this, however, I will validate her and say that you cannot use the basal (resting) cortisol to diagnose a dog. There have been a few papers I've read that do mention that it may be possible to use the resting cortisol to monitor Trilostane treatment; however, I believe that wasn't recommended until the dog is stabilized on the correct dose. I think Marianne probably knows more about this than I so perhaps she can expand on this.

Also in people these tumors are usually benign??

In dogs with adrenal tumors, the chance for malignancy is 50/50.

She was drinking like maybe 16 cups a day she's down to 5 now. That started right after starting the Trilostane*

Was Kira drinking 16 cups a day when the urinalysis was done?

Also why were the blood gases so bad and they are not concerned about that??? I mean the pO2 was 41.5 !!!!

So what do you think it is?

Was the urine done on the trilostane? Because it shows concentrated urine?

I will ask about the p02 thing

Their values are similar to human and should be atleast 80

I am not familiar with PCO2 (partial pressure of carbon dioxide) and PO2 (partial pressure of oxygen so I can’t make a connection between them and cushing's; however, I did see in my medical text, Geratrics and Gerontology of the Dog and Cat by Dr. Johnny D Hoskins, that low PO2 and PCO2 are low if a dog has a thromboembolism. Dogs with cushing’s are predisposed thromboembolisms but I don’t recall hearing about any here on the forum. I'll be looking forward to hearing what Dr. Chung has to say about it.

They just did a ACTH stimulation on Friday

Ok, good let me know how they are. Did they image the left adrenal gland?

They ultrasounded her whole belly both glands. Do you see a pituitary problem?

I see it now, mass is actually on the left kidney not the right (which is normal). This is adrenal not pituitary ,

The pituitary gland is in the head so you would not see it on abdominal ultrasound. I just reread the results of the abdominal ultrasound you posted and it mentions a plump left adrenal and no mention of a mass on the left kidney. I'm assuming that this left plump adrenal gland is the reason why your brother stated that it is adrenal and not pituitary.

Yes and normaly is cancer dr deihl said the other side is a normal size which is not

I'm not sure why Dr. Deihl feels that a very small mass is cancerous so maybe she can explain a bit more to you, yes?

forum is a support group who have had experance with Cushings in there own dogs

I see, if she had cushing you would also expect her to be diabetic.

Never any mention of diabetic*

(I said something about doing a CT scan)

Yes but then when you find a problem you have to deal with it!

You mean it's better not to look?

Yes I know her sugar is norma? Run that by your forum,

That sugar is normal? They didn't mention that either*They are saying maybe both pituitary and adrenal based on where they are going with the tests

I believe Marianne has already told you that a very small percentage of cushdogs have concurrent diabetes.

Depends on your outlook

That hard to read huh?

No don't think pituitary (brain) with the right adrenal normal

I have worn the grooves off of an audio of Dr. David Bruyette, a reknown specialist in endocrinology, and he specifically states in this particular lecture that if an adrenal tumor is functional and secreting cortisol, the other adrenal should be much smaller or completely atrophied. If you see one large adrenal and the other is normal, you are most likely dealing with pituitary dependent disease. This is also what I've read in a number textbooks, reference articles, etc.

Why is she suddenly having so much trouble walking?bCould it be the Trilostane?
Her fur never grew back you know

That is a very good question!!! Like I said does't fit well!!

Kira could have muscle wasting caused by cushing's but it sounds like her trouble walking or apparent weakness really started after you started Trilostane so muscle wasting may not be the real issue. Two other causes come to mind, which I believe have already been mentioned by other members but I'll repeat them. 1) Hind limb paresis is listed as a side effect of Trilostane. Unfortunately, the vet on staff at Dechra doesn't know if this a side effect of the drug dropping cortisol too low or an unrelated side effect caused by the drug. 2) Dogs with uncontrolled cushing's are self medicating themselves with the high cortisol levels in their body and once treatment brings those levels down, a dog will start to feel the aches and pains of arthritis. Your vet should be able to tell the difference between arthritis and cushing's related issues.

Where would you go from here?

Find out why they ignored the low oxygen! Because it looks like a believable test?

Ok And that would lead to?

Why would it be low in Kira?

Dr deihl offered to talk to you. You were the one that said to do the ultrasound on Mira

Well see what they say

I wrote a book on blood gases

[Altira]

Janis, these results were Kira's 1st ACTH after starting trilostane, correct? If so, these are absolutely terrific results. You would expect the ACTH to have dropped because of the medication. Your brother is incorrect in his interpretation of these results. With trilostane, cortisol can continue to drop, & since Kira is on such a high dose, you will need to watch her very carefully which I know you are already doing.

Debbie

Yes the first test...

[Altira]

Lulusmom:
I made a copy of the converstion I had with my brother with your comments in there and sent it to me brothers wife. Hopefully he'll read it.

[Altira]

Hi Janis,

I agree with him about asking Dr. Chung about the significance of the oxygen studies. I'm still not sure why she decided to run them in the first place, but if they are indeed abnormal, then you'll want to know what her thinking is about them.

Marianne

Dr Chung doesn't work until wed but i emailed her. She ignored this question.

[Altira]

My Emails to Chung and her response


Note: I also sent her a copy to the converstion with my brother (she ignored it) I sent it to dr deihl too.

---------------------------
Test results from Friday
Please advise...
I didn't give the trilostane this morning, something is making her
unwell. She doesn't seem any better.
Please advise....
Janis
------------------------------
Should I make an appointment with dr sebastian? Or do we need to get it more figured out first?
Janis
----------------------------------
Janice
The cortisol level was in the normal range(5.6). I'm not sure what you mean by unwell...is se not eating, vomiting or having diarrhea. You can make an appointment next week with Dr. Sebastyn to discuss options
for surgery.
Kerrie
-------------------------------
It's her rear end lameness and lethargy and labored walking that upsets me. Her right rear leg shakes sometimes. Something doesnt seem right. The doggie aspirin does no good. The last time I gave her the trilostane and bp meds was 6pm yesterday. She seems a bit better right now. Acting more normal. Shouldn't we decrease the trilo? What of the bp meds?

My brother is very concerned about the blood gases. He said the p02 was very bad and wondered by you didn't mention that. He said things don't seem to fit. Please comment on that.
Janis
-------------

nothing more from her

[Altira]

I am not familiar with PCO2 (partial pressure of carbon dioxide) and PO2 (partial pressure of oxygen so I can’t make a connection between them and cushing's; however, I did see in my medical text, Geratrics and Gerontology of the Dog and Cat by Dr. Johnny D Hoskins, that low PO2 and PCO2 are low if a dog has a thromboembolism. Dogs with cushing’s are predisposed thromboembolisms but I don’t recall hearing about any here on the forum. I'll be looking forward to hearing what Dr. Chung has to say about it.

I DOUBT WE WILL GET A COMMENT FROM HER

Why is she suddenly having so much trouble walking?bCould it be the Trilostane?
Her fur never grew back you know

That is a very good question!!! Like I said does't fit well!!

Kira could have muscle wasting caused by cushing's but it sounds like her trouble walking or apparent weakness really started after you started Trilostane so muscle wasting may not be the real issue. Two other causes come to mind, which I believe have already been mentioned by other members but I'll repeat them. 1) Hind limb paresis is listed as a side effect of Trilostane. Unfortunately, the vet on staff at Dechra doesn't know if this a side effect of the drug dropping cortisol too low or an unrelated side effect caused by the drug. 2) Dogs with uncontrolled cushing's are self medicating themselves with the high cortisol levels in their body and once treatment brings those levels down, a dog will start to feel the aches and pains of arthritis. Your vet should be able to tell the difference between arthritis and cushing's related issues.

SHE SEEMS TO SHRUG THIS OFF EVERYTIME I BRING IT UP. SHE HAD EVIDENCE OF MUSCLE WASTING IN MAY WHEN THE LAST TTA SURGERY WAS DONE. YOU COULD SEE IT WELL CUS THE FUR WAS SHAVED OFF I'LL POST THE PICTURES HERE.

http://www.k9cushings.com/forum/picture.php?albumid=274&pictureid=2130
First TTA in 2008
http://www.k9cushings.com/forum/picture.php?albumid=274&pictureid=2133
Second TTA 7 months ago... Her rear bone sticks way out.
http://www.k9cushings.com/forum/picture.php?albumid=274&pictureid=2134
Standing.. All the roundness is gone.
http://www.k9cushings.com/forum/picture.php?albumid=274&pictureid=2131
This is her now 7 months later.
http://www.k9cushings.com/forum/picture.php?albumid=274&pictureid=2132
This is her today, her rear is all bony (she is all fur) and I have been walking her every day for months. It doesn't get better... The skin has turned dark too.
I asked Chung if the was muscle wasting and she said yes.

[Squirt's Mom]

Hi Janis,

I have a suggestion for you that may help your communication and future relationships with Kira vets. When asking about something like the blood gases, frame the question so that it sounds like your idea, not your brother's or ours, but your concern. Like, "What do the abnormalities in her blood gases mean?" If they asked how you knew what those values on her tests meant, you can simply say, "I looked it up online" or "I asked my brother who is a human doctor." This will do a couple of things for you; it will put you in charge of Kira's care rather than in an intermediary role between your vets and others; it will let your vets know that you are taking the bull by the horns and trying to learn all you can to help Kira which may lead them to being more open with you and taking more time to make sure you understand things.

It may also help prevent your vets from feeling as if you don't trust them and are second-guessing everything they do by relying on non-veterinary trained people. If Kira's vets start to feel this way, it may become very difficult to work with them - you may even find you have to look for a new vet. :eek:

For Kira's sake, it is important that you are able to work closely with her vets. But this is just a suggestion... one of Squirt's vet in TN wasn't all that keen on what could be found on the web about Cushing's and didn't really encourage me searching except on a site she recommended...which was geared toward vets. So I learned to keep my mouth shut when we saw her about my online activities. But as time passed, she noticed that I had learned much more than she was giving me credit for and was surprised when I told her I had learned it all from this group. After that, there was no problem with discussing what I had read here or anywhere with her because she knew my intent was to help my baby, nothing else.

Keep your chin up, sweetie!

Hugs,
Leslie and the girls :D - always

[Altira]

I know your right about my way of presenting it. It's so much easyer and way faster to do it this way. You know Dr. Deihl wanted to talk to my brother, even asked me several times. She was wonderful. I can understand Chung not being happy with this. I wouldn't like being second guessed either. Steve may not be happy I did this either. But it would have taken me all day to put it together and I need to spend time with Kira. Who I'm currently ignoring.

Besides I'm paying them darn good money for all this. I could buy a car for how much these last two months will cost me. Terible aditude huh?

[Altira]

I have an apointment with dr Sebestyan next Monday. Get this, they said we could do the surgery on that day too. Yikes not blood likely! I need to spend some quiet time with her first. What if i lose her? God I can't believe this is happening. Now I'm crying.

They make it sound like it's no big deal too. I wish I could see it that way. It does need to be done soon. I want that cancer out of her! If she was human there would be no question of it.

[Squirt's Mom]

Hi Janis,

I hope all goes well with Dr. Sebestyan. From what Glynda has said and what Ken has said about him, I would think Kira is in good hands. Is it this coming Mon. or next Mon. that you see him? If you have a week, then you have that much time to spend with Kira doing things ya'll enjoy and preparing for the surgery just in case.

If an adrenal tumor is causing her problems then getting it out asap would be best so it doesn't have time to grow any more or involve blood vessels and such it doesn't at this point, making surgery on down the road more difficult and risky.

I know how scary it is to think about them cutting your baby open and removing part of her. When they told me about Squirt's spenic tumor and the risk of rupture, things went really, really fast after that. She had a week it seems like, or maybe less, from the time I was told about it and the surgery. Those days waiting for the surgery were torture themselves because I was terrified to pick her up yet I had to. Every little thing she did made me want to scream at the surgeon to do it NOW before something really bad happens and it becomes an emergency situation. Yet just as big a part of me was screaming NONONO! What if I lose her during the surgery? What if these are the last days I have with her? Man, those were hard days...from one end of the spectrum to the other over and over day in and day out! :eek:

So I do understand your fear and the desire to want to wait. Try to have faith in Dr. Sebestyan and yourself in knowing this is the right thing for Kira if the doc says "Go!" And remember we are with you all the way, sweetie.

Hugs,
Leslie and the girls :D - always

[Altira]

Ok I'm sweating, and I'm SMILING! :D We just went for a walk and we really walked! Not 100% but it was close enough. Kira did great. She's not hardly panting either. Ok so, either it's the bp meds, or the Trilostane (as you have told me a dozen times), or really bad arthritis (as you have told me a dozen times). Lets put a gaint hex on the later shall we. And next week when I start whining again, hit me over the head.

I'm going to tell Dr Chung. Maybe she'll let me lighten up on the Trilostane. Well it's worth asking. But I'll do as she says. I'm not starting it again until tomorrow though. I need my Kira to feel better for a little longer.

[labblab]

Janis, I just checked the ACCIM website, and Dr. Diehl is listed under their "Critical Care/Emergency" department. I see that she is the vet who first gave you the feedback about Kira's ultrasound (and said that she personally would not be considering surgery at this point). Have you seen Dr. Diehl more than just the one time? Has she provided any services to you guys other than the ultrasound interpretation?

I am especially wondering about this in advance of your appointment with the surgeon. Since Dr. Diehl's recommendation was not to pursue surgery, I would definitely ask Dr. Sebestyan why he DOES think that surgery is a good idea at this time. I would take Dr. Diehl's comments along with you to show Dr. Sebestyan.

Another issue that you'll want to talk over is the potential that Kira may still have Cushing's (and trilostane) to deal with even if you proceed with surgery. It doesn't sound as if Dr. Chung is certain that Kira's adrenal tumor is actually the "culprit" in terms of producing the excess cortisol that is fueling her Cushing's symptoms. Kira may also have a pituitary tumor which is noncancerous and will never be removed, but which is the cause of her Cushing's symptoms. So removing the adrenal tumor may not cure her Cushing's and if not, she'll need to continue with medication such as trilostane for the rest of her life. I think this is also a question that you'll want to talk over in greater detail before proceeding with surgery. Just so you'll know what will and will not be accomplished by removing an adrenal tumor.

OK, those are my thoughts for the moment! I'm sure I'll have more in a few hours...;)

Marianne

[Altira]

Message from Chung:
Discontinue trilostane for now

Cool! At least I hope so.

Message from Chung:
She will need to continue bp meds @ least 2weeks prior to srgery

[Altira]

Leslie you hit the nail right on the head. With Mira boy and that bleeding liver that could rupture and doctors telling what it would be like. I just freaked out when she started coughing. I just moved her picture closer to me. I can't believe that energic little thing is gone.

Kira got El Pollo Loco chicken tonight. And there's more for her too. I seen those bright eyes today.

So what do you all think of Chung discontinuing the trilostane. That rather supprized me. I thought she might lower the dose but not this. I wonder if she thinks it's not cushings now too. Or maybe she wants me to feel better. I hope it's not just to keep me happy.

I know Marianne there is a lot to consider. Even if we still have to live with the trilostane at least that 50% chance of cancer will be gone (hopefully) I just lost a dog to cancer. Let not her death be in vain. And I have already emailed dr Deihl days ago and asked her to review the case again and see if she is still of the same opinion. And whatever Sebestyan says. No way will I decide on Monday. Thats a week from today leslie. I want my 13 years and I'd sell my house to do it damn it. Gods not going to cheet me out of this one if I can help it. I need to start a list. Help me make a list.

[labblab]

Janis, I believe you'll have to ask Dr. Chung why she's discontinuing the trilostane (and for how long a time). All that we can do is just guess. For what it's worth, this is my guess. She's relying on the info that you're supplying about how Kira is reacting to the trilostane. This is what you first wrote to her earlier today, apparently later followed with an email telling her that Kira was doing much better after not receiving any trilostane?


It's her rear end lameness and lethargy and labored walking that upsets me. Her right rear leg shakes sometimes. Something doesnt seem right. The doggie aspirin does no good. The last time I gave her the trilostane and bp meds was 6pm yesterday. She seems a bit better right now. Acting more normal...
So if Kira developed all these new problems for the first time after starting the trilostane, and is now much better after a day off -- I'd guess that Dr. Chung wants to hold off on restarting the trilostane until she's had the chance to talk with you further about the problems that you were seeing.

Marianne

[Altira]

Janis, I believe you'll have to ask Dr. Chung why she's discontinuing the trilostane (and for how long a time). All that we can do is just guess. For what it's worth, this is my guess. She's relying on the info that you're supplying about how Kira is reacting to the trilostane. This is what you first wrote to her earlier today, apparently later followed with an email telling her that Kira was doing much better after not receiving any trilostane?


So if Kira developed all these new problems for the first time after starting the trilostane, and is now much better after a day off -- I'd guess that Dr. Chung wants to hold off on restarting the trilostane until she's had the chance to talk with you further about the problems that you were seeing.

Marianne

Gosh I wish that was true but I'm doubting it. When I saw her last this is what I started off with cus it bothers me so much. But like you have told me, this can happen with this medication. However she has never told me this can happen with this medication. She thinks it is more likely arthritis being exposed. At least I think that's what she was getting at. Which unfortunily makes since. She gave me pain med for arthritis that she said would help with inflammation. But I was afraid to use it cus it had horrible reviews. I did try it twice and it seemed to do nothing. I never had that happen before. Normaly the stuff the vet gives me have little to no sideffects at least unlikely to and say they are the most widely used. Also when explaining this problem to her she seemed to think it was not a problem and I needed to move on with my list. That was the impresion I got. It's a huge concern to me. Cus If she has this surgery and she can't walk, then we would have been better off just leaving things as they are and not treat at all. Wouldn't you agree? Hope that was what you were getting at.

[Altira]

Oh yes and I do want to know why she wanted to stop. That was the first thing I thought. She didn't offer any reason or anything. She does that a lot. Will we start it up again? Is it dangerous to not have those levels right before doing surgery. Gee don't risk Kira just to apeeze me. If it's the right to do then I'll have to try to over look the fact that Kira may look like shed never servive in a million years. Or to say there is no way I will let them do it if Kira is looking so poorly. No way I would have let them do surgery yesterday, she looked like she could hardly make it across the street. Well it wasn't that bad but it wasn't the strong girl I know her to be. But then again what do I know! I thought Mira was in good shape! And she died!! 30 days later! When a dog can't get up, or walk well then all is pretty much lost. Surgery is out of the question. I'm so happy I could just spit!!

[Altira]

Ok maybe we just solved part of the mystery. Chung said to continue with the bp meds right? So I gave her one around 6pm. We just went for a walk. The old speed up, slow down thing... she was doing it really badly. She was a bit skidish too. My guess is the bp meds are doing it. I mean she would slow down to a crawl then speed up and she was plenty ready to come home. It's having a bad effect on her. I wonder if I should call acc?

[AlisonandMia]

What PB med(s) is she on?

I was once on a beta-blocker (a type of BP med but for migraine in my case) and I got something pretty similar - I'd run for a bus, say, and then have to just stop in my tracks. It was as if the med was stopping my cardiovascular system from sort of "rising to the occasion" and I couldn't sustain any sort of physical effort. I also remember it seemed to make me yawn all the time. (Didn't do anything for the migraines in my case either!)

I wonder if what she is on isn't some kind of beta-blocker or something that has a similar effect? It sounds like Kira may need a lower dose or maybe a different med.

Alison

[Altira]

Phenoxybenzamine 10mg

Wow that is weird and sounds just like what I saw.

[AlisonandMia]

Just did a bit of research (thanks, Wikipedia) and it looks like both beta and alpha blockers (Phenoxybenzamine is an alpha blocker) affect the sympathetic nervous system and this would likely be the reason for what I experienced and what it looks like Kira is experiencing. Sounds like something to ask your brother about when you get the chance.

From my recollection the experience wasn't bad - just perplexing and a case of "I'm running down the street - ooops! no I'm not!" rather than anything unpleasant, painful or frightening. I'm sure Kira isn't suffering at all and she probably just accepts this limitation and takes things as they come.

I believe that in the last couple of years treatment with this drug prior to adrenal surgery has become standard protocol and it is done to stop the big surges in blood pressure that often complicate adrenal surgery.

Alison

[Altira]

Janis, I just checked the ACCIM website, and Dr. Diehl is listed under their "Critical Care/Emergency" department. I see that she is the vet who first gave you the feedback about Kira's ultrasound (and said that she personally would not be considering surgery at this point).

FOR BOTH KIRA AND MIRA THAT IS CORRECT. WITH KIRA SHE KEPT SAYING "THIS MAY NOT BE A PROBLEM FOR HER." MEANING IT MAY NOT DEVELOPE INTO ANYTHING. SHE SAID THEY WOULD CONTINUE TO ULTRASOUND IT AND IF IT STARTED TO EVADE OTHER PLACES THEN IT WOULD HAVE TO BE REMOVED. THE PROBLEM WITH THAT IS IF IT DOES BECOME A PROBLEM LIKE IN A YEAR FROM NOW, KIRA WOULD HAVE A HARDER TIME SERVIVING THE SURGERY. IN FACT IT MAY NOT EVEN BE FEASBLE THEN. KIRAS HEART IS NOT IN THE BEST SHAPE. IF IT'S GOING TO BE DONE IT HAS TO BE NOW. IF IT'S DONE AND IT A SUCESS AND NO OTHER BAD THINGS SHOW UP. SHE'D BE CURED AND HAVE A GOOD CHANCE OF GIVING US THOSE THIRTEEN YEARS. AND AS FAR AS COST GOES THE SURGERY WOULD BE CHEEPER. WE HAVE SEBESTYAN HERE NOW TOO.

Have you seen Dr. Diehl more than just the one time?
SHE DID MIRA ON NOV 5 SHE HAD TO TELL ME ABOUT MIRA CONDITION. SHE OBVIOUSLY KNEW WHAT SHE WAS TALKING ABOUT. SHE DID KIRA ON NOV 11 AND WE SPOKE OVER THE PHONE A FEW TIMES.
Has she provided any services to you guys other than the ultrasound interpretation?
NO BUT SHE IS AN EMERGENCY ONLY DOCTOR YOU CAN'T MAKE AN APOINTMENT WITH HER. ALTHOUGH I WARNED THEM I WAS COMING ON THE 11 AND SHE MADE HERSELF AVAIABLE TO ME. SHE WAS VERY COMPASSIONATE. I SUSPECT SHE IS CAPABLE OF HANLING ANY EMERGENCY THEN HANDS OFF PATEINTS TO OTHERS LATER. SHE SPOKE HIGHLY OF DR CHUNG AND SAID THE TWO OF THEM HAD ALREADY WORKED TOGETHER ON KIRA. I LIKE TO THINK SHE STILL CHECKS IN WHEN SHE HAS TIME.

I am especially wondering about this in advance of your appointment with the surgeon. Since Dr. Diehl's recommendation was not to pursue surgery, I would definitely ask Dr. Sebestyan why he DOES think that surgery is a good idea at this time. I would take Dr. Diehl's comments along with you to show Dr. Sebestyan.
MAYBE I'LL BURN THE RECORDING OF DEIHLS REPORT TO ME ON A CD. YOU KNOW I HAVE WONDERED. ACC DOES THE DIAGNOSTICS THEN SENDS SOME OF US THE VSS FOR SURGERY. I DON'T THINK THEY DO SURGERY AT ACC. DOES THAT MEAN SEBESTYAN IS LESS KNOWEABLE ABOUT KNOWING WHAT COULD BE THE RESULT OF A HARD TO READ SITUATION. WHY IS IT HE NEVER MENTIONED TO ME THAT CUSHINGS CAN EFFECT THE KNEE LIGAMENTS? ALL HE SAID IN 2008 WAS THAT OFTEN THE OTHER KNEE DOES GO BAD TOO IN ABOUT TWO YEARS. SURE ENOUGH IT DID. HE KNEW WE HAD A FUR PROBLEM AND HE REALLY WAS CONCERNED BUT HE NEVER MENTIONED CUSHINGS. I KNOW IT IS RARE BUT WITH THE FUR PROBLEM.... HE MAY BE A WIZ WITH THE KNIFE BUT THE REST I DON'T KNOW WE'LL SEE.

Another issue that you'll want to talk over is the potential that Kira may still have Cushing's (and trilostane) to deal with even if you proceed with surgery. It doesn't sound as if Dr. Chung is certain that Kira's adrenal tumor is actually the "culprit" in terms of producing the excess cortisol that is fueling her Cushing's symptoms. Kira may also have a pituitary tumor which is noncancerous and will never be removed, but which is the cause of her Cushing's symptoms. So removing the adrenal tumor may not cure her Cushing's and if not, she'll need to continue with medication such as trilostane for the rest of her life. I think this is also a question that you'll want to talk over in greater detail before proceeding with surgery. Just so you'll know what will and will not be accomplished by removing an adrenal tumor.

WELL RIGHT FROM THE START CHUNG HAS SEEMED POSITIVE ABOUT THE OUT COME, THAT COULD CHANGE BUT YOU SHOULD HEAR HER SAY IT. AND THIS IS A CURE? I ASK AND SHE REPLIES YES! IT IS A CURE! AND I ASK HAS SEBESTYAN DONE THIS OFTEN... OH MANY MANY TIMES YES! AND HOW MANY HAVE BEEN SUCESSFUL? SHE'LL JUST SHRUG AND SAY ... ALL OF THEM! ITS VERY REASURING. SHE HAS TOLD ME THIS IS A CURE MANY TIMES. ALWAYS WITH CONFIDANCE. MAKES YOU THINK SHE IS CONFERING WITH OTHERS MAYBE OR MAYBE JUST HAS THAT MUCH EXPERANCE. YOU HATE TO THINK IT WAS ANYTHING ELSE.
OK, those are my thoughts for the moment! I'm sure I'll have more in a few hours...;)

Marianne

See CAPS above

[Altira]

Just did a bit of research (thanks, Wikipedia) and it looks like both beta and alpha blockers (Phenoxybenzamine is an alpha blocker) affect the sympathetic nervous system and this would likely be the reason for what I experienced and what it looks like Kira is experiencing. Sounds like something to ask your brother about when you get the chance.

From my recollection the experience wasn't bad - just perplexing and a case of "I'm running down the street - ooops! no I'm not!" rather than anything unpleasant, painful or frightening. I'm sure Kira isn't suffering at all and she probably just accepts this limitation and takes things as they come.

I believe that in the last couple of years treatment with this drug prior to adrenal surgery has become standard protocol and it is done to stop the big surges in blood pressure that often complicate adrenal surgery.

Alison

Bummer that means I may have to live with it. That's not going to settle well at all with me. Beings I will base my final call on Kira's current condition. How could I send her in when she doesn't even know which way is up. You know how I am. This could be a gaint wall for me and make me feel all the more worried if i allow it. Christ hells roller coaster all over again. I did call acc tonight to let them know. The said they would call back but didn't. That's ok I told them I didn't think Kira was in danger. Beings she was flopped over on her back look pretty darn confortable at the time. But to look at her walking that way it feels like she must either be having a heart attack or a stroke or is just horribly weak or some other dreadful thing. But if this condition could save her life, damn me all to hell for interfering with it! Her heart isn't the best and even though Chung said it was very unlikly ta heart attack would happen the thought sits right on the edge of my nerves. Rest asured I will be a mess.

So this stuff didn't make you fell stressed at all? Weighed down or out of breath? Maybe just dizzy? What an odd thing. We will see what Chung says. Maybe I should email her. Maybe not, then I'd have to not mention you... But thank you ever so much for speeking up!!

[AlisonandMia]

Not even really weighed down or out of breath or even dizzy - it was as if I found myself driving a car which was suddenly much less powerful than I expected. Not a sick or defective car - just a car that couldn't go that fast... It was weird. The only thing that ever concerned me really was that if I had had to leap out of the way of something dangerous I probably wouldn't have been able too - that was my only worry really - and it never happened. I only took the med for a month or two as it didn't seem to help with the migraines.

It might be worth letting Dr. Chung know what you are seeing - your brother may know what the proper medical term for it is which might help you communicate with her - and see if she thinks this means that a dose adjustment is needed or if it is just something you and Kira will need to live with for the time being.

Alison

[Altira]

You know this reminds me our our dog Sasha. She had a seisure. The first time I'd ever seen one. I was totally freaked out. If she so much as flincked I'd jump right out of my skin. The vet gave her phinabarbatol so it wouldn't happen again. But the stuff messed her up so bad she'll fall over trying to pee. The vet told me that she wasn't in pain when that happened, she didn't even know it was happening and it likley won't hurt her at all. I looked at my little girl falling all over the place and thought, I'm doing this to her just so I won't be afraid. I made myself stop giving it to her so she could live out the rest of her days as was her right. Not like this. Thank the lord she never had another one. I let her go about three weeks later I think. She was 14 1/5. I felt so blessed. Every where we went she'd be looking out the car window, even when she could hardly do it anymore she did it.

Ok Alison I'll write her.

[labblab]

Ok maybe we just solved part of the mystery. Chung said to continue with the bp meds right? So I gave her one around 6pm. We just went for a walk. The old speed up, slow down thing... she was doing it really badly. She was a bit skidish too. My guess is the bp meds are doing it. I mean she would slow down to a crawl then speed up and she was plenty ready to come home. It's having a bad effect on her. I wonder if I should call acc?
Good morning, Janis.

I've just finished reading your conversation with Alison, and I'm really glad you decided to tell Dr. Chung about this. Because if it turns out that the BP med is causing the problems you were seeing, she may think it will be safe to resume the trilostane again once the BP med is adjusted/changed.

When more than one new medication is started at the same time, it does make it harder to sort out the source of ill effects. As Dr. Chung said, Kira's ACTH stim test results were right where we'd want them to be for a dog taking trilostane. So we know that the drug hadn't dropped her cortisol level to a point where she was being overdosed. But then it does become a question of whether any new problems are the result of Kira's system just adjusting to the lower level of cortisol, vs. the "unmasking" of other problems like arthritis, vs. ongoing deterioration from Cushing's that has not yet had a chance to resolve with treatment, vs. an actual drug reaction. Glynda had earlier mentioned that another one of our members has contacted the drug manufacturer with a question about rear-end weakness that developed in her dog after starting trilostane. Here is the actual reply that she got back:


...be aware that just because hind leg weakness is listed as an adverse event that doesn’t necessarily mean that trilostane causes weakness. The FDA requires that we report everything that happens during clinical trials. Thus if a dog developed weakness related to the underlying Cushing’s syndrome during the clinical trial, it is listed as a side effect.
This just shows again how difficult it can be for anyone -- the owner, the vet, even the drug manufacturer -- to be able to definitely link up an ill effect with the cause. But this time, it sounds like you and Alison may have solved at least a part of the mystery. :)

In looking at your pictures of Kira, her poor scrawny rear end and lack of hair regrowth remind me so much of my own Cushpup. Since she does look as though she is suffering from muscle wasting back there, the BP med may not be the source of all of Kira's current weakness, though. So my "words of wisdom" for this morning are just to try to be really clear with Dr. Chung about which problems are brand new ones for Kira (since starting the medications) vs. problems you've seen before at times (although perhaps not as severely). Because that info does help to sort out the puzzle pieces.

Marianne

[Squirt's Mom]

Hi Janis,

You asked for help with a list...here's an idea that just came to me which might help you sort things out for your own mind and to share with Dr. Chung.

Just start listing all the things you see with Kira that concern you. Then, look at the list of problems you have written down and decide which ones were present before you ever heard of Cushing's and list them separately under a heading of something like "Before diagnosis". After that list is done, go back to the first list you made and decide which ones have appeared since the diagnosis and treatment, and list them separately under their own heading. This may help you see which signs have been present for some time, which have just started since treatment started, and it may help Dr. Chung determine if all these things are connected.

In my old age, I have become an avid list-maker. I have to write down the things I need to do that day or I just sit here asking myself, "What was it I was going to do? hummmmm..." So far, I am not to the point I have to write down potty breaks! :eek::p

Just a thought....

Hugs,
Leslie and the girls :D - always

[Altira]

I just talked to Sebestyan some good news

[Altira]

This was a phone conversation so I didn't get to record it damn it. We'll have to rely on my very poor memory.

The blood gas my brother was concerned with.. Sebestyan said that test was only done to get enzymes results. He said it likely sat out too long to get an correct reading of all the items listed. The part my brother noticed was not what they were looking for. Makes since to me.

Gosh he went on about so many things and I've forgotten all ready!

But he said it was ok to stop the bp meds it really isn't nessasary it is likely the reason for the rear end weakness. He said the trilostane was likely not giving her any bad effects and it is important to continue that one. I will do that!

He said they do this surgery maybe once a month. It is fairly common and most cases are worse then Kira's. Meaning they were more advanced tumor were larger and harder to remove. But there are risks that could be faital. And yes they have had to deal with those. He didnt say or I don't recall him saying they had fatalities.

ADDED:

I asked about her heart mur mur and it being enlarged a little on one side. He said it should not be a problem. He said more about it too but I forget what it was.

He said you had her checked even though there were no symptoms. Mira had given no symptoms either and look what we found in her. I wanted Kira checked out. If there was something wrong with her I wanted at least a chance to save her. He didn't say that made her chances any better really not in so many words but maybe he was hinting at that.

I'll add more here if I remember anything else.

[Squirt's Mom]

Hi Janis,

Does Dr. Sebestyan know the dose of Trilo Kira was prescribed and does he concur with that amount?

Hugs,
Leslie and the girls :D - always

[Altira]

Hi Janis,

Does Dr. Sebestyan know the dose of Trilo Kira was prescribed and does he concur with that amount?

Hugs,
Leslie and the girls :D - always

There is a zillion things I should have asked but my main reason for contacting him was the blood gas thing. I couldn't go on until my brothers concern was answered so I asked him.

So no I didn't. Do you think it's not right? If the last test had good results wouldn't it be ok? Sebestyan had all the records in front of him and he didn't mention that. So maybe we give it another go at 6pm and see what happens.

[labblab]

Janis, I'm really glad you had the chance to talk directly to Dr. Sebestyan and to clarify your questions about the blood gases!

And yes, if it were me, I'd continue with the same trilostane dosing since Kira's monitoring ACTH results were so good. There can be a wide range in the doses that different dogs end up needing in order to maintain the desired level of cortisol. So once treatment has begun, the dosing decision really depends upon the ACTH results as well as how the dog is "looking" (are symptoms improved, are there any apparent ill effects from the medication?).

Marianne

[Altira]

You know now that I think about it. Sebestyan has recent X-rays of both of kiras back legs and one front one taken just 7 months ago. If arthritis was a big concern I think he would have mentioned that. He knows her walking was a big concern of mine.

[Altira]

Yes I'm feel better at the moment. Sebestyan is a very acomadating fello. Maybe the surgery is feeling a bit scarier but at least the road to get there looks much brighter. That is what I asked him for

"I was very much hoping you might have a chance to collect all her records from ACC and have a look at them now. So I’d know better what I should be doing right now."

[AlisonandMia]

I agree with what Marianne said re the trilostane dose.

One thing you may want to consider is giving her 24 to 48 hours without either the BP med or the trilostane before restarting the trilostane - just to give you a clearer idea of what is causing what. That way you would be starting with a "clean slate" and any possible effects would be easier to see.

Alison

PS: I am so pleased that Kira has been feeling better lately and that you are getting a feeling for the direction all this is taking.:)

Overwhelmingly most of the adrenal surgeries we see here go well and result in a cure - but I'll warn you there are almost invariably a few little bumps in the road on the way - seems to be par for the course with canine adrenal surgery.

[labblab]

I do "hear" what Alison is saying about the possible benefit of waiting a little while longer before restarting the trilostane, and normally I would be totally agreeing with her. But given the fact that you may be moving forward with the surgery within a week (?), I'd follow Dr. Sebestyan's instructions explicitly. And if he wants Kira back on the trilostane today, then that's what I'd do...

Marianne

[AlisonandMia]

If the surgery is only one week off then every day that the cortisol isn't riding high is important so starting back on the trilostane as soon as you can is probably best. I think the BP med should leave her system pretty quickly anyway - it seemed to take effect quickly so that means it will probably leave the system quickly too.

The reason for lowering the cortisol is that excessive cortisol impairs healing and generally reduces fitness. Trilostane was once a human med and one of its main uses was pre-adrenal surgery cortisol lowering.

Alison

[Altira]

Well he didn't say start today. He did say that it was very important that she take it. And yes I want this done asap IF we do it. And me too I agree Alison has a good point. Cus I did just take her for a walk at 1:00 and there seemed like still some effect of the bp meds there but just how much is there of that or something else we hadn't even realized she was having.

I'm thinking maybe due to the fact I have been so wiped out over Mira that I may have failed to see other signs in Kira maybe a clean slate is a good idea. There is no way I'm going to do the surgery on Monday! So what's another day or two. Maybe start tomorrow morning? What do you think? Longer?


The surgery will be whenever i want it to be.

[AlisonandMia]

Has the surgery actually been scheduled for a particular day yet?

Alison

[labblab]

Janis, if you are seriously considering surgery -- regardless of the specific date -- then I'm not sure what you are gaining by holding off on restarting the trilostane. Since Kira's ACTH test demonstrated that her cortisol level had dropped to a very desirable level on that dose, I think you may just have to temporarily accept any non-life-threatening side effects that might arise as a trade-off in lowering her cortisol sufficiently in preparation for surgery. In other words, even if the trilostane does contribute to some hind leg weakness, for instance --that is probably not anywhere near as important to the outcome of the surgery as is lowering her cortisol. If Dr. Sebestyan has said that it is imporant to restart the trilostane, then I'm really not sure what you will be gaining by holding off on doing so. If the surgery is successful and the adrenal tumor is what is producing the excess cortisol in Kira's body, she'll never have to take trilostane again afterwards.

Marianne

[Altira]

No date has been set. We have a consultation with him on the 13th. For one thing I want to record what he says! So I can go back and think about it. Thank you clarifing why the trilostane is so important. I'll be sure to not let the surgery happen until we are satisfied with that. I sure liked the part about "it was a cure". We just went for a walk. Kira is not what she was a month ago. But maybe we should remember that she isn't trotting beside her pal now either. They did walk out front side by side. This is all different. I don't know. While walking ... Me too... I'm thinking maybe I should start again tonight. It's 6:00, we just ate, come on Kira take your meds then you can pickout a treat.

[Altira]

Dup delete please. :(

[Altira]

please delete

[Altira]

Alison

PS: I am so pleased that Kira has been feeling better lately and that you are getting a feeling for the direction all this is taking.:)

Overwhelmingly most of the adrenal surgeries we see here go well and result in a cure - but I'll warn you there are almost invariably a few little bumps in the road on the way - seems to be par for the course with canine adrenal surgery.

Boy it's nice to hear that! Are any of those threads around here? I'd love to read them.
And what were the BUMPS in the road on the way?
Before surgery? After? During?

[AlisonandMia]

The bumps in the road are usually things like the dog not wanting to eat for several days afterwards - that is always stressful for the humans involved, adjusting doses of replacement steroid - they need to be on some prednisone for a while after the surgery until the other gland kicks in and starts making enough cortisol for the body's needs and many times the dose isn't quite enough or the vets try to wean it down quickly (there are good reasons to try to do this asap) and the dog starts to feel weak and yucky from low cortisol.

Most are reported by the vets to have had some blood pressure surges during surgery as a result of adrenaline and similar hormones being released when the adrenal gland is handled. Usually this isn't a big problem but I have heard of one case where the surgery had to be abandoned mid operation because of this - it was a pheochromocytoma if I recall correctly blood pressure problems are a really big issue with pheochromocytoma surgery. I don't think anyone thinks Kira has a pheochromocytoma (doesn't cause Cushing's) so that particular complication shouldn't be a big deal for her.

This one is about a dog who had an adrenalectomy. The tumor wasn't a cortisol secreting one but another type (pheochromocytoma) - but the surgery is the same (but maybe a bit trickier). This guy just breezed through the surgery!: http://www.k9cushings.com/forum/showthread.php?t=2033


This one mentions bilateral adrenalectomy a really, really serious surgery with very complex after care - the dog did well:

http://www.k9cushings.com/forum/showthread.php?t=220

(Click on the attachment with that post not the link - the link direct to Cornell didn't work for me.)


This one is typical of a problem after adrenalectomy - working out what dose of prednisone is needed: http://www.k9cushings.com/forum/showthread.php?t=395


Sammy - another Pheochromocytoma:

http://www.k9cushings.com/forum/showthread.php?t=1041

We have some other ones from the old site that are stored in Word format that I can email to you if you like.

Ken (Buffaloe) will no doubt drop by soon (you've already heard from him briefly) and he'll be able to tell you about his Shiloh's successful adrenalectomy a bit over 4 years ago (I think). Here's a link to his thread from last year marking the 3 year anniversary of Shi's surgery: Pheochromocytoma.

Alison

[Altira]

It's been over a month since we heard about Oscar?
Sammy ..... Sob. What they went through! I wonder what his quality of life was.
I feel blue.

Kira is doing much better! Those bp pills are horrible.

[Altira]

Alopecia-X is a dermatologic disorder usually described in Pomeranian, poodle, and husky breeds. It is related to an arrest in the normal hair growth cycle and has been associated with deregulation of both growth hormone and adrenal androgen synthesis.23 In classic cases, nonpruritic truncal alopecia occurs; no other signs or changes are noted.

Many of these dogs have elevated concentrations of the precursors to cortisol, particularly 17-hydroxyprogesterone. A recent study evaluating trilostane's effectiveness in 24 affected dogs (Pomeranians and miniature poodles) reported a 90% response rate within eight weeks.24 Trilostane was given once or twice daily, with a mean dose of 10.85 mg/kg/day. No adverse effects were noted, and it was concluded that the hair growth was related to downregulation of adrenal steroid synthesis or inhibition of estrogen receptors within the hair follicles themselves.24 Three affected Alaskan malamutes showed similar positive responses when given 3 mg/kg trilostane twice daily.25

[Altira]

For the record:
Actual Trilostane given prior to ACTH STIM:

11/26 1 lml
11/27 1 lml. X 2
11/28 1 lml
11/29
11/30 1 lml. X 2
12/1 1 lml. X 2
12/2 1 lml. X 2

12/3 1 lml ACTH TEST 3.6 - 5.6 (L)
12/3 1 lml

12/4 1 lml. X 2
12/5 1 lml. X 2
12/6
12/7 1 lml. (bp meds are the problem, not the trilostane)
12/8 1 lml. X 2

[Altira]

I just collected records from Dr Sebestyan's office. I have a blood test taken on May 2010 and one on Mar 2008 that might be of interest.

[labblab]

Janis, if you want to post those results for us, please go ahead. How is Kira doing now that you've stopped the blood pressure medication?

Marianne

[Squirt's Mom]

Hey Janis,

Just popping in to see how things are going for you and Kira. Hope you are enjoying her company!

Hugs,
Leslie and the girls - always

[Altira]

Hi Marianne and Leslie... I've been lonely. Kira had a couple good days but maybe not so good now. She's going off by herself. Breathing a bit labored and she walked poorly last night. She seemed to be afraid of everything. We walked past one guy working on his car and for along way she kept turning around looking back at him all worried like she was afraid he would come after her. Then she slowed way down to a crawl and refused to go across the street. Just earlier in the day she did great. We went to dinner and took her with us and left her in the car. That's not unnormal except of course now she's all alone. She seemed ok with that though. And she started to play with Bud for a minute or so. Maybe it's just me.

She has been off the ph meds for three days and on trilostane for six straight doses. Her mouth looks red to me. Her tounge and everything.

Anyway she goes for another ACTH STIM test this morning.

I will post those blood test results. Not that I could make anything out from it. But there are some high values. I wonder if you can see the on set of cushings.

I'm going to take her for a walk now and see how she does.

[Altira]

Kira
Mar 2008

ALB. 3.9 (2.5-4.4)
ALP 76.0 (20-150)
ALT 112.0 (10-118)
AMY 515.0 L* (200-120)
TBIL 0.3 (0.1-0.6)
BUN 5.0 L* (7-25)
CA 10.5 (8.6-11)
PHOS 3.4 (2.9-6.6)
CRE 0.8 (0.3-1.4)
GLU 122.0 H* (60-110)
NA+ 147 (138-160)
K+ 4.7 (3.7-5.8)
TP 6.7 (5.4-8.2)
GLOB 2.9 (2.3-5.2)

QC OK

May 2010

ALB. 4.7 H*
ALP 300.0 H*
ALT 106
AMY 904 L*
TBIL .2
BUN 7.0
CA 12.3 H*
PHOS 4.0
CRE 0.9
GLU 118.0 H*
NA+ 152
K+ 5.0
TP 7.7
GLOB 3.0

QC OK

[Altira]

HELP I'M CONFUSED

I just got Kiras test results from yesterdays test. It's only one number this time. You know your supposed shake up the liquid first. It fills up with bubbles. Some of the bubbles get in the syringe. Could that be the problem?


Cortisol 7.2 (H). 2.0-6.0

Why is it only one number and why would it be so high? This is a different type of test? It says Cortisol level test this time.

They told me to increase her dose from 1 ml to 1.1 ml.

Last night twenty minutes or so after giving her the trilostane she started whining. She did the exact same thing tonight whining and whining. We had two good walks today. I think she just likes me worrying about her. It's working. She did eat her dinner as fast as she could and went in search for more.

[AlisonandMia]

This could be one of two things - either an ACTH stim test where only the post number was recorded or it was just a baseline cortisol test. A baseline test would have been a lot cheaper - how was the price of this test compared to the previous ACTH stim test?

Alison

[Altira]

Cortrosyn injection on both was $90

ACTH STIM was $135
Cortisol level test was $98

How are they different? The ACTH is blood taken then the injection and an hour later blood taken again and then compared right? The Level test is the injection then an hour later blood taken ? Are they chemical tested differently?

[AlisonandMia]

So they gave a cortrosyn injection each time - the first test a week ago and this latest one?

Alison

[Altira]

Yes. They charged for it each time.

[Squirt's Mom]

Hi Janis,

Just popping in to let you know I am with you in spirit today as you meet with Dr. S about Kira.

Please let us know what you learn when you can. You will do just fine with your questions and talking with him - you have learned much more than you think. Just remember to breath and make him take it as slow a needed until you understand, ok?

Hugs,
Leslie and the girls - always

[Altira]

Leslie. You are such a sweetheart. Thank you for remembering. We talked to Dr S for forty-five minutes. Poor guy. I asked near forty questions. It's all recorded. I'm going to post the actual questions asked after this and if anyone wants to know exacly what he said I would be more then happy to collect that information and post it. A lot of it is over my head.

Basically though... Pituitary cushings in addition is a concern. He said there is no proof that she doesn't have that also. He says there is a chance of complications, one of which would be fatal but she only has like a 2% chance of that. My sister was there too and she said to her he seemed to think the opperation was no big deal. That he seemed very confident about it. She liked him a lot. Well this why I did the ultrasound on Kira on Nov 11th. If something were wrong I wanted a chance to fix it and give her the best possible years to come. I want the threat of cancer gone and cushings cured. If it doesn't cure the cushings then at least the tumor is gone. So it looks like a go for right after Xmas.

Kira just crawled under my feet. She likes me to use her like a foot rest. She falls asleep and i can feel her twitching. She hasn't done this in like a year. My sweetheart. She knows we were talking about her.

[Squirt's Mom]

Hi Janis,

I am so glad you have this part behind you and a plan in place. It was great that your sister could go with you today and help in listening to what Dr S had to say. I bet her take on him was reassuring to you.

It is very unusual for a pup to have more than one form of Cushing's, but it does happen. It is my sincerest wish that this adrenal surgery will cure Kira and she has no more Cushing's signs for the rest of her life. I hope this is the cure we expect in pups with ADH.

Thanks for letting us know what the game plan is. If you want to share the conversation with Dr. S, I am sure we would benefit from it and perhaps be able to help you a bit more along the way.

Hugs,
Leslie and the girls - always

[Altira]

CONSULTATION WITH DR. PETER SEBESTYAN
VSS
TUSTIN, CALIFORNIA

(NOTE: I left out a lot of technical stuff I didn't understand)

She seems to have trouble breathing lately. More so in the last two days. *She’ll walk quickly (by choice) for two miles and not seem to have a problem. *But once at home it took many hours to return to normal once. *She’d take deep breaths now and then, like she was frustrated with it. She doesn’t seem stressed.
*He looked at chest X-ray I brought
(SHE DID IT WHILE WE WERE THERE....) HE SAID IT'S NOTHING.

This will cure her of Cushing’s?
THIS IS A GOOD QUESTION. THE FIRST THING ABOUT THE CUSHING’S WE CAN NEVER BE 100% CURTAIN. WE SPECULATE THAT SHE HAS CUSHING’S FROM THE ADRENAL GLAND BUT SHE COULD HAVE PITUITARY ALSO. THE HORMONAL TESTING WAS INCONCLUSIVE. WHICH IS NOT UNCOMMON. (HE GOT EXTREMELY TECHNICAL HERE) SHE COULD HAVE TO STAY ON TRILOSTANE. MOST LIKELY IT WILL CURE IT.

Could the other side have the same problem later?
THAT IS VERY UNLIKELY. IT'S NOT VERY COMMON.

Will her fur grow back?
AT FIRST HE SAYS YES. BUT WE DON'T KNOW IF IT'S FROM THE CUSHING’S. OTHER DOGS WITH CUSHING’S THE HAIR GROWS BACK NORMAL AFTER SURGERY. (I DON'T THINK HE MEANT ADRENAL GLAND REMOVAL) IT MAYBE UNRELATED TO THE CUSHING'S. IT COULD BE ABOUT A MILLION OTHER REASONS. WITH NORTHERN BREEDS SOMETIMES WHEN YOU SHAVE IT OFF CAN MAKE A DIFFERENCE. SOMETIMES IT COULD TAKE A YEAR. IF IT IS RELATED TO CUSHING’S THEN IT WILL GROW BACK FOR SURE. HOPEFULLY IT WILL, BUT IT MIGHT NOT.

Will it cure the muscle wasting in her rear legs?
YES

Could this end up worse then if we didn’t do it?
WELL IT'S NOT GOING TO END UP WORSE ........... THERE IS A PROBLEM WITH HER LIVER BRAKING DOWN. IT WOULD SHORTEN THEY'RE LIFE EXPECTANCY. IT COULD BE A COUPLE MONTHS. A LOT OF DOGS WITH CUSHING’S LIVE FOR YEARS. EVEN IF IT WAS UNTREATED. IF YOU IGNORED IT MAYBE IT WOULDN'T GET WORSE. IT WOULD BE NICE IF THERE WERE SOME STUDIES TO HELP THE OWNER TO KNOW WEATHER OR NOT TO PUT THEIR PET THROUGH THE SURGERY. BUT I CAN TELL YOU FROM EXPERIENCE PROBABLY NOT A LOT WOULD HAPPEN IF YOU IGNORE IT. BUT THE QUALITY OF LIFE WOULDN'T BE AS GOOD. THEY ARE TIRED ALL THE TIME…(HE MENTIONS ALL THE NORMAL STUFF). OWNERS HAVE REPORTED THAT THERE DOGS ARE BACK TO WHAT THEY WERE LIKE FIVE YEARS AGO AFTER SURGERY. SO MUCH MORE ENERGY. SOMETIMES THIS HAPPENS.

Are you satisfied with the tests ACC has done?
YES

They called us back once cus one got messed up.
OH REALLY? WHICH ONE WAS THAT?
(ME - I WASN'T PREPARED I COULDN'T REMEMBER OF COURSE.)
WELL I HAVE THIS ONE THAT SEEMS FINE...

Tell me about the blood gas test results again. What is it used for?
THERE IS NO CONCERN ABOUT THE FLAGS THERE. NO. THE ONLY IMPORTANT PART IS THE CHEMISTRY. IT'S JUST USED AS A QUICK IN HOUSE BLOOD TEST. THIS NOT A CONCERN AT ALL. SHE WILL MAKE IT FINE.

Why did the ACTH Stem come back good and a week later the Cortisol Test came back so bad?

I know it takes time for Trilostane to correct different problems, will it be the same with this?
IT WOULD BE THE SAME

Knowing what you do about Kira, do you think arthritis will be a problem for her?
NO. NO ITS NOT GOING TO BE A SIGNIFICANT PROBLEM FOR HER. (I COMPLAIN ABOUT THE PROBLEMS I HAVE BEEN SEEING LIKE WALKING STIFF LEGGED AND NOT GAINING ANY MUSCLE TONE EVEN WHEN WE ARE WALKING SO MUCH) WELL SOME OF THAT COULD BE AGE RELATED. IF IT'S FROM THE CUSHING’S THEN ALL THAT WILL BE REVERSED. BASED ON THE X-RAYS WE HAVE, ARTRITIS WOULD BE VERY MINIMAL.

What are the chances that this tumor is cancerous?
FIRST OF ALL IT DOESN'T MATTER, IN MY OPINION, BECAUSE ADRENAL CANCER IS SUCH THAT IT WOULD SPREAD EVERYWHERE. THE SECOND IS SOMETIMES WHEN THEY REMOVE IT THE PATHOLOGIST IS NOT GOING TO BE ABLE TO TELL US IF ISN'T CANCER OR NOT. SO I'M USUALLY NOT WORRIED ABOUT IT. EVEN WHEN PATHOLOGIST CALLED IT CANCER IT DIDN’T GROW BACK. SO THAT IS VERY MINIMAL CONCERN.

If we didn’t do the surgery and just used the Trilostane then your taking the risk that it is and it could spread?
WELL IT COULD SPREAD BUT THOSE DOGS THEY DON’T USUALLY RESPOND TO THE TRILOSTANE VERY WELL. BECAUSE THE TUMOR WILL JUST BE GETTING BIGGER AND BIGGER AND THERE NOT GOING TO BE ABLE TO CONTROL WITH THE TRILOSTANE AT ALL.

How many times have you done this personally?
ABOUT ONE A MONTH. I PROBABLY DO AS MUCH AS, WELL MOST OF IT. MAYBE THAT’S NOT FAIR TO SAY BUT I HAVE DONE A LOT OF THEM, CERTAINLY MORE THEN I CAN COUNT.

Have they all been successful?
NOT ALL OT THEM. BUT MOST OF THEM HAVE BEEN SUCCESSFUL.

You lose the dog while doing it?
WELL THAT HAS HAPPENED TOO. THE MORTALITY IN THIS PROCEDURE COULD BE SIGNIFICANT. THE LITACHURE SUGGESTS ABOUT 10 TO 15 % THAT HAVE SOME SORT OF FATAL COMPLICATIONS. LIKE A BLOOD CLOT IN THE LUNG, OR THEY COULD HAVE BLEEDING, OR INFECTION, OR SOME OTHER ISSUE. CAUSED BY THE EXCESSIVE CORTASOL LEVEL. IT CAUSES THE BLOOD TO COAGULATE FASTER.

So its very important to get that down ahead of time.
THAT’S RIGHT.

Will any other doctors be assisting you?
NO

How is this process done?
THROUGH THE BELLY WAY BACK TOWARD HER SPINE.

How long does it take?
ABOUT AN HOUR

How long must she stay here?
POTENTIALLY JUST OVER NIGHT. IT DEPENDS ON HOW SHE IS RECOVERING WE LIKE TO SEND THEM HOME RIGHT AWAY. (TALKS ABOUT ALL THE POST OP STUFF) BLOOD THINNING, ACTH STEM TEST, SEE IF THE RIGHT SIDE RESPONDS TO IT. IF IT DOES THEN WE DON’T NEED TO WORRY ABOUT IT. BUT MOST OF THE TIME IF ITS HEALTHY ITS GOING TO BE SUPPRESSED. THEN WE WOULD HAVE TO TREAT HER WITH STEROIDS. 6 TO 8 WEEKS. IF SHE’S EATING THE NEXT DAY AND FEELS COMFORTABLE WE USUALLY SEND HER HOME. THIS IS A SMALL TUMOR SO I REALLY DON’T FORESEE ANY MAJOR COMPLICATIONS. I WOULD FORESEE THAT IT WOULD COME OUT VERY QUICKLY.

Tell me about the possible complications again.
THE BIGGEST ONE IS THE BLOOD CLOT, THERE ALL LOTS OF BENIGN ONES (HE LISTED THEM)

There are people here around the clock to check on her?
SHE WILL PROBABLY SPEND THE NIGHT ACROSS THE STREET AT ACC. THEY HAVE A DOCTOR THERE ALL THE TIME.

Are her chances better because she has no other known serious illnesses?
YES, FOR SURE.

How long is recovery time once at home?
HOPEFULLY FROM THE SURGERY SHE WOULD RECOVER VERY QUICKLY LIKE IN TWO WEEKS. MOST LIKELY IF IT’S TRULY THAT ADRENAL CUSHING’S SHE’S GOING TO HAVE TO BE ON STEROIDS FOR TWO MONTHS. AND PERIODIC RECHECKS. THIS COULD BE MORE SEVER THEN THE CUSHING’S.

How do you know her cortical level is low enough?
RIGHT UP TO THE SURGERY WE WILL TEST HER. HER LEVEL WAS A 7 SHE PROBABLY HAS TIMES DURING THE DAY WHEN ITS VERY HIGH DESPITE THE MEDICATION SO I DON’T THINK THE MEDICATION IS VERY EFFECTIVE AT ALL. IT WONT HURT BUT

Bp meds first?
ITS MAINLY NEEDED IF SHE HAS A DIFFERENT KIND OF ADRENAL TUMOR. WE HAVE NO REASON TO BELIEVE SHE HAS THIS. SHE DOESN’T HAVE EXTREMELY HIGH BLOOD PRESSURE. IF SHE HAS ISSUES WITH IT THEN DON’T USE IT. I FEEL VERY CONFIDENT SHE DOESN’T NEED IT.

Kira breezed through the first tta two years ago but the second was harder on her. (Maybe because of Cushing’s?)
POSSIBLY. CUSHING’S IS SOMETHING THEY COULD HAVE FOR YEARS. SOMETIMES EVEN THE CUSHING’S BEEN SORT OF SPECULATED COULD PREDISPOSE THEM TO ? LIGAMENTS. BECAUSE THE MUSCLE AND THE LEGS THEY ARE KIND OF AWKWARD……

How fast could the tumor grow?
THESE ARE USUALLY SLOW GROWING TUMORS.

How soon do we need to do it?
WELL ITS NOT AN EMERGENCY. I GUESS IT’S MORE OF A QUESTION OF KNOWING ALL THESE DETAILS ABOUT IT TO MAKE A DECISION WHETHER TO DO IT OR NOT. IF YOU DESIDE THAT YOU ARE GOING TO PERUSE IT THEN I WOULDN’T PUT IT OFF

I want this tumor out of her, I want the cancer out of her, and to make her as well as she can possibly be. And I’m thinking it should be done as soon as possible. And I think it may be right after Xmas.
YEAH. NO I DON’T THINK IT WOULD BE AN ISSUE TO WAIT THAT LONG

Is her current weight a factor?
NO DON'T PUT HER ON A DIET RIGHT NOW. SHE’S A LITTLE BIGGER THEN THE LAST TIME I SAW HER BUT… I DON’T THINK SHE IS THAT BAD REALLY. MOST DOGS WITH CUSHING’S ARE MUCH MUCH MUCH HEAVER THEN KIRA. I WOULDN’T FEED HER MORE THEN YOU NORMALLY DO.

Rechecks?
CHECK HER IN TWO WEEKS PUT HER ON STEROIDS DO A ATCH STEM TEST THEN ALTERNATE DAYS TO TAKE STEROIDS THEN CHECK HER AGAIN WHEN SHE’S OFF.

Cost?
$4,800 to $5,300. Yikes!!!

If she were a human, there would be no question about doing this?
OH YEAH THAT’S THE STANDARD. IT’S CONSIDERED A ROUTINE SURGERY IN HUMANS. DOGS HANDLE ABDOMINAL SURGERY VERY WELL.

In the future I plan to get my dogs yearly blood tests and if something looks weird then have an ultrasound done.
YEAH YEAH THAT SEEMS REASONABLE.

Is there anything I’m forgotten?
NO THAT’S …. EVERYONE LAUGHS. WELL YOU WANT TO BE PREPARED, SO THAT’S GOOD.

Well I think that we should do it and do it soon but I’m scared to death.
WELL SURGERY IS ALWAYS VERY SCARY

In my opinion she is not in as good a shape as she was 7 months ago. I don’t know if it’s the Cushing’s or she’s getting older or it just took a lot out of her or what. I felt a lot more confident back then then I do now but you don’t suspect that anything would go wrong?
WELL I DON’T SUSPECT IT AND ALL I CAN SAY TO MAKE YOU FEEL BETTER IS THAT THE CHANCES OF SOMETHING BAD HAPPENING TO HER IS EXTREMELY SMALL

And the chances of her being a lot better are good?
ARE GOOD YES. I WOULDN’T HESITATE TO DO IT. IF SHE WAS MY OWN DOG I WOULD DO IT. ESPECIALLY WITH THAT SMALL TUMOR, IT’S TECHNICALLY NOT GOING TO BE THAT DIFFICULT TO GET OUT OF THERE.

[Altira]

Hi Janis,

I am so glad you have this part behind you and a plan in place. It was great that your sister could go with you today and help in listening to what Dr S had to say. I bet her take on him was reassuring to you.

It is very unusual for a pup to have more than one form of Cushing's, but it does happen. It is my sincerest wish that this adrenal surgery will cure Kira and she has no more Cushing's signs for the rest of her life. I hope this is the cure we expect in pups with ADH.

Thanks for letting us know what the game plan is. If you want to share the conversation with Dr. S, I am sure we would benefit from it and perhaps be able to help you a bit more along the way.

Hugs,
Leslie and the girls - always

He talked for 45 minutes straight and got really complicated I'm sure that at least some of it would be of use here and I sure to want to share that with you. Gosh thats the least i could do!

[Squirt's Mom]

I bet as the day passes and maybe even tomorrow, you will start to recall some of the things he said in response to these questions you posed to him. As you do, write them in so you can remember them later then fill us in, ok? There's no rush right now so just as you remember things jot them down then you can share them with us rather than trying to get it all now. Lord, I'd never be able to do it all at one time! :rolleyes: And I have to write things down as they occur to me or they may well be lost forever! :o:p

Do you feel better after talking with him today?

Hugs,
me

[Altira]

Actually I recorded the whole thing so I have his exact word on everything. See above post..

Yes I do feel better about it. But there is always something that doesn't set right. Like conflicting views between what Chung said, Deihl said and what Sebestyan said. Even some of what Sebestyan said today was different then what he said over the phone. I liked he's first answer better. He said she needed to lower her cortisol level before surgery so she would heal better. To keep taking the trilostane. Chung seemed to concur with that. But today he says it's not important.

I'm thinking it would be better to keep her on it to ward off the bad effects of cushings. Surgery is at least three weeks away and maybe she is a little bit brighter and playful now. Maybe it's helping. ANY COMMENTS ON THAT?

I was in favor of surgery before we went but yes Sebestyan did help me feel better about it. So did my sister being there and her opinion of it. Plus I made Bud go to so he'd know just what we are facing and the possibility that she could have a better rest of her life from it. Just yesterday he was saying that she isn't sick at all. Now he knows and that helps a lot too.

[Altira]

HELP! Kira has diareha! Horrible smelling stuff. She went in the house last night way at the other end of the house and the smell woke he up! I have called ACC. In fact I told Chung about five days ago that I suspected she saw getting it.

[Squirt's Mom]

Janis,

Do not give any more Trilo for now. "Never give Trilo to a sick pup" is one of our mantras.

If you have some plain pumpkin, NOT the spiced pie kind, give her a tablespoon of the plain pumpkin. No more...1 tbsp. And wait for the vet to call.

Is there any blood in the stool? You can't always see the blood but if any is present, the smell will be distinctive, different from usual diarrhea and very strong.

If you have any Pedialyte, she may need that later on if it doesn't get better. Just the plain, unflavored kind.

Hang in there! We are here....

Hugs,
Leslie and the girls - always

[Squirt's Mom]

Over the last few days have you seen anything else unusual? Loss of appetite? nausea? shaking/weakness in the rear end more? sleeping more? less responsive?

[Altira]

Thank you for being here Leslie!
No Kira has had no other signs of ill effects since stopping the bp meds. In fact she seems a little better. Maybe a little concerned about potting in the house. I did not give her the Trilostane at 6am like I Normaly do. I didn't feed her either. She is laying here right now flopped over on her back looking perfectly comfortable.

I haven't heard anything from Chung but Sebestyan called right away after receiving my "cc" fax to him. He said to keep her on the Trilostane but be sure to talk to Chung today. He also said to give her the metronidazole that was just given for Mira for five days. You would not believe all the pills I have left from Mira. I have like hundreds of tramadol! It seems like such a waste. I was so hoping to keep her here longer then just twenty two days. Sob

Sebestyan said today was his day off but there he was at work bright and earily.

[Squirt's Mom]

Hi sweetie,

I'm glad Kira seems to be feeling a bit better. Bless her heart....any time Squirt has been sick and made a mess in the house, she seemed so embarrassed about it. :( Poor little Trink has been making so many messes lately I guess she's about to get used to it...but I'M not! :p;) Wakin' up in poop is not my idea of a good start to the day! :eek::rolleyes::p

I personally don't agree with Dr S when he says to keep her on the Trilo while she is sick....but I am not a vet. If she were mine, I would withhold the Trilo until she had solid stools again, but that's just me. You do what you feel is best for Kira.

Let us know how she is doing, ok?

Hugs,
Leslie and the girls - always

PS. One of my Angels, Crys, has really been on my mind a lot these past few weeks. I always miss her...she was less than 2 yrs old when she was killed by a car and the guilt still eats at me sometimes...I let her out and she took off after a squirrel. :( My beautiful, golden-eyed girl....

[Altira]

Hi sweetie,

I'm glad Kira seems to be feeling a bit better. Bless her heart....any time Squirt has been sick and made a mess in the house, she seemed so embarrassed about it. :( Poor little Trink has been making so many messes lately I guess she's about to get used to it...but I'M not! :p;) Wakin' up in poop is not my idea of a good start to the day! :eek::rolleyes::p

GET YOURSELF A "LITTLE GREEN MACHINE" MADE BY BISSEL. I ALREADY WORE ONE OUT OVER THE YEARS. IT MAKES CLEANING UP SO MUCH EASIER!

I personally don't agree with Dr S when he says to keep her on the Trilo while she is sick....but I am not a vet. If she were mine, I would withhold the Trilo until she had solid stools again, but that's just me. You do what you feel is best for Kira.

THE PROBLEM WITH THAT IS SHE'S DUE FOR SURGERY IN ABOUT TWO WEEKS AND IT'S VITAL THAT WE GET HER CORTISOL LEVELS DOWN AS BEST WE CAN.

Let us know how she is doing, ok?

Hugs,
Leslie and the girls - always

PS. One of my Angels, Crys, has really been on my mind a lot these past few weeks. I always miss her...she was less than 2 yrs old when she was killed by a car and the guilt still eats at me sometimes...I let her out and she took off after a squirrel. :( My beautiful, golden-eyed girl....

See above in caps...

Christ Leslie and I thought I had it bad! I can not think of anything more painful then the things you have been through.

Bud leaves the front door open and I get so mad at him. WHAT? They aren't going anywhere with me right here! Yeah well it would only take one dog, or a cat, or even a bird to go by and they'd be gone!!! God Leslie I'm so sorry.

[Buffaloe]

Hi Janis,

It sounds like you had an excellent consultation with your surgeon. Pretty much everything he said is consistent with what my surgeon told me about Shiloh's tumor, adrenalectomy, etc.

My surgeon felt it was imperative to lower Shiloh's cortisol level prior to surgery. Cushing's dogs do not heal well because of the high cortisol. Hence, the Trilostane is important. It will not effect the adrenal tumor but it will lower her cortisol level by interrupting the pathway between the adrenal and pituitary glands. My surgeon told me they have an 85% long term success rate with these types of surgeries. Shi's tumor was much larger than Kira's.

Shi had occasional bouts with very loose stools but always got over it in a day or two. I never worried about it but I took her outside frequently.

Your estimate for the cost of Kira's adrenalectomy and follow-up care is reasonable. Shi's stayed at the hospital with 24 hour veterinary care for three days after her surgery. It took her that long to recover and to eat well. As soon as I got her home I could tell she was so much better than she was before the surgery. But, we took it real, real easy for the first ten days or so, there was alot of healing going on. She took prednisone, a baby aspirin and vitamin A for two weeks....that's it. A month after Shi's adrenalectomy she was a totally happy, healthy dog with a great quality of life.

All the best to you and Kira.

Ken

[Altira]

Ken, boy it's nice to have your input. Thank you so much!! Im sure you told me but how long ago did you have it done? How old was she then? And how is she doing now?

My husband asked if she had a real long incision?*

[Altira]

I talked to Dr Chung. She agreed with the metronidazole. In my fax to her I mentioned that when Kira was very young she had a big problem with diarrhea whenever we boarded her. Sometimes it was bloodily. Chung reminded me that old issues could be getting unmasked and we decided to change her back to the food she ate for years. I changed her to a salmon food recently which she seemed to handle just fine but maybe it's proving to be too rich for her. We decided to go back to Science Diet Light. She asked when surgery might be and she seemed very happy it would be soon. She also said to keep going with the triolstane she doesn't think that is what the problem is. I think I agree. We'll give this a chance and see. Other then the diarrhea Kira seems fine. She just flopped over on her back again laying here between bud and I. Awe...

[Altira]

Since all the tests are in and the consultation with Sebestyan is posted what does everyone think about the surgery? Do it or not?

I think Sebestyan said there was no way to know if it's pituitary? I get confused. I read over the last half or so of the thread and saw things that made me think differently. Of cause now I don't remember what they were. I hate that, I can learn stuff but it's a real struggle. I have to read stuff over and over and make notes and I still get confused. I'd sure like to get everyones opinions, simple ones if possible. Wish I could remember the good points against were.