View Full Version : Tough Question with 15 year old Dog
Our Maizie was a rescue, probably between 14-16 years old. She's a mix with some Jack Russell for sure. Here's the dilemma -- after years of elevated liver enzymes, she suddenly started drinking excessively, had polyuria AND incontinence (waking in a puddle of urine). The 8 hour acth test revealed pituitary Cushings. After the test, we realized the sudden onset might have something to do with the new kibble we were using because we couldn't find her usual. We switched back and her water consumption went down (though still more than normal), fewer home accidents, more walks. The incontinence however remained. She just started on trilostane (3rd day). So far no bad side effects and she may drinking less -- but she still has the be-wetting even when she's just been walked or hasn't been drinking. So I suspect this may have more to do at this point with the condition of her bladder and muscle control than how full it is. Does anyone have a positive story specifically about the incontinence stopping after trilostane in an older dog? How long did it take to kick in? If not, then is anyone using trilostane AND something else for incontinence? I'm going to be frank here, given her age and the outcomes, I'm not sure if we want to go on with this if she will always be incontinent. AND she's not a dog who "does well" at the vets. She was a rescue and after years is still fear aggressive. I don't think she would accept diapers. Anyone have any good news to share?
littleone1
08-29-2011, 05:38 PM
Corky and I want to welcome you and Maizie.
Has Maizie been checked for a UTI (urinary tract infection)? These are very common with our cushpups.
Corky is 14+ and has had cushings for over 3 years. He's been treated successfully with Trilostane for almost 2 years. His symptoms did go away, and he returned to his normal self. The only time he's had accidents in the house now, is when he's had a UTI.
Terri
lulusmom
08-29-2011, 05:38 PM
Hi and welcome to the forum.
I'm sorry for the circumstances that brought you here but I'm very glad you found us. Bless you for adopting a rescue. I am a small dog rescuer so I am always thrilled when somebody adopts from a shelter or rescue. Either way, you saved a life. :D:D:D Now let's talk about cushing's.
Did your vet do any other tests besides the LDDS to diagnose Maizie? Can you please collect copies of all of the tests that were done and post the results here, including the normal reference ranges? With respect to the bloodwork, you only need post the abnormal values. With Maizie having PU/PD, your vet should have done a urinalysis, including a culture. Most dogs with cushing's have dilute urine but normal dogs that are simply incontinent due to age have concentrated urine. I have a dog with chronic PU/PD and I've dealt with it for a number of years. He isn't incontinent but he drinks and pees buckets in his waking hours. His pee is as clear as water and thank goodness, has no smell. Is Maizee's urine still dilute?
Did the incontinence start when all of the other symptoms started? If yes, then it would seem that excess cortisol could be the cause but only time and an acth stimulation test will tell. When is Maizie scheduled for her first acth stim test?
Glynda
These two replies are good to hear. I'd love to hear more good news. The vet is very thorough (also ridiculously overpriced). The first thing they did was a urine culture. No uti. They also did the long ACTH test (8 hours) to confirm the diagnosis. The bed-wetting started with the other symptoms, though I think it might have started a little earlier and we thought it was drool. It isn't very concentrated and doesn't smell like her old accidents. We feel that her quality of life is still good, and if she doesn't completely freak out at the repeated tests, OR fail to respond to treatment OR have terrible side-effects, we're fine with the cost. The fear that I have is that she won't regain bladder control (especially when sleeping) so it's good to hear that this may resolve as well. Any idea of a timeline assuming she's on a good dosage?
She should go in for a 2 hour ACTH test in about a week. (10 days between starting and the test unless we see any problems before).
lulusmom
08-29-2011, 07:55 PM
Every dog responds differently so it's difficult to say when you may expect resolution of all symptoms. Some symptoms resolve within a few days and others take longer. The excessiving drinking and peeing usually improve rather soon once the cortisol is reduced to an acceptable level but sometimes, depending on how long the dog has had PU/PD, it can take a few weeks. Muscle wasting, coat and skin issues can take much longer to see improvement.
The 8 hour test your vet did is called a low dose dexamethasone suppression test (LDDS) and this particular test can very well yield a false positive result in the face of nonadrenal illness or stress. If Maizie gets stressed at the vet's office, this concerns me. Cushing's is the most difficult canine disease to diagnose which makes it one of the most misdiagnosed diseases. Unfortunately, the acth stimulation test and LDDS test can't be relied upon to be 100% accurate as false negatives and false positives are common. If only we had one test that could tell us everything. :(
Physical symptoms are a huge component of a diagnosis and Maizie doesn't seem to have many of the symptoms associated with cushing's. :confused: Does she have a voracious appetite? Does she pant? Any muscle wasting? Any skin or coat issues?
It will really help if you get copies of all testing and post results. I'm hoping the urinalysis included checking the urine specific gravity (USG) Dogs with cushing's usually have low USG.
Glynda
P.S. Acth stimulation tests are very expensive, especially if your vet is using cortrosyn as the stimulating agent. Not all vets area aware that if a dog is smaller, they can get more than one stim out of one vial of cortrosyn. Dr. Mark Peterson explains all of this in his blog. http://endocrinevet.blogspot.com/2011/03/how-to-extend-your-supply-of-cortrosyn.html Be sure to discuss this with your vet. It will definitely be worth your time.
I do trust the dx. She's had elevated liver enzymes associated with Cushings for years. They tested for thyroid, uti's, etc. And they did test her USG levels. She's always had a voracious appetite so that would be a tough one. She had increased shedding (even for summer) and lost significant hair on her back flanks. She has increased panting. Also her face has a bony appearance. She's part Jack Russell. What she doesn't have is a pot belly and prior to a few weeks ago she didn't have excessive thirst and was able to wait up to 8 hour stretches to relieve herself, although she always had some issues. Part of the reason we waited on the LDDS was because we thought the liver enzyme thing could be due to "vet stress." The vet had suggested it about three years ago, but given that we weren't seeing other symptoms, we said no then.
I know the tests will be expensive. Believe me! Prior to this we were on the verge of vet shopping as we also have two cats and in the last couple of years, the vet practice has raised their prices through the roof. Of course, things always happen before you act! At this point, given that at least we can find parking by the vet's, and it's close by (we live in NYC), we feel we should stick to them for the dog. (I'm still shopping for the cats.) However, assuming the vetoryl works, I will INSIST that we get it online and not their overpriced pharmacy. It's not worth talking to them about their protocols. They are pretty insistent.
lulusmom
08-29-2011, 08:49 PM
I do have a habit of confusing people so I apologize if you felt I was suggesting that you change vets. I was not. I was suggesting that you ask your vet if he uses cortrosyn as astimulating agent and if so, is he aware that only 5 μg/kg of cortrosyn is necessary. Small to medium sized dogs, which I believe Maizie would be, requires only a fraction of the ACTH contained in each vial so your vet could store the remaining amounts for future acth stimulation tests. That would be a big savings to you and I can't imagine that your vet would have a problem with that. If he does, then I wouldn't hestitate to suggest that perhaps you might consider asking for a referral to Dr. Mark Peterson. He is a world reknown cushing's expert/endocrinologist and he is located in NYC. We have a number of members who have taken their dogs to him or have had phone consults.
Thank you for the additional information regarding the conditions your vet ruled out and the additional tests that were done. It would still be helpful if you could post test results.
D'oh! As Homer Simpson would say. I trust my vet medically, but I don't trust them to do anything that would save money. Maizie is more medium with biggish body and relatively short legs. But the d'oh is for Mark Peterson. You are the second person to recommend him. The first was another neighborhood vet who I consulted to find out HIS protocols for treatment (and get an idea of his prices). Peterson is actually geographically closer to us than our vet. I realize that it's a bit tricky because of Maizie's age, and I may consider calling Peterson as this is the second referral, but I'm not sure if it's the question is really about the type of treatment at this point. I came across an article in JAVMA talking about using blood cortisol levels vs ACTH for monitoring, but our vet was dismissive. I think from Maizie's point of view, ANY vet is a torturer. My concern isn't so much whether or not it's cushings, and more will the bed-wetting clear up on vetoryl, or is she so weakened by cushings, age, etc. that those muscles aren't coming back. And how long might it take to figure that out. She's waking up looking guilty and confused. I'm trying not to react to the puddles emotionally. I've lined all her beds with mattress underpads and may be buying some washable ones. Maybe because of my own experience with my parents, I really see incontinence as a sign of systematic failure, but I know it's different for dogs.
lulusmom
08-30-2011, 12:04 AM
Dr. Peterson is an amazing internal medicine specialist who has contributed greatly to many of the medical text books that are used in veterinary teaching hospital today. He is a sought after lecturer at veterinary conferences on all conditions involving the endocrine system and contributes to Dechra's (manufacturer of Vetoryl) veterinary continuing education site. There are few veterinary professionals that know more about Vetoryl (Trilostane). I suspect that Dr. P could give you a more definitive answer about the cause for Maizie's incontinence.
Since adopting Jojo, we keep washable, waterproof hospital pads down and I launder them daily. The good news is that Jojo uses them and so do the other four if they can't hold it. I have one furbutt on a diuretic too so he is peeing and drinking a lot too. I need to buy a horse trough; however, all my dogs are vertically challenged so it would have to be modified. :D
Sophie
08-30-2011, 12:23 AM
Here is my two cents even though I am new to Vetoryl treatment. I think the incontinence is due to the water consumption more so than weakening of the bladder. I would assume that as the Vetoryl kicks in and the water consumption is reduced so will the accidents.
As far as it being a sign of systematic failure. I was told by my vet that female dogs are more prone to incontinence, which happened to another one of my previous dogs. She was given some medicine. I can't remember what it was, but it solved the problem right away. I'm sure your vet will be able to give you something. But be patient with the vetoryl and give it some time to work.
Sophie
StarDeb55
08-30-2011, 12:45 AM
I think the incontinence is due to the water consumption more so than weakening of the bladder.
I wanted to expand on this comment. Our pups drink gallons of water because their kidneys have lost the ability to concentrate urine due to the constant bombardment by excess cortisol. With the kidneys overproducing urine, our pups must drink excessively to keep up with the urine production or they can become dehydrated very quickly.
I wanted to offer a late welcome to you & Maizie. I have not used trilostane, but wanted to let you know that I have successfully treated to cushpups, now, both with lysodren. My last little boy was diagnosed at 13, & was flooding the house at points. I could tell when his cortisol was climbing for sure, because the accidents in the house would take a major upswing. I ended up purchasing the washable incontinence pads, setting up a portable playpen type kennel in my living room, lining the floor with these pads. This is where my Harley stayed when I had to leave the house. This system worked very well. I, also, would put out disposable piddle pads in a couple of the areas that were most prone to receive accidents when the pups were allowed out & about in the house.
Debbie
Casey's Mom
08-30-2011, 01:02 AM
Hello and welcome to our forum! My dog has been treated with Lysodren for Cushings for 2.5 years and her incontinence has disappeared (she is 15 1/2). It took about a month but the incontinence did go away once the cortisol was reduced. I have read here that they drink more water because cushings makes them urinate more - not the other way around. Therefore it is very important not to restrict water intake.
Good luck - you are on the right track!
Yes, I asked my vet about restricting water-intake and she set me straight immediately. Again, it's very good to hear that improvement with the bed-wetting is likely. For now I've set out a lot of disposable underpads for Maizie to rest on, but she keeps rearranges them usually with the padding as a pillow for her head! This weekend I'm going shopping for crib size mattress covers. If I could just get her to rest on them, half the problem would be solved! Meantime, her water consumption while still high, is already down from what it was. We've upped the daily walks from 3-4 (depending on timing) to 5 or 6, and so far no accidents this week except the sleeping ones.
Keiko's Mom
08-31-2011, 10:40 AM
Hi. My Dog, Keiko, has Cushings and is going on eleven years old. She does not have any incontinence. My first husky, Chantel, lived to be sixteen and she did have bedtime incontinence. As she got older, her bladder would empty while she was sleeping. I used plastic sheeting under her bed and washed her bed every day. My vet used a small dose of DES (diethylstilbestrol) on her to help manage it. This was in the 80s....I don't think I would use it with a dog with Cushings, but you might want to research it. Sleeping time incontinence seems to be common in older spayed females, even without other health issues. Chantel's only health problem before this, was that she had epilepsy, which started when she was about five years old. It's not that hard to wash the bedding.....don't give up on your baby, unless you have no choice.
Jenny & Judi in MN
08-31-2011, 10:51 AM
that may be the hormone Jenny takes for her incontinence. I had asked both my vets about it in relation to her diabetes. Guess I will ask again tomorrow during her ACTH.
I know this vet was hoping we could get her off the hormone once we got her on a maintenance dose for her Cushings and Diabetes.
hmm
I think what's both surprised me and scared me, was how suddenly her symptoms started. I'm still trying to balance the road ahead versus how much time she has left -- quality of life etc. It's good to hear that with the meds, the symptoms might abate in a month.
My Alivia, 13 1/2 year old Jack Russell Terrier, had a night time incontinence problem for a very short time. Turned out it was a blood pressure medication she was on and as soon as they changed the med the problem ceased and has never occurred again. Unfortunately, I can't remember the name of the med, but it was not "supposed" to cause that problem and yet it obviously did. Is she on any other medications besides the Vetoryl? Sometimes medications can cause side effects even though they are not common. I hope Maize improves!
She's been on a small dose of prosac for years, but I don't think it would cause the incontinence. It's only been 5 days on the Vetoryl, so I probably have to give it at least two weeks. The vet thinks it's simply that her bladder is too full from all she's drinking. It's just driving me nuts. We don't live in a big apartment. The good news is I filled her water bowl when I gave her dinner a couple of hours ago, and there's still about half left. That's a change from earlier in this week.
Edited to update: Now day 8 of vetoryl. This morning I overslept. When I woke up Maizie was ready to go out and amazingly her hindquarters and the padding she slept on were DRY. This the first time that's been the case in at least the last three weeks. She seems a bit more chipper as well. I'm feeling very relieved. Will post again with another progress report. ACTH is on Tuesday.
Maizie who is newly diagnosed is supposed to have her 10-day ACTH test on Tuesday. I had scheduled bringing her in at 1PM that day as I have an early work meeting and wouldn't be able to drop her off in the morning and get there on time. I had a conversation about the 1PM time. I got a message on my phone from the vets saying that drop-off time was between 7:30 and 8:30 and she shouldn't have any food after midnight. They are closed now until Tuesday morning.
First, I was told this was a 2-hour test and that they may not get around to it precisely on time, so to allow more time, but they are open till 8 pm so I think 1:00 would be sufficient. Second, I'm confused about the no food after midnight thing. According to the info with the Vetoryl packet, the dog is supposed to have taken the meds within 4 hours of the test AND she's supposed to take it with food, so which is it. My guess is whoever called (it wasn't the vet) didn't have the correct information, but I can't correct it until Tuesday morning, when I tell them I can't make it before 11 AND she's already eaten so if they need a fasting it will have to be the next day.
I'm not worried about Maizie as so far no bad side-effects that I can see and we're already seeing some improvements. But can anyone more experienced set me straight about the fasting/no-fasting and how long the 2 hour test actually takes?
Harley PoMMom
09-04-2011, 10:29 PM
Remember that the ACTH stimulation test is the most useful test for monitoring dogs being treated with trilostane (Vetoryl) or mitotane (Lysodren) see my blog entitled, Diagnosing Cushing's disease: Should the ACTH stimulation test ever be used? Both medications are fat-soluble drugs and must be given at time of meals, or the drugs will not be well absorbed.
With trilostane, it’s extremely important to give the morning medication with food, and then start the ACTH stimulation test 3 to 4 hours later.
Fasting these dogs on the morning in which the ACTH stimulation test is scheduled should be avoided since it invalidates the test results.
This is an excerpt from Dr. Mark Peterson's blog about the ACTH stim test, you can find this info and more here: What's the Best Protocol for ACTH Stimulation Testing in Dogs and Cats? (http://endocrinevet.blogspot.com/2011/03/whats-best-protocol-for-acth.html)
apollo6
09-05-2011, 01:00 AM
Hi
Glad to hear Maizie is doing better. As you read my Apollo has been on Trilostane since last year.
Hope this helps in describing an Ach stim test.
You would give the TRilostane in the morning eg. 8a.m. with food (see below) then between 4 and 6 hours after the Act stim test would be given. It is two parts first one blood test is taken, then one hour later a second one is taken after the dog is injected with Corysten. Two reading are given and the range for each is also given. I always ask for a copy of the tests. After all you are paying for it and it is a good reference for any further Acht stim tests.
http://www.k9cushings.com/forum/newreply.php?do=newreply&noquote=1&p=61025
With trilostane, it’s extremely important to give the morning medication with food, and then start the ACTH stimulation test 3 to 4 hours later.
Fasting these dogs on the morning in which the ACTH stimulation test is scheduled should be avoided since it invalidates the test results.
Fasting these dogs on the morning in which the ACTH stimulation test is scheduled should be avoided since it invalidates the test results.
http://www.idexx.com/pubwebresources/pdf/en_us/smallanimal/snap/cortisol/cortisol-acth-stimulation-protocol.pdf
Hugs Sonja and Apollo
labblab
09-05-2011, 11:12 AM
Since the monitoring ACTH is such an important and also expensive test, you may want to call first thing tomorrow and reschedule it to a day later in the week so as to first make sure that you and the vet are on the "same page" as far as the timing and also the issue of fasting. As Lori and Sonja have said, both of these considerations are very important in making sure that the test has appropriate monitoring value. Just to add a bit more from Dr. Peterson's endocrinology blog (http://endocrinevet.blogspot.com/2011/03/whats-best-protocol-for-acth.html) that Lori has already referenced:
With trilostane, it’s extremely important to give the morning medication with food, and then start the ACTH stimulation test 3 to 4 hours later.
Fasting these dogs on the morning in which the ACTH stimulation test is scheduled should be avoided since it invalidates the test results.
When a dog ‘s food is withheld, the absorption of trilostane from the gastrointestinal tract is decreased. This leads to low circulating levels of trilostane, resulting in little to no inhibition of adrenocortical synthesis. Therefore, serum cortisol values will higher when the drug is given in a fasted state than when it is given with food.
The higher basal or ACTH-stimulated cortisol results could prompt one to unnecessarily increase the daily trilostane dose. That misjudgment may lead to drug overdosage, with the sequelae of hypoadrenocorticism and adrenal necrosis in some dogs.
It is true that certain blood tests will be skewed if a person or dog has eaten a fatty meal prior to the testing. So a vet may legitimately want a dog to be fasted prior to certain other tests. But based on Dr. Peterson's recommendation, monitoring ACTH testing for dogs taking trilostane should be based on dosing beforehand along with a meal, and NOT after a dog has been fasted.
As far as the timing of the test, if your vet has told you that it will take two hours to perform, they are likely using ACTH gel as opposed to Cortrosyn as the stimulating agent (Cortrosyn only requires one hour between the two blood draws). I will advise you that many specialists in the U.S. prefer Cortrosyn when they can obtain it since they feel it gives more consistent and accurate results. But regardless, if your vet is using ACTH gel, the test will take a maximum of two hours. Therefore, per the recommendations of Dechra (manufacturers of Vetoryl), the test should be conducted within that 4-6 hour time frame after dosing when the Vetoryl is having its maximal effect. For safety purposes, it is important to know what Maizie's cortisol level is at its lowest point. And in judging the appropriateness of making a dosing change, it is important that you are comparing apples-to-apples with the standard, accepted monitoring protocols based upon assessing the cortisol at its lowest level.
I'm hoping that the confusion over Maizie's test can be easily cleared up. Perhaps the assistant who left the phone message is more familiar with ACTH testing in conjunction with dogs being treated with Lysodren, but timing and food intake are both VERY important for "trilostane dogs," and you want to make sure that it is all settled before spending your money on such an important test.
Marianne
Keiko's Mom
09-05-2011, 11:34 AM
Hi. You are being well advised by everyone here about the testing. The girls at my vet's office told me that it had to be a fasting test. I double-checked with Dechra and set them straight. Keiko has Vetoryl and food at 11am....has first blood test at 3pm (I take her back home, so she's not stressed and stuck at vets) and return to have test done at 4pm. Fasting blood draws are best for most testing, but not our Cushings babies on Vetoryl. If you don't give food with the medicine, you might as well not give it......it doesn't work in their systems without food. I do ACTH, CBC and Superchem tests....$318.00....sure can't afford to do it wrong.
frijole
09-05-2011, 12:44 PM
I'd move it back also... I can't tell you how many times the "front desk'' has either failed to mention fasting OR was wrong. I'm just glad you didn't have the test yet - nothing like throwing away a couple hundred bucks. Its hard to 'buck the system' but you are your dog's voice in this and you are doing a good job by reading and asking questions. Kim
Besides all of this good advice you have received thus far, keep in mind going forward you want those ACTH stims done at the same time and the medicine given at the same time so you are consistent with the drug and the test. Otherwise your test results can be skewed. Each stim is 10-14 days and then again at 30 days. If you do a dose change it starts all over so with 14 days and 30 days. You want the Vetoryl given every day at about the same time and the test always done at about the same time.
We've had five since June and Zoe's Vetoryl is given every day at about the same time and each test was scheduled at the same time.
Hugs,
Addy
I really appreciate all the good advice on this. I'm going to call the vet in the morning with the information and quote from Dr. Peterson in hand. I think it's a case of whomever called not knowing or mixing it up with the protocols for the other drug.
I also thought Maizie was doing better as Saturday evening she had no breakthrough incontinence in the evening or overnight after her final walk. However, Sunday and today it's back. Poor girl let us try a diaper but she has a funny build (long body with short legs) and the diaper wasn't working for her. It either fell off or if tight enough her legs were splayed. I'm hoping the vetoryl kicks in soon or that they are either to increase the dose or give her something in addition. She weighs 24 lbs and they started her on 60 mg. In any case, I will get the test results and post them.
Gave Maizie her food and meds at 6:30 am, dropped her off at the vets, 8:00 am and they'll do it when they do it, I think. Now here's my question, they had down, ACTH AND a general blood diagnostic (an additional $150!) Is this part of the protocol? I understand that the side effects of vetoryl can be pretty nasty but Maizie is otherwise strong as an ox, and hasn't displayed any side effects. Is this what everyone gets?
Squirt's Mom
09-06-2011, 10:12 AM
Unless it has been a while since she has had labs run, I wouldn't have them done right now. The labs aren't going to tell anything about the effectiveness of the dose and it is unlikely that the liver values, etc have changed yet. SO unless he is looking for something unrelated to Cushing's, I would tell them to hold off of that right now. The ACTH is enough for one day, IMHO. ;) For Maizie and your pocketbook! :p
Let us know how it goes!
Hugs,
Leslie and the gang
Jenny & Judi in MN
09-06-2011, 10:15 AM
Jenny has had at least 4 ACTH tests and hasn't had her labs drawn since her initial diabetes diagnosis in May
labblab
09-06-2011, 10:59 AM
The manufacturers of Vetoryl recommend that a blood sample be analyzed for the electrolye levels (e.g., potassium, sodium, chloride, bicarbonate) EVERY time that a monitoring ACTH is performed. This test of basic blood chemistries can be done alone or in conjunction with a broader blood analysis. I would think that $150 is pretty steep for just an electrolyte check, so I'm guessing that your vet is including it along with other blood testing, as well.
Checking the electrolytes is an important part of insuring that the trilostane is not overly suppressing Maizie's adrenal function. Not only does trilostane lower cortisol levels, but it can also lower the level of aldosterone, as well. And it is aldosterone that helps regulate the ratio of potassium and sodium in the body. If these ratios get out of whack, very serious problems can arise. And you cannot rely solely upon Maizie's outward appearance in regard to abnormalities in cortisol and/or electrolytes -- by performing the blood tests, you are hoping to nip any problems in the bud, before they translate into a physical crash:
A post-ACTH stimulation test resulting in a cortisol of <1.45 μg/dL (<40 nmol/L), with or without electrolyte abnormalities, may precede the development of clinical signs of hypoadrenocorticism. Good control is indicated by favorable clinical signs as well as post-ACTH serum cortisol of 1.45-9.1 μg/dL (40-250 nmol/L). If the ACTH stimulation test is <1.45 μg/dL (<40 nmol/L) and/or if electrolyte imbalances characteristic of hypoadrenocorticism (hyperkalemia and hyponatremia) are found, VETORYL Capsules should be temporarily discontinued until recurrence of clinical signs consistent with hyperadrenocorticism and test results return to normal (1.45-9.1 μg/dL or 40-250 nmol/L). VETORYL Capsules may then be re-introduced at a lower dose.Especially given Maizie's age and trilostane dose, I do think it is important that the electrolyte check be performed as Dechra recommends. Maizie is being started on a relatively high dose of medication -- at a ratio of approximately 3 mg./lb. Even though Dechra's published literature (including a link that I will give you below) discusses initial dosing within a range of 1-3 mg./lb., their technical representatives are verbally advising patients that it is best to start at the very lowest end of that dosing scale and then working upward so as to minimize the risk of unwanted side effects. Since Maizie has been started at the highest end of that dosing range, I would think that checking her electrolytes will be especially important.
Here is a link to Dehra's U.S. Product Insert in which all this information is discussed in much more detail. You will see that they also recommend regular blood testing of renal and liver function once a dog has been stabilized on any given trilostane dose. This may be your vet's reasoning for also performing more comprehensive blood testing at this time. But at a minimum, the electrolytes should be checked along with every ACTH.
http://www.dechra-us.com/files/dechraUSA/downloads/Product%20inserts/Vetoryl.pdf
Marianne
Keiko's Mom
09-06-2011, 11:28 AM
Hi. I have to get Keiko's tests done again today, because her levels were too low about two weeks ago. I posted earlier on your post that it runs me $318.00 for the tests....have to keep eye on potassium and sodium. I don't have to leave my dog at the vets...it sure keeps her stress down.
The bill with the blood work was $400. I'm waiting for the vet to call with an explanation of the blood work as it just said "general diagnostic". And she just had bloods before they did the LDDS test. If it just needs to be eletrolytes that seems fair. It's Manhattan prices. This is why we are going to start taking the cats elsewhere!:mad:
Keiko's Mom
09-06-2011, 02:02 PM
It's a good idea to pick up copies of your lab tests and medical records (or have them mailed). You have to go to an "Emergency Vet Clinic" here after regular vet's hours....none of the regular vets are on call or go to their offices after hours...it's good to be prepared with all the info you can get. If you ever call Dechra for info, they want to know all of the test numbers. I do the CBC to check for signs of infection, so it's not a complete waste of money to go the extra mile.
frijole
09-06-2011, 03:56 PM
The bill with the blood work was $400. I'm waiting for the vet to call with an explanation of the blood work as it just said "general diagnostic". And she just had bloods before they did the LDDS test. If it just needs to be eletrolytes that seems fair. It's Manhattan prices. This is why we are going to start taking the cats elsewhere!:mad:
You should always ask for and GET copies of all tests that are done. So get the acth test results AND the blood tests... you will then see what was done and have it on file for reference. It also forces them to be honest. ;) Kim
Still don't know any results or why the wanted full bloods as I will talk to the vet tomorrow. I think the relatively high starting dose might have to do with Maizie's build. She has the body of a bigger dog with stumpy legs -- if that makes sense, and no other underlying health issues.
You should always ask for and GET copies of all tests that are done. So get the acth test results AND the blood tests... you will then see what was done and have it on file for reference. It also forces them to be honest. ;) Kim
I think they are honest and other than the phone call about the fasting, which I think was probably just a mistake, I trust their competence. A few years ago when I first started going there, they caught something a vet had missed and saved my cat's life -- for a reasonable price and they also supported my getting my money back from the practice that almost killed him! They also were extremely sensitive and handled things well when my husband's cat was ill and needed to be put down. It's really only in the past two years or so that a lot of the vets have left and every time I go in, I feel I'm being "sold" something that I don't need.
lulusmom
09-07-2011, 02:36 AM
Still don't know any results or why the wanted full bloods as I will talk to the vet tomorrow. I think the relatively high starting dose might have to do with Maizie's build. She has the body of a bigger dog with stumpy legs -- if that makes sense, and no other underlying health issues.
Starting dose is based strictly on weight. Dechra, the Manufacturer recommends starting at 1 to 3 mg per pound but suggests starting at the lower range. With Maizie weighing 24 pounds, the lower range would be 24 rounded down to 20. Based on their own extensive experience, UC Davis dosing protocol calls for a starting dose of 1mg per kg. In Maizie's case, that would be 10mg. 60mg is a far cry from either of those starting doses so I'd be concerned for Maizie's well being. It is always better to start low and adjust upward if needed. Making a dog sick by overdosing them, requiring hospitalization, can cost a lot more money in the long run, not to mention the ordeal for the dog and a pet owner's shattered nerves.
I would have been ecstatic to be able to trust my vet's competence but unfortunately, when my first cushdog was diagnosed, I was an uninformed newbie who could barely spell cushing's so there was no way for me to tell if my vet was competent. As it turned out two years later, my research showed that he couldn't spell cushing's either. I guess what I'm trying to say is that if you have to be able to gauge your vet's level of confidence in order to trust it and your ability to do that will only come with educating yourself. It's not an easy thing to wrap your head around but the light bulb will go on eventually. If something doesn't sound right based on anything you've read or information we have provided, question it and back up your question with facts. In this case, the facts are that two very credible and oober experienced sources, Dechra and UC Davis recommend starting doses for Maizie that are 1/3rd and 2/3rd the starting dose your vet is recommending.
I have two cushdogs who treated with Trilostane and they are much smaller than Maizee. My Lulu eventually stabilized at 30mg which equals 5mg per pound and my other was on 15mg twice daily which also equals about 5mg per pound. We've seen smaller dogs like mine stabilize on much larger doses than bigger ones and we've seen bigger ones have cortisol drop too low on smaller doses....so you just never know, which is why less is better in the beginning. Also because you never know, be wary, be informed and be a great advocate for Maizie. You are her only voice. Just keep a close eye on your girl for signs of low cortisol.
As others have already suggested, please round up all testing that has been done and post the results here.
Glynda
Good news. Her labs looked good. The vet did say the bloods were necessary due to the electrolytes, but my spouse who spoke to her, didn't push on why the full diagnostic. The vet also (THANK GOD) agreed to put her on Pro-In. I asked her about this week's ago, but she wanted to get the Cushing's under control first. Maizie is not pee-ing inside while she is awake, but she has been consistently incontinent for weeks when sleeping, and even with her water intake going down and frequent walks, it's not abating. I realize the Vetoryl might help with this eventually, but in the meantime we need help NOW, so the Pro-In might do the trick. (It's working very well for a neighbor's rescue, a much younger girl who probably will need it lifelong as a result of being spayed too young by her previous owners who abandoned her.) :o
Re the high start -- I think it's part of the reason the vet is being extra careful about the blood levels, and the protocols for monitoring.
lulusmom
09-07-2011, 05:44 PM
Good news. Her labs looked good. The vet did say the bloods were necessary due to the electrolytes, but my spouse who spoke to her, didn't push on why the full diagnostic.
While Vetoryl doesn't have a cumulative effect, it oddly continues to drop cortisol levels well after 10 days. We've actually seen some dogs continue to drop through the 30 day mark. For that reason, if the acth stim results are within the desired therapeutic range after only 10 days, I have some concerns that with such a high dose, it will continue to drop. e vet to give you the pre and post numbers on the acth stimulation test? If you do not have copies of the acth stim test results, can you please ask the vet to give you the pre and post numbers and post them here. Your vet should be happy to give you this information.
Re the high start -- I think it's part of the reason the vet is being extra careful about the blood levels, and the protocols for monitoring.
I'm very happy to see that your vet is checking electrolytes. This is proper protocol for monitoring treatment, regardless of the dose prescribed, so with your vet prescribing such a large starting dose, it is even more important that electrolytes be checked.
The vet also (THANK GOD) agreed to put her on Pro-In. I asked her about this week's ago, but she wanted to get the Cushing's under control first. Maizie is not pee-ing inside while she is awake, but she has been consistently incontinent for weeks when sleeping, and even with her water intake going down and frequent walks, it's not abating. I realize the Vetoryl might help with this eventually, but in the meantime we need help NOW, so the Pro-In might do the trick.
Proin (Phenylpropanolamine) is not a benign drug and it can have some rather serious side effects, the worst being seizures and even death. This drug is known to increase blood pressure and heart rate so prescribing this drug to a dog with cushing's should be done with extreme care and only after confirming that blood pressure and heart rate is normal.
I went back and reread your thread and don't see where you told us which form of cushing's Maize has. Did your vet diagnose pituitary dependent or adrenal dependent cushing's? The vast majority of dogs are pituitary dependent so chances are that Maizie has PDH; however, she could have an adrenal tumor, in which case, high blood pressure is even more likely. Please, please do not give Maizie Proin before confirming that your vet obtained an accurate blood pressure measurement ruling out hypertension. Not all vets take the time to educate themselves on the drugs they are prescribing, which is why I never put a pill in my dog's mouth before I understand how it works, what side effects are common and what drugs and/or physical conditions prohibit its use. I can tell you from experience with my own gp vet(s) that it helped me and my dogs immensely to have members look over my vet's shoulders. I have included the link below for your reference.
http://www.petcarerx.com/pcrx/HealthGuide/Medications/Medication.aspx?mid=10909
I'll be looking forward to your posting the results of the tests done to diagnose Maize as well as the results of yesterday's acth stimulation test. In the meantime, please keep a very close eye on Maizie for signs of low cortisol.
Glynda
Hi All, I know you want me to post labs, and I will (when I find them again). They were good, but here's the NEW issue: Two weeks into the Vetoryl. Maizie does not seem to be having any "bad" reaction to the Vetoryl. She is drinking less and no accidents in the house -- except for puddles when she sleeps. And this isn't just at night -- it's whenever she sleeps, and the old girl sleeps a lot. The puddles range from a few drops to completely soaked. So after the ACTH test and her being stable on the Vetoryl, the vet was willing to try Proin.
Maizie really cannot tolerate it. Her bp is normal when not on it. I don't know if it spikes on it because we haven't tested her when she's on it. The lowest does that seems to work for the incontinence for her is 12.5 mg and after 10-12 hours she's incontinent again. This dose makes her anorexic (something she's never been in her life) and completely different. Anxious, less social, frightened. It's torture for her. We cannot do this to her. We tried a 6.25 mg to see if it work. She still had the side effects (not as much) and it didn't help with the incontinence (at all).
We're trying to reach the vet practice TODAY to see if they can start her on DES. This is sort of the last ditch effort. Anyone have any thougths about DES? We don't see the Vetoryl really addressing this. Any thoughts or experiences with any of the natural products?
Keiko's Mom
09-11-2011, 12:43 PM
Hi. I mentioned my first dog, Chantel, in an earlier post to you. She weighed 32 pounds. She took approx. 1mg DES daily. She also took a human drug, Mandelamine....it is still available in generic form. The Mandelamine is an antibiotic that goes straight to work in the kidneys....sort of like our cranberry treatments. Both of these drugs helped her. She had epilepsy, but no cushings or any other health problems. This was in the 1980s. Her bladder muscles still relaxed and emptied when she slept....never did get that controlled. She made it to 16, which is old for huskies. Her back legs gave out before she passed....we bought a "k-9" cart for her....it was delivered two days too late. DES is still available through vets. There are some good websites with info....just Google DES for canines. Good Luck.....I'll keep an eye on your progress.
Keiko's Mom
09-11-2011, 01:02 PM
I tried to find out more info for you. Vet info sites state that DES enhances activity of corticorteroids such as prednisone and dexamethasone....don't know what that means for cushings pup. Did you know that prolin stuff is the same as Dexatrim for humans? I did see where some vets use it along with DES. I'm sure some of the other people here will have some info....gotta make sure we're making safe choices.
labblab
09-11-2011, 01:02 PM
Hi All, I know you want me to post labs, and I will (when I find them again). They were good, but here's the NEW issue: Two weeks into the Vetoryl. Maizie does not seem to be having any "bad" reaction to the Vetoryl. She is drinking less and no accidents in the house -- except for puddles when she sleeps. And this isn't just at night -- it's whenever she sleeps, and the old girl sleeps a lot. The puddles range from a few drops to completely soaked. So after the ACTH test and her being stable on the Vetoryl, the vet was willing to try Proin.
I know very little about incontinence in dogs, and it may well be that Maizie's loss of bladder control while sleeping has nothing to do with the Cushing's. But I do want to caution you that the reason why we are so anxious to see the actual ACTH results is because "good" may mean a lot of things, and not necessarily that Maizie's cortisol level has yet reached a truly therapeutic range in which all symptoms will be controlled. We have seen instances when otherwise fine vets have assumed that the war has been won once a Cushpup's cortisol has been lowered into a range that is listed as "normal" on the lab results. However, Cushpups being treated with Lyosdren and Vetoryl should be exhibiting cortisol levels that are lower than the listed "norms."
So even though Maizie's incontinence may turn out to be a separate issue altogether, finding out the actual numbers for the ACTH testing remains really important in terms of looking at the big picture. She has only been on the Vetoryl for two weeks now, and her cortisol level still has the potential to move downward. Whether or not this will be a good thing really depends upon those ACTH numbers.
Marianne
@Keiko's Mom -- We knew what Proin was and had looked it up on the internet. Our neighbor's much younger dog is doing really well on it and with the bp looking good, we thought it was worth a shot. We will not use it anymore. She is almost completely anorexic on it and generally miserable. We are trying to reach the vet. One of the oncall vets at the practice had mentioned DES so I'm not sure it's contraindicated with the Cushings. Maizie's back legs aren't any great shakes either, so we're beginning to wonder why we're putting her through all this, but then she'll ask for a belly rub or otherwise seem like herself.
Not sure how to read this and I don't have it electronically to cut and paste:
Before the trilostane:
LDS
Time 1 Pre
Time 2 4 hour post
Time 3 8 hour post
1900 8.3
1902 1.2
1903 2.0
11 days after starting vetoryl acth:
Corisol serial
Time 1 0
Time 2 1 hr
Cortisol Sample 1.4
Cortisol Sample 1.6
Today was pretty frustrating. We didn't hear back from the vet yesterday and called again today and didn't hear back. We didn't realize they closed at 4 Sunday and didn't call them again till almost 5. We gave Maizie a half (12.5 mg) Proin yesterday at about 7 PM and she was just miserable and has been most of today. She's getting back to her old self, but of course she's also leaking again. It doesn't seem to be directly related to the Cushings, in that she's no longer drinking so much that she can't hold it in. It now doesn't seem to matter how much or little she drinks, she just has no bladder control, especially when sleeping.
labblab
09-11-2011, 10:27 PM
Thank you so much for posting these test results! It looks to me as though Maizie's diagnostic LDDS results are likely consistent with pituitary Cushing's (both the 4-hour and 8-hour results are less than 50% of the baseline reading, and the 8-hour result is greater than approx. 1.4 ug/dl).
However, I must tell you that I am very concerned after seeing her 11-day monitoring ACTH results. A post-ACTH result of 1.6 is almost as low as you would want to see, and it is entirely possible that her cortisol will continue to fall during these initial few weeks of treatment. Dechra (Vetoryl manufacturer) gives 1.45 ug/dl as the absolute "basement" in terms of therapeutic ACTH testing: anything lower than that signals the need to discontinue the medication in order to allow the cortisol to rebound, and then resumption at a lower dose:
If the ACTH stimulation test is <1.45 μg/dL (<40 nmol/L) and/or if electrolyte imbalances characteristic of hypoadrenocorticism (hyperkalemia and hyponatremia) are found, VETORYL Capsules should be temporarily discontinued until recurrence of clinical signs consistent with hyperadrenocorticism and test results return to normal (1.45-9.1 μg/dL or 40-250 nmol/L). VETORYL Capsules may then be re-introduced at a lower dose.
The fact that Maizie has dropped this low so quickly worries me in terms of what may happen over the next couple of weeks. She may be just fine, but it is also possible that her cortisol may drop even lower. When does your vet want to test her again? Dechra recommends another ACTH test at the 30-day mark. But if she looks "off" to you in any way before that, I'd feel very concerned about the possible need to back off to a lower dose of Vetoryl.
I realize you may have two separate issues that you are dealing with right now: the incontinence while sleeping in addition to Cushing's. But while the incontinence is a very visible and understandable major concern right now, the risk of low cortisol actually has the potential for life-threatening ramifications. I am not a vet myself, so everything that I write here comes from my own reading and my own experiences. But it worried me that your vet's office initially told you to fast Maizie for her ACTH test, and that they did not seem to be particularly concerned about the timing of the test. So hearing now that her cortisol level has already dropped to 1.6 ug/dl -- I am really hoping that they are planning to monitor her very closely and that they have also warned you as to the signals of overdosing. If you have any questions about this, please do feel free to ask us about them.
Marianne
Marianne,
You are a genius. Here's the scoop. When we realized the Pro-In was a complete FAIL (stopped the incontinence but clearly was not good for her), we were trying to reach the vet Sunday about DES. However, even without the Pro-In in her system Maizie was pretty lethargic and not eating even after we stopped the Pro-In. We took her in this morning almost ready to put her down, but we also insisted on seeing the more experienced vet in the practice who we usually go to, but hadn't been since the initial cushings crisis because of scheduling stuff. He had last seen her in February. He took a look at the labs etc. He is more comfortable with lysoderm, but felt in any case that the trilostane dose might be too high which would explain a lot of the recent symptoms and that DES would be his choice for the incontinence. Her mouth is also in bad shape and she might have an infection. They are keeping he at the Vet's overnight. He wants to try a little prednisone to see if upping her cortisol a little might bring her back to old self. (She was more her old self when we got her to the vet's, which could have to do with her stress level being higher). He also said her kidney's were in great shape btw and he thinks there's life in the old girl yet if he could get the meds managed. (We probably will be making sure the vet visits are with him and not his much younger associate.)
Anybody out there? We still need help. I'm at my wit's end. Per my previous post -- Maizie became very lethargic. Despite being on this board and doing a lot of reading, I didn't put it together that it was cortisol going too low -- I was so focused on the bad reaction she had to the Proin, that I blamed myself for giving it to her, and just thought she was done. But when we saw the senior vet at the practice who we normally see, but hadn't through this crisis because when she first became symptomatic he wasn't around, he immediately knew her cortisol had crashed. So he wanted to give her prednisone and also watch her for a day. We took her home a day later. Both vets had talked. The instruction was -- taper off the prednisone with 1/4 tablet a day for 2 days. They'd already given her her first dose of the DES for the dribbling. They said they'd start her on the trilostane at 30mg a day (not 60) when she became symptomatic again AND after checking her electrolytes again. When we picked her up at the vet, she was VERY chipper. Really, her old self. She peed before coming into the house. She drank more than a bowl of water, which we thought might have been the prednisone. She ate -- but not as enthusiastically as usual. She settled down and was sleeping, than get up. It was only 3 hours later, but I had a "feeling" and went to get her leash. She didn't follow me. When I come back a minute later, there was already a puddle. I took her out a bit later. She peed. The next morning when my husband woke up, there was a puddle. (Not a leaking in her sleep. She was dry. The floor was wet.) He took her out. This was around 6:00 AM. He got back and tried to feed her. She wouldn't eat. He put the 1/4 of a 5mg tab of prednisone in some peanut butter -- normally a favorite. She barely took it. He had to force pill the DES. I got up a little later and tried feeding her various things. An eggy? No! There was an old can of one of her favorites -- high end -- chicken including some stewed softened wing bones -- she ate a little of it but not enthusiastically. A few minutes later she vomited it. She was drinking though, a lot again. Then after we cleaned it up. I was going to take her out. It was only about 90 minutes since my husband took her out, , but she had had a lot to drink. But it was too late again, she'd peed on the floor.
Then she was laying down on the kitchen floor with her head down. I'm thinking: "Did she crash again? Maybe when she vomited she lost he prednisone?" She came around when I went over and I took her out. She peed some more. She took her freeze-dried chicken snacks happily when I got her home. Drank a little more water.
Seems okay.
I'm losing my mind.
lulusmom
09-14-2011, 09:55 AM
How did your vet know for sure that Maizie crashed due to low cortisol? Did he do an acth stimulation test to confirm? When was the last time a blood panel was done to check kidney values? Were you able to get copies of the testing when you were at the vet's office? If so, please post just the abnormal values on the bloodwork, including the normal reference ranges. Dogs in kidney failure are lethargic, drink lots of water, pee buckets, vomit and eventually quit eating. Side effects of low cortisol and DES are much the same.
Glynda
I've got the ACTH taken exactly 8 days ago up on this board already. They didn't do a new ACTH test yesterday. Dr H was looking at the dosage pf trilostane that Dr W had put her on AND the ACTH results which had her cortisol pretty low 8 days ago. I think he based his dx on how she looked and was acting and all the previous labs they had. Let me clear that when we picked her up yesterday she was absolutely her old self, feisty, energetic, etc. The idea was to wean her off the predisone and see. If it's her cortisol we didn't expect it to go up so fast. But the other thing is her appetite isn't completely back. However, she keeps moving her mouth funny, sometimes picking stuff up and dropping it, and grinding her teeth. She may have tooth issues.
I'll look for the bloodwork papers and put more up.
So Tuesday, six days ago we pick up a very fiesty Maizie. She gets weaned off the predizone while eating, drinking and peeing up a storm. We take her Friday to get her electrolytes checked because off the pred she's still drinking and peeing a lot. She starts Saturday (after the test results) on the 30 mg vetoryl. It's only Monday and the water is down to almost normal consumption. No diarhea or vomiting, but she seems a little lethargic, and her appetite seems off, but it's a little hard to tell as she's been grinding her teeth a lot and moving her mouth around, and I'm not sure if it's a tooth ache or a side effect. She did eat breakfast and dinner today but she was picky, and she's never picky. Plus she'become very hard to pill. It used to be we'd just put her fluoxetine in peanut butter and it was a snap. She's rejecting peanut butter and licking around anything else with a pill. I think she's smelling the pill and saying "no." I managed to get her to take the veteryl with some canned food this morning, but she ate around her fluoxetine at lunch and I gave up.
I'm very tired of taking her in. She's tired of going to the vet. She's actually better behaved there than ever, but for the first time ever, she doesn't want to go in the car because she now associates it with the vet. My husband is calling the vet now. We're hoping that whatever they tell us to do -- more pred, take her off vetoryl for a day or two, lower dose, anything, we won't have to bring her back in right away. It's just too much for all of us.
Jenny & Judi in MN
09-19-2011, 06:35 PM
I have no experience with the Vetoryl but I 100% agree with you on being tired of taking them in.
I was updating Jenny's spreadsheets today and realized she's had 5 ACTH tests since June 30th and 8 or 9 all day curves for her diabetes since May.
I hope your vet can help you over the phone and she gets her verve back!
hugs, Judi
Still haven't heard from the vet, who might have called my husband who is currently in transit. Meantime, she perked up after lunch. Wanted to walk. Got feisty with a couple of her frenemy dogs. Drank enough when she got back, that I'm thinking we're going to need to go out again soon or risk another accident. Makes me like an idiot for worrying. Anybody else on vetoryl seeing these ups and downs?
Ok, vet spoke with my husband. Here's Maizie's latest. Her appetite was off this morning (before we pilled her) She ate a little but also has gotten VERY SAVVY about the pill. Doesn't matter what it's in. She'll touch peanut butter, and those overpriced Greenie pill pockets FUGETABOUT IT. Somehow we got her to take her vetoryl (I'm pretty sure). She was then pretty subdued all morning. By supper (around 3 o'clock -- 9 hours post vetoryl, she was eating, but not very much. 6:00 PM I tried again and she ate some more (almost 1/2 a can of dog food). The vet called. He wasn't that concerned but suggested 1/4 of the 5mg pred now and a 1/2 tomorrow, but keep on the vetoryl and call him Thursday (the day following). So what do you all think?
She didn't have an ACTH before she restarted but was peeing and drinking up a storm which was under control within 3 days of her starting again. Now she's only on 30 mg of vetoryl a day. She weighs 24 pounds (down from 25 more recently). Should she be on a lower dose? Is it possible vetoryl just isn't right for her? When they did her electrolytes they also did a blood cortisol which was 2.
Squirt's Mom
09-21-2011, 11:57 AM
My Squirt has gotten really savvy about hidden pills, too, which makes it a PIA at times but I have found a way to fool her most of the time. This won't work with bitter pills like antibiotics but has worked with everything else. Plus she is on home cooked food and that helps, too.
When I have something she will not take, I grind the pill into a powder and add it to her food. When ever possible, I use capsule form not tablet form to prevent this step. With caps, I open them and mix in her food, not sprinkled on top or she won't eat it. :rolleyes:
I have used things like Karo syrup, honey...something sweet to hide ground up ABs. She could taste the med and wasn't happy about it but the sweetness was something she couldn't quite leave alone. :p
They make a contraption for shooting pills down their throat but I have never used one. I will try to find a link about it for you.
Hope this helps a bit!
Hugs,
Leslie and the gang
Ok....here are some links on pill shooters -
http://www.petstore.com/Classic_Products_Mikki_Pill_Gun_Pp1_Dog_Health_Car e_Supplements_Nutrition-Classic_Products-LC04001-DGHC-vi.html
http://pet-supplies.drsfostersmith.com/petsupplies/Pill%20Popper
http://www.google.com/search?q=pill+popper+for+dogs&ie=utf-8&oe=utf-8&aq=t&rls=org.mozilla:en-US:official&client=firefox-a#q=pill+popper+for+dogs&hl=en&client=firefox-a&hs=Ug4&rls=org.mozilla:en-US:official&prmd=imvns&source=univ&tbm=shop&tbo=u&sa=X&ei=If15TsDiMcKOsQLa4YWnAw&ved=0CE4QrQQ&bav=on.2,or.r_gc.r_pw.&fp=5fc836fadfef0546&biw=1582&bih=667
lulusmom
09-21-2011, 01:31 PM
Ok, vet spoke with my husband. Here's Maizie's latest. Her appetite was off this morning (before we pilled her) She ate a little but also has gotten VERY SAVVY about the pill. Doesn't matter what it's in. She'll touch peanut butter, and those overpriced Greenie pill pockets FUGETABOUT IT. Somehow we got her to take her vetoryl (I'm pretty sure). She was then pretty subdued all morning. By supper (around 3 o'clock -- 9 hours post vetoryl, she was eating, but not very much. 6:00 PM I tried again and she ate some more (almost 1/2 a can of dog food). The vet called. He wasn't that concerned but suggested 1/4 of the 5mg pred now and a 1/2 tomorrow, but keep on the vetoryl and call him Thursday (the day following). So what do you all think?
I think it's highly irregular for a vet to prescribe prednisone concurrently with Vetoryl. I am always concerned when a dog on Trilostane or Lysodren is not eating well because the most likely culprit is low cortisol. If a dog is not eating normally, that should be the assumption and Trilostane should not be given. My two dogs treated with Trilostane and if their appetite was off or if they had loose stool, I discontinued dosing until they were completely normal. Sometimes it was a day and sometimes it was three or four.
I think the reason Maizie has more of an appetite in the evening is because after 12 hours the effects of Trilostane have probably worn off and cortisol has come back up a bit. It is very possible that 30 mg is still too high for Maizie. If you look back through your thread, you will see where Marianne and I posted that Dechra, the manufacturer of Vetoryl recommends starting at the low end of the scale, 1mg per pound. In Maizie case, the dose would be rounded down to 20mg.
A lot of us know from first hand experience the strain placed on us, our dog and our wallets when we have to make frequent trips to the vet. Unfortunately, inexperienced gp vets sometimes cost us a lot more in the long run. If Maizie's appetite is not good, please do not give her any more Trilsotane. If her cortisol is too low already, continuing the Trilostane could make it go lower. If you give concurrent prednisone, there is no way for you or your vet to know if Maizie's adrenal glands are producing inadequate amounts of cortisol because prednisone will mask the usual symptoms.
She didn't have an ACTH before she restarted but was peeing and drinking up a storm which was under control within 3 days of her starting again. Now she's only on 30 mg of vetoryl a day. She weighs 24 pounds (down from 25 more recently). Should she be on a lower dose? Is it possible vetoryl just isn't right for her? When they did her electrolytes they also did a blood cortisol which was 2.
It's very possible that Maizie needs a lower dose and it is also possible that Vetoryl may not be the optimum treatment for her but I think it is too early to make that call. For what it's worth, if Maizie were mine, I'd stop the dosing, wait until her appetite is totally normal again and restart her on 20mg. Starting low and increasing if needed is preferrable and much easier on the dog than the other way around.
LulusMom -- How did you get so smart? Maizie crashed AGAIN. The vets are arguing amongst themselves. We are hemorrhaging money and feeling like we never should have put her or us through any of this. After this past addisonian crisis and two days of intensive care at the vets, she's back home being tapered off the prednisone. Her electrolytes were good by the time she got home though prior to that they were considering giving her a shot of DOCP, but decided it had resolved, so she just left with the prednisone. She's back to eating, trolling, drinking like a fish and peeing like a racehorse. The vet agreed we could lower the dose of pred immediately. I really, really, really, don't want to see her on vetoryl again. Even if they only give her 10mg. We can't go through this again. Nor can we live with a dog who constantly urinates in a one-bedroom apartment. (Honestly, I work from home. I can take her out every two hours and it's not enough.) So here's my question oh wise ones: Assuming this isn't just the pred and she is indeed Cushingnoid again, Anipryl???? Am I grasping at straws? She's kind of a nutty, idosyncratic girl. She's been on prosac for years and is only off it now because we couldn't pill her when she went Addisonian and we didn't want to restart her on too many meds when she started eating. From what I'm reading it may work better on symptoms than on lab values, which would be fine with us. We just want her to stop urinating on everything. Has anyone had any experience with it?
Hi,
My dog, Hannah is on Anipryl, and there are certainly no side effects to worry about, but most research says it works on about 25% of dogs. Hannah's Cushing's is pretty mild and her drinking and urinating are increased, but not out of control. I felt that it helped to control her begging for food for awhile, but that seems to be starting up again. She has been on it since April. Her ALKP value was over 1700 when she started and at the beginning of August it was just over 300. We think Anipryl may be the reason for that. It certainly can't hurt anything to try it, but it doesn't have the highest success record. It is fairly expensive, especially depending on the size of your dog. My vet has had a couple of clients with dogs who have responded really well to it.
Good luck to you!
Julie & Hannah
Thanks. I'm sitting here listening to her drink with a sick feeling in my stomach. Twenty minutes ago, she woke up from a nap. I was about to walk her even though we'd gone out about two hours before. I was just throwing something down the chute which is right outside the door in the hallway. She followed me out and before I could stop her, just squatted in the hallway. Fortunately, none of my neighbors came out, but I was mortified. Grabbed the paper towels and the gallon jug of the super advanced Nature's Miracle! I'm really beginning to wonder if it could be senility at this point. She really seemed kind of proud of herself. Now she's lying down again, but she was drinking more and walking. I may go look for puddles. I know Anipryl might not work, but I won't put her or us through Vetoryl again. If anyone has any other ideas let me know. Honestly, if i had a basement or something that could just get smelly, I could live with it. Or a backyard. But I don't.
Cyn719
10-01-2011, 12:37 AM
Ditto to what Glynda said and she said it well ------- sorry your dog has crashed again - I know how awful it is - my Penny crahsed also - was on a way to high does of trilo - now only on 10 mg (82lb) and it controlled her drinking - peeing - and appetite - so I have to say I would try a low does of the trilo --- call Dr Allen at Dechra - he can answer all the questions you have about the trilo -- the dog is drinking alot from the predisone itself and from the cotrisol levels risings as that is what it should be doing now - but if you dont contol it the drinking and peeing and appetite and fur lose will only get worse - the others will come on to give you advice - I am not as advanced as they are - all I know is they saved my dogs life back in June - they will help you - your in my thoughts -- try to hang in there
Thank you Cyn. It's interesting that 10mg is working on an 82 lb dog. And it's really good to know that your dog is doing well on it. Granted Maizie may have been way overmedicated, but the crash seemed to come so quickly both times, and the last time we almost lost her. Until your post, I was feeling like I'd rather put her down than put her on vetoryl again to see her go down, but maybe I should consider it. I'm really hoping that today's episode was the result of the pred (and maybe her weekly dose of DES which she takes to stop leaking). I guess we'll see how it goes as she tapers. Deep breaths! (At least it's the weekend, so my better half who doesn't work from home can deal with her!)
lulusmom
10-01-2011, 04:44 AM
I am another member who can attest that Trilostane is very effective. Both of my cushdogs were treated with it for two years and did quite well. Cindy's dog and my dog are perfect examples of how different dogs respond to Trilostane. Penny weighing 82 pounds is being well controlled with just 10mg and my Lulu, weighing 4.5lbs was stabilized on 30mg. There is no rhyme or reason which is why starting low is safer for the dog and probably cheaper for the pet owner.
Anipryl was approved by the FDA for treatment of canine cushing's; however, it turned out to be a real disappointment. Some say it's effective in 20% to 25% of dogs but Dr. Mark Peterson, a reknown endocrinologist, says it's more like 10%. The developer of Anipryl, Dr. David Bruyette, doesn't even prescribe the drug unless the dog has very mild symptoms and/or the pet owner cannot afford to do the necessary bloodwork to monitor treatment. Dr. Bruyette's treatment of choice is Trilostane.
If you decide to resume treatment with Trilostane, I have some information that will save you a good amount of money on acth stimulation tests. The stimulating agent used for this test is cortrosyn and it is very costly. It comes in a .25ml vial with directions to use the entire vial, regardless of weight. Any vet that is inexperienced with cushing's probably doesn't know that only 5 mcg per kg is needed. In other words, a 20 pound dog needs only 50mcg for each stim test. There are 250 mcg in one vial so you could get five stim tests from one vial. That is a huge savings. Please give your vet the link below which provides Dr. Peterson's source for Cortrosyn, as well as information on amounts to use when reconstituting and how to store for future use.
http://endocrinevet.blogspot.com/201...-for-acth.html
We have another member who was very appreciative of the heads up about cortrosyn and being a rescuer myself, I was heartened to hear that the money saved for one dachshund rescue will allow them to rescue more dachshunds in need. If I did the math correctly, this particular member's cost for an acth stimulation test went from $350 to $112 for the actual blood draw and lab costs, plus the cost of 1/4 or 1/5 of a $100 vial of cortrosyn. I'd say that is a really big savings.
http://www.k9cushings.com/forum/showpost.php?p=62107&postcount=16
I'm really sorry that Maizie has had such a difficult time but I can't say that I'm surprised. It's been our experience that dogs get into trouble when vets aren't intimately familiar with the drug they are prescribing and don't follow proper protocol. I believe this is what happened to Maizie. Unfortunately this isn't an isolated incident. We've seen it many times. I know from first hand experience that it's usually okay to place blind faith in a vet to treat common, every day canine ailments but not so when it comes to cushing's. It's a team effort between an educated, vigilant pet owner and an experienced vet that facilitates safe and effective treatment. You are Maizie's only voice so ask questions and don't go away until you get satisfactory answers.
I recall that you wanted to know how I came to know so much....well, my k9cushings family has been there for me since the day I got here and they encouraged me to educate myself so I could be an excellent advocate for my cushdogs. Somewhere along the way I became OCD about it and have spent the last six years researching and reading every study I could get my hands on. Most people read novels or the newpaper...I read veterinary publications dealing with cushing's. Most people listen to music while driving but I listen to audios of lectures given by world reknown endocrinologists on diagnosing and treating canine cushing's, hypothyroidism, liver disease, etc. I did manage to take time off to get married four years ago and I am blessed to have a patient and understanding husband. I couldn't do what I do without him.
Glynda
I really don't trust my vet to take the less expensive route, even if it is less expensive for them. For all I know, they are already doing saving the cortisol. I think the issue is that Dr. W -- the associate we saw because Dr.H wasn't there, is less experienced (although she has a few dogs on trilistane) and went strictly by the weight and recommendations. Dr. H who came back later is more experienced, but more experienced with lysoderm which probably would have been his choice. We aren't that far from Dr. Peterson. Given that we have all this info, I might call him Monday, to find out about a consult or whether given all the lab work done on Maizie, he'd consider doing the next ACTH and starting her if her symptoms come back. Right now though, we really have to live with the prednisone taper which isn't making life any easier. The only good news is that Maizie is finally figuring out what the wee-wee pads are for, so maybe we'll be able to contain the flood. Thank you all for your info and support.
lulusmom
10-01-2011, 02:10 PM
One of my cushdogs has diabetes insipidus, which does not respond to any type of treatment, so I know what it's like to deal with lakes of pee. I've been dealing with it for several years. I also know what a momentous event it is when our pee buckets figure out what the pee pads are for. Congratulatons Maizie!
Just wanted to give a quick update. Maizie is still being tapered off the pred, but now she's on very little. Her energy and everything else is way up. She's not drinking as much as she was, but she can't hold in like she used to. She's signaling more though to go out, and when she's not she's using the wee-wee pads. (Smart girl).
Her last vet bill from the big crisis was so high, we're tapped out. They want us to come back in another week so they can do yet another ACTH test to determine if the Addison's is permanent. We can't afford to get on this roller coaster again and we won't put her through it. She's given us pretty clear clues: Addison=no appetite, may still be drinking, probably still peeing a lot, looks suicidal. Cushings=drinking gallons, wants to eat everything in site, peeing buckets, doesn't look suicidal. If the Cushings symptoms return, we're not sure what we will do. We may look at other vets. I'm not sure about bringing her to Dr. Peterson at this point, because I don't want to start all over. My nephew is planning to go to vet school, and working for a vet this year. It's not that convenient, but my nephew thinks he's honest and relative to NYC not that expensive. We may be going there. I doubt the Addison's is permanant because she's on so little prednisone and she's as lively as ever.
Just wanted to give a Maizie update: The bill for her two days of intensive care including various tests and fluids etc, was more than we had budgeted for a year of ACTH testing when we decided to treat her.
She looked so bad, we weren't sure we were going to get her back. The good news is there's life in the old girl. Her energy level is great, she seems happy, her appetite is great, etc.
The bad news is she's kind of where she was before we started treatement for the Cushings -- drinking a lot of water, eating voraciously, and urinating many, many times daily.
The good news is the DES is working and she no longer "leaks". She may have to go quickly when she wakes up, but she's not waking up wet. She has also completely mastered wee-wee pads. She still signals when she has to have a b.m. or to go out in order to get the treat we give her when she gets back. When she can't make it to outside or we aren't here or paying attention she makes it to the wee-wee pads.
The question is do we treat -- with what, where? We not only can't afford more ACTH tests, we don't want to put her through them and given that she had one prior to her first Addisonian crisis, we are not sure we see the point. I know that a MUCH lower dosage of Vetoryl might work for her, but frankly I'm afraid of it and we don't want to put her or us through more ACTH testing. I don't trust the tests. Even the vet has said her appetite is a better indicator. I'm wondering if anyone has had luck with Anipryl? Maizie has been off her fluoxetine for several weeks so we could start her. I'm even wondering about Melotonin. At this point, all we are concerned with is a little symptom relief around the polyuria and polydypsia. We don't trust our vet, and may switch vets, but we don't want to start all over again with treatment and tests.
(BTW, the vet had wanted us to come back when she was off the prednisone for ANOTHER ACTH test to check if she was permanently Addisonian. There is no was she has Addison's, and there is no way we are testing her for that. )
Any thoughts?
lulusmom
10-10-2011, 05:30 PM
Apparently Maizie is simply not ready to give up on life with you and I couldn't be happier to hear your little trooper is doing so well. :D:D
DES can cause polyuria/polydipsia, and a host of other issues, which is why it is recommended that you give the lowest dose possible for the shortest period of time. Did your vet discuss this with you and give you complete instructions on dosing?
At 15 years old Maizie has already reached the average life expectancy for a JRT..way to go Maizie... so I agree with your approach. The problem with treatment other than Trilostane and Lysodren is that they are usually not effective in resolving symptoms. If they were, most of us wouldn't be treating with Lysodren or Trilostane. Some of our members have reported pretty good results with Anipryl and I hope they will be dropping by to share their experience. Anipryl is metabolized to amphetamine so you'll probably have a better chance at resolving the voracious appetite with Anipryl. I've always said that if my dog was very senior and could not tolerate the more effective treatments, I would give Anipryl a try.
Melatonin and lignans are not usually prescribed for dogs with elevated cortisol because they aren't effective in reducing cortisol but who knows, they may help reduce other adrenal hormones that may be contributing to some of the symptoms you are seeing. It certainly couldn't hurt to give them a try.
I hope this helps.
I read about the DES side-effects after it was started. The vet hadn't mentioned it. I know it could be contributing and I think she may be worse on Fridays, which is her dosing day. Then again, it might not be making a difference. The leakiness was the thing that probably freaked us out the most (and we may have conveyed this to her). I'm thinking maybe we could not give it to her on Friday and wait a couple of days to see if the leaking starts again. She's only on 1mg one time a week at this point. The new goal is the least meds. I'm figuring even if the melatonin doesn't work for the cortisol, it might be a less expensive and be easier on the organs than the Fluoxetine. It's sort of a Hail Mary pass, but we figure it's probably harmless.
Frankly, I'm shocked that she "got" the wee-wee pad thing so quickly and has adapted so well to it.
jrepac
10-10-2011, 10:48 PM
Nice to hear that Maizie is doing a bit better.
A few of us have had a bit of luck w/Anipryl, myself included.
It's real "hit and miss"...either it helps or not, but you'll know in about 30 days or so. It's pretty safe and you can get the generic version.
It definitely helped my baby with a lot of the troubling symptoms, but as others will note, trilostane is more effective. [Lysodren works for many, but I've never cared for the associated risks of the drug].
I also used melatonin & lignans, but in part because my baby was atypical; her cortisol levels were elevated, but not wildly high....and the accompanying hormones were way off, which led to the atypical diagnosis. So, we chose a fairly non-traditional path, that worked for the situation at hand.
Keeping your baby comfortable and relatively symptom free, I think would be a priority at her age. But, do discuss all of this with your vet.
All the best.
Jeff, Angel Mandy and the Girls
Thanks, it's good to hear from someone for whom Anipryl was effective. I realize Vetoryl at a small dose might help, but I'd feel too terrible if anything happened. I'm not even sure my vet will prescribe the Anipryl, but we may have the conversation.
Hi All, just checking in again. Maizie is continuing to do well. At the moment she's only on 1 mg of DES 1 time a week for her incontinence. I also started giving her 1.5 mg of melatonin in the evenings because it couldn't hurt. I don't know if it's made much difference. She's also off fluoxetine for the first time in years. She stopped taking it when she had Addison's, and we just didn't restart it. She's still drinking a lot of water, hungry a lot (but she's always been), and urinating a lot -- but thanks to the DES not leaking or peeing in her sleep. She's about 100% wee-wee pad compliant and mostly goes to the same corner. She'll still signal for a bowel movement or just to get outside. We've basically decided this is it and we'll enjoy for as long as we can. She has a fair amount of energy for her years and seems happy.
Squirt's Mom
11-11-2011, 08:56 AM
Mornin',
Good to hear from you. I always read even if I don't post so it's nice to hear that Maizie is doing alright. It sounds as if she is enjoying her life and you are enjoying her - that is what counts.;) In your shoes, that is certainly what I would do as well! :)
Did you talk to your vet about the Anipryl? My Squirt was on it for about 9 months with good results. She is an exception to the typical Cush pup in this area. Anipryl usually only works for a couple of months, if it will help at all - so I am a big fan of Anipryl. ;) It is something you can consider later if needed. It can help curb appetite as well as give them some energy - and it is good for older dogs who experience some cognitive issues.
Hope things continue to go well for you all and that you find joy in each and every day with Maizie.
Hugs,
Leslie and the gang
Hi-
Thanks for the update! I'm glad to hear things are going better and that the potty pads are working. I think it sounds like a great system!
Julie & Hannah
Hi All,
Maizie is still going strong. We haven't gone on the Anipryl. My better half feels more strongly than I do that after all the meds and the crisis from the Vetoryl, we are better off letting Maizie just be Maizie. (She was on something years ago for her "temperment" issues, and he felt she just wasn't her on it.) Her energy seems very good for a dog her age. As for the appetite thing -- the fact is we just feed her a lot. She doesn't seem to gain much weight. She's still just on the DES and she still has enough control not to wake up in her urine. She's down to wee-wee pads in one corner that she knows is her corner and she can make it there. Honestly, if you saw her on the street, and you didn't know notice how barrel chested she is at this point, you'd think she was a pretty spry old gal.
Squirt's Mom
11-28-2011, 08:39 AM
Good to hear from you and good to hear that Maizie is doing well. I sounds like the DES is helping her. And I can't say that I disagree with your partner about the Trilo - but the Anipryl wouldn't change her personality (...well, unless she is showing signs of cognitive dysfunction) so keep it in the back of your mind as an option, if needed.;)
Keep up the good work and let us hear from you!
Hugs,
Leslie and the gang
jrepac
12-01-2011, 08:39 PM
Good to hear from you and good to hear that Maizie is doing well. I sounds like the DES is helping her. And I can't say that I disagree with your partner about the Trilo - but the Anipryl wouldn't change her personality (...well, unless she is showing signs of cognitive dysfunction) so keep it in the back of your mind as an option, if needed.;)
Keep up the good work and let us hear from you!
Hugs,
Leslie and the gang
To your point Leslie, I found that Anipryl helped correct some unattractive behavioral/personality problems that arose from the Cushings syndrome....probably originating from my baby being constantly hungry. We had many sleepless nights because of this, it was awful.
It did make her quality of life better, no question. She was much more her "normal" self once the anipryl kicked in; hunger diminished and incontinence went away too. Something to consider for Mazie if the situation changes.
Jeff, Angel Mandy & the Girls
I just wanted to chime in about Anipryl. My Hannah took it for about 6 months with no problems at all. We just took her off of it about a month ago to see if I could see any difference. Since her Cushing's was not very bad to begin with and I have not noticed any major changes, we are taking a break from it for now. The only real change I saw was that her begging for food did seem to decrease. Her ALKP level was really high pre-Anipryl and it dropped a lot after being on it for a month. Two different vets told me that was common. Anyway, I wouldn't worry about trying it. It might really help. My parents had a dog who took it for cognitive (old age) reasons and she also did really well on it. I am so glad to hear she is doing well though!
Julie & Hannah
jrepac
12-02-2011, 10:51 AM
I just wanted to chime in about Anipryl. My Hannah took it for about 6 months with no problems at all. We just took her off of it about a month ago to see if I could see any difference. Since her Cushing's was not very bad to begin with and I have not noticed any major changes, we are taking a break from it for now. The only real change I saw was that her begging for food did seem to decrease. Her ALKP level was really high pre-Anipryl and it dropped a lot after being on it for a month. Two different vets told me that was common. Anyway, I wouldn't worry about trying it. It might really help. My parents had a dog who took it for cognitive (old age) reasons and she also did really well on it. I am so glad to hear she is doing well though!
Julie & Hannah
I think that for milder cases (as mine was also) Anipryl may work "just enough" to make the situation better. I was supplementing with other non-Rx stuff too (lignans, melatonin). My prior/2nd Aussie, who passed from Cushings way back in '97 (and was on lysodren), had a much more severe case and I suspect Anipryl would've been a blip on the radar screen (she passed a few months before anipryl came out, actually). This is a really tough disease to treat because pups seem to respond differently to these various treatment options, which I can only attribute to the circumstances around their cushings (type, location of tumor, size, etc., etc.).
Jeff
Thanks. The new vet said he doesn't think it will give us the results we want, so for now no anipryl. Maizie continues to do well though we got a scare a couple of weeks ago, when she had a seizure, followed by another one the next day, at which point we really thought it was time. However, she's been fine since, was fine within minutes after each seizure. He was skeptical about the 1.5 miligrams of melatonin I give her at night, but didn't think it could hurt.
At this point, some days we think the end is near, but mostly we think she's a mixed breed tough old lady who could live forever.
Squirt's Mom
01-15-2012, 06:34 AM
How scary! :eek: But I'm glad to know there doesn't seem to be any lingering effects. I hope she hasn't had any more seizures. Bless her heart...and yours.
Sometimes these geriatrics can surprise us. Against all odds and understanding, they keep on ticking...and ticking happily, which is the most important factor. We cherish every day we have with them. My Squirty is showing more and more signs of her age but yesterday, she wanted to play - and we did. It was a short play time, but it was play. I have replayed those moments over and over since. Today, those few minutes mean more than the hours we spent playing when she was young. ;)
Hugs,
Leslie and the gang
Hi All,
I'm just back to say that Maizie is still alive and kicking. Today she was downright jaunty. We still haven't gone back to treating her. I'm still giving her 1.5 mg of melotonin. She also gets 10mg of fluoxetine which she's been on forever, and DES once a week for incontinence.
She's urinating a little less than she was when she first became symptomatic. We generally walk her 4 times a day and she may use the wee-wee pads 0-2 times in addition. We stopped feeding her dry food and feed her a high quality balanced can food along with a lot of treats and a little boiled chicken -- sometimes with rice because she seems to need it.
She had another seizure in March, but she's not having them regularly.
What continues to amaze me is how well she caught on to the wee-wee pads. She never misses and seems to feel secure knowing that there is a place where it's ok for her to go. On the other hand she usually signals because she's smart enough to know that if she goes outside, she'll get treats when she comes in.
If you have an older dog and it starts to urinate in the house for whatever medical reason, please be aware that you can teach an old dog new tricks. The wee-wee pads are a little pricey but they are easy to use and the house doesn't smell.
Sabre's Mum
04-17-2012, 04:34 AM
Thanks for the update! Maizie sounds as though she is striding along nicely.
Angela and Flynn
mytil
04-17-2012, 07:48 AM
I am glad to hear this happy news! - what a little trooper she is.
Terry
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