Food-dependent Cushing's?

[mattwho]

I just joined the forum and am seeking information on food-dependent Cushing's. Anyone here have a dog diagnosed with this? Here's my story:

I have a 9-year-old mutt; my best guess is that he's a Rottweiler / Queensland Heeler mix. For at least the last three years, he's been drinking an abnormally large amount of water. That was his only symptom, and he tested negative for diabetes, so I assumed it was purely behavioral and didn't pursue it further, until a couple of months ago when he started exhibiting other symptoms.

He had dramatic weight loss, but this was found to be caused by giardia. He also had bald spots, but they have now cleared up since treating the giardia. The symptoms he's having now are: increased drinking, difficulty getting weight back up, very high alkaline phosphatase, borderline high on other liver enzymes (ALT, GGT, protein), excessive dandruff with several reddish, flaky, slightly raised areas on his skin, and weakness in his hind legs.

We did an ultrasound after finding the high liver values and the liver didn't look damaged, but did look inflamed. Both adrenal glands were somewhat larger than normal (1 cm, IIRC) with no visible tumors. Gallbladder showed some sludge. I haven't been able yet to afford to test for Cushing's, but my vet recommends an ACTH stimulation test (at over $400).

I currently am giving him milk thistle, SAM-e, and Ursodiol to help with liver and gallbladder function, an Omega-3 supplement to help his skin and inflammation, and glucosamine for his joints. Also had him on metronidazole for 14 days in case of an infection in the liver. I also switched him to Avoderm from Nutro Natural Choice (thinking there could be an allergy to wheat or corn going on). He's been on this regimen for about 4 weeks and I have not seen any improvement in symptoms.

But, this leads me to why I now suspect food-depedent Cushing's. Last week, he had a bout of diarrhea (possibly due to finishing the metronidazole). The usual treatments weren't working, so I fasted him for 36 hours. To my amazement, during this period of fasting he was all of a sudden drinking a normal amount of water! He's eating and digesting well again now (and back to drinking excessively), but here I am now thinking my dog may have a fairly rare form of this disease. Once he's been eating and digesting normally again for a week or so, I'm thinking of fasting him again to see if the result is repeated.

I've found a handful of information online - medical papers and abstracts on both dogs and humans about food-dependent (or GIP induced) Cushing's, but if anyone here has had any experience with it, I'd love to hear your story and especially how it was diagnosed and treated.

Thanks for reading...

Moderator's Note: I have manually approved your first post. Please check your e-mail, especially your spam folder, for an message from k9cushings which you need to respond, so we can get your membership approved.

[labblab]

Welcome to you and your dog!

I must admit that when I first read your post, I was definitely scratching my head because during my eight years as a member of this forum, I had never heard of food-induced Cushing's :confused:. But I've just Googled it, and sure enough, there is such a disorder (at least in humans):


One particular form of truly ACTH-independent Cushing’s syndrome has been described recently by several groups (6, 7, 8, 9, 10). All the patients had food-dependent Cushing’s syndrome resulting from an inappropriate sensitivity of their adrenocortical gland to a normal postprandial increase in the secretion of gastric inhibitory polypeptide (GIP).

http://jcem.endojournals.org/content/83/12/4514.full

I have only had a couple of minutes thus far to try to research the disorder. Have you found references to it occuring in dogs? I'll keep looking, myself. As you can tell from my response, we have not yet had any members here with dogs who have been diagnosed. So I'm afraid you and your dog will be charting new territory for us if, in fact, he has this abnormality. :o

Have you had the chance yet to discuss this possibility with your vet? I'll try to do some additional searching myself, later today.

Marianne

[Squirt's Mom]

Hi and welcome to you and your baby! :)

Like Marianne, this is something new to me and quite interesting to say the least. I have found this reference so far in my research -

http://www.2ndchance.info/cushingskooistra2010.pdf

In part, this paper states -


HYPERCORTISOLISM DUE TO ECTOPIC OR HYPERACTIVE EUTOPIC ADRENOCORTICAL RECEPTORS

In addition to autonomous cortisol secretion by an AT, ACTH-independent hypercortisolism can also be caused by aberrant adrenal expression of either ectopic or overexpressed eutopic hormone receptors.2,3 Most of these hormone receptors belong to the superfamily of G protein-coupled receptors.31 In humans, various adrenocortical membrane-bound receptors functionally coupled to steroidogenesis have been reported, including glucose-dependent insulinotropic polypeptide (GIP), catecholamine, vasopressin, serotonin, and luteinizing hormone receptors.

In a recently published case report of a dog with food-dependent hypercortisolism, the ACTH-independent hypercortisolism was most likely due to aberrant adrenocortical expression of GIP receptors.4

I will post more as I find it! :)

Hugs,
Leslie and the gang

[Squirt's Mom]

http://www.sciencedirect.com/science/article/pii/S1090023307001517


Here we report on a 6 year old Vizsla dog in which ACTH-independent hyperadrenocorticism was associated with meal-induced hypercortisolemia. Diagnosis was based on history, physical findings, biochemical changes, and elevation of the urinary corticoid/creatinine ratio (UCCR) on two consecutive days...

The combination of (1) low plasma ACTH concentration in the absence of an adrenocortical tumour, (2) an increase of >100% in UCCR after ingestion of a meal, (3) prevention of the meal-induced increase in plasma cortisol concentration by octreotide, and (4) reversal of signs of hypercortisolism by administration of trilostane a few hours before the meal led to the diagnosis of food-dependent hyperadrenocorticism in this dog.

[Cyn719]

Welcome to the forum - I dont know anything about this type of cushings but if its out there Leslie and Marianne and some of our other Cush Angels are fantastic and they will help you - hope you find a answer and also AHTC - is $200 for my dog - did you say $400 for jsut the test?

[Squirt's Mom]

http://igitur-archive.library.uu.nl/dissertations/2010-0610-200141/UUindex.html

Food-dependent hypercortisolism has been diagnosed in a dog with mild clinical signs of hypercortisolism, suppressed plasma ACTH concentrations and bilateral enlarged adrenal glands. UCCR increased after ingestion of the meal. Treatment with ocreotide, which suppresses release of gastric-inhibitory polypeptide (GIP), blocked cortisol secretion, while plasma ACTH concentration remained suppressed. Treatment with trilostane was successful only when trilostane was administered before ingestion of the meal, which provided an additional information for food-dependent hypercortisolism in this dog. The differentiation between ACTH-dependent and ACTH-independent hypercortisolism can be done by the measurements of the urinary corticoid:creatinine ratio (UCCR) combined with the high dose dexamethasone suppression test.

http://www.vin.com/proceedings/Proceedings.plx?CID=WSAVA2002&Category=7889&PID=52354&O=Generic

In the dog, the suspicion of the existence of functional gastric inhibitory polypeptide (GIP) receptor has been raised in a patient diagnosed with food-dependent hypercortisolism (Galac et al. 2007). In addition, the presence of vasopressin receptors on adrenocortical tumors (ATs) has been indirectly postulated by the finding of non-ACTH-mediated cortisol responses to systemic lysine vasopressin (LVP) in dogs with adrenal hypercortisolism (Maaskant-Van Wijk et al. 1994).

[labblab]

Leslie, great work on finding these research summaries!!!!!! ;)

Marianne

[Squirt's Mom]

Hi,

I must say your post has excited me no end! :p A learning opportunity always excites me - yes, I lead a boring life! LOL :D

Before you spend that $400 on the ACTH, I would do a bit more research, including contacting some of the leaders in canine Cushing's research like Dr. Peterson or Dr. Feldman. Most of the studies I have found pertain to humans, but much of canine research is based on human studies. I have contacted Dr. Peterson and asked for more info and will let you know what he had to say, if he responds. He may be more apt to respond to the parent of a pup who is suspected to have this very rare form. ;)

From what I have gathered so far, the testing is a bit different as is the timing of the med for treatment - which seems to be Trilostane (Vetoryl). I have not been able to discern whether diet has any affect - ie, if a particular diet will help or not. It may be that all proteins, which are vital nutrients, will cause this reaction. I am just not clear on so much about this form yet but I am working on it. ;)

Have you talked to your vet about this? What did he/she have to say? Is your baby back on the original feed, the Nutro, or is he still on the Avoderm? How is he doing today?

I look forward to hearing from you again and learning more about this form of Cushing's!

Hugs,
Leslie and the gang

[mattwho]

Wow - first off, thank you Leslie and Marianne for all the info. I had found a couple of those articles before posting here, but several were new to me. I spent several hours researching online before I posted here - I also enjoy learning new things and am a science nerd!

I haven't had a chance to talk to my vet yet about ACTH-independent / food-dependent Cushing's. When I noticed the change when he was fasting, I didn't know such a thing existed either. I was searching like crazy online thinking maybe there was a connection between fasting and regular Cushing's, and discovered this as the only possible link. My guess is it will be something new for my vet also.

Of course, I don't know for sure that this is the explanation. It looks like UCCR before and after a meal is the way to initially screen for it. Now that I have this information, I will talk to my vet about it. I'm really hesitant to fast him again, since he is underweight, but I may try doing 24 hours this weekend to see what happens.

My dog, Moby, is now on half Avoderm Chicken and Brown Rice, half Nutro Max Beef and Rice. I know Max isn't the best food out there, but he lost a lot of weight with the giardia and he still needs to gain some of it back, although he is slowly getting there. That variety of Max has high protein and high fat (and low price), which is what he needs right now. I plan to keep doing the Avoderm, as he seems to digest it better than the Nutro, and when the Nutro has run out, do half Avoderm puppy if he is still underweight.

He's been drinking even more water than usual the last day or two. His symptoms tend to wax and wane over several days though. He's always the same happy, loving goofball of a dog. People that first meet him usually still think he's much younger.

I'll get in touch with my vet before anything else and post back what I find out or end up doing.

Matt

[mattwho]

Welcome to the forum - I dont know anything about this type of cushings but if its out there Leslie and Marianne and some of our other Cush Angels are fantastic and they will help you - hope you find a answer and also AHTC - is $200 for my dog - did you say $400 for jsut the test?

Yes - this is something else I was wondering about. I asked my vet why it was so expensive, and she said the ACTH, or whatever it is that they give the dog, is very expensive itself. Add two blood tests to that, and it gets up there I guess. The liver panel alone from them was $147.62 plus $19.00 for collection. They send bloodwork out to a lab they say is very good...she told me the name but I can't remember it. Is that too high? I like this vet - she's a science nerd like me and shows genuine interest in my dog's case. I'm also on a budget though.

[Squirt's Mom]

Hi Matt,

I love that face! :D Moby looks like a real character!

Here is a link you can print and share with your vet that may save you a dollar or two. The stimming agent, Cortrosyn, can be cut into several doses without losing any effect - making that expensive vial last much longer as well. ;)

How to Extend Your Supply of Cortrosyn and Lower the Cost of ACTH Stimulation Testing
http://endocrinevet.blogspot.com/2011/03/how-to-extend-your-supply-of-cortrosyn.html

Hope this helps!
Hugs,
Leslie and the gang

[Squirt's Mom]

Hi Matt,

Haven't heard from you in a while and am curious as to how things are going with Moby? Did you ever get to talk to the vet about the food connection and, if so, what did you learn?

Would love an update when you can!
Hugs,
Leslie and the gang

[mattwho]

Finally updating this thread - hard to believe 6 months have passed.

My regular vet didn't know anything about food-dependent Cushings, so I took Moby to an internal medicine specialist with a lot of Cushings experience. They had me take two urine samples from Moby - one after fasting and one after a meal, and then ran a UCCR on each. They both came back with high cortisol - with the fasted sample actually slightly higher than the post-meal sample; consistent with Cushings, but not food-dependent. So the apparent, repeatable connection between fasting and reduction in symptoms remains a mystery.

Next they did an ACTH stim to confirm, and it was also consistent with Cushings.

We started him on Trilostane - 68 mg twice per day (he weighs 34 kg), which now to me seems like a higher starting dose than I would have chosen - I would have prefered half that. Within 2 - 3 weeks he had shown a lot of improvement in symptoms and his skin and coat had noticeably improved in about 8 weeks. He's been on it about 3 months now and we just did the first follow-up ACTH stim. Pre- ACTH was 3.3 (normal: 2 - 6), and post was 7.0 (normal: 6 - 18). I think they use IDEXX labs. The vet is happy with the results and wants to stay with this dose.

Since he's right on the lower end of normal, I'm wondering if it would be worth trying a lower dose, like 1.5 mg/kg bid, instead of 2. He hasn't had any vomitting or diarrhea - in fact, with the reduced water intake his stool has firmed up to normal consistency, and his appetite is fairly good although he is a picky eater. But he is a little lethargic. Then again, he is 10 years old with arthritis and hard to say if he's any more lethargic now than he was before getting Trilostane. I just prefer to minimize medication (for both him and myself) as a general rule and I wonder if he would do as well or even better with a lower dose. Also it would reduce my cost some - currently paying $81 for a 1 month supply.

Any opinions on the ACTH stim results vs. dosing? The numbers they gave me for normal don't seem to match up with others I've found online, so that makes it harder to judge.

Thanks.

[mattwho]

Just found the IDEXX ACTH stim test flowchart, which makes me feel better about his results since post-stim between 2 and 6 is considered inconclusive, and only bleow 2 is considered hypoadrenocorticism.

Still, he is on the low end of normal, but I have no idea how dosing would correlate to a change in test results, like a ratio of change in dose vs. change in results.

BTW - the vet would have done fllowup testing sooner, but it was my budget that dictated the schedule.

[lulusmom]

Hi Matt,

You cannot use the normal reference ranges for purposes of monitoring treatment. The goal of Vetoryl (Trilostane) treatment is to get both the pre and post stimulated cortisol within the therapeutic range of 1.45 - 5.4 ug/dl. A post stimulated level up to 9 is allowable if symptoms are well controlled. If Moby's symptoms have resolved, then a post level of 7 is very good and I would agree with your vet that Moby should stay on his current dose. Good job!

Glynda

P.S. Take a look at a paper written by Dr. Ellen Behrend entitled Update on the Use of Trilostane. Dr. Behrend is an expert consultant for Dechra who is intimately familiar with Vetoryl. There is a handy dosing and monitoring flow chart on page four that will help you understand proper protocol.

http://www.dechra-us.com/Files/dechraUSA/downloads/Case%20Studies/Clinicians%20Brief-trilostane.pdf

[mattwho]

Thanks. I didn't realize that the target range is different when the dog is taking trilostane. The technician who called me with the results didn't mention that, and said normal for pre was 2 - 6 and post 6 - 18, so what she told me conflicts with that.

What you're saying is also confirmed here: http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=11916

[lulusmom]

Hi Matt,

Most gp vets aren't really that well versed in how to assess an acth stim test for purposes of monitoring treatment so I'm not surprised that a technician rattled off what she was reading on a piece of paper. Perhaps you should share the link I provided a few weeks ago and the link you just gave us with your vet and vet tech so that if clients call in for results of stim tests, they are given correct information.

I had to explain to my gp vet why he can't use the normal reference ranges listed by the lab and I'm still not sure he gets it. This is a guy who told me he treats many cushdogs so I'm hoping our lesson will help the other dogs he is treating. I am very concerned for them. I only go to him for acth stim tests because he is much cheaper than the specialists.

[mattwho]

Hi again to everyone. You've all been so helpful and supportive in the past, so I wanted to post an update and new questions here. I just had Moby's second ACTH stim done and it came back almost nonstimulated. Results from IDEXX Labs...

12/2011: both pre and post high (don't have numbers available) Started on 68mg twice/day Trilostane (Moby weighs 34kg)

(waited 3 months before first followup due to finances and excellent outward improvement)

3/2012: pre: 3.3; post: 7.0 - Symptom-wise Moby was doing great at this point.

9/5/2012 (9 months into Trilostane): pre: 0.8; post: 0.9

The only outward signs he's shown of Addison's are somewhat decreased appetite and some lethargy. I brushed them both off because he's always been a picky eater, and he has arthritis, which slows him down. Neither were a marked change. I was expecting another good result with this test. And now I feel absolutely terrible for not being more attentive and harming my dog. I feel like I had a false sense of safety with the Trilostane.

So how weird is this type of result? He was doing great at 3 months, and now, 6 months later, he's almost non-stimulated.

The IMS wrote a script for 55mg Trilostane, and the tech I spoke with said to start it right away. Unfortunately, the results came back Friday afternoon and the doc is out until Monday, so I won't be able to speak with her until then.

I've done some reading tonight, and it seems like I should instead stop the Trilostane altogether for at least 3 days and even maybe administer prednisone.

I'm sort of at a loss because his IMS is supposed to have a lot of experience treating Cushing's, but did not recommend I stop dosing. I'm leaning towards stopping the Trilostane until (and if) Cushing's symptoms return and considering trying to get into his regular vet tomorrow to possibly get prednisone and/or check his electrolytes.

[frijole]

Well congrats because I think you are doing a better job than the vet! Absolutely cease the trilostane and I would be demanding prednisone and check those electrolytes as well.

We do seem to have a large number of people that come here in distress as a result of 'overconfidence' in vets in trilostane. They think it's easier and less risky than lysodren but they don't understand that it too can result in addisons or at the least very low cortisol.

What we have seen is that the drug has a cumulative effect and what happens is exactly what happened to you - the dose needs to be tweeked downwards after time and THAT is why a vet should not allow a dog to go for 3 mos without testing in the initial stages.

Luckily your babe seems to be handling it ok. Still do give the trilo a break and I'd wait for more than 3 days. Sorry to say but I would not give trilo until I did another acth test PROVING that the cortisol has reached a safe level of 2.0 or higher. Obviously I would then go to a lower dose.

I would also make a point to let the vet note that the tech told you to continue dosing. An honest mistake but it could have been fatal. They need to teach the tech a lesson. This 'aint' aspirin!

Kim

[mattwho]

Thanks for the feedback. It's nice to have someone "backing me up" with what it seems to me I should be doing at this point. I was shocked that his numbers were that low and that the tech still seemed unconcerned. She did confirm with me that he didn't have any vommiting or diarrhea, as I told them when he checked in, but still...she didn't mention checking his electrolytes or that any kind of followup was warranted. I'm thinking about not returning to this IMS at this point. Very disappointed.

I will definitely stop the Trilostane and try to find a way to do another ACTH if and when Cushing's symptoms return, and try to get into his regular vet tomorrow.

Poor doggie.

[labblab]

I agree 100% with Kim's advice, and as does she, I also think it's very important to let the IMS know exactly what her tech did/did not instruct you to do. The instructions really were not appropriate, and this needs to be discussed with the IMS.

As far as the IMS herself, I am not clear how much involvement she has personally had in the testing thus far. Was she aware that you were planning to test only at the 3-month mark, and then not until 6 months later? If so and she approved this protocol, then she really is negligent. It is her responsibility to make clear how important the monitoring testing is to the health of the dog. And obviously, she is also responsible for the instructions that are being given out by her tech.

But whomever you end up seeing, this situation does highlight the importance of monitoring at regular intervals. Even though your dog should have first been tested prior to the 3-month mark, I can't fault the IMS for leaving the dose unchanged at that time given the ACTH results. But 6 months was far too long to wait for a retest that should have been done in half that time. So I know you will consider that a lesson that has been learned for the future. For the time being, I wouldn't restart the medication, either, until symptoms return and you retest.

Further down the road, if and when you resume the trilo, there has been some research directed at determining whether or not baseline cortisol readings can sometimes be of monitoring value in lieu of full ACTH stim tests. This approach has not yet been thoroughly validated and would only even be considered once a dog has been stabilized on a given dose and is clinically doing well. But in situations where finances would otherwise prohibit treatment, a vet might consider it as an occasional monitoring option. But we can talk more about that later on.

Marianne

[mattwho]

Well, I took him to his regular vet today and drew blood for an electrololytes panel. Being the weekend, I won't have results until Monday so until then I'll be watching him very closely. The first thing the vet asked when I requested the panel was if the IMS had recommended it, so I explained the situation. The vet said she didn't think it was necessary, but I suspect some of that may be "professional courtesy" - not wanting to make a recomendation that goes against another doc without having all the information first-hand.

I don't want to put him on prednisone unless I'm sure he needs it, so that will have to wait for the electrolyte results. If he starts showing any acute signs of Addison's I'll get him to an emergency vet immediately.

I will have some tough questions for the IMS on Monday. Even Dechra's protocol says if pre- or post- are below 1ug/dL to stop dosing for 2 - 3 days, and IDEXX says to stop for 7 days if post- is under 1.5. Being a Friday afternoon, what the IMS tech said to me was "If the pharmacy doesn't have the new dose ready tomorrow morning <they're open Sat mornings, closed Sun> it's OK to stop dosing until Monday." So I asked, what if I drop down to one a day of the current dose until Monday, and she said that would be fine also. Never a mention that I should stop dosing, just that it would be "ok" if I did and only until I could get the new dose.

As far as the followup testing - I know the IMS would have preferred sooner than the 3-month point, but that was my choice because at $400 a pop, the ACTH stim isn't something I can afford to do monthly, and I was watching him very closely and he was doing great. I can't fault her for that. If I had unlimited funding, I'd do one every week! For the second test, I thought 6 months was a normal interval if at 3 months things look good (which they did).

[frijole]

$400 for an acth is HIGH. We pay $150 here and it is because the Cortrosyn is $125. Anyway.. there are ways that vets can save you money and not all vets are aware of this. I am quoting Glynda because she wrote a very good explanation:

Acth stimulation tests...ARGH!!! They are the bane of my existence and I was so happy to learn that there is a way to save money but only if you have a smaller dog. Rascal is small enough to save you money too. Way to go, Rascal!!! Most vets use a stimulating agent called Cortrosyn but we call it liquid gold because it's that little vial that dictates the cost. The vial is .25mg and instructions say to use entire vial but not all dogs need the entire vial. There have been studies done that show using just 5mcg per kg is all that's needed. Since there are 250mcg in one vial, your vet can get two stim tests out of one vial. This has saved members a lot of money, especially those of us with teeny dogs who can get five and six stims out of one vial. Formula for Rascal's weight in pounds converted to kg is 39 divided by 2.2 = 17.73 x 5mcg = 89mcg. Your vet can round that off to half a vial or 125 mcg.

Some vets are not aware of this so we always provide the url to Dr. Mark Peterson's blog which instructs vets on how to dilute and store cortrosyn for future use.



http://endocrinevet.blogspot.com/2012/03/how-to-dilute-and-store-cortrosyn-for.html
You have nothing to lose and everything to gain by printing this out or providing the URL to your vet and asking if s/he will please split the vial.

[frijole]

I forgot to mention regarding prednisone.. it used to 'scare' me because I became "anti cortisol" when fighting cushings. :p Anyway... it is a life saver and I disagree with the vet's office for not giving you some today. I have been on here on Saturday nights and had members using trilostane come on with a dog in trouble and no prednisone in the house. It is frightening and can be very difficult to get to the hospital or get the drug in time. These tiny pills cost next to nothing and are life savers. All dogs being treated for cushings should have them on hand because even a dog on trilostane for months can all of a sudden go low. Dogs DIE if not seen right away and treated.

I am very very happy that Moby is so far feeling fine. Just so you know - should it hit you will think Moby is dying - it is very frightening - lethargic, sometimes dogs can't lift their head up let alone stsand, they refuse food and/or water.

[mattwho]

Yeah, I know it's high. They charge $157 for the two blood tests, $40 for the two blood draws and injection, and $194 for .25mg Cortrosyn. I checked with my regular vet and they charge the same, or at least within just a few dollars. I think this area just tends to be expensive for vet services.

So even if they only used 170mcg (34kg * 5) and agreed to not charge me for the 80mcg unused it would only save me about $60. I should probably call around to some other vets and get quotes, especially now that I may not stay with this IMS anyway.

Very good to know about the prednisone. I will definitely get some ASAP to have on-hand in case of emergency.

EDIT: Both the IMS and regular vet use IDEXX for testing, so I imagine that's why the test is so expensive.

[frijole]

FWIW my vet that charged $124 for acth tests uses IDEXX. It isn't the lab, its' the cortrosyn which is the ingredient used for the test.

We have alot of members from the Phoenix area so hopefully they'll chime in with what they pay... and remember it isn't just the cost of the test but also the experience of the vets. Hopefully we can help you find a great vet in your area. What part of Phoenix are you in? We have a couple mods from your area fwiw. Kim

[mattwho]

Cool - I'm in West Mesa and my vet and IMS are both in Gilbert. I'm definitely open to recommendations for both IMS and vet.

[StarDeb55]

I'm not on the forum much any more but happened to see that you are in W. Mesa, & both your IMS & regular vet are in Gilbert. I'm in Chandler. By any chance, is your IMS Dr. Janet Bailey at Az. Vet Specialists on Gilbert Rd.? If Dr. Bailey is your IMS, this is why you are paying an arm & a leg for a stim. I speak from previous experience.

Debbie

[mattwho]

(Moved this discussion to private msg and Debbie has given me a local recommendation.)

Thanks, Debbie!

[frijole]

:D:D:D:D:D:D:D:D:D:D:D:D:D

Kim

[mattwho]

Just a quick update - Moby has been off the Trilostane for just 36 hours and, maybe it's my imagination, but he seems to have more energy, less of what I had chalked up to arthritis, his mood seems elevated, appetite improved, and he has not yet returned to PD/PU. None of these symptoms were severe and they came on so gradually over several months that I I had chalked them up to age, arthritis, and his usual finicky eating habits, but it looks like at least some of it was his low cortisol.

Will be interesting to see how things progress.

[labblab]

Matt, don't know whether you've had a chance to see this before, but here's a link to the Product Insert for Vetoryl (brandname trilostane). It contains a lot of helpful info re: proper monitoring protocol as well as other important stuff:

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

Marianne