Duncan, 15yo Cocker, is back...Duncan has passed

[Carin]

Hi, Temporary Forumites,

Duncan, my 14-year-old Cocker, has been on trilostane since he was diagnosed with PDH 27 months ago. He originally started on 60 mg once a day, to which he responded immediately and well. Over the 2+ years since then, in response to regular stim testing, we've reduced his dose till now he's getting only 2 mg twice a day (i.e. 4mg a day total)! He went through a period last summer of gastro-intestinal problems that resulted in severe weight loss, despite having a pretty good appetite, but that seems to have leveled off - he's now about 22 lbs, down from his mature high weight of about 26 lbs and up from his low of last summer of 19 lbs. Apart from that period of weight loss, his energy, appetite, and quality of life have been great. Despite stims that keep trending lower, he's shown no signs of an Addisonian crash. So I'm writing not out of concern, but out of curiousity: have any of you experienced a similar reduction in the need for meds over the course of long-term trilostane treatment? I wonder if we're heading towards a time when he won't need the trilo anymore.

Thanks,

Carin

[ventilate]

Carin;
I dont use trilostane but use lysodren. My experience is sort of the same. Nike had been on lyso for a year and half, stable as a rock in fact I had to do a couple miniloads (for us it was a couple extra doses in a week) to take her down a bit as she continued to creap up. a year and half ago I did a miniload and she went a bit low, it was under 1, but she had been there before when we loaded and when the IMS took her there for specific reasons, she shows no signs of overloading either. Anyway I held her lyso for a couple weeks, as I had before when she was to low then had her stimed again and it showed her even lower so she was off from sept till Dec then stimed again and she had come up so started her on lyso at half her previous dose. I have been treating her by her signs and symptoms since as she is a very geriatric giant schnauzer at 12 and half years old. I had given her very few treatments in the last year and had her stimed in Feb and her levels were <0.2 again not symptoms SO she is now on a lysodren holiday and I will have her stimed again in June.
I have seen where others have had to drop the trilo for the same reasons you have had to, I dont know that it is common but I can recall a few here that have done that.

Sharon

[Spiceysmum]

Hi Carin,

Spicey has been off Trilostane for 6 months now. She also started with ACTH test numbers that were always on the high side but over the 18 months she was on it they gradually got lower even though she stayed on the same dose throughout. Her last result in October was less than 1 so we decided to take a weeks break then start back on a lower dose. None of her cushings symptoms returned in that week so we decided to hold off until they did. Six months later she still has no cushings symptoms. Spicey didn't show any signs of being that low so if it wasn't for the tests we would not have known. I still find it strange that she was as well when her number was that low as she is now. I know we will have to have another test at some time to see what her number is now but wouldn't treat her anyway unless she had some symptoms back. How low were Duncan's last ACTH results?

Linda and Spicey

[Patricia ann Wh]

The more I'm reading about tilostane dosing - the more complex is gets.
I read yesterday about a pony - over 400 lbs - on 125 mg. a day for 2 years and showing no signs of cushings.
It sounds like the dosing should always start out very very low, for safety reasons and because the low low dose just might be all that is needed, considering its a dangerous drug - why go and look for trouble.
I'm glad your guy is on such a small does - is that right - 4 mg. a day.???
Excellent.

[Carin]

Sharon and Linda, that's very helpful to know. Linda, Dunc's recent stims were as follows:

From mid-late 2008, when he was on 20mg/day, in two doses:
5/27/08 pre 1.3, post 2.2
8/28/08 pre 1.57, post 4.1
12/9/08 pre 1.1, post 2.54

Since he was trending low on the pre- results and his red blood count and globulin were a little low on the December test, the vet cut him back to 10mg/day, in two doses, and retested:

2/6/09 pre 0.6, post 2.47, at which point we switched to a single 5mg/day dose, which brought the "post" up, but not the "pre":
3/6/09 pre 0.619, post 4.01

After which we switched to 4mg/day in two doses. My vet was happy with the "post" at the 3/6 stim, but thought the low "pre" might reflect the fact that Dunc was getting his whole dose in the morning. (I was really suprised at how low these last tests were, because Dunc had been SO energetic and apparently well - probably better than he had felt a year or two ago.) We'll retest in a couple of weeks and see how the 4mg split dose is working, but it does look like we might be trending towards being ready for a trilo vacation.

Carin

[Carin]

Hi Patricia Ann - sorry I missed your post while I was replying to Linda. Yes, Duncan's currently on 4mg/day. My vet echoes your thoughts: even though he started Duncan on 60mg/day back in early 2007, his experience with several clients means he wouldn't do that today. I feel so lucky to have a vet who's actively keeping up on the research. Early in his treatment of Dunc, my vet actually called me from a veterinary conference to report on the paper he had just heard about twice-a-day dosing.

[Patricia ann Wh]

Hi Carin,
Thats amazing - how much does Duncan weigh??
Its wonderful.
You are extremely lucky to have a great - intelligent vet.
So your vet would start all dogs out on very low doses??

[Carin]

He weighs about 22 lbs.

Yes, my vet has been saying he can hardly believe he started Duncan on such a high dose, though we haven't discussed specifically what he's doing for newly-diagnosed clients. (This is Brian Collins at Colonial Vet in Ithaca, btw, if anybody needs a fabulous vet.)

[Patricia ann Wh]

Carin ---

Do these numbers mean anything to you from the 1 hour acth test.

Cortisol Pre 5.9
Cortisol 2 26.7

Patti

[Roxee's Dad]

Carin ---

Do these numbers mean anything to you from the 1 hour acth test.

Cortisol Pre 5.9
Cortisol 2 26.7

Patti

Hi Patti,
These numbers seem to suggest cushings as the post is high but have seen much, much worse. But it does not neccesarily suggest what type of cushings.
John (Roxee's Dad)

[Carin]

Patti - others here will be much more informed about interpreting test results than I am, but my understanding is that the goal is to get the second result in the range of 1.45-5.4, so that result is very high. The flow chart in the Vetoryl pdf in the forum's files makes things fairly clear: http://www.dechra-us.com/File/vetoryl_Treatment_and_Monitoring_Flowchart.pdf

Carin

[frijole]

Hi Carin. You are right that those numbers are high because Jesse hasn't started treatment and is still being diagnosed. "Normal" dogs cortisol levels are 22 or below so that number is high but not "way high". ;) The 1 to 5 numbers that we talk about are the goals for decreasing cortisol in cush dogs.

Cush dogs need way lower cortisol levels than others dogs since their poor bodies want to keep producing it. Hope this makes sense. :) Kim

[Carin]

Hi Kim. I replied to Patti's question on this thread without catching up on Patti and Jesse's story in their own thread. Going over to read that now...

Carin

[Patricia ann Wh]

Hi,

So should the lower number be from 1 - 5 ??

I'm sorry I looked at that flow chart, and I'm confused, I'll look at it again.

Oh My Lord, I can't believe you guys understand all of this.

Two vets said (no three) that they would start Jesse on low dose trilostane. (Not that any of them have used it) Oh BOY

Thank you all

[lulusmom]

To answer Patti's question, the basal or pre draw number is of little value when interpreting the acth stim test for monitoring of treatment. The normal resting or basal range is usually 1 to 6 (depending on the lab) and anything above that can usually be attributed to the stress of being at the vet's office. It is the post draw that you want to be within the 1 to 5 range, ideally anywhere between 1.5 to 4.5.

Glynda

[Carin]

Thanks, Glynda. Patti - don't worry about this, I'm just processing Duncan's experience after long treatment - but my vet is clearly somewhat concerned about the drop in Duncan's basal level over time. My impression was that he was worried that if his basal level was so low, he would be more prone to an Addisonian crash, and that the low basal number suggested we might be approaching a point where the adrenal gland wasn't functioning. But I will clarify that with him next time we talk.

Carin

[lulusmom]

Hi Carin,

You made a very good point about monitoring the basal number for purposes of determining possible Addison's Disease or Addisonian crisis. I failed to mention that. If resting/basal cortisol is low (less than 1) and the dog has no or a very low response to stimulation, then Addison's is a good bet.

Trilostane definitely affects aldosterone levels so it is very important that electrolytes are checked every time a stim is done. This is absolutely critical if acth stim results are too low for comfort.

Glynda

[zoesmom]

Carin -

I'm jealous. I wish Zoe could be on a much lower dose. She's on the 180 bid. I think it's interesting what you describe has happened with Duncan. I had hopes last August when Zoe's consistently stubborn numbers took an unexpected plunge. Similar to Duncan's - a pre of .7 and a post of 1.6. She'd never had anything close to that before, always 5-ish to 10-ish, once even going back up to 13-something. So you can imagine my surprise. She WAS acting strange, but I never dreamed it was from too low cortisol. But it was.

So we did do a dose reduction.....all the way down to 150 mg. bid:rolleyes::p:p:rolleyes: It was short-lived.....but it lasted a few months which is better than none. By Nov. she'd crept back up to 9. We didn't change her dose tho'. Then just about a month ago, we retested and her post was well over 10.....so this time we decided it was time for an increase and back to 180 mg. she went. So it's the usual roller coaster with the Zo.

The only thing we can say for sure is > All the dogs are so different. You just can't predict anything with any of them. But I'll keep my fingers crossed that Duncan is headed for a remission! Zoe has a long way to go, I think, to reach that point!;) Sue & Zo

[Carin]

Hello, all. My Duncan (14y8m Cocker with PDH, on trilostane for the last 2 1/2 years) had a stim test yesterday at the vet where I am staying at my mom's. I got the results today and but I have to wait till the middle of next week to consult with my regular vet, who has been guiding his treatment.

The puzzle: the pre was HIGHER than the post! Results: pre 9.6, post 7.5. In all Dunc's stim tests, I've never seen a result like this, and I just wondered if anybody had any guidance about what this could mean.

Background: the "pre" number in Dunc's stims had been trending lower over last winter, even as we reduced his trilo dose, with pre numbers below 1 and posts in the 2-4 range. He showed no clinical signs of Addison's, but my vet was concerned about the low "pre"s, so in March we reduced his trilo dose to 2mg twice a day (i.e. 4mg a day total). In May, he had a stim and the results were pre 1.98/post 7.79. Even though the "post" was high, my vet was happier with slightly high than with too low, so we kept him at the 4mg/day split dose until now - and now, this weird result.

I took him in for the test yesterday because it seemed like he was hungry all the time, unusually so, but I've seen no pu/pd or other clinical signs, and he seems otherwise fairly energetic and perky, for a 14-year-old. He's put on a little weight over the past couple of months, his coat looks good, digestion normal, attitude good, etc.

Any thoughts?

Thanks,

Carin

[gpgscott]

Hi Carin,

I see you have found the merged thread:)

Sorry that I am not familiar with your case but will be reading it to see if I can add anything worthwile.

Stick around, those who have already replied to you will most certainly have thoughts.

Scott

[BestBuddy]

Hi Carin,
I have no answers to you question but my Buddy nearly always had lower post ACTH numbers than the pre and he had been off trilo for two years. His numbers were similar to what you just got. He was always very stressed when we got to the vet for testing so it was assumed that the high pre number was a natural release of cortisol (flight or fight response). I know it is totally different because Buddy was not being medicated at the time. What did your vet say?
Jenny

[Wylie's Mom]

Hi Carin,

I'm not familiar with your thread, but I'm wondering if Duncan wasn't familiar with the place where you had this stim done, and maybe he was just extra stressed being in an unfamiliar place, but then calmed down by the time the post was drawn:rolleyes:?

-Susy

[Carin]

Scott and Jenny - Am now confused by the merged thread, but it's nice to see my old messages on this page. :) Anyway, the stress of being at a different vet could conceivably explain the unusually high pre number. My mom's vet, who did the stim, wanted Dunc's regular vet to interpret the results, and they've been faxed to him, but he's on vacation, so I'll have to wait till next week to talk to him - unless he gets my email while he's traveling. Ah, August.

Carin

[BestBuddy]

Carin,

Don't be confused, one of the mods or admins would have merged your new post to your old thread. I know old threads are sometimes hard to find sometimes but it is so much easier to be able to go back and read the history so that's why it's good to keep the same thread.

Jenny

[gpgscott]

Carin,

I merged the new thread you started about the stim results with the old one and changed the title, I then sent you a PM with a link. When threads are merged the program puts them all in order by the time and date they were posted, this ensures continuity.

It works best to keep all discussion about a pup in one thread, not all sites do this but we think it works best as all of the talk about that pup is in one place. Sometimes the threads get very long but that is not an issue.

It is easy to find your thread, just click on your username and you will be taken to your public profile, then click on the statistics button and you can view all posts and all threads.

Scott

[Carin]

Ah - I understand! Thanks, Scott. The mods here are MUCH more sophisticated than on any other forum I belong to!

[gpgscott]

Ah - I understand! Thanks, Scott. The mods here are MUCH more sophisticated than on any other forum I belong to!

May we qoute you:D

[Carin]

Of course!

[Harley PoMMom]

Hi Carin,

Was wondering what your vet said about those stim numbers and how is Duncan doing these days?


Hello, all. My Duncan (14y8m Cocker with PDH, on trilostane for the last 2 1/2 years) had a stim test yesterday at the vet where I am staying at my mom's. I got the results today and but I have to wait till the middle of next week to consult with my regular vet, who has been guiding his treatment.

The puzzle: the pre was HIGHER than the post! Results: pre 9.6, post 7.5. In all Dunc's stim tests, I've never seen a result like this, and I just wondered if anybody had any guidance about what this could mean.

Background: the "pre" number in Dunc's stims had been trending lower over last winter, even as we reduced his trilo dose, with pre numbers below 1 and posts in the 2-4 range. He showed no clinical signs of Addison's, but my vet was concerned about the low "pre"s, so in March we reduced his trilo dose to 2mg twice a day (i.e. 4mg a day total). In May, he had a stim and the results were pre 1.98/post 7.79. Even though the "post" was high, my vet was happier with slightly high than with too low, so we kept him at the 4mg/day split dose until now - and now, this weird result.

I took him in for the test yesterday because it seemed like he was hungry all the time, unusually so, but I've seen no pu/pd or other clinical signs, and he seems otherwise fairly energetic and perky, for a 14-year-old. He's put on a little weight over the past couple of months, his coat looks good, digestion normal, attitude good, etc.

Any thoughts?

Thanks,

Carin

Love and hugs.
Lori

[Carin]

Lori, thanks for asking. Duncan's longtime vet was pretty much stumped and thought the most likely answer is that there was some kind of error, on the theory that if he had been stressed enough to send his "pre" to 9, it wouldn't have come down an hour later after the cortisol. We agreed in mid-August that, since he was clinically well, we'd continue at the current dose and retest this month. In the last ten days, however, pu/pd is back with a vengeance - and I'm just back Columbus after a two-day road trip with the dogs, and let me tell you how much fun THAT is in a hotel room :-) I talked to Dunc's old vet and we agreed to raise his dose from 4mg/day to 6mg/day (4 in the morning and 2 in the evening), see if the pu/pd abates, and retest in a couple of weeks.

Meanwhile, I have another question. Dunc's longtime vet is in Ithaca where we used to live, and I'm now in Columbus for the fall, so I scheduled a stim for him on 9/25 at the vet we're seeing here. (The weird/possibly-in-error stim was done at yet a third vet, at my mom's in DC.)

The protocol for the stim test is different at the new vet. They want him to come in having fasted since midnight, and so not to have had his trilo dose in the morning before he comes in. They said to bring his pills and food with me and they'll take a fasting draw, then feed him and give him his pills, and then take a number of subsequent draws. At his Ithaca vet, and at my mom's vet, they had him eat breakfast and have his pill as normal before he came in, and then they'd do just the pre and post draw at a 1-hr interval, between 4 and 6 hours after his morning pill. I haven't kept up with testing protocols, because for 2 1/2 years we'd always had it done the same way. Is the new vet's protocol something others on the forum are familiar with? (Sorry I haven't re-read through the files; it's been so hard to connect to the forum today, plus my car broke down, plus... oy.)

Thanks,

Carin

[Harley PoMMom]

Carin,

I'm not an expert on Trilostane, but I thought the stim test was supposed to be given within 4-6 hours after the dose of Trilostane to get an accurate reading.

I'll search and see what I can find...so sorry your having all these issues. :( you poor girl...hang in there.

Love and hugs.
Lori

[Carin]

Lori, that's what I thought, too. I've just done some more reading around, and it sort of sounds like what the tech I spoke to on the phone was describing was the Low Dose Dexamethasone Suppression Test, instead - which is, I gather, supposed to start with a fasting baseline level and then have multiple draws over 8 hours. I need to stop by the vet to pick up some meds tomorrow, so I'll clarify in person. They have Duncan's files and this vet saw him for his annual checkup in August, but they may not have in the front of their minds that they're doing trilostane monitoring, not something else.

[Harley PoMMom]

Yes I just found an article about it:

Trilostane: test needs to be run 4-6 hours after the morning-dose of trilostane to assess the peak effect of trilostane on cortisol synthesis.

http://www.qml.com.au/Files/Vet_NL_May08.pdf

You have to scroll down some.

Love and hugs.
Lori

[gpgscott]

Hi Carin,

Neither of the numbers 7 or 9 and in which order do not concern me much.

What does concern me a great deal is the increase from ealier this year when the numbers where in the 2 and 3 range.

What about symptoms?, is Duncan feeling and behaving well?

Scott

and yes to Lori's link concerning testing, the timing of which is very important with a Trilo pup. You may also wish to consult this link to the resources area.

http://www.k9cushings.com/forum/showthread.php?t=222

[Carin]

Hi Scott. From late in the spring until the last couple of weeks, Dunc was clinically well despite the high numbers. Now he's clearly showing a recurrence of Cushing's symptoms. (Peeing and drinking to excess.) We've increased his trilostane dose as of today; I just want to be sure I'm getting the right test when we go in in a couple of weeks to check how he's doing on the higher dose. It might just be a matter of miscommunication with the new vet's office.

Carin

[gpgscott]

Dunc was clinically well despite the high numbers. Now he's clearly showing a recurrence of Cushing's symptoms. (Peeing and drinking to excess.) We've increased his trilostane dose as of today;
Carin

Carin,

I think this is the wrong thing to do.

After reading your recent post concerning the fasting and denial of Trilo prior to testing I am suspect of the results of the tests.

We do not administer Trilo but there are many here that do and I know we will hear from them soon.

Scott

[Carin]

Scott, just to be clear: the puzzling-but-high result that I posted about in mid-August was obtained after an (apparently) normal stim test done 4-6 hours after the morning trilo dose. The suspect, fasting test I described in my post today is what the new vet wants to do on Sept. 25th, but we haven't done that test yet and will not, if it is not the correct way to test.

The decision to raise Dunc's dose was taken in consultation with the vet who's been treating Dunc for the last 2 1/2 years, and is based on Dunc's stim numbers trending higher over time and on his current symptoms. When we got the high "post" in May, and again when we discussed the mid-August 9ish/7ish results, my longtime vet and I agreed that as long as Dunc was showing no symptoms and doing well in all lifestyle particulars, we would not increase his dose, but if symptoms reoccurred, we would increase his dose and I would schedule a monitoring stim test for two weeks or so after raising the dose - so that's where we are now. After seeing a sudden onset of pu/pd in first days of this month, I called Dunc's longtime vet to confirm with him that I should go ahead as planned and raise his dose, and then I called the vet in the town where we're spending the fall semester to schedule the stim - and got these weird instructions about fasting from the tech. The test isn't for two weeks, and I'll talk to them in person and straighten things out before we go ahead with it.

All discombobulated today by travel, car trouble, and pee cleanup :-) - sorry if the narrative has become a bit unclear.

Carin

[lulusmom]

Hi Carin,

I am not quite sure why your new vet is requiring a fasting draw, unless s/he wants to determine how high the cortisol is climbing during the last 12 or so hours before Dunc gets his morning dose. However, since Dunc is already on twice daily dosing, this determination doesn't need to be addressed. :confused::confused: If it were my vet, I would simply be honest and tell him/her that this testing protocol is not something I'm familiar with and ask what information s/he is attempting to ascertain by doing a 12 hour fasted draw. Plus, if I was paying for that additional draw, I'd sure as heck want to understand the rationale behind it. I do hope you make the inquiry and will let us know what you find out.

Unless there is another underlying condition that has caused Dunc's excessive drinking and peeing to return, I suspect that his current Trilo dose is simply too weak to effectively control the cortisol and it has increased enough to see a return of symptoms.

It is amazing that 2mg twice a day is doing anything at all but we've learned that every dog is different. Those of us that have or are treating our dogs with Trilostane should be so lucky. My Lulu weighs less than 5 lbs and she was taking 30mg daily for two years. Jojo weighs 8lbs and was taking 15mg twice daily for a year. My refills would have been a fraction of the cost at 2mg BID. WOW!!

Glynda

[Carin]

I will speak to the vet and find out what he intends, and why, before we do anything. Thanks, everybody.

Carin

[Carin]

All is now cleared up. The instructions to fast Duncan before the test were just a misunderstanding with the person I spoke to when I made the appointment. I stopped by the vet's office today and found it unusually un-busy, so I was able to have an extended, quiet conversation with the tech who actually does the draws. She confirmed that I should give Duncan his breakfast and trilostane as usual on the morning of the test; they would do the normal test in the 4-6h range, and then do one more followup draw at 8h, which is fine and will actually be useful in helping me to time his evening dose most appropriately. I am reassured, and Duncan is very cheerful and energetic today.

Thanks again to everybody who responded last night!

Carin

[Squirt's Mom]

Hi Carin,

Glad the confusion is cleared up! So easy to get things mixed up with the info going through several folks before it reaches our ears!

Hugs,
Leslie and the girls

[Harley PoMMom]

Hi Carin,

Susan was having similar problems with Palmer, Glynda advised her to do a UC:CR instead.


Hi Susan,

Those numbers are pretty darn nice and they would be perfect if all of Palmers symptoms have resolved. However, just a week ago you mentioned that "the thirst is still large. The eating is down in quantity....more times than not. [Today I think feeding him a whole pig would not have satisfied him!] The belly is getting larger....almost to the point where it may be starting to inhibit his ability to move around".

If Palmer is still symptomatic and is getting once daily dose of Trilostane, then it could be that he may need to go to twice daily dosing. Remember that Trilostane's enzyme blocking abilities starts to diminish after 8 to 12 hours so any time after that, circulating cortisol levels start to rise again. Some dogs, like my Lulu, can make it through the second 12 hours without being symptomatic but some don't and ultimately require the second dose for consistent 24 hour control. A urine cortisol creatinine ratio (UC:CR) can be done by your vet to determine if cortisol levels are too high in the second half of the day. This would involve your collecting a urine specimen, preferably the first pee of the day, before meals and meds.

As I mentioned earlier, if you are not seeing symptoms improve, another possibility could be that the Trilostane has had an impact on the intermediate hormones and one or more could be elevated. Sex hormones can cause the same type of symptoms as typical cushings. As others have mentioned, the only way to determine if this is the issue is to have a full UTK adrenal panel done. The (UC:CR) is relatively inexpensive so that would be where I would start.

I also want to mention that Dechra, the manufacturer of Vetoryl, indicates that a post stim of up to 9 may be acceptable if symptoms have resolved. However, I believe UC Davis' experience with Trilostane dictates that you must get the post stim number below 5 if you want to see complete resolution of all symptoms. I think Palmer is pretty darn close but no banana. So that's my unsolicited two cents worth, again.

By the way, what did your vet have to say about the acth stim results versus Palmer's continuing symptoms?

Glynda

Love and hugs.
Lori

[Carin]

Interesting! I'll see how Dunc's symptoms do over the coming two weeks and discuss this with the vet if it seems indicated. Duncan is already on 2 doses a day, so he shouldn't be seeing wide swings if we can get the total dosage back to the right level.

Carin

[gpgscott]

Carin,

Very good,

Blood draws are frequently done after a fasting.

Cushing's is an uncommon issue and when you are talking to other than the Dr. you have to be sure.

Please let us know.

Scott

[Carin]

I was curious about whether anyone has a dog taking Trilostane three times a day. In reading up on testing protocols for trilostane monitoring, I saw a couple of references to 3x/day dosing, but that was the first I'd heard of it. I'm currently in the waiting period to see how my Duncan will do with his dose increased from 4mg/day (in two doses) to 6mg/day (in two doses), and I was just idly wondering whether thrice-daily dosing wouldn't keep the levels of the drug more consistent over the whole 24h. (Don't worry, I'm not going to experiment without a vet's instructions; just curious.)

Carin

[jrepac]

I have heard once a day, or 2x a day; 3x a day must be a new protocol.

[gpgscott]

Carin,

We do not administer Trilo, but from what I understand about the persistance of it in the pup more than twice daily would not be necessary to maintain a more or less uniform level of the med. In the case of many meds a constant release is better than peaks but I have not heard of more than twice daily dosing with Trilo.

I know we will hear from others soon.

Scott

[labblab]

Carin, can you possibly give us references for the protocols that you have seen discussing dosing three times daily? I've also only seen once or twice daily dosing discussed, and would be very interested in reading about alternative protocols.

Thanks!
Marianne

[Carin]

Marianne, I saw a mention of the practice here: http://www.vshsd.com/For_Veterinarians-Continuing_Education/Tips%20on%20Diagnosis%20and%20Treatment%20of%20Hyp eradrenocorticism.pdf - but he wasn't advocating it; just mentioned the possibility.

Carin

[Carin]

Just checking back with an update about Duncan. We raised his trilostane dose two weeks ago to 4mg in the morning/2mg at night. On Friday, he had a stim, and the results were pre 1.7, post 4.0. Right on target! Hurrah. Let's hope he can stay stable on this dose for a while.

Carin

[labblab]

Carin, that's great news!!!!! Thanks so much for letting us know, and please do keep on updating us.

Congratulatory (((hugs))),
Marianne

[Harley PoMMom]

Congratulations on those great stim numbers...what a relief, huh? After all you've been thru here lately it's about time for you and Duncan to catch a break.

Great job, Carin. :D Keep us updated. :D

Love and hugs.
Lori

[John II]

Great news Carin!
Congratulations to the both of you! :D

[Carin]

Thanks, all. I have to say, Dunc and I have had a pretty easy ride compared to a lot of dogs. I feel really lucky. Trilostane has worked wonders for him for more than two and a half years; his only major setbacks have been a couple of periods of digestive unhappiness apparently unrelated to the meds; and his dose is now so small that it's downright affordable. This last couple of months is the only time since we started treatment that we had trouble getting his dose adjusted correctly. Could be a lot worse!

Carin

[MiniSchnauzerMom]

Carin,

Congratulations! What good news about Duncan. I'm glad the Trilostane is doing it's job and I'm happy for you (and your pocketbook) that the small dose is successful. A post ACTH right on target...who could ask for more. :D

Louise

[Carin]

Hello all. I haven't posted in a couple of months because things have been going pretty much fine with Duncan. I'm really seeing his age - he's so skinny and quavery - but Cush-wise, things are under control, and his energy and appetite are good. In about 3 weeks, it'll be time to rename this thread "...15yo Cocker..."!

Anyway, I'm posting this time because in early January, Dunc - fingers crossed! - and the other dogs and I will be moving back to Toronto after 10 years away. Amazing to think that Dunc was not quite 5 years old when I left Toronto, and to be planning this move back within sight of his 15th birthday.

I gather from searching the archives that a few people on the forum are in Toronto, and I wanted to consult about vets there, and about treatment with trilostane. On the latter point, I will take in as large a supply as I can and arrange smuggling with visitors from the States as necessary thereafter :). Am I right in thinking that you can't get trilostane at all in Canada? Or are there sources for those in the know? Any tips greatly appreciated.

On vets: I'm looking forward to going back to our neighborhood vet, Dr. Koroknai at Bathurst-Dupont, who treated Dunc when he was young and saw me through many years with a diabetic kitty. But I'm wondering if I should seek out a specialist for monitoring treatment with trilostane. Any specific recommendations for TO vets who have experience with trilo?

Thanks,

Carin

[acushdogsmom]

Yes you can get Trilostane (Vetoryl) in Canada. It was approved for sale in Canada last year I think it was. Vets buy it from a company called Vetoquinol and then the vets sell it to their own clients directly.

You may possibly be able to buy Vetoryl for a bit less from Petpharm, who will sell prescription meds as long as you can provide them with a Veterinarian's prescription. They are an online pharmacy for pet meds, but they are a division of Broadview Pharmacy which is a real pharmacy in Toronto. My friend used to go right in to the back of Broadview pharmacy, to the Petpharm division, to pick up her dog's prescriptions there instead of getting them mailed to her by Petpharm. And I used to buy all my supplements (Denosyl etc) from Petpharm, even though I'm not in Ontario (where they are located). I preferred phoning in my order (rather than ordering online). They were always honest and had very good customer service when I dealt with them.

http://www.petpharm.org/index-can.htm

http://www.petpharm.org/list-can.htm

http://www.petpharm.org/contact-can.htm

Their actual price list (Vetoryl, 10 mg, 30 mg and 60 mg is on pg 4):
http://www.petpharm.org/Petpharm_canprices_Nov18_2009.pdf

(note that prices are in Canadian dollars)

As for Vets who use Trilo in Toronto, I'm sure that there are many Vets in Toronto now using Trilostane. Maybe you can see your old Vet and get consults with a Specialist too? You can maybe have them work together on your case. :)

I'm not good with Toronto geography, so I don't know if these are close to where you want your Vet to be or not, but we've had several folks here in the past who took their dogs to see one of several Internal Medicine Specialists at the VEC SOUTH in Toronto ( 920 Yonge St. - (416) 920-2002 )

Here's a link to their webpage that talks a bit about the four Internal Medicine Specialists who work there:

http://www.vectoronto.com/staff_internal_medicine.php

(Here's the link to their main page http://www.vectoronto.com/ )

I think that the folks we had here who took their dogs to the VEC used Dr. Mason and Dr. Norris at VEC South, although one may have used Dr. Finora, I'm not sure. I do remember that they were very happy with the expert care that their dogs got there. The Internists at VEC South are probably all very good and very knowledgeable about diagnosing and successfully treating Canine Cushings. (I think I also remember that they may have tended to prefer treating Canine Cushing's with Vetoryl/trilostane rather than Lysodren)

Also, although we haven't had an update from him very recently, we have a member here who not very long ago took his dog Lulu to see Dr. Mason at VEC. And I think he was pleased with Dr. Mason. Here's a link to Lulu and Bomi's thread:

http://www.k9cushings.com/forum/showthread.php?t=1140

We've also just had someone on the board who went to see an Internal Med Specialist in the Scarborough area named Dr. Foster. Her dog doesn't have the kind of Cushing's that needs to be treated with trilostane - just Atypical Cushing's I think, but she really liked Dr. Foster.

http://www.k9cushings.com/forum/showthread.php?p=19648#post19648

Both VEC and the Scarborough Clinic (TVEH/Morningside Clinic) have 24 hour Emergency services available, too.

[Carin]

Oh, that is good news! I don't know how I missed the news about trilostane in Canada; last I checked, people were saying, "Canada next, please!" after approval in the U.S.

I will be right in central Toronto (in the Annex), so VEC South is convenient. It sounds like I can start with my old vet and get a referral to them if necessary.

For other Canadian members: is anybody getting trilo compounded in smaller doses than the 10mg pills? Duncan takes 6mg/day in a split dose.

Carin

[acushdogsmom]

About the compounding ... I'm sure that can be done by a veterinary drug compounder in Toronto, too. :)

Your Vet(s) in Toronto should know exactly where to get the Vetoryl compounded so that Duncan can continue to get the exact dose that he needs.

[Carin]

Happy, windy December, everyone. Duncan just had another perfect stim (1.5/3.8), but is drinking and peeing a lot. He wet his bed last night. Barring that incident, and let's hope it's an anomaly, it still seems to me like he's "cognitively continent" - that it, he knows when he needs to go and doesn't seem to leak, but the pu/pd is definitely back. Any ideas about what I should investigate? I am traveling for the holidays with Dunc starting tomorrow, but we can see my mom's vet before we get settled with our regular vet in Toronto in January.

Thanks,

Carin

[Squirt's Mom]

Hi Carin,

Congrats on the good stim numbers! Those are right on the mark! :D

You might want to have Duncan checked for a UTI. That can sure cause what you are seeing with the loss of control.

What dose of Trilo is Dunc on at the moment? With those numbers it is unlikely that loss of cortisol control is the problem but some pups will do better with a slightly higher post number than is recommended. If the urination is the only sign, I would lean more toward a UTI.

Let us know how things go and enjoy your trip!

Hugs,
Leslie and the girls

[Carin]

Thanks, Leslie. I will definitely have him checked for a UTI.

He's currently on 6mg/day. His energy and appetite are good and his coat, after a somewhat too-short haircut, is coming back in very sleek, so no Cushing's signs on that front. He is shaking a lot, but I'm not convinced that's Cushing's-related. He had been panting a great deal recently, but giving him twice-daily tramadol seems to have alleviated that. He's quite wobbly in the back end. But Dunc also has laryngeal paralysis, so panting and weakness could equally well be related to that.

[labblab]

Hi Carin!

I'm guessing that a UTI has been ruled out? If so, one other less-than-ideal possibility is that even though the trilostane is adequately controlling Duncan's cortisol level, it may also be increasing some of his intermediate hormones to the extent that the elevations are resulting in increased urination and thirst :(. Even though it lowers cortisol and aldosterone, Trilostane inevitably increases certain other adrenal hormones. For many dogs this never creates any problems. But apparently, for some dogs, Cushing's symptoms may recur.

The only lab in the U.S. that tests the complete panel of adrenal hormones is the University of Tennessee in Knoxville. Any vet can perform the blood draw, however, and then send the sample off to Tennessee for analysis. Dr. Jack Oliver oversees the lab there, and he is a wonderful resource for any vet who wishes to discuss intermediate hormone elevations. Prior to considering sending a sample, I'd recommend that your vet talk directly to Dr. Oliver. This is because he can offer the best guidance as to the value and the timing of the test -- the test may or may not be of diagnostic help while a dog is actively being treated with trilostane. In some instances, the recommendation is to withhold the trilostane for a period of time prior to testing.

This is just a thought, but if you are interested in pursuing this possibility, I'll be happy to give you the contact info for Dr. Oliver.

Marianne

[Carin]

Hi, Marianne. I haven't had him tested for a UTI yet. The pu/pd only became apparent over the last couple of weeks and I had the stim done in response to the symptoms. I got the stim results yesterday. Tomorrow we are driving to my mom's and my first step once there will be to check for a UTI at her vet. If that's not it, I may well want to pursue a complete adrenal panel, and I'll get in touch if it looks like that's indicated. I hate to ask - if other hormones are elevated, what are the treatment options?

Carin

[labblab]

I hate to ask - if other hormones are elevated, what are the treatment options?

Carin
It depends upon the dog's profile. For dogs with normal cortisol levels but other elevations, combinations of the rather benign supplements of melatonin and flaxseed can be helpful for some dogs. But for dogs with significant cortisol elevation, the cortisol needs to be addressed as well. And depending upon their specific intermediate hormone profile and associated effects, it appears as though some dogs may end up with better long-term symptom resolution if they are treated with Lysodren rather than trilostane. This is because Lysodren lowers most all of the other intermediate hormones in addition to cortisol. I can't remember whether or not you have ever considered Lysodren as a treatment option previously?

There are other folks here who are more knowledgeable about intermediate hormone elevation than am I. So I am hoping that they will be by soon to offer you some additional feedback, as well.

Marianne

[Carin]

I've never considered Lysodren because Dunc was put on trilo as soon as he was diagnosed and responded beautifully - no problems until very recently.

Sounds like I can deal with hormone possibilities if and when they're diagnosed, but it's always good to know what to raise with the vet, especially since we're moving again and no longer seeing the vet who treated Dunc for the first 2 1/2 years of Cushing's.

Carin

[labblab]

And once again, I'd really encourage your vet to talk with Dr. Oliver in advance of any testing, anyway. It may be the case that Duncan's treatment time frame may not even support worry about the effect of trilostane on Duncan's intermediates -- I don't know whether the expectation would have been that if trilostane was the "culprit," you would have seen problems much sooner than 2 1/2 years down the road...

Marianne

[Carin]

That makes sense. It's actually almost 3 years since Dunc started trilo!

I've made a vet appointment for him at my mom's vet for Friday morning, so we'll start on the UTI front and see what we find.

Carin

[Carin]

Happy Birthday, Dunc! Time to rename this thread "Duncan, 15yo Cocker"!

This is not the post I expected to be writing this morning. We had quite the weekend. I had been mentally composing a farewell post announcing Duncan's passing.

Saturday afternoon, I came home from an hour or so of Christmas shopping to find Duncan collapsed just inside the dog door. He was conscious but completely unable to use his rear legs, and quite limp all over. Since he showed no signs of agitation or pain, and since I had decided several months ago not to seek extraordinary interventions if it looked like the end was near, I laid him in his dog bed, tucked towels around him, and settled down to watch and wait. He panted a little later in the night, so I tried carrying him outside and holding him up; he peed a bit, but was trying to drag himself off under a bush in the cold rain, so I bundled him back inside. Sunday morning, he drank a few sips of water, but after that, nothing. He clamped his mouth shut when I brought him food or water. He continued to be calm and seemingly in no distress, and I couldn't bear the thought of taking him out to the terror of the emergency vet, even if it was just to hasten the end. Sunday night, he was practically completely limp and immobile. Monday morning, I was astonished to find him still alive in his bed in my room, after 24 hours without water and 36 hours without food. He was only barely breathing and almost unresponsive when I lifted his paw or touched his nose. I sat with him on his bed for a while at dawn, waiting for the end.

At 7, I decided I really needed coffee, so I carried him to the main floor of the house and settled him in the dog bed in the living room and went into the kitchen. I turned around a moment later to see Duncan standing at the kitchen water bowl, drinking. You could have knocked me over with a dog hair. The towel I had swaddled him in lay discarded in the middle of the living room. After taking a drink, Dunc ate a little scrambled egg for breakfast and then walked out with me to the yard on a leash. Since then, he's been drinking moderately, eating small meals, and is about 90% steady on his feet.

We had been to the vet on Friday to see about his pu/pd, and the vet wanted to do a complete body function blood panel, since it had been a while. I talked to her Tuesday to go over the results, and there was nothing in the bloodwork that would have indicated a crisis was coming. His electrolytes were normal, kidney and liver function indications good, all remarkably unremarkable. I asked the vet if she thought it was possible this was an Addisonian crisis, despite the previous week's perfect stim, and she thought it possible, though she was inclined to think a stroke was equally or more likely. In any event, he's now drinking and peeing normal amounts. He seems to be a little bit gaggy, but is interested in eating and is pretty much keeping his food down and has had no diarrhea. We agreed that we'd stop all of his meds, including his trilo, until and unless symptoms recur.

Weirdly, Duncan has not panted at all since his Monday morning "resurrection", and he has two chronic diseases that cause panting (Cushing's and laryngeal paralysis), plus he had had bouts of panting from apparent discomfort for several months. The vet thinks maybe the sudden and complete cessation of panting might point to a neurological event like a stroke, as if something had been reset in his brain.

Carin

[littleone1]

HAPPY BIRTHDAY, DUNCAN

Hi Carin,

I was so sorry to hear about Duncan's episode. I'm glad he's doing better now, and I hope he continues to improve.

Terri

[Roxee's Dad]

Hi Carin,
Oh my gosh what a scary time for both you and Duncan.:eek: I am so happy that he has seemingly recovered. :) I wish I had some words of wisdom as this would be driving me crazy and as Leslie call's it "My twitcher would be going 24/7 for a while.

We'll keep you and Duncan in our thoughts and prayers that he does not have a repeat episode.


:D:):D Happy 15th Birthday Duncan:):D:)


We had been to the vet on Friday to see about his pu/pd, and the vet wanted to do a complete body function blood panel, since it had been a while. I talked to her Tuesday to go over the results, and there was nothing in the bloodwork that would have indicated a crisis was coming.

Would you be able to post the results? I have been following Lori's and Harley's thread and I now wonder if Dunc's pancreas has been checked? Lori would know more about the symptoms and I'm sure she will check in later.

Again, I am so happy Duncan made it thru this terrible ordeal.

[Carin]

Thanks, John. I just had an oral account of the results from the vet, so I don't have all the numbers. She said his amylase was very slightly elevated, but absent any other signs of pancreas trouble, she didn't think it was significant. (Another of my dogs has had pancreatitis, so I was on the lookout for symptoms of that, but throughout this episode, Dunc had no signs of nausea, no abdominal tenderness, no pain when he did go to the bathroom, etc. etc.) I will see if I can pick up a copy of the full test results in the next couple of days.

Carin

[Squirt's Mom]

Oh Carin,

How terrifying for you! :eek: Had you by any chance just giving him heart-worm meds before this happened, especially one containing Ivermectin? Whatever, however, why-ever....I am so glad Duncan decided to stay with us! :) What a relief that had to be, as well as astounding!, to see him at his water bowl! :cool: Wouldn't it be really nice if this "brain re-set" turned of the cortisol pump, too!? :cool::cool:


Happy 15th Birthday, Duncan!!!

We expect to see you on your 16th! :D

Hugs,
Leslie and the girls

[Carin]

Leslie - It's amazing I didn't fall and clunk my head on the kitchen counter when I turned around and saw him standing there!

He had not had a recent heartworm preventative dose, or anything else unusual. He had been on tramadol for arthritis, anxiety, and other nonspecific pain, and it's possible that he had too much cumulative tramadol, but the vet didn't think his symptoms, and their duration, were consistent with tramadol overdose.

For the moment, it sure looks like the cortisol has been shut off! I live to be surprised. :)

[Squirt's Mom]

Is he by any chance on SAM-e as well? There is some support for an interaction between the two is why I am wondering...

[Carin]

Leslie - no, what's SAM-e?

Dunc's regular meds have been just trilostane, tramadol, and a daily pepcid.

Carin

[Casey's Mom]

Wow what a story - our dogs will never cease to amaze me.

Happy Birthday Duncan!

[Squirt's Mom]

Cool...SAM-e is used by several of us here. It helps with many things - liver function, inflammation, to name a couple - but I have become a bit leery of using in with Tramadol.

Well, that exhausts the synapses firing on what could have happened with Duncan on my end. :p Just kinda wool-gathering as it was very odd the way it happened all the way around. I love puzzles. ;)

Hugs,
Leslie and the girls

[jrepac]

Wow!

what a story!

sometimes it pays just to watch and wait :)

[Carin]

That's the lesson I take from this.

Carin

[Harley PoMMom]

Hi Carin,

OMGosh, I am so sorry to hear about your issue with Duncan, I would have been frantic, to say the least, but I am so very happy that he is alot better and I want to wish him a very:

:D:) Happy 15th Birthday Duncan!! :D:)

Since you already had a pup with pancreatitis then you know the symptoms/signs, and Duncan symptoms, IMO, seems to be more fitting to an Addisonian crisis or seizure/stroke. Like I've said before, if only our pups could talk to us!! :p:rolleyes::)

Please keep us updated on Duncan, and you and Duncan will be in my thoughts and prayers that he continues to be in remission...Yaaa no Trilostane!!

Love and hugs,
Lori

[lulusmom]

Hi Carin and Happy 15th Birthday, Duncan!!!

I'm a sap for old Christmas classics and I wasn't sure I believed in Christmas miracles until now. Sue's Zoe and your Duncan's lives were hanging in the balance and both have made remarkable recoveries that have amazed us all. Those are the best Christmas miracles ever!!! The Holiday Season just got a whole lot happier. :D:D:D:D:D:D

Glynda

[Carin]

OK, I have Dunc's labwork. This is from the day before his collapse. High results are in bold. The vet said the high Alk-Phos was to be expected with Cushing's and the slightly high BUN/Creatinine ratio could be due to mild dehydration. (Edited to add: is this right? I haven't focused on Dunc's alk phos since his initial diagnosis. Should it have come way down with successful trilostane treatment, or does it always stay high in cushdogs?)

SUPERCHEM: Result (reference range)
Total Protein 7.1 (5.0-7.4)
Albumin 4.0 (2.7-4.4)
Globulin 3.1 (1.6-3.6)
Albubin/Globulin ratio 1.3 (0.8-2.0)
AST (SGOT) 19 (15-66)
ALT (SGPT) 55 (12-118)
Alk-Phos 898 (5-131)
GGTP 12 (1-12)
Total Bilirubin 0.1 (0.1-0.3)
Urea Nitrogen 24 (6-31)
Creatinine 0.8 (0.5-1.6)
BUN/Creatinine Ratio 30 (4-27)
Phosphorus 6.0 (2.5-6.0)
Glucose 80 (70-138)
Calcium 10.2 (8.9-11.4)
Magnesium 1.8 (1.5-2.5)
Sodium 149 (139-154)
Potassium 5.0 (3.6-5.5)
Na/K Ratio 30
Chloride 108 (102-120)
Cholesterol 259 (92-324)
Triglycerides 116 (29-291)
Amylase 1218 (290-1125)
Lipase 675 (77-695)
CPK 123 (59-895)

I won't type out the whole CBC, but his platelet count was a little high and everything else was smack in the middle of the normal range.

Carin

[Franklin'sMum]

Carin,

Oh, you must have been terrified, finding Duncan like that. I am so happy, overjoyed, that Duncan is now seemingly better. :D Oh Carin, I hope he's on the road to full recovery, and doesn't have something like that happen to him (or you) again.

And a VERY HAPPY 15TH BIRTHDAY, Duncan!! :):):)

Thinking of you both,

Jane and Franklin xx
________
CHEAP VOLCANO VAPORIZER (http://vaporizers.net)

[lulusmom]

Hi Carin,

Duncan's Superchem results look pretty darn good. I have no idea what the ALKP value was on Duncan's last bloodwork so I can't determine if there's been an improvement. If you have the previous results, can you please post the abnormal values? Some dogs see a great improvement in ALKP when stabilized on treatment and others see some improvement but may not drop to within the normal range. We've seen those numbers a whole lot higher than Duncan's. Do you have him on liver support? You can buy supplements over the counter but it's always a good idea to coordinate things with your vet. Here's a link to some reading material on the subject:

http://k9cushings.com/forum/showthread.php?t=192&highlight=liver

Trilostane is known to elevate one or more of the adrenal sex hormones. Estradiol is commonly elevated and this particular hormone can impact the liver just like cortisol. Even though Duncan is on a very light dose, this could be a possibility.

Glynda

[Carin]

Glynda, I don't think I do have any of his previous bloodwork results, just a record on my calendar of his stims. I believe the last time he had had a complete blood chem profile was a year or so ago when he had an episode of colitis that wouldn't resolve. Honestly, from his first dx with Cushing's until just the last few months, he was so stable and clinically well that we didn't do extensive testing beyond regular stims. Right now, matters are complicated by the fact that we were in temporary digs with a new vet for the last six months, we're at my mom's now for the holidays, seeing her vet, and we're moving again Jan. 1, so we no longer have easy access to the clinic where Dunc was dx'ed and treated from Jan '07-July '09 AND my records are mostly in storage. I do remember that it was elevated alk phos at Dunc's annual checkup in summer '06 that alerted us to be on the lookout for Cushing's, and five months later, there it was. But Dunc's longtime vet never expressed any concern about his bloodwork during the time he's been on trilo.

I will look into the liver support question and maybe talk about it with the vet in Toronto when we get there.

Carin

[lulusmom]

Hi Carin,

ALKP is a liver enzyme but it can also come from the gut so if Duncan's last bloodwork was done when he was having a bad bout of colitis, he had two conditions that were contributing to elevated ALKP. Even if you had copies of that bloodwork, the colitis factor makes it impossible to draw a comparison between then and now. The good news is that you have a copy of the latest so if your vet wants to monitor the liver enzymes, s/he has a baseline for comparison.

Glynda

[Carin]

(Oops - my post was posted twice. Sorry 'bout that!)

[Carin]

Just a brief update to say Duncan the miracle dog is eating well (well, my mom made chicken soup), walking as steadily as he did before his Near-Death Experience (a little quivery, but he's no longer losing control of his hind legs), and starting to be a little more normally alert and waggy, rather than sleeping 23 3/4 hours a day, as he was earlier in the week. Amazingly, still no panting, and his drinking and peeing are at normal-dog levels. Could this really be remission? He does seem to be having substantially more trouble seeing than he did before last Saturday's collapse: he has more trouble locating me if I've moved into the next room, and he'll get up and take himself outside when he needs to, but only if I leave bright lights on in all the rooms on his path. I guess the rather sudden diminishment of vision supports the notion that what he had was a stroke of some kind. Amazing. Hope everyone else is well on this snowy morning.

[littleone1]

I'm glad Duncan is doing better, Carin.

It could be possible that he did have a stroke that affected his vision.

I hope he continues to do well.

[Casey's Mom]

Duncan's story is an amazing one - he is a miracle and a very happy, tail wagging one at that!

[Carin]

Thanks, everybody. I just posted a picture of Dunc venturing boldy out in today's blizzard in an album under my profile.

[Carin]

February greetings to everyone, and my deepest sympathies to those who have losts their dogs since the holidays.

I'm wondering now if I'm seeing the return of Cushing's symptoms in Duncan. Within the last 10 days or so, Duncan's coat has turned cottony, greasy, and dandruffy all at once. He never exhibited coat problems with Cushing's before, either before his initial diagnosis or at any point during treatment. His hair has tended to grow somewhat less quickly in the last couple of years, but he's never had serious skin-hair texture issues, or dandruff like this. (He has been covered with more and more and more little old-guy bumps over the years, and his last haircut, back in November, the groomer cut a little close and left him with lots of little scabs.)

Other than skin/coat issues, Dunc is doing remarkably well. He's had no drugs at all since his miraculous resurrection six weeks ago. He's perky most of the time, handles the stairs in our new house ok, eats enthusiastically most of the time, though not in huge quantities, and drinks and pees normal amounts. I guess the only behavioral symptom I'm seeing is that he more frequently trips over his front paws; not sure if that's neurological or related to limited vision, but it doesn't seem out of line if what he had in mid-December was some kind of stroke.

I need to call my vet about other issues, so I will ask, of course, about Dunc. He hasn't had a stim since his collapse-and-recovery, either, but I'm reluctant to rush him in for testing when he seems to be feeling well in all respects except coat. Meanwhile, I've scheduled him to have just a gentle shampoo - no cut at all - at the new, wonderful groomer here. Any thoughts on coat issues as a symptom gratefully received.

Carin

[gpgscott]

Hi Carin,

We have seen various coat issues, but I really have no advice. I am glad you are bringing it up with the Dr. though.

I am sure some other member will have some thoughts.

Thanks for the note and best wishes to you both.

Scott

[Carin]

Hello all. I've been away from the forum for almost 8 months (and so am out of touch with what everybody's going through) because Dunc continued to be in remission all that time. As a reminder, Dunc collapsed last December and then after three days had a miraculous recovery and was apparently in complete remission after that! His coat issues of last winter cleared up and his weight and energy were good for spring and summer.

In the last little while, however, pu/pd returned. I took him to the vet yesterday for some basic tests and to have a couple of sores seen to. He had lost two lbs in two months (21.5 down to 19.6). His alk-phos was elevated (596) and his urine cortisol-creatinine ratio was high (need to get specific numbers from vet). That's exactly what we saw when his Cushing's was first setting in in 2006. I've scheduled a stim test for Tuesday, so we can see exactly where he is, and I'm about to count out how much trilostane I have left and in what doses. So here we go again.

The good news is that Dunc is here and clearly still enjoying being a dog at 15 and three-quarters! I never would have expected it. His longevity is bitter-sweet because just last week I lost my beloved middle dog Jenny at only 9 years old to hemorrhagic gastroenteritis. Strange to think that Dunc was already a mature dog when I brought Jenny home as a puppy.

Best wishes to all dogs and people, and please hug your dog tonight.

Carin

[Harley PoMMom]

Hi Carin,

Although it is great to hear from you I wish it was under happier circumstances. I am so sorry to hear about your sweet Jenny. We are here for you, Carin, remember that, ok?


So Duncan's pu/pd have returned...darn! Well you're a cushing's pro, and we're here if you need us. ;):) Keep us updated and let us know how he makes out with his stim test.

Love and hugs,
Lori

[Carin]

Thanks, Lori. Dunc and I are, indeed, Cushing's veterans. I have to say, for those who are scared at a new diagnosis, don't be!

Since we've moved back to my home town (DC) since Dunc's last treatment and I know my family vet here has less experience with trilostane than the folks in Ithaca did, I've been reading up on current dosing recommendations so I can consult with her in an informed way about where to start him this time. Dunc was diagnosed so long ago that he was started on 60mg/day – for a 20lb dog! Talk about old school! Over the three years of treatment, that was gradually reduced till he was on only 4mg/day, split between morning and evening, before his collapse last winter. It looks like if we follow the UC Davis recommendations, he'd probably start on only 1mg/day, and I see that they are recommending a once-a-day dose.

Questions, then:

Is there a link to the Davis research besides the summary that's posted in our resources area?

Are there other members who've started their dogs on the Davis protocol? How has it gone?

What's the group's current thinking about once-a-day vs. twice-a-day dosing, and does anybody see difference in their dogs' behavior over 24h if they do once-a-day? Once-a-day would actually be good for us logistically because Dunc is almost never willing to take food before about noon these days, so the old routine of the pill with breakfast is going to be very difficult. He's eager to eat in the afternoon and evening, so a once-a-day pill with dinner would be easy. Anybody out there doing a single dose in the evening?

Thanks,

Carin

[gpgscott]

Hi Carin,

Of course we remember you and Duncan. Condolances over your Jenny.

Strange about remission, I remeber we have a few members the first one to come to mind I Jen in Austrailia.

At least you are equipped to deal with it, I am not going to address any of the Trilo specific issues, there are plenty of others with current advice there.

Good Luck. Scott

[Harley PoMMom]

Questions, then:

Is there a link to the Davis research besides the summary that's posted in our resources area?

I hope this is what you're looking for: http://wvc.omnibooksonline.com/data/papers/2009_V103.pdf Diagnosis & Treatment of Canine Cushing’s III
Edward C. Feldman, DVM, DACVIM
Professor, School of Veterinary Medicine, University of California, Davis, Davis, CA,
USA

Scroll down to "Author Experience."




What's the group's current thinking about once-a-day vs. twice-a-day dosing, and does anybody see difference in their dogs' behavior over 24h if they do once-a-day? Once-a-day would actually be good for us logistically because Dunc is almost never willing to take food before about noon these days, so the old routine of the pill with breakfast is going to be very difficult. He's eager to eat in the afternoon and evening, so a once-a-day pill with dinner would be easy. Anybody out there doing a single dose in the evening?

Thanks,

Carin

I believe in certain situations the twice-a-day dosing is beneficial. I'm pretty sure most diabetic dogs benifit most from twice-a-day dosing. Now if one is giving their pups trilo in the morning and the stim tests show that the cortisol is within range but the pup is still displaying signs of Cushing's at night, this is when twice-a-day dosing can help too.

Although the preferred method is giving the Trilo in the morning, if giving Duncan in the evening works out better for you and him, I would talk this out with your vet. :)

Love and hugs,
Lori

[Carin]

Thanks, Lori - that's exactly what I was looking for, and that's helpful on BID dosing. I will definitely talk about it with my vet. I'm thinking that since we will definitely need compounded trilo anyway, it makes sense to order it in the sizes we'd use for BID dosing, so we'd have the flexibility to do that or to adjust the dose in small increments as needed.

Carin

[Carin]

Argh - Duncan's stim was normal! Pre=4, post=8.

That's a strange thing to say, I know, but I was hoping for a clear result indicating Cushing's was back so we'd know how to proceed. His water consumption and pee output are increasing by the hour. His kidney and liver function and blood sugar are normal, according to bloodwork last week. His alk-phos is high, which was the first sign of impending Cushing's we saw back in 2006, about 4 months before he was diagnosed. His UCCR was elevated, which could have been caused by the stress of the vet visit, but does seem consonant with his symptoms and the high alk-phos.

I discussed with the vet that the course of his initial diagnosis four years ago was 1) high alk-phos at annual checkup; 2) pu/pd started appearing about a month later; 3) off-the-charts stim and Cushing's diagnosis three months after that. Given that the current symptoms are mimicking those of his intial onset, that we know he had Cushing's for three years, and that he responded well to trilostane all that time, we're inclined to try him on a very, very low dose of trilo now and see if it affects the pu/pd, despite the stim results. The vet is doing some reading and thinking about possible dosage. Hmm...

Carin

[labblab]

Hi again, Carin.

I'm so sorry that Duncan's treatment "vacation" seems to be over! And unfortunately, I only have a few minutes to post right now. But I do have one thought to throw out that you might want to consider prior to starting him back on trilostane. I am wondering whether he might be suffering symptoms from elevated intermediate hormones rather than from cortisol alone (or cortisol at all, right now). In looking back through your thread, I see that we talked about intermediate hormones earlier on, but then his collapse occured and it all became a moot point.

But we brought the subject up when his ACTH results showed that his cortisol was well-controlled but his Cushing's symptoms were recurring. One thought was to try twice-daily dosing. Another was to check the levels of his intermediate hormones. Since Duncan had been doing fine on trilostane for a couple of years previously, I remember thinking that perhaps it would be odd for intermediate hormones to emerge as an issue that far down the road in trilostane treatment. But the trick is that if intermediates ARE causing a problem, then it is likely that trilostane would only aggravate the problem since it inevitably elevates certain of those intermediates even further (Lysodren, on the other hand, lowers them as well as lowering cortisol). The other trick is that if you are, in fact, interested in looking at the status of Duncan's pre-existing intermediate hormone levels, this should probably be done prior to starting back on the trilostane (because we know that trilostane will cause elevation in the intermediates all by itself).

The only lab in the U.S. that performs analysis of the complete adrenal hormone panel is at the University of Tennesse at Knoxville. Dr. Jack Oliver is the veterinary researcher who is the expert in this testing. He is very accessible, and I know he would be happy to talk with you or your vet about Duncan's history and the possible advisability of performing this testing. It might not be a helpful test to perform in Duncan's case, but I feel certain that Dr. Oliver would offer guidance in that regard. He responds promptly to emails when he is in the office, and here is his address: joliver@utk.edu.

Here's a link to a thread on our "Important Information" forum that gives a better description of the issues that can be associated with elevated intermediate hormones:

http://www.k9cushings.com/forum/showthread.php?t=198

Just one more thought to throw into the mix...

Marianne

[Carin]

Thanks so much, Marianne. I'll share this with my vet.

Carin

[Carin]

Dear All,

Well, we're 11 days away from Duncan's 16th birthday...knocking wood and holding breath, he's doing remarkably well. After the resurgence of his pu/pd in early fall, we put him back on 5mg of Trilostane once a day and he responded immediately. His energy and appetite have been pretty good for someone his age - i.e. he sleeps through the night and most of the morning and then is eager to eat and go for walks in the afternoon. A mystery is that he continues to slowly lose weight, but it doesn't seem to be debilitating him and he is no wobblier on his feet than he was a year ago. (Marianne, we did not pursue testing intermediate hormones and decided to try him on his old trilo dose, and since he responded to it so well and so quickly, we decided not to pursue further testing at that point.)

I do have a question about hair thinning, however, for those of you whose dogs have had this as a Cushing's symptom. In three+ years of Cushing's, from the first symptoms through treatment w/trilo to his remission last winter, Duncan never showed any sign of the hair loss that's typical of the disease, so I don't know what the pattern for a Cocker typically looks like when they do show this symptom. I've noticed that this time around, in the three months since the resurgence of his Cushing's and since his last haircut, his hair has not grown back evenly. For those who know American Cockers, normally their hair grows evenly in all directions if untrimmed :-) At Dunc's late-August haircut, he was shaved evenly all over, so any difference in hair length now should be due to the effects of Cushing's (or to something else, conceivably). His hair has gotten long everywhere except along the back of his neck and all the way down his spine to the base of his tail, plus on his muzzle. Normally, his muzzle gets quite fuzzy over the course of about three months, so that he has a little beard and I have to trim it so it doesn't stick up in front of his eyes, too. So my question, after this long post, is whether those of you with Cockers or breeds with similar hair patterns have seen lack of hair growth on the face as part of the Cushing's pattern of hair thinning. I'm wondering whether Dunc's pattern is typical of Cushing's or could be due to something else - especially since he never had hair issues in his first three years of the disease and since his pu/pd responded to trilo treatment.

Thanks,

Carin

[Squirt's Mom]

Bumping up.....

[Squirt's Mom]

Hi Carin,

I don't have any clue about Duncan's hair loss but hoped someone else would so I "bumped" this up this morning. Maybe someone who has an idea will see it tonite and get back to you.

Wish I could do more to help! :(

Hugs,
Leslie and the girls :D - always

[lulusmom]

Hi Carin,

I'm not an experience Cocker owner but I can tell you that the hair loss pattern you mentioned was a fit for a cushdog until you mentioned the muzzle. Losing hair on the face is definitely not the norm in cushing's; however, my own dog, Lulu, has been experiencing some issues on her head and face in the last year. She would get little tiny bald patches on her muzzle and lower jaw. I spent $300 to $400 for biopsies, cultures and skin scraping three time and came back negative three times. There won't be a next time unless she starts to look like Telly Savales. Actually, she kinda does look like Telly Savales from the back. She has gone bald on the back of her head and that hair has not grown back for several months now. Lulu is a Pom and they are predisposed to alopecia x/black skin disease, cushing's and hypothyroidism and she has all of them. Thank goodness for sweaters. Do they make hair pieces for dogs? :D

I did run across something interesting in my obsessive research on alopecia x. The University of Utrecht conducted a study to determine why dogs with alopecia x and cushing's lose hair everywhere but their head, legs and feet. The answer was hair loss occurs in areas with the heaviest concentration of sex hormone receptors. Apparently the head and face are not one of those areas.

Glynda

[Carin]

Thanks, Glynda. We're going in for regular bloodwork on the 17th and I'll see if that turns up any hints. Since Dunc seems to be feeling well, I don't think we'll pursue other testing or treatment, but it would be interesting to have some answers! I've been very fortunate that despite a number of anomalies in the profile of his disease, Dunc has trucked along on a fairly even keel and lived to this great old age.

Carin

[Carin]

Just a brief update and request for your thoughts and prayers. Dunc celebrated his 16th birthday a week ago, but today we found a big mass in his abdomen that was pressing on his intestine and he had emergency surgery to remove it and his spleen, which also had some nodules in it. The surgeon said the big mass came out cleanly and the things in the spleen appear to be something different. So far so good, but recovery from surgery could be a long road for so old a dog. He's in the ICU tonight and we'll know more tomorrow.

Carin

[Harley PoMMom]

Oh Carin,

I am sorry to hear that Duncan has had to have surgery. My prayers and healing thoughts are being sent your way. Please keep us updated, ok.

Big hugs to you, with love...Lori

[Casey's Mom]

Prayers and warm wishes for you and Duncan.

Love and hugs,

[mytil]

Oh poor little Duncan. My prayers and healing thoughts coming your way.

Terry

[Carin]

Thanks, everyone. I just talked to the nurse who was with him overnight and he's doing pretty well - vitals pretty much normal and he was willing to walk, if not yet willing to eat. It doesn't surprise me he won't eat yet, since he's uninterested in breakfast even when he hasn't just had major surgery. They don't know for sure what the mass was; from the look of the larger mass, hemangiosarcoma seemed likely, but they hadn't biopsied it yet. Dunc may get to come home this afternoon, but more likely tomorrow, since they won't discharge him till he can reliably take pain meds orally. If he isn't coming home today, I can go visit him this afternoon. I'll keep you updated!

Carin

[Bichonluver3]

We're standing beside you. Sending healing energy to our Duncan. Give him a hug from us.
Carrol & Chloe

[Squirt's Mom]

Hi Carin,

I am glad to read that Duncan had a good nite and is feeling perkier this morning. Seeing you will do him a world of good, I bet! You might take him some article of your clothing or his blanket, something with a familiar scent on it to help comfort him until he is back home.

Sending healing white light and prayers your way!
Hugs,
Leslie and the girls - always

[Carin]

Dunc came home this morning, ate a smidge of stewed chicken, and is resting. He's pretty uncomfortable, but I'm happy to see him willng to eat and resting on his own bed. Merry Christmas to all!

Carin

[Squirt's Mom]

Hi Carin,

What a wonderful Christmas gift to have Duncan home to share in this day with his family! I hope he enjoys more chicken but I KNOW he will enjoy being home most of all.

Hugs,
Leslie and the girls - always

[Carin]

Duncan update: We had a few rough nights of lots of pacing and panting for Dunc and very little sleep for me. I now have a raging cold – no doubt because of the severe sleep deficit – but Dunc is so much more himself this morning! He's eating eagerly, he POOPED! (any dog owner will recognize how exciting a good poop can be :)) and he seems much more comfortable getting into a lying-down position, so between walks and food breaks he's settling down quickly and resting comfortably, which he was not for the first couple of days. His regular vet would like to wait a week from the date of surgery before we resume his trilostane. It'll be at least 10 days before he's cleared to go on walks or attempt stairs, and even then, I think there's a lot of Duncan-lifting in my future, because he didn't handle the stairs so well even before major abdominal surgery. I'd been helping him up and down with a harness that goes under his tummy, but he obviously can't wear that any time soon. For the moment, we're camping out at my mom's, across town from me, since she has a ramp and an elevator, which make old-dog management much easier.

We'll know late this week or early next about the biopsies of the mass they took out of his abdomen and the things in his spleen, and I don't expect good news, but something slow-moving and not too aggressive would be ok news.

On balance, I am amazed at how resilient this little guy is. That at 16 he could have major surgery and five days later be trotting around, asking for hamburger? Incredible.

Carin

[Squirt's Mom]

Hi Carin,

It is wonderful to see them coming back around, isn't it? Gives you that warm fuzzy feeling to see the light in their eyes after wondering if you ever would again! I am so glad to hear that Duncan is asking for hamburger and pooping good. YAY! good poopies! :p

I hope he continues to improve and that the news is better than expected from the pathologist.

Hugs,
Leslie and the girls - always

[addy]

I know the joy of good poops. :D

Hip, Hip Hurrah for Duncan. I hope he continues to do well.

Hope your cold gets better too.

Hugs,
Addy

[Casey's Mom]

I remember your episode with Duncan last year which I considered a miracle and again he is showing his strength. He is an amazing little doggie and a heartwarming story.

Love and hugs,

[Carin]

He is, indeed!

Carin

[Carin]

April Fool's Day seems like a particularly appropriate time to post a brief Duncan update, because you won't believe this. When I last checked in just after Christmas, Duncan had celebrated his 16th birthday (4 years after Cushing's diagnosis) and had had emergency surgery to remove a mass in his abdomen.

A couple of weeks later, we got the diagnosis: hemangiosarcoma. Prognosis: 3-8 weeks' survival time after surgery.

13 weeks later: Duncan is alive and trucking, sleeping almost all the time but WIDE AWAKE when I start cooking him chicken or hamburger. His Cushing's is stable on 5mg of trilostane/day. He's definitely fooling somebody!

Best to all,

Carin

[labblab]

Oh Carin, what a sweet way to start off this new month! Thank you so much for checking back in with us. And please give Duncan a big hug for me!!!

Marianne

[Carin]

Will do!

Carin

PS: I also posted a new Duncan pic (http://www.k9cushings.com/forum/album.php?albumid=334).

[Harley PoMMom]

Oh Carin! I took a look a Duncan's picture and what a sweet, adorable, and handsome fella he is! ;):D Sending big hugs to you both...Love, Lori

[frijole]

Wonderful wonderful news. Sweet 16 and looking fantastic too. Thanks for the photo. Hug dear Duncan for us. Kim

[Casey's Mom]

Thank you for the update on Duncan, the miracle doggie!!

Love and hugs,

[Carin]

Thanks, everyone. Forum Hugs have been passed on to Dunc.

Carin

[Squirt's Mom]

Hey Carin,

Add another hug for Duncan from me! It is really good to hear that he is doing so well! :)

I think vets really underestimate the power of a loving, devoted mom, which you certainly are. Your vet had no idea he was dealing with a miracle maker when he gave that prognosis on Duncan. ;) Your boy is so lucky to have you as his mom!

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

[Carin]

Leslie, the surgical oncologist who told me the diagnosis had no idea, but my family vet certainly knew, when she told me on Christmas Eve, "Yes, have this surgery, because I know you and you're not the type to give up." I was skeptical, but she was right.

Carin

[Carin]

Dear Friends,

I'm sad to have to report that Duncan left us at last a week ago. For the past several months, he'd been showing signs of canine dementia (disorientation, pacing, getting stuck in corners) but had been eating (etc.) regularly and had been making his own way to his bowl and his bed. I figured a dog who still cared when chicken was roasting in the oven was a dog who still had some zest for life left! I'd almost begun to doubt his cancer diagnosis, because he was so persistent. In the first week of August, though, he went rapidly downhill, until by last weekend he had stopped eating and drinking and could no longer stand by himself. It was clear that the time had come to help him on his way. People say you will know when it's time, and I did. Lots of people thought it was time long before it was, but I can tell you that Duncan and I knew when it was time. He'd been with me for a third of my life and we knew each other very well.

Though I'm desolate at his passing, I have to admit that I've never been so confident that a dog had lived life to its fullest. He lived to be 16 years and eight months old - 4 1/2 years after diagnosis with Cushing's, 20 months after his mysterious collapse and revival in December 2009, and 7 months after surgery for hemangiosarcoma last Christmas - off the charts! What a survivor! I hope his story gives hope to folks whose dogs have just been diagnosed. I didn't post often here because Dunc's Cushing's treatment went remarkably smoothly for all those years. I was very lucky to have been living in Ithaca when Dunc was diagnosed and to have had a Cornell-trained vet who not only knew about Trilostane and how to get it before it was legal here, but used to call me from veterinary conferences to update me on the latest reports on dosing and testing protocols. I'm grateful to everybody here for your support over the years. My best to all of you and your furkids.

Carin

http://www.flickr.com/photos/23165569@N03/6038124598/

[Squirt's Mom]

Dear Carin,

My heart is breaking with yours to read of Duncan's passing. He truly was a trooper and gave his best always. You are an exceptional mom and I know your love for him gave Duncan the strength to fight everything that came his way. He is an inspiration to many, as are you.

Duncan's name has been added to our Remembering list for 2011. He will always be remembered with love by his family here. When you feel up to it, you can write a memorial, or tribute, to Duncan in the In Loving Memory section. It would be an honor for us to share in celebrating his life with you through your memories.

Know we are here any time you wish to talk.

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


If It Should Be

If it be I grow frail and weak,
And pain should wake me from my sleep,
Then you must do what must be done,
For this last battle can’t be won.

You will be sad, I’ll understand,
Don’t let your grief then stay your hand,
For this day more than all the rest,
Your love and friendship stand the test.

We’ve had so many happy years,
What is to come will hold no fears,
You’ll not want me to suffer, so,
When the time comes, please let me go.

I know in time, you too will see,
It is a kindness you do me,
Although my tail its last has waved,
From pain and suffering, I’ve been saved.

Do not grieve that it should be you,
Who has to decide this thing to do
We’ve been so close, we two, these years,
Don’t let your heart hold any tears.

[k9diabetes]

I'm very sorry to learn that Duncan's journey with you has come to an end. He certainly was an incredible survivor. And a very handsome boy.

Godspeed to him,

Natalie

[littleone1]

I'm so sorry for your loss Carin. My thoughts and prayers are with you. Duncan had a wonderful life with you.

[BestBuddy]

Dear Carin,

So sorry that Duncan has passed. He will be loved and remembered always.

Jenny

[Carin]

Thank you for your thoughts, everyone.

Carin

[Nika'sMom]

I am so sorry to hear that your Duncan has passed...I have you in my thoughts and my prayers.
many hugs, Lynda and Nika

[Cyn719]

So sorry to hear about Duncan - just remember he had a wonderful life and a wonderful mom! Love and prayers to you -

[Casey's Mom]

Duncan is truly an inspiration and always was to me - I will always think of him as the miracle dog from his collapse in December 2009. My thoughts are with you Carin. RIP angel Duncan.

[bgdavis]

I'm so sorry to hear of Duncan's passing. You and he were so fortunate to have had each other for so long. Duncan, you had a great run! RIP.

Bonnie and Angel Criss

[gpgscott]

Carin,

They are so hard to lose. But we cannot keep them forever, except in our hearts.

Godspeed, Duncan.

Scott

[jrepac]

Carin,
sorry to hear of Duncan's passing. Rest easy boy, you deserve it.

Jeff, Angel Mandy, Pebbles & Pepper