Received Cushing's Diagnosis yesterday [Archive] - Canine Cushing's Information and Support Forums

stacyh2000

12-28-2011, 08:56 AM

Hello everyone, my name is Stacy. My 10 yr old Shih Tzu, Pebbles, was diagnosed yesterday with Cushing's. My worst fear was confirmed and I've been an emotional wreck ever since. I found this forum last night and read here for about 6 hours last night. So much information and so many questions.

In November I noticed Pebbles getting up in the middle of the night to drink. (Both my dogs are in my bedroom at night with the door shut) I really didn't think much about it the first couple of nights and attributed it to the fact that I had just recently turned our furnace on which is gas heat and thought maybe she was just dried out like the rest of us were/are when winter first arrives.

I took both my babies to the vet for their scheduled dentals, which went well. The first night after that, she was up all night drinking and peeing. Two mornings after that, I awoke to find bloody urine in the pet room. (This is the room I keep them in when I am at work. ) Naturally I freaked out, stayed home from work and took her in to be seen. I also took a urine sample in to be tested. The vet decided to treat her for a UTI. After the 2 weeks of antibiotics, the blood in the urine was gone, but the massive water consumption and frequent peeing was still happening.

I took her back in and brought along another urine sample. The infection was gone. The vet wanted to draw a blood sample and do testing. She called me when the results came in. No diabetes, liver good, kidneys good. I was happy because I had feared diabetes, but still we had no answer as to what was going on. The vet said she had enough blood to do another test to see if it was her thyroid. She phoned a couple of days later and said that her thyroid was "off" and said we had to treat her for hypothyroidism. She explained that this may not be the reason for the drinking/peeing but she had this condition and had to be treated. She told me to keep her on the meds for two weeks, and if this was causing the symptoms she had been having, they would be alliviated by then. Well, of course, she still had the symptoms.

Now I am not educated enough at this point to tell you what the names of the next two tests are, but I will describe what she told me they were. The vet told me to bring in a urine sample again and that they would do a test that wouldn't tell if she had Cushing's definitively but if it was a negative result, we would know it wasn't Cushing's. Of course the result was positive, but still we had hope it wasn't Cushing's.

I took her in yesterday for the test where they take blood, inject her with something, and re-draw blood an hour later. I was told that they would send the blood out to be tested and I would know something within a couple of days. Well they were fast because she got the result yesterday and said findings suggest it is Cushing's.

Immediately I am given 3 different treatment options. 1) Basically do nothing. 2) Start a drug specifically for one type of Cushing's 3) Start a drug that would treat both. She told me treating without an ultrasound first would be risky since both drugs can be dangerous.

So this is where I am this morning. So much information gathered last night my heading is swimming. I am not rushing to do anything at this point. I would like to get as much information I can before I decide what to do.

The vet is suppose to call me today with costs of all treatments and with cost of an ultrasound done at a specialist's office. I will tell her then that I want copies of all test results so I can post these here.

In the meantime, Pebbles is the same. Basically a "healthy" dog who still barks like a crazy woman when she's outside. Runs around with her toy and mainly acts like my normal baby girl. Her only symptoms are the drinking/peeing frequency. She does seem to sleep more than usual on some days as well. She has not been panting at all and doesn't have any of the other symptoms of Cushing's yet. I have also noticed that she drinks the most as soon as she wakes, not sure if that is significant or not.

I will post the test results when I get them. Like I said, I am not rushing to do anything at this point. I don't want to make the wrong decision and end up hurting her more.

One last thing, I cannot figure out how to get her pic to post by my post. I did upload 3 pics to an album though.

labblab

12-28-2011, 09:42 AM

Welcome to you and Pebbles, and kudos to your vet!! It sounds as though she has been very thorough and provided very accurate information. If it were me, I would follow through with her recommendation that an ultrasound be performed. There are several benefits: the appearance of the adrenal glands can help corroborate the Cushing's diagnosis and also distinguish between the pituitary and adrenal forms of the disease, and the status of Pebbles' other internal organs can be assessed in order to rule out any other contributing medical problems. Although an ultrasound is expensive, around here we like to say that an ultrasound gives you a lot of "bang for your buck."

I do not know whether your vet has already told you that the adrenal form of the disease has the potential for a complete cure through surgery. Adrenalectomy is a major surgery that is not undertaken lightly, and some dogs are not even considered to be good surgical candidates. But this is information that the ultrasound can reveal: whether Pebbles has enlargement of both adrenal glands (consistent with pituitary Cushing's), or whether there is a growth or mass present in one gland alone (consistent with an adrenal tumor).

If Pebbles does have adrenal Cushing's and surgery is not an option, then you still have the ability to proceed with medication. As your vet has told you, there are two standard medical treatments for Cushing's: Lysodren (chemical name: mitotane) or Vetoryl (chemical name: trilostane). The one departure that I would make from what your vet has told you is that we have seen veterinarians recommend either of these drugs for either form of Cushing's. Different vets/specialists have different preferences in this regard, but we have seen both drugs used to treat both conditions. So depending upon the outcome of the utrasound, the medication options are something that you will want to discuss further with your vet.

OK, that's enough for now! But please take a deep breath, because you are now among friends and family. :)

And please feel free to ask all questions that come to your mind.
Marianne

P.S. In order to add an "avatar" or photo of Pebbles to your username, go to your "User CP" (User Control Panel), and select "Edit Avatar" from the menu on the left side of the page. Let us know if you still have problems.

stacyh2000

12-28-2011, 09:52 AM

Thank you so much for the reply. I am leaning toward the ultrasound before any treatment is started. It didn't make sense to me to be given two med options when we don't even know which type of Cushing's she has yet. In the meantime, I will keep reading here and educating myself. I will post the results of past testing that has already been done and then post the results of the ultrasound.

I have only been on this site for a day but I already feel so supported just by reading the many posts. I am also glad I have time to figure out how to proceed.

Thank you so much!

labblab

12-28-2011, 09:58 AM

AWWWWWWW! I just saw your avatar pop up, and Pebbles is such a cutie-pie!!! I'm off to see your album! ;)

Squirt's Mom

12-28-2011, 10:11 AM

Hi Stacey and welcome to you and Pebbles! :)

It sounds like the two tests she has had so far are the UC:CR (the urine test) and the ACTH (where the blood was drawn twice). I completely agree with your vet's suggestion to have the abdominal ultrasound done before starting any treatment. This test saved my Squirt's life by finding a tumor on her spleen which was causing her cortisol to elevate. Once the tumor was removed, her cortisol returned to normal and has remained within range since. It really is the test that gives the "biggest bang for the buck"!

Lysodren (Mitotane) and Trilostane (Vetoryl) can be used to treat either the adrenal form or the pituitary form of Cushing's. There really isn't one drug for one type and one for another. However, she may have been talking about a form where the intermediate hormones are elevated but the cortisol is normal, called Atypical. In this form, Trilo is not recommended tho it is used with success in some of these pups. One of the most important factors in choosing which treatment is your vet - what are they most familiar with? what have they used with the most success?

Now, Cushing's a very slowly progressing condition taking literally years to do damage. This means you have time to take a deep breath, relax a minute, and learn all you can about Cushing's. You have plenty of time to do the testing and make absolutely sure it is Cushing's Pebbles has. Because so many other conditions mimic Cushing's and can cause false-positives on the testing, the diagnostic phase is very important. Other conditions like that tumor my baby had, kidney and liver disease, diabetes, thyroid issues to name a few. But there is time to look into all these things. Diagnosing Cushing's is as much a process of eliminating other possibilities as it is anything else. ;)

The most important thing I can tell you today is this - you and Pebbles are not alone on this journey. We will be with you every step of the way. Never hesitate to ask any questions you may have and we will do our best to help you understand. And, trust me, being a bit bonkers right now is completely normal! :D As you learn more, you will relax more and be much more comfortable with the whole deal. Cushing's is NOT a death sentence. You and Pebbles have a very supportive, knowledgeable family on your side now.

Hugs,
Leslie and the gang

Squirt's Mom

12-28-2011, 10:13 AM

AH! Just saw Pebble's avatar! :) What a cutie patootie! No need to give you the link on how to get the avatar up now! See how smart you are! :D

stacyh2000

12-28-2011, 10:37 AM

Thank you so much for the warm welcome. I am off this week due to the holiday, so I am hoping to get her in for her ultrasound and see where we stand. After we have results for that, I will take my time and research all options. I am so glad I don't have to make an immediate decision.

I will keep you posted. Thanks again!

Rebelsmom

12-28-2011, 10:46 AM

Just wanted to welcome you Stacy. You have come to the right place, everyone here is great.. You have taken all the right steps so far with pebbles and like others have said you have some time to make you decision. My Rebel started out with only the excessive drinking and peeing, but had a slight pot belly also. I started him on Trilo back in March of 2010 and he has been doing really well ever since. So welcome again, and Pebble is really really cute :)

lulusmom

12-28-2011, 11:49 AM

Hi Stacey and welcome to the forum.

Marianne and Leslie have done their usual great job of providing information but I do have a few comments and a few questions. Please see my comments in blue below:

My worst fear was confirmed and I've been an emotional wreck ever since.

Fear, anxiety and frustration is the norm for folks getting the dreaded diagnosis but once you get your feet more than wet, you'll figure out that a cushing's diagnosis is not the worst fear you can experience. There are many diseases which are much worse. Cushing's is not a death sentence. As a matter of fact, with effective treatment, a cushdog can live out their normal life span with a really good quality of life.

I took both my babies to the vet for their scheduled dentals, which went well. The first night after that, she was up all night drinking and peeing. Two mornings after that, I awoke to find bloody urine in the pet room. (This is the room I keep them in when I am at work. ) Naturally I freaked out, stayed home from work and took her in to be seen. I also took a urine sample in to be tested. The vet decided to treat her for a UTI. After the 2 weeks of antibiotics, the blood in the urine was gone, but the massive water consumption and frequent peeing was still happening.

Aside from the excessive drinking an peeing, does Pebbles have any other symptoms that are commonly associated with cushing's? i.e. voracious appetite, panting, muscle wasting (especially in the hindquarters), loss of or thinning coat, change in skin pigmentation?

When your vet did the urinalysis, do you remember if she checked urine specific gravity (USG)? Dogs with cushing's lose their ability to concentrate their urine so it is like water, completely dilute, usually without odor and USG is low. Have you observed that Pebbles urine is clear?

I took her back in and brought along another urine sample. The infection was gone.

The white blood cells which are abundantly present in infection is not always easy to find in dilute urine. Do you know if your vet did a urine culture?

The vet wanted to draw a blood sample and do testing. She called me when the results came in. No diabetes, liver good, kidneys good. I was happy because I had feared diabetes, but still we had no answer as to what was going on. The vet said she had enough blood to do another test to see if it was her thyroid. She phoned a couple of days later and said that her thyroid was "off" and said we had to treat her for hypothyroidism. She explained that this may not be the reason for the drinking/peeing but she had this condition and had to be treated. She told me to keep her on the meds for two weeks, and if this was causing the symptoms she had been having, they would be alliviated by then. Well, of course, she still had the symptoms.

There is a condition known as Sick Euthyroid Syndrome. Dogs with this don't really have low thyroid but rather an underlying condition which is transiently lowering thyroid hormones. Things usually normalize once the underlying problem is addressed. Any number of conditions can cause this. If thyroid function returns to normal on it's own or too high of a dose is given, a dog can flip flop from "hypo"thyroid to "hyper"thyroid. The hallmark symptom of hyperthyroidism is excessiving drinking and peeing so I'd be curious to know when your vet check Pebbles thyroid values last?

Immediately I am given 3 different treatment options. 1) Basically do nothing. 2) Start a drug specifically for one type of Cushing's 3) Start a drug that would treat both. She told me treating without an ultrasound first would be risky since both drugs can be dangerous.

I have two cushdogs, the first diagnosed in 2005 and the other in 2007. They treated with both Lysodren and Trilostane and both are an excellent choice, no matter which form of typical cushing's a dog may have. The goal of treatment is to remedy problem symptoms, symptoms which are usually more problematic for the pet owner than the dog. Having accidents in the house and the constant foraging for food can be really frustrating. Is Pebbles having accidents in the house? Based on your preliminary information, if Pebbles were my dog, I'm not sure I'd opt to treat with anything until more overt symptoms are apparent.

Her only symptoms are the drinking/peeing frequency. I have also noticed that she drinks the most as soon as she wakes, not sure if that is significant or not.

It is significant because dogs who aren't concentrating their urine, usually drink and pee all night long. A lot of us without doggie doors lost a lot of sleep before our cushdogs were diagnosed and stabilized on treatment. :D Is Pebbles waking you up to go outside?

I will post the test results when I get them. Like I said, I am not rushing to do anything at this point. I don't want to make the wrong decision and end up hurting her more.

That's a great decision.

stacyh2000

12-28-2011, 02:42 PM

Thank you for your replies.

Aside from the excessive drinking an peeing, does Pebbles have any other symptoms that are commonly associated with cushing's? i.e. voracious appetite, panting, muscle wasting (especially in the hindquarters), loss of or thinning coat, change in skin pigmentation?

When your vet did the urinalysis, do you remember if she checked urine specific gravity (USG)? Dogs with cushing's lose their ability to concentrate their urine so it is like water, completely dilute, usually without odor and USG is low. Have you observed that Pebbles urine is clear?

No other symptoms that I have noticed. I have noticed a "pot belly" but only after she has gorged herself with water. It is usually back to normal after an hour or so.

Her urinalysis did show her USG as slightly low. I don't remember the numbers, but I am going to get all of her test results to post here. Her urine is quite clear and has been exept for the morning there was blood present. The doctor said that was because of all of the water she was drinking I believe.

The white blood cells which are abundantly present in infection is not always easy to find in dilute urine. Do you know if your vet did a urine culture?

Not that I am aware, only a couple urinalysis'.

There is a condition known as Sick Euthyroid Syndrome. Dogs with this don't really have low thyroid but rather an underlying condition which is transiently lowering thyroid hormones. Things usually normalize once the underlying problem is addressed. Any number of conditions can cause this. If thyroid function returns to normal on it's own or too high of a dose is given, a dog can flip flop from "hypo"thyroid to "hyper"thyroid. The hallmark symptom of hyperthyroidism is excessiving drinking and peeing so I'd be curious to know when your vet check Pebbles thyroid values last?

She has not rechecked those levels since starting her thyroid meds 4 weeks ago.

I have two cushdogs, the first diagnosed in 2005 and the other in 2007. They treated with both Lysodren and Trilostane and both are an excellent choice, no matter which form of typical cushing's a dog may have. The goal of treatment is to remedy problem symptoms, symptoms which are usually more problematic for the pet owner than the dog. Having accidents in the house and the constant foraging for food can be really frustrating. Is Pebbles having accidents in the house? Based on your preliminary information, if Pebbles were my dog, I'm not sure I'd opt to treat with anything until more overt symptoms are apparent.

Yes she does have accidents when I'm not home. If we are here, she gets let outside plenty. She is no longer able to hold her urine for an entire work day or throughout the night.

Our "schedule" since all of this began is she starts the night in my room. It's usually an hour or a little more before she's whining at the door to go drink. I then put her and my lab in the dog room for the rest of the night, so we can sleep. I hate having to put my Lab, Vader, in there too. If we don't, she will whine herself almost into a panic/anxiety attack. She is much more comfortable with her "brother" with her.

Still waiting to hear from the doc about the specialist for the ultrasound. She is off the next two days, so I hope she let's me know something before the end of the business day.

If there are any other questions, please ask me. I am so scatter brained right now, I'm afraid I have left some info out.

I really appreciate the help and guidance.

stacyh2000

12-28-2011, 03:00 PM

Just wanted to add that Pebbles' ultrasound is scheduled for Friday at 11:00. Going to try to let my mind relax until we get the results in. Also, picking up all of her lab results on the testing she has had done so far tomorrow.

Thank you so much for your help. I will keep you posted as I'm sure I still have 100 questions.

Snoopy&Rummer_Mom

12-28-2011, 03:53 PM

Stacy:

Hello and welcome. I am a newbie here also, so I do not have a lot of advise. But the wonderful ladies in this forums have tons of info. Aww, when I read your introduction post I had a flashback of me three weeks ago when the diagnosis journey started. When I heard the word Cushing's I went into full freak out mode. Then once it was officially confirmed this past Friday, I went into a guilt trip over not paying more attention. Luckily the ladies kept me from getting myself all black and blue with my self-inflcited beatings :-)

The one thing I do agree with is that the ultrasound is a must and I see you scheduled one. It just have me peace of mind because we were able to check if there was anything else going on inside my little girl. And it paid off especially knowing that it is the pituitary-dependent Cushing's vs Adrenal.

Like I said, you will find tons of info here and everyone is so helpful and always ready to answer your questions. Good luck tomorrow and keep us posted!

Maria

Rebelsmom

12-29-2011, 10:18 AM

Stacy & Maria, I can totally sympathize with the freak out mode. I went back not that long ago and re-read my beginning posts when I joined here in early 2010. I was totally freaking out.. Now all this time later and my boy doing well it was a comical read for me.. The people here are wonderful and helped me get through and still get through some trying events relating or not relating to cushings. I'll give you both the same advice I was given, BREATHE :)

That is not to say that there still won't be freak out moments or moments when you fur baby thinks you are crazy. I know Rebel looks at me looking at him intently and is probably thinking leave me alone mom I'm fine!!

Stacy wishing you luck with the u/s and future treatment.

addy

12-29-2011, 01:24 PM

Oh my Goodness,

When I arrived at this forum I was crying non stop and a babbling idiot.:rolleyes::rolleyes:

I wanted to stop by to say hi and welcome. I also remind new members, don't forget to breathe:D

The best part is knowing you are no longer alone.

Hugs,
addy

stacyh2000

12-29-2011, 03:16 PM

Thanks again for the warm welcomes. I stopped by and picked up results from all of the testing have had done so far. I'll post a shortened version of each and if there are specific numbers you'd like to see, just let me know. It's all Greek to me.:D

Urinalysis done 11/28: SG 1.004

Blood panel done 11/29: TSH .20 and Free T4 .5 (LOW)

Free T4 (Equilibrium Dialysis) done 11/29: 4.2 (LOW)

Urine Cortisol/Creatinine Ratio done 12/21: 130

ACTH done 12/27:

Time 1 8:45
Time 2 9:50
Cortisol Sample 1 1.7 Ref. Range 1.0-5.0
Cortisol Sample 2 34.7 Ref. Range 8.0-17.0

These are what I have thus far. I have no idea what they mean, but I'm sure most of you are familiar with these tests.

We are having her ultrasound tomorrow at 11:00. I don't know if I'll know the results while there or if they send to our vet.

Squirt's Mom

12-29-2011, 04:23 PM

Hi Stacy,

The ACTH certain indicates elevated cortisol consistent with Cushing's and the ultrasound should be able to confirm diagnosis and which type.

Would you mind giving the normal ranges and units (ug/dl, etc) for the following if you have them? Thanks...

Urinalysis done 11/28: SG 1.004

Blood panel done 11/29: TSH .20 and Free T4 .5 (LOW)

Free T4 (Equilibrium Dialysis) done 11/29: 4.2 (LOW)

Urine Cortisol/Creatinine Ratio done 12/21: 130

Is there a lab report that shows things like ALKP (or ALP), BUN, TP, etc? If so, would you list just the abnormal values - too high or too low - if they differ from what you have already posted? Thanks again...

You're doing a good job, Mom!

Hugs,
Leslie and the gang

stacyh2000

12-29-2011, 06:44 PM

On the Urinalysis Report, they have "norm" checked for Glucose, Ketone, Bilirubin, Protein, Nitrite, Leukocytes, Blookd and pH.

Blood panel shows about 25 different things listed but at the bottom it has:

TSH .20 Ref Range 0 - 0.60 Units ng/mL
T4 .5 Ref Range 0.8-2.9 Units ug/dL (not sure on this one, first
letter may actually be a symbol)
It also shows that her Cholestoral, Triglyceride ad Differential Neutrophils were high.

Cholesterol 458 Ref Range 92-324 mg/dL
Triglyceride 637 Ref Range 29-291 mg/dL
Diff. Neu. 11297 79% Ref Range 2060-10600 /uL (again symbol?)

Equilibrium Dialysis

Free T4 4.2 Ref Range 8-40 pmol/L

The Urine Cortisol/Creatinine Ratio on shows results of 130.

ACTH

Cortisol Sample 1 1.7 Ref Range 1.0-5.0 ug/dL
Cortisol Sample 2 34.7 Ref Range 8.0-17.0 ug/dL

I hope some at that makes sense to someone. Thanks Again!:)

stacyh2000

12-29-2011, 06:49 PM

Also, from blood panel report.

BUN 12 Ref Range 6-31 mg/dL
Total Protein 6.2 Ref Range 5.0-7.4 g/dL

The ALKP or ALP isn't listed that way and I don't know what they are. They probably aren't abbreviated on the report maybe? The figures in the post before this one were the only ones that indicated "out of range".

Rebelsmom

12-29-2011, 10:17 PM

Rebel's cholesterol and triglycerides were high also when he was first diagnosed, but are normal now. I think that had to do with his diet change and once he was under control he stopped eating everything he could get his mouth on.. The ALK and ALP are liver enzymes that usually high with cushings.. They should normalize again once the cushings are under control..

stacyh2000

12-29-2011, 11:06 PM

I don't know how to tell from the results what the liver enzymes were because I'm don't know how they are listed on the report, but I do remember at the time of this test the vet told me her liver and kidneys were good.

I'm very nervous about tomorrow's ultrasound. Pebbles has been drinking a little more today and has slept alot. The weird thing is when I let her out, she tears out the backdoor and chases the birds like nothing is wrong with her. The fact that she is still acting like a "normal" pup at times, makes me feel good.

Hope I can get some sleep tonight.

Harley PoMMom

12-29-2011, 11:58 PM

(ALP) = Alkaline phosphatase. Alanine Aminotransferase/Alanine transaminase: (ALT) is an enzyme that is more specific to the liver.

Wishing you and Pebbles the best of luck with the ultrasound and sending positive energy.

Love and hugs,
Lori

stacyh2000

12-30-2011, 12:47 PM

Hello everyone. Just returned from Pebbles' ultrasound.

Diagnosis: Pituitary Dependent Hyperadrenocorticism
Small Splenic Mass

Medications: Vetoryl 30 mg. once a day

The doc recommends another ultrasound in 3 mos to check the splenic mass. She stated that she doesn't think it's anything to worry about, but we should keep an eye on it.

She also recommended another ACTH test done 3 weeks after Vetoryl has been initiated.

That is all I have so far. I'll get complete report from my vet when they are ready for pickup.

Since the vet is closed on this coming Monday for New Year's, I will be waiting another week to start meds.

Rebelsmom

12-30-2011, 02:45 PM

Stacy, I would question more on the mass on the spleen. As Leslie stated earlier he pup had one also and once it was removed the cortisol returned to normal.

I also didn't see how much she weighs, can you let us know that?

Squirt's Mom

12-30-2011, 03:33 PM

Hi Stacy,

Based on Squirt's history, this bothers me as well. If you were treating with Lysodren, it wouldn't bother me quite as much since it is my understanding Trilo should never be given to a pup who doesn't have Cushing's. If Pebble's elevated cortisol is from the tumor on her spleen and not from Cushing's, this could pose a problem if my understanding is correct. Hopefully, those with experience and more knowledge about Trilo will have some input here.

Another factor bothering me is starting treatment with so few signs. The signs are critical in monitoring treatment as well as for diagnosing the disease in the first place. With so few signs, it will be more difficult to determine her progress. The signs Squirt was displaying were basically lethargy, panting and a loss of interest. She never had the typical cush signs until this past spring.

Keep a very close eye on Pebbles if you do decide to start the Trilo. If you see loose stools or diarrhea, nausea or vomiting, loss of appetite, muscle weakness stop the med and call your vet asap. Not because Pebbles is a "special case" or anything but just so you know what to look for that would indicate her cortisol has dropped too low - something we all have to watch for once treatment starts regardless of which drug the pup is on. ;)

I know this is just more and more confusing right now but remember there is no rush. Pebbles isn't displaying any signs other than the drinking and peeing right now so just breath and take your time about starting treatment. You have plenty of time to find answers to any questions you may have.

Hugs,
Leslie and the gang

stacyh2000

12-30-2011, 04:23 PM

Now I'm worried about the mass on her spleen after reading your replies. The specialist said she wasn't worried about it and said it could have been from an injury. I'll see what my vet thinks when she calls me tomorrow.

She didn't say I needed to treat right away. It's just that Pebbles wears herself out running to drink and pee. Doesn't get a full night's sleep. I thought treating her would good give her some relief.

I've got some thinking to do.

Forgot to add: The specialist said her adrenals were "plump".

stacyh2000

12-30-2011, 04:24 PM

Oh, and she weighed 25 lb today.

stacyh2000

12-30-2011, 04:38 PM

Strange as I was typing my last response, the vet's office called. I asked her about the spleen mass causing cortisol levels to rise. She checked her blood panel and said that her Alk Phosphatase wasn't elevated and all other levels were in range as well, except for the 3 that I listed a couple of days ago.

She is very confident in the specialist's recommendations. She also feels that if the specialist thought we needed to do something about the mass now, she wouldn't have told me to re-check in 3 months and would have done something now.

My regular vet is going to call me tomorrow. (The owner called today because she is off and wanted me to know they had received the report) I will again share concerns about the spleen mass when she calls.

Rebelsmom

12-30-2011, 06:27 PM

The adrenals are enlarged because of the excess cortisol which is consistent with pituitary cushings. But like Leslie pointed out once the mass was removed from Squirt her levels dropped on there own afterwards. if you do start treatment for her please watch her closely at 25lbs and 30mgs to me is higher than I would want to start based on my experience. Rebel is now at 30lbs and started at 60mgs which was high. His levels dropped pretty low pretty quick. I now have him on 15mg twice a day which is still 30mg just divided in half. Just make sure you keep a close eye on her. You want to look for vomiting, diarrhea, and lethargy.

stacyh2000

12-30-2011, 10:52 PM

Are you saying I should insist on having the mass removed before any meds are started? I'm so confused as to what I need to do. I have 2 different vets telling me not to worry about it, but I am.

StarDeb55

12-31-2011, 05:31 AM

Does the report say specifically what the size of the mass is? If it's still pretty small, IMO, watch & wait is probably the way to go. You don't undertake splenic surgery lightly as it's a highly vascular organ with an increased risk of bleeding. With only the drinking/peeing being her only symptoms, I think I would wait to start treatment. Strong symptoms are a huge part of the diagnosis. Symptoms are also how you monitor the effectiveness of treatment, such as a decrease in the usual voracious appetite, decreasing in drinking the copious amounts of water, etc. This is just my nickel's worth.

Debbie

labblab

12-31-2011, 07:07 AM

Hi Stacy,

I've just gone back to review your entire thread once again, and I'm going to offer a bit of a different slant from what the others are thinking, in that I believe I would go ahead and start the trilostane treatment per the specialist's recommendation. All of the testing thus far is consistent with a dog who truly does have pituitary Cushing's, as is the excessive thirst and urination. In my mind, there are three lingering "question marks" -- the lack of additional symptoms, the mass on the spleen, and actually the fact that your dog's liver enzymes are NOT elevated. Most Cushpups do show liver abnormalities in their blood tests.

However, everything else is consistent with Cushing's, and it sounds as if the massive thirst and urination is uncomfortable for your dog and a problem for you, especially since it occurs throughout the night. Even though you have not been able to list the norms for the thyroid values you have given us, I went back to some thyroid tests conducted for my own dog in order to compare results. And if your lab norms were the same as mine, I do believe your dog's thyroid results were consistent with the "Sick Euthyroid" condition that Glynda described earlier. In other words, the low thyroid result is likely secondary to another condition. Cushing's is such a condition. So once the Cushing's is under control, your dog may no longer need ongoing thyroid supplementation. But since the thirst and urination preceded the thyroid meds, I would not be looking to the thyroid medication as the current cause of that symptom.

As far as the mass in the spleen, I do believe I would "go" with the advice you are being given by the vets. The specialist is the one who has actually had the opportunity to review the images, and if it is her opinion that the mass is not an immediate issue, I see no reason not to trust it. It is good that it has been identified so that you can keep tabs on it. But if the specialist is still advising going forward with the trilostane, I would trust that recommendation.

So in my own mind, your own vet has been very methodical in approaching the initial testing. And you now have an ultrasound and a specialist's opinion that also corroborates the diagosis of pituitary Cushing's. The recommended starting dose of trilostane is right where I would want to see it: approx. one mg. per pound of body weight. So since your dog's thirst/urination is uncomfortable for you both, I'd give the trilostane a try. It is definitely true that trilostane is a serious drug that should not be taken lightly. But for the majority of dogs, the effects of the drug are short-lasting (only active in the body for approx. 12-18 hours) and can be reversed relatively quickly by discontinuing the drug. So if you do start treatment and observe anything being "off" or worrisome, you should stop giving the trilostane. If it were me, I'd go forward with your vets' recommendations and go ahead to see if the trilostane does indeed resolve the excessive thirst and urination. So that's one more opinion to add to the mix.:o :)

If you do choose to start the trilostane, I encourage you to ask your vet for a small supply of prednisone to also keep on hand. In that way, should the trilostane ever drop your dog's cortisol level too low (resulting in lethargy, vomiting, or diarrhea), you would have the ability to quickly counteract the effect. Since trilostane has such a short active life in the body, many vets do not feel that prednisone is a necessity and that just stopping the trilo is "enough." But our experience here has been that enough problems come up during nights or long weekends -- when vets are unavailable -- that it is added security for the owner when prednisone is on hand in the event of a crisis. If you explain that you know that prednisone is only to be used in that way, in a crisis, I'm hoping your vet wouldl be agreeable to prescribing some for you.

Marianne

stacyh2000

12-31-2011, 09:52 AM

Thank you Marianne. I spoke to my regular vet this morning. She called me just to see how I was doing with all the information I have received this week. She really is a very caring person.

We discussed the mass and her current symptoms. She agreed that it would be okay to wait until any further symptoms arise before starting the meds. She also told me if I change my mind tomorrow, that's okay too. We both would like to see if there are any changes in the mass size in 3 months.

Even though the excessive thirst is bothersome, we have adopted the new routine of waking after an hour or so to get her a drink. We have massive quantities of "pee pads", which she does use.

So as of right this moment, we are waiting. My mind has been flip flopping from medication to waiting so much that I'm waking with migraines in the mornings. I may change my mind again in a day or so. But the vet told me there was no rush.

I have scheduled Pebbles for her thyroid re-check on the 7th. Thank you all for your help and kind words. I will keep everyone updated as things progress.:)

stacyh2000

12-31-2011, 09:53 AM

Oh I wanted to ask a couple questions as well.

1) Should I change her diet at all?

2) Has anyone used Cushex? I asked my vet about it and she had never heard of it. She is going to research and let me know what she thinks.

Thank you.

Snoopy&Rummer_Mom

12-31-2011, 12:51 PM

Stacy, I'm by no means an expert but in my readings i have found that a holistic approach with a more natural diet us recommended. In my case I notice that Rummer was more comfortable when I took her off the kibble she was eating and put her on a raw diet. I use The Honest Kitchen, and although pricey, Rummer had responded tremendously to it because it is not highly processed. It is much more gentle for her. The food is dehydrated raw food that is reconstituted by adding water. Again, just my opinion.

addy

12-31-2011, 12:56 PM

Hi,

What do you currently feed? Is it causing any probems? Sometimes it is better to not change things all at the same time especially if you are going to start Trilostane. I would not even think about a food change if you are starting Trilostane.

As for the Cushex, in my opinion, save your money.

Hugs,
addy

stacyh2000

01-10-2012, 09:35 AM

It is has been a couple of weeks since I've been here. Been letting everything settle in my head a bit. Nothing much has changed since I was here last except Pebbles' thirst has increased some. She was already drinking gobs. I have since decided to go ahead and start giving her the Trilostane. Planning on starting this coming Sunday.

Even though the thirst is her only symptom as of right now, I feel it is time to start medicating. It's just not fair to have her and her brother locked in "their room" most of the day to avoid accidents and to allow us to get more sleep at night. I have to keep her brother with her because she works herself up into almost an anxiety attack when in there alone and I don't blame her. Feel like I'm punishing her and him for something neither can help. I'm ready for us all to get back to some "normalcy" and have my babies back in bed with me.

Also, she had another thyroid test done Saturday to see if the meds are helping. Her "levels" were in the high normal range and the vet cut her dosage in half. I haven't had a chance to go by and pick up the actual test results to post.

I will keep you informed about how she is doing on the new meds. Keeping my fingers crossed that it works for her without any major side effects.

Squirt's Mom

01-10-2012, 10:22 AM

Hi Stacey,

Just to repeat what Marianne suggested earlier - please get a little pred to have on hand before you start the Trilo. With so few signs to use to gauge Pebble's progress, it will be much easier to get into a situation where her cortisol drops too low. The signs are what guide us and the docs in the treatment and with few signs it is easier to miss the indications of a crisis pending.

Watch carefully for diarrhea (even loose stools should put you on guard), signs of nausea or any vomiting, loss of appetite, and lethargy once the med is started. These are indications that the cortisol has gone too low; which means the Trilo should be stopped immediately, the vet contacted, and the pred may be needed.

We are here any time you need to talk or have a question. Our Trilo moms and dads will be watching closely, I'm sure. Watch her like a hawk and follow the protocols for testing once the Trilo is started. The first ACTH is 10-14 days after the first dose, I think. Our Helpful Resource section has some great info on Trilo and I encourage you to read it thoroughly, if you haven't already, while you wait to start the treatment so you know what to expect and look for. The good thing about Trilo is that is has a short life in the body, meaning, if there is any problem, it leaves the body fairly fast. Also, Trilo can be stopped and restarted without losing any ground.

Keep in close touch and let us know how things are going.
Hugs,
Leslie and the gang

stacyh2000

01-10-2012, 10:41 AM

Thank you for the reply. I will call my vet and get the pred. She didn't say anything about having it on hand. I am waiting to start on Sunday because I am off Monday and can easily take her to the vet if need be.

If she does have a bad reaction or her cortisol levels do drop too low, how long after taking the meds would this happen? Wondering if maybe I should wait and start on Monday morning since the vet will be open?

Also, during the week, I would be giving her the meds at approx. 5:45 a.m. and on weekends at 8 or so. Will the time difference make a difference?

labblab

01-10-2012, 11:40 AM

Ideally, the medication is given as consistently as possible on the same timeframe every day. But sometimes "real life" trumps the ideal, as is the case for you. I wouldn't expect a safety issue with your time shifting by a couple of hours, but I suppose it's theoretically possible that you'd see some increased thirst and urination during mid-morning on Saturday before the 8 a.m. dose kicks in, since Pebbles will have gone for 26 hours between doses. The one thing I would suggest is to have the monitoring ACTH tests performed later in the week, after Pebbles has been dosed consistently for several days at 5:45 a.m. The timing of the ACTH testing is important -- Dechra recommends between 4-6 hours after dosing. So I'd do the testing on a Thursday or Friday rathger than on a Monday.

As far as the timing of possible ill effects, that is really variable. But I wouldn't expect any particular problems after only one dose. So if it's easier for you to start on Sunday so that you can watch her at home for two days, I think that's fine. Good luck!!!!

Marianne

stacyh2000

01-10-2012, 12:26 PM

Thanks Marianne. I'm so nervous. Every time I see that bottle of Trilostane on the kitchen cabinet, I feel I'm looking at a time bomb. Scared to touch it. Silly thoughts, but they are there just the same.

labblab

01-10-2012, 12:41 PM

Stacy, I surely do understand. But it sounds as though you have a great vet team supporting you and I'm betting that everything will go just fine! We'll be here, every step of the way, to answer any questions we can. :)

Marianne

stacyh2000

01-10-2012, 06:01 PM

Just wanted you to see a couple picks I added tonight. She got a new toy and loves it!

stacyh2000

01-15-2012, 07:25 AM

Just gave Pebbles her first dose of Trilostane. I am thankful that up to this point her only symptoms have been the excessive thirst and urination. I feel that will make it easier to notice anything out of the ordinary in her behavior.

I picked up the Prednisone yesterday to have on hand. I also went ahead and scheduled her ACTH for two weeks from yesterday. I think I have all my ducks in a row. I'm also off tomorrow, so two full days at home to monitor her.

I will keep you informed. Thanks for being there for us!

addy

01-15-2012, 07:36 AM

Hang in there. We are all here for you.:):):)

I hope Pebbles does just fine. Gosh I remember when I gave Zoe her first dose:o:o:o It gets easier.

hugs,
addy

labblab

01-15-2012, 07:38 AM

Stacy, good luck to you and Pebbles!!!!! You are doing a great job, mom! :) :) :)

And all your photos are wonderful -- I especially love the one of Pebbles sleeping with your son. It is too cute! :o

stacyh2000

01-15-2012, 07:42 AM

Thank you! Hopefully Pebbles will again be sleeping all night with one of us again soon!

stacyh2000

01-16-2012, 06:41 AM

Well I am happy to report day 1 went wonderfully! I know it's early and anything could happen, but I'm happy anyway.

The specialist told me that it would probably take a week or so for her symptoms to get better. But last night, she actually slept 3 full hours before waking me. When I woke to let both dogs out, no pee anywhere in their room and minimal change in the water level in her bowl!!! Yay!

This morning it wasn't my dog to wake me, it was the neighbor's!:p Hoping for continued improvement!

stacyh2000

01-22-2012, 11:25 AM

Well it's been a week on the Trilo. No notable changes. Must've just had a good day when I lasted reported on her water intake, because she's back to drinking/peeing excessively. Hoping it's still too soon to have relief and that change is coming soon.

Taking her Saturday for her ACTH. Will keep you informed.

addy

01-22-2012, 01:15 PM

Don't be disappointed. Sometimes the dose takes a bit of tweaking and it may take a bit of time for those issues to totally resolve. The air has been so dry at our house even my non Cush pup is drinking more water.;)

Every time I look at the picture of Pebbles with that blue toy, I just can't help but smile. Just too darn cute.:D:D

Hang on, you'll get there.

hugs,
addy

stacyh2000

01-22-2012, 01:24 PM

OMG, she just loves that thing. Best $3 I ever spent! It's like she knows what is written on it. She's such a diva!:)

lulusmom

01-22-2012, 09:09 PM

:D:D:D:D:DPebbles' new toy is too cute. :D:D:D:D:D

Cyn719

01-22-2012, 11:15 PM

Hi Stacey

I was just catching up on Pebbles - so cute - I just posted on her pictures!! I agree with Addy - it seems like they drink more cause the house is warm - I think thats what my Penny is doing - Will be checking in on you and Pebbles - so far so good!!

Sending you lots of prayers - support - love and hugsssss xoxo

stacyh2000

01-30-2012, 06:30 PM

I have wonderful news! The vet called today with Pebbles' ACTH results and she said they were "excellent"! I don't have the actual test results in front of me (picking them up tomorrow), but she said her cortisol sample # 2 was 34 when we first had it done. Now it is down to 10!!

She conferred with the specialist and they both agreed to keep her on the same dosage of 30 mg once daily. I am to bring her back in 3 months for another ACTH test. Of course, if anything changes before then I will take her earlier.

My only concern is still the water consumption. It has dropped dramatically, but she still needs to get up after about 3-4 hours of sleep at night for a drink and pee. I was hoping that we would be back to "normal" by now, but I am still happy with the improvement thus far.

Thanks so much for everything. I will keep you posted on any new developments. You guys have been a great support for me. My friends are supportive but they aren't "pet people" like me. They don't understand going to the expense that I go to for my babies. But when I "adopt" a furbaby, it's the same as if I adopted a child. I love them just as much and intend on giving them the same care/love that I would a child.:)

labblab

01-30-2012, 06:57 PM

She conferred with the specialist and they both agreed to keep her on the same dosage of 30 mg once daily. I am to bring her back in 3 months for another ACTH test. Of course, if anything changes before then I will take her earlier.

My only concern is still the water consumption. It has dropped dramatically, but she still needs to get up after about 3-4 hours of sleep at night for a drink and pee. I was hoping that we would be back to "normal" by now, but I am still happy with the improvement thus far.

Thanks so much for updating us! I am very happy for you that you are seeing improvement in Pebbles' ACTH results and also her symptoms after these first two weeks of treatment. And with a cortisol drop from 34 to 10, I surely understand why your vets would not want to increase her trilostane dose at this time since her cortisol may drop further within the next couple of weeks.

However, the one piece that I'm concerned about is the idea of waiting for three months before testing Pebbles again. All of the protocols with which I'm familiar recommend testing again at the 30-day mark when starting out with treatment. Importantly, you don't want to risk her dropping too low. But in addition, there is no need for you and Pebbles to suffer through 2 1/2 more months of incomplete symptom resolution if her dose is not yet high enough.

We've probably given you this link before, so I apologize if I'm repeating things. But here is the U.S. Product Insert for Dechra (manufacturer of brandname Vetoryl). You'll see that a post-ACTH result higher than 5.4 ug/dl is only acceptable if all symptoms have resolved. And a post-ACTH result higher than 9.1 ug/dl is generally undesirable for a Cushpup under any circumstance.

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

So I'd encourage you to ask your vet about the basis for his/her recommendation to wait for three months before testing again. But in the meantime, congrats on seeing this much improvement already!

Marianne

stacyh2000

01-30-2012, 07:07 PM

addy

01-30-2012, 07:22 PM

From 30 to 10 in 2 weeks is great news!!!!

I also am giving you a link from the Dechra website showing an update to dosing.

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

Marianne is right that you should be having another ACTH test at the 30 day mark. My Zoe went up and down for the first 3 months. I then let her ride and she dropped down a bit more after 3 months.

Some dogs will continue to drop the first 30 days. But your pup may be like Zoe and pogo back up, so you really need to test again.

Hang in there and you should still celebrate. 10 is better than 30!!

hugs,
addy

labblab

01-30-2012, 08:33 PM

I will call the specialist tomorrow and run those numbers by her and ask if she is sure about not testing again in a couple of weeks. I was not aware of the "acceptable" levels. I must have missed it. Thanks for the information. May jubilation may have come too soon.

Oh, you still have every reason to feel jubilant and I'm very sorry if I made you feel otherwise! You're seeing a great improvement in Pebbles' ACTH result. I just don't want you girls to wait a really long time for additional monitoring in the event that Pebbles would benefit from a dosing change sooner than three months from now.

Marianne

stacyh2000

01-30-2012, 08:50 PM

This crazy disease has me up one minute and down the next. The nature of it all I guess. I do appreciate your insight though. Please keep informing me because I'm still so new to this.

Hope the vet understands my apprehension to follow her recommendations. If she doesn't, I will have to find another vet. Although she shouldn't have any problems with doing the test again in two weeks.

Leena

01-30-2012, 11:46 PM

This crazy disease has me up one minute and down the next

How I understand this statement! Hang in there! I'm trying to with my girl Precia as well!!!! It's a one day at a time thing!

Cyn719

01-31-2012, 12:05 AM

Hi. So glad to hear the good news! 34 to 10 is great! But do have to agree you should not wait 3 months. Penny's vet waited a very long time to check her ATCH and her numbers went to a very dangerous low number. Not saying this will happen to Pebbles but it's better to be safe. Some dogs numbers stay the same, some go up, some go down. If you express your concern to the vet hopefully she will understand and maybe you can get her to look at the the links Marianne and Addy gave you.:) Believe me I know how you feel, there are so many ups and downs with cushings it can drive you crazy! Sending you lots of support strength and hugs xo

lulusmom

01-31-2012, 12:24 AM

Hi Stacy,

Marianne has provided you with some very good advice so please don't wait for three months to have the next acth stimulation test done. Speaking of acth tests, I'd like to share a bit of information that might save you money. Rather than tax my aging arthritic fingers, I'm going to cheat and insert a quote from a post I made on another member's thread.

Hi Wendy,

Kim has done a great job of providing information but I wanted to share a cost savings tip with you in the hopes that you can save some money on the acth stimulation tests.

The most accurate and widely used stimulating agent is cortrosyn. We call it liquid gold around here because it is so dang expensive. Cortrosyn comes in a .25 mg vial and the instruction on the label says to inject the dog with the entire vial. What most gp vets don't know is that only a fraction of that is needed for smaller dogs. Any remaining cortrosyn can be stored in the freezer for up to six months and I believe in the refrigerator for a month. If Katie weighs 20 pounds, your vet should be able to get five acth stimulation tests out of one vial. That is a huge savings to you so it is well worth dicussing this with your vet. Here is a comment from another member who let us know how much she saved with this bit of information.

That is definitely a money saving tip on diluting/freezing cortrosyn. I will be paying $152.00 (one-time fee) for the bottle of cortrosyn and will be getting five stims from it. So, I will only be paying the cost of lab work which is $142.00 each time Logan gets stimmed = Big Savings. Thank you for that good information

This member went from paying a max of $1,470 for five stim tests to $862. That's quite a savings. I have included a link below to Dr. Mark Peterson's veterinary blog where he provides information on the amount to use as well as how to reconstitute and store the remaining cortrosyn. You can either provide the link to your vet or print the blog. Dr. Peterson is a reknown endocrine specialist and I suspect s/he knows who he is.

http://endocrinevet.blogspot.com/2011/03/how-to-extend-your-supply-of-cortrosyn.html

Glynda

Most vets do use cortrosyn so I suspect yours does too so make sure you talk to her about splitting the vial for you.

labblab

01-31-2012, 09:13 AM

Stacy, I just wanted to come back to add that I'm not really as rigid about "numbers" as I might have sounded yesterday. In other words, it's not that I think you have to test again in exactly two weeks. Or that there would never be a reason to let a Cushdog's cortisol run somewhat higher than those published guidelines. People here often say, "you're treating the dog, and not the numbers." And I do believe that's true. It's just that the numbers give a guideline, and an indication as to whether or not the cortisol is being controlled to an extent that ought to provide symptom relief. For dogs with multiple health issues, sometimes there has to be a trade-off so that the worst symptoms of all diseases are controlled, but all symptoms are not completely eliminated. And for those dogs, a higher cortisol may be preferred.

But in Pebbles' case, I especially wanted you to know that the major improvement you've been hoping to see is definitely still possible once her cortisol is lowered even more. And it's not so much that I think you have to test again in exactly two weeks (maybe you'll want to wait a bit longer than that) -- it's just that waiting for three full months seems way too long.

Marianne

stacyh2000

02-01-2012, 04:44 PM

Thanks Marianne. After some more thought, I completely agree with you about not waiting 3 months. We had a bit of a bad day today. Took her for her groom and she came home and gorged herself with water. They had some water in her cage and she was only there 3 hours.

I am going to wait a couple of weeks and see if the water/pee symptom lessens any more. If they haven't, thinking maybe that an increased dosage may be in order. I'll call the vet at that time and see what she thinks.

stacyh2000

02-01-2012, 04:47 PM

Thanks for the info lulusmom. I'm not sure this is possible as my vet sends the samples to a lab somewhere else. But I will check.

lulusmom

02-01-2012, 04:56 PM

Hi Stacy,

Unless your vet is sending you to another facility to do the actual blood draws, then it would be your vet purchasing the cortrosyn and doing the blood draws. The lab simply runs the test on the blood specimens submitted by your vet. Because cortrosyn is so expensive, the cost of one acth stimulation tests is ridiculous. You can save a lot of money if your vet is willing and able.

Glynda

stacyh2000

02-01-2012, 05:06 PM

That makes sense. Thank you!!

Cyn719

02-01-2012, 05:21 PM

Was just checking in on Pebbies. Sorry about the increased drinking. I know it's frustrating. I remember when. Well if it continues another ACTH test is needed soon. You're during a great job mom!:)

hugsss and love do

stacyh2000

03-27-2012, 10:36 AM

Well it's been almost 2 months since my last post. Yesterday we had another ACTH done. Today, another ultrasound to re-check the splenic mass.

I was at the specialist's office getting the ultrasound today, when my regular vet faxed over her ACTH results:

Cortisol Sample 1 1.3
Cortisol Sample 2 5.8

While I am pleased with the ACTH results, her thirst is still the same. Drastically less than when we first started on Trilostane, but still excessive in my opinion. Still doesn't make it through the night. I'm guessing this is the new "norm"?

The specialist said her mass has decreased in size and she doesn't think it is anything to worry about. No re-check unless problems arise.

Was instructed to keep her on the current dose of 32 mg. once a day of Trilostane. Also, recommends another ACTH in 3 months.

So, is this the new norm? Any suggestions? Thanks.

lulusmom

04-15-2012, 12:10 AM

Hi Stacy,

I merged the other thread you started with your original one so as to keep all of Pebble's medical history in one place. I noticed that you posted a duplicate to your original thread so I deleted that one for good housekeeping.

The results of the most recent stim test are excellent. With reference to Pebbles continued excessive drinking and peeing, did you mention this to your specialist? One of four things could be happening. 1) Not all dogs see an immediate improvement in this symptoms due to medullary washout. Some dogs who have had pu/pd for a very long time have lost all of the solute that the kidneys need to start concentrating the urine again and it can take a little time to get jump started again. 2) According to UC Davis, they have treated dog with Vetoryl who never saw an improvement in pu/pd so it is possible that this could be what is happening with Pebbles but I wouldn't bet on that just yet. 3) It could be that Pebbles has been drinking and peeing in excess for so long that it has become a habit. The best thing to do would be to have a urinalysis done to check the urine specific gravity as well as do a culture to make sure she doesn't have a UTI. 4) Since Pebbles is on once daily dosing, it could be that the effects of Trilostane are wearing off after 9 or so hours and cortisol increases enough during the next 15 hours to prevent total resolution of symptoms. Your specialist can figure out if this is the problem by either doing a stim test later in the day or you can collect a urine specimen at home and ask the vet to do a UC:CR. If the results are high, chances are Pebbles might do better on twice daily dosing.

I hope I've been of some help.

Glynda