Trixie, 10 y/o Boxer (Possible Calcinosis Cutis; Considering Treatment)

[busyman370]

Hello all, my name is Fred and my 10 year old Boxer girl has Cushing's, and she's been through allot. I am trying to do all I can to help her, and as quickly as possible.

I am trying to find out more about using Selegiline to treat her Cushing's.

Does anyone know what the current status is on treating with selegiline?

I will speak more about all that she'd been through later, but I am very late for an appointment and wanted to get this question to the forum as soon as I could.



Thanks, Fred.

[Squirt's Mom]

Hi Fred and welcome to you and your baby girl! :)

Selegiline, or Anipryl, can help some Cushing's dogs but not many. For Anypril to have any effect the pup 1) must have PDH, the pituitary form (Anipryl will NOT help ADH, the adrenal form) and 2) the tumor must be located in the pars intermedia portion of the pituitary gland. Even if all these requirements are present, Anipryl will help only about 25% of pups...and for a limited time in most cases.

Now, having said all of that, I am a big supporter of Anipryl for cush pups who are showing mild signs, who are in the early stages of the disease, and for pups who cannot use Lysodren or Trilostane for whatever reason. This is the first drug I used to treat my Squirt and it helped her for nearly nine months but her story is not the typical cush story either. ;)

Here are some links about Anipryl (Selegiline) -

http://www.marvistavet.com/html/body_anipryl.html

http://vetmedicine.about.com/cs/diseasesall/a/aniprylseniors.htm

http://www.lbah.com/anipryl.htm

http://www.selegiline.com/

http://www.petplace.com/drug-library/selegiline-hcl-anipryl/page1.aspx

http://www.drugs.com/vet/anipryl-5-mg-can.html

I will be back to ask questions but this will hopefully answer some of yours right now.

Hugs,
Leslie and the gang

[Harley PoMMom]

Hi Fred,

Welcome to you and your sweet girl! So sorry for the reasons you are here but happy you found us.

Anipryl (Selegiline) use in the treatment of elevated cortisol, Cushing's, is only effective in about 20% of dogs. Anipryl (Selegiline) only works in dogs with PDH and the tumor has to be located in the pars intermedia of the pituitary gland.

Trilostane/Vetoryl and Lysodren/Mitotane are the more commonly prescribed medicines for use in dogs with Cushing's disease. Although these are strong drugs, they are very effective in lowering the elevated cortisol whether the dog has an ADH or PDH.

I was wondering if you could get copies of all tests that were done on your girl and post any abnormalities that were found here. Does your girl have any other health issues, is she taking any other herbs/supplements/medicines? How much does she weigh?

Sorry for all the questions but the more we know about your girl the better our feedback will be, ok?

Please know we will help in any way we can so do not hesitate to ask any and all questions.

Here is a link with info about Anipryl (Selegiline): http://www.k9cushings.com/forum/showthread.php?t=224

Info about Trilostane/Vetoryl:
Trilostane/Vetoryl Information and Resources (http://www.k9cushings.com/forum/showthread.php?t=185)

Info about Lysodren/Mitotane: Lysodren loading Instructions and related tips. (http://www.k9cushings.com/forum/showthread.php?t=181)

Hope this helps.

Love and hugs,
Lori

[busyman370]

Thanks for the replies. Here's what I know so far:

I spoke with my Vet by phone today in length, and long story short, he says he is willing to treat my Boxer for Cushing's, but in his opinion, after all is said and done, he thinks it may end up not being the best choice.

Because she is 10 years old, and that's really at the top end of a normal life expectancy for a Boxer, he told me that if it were his dog, the only thing he would do is to ultrasound for adrenal, and even then, at her age and condition, surgery may not be a wise thing to do to her. And is concerned about how the treatment could negatively effect her quality of life, put her health and life at risk, and also mentioned that the rather large financial expense, as well intended as it would be, may not end up being a benefit to the dog.

He is being very sincere and actually told me that he does understand and deeply cares about me and my dog, and will do whatever I want him to do. I believe that he is coming from the heart on this. He's been my Vet for almost 30 years and he knows how much I care about my dogs. He knows that my main concern is what's best for my dogs, not me.

So, needless to say, I am not feeling the greatest right now. My only concern is to do the right thing for my dog. She's not the dog she used to be, but otherwise she is having a reasonably happy life.

However, over the last week, soon after going to bed, and just about the time we all wake up in the morning, she will cry and yelp to go outside and potty. When I let her out before bed, she's in such a hurry to come back in that I am thinking that she's not finishing her potty. I am going to make her stay outside a little longer and encourage her to really finish everything that needs finishing before I put her to bed.

We've been treating the symptoms caused by Cushing's instead of treating the Cushing's itself. Her "diabetes insipidus" is a non event thanks to the desmopressin, and the soloxine is doing a good job in the hypothyroid department, and the slowly but progressive muscle weakness. The only overt problems are the skin issue, which I hate to say is probably calcinosis cutis. I'm hoping it's a skin infection, she's on Baytril a the moment for the skin infection part.

My real concern is that I don't want to step in and basically ruin what quality of life she has now, and just bring her discomfort from repeated testing, and especially by putting her at the potential risk(s) that are a real possibility of treatment, especially at her age.

Plus, I am concerned that there's already been some damage done to her health because of all the cortisol blasting through her body, and who knows what else could be going on as we speak; cancer, cardiovascular, etc and etc.

The bottom line at this point in time is that I am very concerned that because of her age, very old for a Boxer, and the very possible weakened stage of her overall health, no matter what I do, other than medicate around the Cushing's to treat symptoms, it's not really going to improve or extend her life in a quality way, for any appreciable length of time. I believe that just a run of the mill Vet can not properly treat Cushing's, and from my experience, my Vet is one of the best around, and even he has not had much luck treating it. I am afraid that I may make things worse for my girl by messing around with this, and that's what's holding me back from pursuing further aggressive treatment.

I hope you all understand where I am coming from, because it's exactly what's going on in my mind at this time, and if anyone can offer some suggestions that can help me make the decisions I need to make going forward, for the sake of my girl, I'd really appreciate it.

Thanks, Fred.

Trixie - Boxer dog.
Female - Spayed.
10 Years Old.
48 Pounds. (5 pounds lighter than in her youth)

Symptoms:
Around Spring of 2011 began to notice the following:
Slowly developed lack of interest in exercise, increasingly aggressive
drinking/eating. Developed so slowly that was not readily noticed as
being abnormal. Seemed very healthy looking.

At her March 2011 Physical; noted weight gain. Noticed she was quickly finishing her food, then stealing from the bowl of my other dog. They've eaten side by side since birth, so when I realized what she was doing, I prevented her from continuing on with it, and then Put her on a diet. She lost the weight quickly and easily. (which suggested maybe hyperthyroid, but not Cushing's) And if memory serves me, some hair thinning began.

Tested positive for hypothyroid, was put on Soloxine.

Soon began profound increased thirst/appetite/frequent and dilute
urine, hair loss, skin infection, muscle weakness, lethargy and cold intolerance. Thought this was caused by the Soloxine dose was too high so we lowered it.

November 2011 Developed skin infection. Two weeks Cephalexin for skin infection thought to be caused by "moist skin" and or hypothyroid. Infection cleared up.

Diagnosed:

September 2011 - Hypothyroid - Blood panel.

January 2011 - Cushing's - LLDS.

0.6 mg. Soloxine daily.

0.450 mg. Desmopressin daily.

Currently on 21 days Baytril for another skin infection. It seems to be a possible mix of a skin infection and calcinosis cutis.

Waiting to see if goes away. If not, Cushing's will be the assumed cause, and the skin lesions will be seen as calcinosis cutis.

Food - Wellness Super 5 Lamb and Rice.

[marie adams]

Welcome Fred and Trixie,

You will get the information you need explaining Cushing's more in depth here from the experts. They helped me get thru it with better understanding of the disease. :)

I treated my Aussie Maddie with Lysodren which helped her and she was 11 yrs old at the time. She didn't have any side effects from the medication--in fact it helped clear up skin problems and grew her fur back. She ended up dying from cancer in her left hind leg which didn't have anything to do with treating the Cushing's or the disease itself.

Yes it does cost to treat, but I would do it again. What I refused to treat was the cancer because I felt that wasn't fair to put her through that ordeal.

You know Trixie better than we do and we will all stand behind you and help you through whatever you decide. I took my Maddie off off grains of all sorts because I had read it wasn't good for a Cushing's dog.

Take care and ask all the questions you want because you will get answers or the experts will research it for you!!! :)

[Lady's mom]

Fred, I just had to respond to the age issue. I currently have boxer girls #3 and #4, ages 3 and 4, approx. Boxer #1 died at 8 years due to a heart ailment and probable brain tumor. (a definite diagnosis could not be made because of the heart issue.)

But boxer #2 lived to be at least 15 years old. Like all the others, she was a rescue, so her age was a best guess and conservative. She also probably was not full. Loaded boxer, which I realize is a factor. (that's "fullBlooded," dang autocorrect!)

But my point is, I wouldn't be too quick to consider this the end of your dog's life, based solely on the number of years. You might have another 2 or 3 years together, at least.

Just a thought, and only my opinion. Good luck to you.

Karen

[labblab]

Hi Fred,

I surely understand why you are struggling with a treatment decision for your girl, especially if your family vet does not feel optimistic. Do you know how many Cushing's dogs he has worked with, and which medication/s he has used? I would never mislead you by saying that Cushing's is a "snap," and that we have never experienced treatment failures or difficulties among our members. But we also have witnessed many, many success stories, as well, which allowed dogs to live out their normal lifespans with an excellent quality of life. So perhaps your vet has had the bad luck to have encountered a smaller group of dogs that have had special problems that interfered with their ability to respond favorably to treatment. In that vein, I hate to say it, but calcinosis cutis *is* a special problem that afflicts a smaller subset of Cushpups. If your dog really does have calcinosis cutis, that may have a huge impact on your treatment decision.

Setting that aside for a moment, here are a few personal thoughts from me. Other members may think differently, but for a dog who is already approaching the end of his/her normal lifespan, I would base a treatment decision largely on quality of life issues. We do know that untreated Cushing's has the potential to cause slow, systemic damage over the course of time. So for younger dogs, I have equal concern about halting the chronic damage that does, indeed, have the potential to shorten their lives. But for an older dog, my concern shifts more to comfort. As you say, balancing the need for medication, tests, and vet visits vs. the quality of the dog's life for their remaining time. However, sometimes that question is itself a no-brainer. For instance, prior to treatment, my own Cushpup was so miserable from overt symptoms that I could not imagine withholding medication if it would help (panting, ravenous hunger, excessive thirst/urination, hindleg weakness that increased to the point he could not negotiatie stairs or jump onto the couch or in the car). And the good news is that effective treatment really DOES help resolve those symptoms -- some of them very quickly. So that's where I differ from your vet. At any age, I would not hesitate to consider treatment if I was able to afford it and if my dog was uncomfortably symptomatic. But for an older dog, if symptoms were minimal and quality of life was still good "as is," I might be more likely to hold off.

However, for your girl, the calcinosis cutis may be the deciding factor as to her quality of life. If she truly suffers from it, I'm afraid that you must gain control of the circulating cortisol in order to have hopes of containing it. It is an uncommon condition, but we have had sufferers in the past and currently have some dogs who are currently afflicted. I am not an expert and have no first-hand knowledge, but my impression is that it will worsen and spread in the absence of treatment. And it is a condition that can absolutely make a dog miserable. I am not telling you this to force you into treatment. But instead to let you know as to the importance of making that diagnosis in a timely fashion so that you know what you are facing. If there is any doubt about it and if it is at all possible, you may try to see a veterinary dermatologist. As I say, ultimately the treatment decision will still be up to you. But if you do want to try to gain the upper hand on that disorder, it is best not to wait.

I see I've written a book, so I will close. But I am truly glad you've found us. And I'm certain other folks here will also share their own perspectives.

Marianne

[busyman370]

Fred, I just had to respond to the age issue. I currently have boxer girls #3 and #4, ages 3 and 4, approx. Boxer #1 died at 8 years due to a heart ailment and probable brain tumor. (a definite diagnosis could not be made because of the heart issue.)

But boxer #2 lived to be at least 15 years old. Like all the others, she was a rescue, so her age was a best guess and conservative. She also probably was not full. Loaded boxer, which I realize is a factor. (that's "fullBlooded," dang autocorrect!)

But my point is, I wouldn't be too quick to consider this the end of your dog's life, based solely on the number of years. You might have another 2 or 3 years together, at least.

Just a thought, and only my opinion. Good luck to you.

Karen

Thanks Karen,
Thanks for the good wishes. Believe me, I wish I could take the life span of the Boxer out of the equation regarding decisions regarding medical treatment, but I've seen too much in my life regarding the life span of the Boxer and how various illnesses impact it.

I want to do everything I can to help my Trixie, but in the same breath, I do not want to do anything that may possibly cause most of the remaining time she has to be less than the quality of life she has now, or as close to it end as I can.

That's why I am looking into the issue of treating Cushing's as deeply as I am. I've got allot of things to consider in order to keep the whole in balance along the way.

I have been an AKC show Boxer breeder and exhibitor for many years, and was very involved in Boxer Rescue.

When I lost my wife to cancer a number of years ago, I ended the dog shows and breeding. It just wasn't the same without her. However, I'm always on the lookout to help a Boxer in need.

We were not big breeders, maybe a litter every three or so years. There's more than enough dogs in the world without us adding more, but we did want to try to help the breed improve regarding health and temperament issues, and thus bred very carefully.

Regarding life span; in my life, I have seen a very few Boxers live to be 12, in fact my last male's grandmother was 13 when she died from failed kidneys, but she was a rarity.

From my experience, most otherwise healthy boxers start to pass away from "breed specific natural causes" as early as nine years old, and the most common age of death among the boxer community is ten years.

It used to be worse before enough caring Boxer breeders started to work together and push for health testing. These days no well meaning breeder will breed with Boxers unless they have been tested, and then work hard to breed around the genetic problems and make the Boxer the hearty dog it used to be before the egocentric breeders got hold of it.

Yes, there are still breeders of all kinds of dogs that are only in it for the money, but the law allows it, so you really can't stop them. Personally I wish I could.

I lost one Boxer at nine. She was a rescue and had one of the best temperaments of any Boxer I've seen. Her death was due to a disease where the nerve impulse from the brain couldn't reach the rear legs to make them move. It's called degenerative myelopathy, and it is the most heartbreaking thing to see. an otherwise perfectly healthy and robust dog, but they can't move their rear legs. It is known to hit Boxers a little harder than some breeds, and it is absolutely untreatable.

My point here is that even though my rescue girl did not die of Cushing's or cancer or heart, she still died at age nine none the less.

Getting back to Trixie, she is so much like her father. She is like a female clone of him, and he died from an in-operable brain tumor at a month past his tenth birthday.

In my heart, I have to wonder what's going on inside Trixie, other than The Cushing's. I have had two tumors removed from her, and I was always concerned about her getting brain tumors, now she has Cushing's, which is caused by a tumor, and it happens to located near the brain. How do you think that makes me feel?

I'm concerned that she could have a number of tumor or tumors, located in various areas of her body as well as those that are effecting the endocrine system in ways that produce the end effects of "normal Cushing's," that would require surgery, and putting her through that level of surgery is something I won't do to her at her age and weakened state of health.

Every time a dog goes under anesthesia, there is real threat of kidney damage, and she' had Three, not counting dental cleanings. So I'm not going to be heroic and end up finishing off her kidneys as the result?

So as I said earlier, that's why I am looking into the issue of treating Cushing's as deeply as I am. I've got allot of things to consider in order to keep the whole in balance along the way.

But I do appreciate your concern, and I could how Trixie could live those two more years. I just need to handle this correctly.

Thanks again,
Fred

[busyman370]

Hi Fred,

We do know that untreated Cushing's has the potential to cause slow, systemic damage over the course of time.
Marianne

Hi Marianne,
This is exactly what I am concerned about!

Looking back, I think she had Cushing's for possibly two years before we discovered it. I shudder to think of the damage that's been done to her during this time, and especially over the last months.

We started out thinking something was going on with her thyroid and that led up to where we are now.

I feel in my gut that the "probable" damage that's been done by the cortisol over the two years has taken away her chance to undergo treatment with a strong body, and to try to jump in now may just end up finishing her off.

I really do think that her whole system has been harmed and am very concerned if she could take treatment and respond well.

However, the possibility of calcinosis cutis is a concern as well.

My Vet and I are treating her with Baytril for her skin infection, and are looking to see if clears like it did the last time, although I think we both know that this time it's more than just an infection.

That's why I am trying to learn on this Forum so between my Vet and myself we can make an informed decision.

I don't want to throw my Vet under the bus. He is well meaning and does want to help. Maybe it's because he has seen a similar dog under similar conditions and is trying to do what he thinks is best all the way around.

Either way, we will be discussing this in detail and soon. Largely because of the possibility of calcinosis cutis.

Thanks,
Fred.

[busyman370]

My dog was recently diagnosed for Cushing's from a LDDS, but I think she's had it for about two years. Other than test results, what would be some visible signs of advanced Cushing's that I could look for? Thanks.

[Lady's mom]

Fred, thank you for understanding where I was coming from. You certainly know much more than I ever will about boxers! I co hope you find the right combination for your girl.

I know you agree that boxers are the most amazing dogs. I'm sure we could share some great stories.

Karen

[labblab]

My dog was recently diagnosed for Cushing's from a LDDS, but I think she's had it for about two years. Other than test results, what would be some visible signs of advanced Cushing's that I could look for? Thanks.
Hi again, Fred!

As you will see, I have merged this new post of yours into your original thread about Trixie. We like to maintain only one single thread for each member so that all the related info and replies are consolidated in one place. This makes it a lot easier to "track" events and progress, and facilitates more meaningful feedback.

You are asking about visible signs of advanced Cushing's. However, to start off, I'm going to give you a link that discusses potential internal consequences (one item that is missing from the list is changes to the liver, as evidenced by elevated liver enzymes). These are the types of internal damage that can progessively advance over time:

http://www.k9cushings.com/forum/showthread.php?t=195

In terms of visible signs, my own experience on this forum is that it is somewhat hard to label outward symptoms as being "early" or "advanced." They are either present or absent in any given dog. There are lots of possible issues: excessive hunger, excessive thirst/urination, panting, seeking out cool places, pot belly, skin and coat issues, muscle wasting (to name a few). Not every dog will exhibit every symptom, or to the same degree of severity. With my own dog, fur loss preceded any of the other outward symptoms by quite a long time. And on the other end of things, hindleg muscle wasting took time to progress. But the panting, appetite, thirst/urination, seeking out the hardwood floor -- once they kicked in, they were there with a vengeance! It was not really a matter of "worsening."

But that can be the surprising aspect of treatment -- many of those severe outward symptoms can resolve quite rapidly as soon as the cortisol level is reduced to a therapeutic range. And as for special risks associated with treating older dogs, I can think of only a few. First, elevated cortisol does have an anti-inflammatory effect. So if an older dog suffers from a condition that benefits from steroids such as arthritis, lowering the cortisol may "unmask" discomfort that was previously being naturally controlled. So alternative treatment must be undertaken for that condition. Secondly, there are specific warnings against giving trilostane to a dog suffering from severe kidney or liver problems (over and above the types of changes that Cushing's initially causes). This is because adequate kidney/liver function is required in order for the drug to be metabolized safely and properly. Since older dogs may be more prone to insufficiencies of the kidney or liver, the status of those organs should be checked before starting treatment with that drug in order to make sure that they are performing adequately. I am not as sure about Lysodren, but there may be similar cautions in that regard.

But in general, I can think of no other reasons why an older dog (who has suffered from Cushing's for awhile) should have greater difficulty handling treatment than does a younger dog. Any dog who dislikes vet visits may be stressed by the need for periodic testing, but that can occur at any age. My "baby" girl is terrified at the vets and always hides under my chair, while my "senior" girl LOVES going to the vet and sees it as an opportunity to meet-and-greet every person and dog in sight. :)

Once again, I am not trying to push you into treatment for Trixie. There can be a whole range of issues that affect your decision on her behalf. But I'd encourage you not to discard the notion of treatment just because of age or duration of illness.

Marianne

[busyman370]

Hi all,
When I found this Forum I was in tough shape. Watching my girl slowly deteriorate and knowing the damage cortisol can do, was ripping me apart. I won't even go into how my confidence in treating Cushing's was destroyed.

However, thanks to this Forum I just hung up the phone from speaking with my Vet and I informed him that we are going to initiate treatment as soon as he can pull the plan together.

He is going to be away on a seminar for ten days during the middle of March and we're going to have to work the beginning of treatment around that block of time, although he said that he could manage some thing's by phone to other Vet's in his practice if need be, so he is completely on board with treating the Cushing's.

I would greatly appreciate any help from you folks that you may be willing to offer regarding the science end of the treatment. As much as I may need my hand held at various points along the way, once the treatment begins it's all about my Boxer girl, and that is going to be all about the science not emotion.

I have learned that there are different camps regarding the use of
Trilostane verses Lysodren. It's thing's like that that I am eager to learn more about before we make up the final treatment plan.

I actually told my Vet that guys like him and me are old school and asked him if he had any problem checking in with Vet's that are up to speed on today's treatment. He replied that he had already decided to do that as we were speaking, and that made me feel quite good.

Well, I am going to take a break right now. I have been up for most of last night, and did not get any sleep the night before because I have been researching treatment.

I just wanted to post this to you all to let you know that I am going to treat my girl.

I can't say enough in the way of thanks to this Forum for helping me get my head around this and helping me to allow my true feelings regarding treatment to surface. Thank you all so very much

I am aware of the risk end, I am firmly grounded with this. However, watching my girl just get weaker and weaker, knowing that the cortisol is ravaging her is something I can no longer allow to continue.

To be honest, my bottom line feeling is that I may as well just put her down than to allow her to just get slowly destroyed.

She's started to cry and yelp shortly after going to bed and just about the time we all wake up. That is not right to let her continue on like that, and lets face it, it's only going to get worse.

Years ago, I was a Boxer breeder. I did not produce many litters as selling the pups was not something I looked forward to. Too many dogs out there now, and too many "unqualified" pet owners.

I just loved the dogs and really loved the shows and agility.

The point is that I have lost many dogs in my life and am well aware of the pain of loss as each is an individual personality and so very lovable in their own right.

I've lost Boxers to heart problem, cancer, degenerative myelopathy, which are tough cases in their own right, especially the degenerative myelopathy, but not until now have I ran into this Cushing's disease.

So, that's it for now. I'll be back for sure.

Thanks again all of you,

Fred.

[Lady's mom]

I'm so glad for you and trixie, that you found this group. I'll tell you briefly what happened to me.

Lady's ims started her on 60 mg trilo daily (she only weighs 35 lbs.). Everyone here was really concerned the dose was too high, but I trusted our ims and my vet to know the correct dosage. Well, after 3 or 4 doses, lady started to get very, very sick and we couldn't decide whether it was pancreatitis or chronic back pain, but I stopped the Trilo until she was feeling beTter, which began to happen the day after stopping the meds. Not only did her illness stop, so did all her cushing's symptoms, every single one of them. That was several weeks ago, and she's still symptom free. Go figure.

One very important thing people here recommended - one MORE - was to keep prednisone on hand for an emergency. You'll get lots more advice here, all of it good.

Good luck to you and Trixie!

[labblab]

Hi Fred,

I hope you won't mind, but I'm at it again -- I just moved your newly posted thread over "here" to join your original thread. I'm also going to take the liberty of editing your thread title a bit, so as to reflect Trixie's current situation. You can let me or another staffer know if you ever want your thread title changed, and we'll be happy to help with that (unfortunately, members do not have the ability to change their thread titles themselves).

I very much appreciate all the thought and care with which you are approaching possible treatment plans for Trixie. We'll definitely do our very best to answer your questions and offer suggestions as you consider your options and your preferences!

Marianne

[lulusmom]

Hi Fred and a belated welcome to you and Trixie.

You’ve already gotten some very valuable information from Marianne and others but as usual, I still have questions which I’ve listed below:

1. You mentioned that the diabetes insipidus is a thing of the past since desmopressin. Did your vet formally diagnose Trixie as having diabetes insipidus (DI)? DI is a very rare condition so I’m thinking that perhaps your vet was experimenting with the desmopressin to see if it helped Trixie’s excessive peeing and drinking, yes? Was Trixie on Desmopressin when the LDDS test was done? If so, it’s quite possible that the results are inaccurate as Desmopressin will increase cortisol levels.

2. Can you please list the actual symptoms associated with cushing’s that Trixie has right now.

3. Can you please round up the results of all bloodwork and urinalysis done by your vet to diagnose Trixie? With respect to the blood chemistry and complete blood count (CBC0) you need only post the abnormal values, to include the normal reference ranges. Was a full thyroid panel done or did your vet prescribe Soloxine based solely on low T4? Have Trixie’s thyroid values been checked since starting treatment with Soloxine?

4. Can you please post the actual results of the LDDS test? There should be three numbers. The baseline (preinjection draw), the 4 hour draw and the 8 hour draw.

5. Was an abdominal ultrasound ever done? If not, I would highly recommend that you do that before starting treatment so as to validate the LDDS as well as give the vet a good look at the adrenal glands and surrounding internal organs. Regardless of overt symptoms associated with cushing’s, I’m personally never comfortable with a diagnosis based solely on a the LDDS test, especially if done under under less than desirable conditions. i.e. while dog is receiving desmospressin or has active infection.

My first cushdog was diagnosed with hypothyroidism at one year old and was subsequently diagnosed with cushing’s at three years old. She had the common symptoms associated with cushing’s for at least a year before diagnosis. She is now 10 years old . My second cushdog was a rescue who was pretty debilitated, hollow eyed, skeleton looking skull, pot belly and displaying every symptom associated with cushing’s. Both looked and acted like they were 100 years old prior to treatment and the transformation was pretty amazing. Most dogs have had cushing's for a very long time before diagnosis so please don't worry about any permanent damage. Most, if not all, lab abnormalities and symptoms usually resolve with treatment.

You mentioned that your vet has not had good luck with treating cushingoid dogs. That doesn’t come as a surprise to most of us as we’ve learned that most gp vets don’t really have the knowledge or experience to diagnose cushing’s or direct treatment. As a layperson, who has spent the last seven years obsessing over everything canine cushing’s, I firmly believe that diagnosing and treating cushing’s is rocket science that is best left to internal medicine specialists. These are the veterinary professionals who deal with this disease day in and day out so I hope it is an internal medicine specialist that your vet will be conferring with.

You mentioned that you had two tumors removed from Trixie. What type of tumors were they and when were they removed? Did you notice any change in symptoms when they were removed?

Boxers are at the top of the list of breeds who seem to be genetically presdisposed to cushing’s so it’s pretty amazing that you’ve been around Boxers a good part of your life and are just now having to deal with Cushing’s. Apparently, you’ve had some very good genes in your lines. :D Being a brachycephalic breed, Boxers tend to have bigger pituitary tumors, which is why I want to mention that there is a possibility that treatment can hasten the growth of pituitary tumors. I'm not trying to rattle you any more than you already are but I want to arm you with as much knowledge as possible. If your vet is unaware that Boxers are at greater risk, please have him discuss this with the specialist he will be consulting with.

http://www.ncbi.nlm.nih.gov/pubmed/19041802


Trilostane-induced inhibition of cortisol secretion results in reduced negative feedback at the hypothalamic-pituitary axis
Domest Anim Endocrinol. 2009 Jan;36(1):32-44. Epub 2008 Nov 11.
Teshima T, Hara Y, Takekoshi S, Nezu Y, Harada Y, Yogo T, Teramoto A, Osamura RY, Tagawa M.
Division of Veterinary Surgery, Department of Veterinary Science, Faculty of Veterinary Medicine, Nippon Veterinary and Life Science University, 1-7-1 Kyonan-cho, Musashino-shi, Tokyo 180-8602, Japan

Cushing's disease caused by pituitary corticotroph adenoma in dogs is usually treated by medical treatment, and the efficacy of this treatment has been reported. However, controversy remains as to whether reduced negative feedback through the inhibition of cortisol secretion, similar to Nelson's syndrome, may appear as an adverse effect.

The purpose of this study was to investigate the effect of reduced negative feedback through the inhibition of cortisol secretion by daily trilostane administration on the pituitary-adrenal axis in clinically normal dogs.

Dogs were administered 5mg/kg trilostane twice a day every day for 8 weeks (n=8) or 16 weeks (n=3). After the initiation of trilostane administration, plasma adrenocorticotropic hormone (ACTH) concentrations were increased remarkably.

As assessed by magnetic resonance imaging (MRI) during administration, the pituitary became enlarged. After trilostane administration, the cytoplasmic areas of the pituitary corticotrophs were increased and the ratio of pituitary corticotrophs to all cells in the anterior lobe was greater in the trilostane-treated dogs than that in untreated animals.

In addition, histological examinations revealed bilateral adrenal cortical hyperplasia. Using real-time PCR quantification, the expression of proopiomelanocortin (POMC) mRNA in the pituitary and ACTH receptor (ACTH-R) mRNA in the adrenal gland was greater in the dogs treated with trilostane than in untreated dogs.

These results indicate that reduced negative feedback induced hyperfunction of the pituitary corticotrophs and pituitary enlargement in healthy dogs. These changes suggest that the inhibition of cortisol secretion by trilostane may increase the risk for accelerating the growth of corticotroph adenomas in dogs with Cushing's disease.

Glynda

[Harley PoMMom]

However, thanks to this Forum I just hung up the phone from speaking with my Vet and I informed him that we are going to initiate treatment as soon as he can pull the plan together.

I am so proud of you! We will definitely be here to support you in any way we can.



I would greatly appreciate any help from you folks that you may be willing to offer regarding the science end of the treatment. As much as I may need my hand held at various points along the way, once the treatment begins it's all about my Boxer girl, and that is going to be all about the science not emotion.


I have learned that there are different camps regarding the use of
Trilostane verses Lysodren. It's thing's like that that I am eager to learn more about before we make up the final treatment plan.


You are correct that Lysodren/Mitotane and Trilostane/Vetoryl work very diiferent.

Lysodren acts to suppress adrenal gland function by eroding the top layers of the adrenal gland that produce corticosteroid hormones, thereby reducing the production of cortisol.

Trilostane/Vetoryl works to block the normal steroidogenisis pathway of pregnenolone to progesterone to cortisol.

Please do not hesitate to ask any and all questions and remember you are not alone as we are with you on this journey.

Love and hugs,
Lori

[KarenJ]

Hi Fred,
I'm also have Boxers, one 10 year old girl with Cushing's and a 5 year old male. Her first symptom was hair loss. You could see through to the skin on her back. Her skin also got flaky. Then she started gaining weight but I thought it was all just part of the aging process. It wasn't until she started panting and drinking excessively that I became concerned. I was thinking diabetes but my vet immediately suspected Cushing's. We started with a urine test and blood work. Nothing ruled out Cushings so I agreed to an ACTH stim test and LDDS. Neither were completely conclusive but I opted to start her on Trilostane. I decided against the ultrasound because I did not want to put her under. And I would not have surgery even if it showed a tumor.

I do understand your concern with subjecting Trixie to anything that will not improve her quality of life. I will tell you that Maggie's symptoms are much better and I do believe she feels good now. I was concerned with suppressing her cortisol since she has arthritis. I was worried that her pain would increase but I haven't seen any signs of that.

Maggie is 72 lbs and on 30mg in the morning and 30mg at night. That's a fairly conservative dose for her weight and we've had no medication related issues.

I wish you luck and feel for you. Our Boxers steal our hearts for the short time we have them but I wouldn't trade them for the world. I lost my first at 7 yrs and my second one at 8 yrs. I feel blessed to have had Maggie for over 10 and am thankful for every day.

Hugs,
Karen

[labblab]

As usual, Glynda has done a great job of listing a series of questions that will go a long way towards clarifying Trixie's situation. One additional thought that I also want to add is that if you and your vet do suspect calcinosis cutis, it probably would be helpful to have an actual biopsy performed on one of the lesions (and Glynda may very well know more about this process than me -- I admit I know next to nothing!). But if calcinosis cutis is confirmed for Trixie, I believe that would essentially be a definitive diagnosis for Cushing's, as well. So that info might facilitate additional treatment decisions on Trixie's behalf.

Marianne

[Sabre's Mum]

Hi

I just wanted to comment on something that Marianne said ..... re the biospy. Sabre had a biopsy to confirm his calcinosis cutis ... actually it was more to confirm what his skin condition was as the vet(s) [two looked at him and had never seen it before]. For this he was sedated - they considered a punch biopsy but decided that one under sedation, with a larger sample, was going to produce a more definitive diagnosis.

Angela and Flynn

[busyman370]

Because this post is very important, I wanted to make sure it got through. I tried to sent by hitting reply, but it wouldn't send. Message said the post was too short.


Hi Fred and a belated welcome to you and Trixie.

You’ve already gotten some very valuable information from Marianne and others but as usual, I still have questions which I’ve listed below:

1. You mentioned that the diabetes insipidus is a thing of the past since desmopressin. Did your vet formally diagnose Trixie as having diabetes insipidus (DI)? DI is a very rare condition so I’m thinking that perhaps your vet was experimenting with the desmopressin to see if it helped Trixie’s excessive peeing and drinking, yes? Was Trixie on Desmopressin when the LDDS test was done? If so, it’s quite possible that the results are inaccurate as Desmopressin will increase cortisol levels.

• Yes, my Vet used the desmopressin to make the kidneys
concentrate the urine, not because she was diagnosed with DI.

• And yes, she was on desmopressin when the LDDS test was done.

2. Can you please list the actual symptoms associated with cushing’s that Trixie has right now.

• Yes, here they are.
• From the beginning, they were as follows:
• lethargy, reluctance to run and play.
• hair loss.
• hypothyroid.
• skin pigmentation.
• skin infection.
• hind leg weakness.
• resistance to going out in colder weather.
• aggressive drinking and increased urination.
• peeing in the house.
• increased appetite.
• weight gain -which was attributed to over eating/stealing other dogs
food, but once corrected and put on diet, lost the weight and has
maintained weight well.
• general poor skin condition.
• thinning hair, hair loss, lack of hair regrowth, and no regrowth where
she was clipped for IV.
• loss of muscle.
• skull-like appearance of the head.
• difficulty completing jumping up on the couch. Front and rear
weakness.
• what appears to be a recurrent skin infection.
• "apparent" calcinosis cutis.
• recently she's been crying out shortly after bed and shortly before
out wake up time. Sometimes she will go out and potty, but to me
it seems more like anxiety. (worry about brain tumor)
• I hate to say this, but lately she has been showing slight signs of
megaesophagus when drinking, and I've also noticed maybe a
month ago that her eating has "slowed down." Not dramatically, but
noticeably.


3. Can you please round up the results of all bloodwork and urinalysis done by your vet to diagnose Trixie? With respect to the blood chemistry and complete blood count (CBC0) you need only post the abnormal values, to include the normal reference ranges.

• I don't have the bloodwork results, as I was told the blood panel was
normal I just let it go from there not knowing that I may need them
in the future.
• There never was a urinalysis done, just specific gravity. But that's
another thing that I would want done before we progress to
treatment.

Was a full thyroid panel done or did your vet prescribe Soloxine based solely on low T4? Have Trixie’s thyroid values been checked since starting treatment with Soloxine?

• Yes, a full panel way done and sent to Michigan State. My Vet did
not prescribe Soloxine based only on T4.
• Yes, her thyroid was checked by full panel two times since Soloxine.

4. Can you please post the actual results of the LDDS test? There should be three numbers. The baseline (preinjection draw), the 4 hour draw and the 8 hour draw.

• I do not have them, but my Vet said that it looked like she was in
the early stages of Cushing's, so would have to assume that her
numbers were in the lower range of a Cushing's diagnosis. At the
time I did not feel that I needed them because I trusted my Vet's
judgement.

5. Was an abdominal ultrasound ever done? If not, I would highly recommend that you do that before starting treatment so as to validate the LDDS as well as give the vet a good look at the adrenal glands and surrounding internal organs. Regardless of overt symptoms associated with cushing’s, I’m personally never comfortable with a diagnosis based solely on a the LDDS test, especially if done under under less than desirable conditions. i.e. while dog is receiving desmospressin or has active infection.

• Yes I agree. My phone conversation with my Vet yesterday was
rather brief. I just wanted to give him the heads up that I do want
to treat, and if I remember properly, he did say that some testing
would need to be done, and that he was going to start by
researching the latest up to date treatment protocol. So I would
assume he is planing an ultrasound, and if not, I do want one done,
and perhaps other diagnostics to rule out something like life
threatening cancer, which would make treating her for Cushing's not
worthwhile.

My first cushdog was diagnosed with hypothyroidism at one year old and was subsequently diagnosed with cushing’s at three years old. She had the common symptoms associated with cushing’s for at least a year before diagnosis. She is now 10 years old . My second cushdog was a rescue who was pretty debilitated, hollow eyed, skeleton looking skull, pot belly and displaying every symptom associated with cushing’s. Both looked and acted like they were 100 years old prior to treatment and the transformation was pretty amazing. Most dogs have had cushing's for a very long time before diagnosis so please don't worry about any permanent damage. Most, if not all, lab abnormalities and symptoms usually resolve with treatment.

You mentioned that your vet has not had good luck with treating cushingoid dogs. That doesn’t come as a surprise to most of us as we’ve learned that most gp vets don’t really have the knowledge or experience to diagnose cushing’s or direct treatment. As a layperson, who has spent the last seven years obsessing over everything canine cushing’s, I firmly believe that diagnosing and treating cushing’s is rocket science that is best left to internal medicine specialists. These are the veterinary professionals who deal with this disease day in and day out so I hope it is an internal medicine specialist that your vet will be conferring with.

• I agree, and not knowing who he will be conferring with at this time,
I do know that he is taking this very seriously, and I sensed that he
is dedicated and committed to doing whatever it takes to treat Trixie
to her best advantage. He is a smart man, and I feel confident that
with the correct information, he can treat her, and monitor her
properly.

You mentioned that you had two tumors removed from Trixie. What type of tumors were they and when were they removed? Did you notice any change in symptoms when they were removed?

• The tumors were not related to Cushing's, they were kind of like a
mammary tumor, but of the vascular nature. Kind of a clump of
vascularity.

Boxers are at the top of the list of breeds who seem to be genetically presdisposed to cushing’s so it’s pretty amazing that you’ve been around Boxers a good part of your life and are just now having to deal with Cushing’s. Apparently, you’ve had some very good genes in your lines. :D

• I've had my share of problems. Degenerative myelopathy, Cancer,
heart.

• I have never dealt with Cushing's before with any of my boxers, and
frankly, no one I knew that had a Boxer with Cushing's ever treated
it. At least if they did, I didn't know. It's not like we all live in the
same town, or even the same State. In general, breeders don't
really like to talk about health issues in their line. Only a few of us
really care enough about trying to better the breed that we feel it's
important to share our experiences. But, having said that, there is
now wide spread health testing before breeding selection, so that's a
good thing. Unfortunately there are too many who still breed for ego
and money, but let's not go there.


Being a brachycephalic breed, Boxers tend to have bigger pituitary tumors, which is why I want to mention that there is a possibility that treatment can hasten the growth of pituitary tumors. I'm not trying to rattle you any more than you already are but I want to arm you with as much knowledge as possible. If your vet is unaware that Boxers are at greater risk, please have him discuss this with the specialist he will be consulting with.

• Absolutely! In fact, that is probably the main reason (in the deepest regions of my mind) I was on the fence regarding treating her for Cushing's! Even as I sit here right now, in my gut I just shake my head thinking; here I am worried about Cushing's, when by the time we get that stabilized, she'll die from cancer. She's a ten year old Boxer! If they don't die from heart problems, cancer usually takes them out right around this age, if it hasn't already. Don't think that hasn't been plaguing me. It sure has!! and IS!! She's showing some familiar signs of brain cancer. You sort of acquire an eye for it after a while. But she's also showing the classic signs of Cushing's too, but the recent crying out and yelping, among other things, has taken me back, so here I am.

• GREAT questions and comments by the way. Thank you so much.

Fred.

http://www.ncbi.nlm.nih.gov/pubmed/19041802

Glynda

MODERATOR NOTE: I have merged this post with Trixie's original thread and deleted the duplicate post. Unlike some other sites, we like to keep all the info about each pup in one thread. That way the history can be more easily searched.

[Squirt's Mom]

Hi Fred,

OK! I have redone my post here and worked on your post above so your responses to Glynda stand out.

When replying within a quote box, the system doesn't "see" the characters entered there as new characters, so you have to post something outside the quote box for the post to submit...just as you did. ;)

[busyman370]

I'll try it again to see if I can make it work.

[busyman370]

it seemed to work fine this time!!

[Squirt's Mom]

It's fine now! You done good! :D

[busyman370]

Just happened to remember something. No, Trixie has not had a punch biopsy for the calcinosis cutis, but the Vet is quite sure she has it. Going on the premiss that is is calcinosis cutis, wouldn't that be enough diagnosis of Cushing's in and of itself?

[busyman370]

It's fine now! You done good! :D

I'm smiling .....

[labblab]

Just happened to remember something. No, Trixie has not had a punch biopsy for the calcinosis cutis, but the Vet is quite sure she has it. Going on the premiss that is is calcinosis cutis, wouldn't that be enough diagnosis of Cushing's in and of itself?

Yes, in combination with Trixie's other symptoms, I would think that confirmed calcinosis cutis would essentially be a definitive diagnosis for Cushing's.

Fred, you spoke earlier about Trixie's appetite having slowed down within the last month, and also signs of megaesophagus when she's drinking. I'm familiar with megaesophagus in terms of food regurgitation. Is Trixie regurgitating water? Also, would you characterize her food intake as being back to that of a normal dog now, or is it still somewhat increased (or even less than normal)?

Marianne

[busyman370]

Yes, in combination with Trixie's other symptoms, I would think that confirmed calcinosis cutis would essentially be a definitive diagnosis for Cushing's.

Fred, you spoke earlier about Trixie's appetite having slowed down within the last month, and also signs of megaesophagus when she's drinking. I'm familiar with megaesophagus in terms of food regurgitation. Is Trixie regurgitating water? Also, would you characterize her food intake as being back to that of a normal dog now, or is it still somewhat increased (or even less than normal)?

Marianne


Maybe I mis-spoke.

Her appetite has not slowed down, the pace at which she eats has slowed just a touch, it's almost not worth mentioning, but when trying to diagnose a dog's health, anything could be a factor.

No, she's not regurgitating anything. But in some early stages of mega, they have to allow gravity to get down before they put more in. HOWEVER, this is just a minimal observation at this time, but enough to have caught my attention and keep my eye on as we go forward.

Her appetite I would consider normal, but again with another HOWEVER; there may be a slight increase in her interest in eating, something like the very first signs of aggressive eating, which makes me think that the Cushing's may be on the increase, and her thyroid med isn't keeping the hyper aspects as much under control as it has been. Again, not critical right now, but makes me curious enough to keep watching it.

But both my girls get excited when it's meal time, and because Trixie is not operating with a "normal brain" because of her condition, I have to factor that into everything I see with her.

My bottom line - at this point in time is, I consider these observations something to be aware of and to keep track of as we go forward.

The only real change that bothers me is something she started doing over the last couple of weeks, which is crying and yelping just about fifteen minutes after we've all gone to bed, and about one hour before we usually get up.

On the after bed; I get up and let her out. About 50% of the time she will pee or poop, or will just walk around and then rush to be let back in. But a little while after that, she goes to bed and sleeps through the night, at least most of it. (see below )

On the AM; she just seems to want to get me in there and get the morning started. I call it anxiety, and is one of the sign's that I've seen with brain tumor. And, as I have stated before on this forum, I am very concerned about that.

My gut is in overdrive over this because of what I've seen before.

I know there are diagnostic tools we could use to try to confirm the brain tumor, but how much do I want to put the poor girl through? Most brain tumors end up not being operable anyway. You just give prednisone, but more steroid would not be a good thing with Cushing's.

If push came to shove, I'd choose to treat her for Cushing's and see how things shake out down the road, which is what I am planning to do, unless something vivid and profound comes up that would make me change my mind.

thanks Marianne,
Fred.

[Squirt's Mom]

Hi Fred,

I want to comment on the cush appetite. My Squirt is a Miss Piggy and always has been. If it didn't eat her first, she was game - she even ate ammonia nitrate once that I was putting out to kill weeds. :eek: She has always been very food driven so I didn't think that would be a good sign in her case. Boy! was I wrong!

The cush appetite is heart-rending to see. They literally feel as if they are starving and that is immediately after emptying their bowl. Squirt was on a food search every second of every hour that she was awake and would wake me at nite asking for food. The look in her eye was haunting; she was begging me to feed her or she knew she was going to die. :( They will get into trash where they never did before; they will counter-surf, again a new activity; they will fight to the bloody end with their bonded friends over a bread crumb - a Cushing's dog really, truly feels they are starving to death 24/7. It isn't an increase in interest - it is an obvious change in attitude toward food of any kind...even things that are non-food items are subject to being gulped down in a desperate effort to feel satisfied.

Since an abdominal ultrasound hasn't been done and the LDDS was done with the desmopressin in her system, I think I would hold off treatment just now. The LDDS is invalid so no diagnosis can be made based on that test...in fact, I would expect a free LDDS since your vet should have been aware of this fact. ;)

It would be incredibly helpful if you could get copies of the testing done to date on Trixie and post them here. Just the abnormals from the chem, CBC but all info listed from the others, including the units of measurement (ug/dl, mnol/l, etc) and normal ranges for each value.

I would also like to suggest that you take Trixie to an IMS. It has been our unfortunate experience here all too often that a long-time, beloved vet proves to be woefully inadequate when faced with Cushing's. And that is NOT a judgement about your vet or anyone else's. But here are some simple facts - Cushing's is one of, if not the THE, most difficult disease to diagnose (as you may be starting to grasp ;)) and, again unfortunately, most vets are taught in their training very little about Cushing's because the majority of folks won't/can't treat so why waste time/energy, plus vets are taught it is a two-year life span with or without treatment - which is absolute phooey, by the way. An IMS (Internal Medicine Specialist) has more in-depth training and can more times than not see things and connect things a GP vet cannot. So with cases that are not clear cut Cushing's, getting an IMS on board is always a wise move. ;) Your GP vet can often work with the IMS, continuing to provide the care they always have but guided by the IMS. Some of us have chosen to have an IMS take over completely...but it would be a good thing to consider even if it just for an evaluation. ;)

Hugs,
Leslie and the gang

[labblab]

Fred, thanks very much for clarifying re: Trixie's thirst and appetite. In addition, you wrote this:


I know there are diagnostic tools we could use to try to confirm the brain tumor, but how much do I want to put the poor girl through? Most brain tumors end up not being operable anyway. You just give prednisone, but more steroid would not be a good thing with Cushing's.

If push came to shove, I'd choose to treat her for Cushing's and see how things shake out down the road, which is what I am planning to do, unless something vivid and profound comes up that would make me change my mind.

As far as Cushing's treatment and brain tumors, I think the issue that Glynda has brought up relates to expansion of the pituitary tumor that is causing the Cushing's, as opposed to brain tumors in general. Most pituitary tumors that cause Cushing's are very tiny and are not cancerous. Typically, they grow very slowly. But if they get big enough, they can place pressure on other areas of the brain, resulting in neurological problems. And there is research to suggest that Cushing's treatment (or at least, trilostane) has the potential to speed up the growth of these tumors. For most Cushpups being treated, the tumors still never enlarge enough to become a problem. But certain breeds, like Boxers, may be at a greater risk for neurological issues to arise from these tumors to begin with, before even introducing Cushing's treatment. And I think Glynda just wanted you to be aware of that.

There are treatments possible for large pituitary tumors ("macroadenomas"), including conventional radiation and also some cutting-edge surgery being performed at a couple of places here in the U.S. But the treatment is both expensive and very involved. We have had members here, though, who have enjoyed success with both radiation and surgery. I am very familiar with this issue, because my husband and I believe that our own Cushpup developed one of these enlarging pituitary tumors, and his problems became severe enough that we lost him -- we did not opt for invasive treatment.

The point of all this is to tell you that, knowing what I know now, I still would have treated my boy for his Cushing's, regardless. Once again, I don't say this in order to tell you what is best for Trixie. But from what you wrote above, I think you and I may be on the "same page" about this. I'll share a quote that I wrote a while back to another member. And once again, it comes back to those quality of life issues.

And so when weighing quality of life issues, it is important to consider the damage/discomfort that is known to be associated with untreated Cushing's in symptomatic dogs. My own dog was miserable prior to starting trilostane treatment. He then had several months in which he rebounded prior to exhibiting serious neurological abnormalities. So even had I known that the trilostane might hasten the growth of his enlarging tumor, I still would have chosen to treat for those months in order to relieve him of his awful Cushing's symptoms.

Marianne

[busyman370]

Hi Fred,

Since an abdominal ultrasound hasn't been done and the LDDS was done with the desmopressin in her system, I think I would hold off treatment just now. The LDDS is invalid so no diagnosis can be made based on that test...in fact, I would expect a free LDDS since your vet should have been aware of this fact. ;)

I understand what you are saying, and believe me it is unsettling. I don't have allot of choices. Logistics prevents me from selecting a reasonable and workable alternative for treatment.

The subject of suggesting that the Vet do another LDDS test at no charge is a touchy one. Yes, technically he should have been aware, but in his defense, he's admitted that he hasn't treated allot of Cushing's cases. And based upon what you've said regarding the old school Vet's approach to Cushing's, I am sure that 99% of the best Vet's in the area would have done the same thing and for the same reason.

They don't believe in the treatment, so just treat around it, believing that's the best thing they can do for the dog and the owner.

As a matter of fact, I do sincerely believe that if my Vet really knew that Cushing's was treatable by today's standards, and he also knew that he was not really qualified, he would try to refer me elsewhere, or make some other kind of arrangement for treatment.

As of now, he has fully embraced treating Trixie for Cushing's and is in the process of consulting with the new schoolers to get himself prepared for the task.

And I know, even with that, my girl would be best served by a specialist, but there isn't any around here. If there was, I'd have been in contact with them long before now.

So to ask him to cover another test at no charge might just put some kind of accusative based negatives into our future progression. It may just be smart to let this one go and allow him to proceed with the confidence building he is trying to arm himself with along with the feeling of dedication he now has. But your point is well taken.

It would be incredibly helpful if you could get copies of the testing done to date on Trixie and post them here. Just the abnormals from the chem, CBC but all info listed from the others, including the units of measurement (ug/dl, mnol/l, etc) and normal ranges for each value.

I do have her thyroid panels, but they're not very telling. She presented just a tough below low normal, and the soloxine has her in a nice range.

The CBC was from spring of 2011, so I would think we'd need to do a new one. With her on soloxine and desmopressin, I don't know what we'd have to do to get a reliable blood panel on her though. If we can do what's needed and get that good panel, I would immediately post the results to the forum.

I would also like to suggest that you take Trixie to an IMS. It has been our unfortunate experience here all too often that a long-time, beloved vet proves to be woefully inadequate when faced with Cushing's. And that is NOT a judgement about your vet or anyone else's. But here are some simple facts - Cushing's is one of, if not the THE, most difficult disease to diagnose (as you may be starting to grasp ;)) and, again unfortunately, most vets are taught in their training very little about Cushing's because the majority of folks won't/can't treat so why waste time/energy, plus vets are taught it is a two-year life span with or without treatment - which is absolute phooey, by the way. An IMS (Internal Medicine Specialist) has more in-depth training and can more times than not see things and connect things a GP vet cannot. So with cases that are not clear cut Cushing's, getting an IMS on board is always a wise move. ;) Your GP vet can often work with the IMS, continuing to provide the care they always have but guided by the IMS. Some of us have chosen to have an IMS take over completely...but it would be a good thing to consider even if it just for an evaluation. ;)

As stated above, I would love to do that but I have to be real regarding my abilities to carry it through. I am under the impression that my Vet is delving into the world of treating Cushing's, and until I am proven wrong, I also believe that he has reliable sources from which to educate himself. He is a smart man, and if he really wants to apply himself to this, I do have faith in him. ALTHOUGH, if things were different with my situation, you bet I'd have Trixie under the care of a specialist.

But let me say one more thing. IF she has calcinosis cutis, then it's pretty much a slam dunk that she has cushing's. Ultrasound would be a good thing to do, if only to see what else may be going on regarding tumors.

Hugs,
Leslie and the gang

Thanks Leslie, very good comments and suggestions.
Fred.

[busyman370]

Bye the way, while we're on the subject of brain tumors and neurological issues.

Getting back to the Cushing's; are there any symptoms caused by Cushing's itself that would cause things like the crying after bed, or a minimized state of awareness, or an affected gait?

I know that the muscle weakness caused by Cushing's could be applied to how the dog moves, I know that a brain tumor, which can have a number of locations, can and does do this, and of course all that cortisol!

But I keep forgetting to ask you all about what role, if any, Cushing's can play in causing type of neurological symptoms my girl is having.

I'd really like to hear your feedback on this one.

Thanks, Fred.

[busyman370]

I just thought of something else. If Desmopressin raises cortisol, then that's got to be making her Cushing's worse. Now I wonder if the calcinosis cutis was made worse by the added increase of cortisol.

She did have a skin infection, which we blamed on the hypothyroid, and the antibiotic cleared it up, but it took forever.

I do remember that she did have three areas of calcinosis cutis. On both ears in the temporal region, and under her groin area. They were very small. I noticed how they differentiated from the other infection in appearance.

Not trying to throw my Vet under the bus, but I asked him what those were and he didn't know. He said it could be a form of cancer.

I know, he could have taken biopsies, but I can also see where he was coming from at that time. Let's keep "this old girl" as comfortable as we can for as long as we can, and let's try to make Fred's life likewise.

And I must say that these kind of comments can make him look like an idiot, and that's that last thing I am trying to do. An idiot he is far from being.

The desmopressin and soloxine were administered under the full knowledge that she could very well have cushing's, he told me that, and also told me how treating it could cause her much discomfort and could kill her before what was going on inside her would.

At that time my Vet didn't feel good about engaging her in the treatment, but that's old history.

However, he may not have known about the desmopressin raising the cortisol, or he did know but wasn't concerned because of the reason for the treatment, which was to treat around the probable cushing's.

And I must add that I concurred with that line of thinking. He did tell me about the cushing's treatment, I could have pushed for more aggressive treatment, but I agreed with his view at that time.

He suggested the treating around it, explained why, and I agreed to it.

So this is mostly on me. Yes, I can see where he should have been more up to speed, but I also understand that, in his own words, most people don't opt to treat cushing's, plus when he sees when an older dog has crossed over into the critical illness/end of life stage, he plays the odds and is more interested in the comfort of the dog, and of the owner, rather than being aggressive, especially when he doesn't have enough faith in the dogs ability to handle the treatment, putting an old and sick dog through it, and also in the odds of success of that treatment, to try to push the owner into it.

However, having said that; I have been impacted by how he has fully embraced treating Trixie for cushing's. I do believe that if we continue down the path of treatment, that he will do his absolute best for her. I think that once he saw that I was serious about treatment, the scientist in him came out, and together with that and his ego, he actually wants to skillfully attack and successfully treat her cushing's.

Fred.

[busyman370]

I made a rather big mistake!
Looking through Trixie's records, I realized that I made a big mistake!

Trixie did NOT have her LDDS test while on desmopressin.

It was the day the results came back from the LDDS test that it was agreed upon to begin treatment with desmopressin.

She was on Soloxine though.

It seems like an eternity since this all began, and it's getting harder to remember everything.

My sincere apologies to all.

Fred

[busyman370]

Well, it's getting close! My vet wants me to have an ultrasound done on Trixie's Adrenals tomorrow. He is planing on treating her Cushing's with Trilostane.

I have been of the belief that Trilostane was used to treat Pituitary Cushing's and Lysodren was used for Adrenal.

Since we're getting close to treating her, I'd appreciate your helping me understand the treatment of Pituitary and Adrenal Cushing's, and how the selection of one particular drug over another is arrived at.

Is there a specific reason to choose one drug over the other?

I do remember what you told me about Cushing's treatment, especially Trilostane, has been known to hasten the growth of Pituitary tumors in Boxer's. I'd appreciate talking to me about this again.

Also, she is on Soloxine and Desmopressin. Would you advise taking her off one or both drugs at the start of treatment, or wean her off them gradually.

Thanks,
Fred.

[busyman370]

I have a question regarding continuing to give Trixie desmopressin as we start treatment with Trilostane to help control the frequent urination, then wean her off as the treatment shows that it's beginning to work.

My Vet is planning on the go low and go slow mode of administering the Trilostane, which I like, and see that UC Davis also agrees with it also.

Also, I don't see much sense in doing the usual tests because the calcinosis cutis confirms Cushing's, but maybe some tests would be recommended by you all.

PS. I was wondering if you saw that I looked back and the LDDS test was done BEFORE the desmopressin, so it can be considered valid.

I am looking forward to your input,

Thanks,
Fred.

[Sabre's Mum]

Hi Fred

I just have a moment to post ..... Lysodren and Trilostane may be used for both forms of cushings. Some view that Trilostane may be more suitable for Pituary Cushings but there are some vets that will use it for Adrenal cushings. Personally I would prefer Lysodren for Adrenal and either Trilostane for either Adrenal or Pituary.

Angela

[labblab]

Fred, in order to muddy the water again :o, here's a couple more thoughts to throw out for your consideration with your vet. I read above that your vet plans to start Trixie on trilosotane, and we do have at least a couple other dogs here with calcinosis cutis who are being treated with trilostane. I think they are pretty early on in treatment, so it's hard to know yet how well the skin lesions will resolve. I do want to share a quote that Glynda has posted elsewhere, however:


...Calcinosis Cutis can be very difficult to resolve and you have already heard from our resident expert, Angela. As she mentioned, her Sabre treated with lysodren, which may be a better choice of treatment for dogs with calcinosis cutis. Dr. David Bruyette, one of our country's reknown veterinary endocrine specialist, stated in one of his lectures that his facility (VCA West Los Angeles) has not had good luck with resolving the calcinosis cutis in dogs being treated with Vetoryl (Trilostane). VCA West Los Angeles treats hundreds of dogs with cushing's so they have lots of experience under their belt. If your friend's vet is out of suggestions, you may want to ask her to ask the vet to contact Dr. Bruyette to discuss Vicki's case.

http://www.vcahospitals.com/west-los-angeles
For what it's worth, your vet may want to contact Dr. Bruyette in order to see whether he's revised his assessemnt or has any additional treatment suggestions to offer out. Also, as far as possible effects of Lysodren on pituitary tumor growth, here's a quote from an article on our Resources thread:


Because most chemotherapeutic agents have no effect
on the pituitary itself, they do not inhibit ACTH secretion,
which may actually increase with therapy.This phenomenon,
known as Nelson’s syndrome, has been well
documented in humans with pituitary tumors treated
with bilateral adrenalectomy. Nelson’s syndrome refers
to rapid enlargement of a pituitary mass that occurs after
loss of negative feedback from adrenal cortisol production,
which has an inhibitory effect on ACTH release.
While this phenomenon has been suggested to occur in
dogs, studies have shown no correlation between
treatment with mitotane and pituitary size or rate of
pituitary tumor growth. However, because the exact
mechanism behind the development of Nelson’s syndrome
is not completely understood, the potential for tumor expansion
as a result of adrenal corticolysis or decreased cortisol production seems plausible.

http://www.k9cushings.com/forum/showthread.php?t=229

The above 2008 article says that no correlation had yet been established at that time with treatment by mitotane (Lysodren), even though it seems reasonable that the potential for that treatment effect does exist. When my specialist told us about this possible effect back in 2004, trilostane really wasn't being used widely in the U.S., even though that is what we were using to treat our dog. So based on my specialist's comments, I assume that it was mitotane that had already been theoretically linked to this effect. But whether the link remains to be proven, I do not know.

As it turns out, Dr. Bruyette is also an expert re: pituitary macrotumors and was a driving force behind pioneering surgery that is being performed on dogs at UCLA's Medical Center (one of our members' dog was the first patient for this surgery!). If anybody knows whether trilostane or Lysodren has a greater potential to hasten tumor enlargement, I'm betting it would be Dr. Bruyette. So that might be another reason for your vet to try to contact him.

Marianne

[lulusmom]

Hi Fred

Please see my comments below in blue.


Well, it's getting close! My vet wants me to have an ultrasound done on Trixie's Adrenals tomorrow. He is planing on treating her Cushing's with Trilostane.

I think that’s a great idea and we’ll look forward to hearing the results.

Since we're getting close to treating her, I'd appreciate your helping me understand the treatment of Pituitary and Adrenal Cushing's, and how the selection of one particular drug over another is arrived at.

Is there a specific reason to choose one drug over the other?

Both Trilostane and Lysodren are effective in treating pituitary and adrenal depending cushing’s. For me, I’d choose the one that my vet is most familiar with. If the vet isn’t familiar with either, then whatever drug I did choose, I wouldn’t place blind faith in my vet to do the necessary research. I would make sure I understand how the drug works, how it is administered, what side effects to watch for and how to properly monitor the dog’s treatment. My dogs have treated with both and responded well to both.

I do remember what you told me about Cushing's treatment, especially Trilostane, has been known to hasten the growth of Pituitary tumors in Boxer's. I'd appreciate talking to me about this again.

The same thing is suspected with Lysodren. Please see page 35 of the attached article for a bit of information on why this happens.

649

Also, she is on Soloxine and Desmopressin. Would you advise taking her off one or both drugs at the start of treatment, or wean her off them gradually.

I was glad to read that the LDDS test was done before starting the Desmopressin. That makes me a lot more comfortable with the diagnosis. It is quite possible that once you get Trixie stabilized on treatment, neither Soloxine or Desmopressin may be needed. Your vet should recheck the thyroid 30 days after starting treatment, if you've got Trixie stabilized. If cushing's is cause of the excessive drinking and peeing, it should resolve with treatment. That would be a good thing considering the cost of Desmopressin. It is very important that you get accurate acth stimulation test results and since Desmopressin can skew the results, I would seriously consider discontinuing it. Talk to your vet about it.

Glynda

P.S. I see that Marianne was posting while I was typing. As usual, she is spot on. As for Lysodren (Mitotane) allowing unabated enlargement of a macroadenoma, I first became aware of this through an audio lecture given by one of the canine cushing's Gods, Dr. Edward Feldman. Dr. Feldman agrees that both drugs are very effective but his choice is Lysodren because that's what he's prescribed for 35+ years and he knows it like the back of his hand. I wasn't aware that Trilostane could possibly have the same effect until Marianne educated me.

[busyman370]

First let me thank you all so very much for your help. Believe me, I appreciate it.

I'll start by saying that the ultrasound showed all organs in good shape and size, and no Adrenal tumors. The abdominal area looks very good.

So, the Adrenals are not causing her Cushing's.

I decided that we are not starting any treatment on Trixie until my Vet gets back from his conference on March 18th. He is planning to speak with Dr. Bruyette regarding Trixie's treatment while he is there. He is also going to take some of the information that I have found through my own research, and run over some of it with Dr. Bruyette. I also sent him highlights from what you all brought to my attention on this Forum. So He'll have plenty of questions!

The calcinosis cutis information is very interesting, but of course very disheartening as well. I had thought that which ever cushing's treatment was used, it would automatically take care of the calcinosis cutis along the way. Maybe not immediately, but at some point along the way. That bothers me.

Regarding that hastened pituitary growth; I do have mixed feelings over that. My concern goes something like this;

• At the start of treatment, Trixie is alive, but is living with what cushing's has
done, and is continuing to do, to her.

• Then we start treatment, and for the sake of time here, let's say things go
very well, and Trixie doesn't have any really bad affects from it.

• She starts to feel better, but the pituitary tumor is growing.

• Trixie reaches a point where she is no longer suffering from the affects of
cushing's, or the medication, and has reached the point where she feels really
good, but almost simultaneously begins to suffer from the affects of the "brain
tumor."

You all don't know me, but may I say this much;
I always look at the glass as being half full, not half empty, but I've learned in life that if you don't look at the glass practically and realistically, you'll be wrong on both counts.

Needless to say, I'll mention this, in particular, to my Vet before he leaves for the conference, believe me!

"Both Trilostane and Lysodren are effective in treating pituitary and adrenal depending cushing’s. For me, I’d choose the one that my vet is most familiar with."

That's a tough one. He is familiar with treating cushing's, but then again, probably mostly he's not. That's the old school thing again. Other Vet's in his practice have treated cushing's, but they're in the same boat he is. He does have a newly graduated Cornell Vet in his practice who seems to have some updated thoughts on treating cushing's, so that's a good thing.

But, because of this whole thing with Trixie, he's been really trying to get up to speed. He is looking to gain allot of knowledge at the conference in March. He wants to learn, and that's another good thing.

"If the vet isn’t familiar with either, then whatever drug I did choose, I wouldn’t place blind faith in my vet to do the necessary research. I would make sure I understand how the drug works, how it is administered, what side effects to watch for and how to properly monitor the dog’s treatment."

I know exactly what you mean, and believe me, I am trying my best, but all while trying to beat the clock, and working to keep everything in the proper perspective, and working with my Vet, to do our best in our decisions regarding Trixie.

He has been really good about giving allot of his time to talking with me about how we're going to treat Trixie, and at no charge for his time I might add. He really wants to help Trixie, and me too. And I have to remember that although we're friends outside of the practice, I am not his only patient! He may not be an expert on treating cushing's, but he still knows way more than I do, especially in the Veterinary Science/chemistry end, and I have to continue to respect that.

I am researching all the time, trying to not only to understand it all for myself, but to also bring some good stuff to my Vet too.

Not that he isn't looking on his own, but he doesn't go to Forums like this, he relies on his professional sources, and as great as they are, he's also benefited from all you folks with hands on experience too. So my Vet and I are becoming to be a team. He welcomes every bit I throw his way, and I do appreciate the value in that. Some Vet's act like they're little Gods, and I've been around enough to appreciate that.

I am dedicated to doing the best I can for Trixie, but I am nowhere close to being as reliable at ridding shotgun for Trixie as you all are. I am learning too, but she is dieing along the way. Time is not on her side. That's why I need to work as well as I can with the Vet I have, and he's trying his best. I see how hard he's trying. we're working to give Trixie the best care we can give her.

"It is quite possible that once you get Trixie stabilized on treatment, neither Soloxine or Desmopressin may be needed."

I am really glad to hear that. I was afraid that because desmopressin elevates cortisol that it would not be advisable. The desmopressin controlling the drinking and urination, and the soloxine maintaining her thyroid until the cushing's drug takes over, would be very welcome.

In response to her kidney involvement in her cushing's;
We "believe" that there's nothing wrong with her kidneys, past tests have shown them to be OK. So my belief is that it's the cushing's that's causing the dilute urine and aggressive drinking.

"That would be a good thing considering the cost of Desmopressin."

If I had all the money I've spent throughout my life on my dogs, Trump Tower would be called Fred Tower! LOL

A question repeat;
Is it reasonable to believe that Cushing's itself would cause things like the crying after bed that she's recently started doing?

And does the muscle weakness resolve somewhere along the line of treatment? She's starting to have a hard time pooping because her rear legs are beginning to fade when she tries to "squat."

She is really on the edge here, and I know it.


Well, another short post! LOL

Thanks again all,
Fred.

[busyman370]

I forgot to ask you all about Retinoic Acid. I know it's expensive, but beyond that, I've read very good thing's about it, and am curious what your take on it is for treating cushing's?

Thanks,
Fred.

[Squirt's Mom]

Hi Fred,

Just some thoughts on the nite time crying - Cushing's causes fat in the body to be stored and distributed in the belly causing the liver to push forward in the body, pressing on the lungs leading to panting. The enlargement of the belly not only presses on the liver but other organs as well so it could be that when she lays down, she is uncomfortable in a way that is disturbing to her so she cries out.

Elevated cortisol can cause restlessness so the pup's day/nite cycle is out of whack, the circadian rhythm in other words.

Dogs with dementia may cry out during the nite hours due to confusion or agitation just as human Alzheimer patients are more agitated at nite. But with this condition you would be seeing other signs as well.

http://holisticvetpetcare.com/cognitive-dysfunction-syndrome.htm

http://www.swiftwaterfarms.com/swiftwater/p22CanineCognitiveDysfunction.htm

Neither of these articles specifically mentions the crying out that I noticed in a quick scan but recently I read an article in the vets office about doggy dementia and it was mentioned in that article. The pups they were talking about cried out during the day from confusion/fear but seemed to be more agitated at nite.

These are just THOUGHTS, not things I consider a possibility for Trixie. What have the vets said about it?

Hugs,
Leslie and the gang

[labblab]

I forgot to ask you all about Retinoic Acid. I know it's expensive, but beyond that, I've read very good thing's about it, and am curious what your take on it is for treating cushing's?

Thanks,
Fred.

Fred, aside from that research that's already posted on a thread here, I'm afraid I don't have any additional info. Those earlier results are intriguing, but I don't know any clinician who is using it in "real life."


And does the muscle weakness resolve somewhere along the line of treatment? She's starting to have a hard time pooping because her rear legs are beginning to fade when she tries to "squat."

Yes, once cortisol levels are reduced through effective treatment, the issues with muscle weakness do start to resolve. However, in the same way that it took time for the problem to develop, it also takes time to see improvement. Problems with hair/coat/skin and muscle weakness generally take a longer time to resolve. It's the excessive appetite/thirst/urination that have the potential to reverse very quickly.

Marianne

[busyman370]

Thanks Marianne,

Thanks for the input regarding the crying. I also had a thought about her soloxine dose being involved in this.

I did allot of research on soloxine and learned if the dog is hypering out, you can take them off it for a few days, the resume at at lower dose.

At the 0.35 mg per day, she tested within normal, but at the low ends, so I tried bumping her up to 0.525 because I understand cushing's can alter the dose of soloxine, as she seemed like she could use a little more.

That's right around the time the crying began. I took her to 0.175 for a couple of days, then put her on 0.4 per day, as that seemed to be a perfect dose regarding her test results. The crying has stopped. However, I also let her sleep on her loveseat instead of her usual bed, and that may be it. Will have to wait and see.

I know Dr. Dodds does not believe a senior dog should be dosed as high as a younger dog and I agree with her reason.

Regarding the visceral fat; she's not fat. In fact her weight seem perfect. She's about 5 lbs less that in her prime, so that's one thing I am not worried about, but along your thought, I do suspect that she may feel some difficulty trying to move/adjust herself because of her rear leg weakness, and front too for that matter, but that remains to be seen.

My Vet didn't say much about the crying, he probably figures we have much larger things to worry about, and since I didn't make a big deal out of it, wanting to see if the soloxine and or her new sleeping arrangement might make a it moot issue anyway, neither did I. Wanted to see of any of the changes made a difference first.

Bye the way, I don't just jump in and mess around with her medication without running it by my Vet. I feel that's important for you to know.

".....0nce cortisol levels are reduced through effective treatment, the issues with muscle weakness do start to resolve. However, in the same way that it took time for the problem to develop, it also takes time to see improvement. Problems with hair/coat/skin and muscle weakness generally take a longer time to resolve. It's the excessive appetite/thirst/urination that have the potential to reverse very quickly."

That's good to hear. I can live with that.

Now, regarding the Retinoic Acid. My Vet and I are going to pursue this. We are both very interested in considering it for Trixie's treatment. We're hoping that after he returns from his conference he will have some usable info. I understand it's expensive, but I am not concerned about that at this point. I am more concerned about if it's obtainable in medication form, and getting accurate info as to how to dose it.

Other than that, my concerns right now are the calcinosis cutis, and the hastening of the pituitary tumor growth, but we've covered them pretty well, at least for now. But when the treatment plan has been established, I am sure they will be revisited before conclusion.

Had to rush this one, off to the dentist.

Thanks again, very much.
Fred.

[Lady's mom]

Fred, how is trixie? I see that you haven't posted in several days, and so I was a little worried about her.

[busyman370]

Fred, how is trixie? I see that you haven't posted in several days, and so I was a little worried about her.

Thank you so much, Lady's mom, for asking. It can get quite lonely sitting here with a Cushing's dog, especially with all the unknowns.

I have put things on hold until my Vet returns from his conference in Colorado. He will return on March 19th, and we will resume from there.

She does have calcinosis cutis, which I am most unhappy with, but I was at least able to try to do something to try to slow it down.

The story goes like this; in the beginning, my Vet was not confident in the cushing's treatment, and since her tests showed that she was just barely in the stage of cushing's, he advised just treating around it with soloxine and desmopressin. It did help her almost immediately, even though I knew that the cushing's would eventually take hold.

He put her on a starting dose of 0.01 mg of desmopressin given three times daily, which controlled her thirst and urination problems very well. However, after testing her specific gravity, he felt it should be higher, so increased the dose to one and one half tablets, three times per day. I thought all was well.

BUT! I did notice that her calcinosis cutis began to worsen, just around the time the dose was upped, and started searching for answers, and after allot of searching, I actually found one. Desmopressin can significantly raise the cortisol! I didn't know that, and neither did my Vet. Once again, making him look bad, but, once again, I am defending him as he never had a reason to look into that aspect of Des because for diabetes insipidus, the cortisol is a moot issue. So the issue never crossed his mind. When I told him what I had found, he was bothered by it, but I didn't try to make him feel any worse and just moved forward by asking him if her specific gravity needed to be at a certain level regarding removing toxins and etc, and he said no because her kidney's were functioning well, they just weren't getting the signal to concentrate because of the cushing's, he just wanted to bump up the concentration a little. He thought he was doing the right thing, not knowing about the Des and cortisol.

A specialist or endocrinologist may have known, but that's not his speciality, so I cut him some slack.

I immediately experimented with the dose by reducing to one pill am, 1/2 pill mid day and one tab at bed. Not enough, so I put her back on the one pill three times daily, and all is well regarding controlling the thirst and urination.

Now, I am just unhappy that the C-cutis has increased. Was it because of the Des? I'll never know, but the last thing she needs is anything that produces more cortisol.

For a dog that lives outside and has constant availability of water, they'll be OK, but an inside dog, that can pee on herself is not a good thing. Her skin is already sensitive to infection, so I feel it's best to make sure that doesn't happen.

I've reduced her Des by one and one half tablets per day, so that's significant with the cortisol thing.

I am going to meet with my Vet before he leaves to discuss some of my notes and questions with him, and he will get the answers at he conference. I am also going to ask him to hook up with someone to serve as a contact that my come in handy during treatment.

Trixie is doing well considering all that's going on with her. Well enough to wait the 12 more days before starting treatment. I feel that when my Vet returns, he is going to be much more capable of treating Trixie than he would have been, so better to measure twice and cut once.

She's started marching rather than walking, and she is taking much longer to finish her meals. That's got to be a combination of the c-cutis and the muscles weakening.

I also give her a natural fiber to help her poop because her rear legs are just starting to show that someday they won't be able to hold her up to poop.

The c-cutis is along her hock and under the rear end of her abdomen, bye the way, just so you know. I do spray the areas with an antiseptic twice daily to help them from becoming infected.

So that's it for now. And once again, thank you so much for thinking of us.

Fred.

[busyman370]

Bye the way, would you give me some kind of guide as to what to expect regarding the progress of her treatment? At this time we are thinking Trilostane, but as I said, I am very interested in my Vet learning all about Retinoic Acid, so as far fetched as the RA sounds, I am not ruling it out yet.

When treatment is started, and if it is successful, what can I expect to see regarding changed happening to Trixie, and the time frames.

I know this must differ with each dog, but a little heads up would give me something to hang onto.

Thanks again,
Fred

[labblab]

Bye the way, would you give me some kind of guide as to what to expect regarding the progress of her treatment? At this time we are thinking Trilostane, but as I said, I am very interested in my Vet learning all about Retinoic Acid, so as far fetched as the RA sounds, I am not ruling it out yet.

When treatment is started, and if it is successful, what can I expect to see regarding changed happening to Trixie, and the time frames.

I know this must differ with each dog, but a little heads up would give me something to hang onto.

Thanks again,
Fred

Hi again, Fred.

Take a look at this "Technical Brochure" published by Dechra, the manufacturer of brandname Vetoryl. It contains helpful information about expectations re: the timeframe associated with resolution of different Cushing's symptoms:

http://www.dechra-us.com/files//dechraUSA/downloads/Client%20Literature/38965_Technical_Brochure.pdf

Marianne

[busyman370]

Thanks Marianne!

[jackiev]

Hi Fred. I'm sorry you're going through this with your Trixi girl. My frenchie was only diagnosed a little over a month ago so I'm certainly not an expert here but Ugga and Trixie have something in common. Unfortunately he has calcinosis cutis also. That and increased thirst were his only symptoms. We are treating with Trilostane and having pretty good results. Within a week he was sleeping through the night again (before that we were getting up twice a night to let him out). His skin, however, is a different story. It's definitely improving now but when we first started the meds (first week) his skin became extremely itchy and painful. We started him on Gabapentin (for pain) and it works GREAT. My vet also gave us a topical spray that's almost like a lotion (Humilac). It works really well and keeps his skin from cracking open and bleeding. We also give him 10mg Claritin and a fish oil pill every morning, they seem to help with the itching. I have to say though, after a month of treatment, he still looks bad. Improved, but bad. It's ok because he's comfortable but I get some funny looks when I have him out. I've tried putting shirts on him but they irritate him too much. Oh well, let people stare...Ugga couldn't care less, he's happy as could be. Good luck with your girl. You and Trixi are in our thoughts. *Hugs*

~Jackie and Ugga

[busyman370]

Hi Fred. I'm sorry you're going through this with your Trixi girl. My frenchie was only diagnosed a little over a month ago so I'm certainly not an expert here but Ugga and Trixie have something in common. Unfortunately he has calcinosis cutis also. That and increased thirst were his only symptoms. We are treating with Trilostane and having pretty good results. Within a week he was sleeping through the night again (before that we were getting up twice a night to let him out). His skin, however, is a different story. It's definitely improving now but when we first started the meds (first week) his skin became extremely itchy and painful. We started him on Gabapentin (for pain) and it works GREAT. My vet also gave us a topical spray that's almost like a lotion (Humilac). It works really well and keeps his skin from cracking open and bleeding. We also give him 10mg Claritin and a fish oil pill every morning, they seem to help with the itching. I have to say though, after a month of treatment, he still looks bad. Improved, but bad. It's ok because he's comfortable but I get some funny looks when I have him out. I've tried putting shirts on him but they irritate him too much. Oh well, let people stare...Ugga couldn't care less, he's happy as could be. Good luck with your girl. You and Trixi are in our thoughts. *Hugs*

~Jackie and Ugga

Thanks Jackie and Ugga.
This helps me to have some kind of idea as to what I can expect when I begin treatment. As of today, we are still planing to use Trilostane too. I hope the treatment is doing it's job and Ugga is doing considerably better by now, and will continue to do so.

Thanks again,
Fred.

[Squirt's Mom]

Hi Fred,

How is Trixie doing?

Hugs,
Leslie and the gang

[busyman370]

Hi Fred,

How is Trixie doing?

Hugs,
Leslie and the gang


She's hanging in there. The C-Cutis does not seem to be spreading. I'm waiting for my Vet to return from his conference in Colorado where he's meeting with some specialists on Cushing's treatment. I am expecting to discuss things with him and select how we're going to treat Trixie sometime next week after he returns. From my observations of her current state, if we start things out correctly, and monitor and adjust correctly, I think she'll do well with treatment. She seems to be in the earlier to mid stage of Cushing's, and even though she's sick, she's still pretty healthy and relatively strong, and based on that, I think she'll so well with treatment.

Thanks for checking in,
Fred

[busyman370]

Hello All,
I decided to update you on Trixie.

Especially over the last couple of days, I've had to force myself into accepting the reality and admit that Trixie is in real and untreatable trouble.

Yes, she has Cushing's, and we can treat that, but I've also had to allow myself to admit that she also has a "brain tumor" that is not just the "one" related to her Cushing's, but also related to other progressive neurological symptoms that she's been displaying as well.

I termed it "brain tumor" because of all of her symptoms, and although the one on her pituitary can grow large enough to cause those symptoms, there can also be more than just that one.

I tried as hard as I could to write her symptoms off to being caused by Cushing's, but I needed to stop fooling myself, especially since I'v seen these symptoms before in dogs.

To give you a general overview; the past few weeks, especially the last couple of nights have been increasingly hard on her. She cries out, yelps, and paces around and around. She staggers, ataxia, walks between a sofa and the wall and just stands there, paws at the air, looks at me with a desperate look on her face, and her comfort level is not where it should be.

I am going to have a talk with my Vet when he returns and decide what I am going to do, but from what I've learned from past experience, it doesn't look good.

My Vet will be back this Sunday, and I am going to talk with him about this as soon as we can get together.

So that's where things are as of today with Trixie. I'll let you know where we're going to go with this after I discuss this with my Vet.

Fred.

[lauraperla]

Fred, I am so sorry. Tough times, I am sad for you. Enjoy the time you have with your beautiful girl, and very best wishes for your consultation on Sunday.

Laura and Saoirse xx

[Lady's mom]

I am so sorry. It does sound like there is more going on than cushing's. I remember when we thought Queenie might have a brain tumor, she started bumping into things on only one side of her body, she could no longer catch peanuts in mid-air, she would sit and bark at us as if trying to say "listen to me. You need to know something's wrong."

Cherish the good times, and stay close to your girl.

[Squirt's Mom]

Hi Fred,

Please know we are here any time to listen, to share our experiences, to hold your hand. We all want the very best for our babies and sometimes that means we have to hurt so they don't.

We are still walking every step with you, Fred. You are not alone now either.

Hugs,
Leslie and the gang

[busyman370]

Thanks to all,
I do appreciate knowing you're there. It does help.

I am not one to jump to conclusions, or quit when the going gets tough, and as I said, I am reserving final judgement until I consult with my Vet, but as you can tell from my last post, things don't look good. It sure looks like the effects of a brain tumor.

HOWEVER, I am going to pursue one more possible cause for how she's acting. I am going to dramatically reduce her desmopressin, and or take her off of it entirely! As long as she has water available 24/7 she will be fine, just drink and pee allot, but no health risks.

Desmopressin produces many of the side effects that Trixie is experiencing, and especially so if the dog is hyper sensitive to it, and I need to know if it's the desmopressin that's causing this or not. She could be super sensitive to it, and I need to find that out asap. Plus, it can mess up the sodium balance and cause serious health issues as well. And also, it does raise the cortisol, which is too high already.

I've been waiting for my Vet to return to start treatment, and figured I'd just leave well enough alone for one week, but maybe it's not "well enough" at all. Maybe it's causing more harm than good.

It was her red, rash like area of her abdomen, that just began a couple of days ago, that led me to pursue the desmopressin link. Skin rash is one of the possible side effects of desmopressin.

She did not show any of the symptoms she is showing now when she was on the initial dose, it was when my Vet increased the dose that she started showing some of the signs she's showing now, but I had such a strong belief that it was a brain tumor that I did not suspect the desmopressin, plus I had no idea that it had so many possible side effects. I thought it was basically benign.

It wasn't until today, when I researched side effects of desmopressin IN DEPTH, that I started thinking that it may be the cause of her problems, and not a brain tumor.

This test may be a mess for me, as I am not home 24/7, but I have a good Hoover rug cleaner, and if she pees in the house, so be it.

I am going to confine her and her sister, Trudie, to their room whenever I am not home, so if she pees, it won't ruin my whole house. The most I'll need to do is to replace the carpet, but if it is the desmopressin that's messing her up, then it's well worth it to find out.

Her symptoms seem to be amplified during the night, but during the day, Trixie is enjoying an acceptable level of a quality of life, no crying or the etc's, and seems strong in many ways, so this desmopressin thing will be a worthwhile test. And I'll know real quick if it is, once the drug is reduced and or removed from her system, it's effects will quickly diminish.

So, let's see what happens. I am going to begin this immediately. She's had her morning "higher" dose, and is now due for her afternoon dose, and again before bed.

Below my signature I've included the list of desmopressin side effects for you to review so you'll see where my concern comes from. Confusion, hallucinations and all the rest of her symptoms are listed there.

Wouldn't THAT be something?! Take a peek below and see for yourself.

Thanks again for your concern,
Fred.

Side effects of Desmopressin:

Severe allergic reactions: rash; hives,itching.
difficulty breathing.
tightness in the chest.
swelling of the mouth, face, lips, or tongue.
confusion.
hallucinations.
feeling faint - fainting.
nausea, vomiting.
loss of appetite.
headache.
mental or mood changes.
Restlessness, agitation, irritability.
muscle pain or weakness.
spasms, or cramps.
personality changes.
seizures.
swelling.
unusual headache.
unusual tiredness or sluggishness.
unusual weight gain.

dangerously high blood pressure: severe headache, blurred vision, buzzing in the ears, anxiety, confusion, chest pain, shortness of breath, uneven heartbeats, seizure.

Less serious side effects may include:

headache;
nausea, mild stomach pain;
diarrhea; or
warmth, redness, or tingly feeling in your face.

[jmac]

Hi Fred-
I'm sorry to hear Trixie is struggling. I hope you will get some helpful information when your vet returns.

We are here to support you with whatever you need...

Julie & Hannah

[busyman370]

Hello All,
Thought I'd report in on Trixie. I dramatically reduced the desmopressin and to make a long story short, her crying/yelping, agitation and otherwise symptoms of a brain tumor all but went away. Other than her Cushing's symptoms, she's like a new dog!

She does pee on her rug sometimes early in the am, but I don't care about that.

Also, here's another mistake I made, thinking I was helping her. I was spraying her C-Cutis with an antiseptic spray that contained lidocaine, thinking that I could help keep her from getting a skin infection, plus relieve any pain or itching from the C-Cutis.

I never knew the side effects THAT can produce too. I thought it was an innocent little spray. Well, I went through all the medications she was taking, and reviewed the total circumstance of her daily life, trying to find anything that may be causing those brain tumor symptoms. I decided to research lidocane. I was shocked with the side effects. I stopped that too. I instead bought some Aloe gel, but when I got home, I saw that it contains lidocane, so that's out.

I went back to neosporin creme.

So, she is doing much better, and I got a call from my Vet today, he's going to attend the endocrine seminar tomorrow, and is going to call my Saturday to discuss what he learned. Monday he'll be back to work, and hopefully soon thereafter we can start treating Trixie.

I've included some side effects of lidocane, should you be interested.

Take care all,

Fred.

Side effects of lidocane:

Adverse experiences following the administration of lidocaine are similar in nature to those observed with other amide local anesthetic agents. Adverse experiences may result from high plasma levels caused by excessive dosage or may result from a hypersensitivity, idiosyncrasy or diminished tolerance on the part of the patient. Serious adverse experiences are generally systemic in nature. The following types are those most commonly reported. The adverse experiences under Central Nervous System and Cardiovascular System are listed, in general, in a progression from mild to severe.

1. Central Nervous System: CNS reactions are excitatory and/or depressant and may be characterized by light-headedness, nervousness, apprehension, euphoria, confusion, dizziness, drowsiness, tinnitus, blurred or double vision, vomiting, sensations of heat, cold or numbness, twitching, tremors, convulsions, unconsciousness, respiratory depression and arrest. The excitatory reactions may be very brief or may not occur at all, in which case, the first manifestation of toxicity may be drowsiness, merging into unconsciousness and respiratory arrest.

2. Cardiovascular System: Cardiovascular reactions are usually depressant in nature and are characterized by bradycardia, hypotension and cardiovascular collapse, which may lead to cardiac arrest.

3. Allergic reactions as a result of sensitivity to lidocaine are extremely rare and, if they occur, should be managed by conventional means.

4. Neurologic: There have been reported cases of permanent injury to extraocular muscles requiring surgical repair following retrobulbar administration.

[lauraperla]

Hi Fred,
I am delighted that Trixie is doing much better. Superb detective work on your part, well done!
Her early morning per issue could well be that once she goes through the night she has a capacity issue. Once you are on your way with Cushings treatment that should resolve.
I use various herbal creams on the various furries and featheries we have here, starflower (also called borage) is a good soother and healer, as is calendula. I use neem alot too but it has an odd smell. The aloe I use is from a health food shop and is a pure gel.

Laura and Saoirse x

[Squirt's Mom]

Hi Fred,

I am so glad to hear that you are seeing such great improvement off the desmopressin and hope that has been the root of all the neurological signs you have been seeing all along. Great job figuring that out! :):cool::) You have taught us something! :)

I would give her some time to get over this period of stress and make sure all the drugs are out of her system, then start the testing for Cushing's and go from there. Any testing that has been done during this period with these drugs on board may well have been skewed so a fresh start is important.

Keep up the good work, Dad!
Hugs,
Leslie and the gang

[busyman370]

Hi Fred,

I am so glad to hear that you are seeing such great improvement off the desmopressin and hope that has been the root of all the neurological signs you have been seeing all along. Great job figuring that out! :):cool::) You have taught us something! :)

I would give her some time to get over this period of stress and make sure all the drugs are out of her system, then start the testing for Cushing's and go from there. Any testing that has been done during this period with these drugs on board may well have been skewed so a fresh start is important.

Keep up the good work, Dad!
Hugs,
Leslie and the gang

Thanks Leslie and gang,
I ended up not taking her off desmopressin completely. I tried an experiment of a very low dose of desmopressin to see if could help her with the excessive drinking and urination, while at the same time, getting rid of those brain tumor symptoms.

The desmopressin is out of the system so quickly, that the results are verifiable in about one day. If the test gave good results, then good, if not, then off the desmopressin completely. It worked almost flawlessly. Within two days she was back to normal, hard as that is to say regarding having cushing's as being normal.

As I said, a little pee here and there, but that's it. And if I catch her within six to seven hours, she'll go outside and pee. Plus, my big Hoover rug shampooer treats the whole thing like it never happened.

So I consider that a win. Her drinking is normal, and so is her urination, and no more brain tumor symptoms.

My main reasoning behind continuing to keep her on desmopressin is that in less than one week we are probably going to be treating her, so if I can keep comfortable and sleeping well until then, I'd rather do that. Like you said, eliminate as much stress as possible.

Other than posting an update on Trixie, I did want to also post that info on adverse reactions of lidocane, like I also did for desmopressin, in the hope that it may be of value to the forum. I appreciate all the help I am getting from this forum, and whenever I can contribute, I am more than happy to.

Trixie was never tested while under the influence of desmopressin. The desmopressin was started after her LDDS test, and I started using the antibacterial spray about a month after that.

However, her calcinosis cutis pretty much confirms cushing's anyway.

Her ultrasound pretty much confirmed it's pituitary. The abdominal all looked good, the adrenals were fine, just large, which is because they're doing so much work because the pituitary tumor. So we will be treating her for pituitary cushing's.

I am expecting to begin treating her sometime next week, and am looking forward to consulting with my Vet upon his return from a conference in Colorado, where Dr. Bruyette is speaking. That's the reason both my Vet and I decided to hold off treating Trixie until after he attends the conference.

Before he left, we had decided on Trilostane, but will finalize that decision based on his discussion with Dr. Bruyette. My Vet is also going to see if he can arrange things with Dr. Bruyette so he can consult with him if need be during treatment, and especially if we run into problems. Hope it works out.

And, yes, Trixie now only exhibits signs of cushing's, and not those brain tumor signs. So I feel much better about treating her again. She is quite strong and healthy otherwise, just is getting thin, weaker and looks cushing-ie.

Thanks again,
Fred.

[busyman370]

I have a question.

I have read that the proper diet for a dog with cushing's is a low fat diet. Would you help me with this?

What is the recommended diet?

And can you recommended a brand or brands of dog food?

I used to feed the raw diet, but because of an emergency circumstance, I needed to switch to kibble for the short term. Through my research, I found and began to feed the wellness lamb and rice. I love it. My dogs look and act better now than they did on the raw. I'd never feed raw again because of it. I especially noticed how clean their teeth are with the wellness.

So I do appreciate your input on this.

Thanks,
Fred.

[Squirt's Mom]

Hi Fred,

Since cush pups are prone to pancreatitis, low fat is important for them. Typically, you want to look for lower fat and moderate protein for a cush pup diet. If they are doing good on the Wellness, I don't know that I would worry about switching just now. Lamb does tend to be a bit higher in fat than other meats so be sure to check the nutrient analysis. Some other good, high quality feeds are Acana and Fromm. There used to be several I was comfortable recommending but most of them were bought out by P&G - which probably means the formulas and ingredients have changed for the worse. :rolleyes:

You can cut fats a whole lot with the treats you use. Give apples, carrots, green beans, banana, oranges - fresh fruit and raw veggies are great as treats!

Hope this helps a little bit.
Hugs,
Leslie and the gang

[busyman370]

I have a couple of things today.

First, I spoke with my Vet, and he told me that Dr. Bruyette said that Lysodren is now considered an orphan drug, and soon, will no longer be available due to a declining use in humans. Even though it has been of great value to the animal community, the drug manufacturers are no longer finding it profitable.

Second is in regard to calcinosis cutis. In a post on this forum, I read the following; "Dr. David Bruyette is a reknown and widely published endocrinologist/specialist whose treatment of choice for his patients is usually Vetoryl (Trilostane); however, he readily admitted on an audio of one of his lectures that his clinic has not had good luck in seeing improvements in calcinosis cutis with Vetoryl. I believe this could be because Vetoryl does not address the other adrenal hormones, which probably contribute to skin issues. Because of Lysodren mode of action, it almost always takes care of all of the adrenal hormones."

My question is; because c-cutis is hard to treat because of the lack of Trilostane addressing the "ADRENAL" hormones, does it matter if the cushing's is caused by an adrenal tumor, or pituitary tumor?

I am wondering if the cause is pituitary, and the adrenals are otherwise fine, treating cushing's to halt the pituitary's stimulating the adrenals might allow the adrenal hormones to normalize, thereby helping to allow the c-cutis to resolve.

What's your take on this?

Bye the way, we're going to begin treating Trixie with Trilostane this coming week, as soon as my Vet gets the drug.

Thanks,
Fred.

[lulusmom]

Hi Fred,

Dr. Bruyette is an inactive member. He stayed on a short time and answered some questions for us. He did mention that Lysodren was an orphan drug which would probably be discontinued but that was well over two years ago. Many of us are still treating our cushpups with Lysodren and a good number of vets continue to prescribe Lysodren. I called the manufacturer and asked them if they had any intention of discontinuing the drug and was told that all they could say is that it remains available.

Dr. Bruyette admittedly prescribes Lysodren for a small amount of patients who can't tolerate or don't respond to Vetoryl. Did your vet ask Dr. Bruyette about his experience with Vetoryl's efficacy in resolving calcinosis cutis and whether he felt Lysodren, despite his prediction, would be a better choice for Trixie?

Vetoryl does not have any effect on the pituitary. It is an enzyme blocker which interferes with the synthesis of cortisol. I'll try to find an easy read of its mode of action and will come back to provide a link.

Glynda

P.S. I found an older version of the Dechra technical brochure that has an explanation of the mode of action and a flow chart that might help you understand how it works. See the second page, which is labeled as page four.

http://www.specific-diets.com/Files/Filer/RelatedDownloads/vetoryl_technicalbrochure.pdf

[busyman370]

Hi Fred,

Dr. Bruyette is an inactive member. He stayed on a short time and answered some questions for us. He did mention that Lysodren was an orphan drug which would probably be discontinued but that was well over two years ago. Many of us are still treating our cushpups with Lysodren and a good number of vets continue to prescribe Lysodren. I called the manufacturer and asked them if they had any intention of discontinuing the drug and was told that all they could say is that it remains available.

Dr. Bruyette admittedly prescribes Lysodren for a small amount of patients who can't tolerate or don't respond to Vetoryl. Did your vet ask Dr. Bruyette about his experience with Vetoryl's efficacy in resolving calcinosis cutis and whether he felt Lysodren, despite his prediction, would be a better choice for Trixie?

Vetoryl does not have any effect on the pituitary. It is an enzyme blocker which interferes with the synthesis of cortisol. I'll try to find an easy read of its mode of action and will come back to provide a link.

Glynda

P.S. I found an older version of the Dechra technical brochure that has an explanation of the mode of action and a flow chart that might help you understand how it works. See the second page, which is labeled as page four.

http://www.specific-diets.com/Files/Filer/RelatedDownloads/vetoryl_technicalbrochure.pdf


First, I do hope that Lysodren stays around as so many dogs are helped by it. I was only reporting what my Vet told me, I will now tell him what you have told me.

Thank you for the literature on Trilostane. I have a similar brochure and have read the mode of action for Trilostane, and of Lysodren. I will keep this literature also.

I have so much information stored on my computer that it's getting hard to readily access something I want to review quickly. I have been going through it, and cherry picking, condensing and storing what I find most important and applicable in one folder.

We know that Lysodren is the choice for having the best chance at beating the C-Cutis, but my Vet feels more comfortable treating with Trilostane because of the lesser chances of bringing about negative side effects.

I have learned that not every dog will respond the same way to treatment. I have also learned that Trixie seems to be very sensitive to drug therapy, and am taking that into consideration with every step I take.

At this point, the plan is to start low and go slow, and watch to see how she is reacting both by my observation, and with what her tests indicate is happening.

Although I have seen that Lysodren is the drug of choice when C-Cutis is involved, I have also read of cases where the Trilostane had a positive effect on the C-Cutis as well.

As much as, in general, the information regarding the different modes of treatment is made up of constants, I have also found a number of inconsistencies as well.

I have also found some information on a drug called Atopica, which is showing good results in treating C-Cutis, but I just found it and need to pursue it further.

The bottom line here is Trixie is really in rough shape. Yes, she is still "strong" enough that I feel that she will tolerate treatment, but she's still in rough shape none the less. I see her every day and her health is really at a fragile state. I choose to keep looking on the positive side, but I am also aware of the negative side of her health as well, and I want to be very careful how we approach treating her.

My thinking is to go with the Trilostane, as it is less apt to cause problems, and see how she does, and how the C-Cutis is responding. At least get the cortisol under control and let her body heal up for a while and let her get her strength and "health" back. Then, if the C-Cutis is not responding to the Trilostane, and or, is creating a problem, we can switch to Lysodren after she has become healthier and is displaying a stable physiology.

I've also been looking into modifying her diet to help combat the C-Cutis, and of course the Cushing's as well, but I've had a hard time finding allot of good and reliable info. However, I do have some, and am working on putting it into a practical application, but since the food she's eating now is really not that far off from what is recommended as a Cushing's diet, I am not spending allot of my time on that. Most of my time as been on getting her treatment underway.

However, having said all that, I will be discussing this with my Vet soon, and will certainly tell him what you said regarding the matter of treatment, especially as it relates to the C-Cutis.

Thank you for your interest, help and advise,
Fred.

[busyman370]

I want to step out of the box for a moment, and thank all of you for your caring and support, and for all the valuable help you offer. This forum is a wonderful community made up of wonderful folks.

Thanks again,
Fred.

[Altira]

Busyman.... Ive been reading some of your thread and i just had to say.... Trixie is a mighty lucky dog to have you! Wow!

[busyman370]

Busyman.... Ive been reading some of your thread and i just had to say.... Trixie is a mighty lucky dog to have you! Wow!

That's very kind of you. I am mighty lucky to have her too!

Fred.

[busyman370]

I have a question regarding the dose of Trilostane.

We are preparing to begin treating Trixie, and her weight is 22KG. To start her out on the lowest dose for her weight, it would be 44 mg. of Trilostane.

My Vet says that we should start at 50 mg. because the pill only comes in 10 mg increments. How does that sound to you all?

Thanks,
Fred.

[labblab]

Fred, if you wish to apply the initial dosing formula recommended by Dechra (manufacturer of brandname Vetoryl), her starting dose would be almost 50 mg. The lower range for Dechra's formula is 1 mg. per pound, or 2.2 mg. per kg. So if Trixie weighs 48 pounds, 50 mg. would be pretty much right on the mark.

Brandname Vetoryl comes in 10 mg., 30 mg., 60 mg., and 120 mg. capsules. So in order to arrive at 50 mg. (or 40 mg., for that matter should you wish to start a little lower), you will need to combine capsules. If Trixie ends up requiring a dose that does not correspond to the Vetoryl capsules, you will need to have a compounding pharmacy either "repackage" Vetoryl or else prepare custom-made capsules from their own supply of bulk trilostane. Compounded trilostane capsules can be purchased in virtually any strength you wish, except for the exact strengths of brandname Vetoryl.

In the long run, combining different strength Vetoryl capsules may end up being rather expensive for you. So if you and your vet wish to stick with the brandname product, I'll keep my fingers crossed that Trixie will ultimately settle out on a dose which is simpler to administer, such as 60 mg. But to begin with, it will probably be helpful to have a combination of 10 mg. and 30 mg. capsules on hand so that her dose can be tweaked upward or downward.

Marianne

[busyman370]

Fred, if you wish to apply the initial dosing formula recommended by Dechra (manufacturer of brandname Vetoryl), her starting dose would be almost 50 mg. The lower range for Dechra's formula is 1 mg. per pound, or 2.2 mg. per kg. So if Trixie weighs 48 pounds, 50 mg. would be pretty much right on the mark.

Brandname Vetoryl comes in 10 mg., 30 mg., 60 mg., and 120 mg. capsules. So in order to arrive at 50 mg. (or 40 mg., for that matter should you wish to start a little lower), you will need to combine capsules. If Trixie ends up requiring a dose that does not correspond to the Vetoryl capsules, you will need to have a compounding pharmacy either "repackage" Vetoryl or else prepare custom-made capsules from their own supply of bulk trilostane. Compounded trilostane capsules can be purchased in virtually any strength you wish, except for the exact strengths of brandname Vetoryl.

In the long run, combining different strength Vetoryl capsules may end up being rather expensive for you. So if you and your vet wish to stick with the brandname product, I'll keep my fingers crossed that Trixie will ultimately settle out on a dose which is simpler to administer, such as 60 mg. But to begin with, it will probably be helpful to have a combination of 10 mg. and 30 mg. capsules on hand so that her dose can be tweaked upward or downward.

Marianne

Thanks Marianne, once again,
It did dawn on me that the difference between 44 and 50 mg. is "probably" not a life threatening event, but then again, I do respect the powerful effect the Cushing's drugs have on the dogs system, and wanted to bounce my concern off those who are experienced.

If we do end up going with Trilostane, I'd rather go with the Dechra, especially at the start.

Yes, my Vet did say that he would administer her dose with the 10 and 30 mg.

Trixie is going in tomorrow for the ATCH test so we will know what we're starting with. From there, I'll certainly keep you posted.


Fred.

[Lady's mom]

Don't forget the prednisone to keep on hand.

[addy]

Hi Fred, I am sure Trixie will do just fine. Just remember, when in doubt, withhold the pill. It gets easier.

hugs,
addy

[busyman370]

I have a question.

I understand the testing protocols, and the need to have some Pred on hand, but want to ask you all about my part in monitoring Trixie between those tests.

Beginning the first day that treatment with Trilostane is started, what would be considered adequate "visual" monitoring?

I will see Trixie, at various intervals, every day from 2:00 pm and bed time.

Should she be watched every hour of the day for the first ten to fourteen days, or should I just go on with my life regarding the scheduling of appointments and etc.?

I'll do whatever it takes, but I don't want to over do it, be overly protective, if it's not necessary.

Thanks,
Fred.

[addy]

My IMS told me I did not have to take off of work but I did anyway because I am a worry wart.;);)

Trilostane peaks at about 3-6 hours and has a short life of appx 8 -10hours if I remember right. I am sure others will correct my bad memory.

I think the answer is do what you are comfortable with. If you have to leave her alone from early morning until 2:00pm and then you are checking on her periodically after that it might be okay.

Hopefully others will share their thoughts.

hugs,
addy

[Harley PoMMom]

In dogs, peak Trilostane concentrations are seen within 1.5 hours and decrease to baseline values in about 18 hours but remembering that all dogs are different.

If you are starting at the lower end of the recommended dosage that Dechra suggest (1 mg per pound) than I really do believe that there is a less of chance that adverse reactions will be seen, if any.

I'd watch for changes in eating, drinking, bowel movements, and her overall behavior.

Seeing how devoted you are to Trixie, I am positive that if Trixie displays any abnormal signs you will definitely notice. ;):)

Hope this helps.

Love and hugs,
Lori

[busyman370]

In dogs, peak Trilostane concentrations are seen within 1.5 hours and decrease to baseline values in about 18 hours but remembering that all dogs are different.

If you are starting at the lower end of the recommended dosage that Dechra suggest (1 mg per pound) than I really do believe that there is a less of chance that adverse reactions will be seen, if any.

I'd watch for changes in eating, drinking, bowel movements, and her overall behavior.

Seeing how devoted you are to Trixie, I am positive that if Trixie displays any abnormal signs you will definitely notice. ;):)

Hope this helps.

Love and hugs,
Lori

We are starting out at the lowest dose. Technically, Trixie's ideal dose would be 48 mg. but since Trilostane only comes in 10 mg. doses, we are going to start her on 50 mg. once per day.

I did figure that with such a low dose, the only thing I'd see was maybe a little improvement in how she acts, and not really any adverse effects, and just wait for the ten to fourteen day ATCH test.

But, I don't want to go into this based on assumptions, that's why I presented my concern to this forum. I like to measure twice and cut once.

Yes, I am devoted to Trixie's care, and am VERY in tune to "reading" her.

I will absolutely do whatever is needed to give her the best care possible, and without hesitation, but I don't want unnecessary emotional reaction to cause me to over do it, when it's not actually called for.

In other words, if I need to be with her 24/7, I will make that happen, but if I can both take proper and responsible care of Trixie, and deal with the rest of my responsibilities as well, then that would be my first choice.

I would be with her for one and one half hours after she gets her morning dose, then be away, on average, for about five hours, then return home and be with her. The rest of the day and night would be spent with her.

So I am working to get all my ducks in a row before we actually begin, and appreciate the advise of you all so when the day comes, I'll be ready.

Thanks,
Fred.

[busyman370]

My IMS told me I did not have to take off of work but I did anyway because I am a worry wart.;);)

Trilostane peaks at about 3-6 hours and has a short life of appx 8 -10hours if I remember right. I am sure others will correct my bad memory.

I think the answer is do what you are comfortable with. If you have to leave her alone from early morning until 2:00pm and then you are checking on her periodically after that it might be okay.

Hopefully others will share their thoughts.

hugs,
addy

My Vet told me basically the same thing, but this will be his first treatment using Trilostane, so I would rather discuss these kind of things with you all.

I do want to be comfortable with how I handle this, and am turning to this forum to help me establish that comfort level.

I think she'll be fine, as the dose is very low, and as much as I care about her, and would do whatever it takes to help her, I do not want to be a worry wart during this treatment. I work very hard to keep my emotions in check when I am around my dogs. They pick up on EVERYTHING, and I do not want Trixie to pick that up while she's being treated. She needs to feel as stress free as possible.

So the feed back and input I receive from this forum regarding my question will be well received and put to good use.

Thanks,
Fred.

[labblab]

Fred, I think you and Trixie will do just fine with your normal daily schedule. Of course, none of us ever wants our dogs to be uncomfortable in any way. But even if Trixie were to experience an unwanted side effect from the trilostane, the odds are that it would be in the form of discomfort rather than an acute emergency. For instance, even if you were to discover that she had vomited during the few hours you were away, upon your return during the afternoon you would have time to call your vet and decide on a plan of action, perhaps just as simple as giving her a dose of prednisone and withholding any more trilostane for the time being.

And as closely as you will be watching her while you're at home, I think you will be aware of even subtle indications that she is not feeling well. In that event, since you have the 10 mg. capsules on hand, you and your vet would have the capability of immediately lowering her dose after a brief break in the medication. Once again, I think you guys will do fine carrying on your normal daily routine.

Marianne

[Squirt's Mom]

Hi Fred,

You have been and continue to work so hard to learn all you can to help your sweet girl. That in itself says that you are going to do just fine with treatment - diligence on our part is just as important as anything else and you have that part down. ;)

And, of course, you know we are here anytime you have a question or simply freak out - my personal specialty. :D

Hugs,
Leslie and the gang

[busyman370]

Fred, I think you and Trixie will do just fine with your normal daily schedule. Of course, none of us ever wants our dogs to be uncomfortable in any way. But even if Trixie were to experience an unwanted side effect from the trilostane, the odds are that it would be in the form of discomfort rather than an acute emergency. For instance, even if you were to discover that she had vomited during the few hours you were away, upon your return during the afternoon you would have time to call your vet and decide on a plan of action, perhaps just as simple as giving her a dose of prednisone and withholding any more trilostane for the time being.

And as closely as you will be watching her while you're at home, I think you will be aware of even subtle indications that she is not feeling well. In that event, since you have the 10 mg. capsules on hand, you and your vet would have the capability of immediately lowering her dose after a brief break in the medication. Once again, I think you guys will do fine carrying on your normal daily routine.

Marianne

Thanks Marianne,
I do think that at least this first course of Trilostane will be uneventful because the dose is lower than the manufacturer recommends for the starting dose.

The leaflet that came with the Trilostane says that for the weight greater than 22 lbs. but less than 44 lbs, the starting dose should be 60 mg.

The next range is greater than 44 lbs. but less than 88 lbs., the starting dose is 120 mg. given in two doses of 60 mg.

Trixie is at the high end of the 60 mg. range, and the low end of the 120 mg. range.

She is 47 1/2 pounds and is starting at only 50 mg., so she is going to begin at a lower dose than is recommended, which I feel is the safest way to begin her treatment and see how things progress from there.

I don't know if there is any such thing as the dogs system getting used to the drug, being dosed on a gradual basis, rather than hitting them hard with it right up front, but if it can, this will be the way to do it.

Fred.

[busyman370]

Hi Fred,

You have been and continue to work so hard to learn all you can to help your sweet girl. That in itself says that you are going to do just fine with treatment - diligence on our part is just as important as anything else and you have that part down. ;)

And, of course, you know we are here anytime you have a question or simply freak out - my personal specialty. :D

Hugs,
Leslie and the gang

Thanks, that means allot.
Fred.

[busyman370]

Hello all,
Well, tomorrow morning I start treating Trixie.

I think the timing is very good, as over the last few days she began showing more progression with her Cushing's symptoms, so I am more than ready to start treatment.

I am very glad the Trilostane came sooner than we expected because I can start her off tomorrow morning and have the rest of the day to watch her.

Monday I will be with her for about an hour and a half after her morning dose, and will return about four hours later, and will have the rest of the day to observe.

As an aside, when I discussed having some Pred on hand with my Vet, of course he agreed, but said that he would rather I call him before I give her any.

He wants me to tell him what her symptoms are, and if he feels the need, he wants me to put Trixie in the car and meet him at the hospital. He wants to make the final decision after he evaluates her.

He's really on board with this. We've become a team with treating Trixie's Cushing's

I'll keep the forum posted,
Fred.

[StarDeb55]

Fred, I have not posted to you before, but have been following Trixie's story. I'm very impressed about your efforts to get yourself up to speed on Cushing's so you can be a great advocate for your girl.

I wanted to make a couple of comments about what you posted concerning trilo dosing. A former vet technical rep at Dechra, now retired, had been verbally recommending that pups starting dosage be 1 mg/lb to a number of our members during phone calls, cautioning members that the package insert didn't reflect the verbal recommendations. I believe that the UC Davis vet school & Dr. Edward Feldman, the chief endocrine vet at Davis using a starting dose of 1mg/kg, thus even lower. We have seen time & again on these boards that it's much easier to start low with trilo & work up if needed, than start high, & put a pup at risk.

Hope this helps.

Debbie

[labblab]

Hi Fred,

Just to expand on what Debbie has said above, even though Dechra's published dosing chart lists a higher starting dose for a dog of Trixie's size, the written commentary that appears right above the dosing chart gives an initial dosing range of 1-3 mg. per pound. And so the verbal recommendation we received from the technical rep at Dechra was to start at the lower end of that published range. Here's the statement as it appears in the Product Insert, right above the chart:


DOSAGE AND ADMINISTRATION:
Always provide the Client Information Sheet with prescription. The starting dose for the treatment of hyperadrenocorticism in dogs is 1.0-3.0 mg/lb (2.2-6.7 mg/kg) once a day based on body weight and capsule size (see Table 1). VETORYL Capsules should be administered with food.

So you are starting Trixie right at that recommended lower dosing range.

Marianne

[busyman370]

Fred, I have not posted to you before, but have been following Trixie's story. I'm very impressed about your efforts to get yourself up to speed on Cushing's so you can be a great advocate for your girl.

I wanted to make a couple of comments about what you posted concerning trilo dosing. A former vet technical rep at Dechra, now retired, had been verbally recommending that pups starting dosage be 1 mg/lb to a number of our members during phone calls, cautioning members that the package insert didn't reflect the verbal recommendations. I believe that the UC Davis vet school & Dr. Edward Feldman, the chief endocrine vet at Davis using a starting dose of 1mg/kg, thus even lower. We have seen time & again on these boards that it's much easier to start low with trilo & work up if needed, than start high, & put a pup at risk.

Hope this helps.

Debbie

Hello Debbie,
That's how I feel, and my Vet agrees. Why not start low, see how the dog is reacting to it? You can always raise it.

I have seen how sensitive Trixie was to the really minor increase in cortisol, that was caused by the Desmopressin dose increase, and how quickly she normalized when I reduced it, so even with the lower starting dose. I am expecting to see some kind of positive reaction between today and the probable 12th day when we do another ATCH.

Thanks,
Fred

[busyman370]

Hello,
I began Trixie's treatment this morning, and was somewhat surprised by her reaction. About 20 minutes after the dose, she was sitting and I saw it hit. She seemed to burp, and went right up on her love seat and went right to sleep.

I was expecting just the opposite, so you can understand my surprise.

After a few hours, I did her nails, and she was just sleepy.

A few hours after that I offered her a strawberry and she went right for it, but then went back to sleep, so her stomach doesn't seem upset.

around 2:00, I got her off the love seat and sent her outside, she walked around quite well and pooped, then came back in and got right back up on her love seat and went back to sleep.

Actually, her sister, who is her littermate, has been sleeping most of the morning too. Maybe because it's kind of a misty, almost rainy day.

My only explanation at this point is that perhaps the effect of the Trilostane is calming down her physiology that's been ramped up by the cortisol, and or, is just making her more relaxed because of even the slightest reduction of the effect of the cortisol.

Let's face it, a dog with Cushing's can't really be feeling very comfortable, and perhaps even the slightest buffering of her cortisol may make her feel more at ease, even though my understanding is that it takes a number of days before seeing any worthwhile changes, but who knows, every dog is different and maybe it's hitting Trixie right up front.

I am sure she will eat her supper with no problem, judging by how she went after the strawberry, and also a piece of bread, but I'll have to wait and see how supper goes.

I am glad I started this morning instead of waiting until tomorrow. It gives me a chance to really watch her and gives me something to go by regarding how the Trilostane is effecting her.

I chatted with my Vet this afternoon about a totally unrelated subject, as we were just talking as friends, and did tell him that I started Trixie. I am glad that he's only a phone call away 24/7.

I am calling tomorrow to schedule the ATCH stim test. I am really looking forward to seeing what it shows.

That's it for now. Any comments or observations from the forum would be most welcome.

Fred.

[Lulu]

Did your vet have any thoughts on retioic acid? I know you were
Looking into retinoic acid from your previous posts.

My dog just got diagnosed with cushings and I am not sure how to handle this. Besides crying.

Thanks so much and I hope goes well with your boxer. It is so difficult to watch a dear companion dog take sick. ... Sweet about your dog eating the strawberry!

[busyman370]

Did your vet have any thoughts on retioic acid? I know you were
Looking into retinoic acid from your previous posts.

My dog just got diagnosed with cushings and I am not sure how to handle this. Besides crying.

Thanks so much and I hope goes well with your boxer. It is so difficult to watch a dear companion dog take sick. ... Sweet about your dog eating the strawberry!

Hello Lulu;72656,
Sorry to hear about your dog, but you're in good hands here. I can attest to that personally. There are many people here that can help you. Myself, I just joined a few weeks ago, and have been helped greatly and in a short amount of time.

I would recommend that you search the forum as there are many answers to your questions already there, and you may come across some that you never thought to ask about.

My Vet did comment on the Retinoic Acid, but the subject is so ridiculous that I put it out of my mind and even forgot to mention what I found out to the forum. Dr. Bruyette said it costs something like $2,000.00 a day or a week, and even if you did want it, it's near impossible to obtain regardless. So it quickly became a moot issue, and I focused on working with the folks here, and on treating my girl.

As I said, you're in a good place here, just stay calm and focused on the best way to deal with your dogs recent diagnosis.

And yes, Trixie likes strawberries!

Take care,
Fred.

[busyman370]

In my searching to see what I could find related to the way Trixie was acting shortly after receiving her first dose of Trilostane, I came across this, and thought it may be valuable to the forum. I believe it is from a British source.

I was especially taken by the part that said; "A small percentage of dogs (on Trilostane) may develop corticosteroid withdrawal syndrome within 10 days of starting treatment."

"Corticosteroid Withdrawal." That made my mind work, let me tell you!

Also, near the end of the writing is a very good explanation regarding the subject of; Trilostane may hasten the growth of pituitary tumors.

Below is what I found,
Fred.

Vetoryl 60 mg Caution

The product should be used with extreme caution in dogs with pre-existing anemia as further reductions in packed-cell volume and hemoglobin may occur. Regular monitoring should be undertaken.

Hypoadrenocorticism can develop at any dose of VETORYL Capsules. In some cases, it may take months for adrenal function to return and some dogs never regain adrenal function.

During routine monitoring in the 84 day field study, 26.2% of dogs had an ACTH stimulation test result of <40 nmol/L (1.45 µg/dL), but this was not necessarily associated with clinical signs.

A small percentage of dogs may develop corticosteroid withdrawal syndrome within 10 days of starting treatment.

This phenomenon results from acute withdrawal of circulating glucocorticoids; clinical signs include weakness, lethargy, anorexia, and weight loss.

These clinical signs can be differentiated from an early hypoadrenocortical crisis by normal serum electrolyte concentrations and normal ACTH stimulation test results.

Corticosteroid withdrawal syndrome should respond to cessation of VETORYL Capsules (duration of discontinuation based on the severity of the clinical signs) and restarting at a lower dose.

The use of VETORYL Capsules will not affect the progression of the adrenal or pituitary tumour.

By inhibiting cortisol, it may stimulate some pituitary tumours to grow.

Twice daily dosing may not allow time for adrenal recovery and excretion of physiologically necessary glucocorticoid and mineralocorticoid hormones in some dogs.

The risk of developing hypoadrenocorticism may be greater; however, in dogs with clinical signs that are not controlled for an entire 24 hour period, twice daily dosing may be required.
.
.
.

[lauraperla]

Thinking of you and Trixie, I hope all is going well.

Laura and Saoirse x

[addy]

Checking in on you and Trixie. I am sure day 2 will be just fine.
When I started Zoe on just 10mgs of Vetoryl- she weighed 18 pounds -she dropped like a ton of bricks that first week. I did not expect that with such a small dose. Anyway, she was tired in the morning, I remember, but then perked up in the afternooon when the Vetoryl started wearing off.

Hugs for a good day!!!

addy

[KarenJ]

Hi Fred,

I've been following your posts since Maggie is also a 10 y/o Boxer and I'm curious to see if their reactions are similar (breed specific?). Maggie has been off her Trilostane for 3 weeks and I'm getting ready to start her back on it today at 1/2 her previous dose (30mg once a day instead of twice a day). The reason for this is that she seemed to be overcontrolled at 60mg. She was so letargic she was barely awake ever. Based on what you've seen with Trixie (sleepy soon after her dose) I'm going to try giving Maggie her pill at night instead of morning. That way maybe she'll perk up during the day. Keep posting! I look forward to hearing about Trixie's progress.

Karen

[Lulu]

Thank you or your response. Did the doctor refer to the efficacy of the treatment? If the use is efficacious then it is a cost issue.

Retinoic acid may be cost effective for smaller dogs; particularly when compared to the cost of other medications, tests, and the possibility of
eliminating the pituitary tumor rather than merely addressing the symptoms of cushings. Large quantities sold at the wholesale level could be cost effective

for a smaller dog.

Also I understand that dogs create retinoic acid through vitamin a ingestion

It would be wonderful if instead of attempting to ameliorate the symptoms if cushings if the cause could be addressed.

[busyman370]

Thank you or your response. Did the doctor refer to the efficacy of the treatment? If the use is efficacious then it is a cost issue.

Retinoic acid may be cost effective for smaller dogs; particularly when compared to the cost of other medications, tests, and the possibility of
eliminating the pituitary tumor rather than merely addressing the symptoms of cushings. Large quantities sold at the wholesale level could be cost effective

for a smaller dog.

Also I understand that dogs create retinoic acid through vitamin a ingestion

It would be wonderful if instead of attempting to ameliorate the symptoms if cushings if the cause could be addressed.

Lulu,
I've put the matter to rest. You are way ahead of where I ever was on the topic. Hope it works out for you.

[busyman370]

Hi Fred,

I've been following your posts since Maggie is also a 10 y/o Boxer and I'm curious to see if their reactions are similar (breed specific?). Maggie has been off her Trilostane for 3 weeks and I'm getting ready to start her back on it today at 1/2 her previous dose (30mg once a day instead of twice a day). The reason for this is that she seemed to be overcontrolled at 60mg. She was so letargic she was barely awake ever. Based on what you've seen with Trixie (sleepy soon after her dose) I'm going to try giving Maggie her pill at night instead of morning. That way maybe she'll perk up during the day. Keep posting! I look forward to hearing about Trixie's progress.

Karen

Hello Karen,
Trixie weighs 47 pounds, and even though the lowest recommended starting dose was 60 mg., I Started Trixie's Trilostane dose at 50 mg., given one time per day. I give it in the morning, with food, as directed and recommended.

I am certainly not an expert, but I don't know if giving your Boxer her dose at night is a good idea. It may be fine, but I have always seen that it should be given with breakfast. Hopefully someone more knowledgeable that I am can help with the preferred dosing time and explain the reason for it better than I can.

In one of my posts, I included some info regarding the down side of giving Trilostane twice daily, here's the part that pertains to the twice daily dosing:

"Twice daily dosing may not allow time for adrenal recovery and excretion of physiologically necessary glucocorticoid and mineralocorticoid hormones in some dogs.

The risk of developing hypoadrenocorticism may be greater; however, in dogs with clinical signs that are not controlled for an entire 24 hour period, twice daily dosing may be required."

I would be very careful with how you treat with this drug, and would not do anything off the recommended path without confirming it with someone who is an expert at treating with Trilostane. If your Vet isn't sure, have them contact someone in their profession who is before doing any modifications regarding the dose or the timing of it.

Bye the way, how much does Maggie weigh?

When you say she "seems" to be over-treated, did you confirm that with an ATCH stimulation test, or did someone just guess at it?

I would recommend using the ATCH test, especially at the beginning phases of treatment, then after she is past her two months of treatment, perhaps going by her visual signs may be OK to do, but I would not take that kind of chance in the beginning, especially when her dose needs to be established. I am going to go by her visual signs, but will always be taking the ATCH tests to factor in as I make my final decisions regarding her overall treatment.

Let's face it, the dog is going through allot once it starts treatment, and their whole body needs to adjust to the changes. I am not surprised the dog's get "tired."

But, having said that, being tired and crashing are two different things, and that's why the Vet - AND THIS FORUM - should be involved with the evaluation of how the dog is doing.

Trixie does seem quite knocked out for most of the day after her morning dose, but she perks up right around supper time, then gets tired again and just lays around. But, it doesn't seem to be life threatening. All I have to do is to say the word "COOKIE" and her ears perk up! That's a good sign.

Next week, she will get her ten day ATCH stimulation test, and I am really looking forward to seeing where we are regarding how the present dose is working.

I really do not feel comfortable giving my opinion because I am far from being an expert with treating with Trilostane. I am comfortable with my decisions regarding my own dog so far, but not comfortable enough to be giving advise that may put someone else's dog at risk.

Yes, Trixie goes through the being tired phases during each day, but overall, I feel she is not in any jeopardy, so I am continuing with her starting dose with confidence, knowing that the ATCH will give me a more accurate picture of how we should continue regarding dosing.

My guess is that following that ATCH test, I will choose to stay on the clinically low dose of 50 mg. once per day given with breakfast for the next two weeks, even if her ACTH test suggests we should up it, then do her next scheduled ATCH test, and then have a real accurate basis to progress forward from. If her dose needs to be raised, I want to do it gradually so we diminish the risk of over medicating as much as we can. I don't want to rush things. I'd rather test her a couple of times to be sure we're not overdoing things.

I will add that her frequent drinking and urination almost stopped, and that was after the first day of Trilostane! I did not expect that to happen so soon. That tells me that even though her dose is lower than normal, it's having an effect on her, and gives me an idea of her sensitivity to it. BUT, that's just an idea. The ATCH will play an important role in helping me assess and conclude this first step of treatment.

All the best to you and Maggie,
Fred.

[busyman370]

Checking in on you and Trixie. I am sure day 2 will be just fine.
When I started Zoe on just 10mgs of Vetoryl- she weighed 18 pounds -she dropped like a ton of bricks that first week. I did not expect that with such a small dose. Anyway, she was tired in the morning, I remember, but then perked up in the afternooon when the Vetoryl started wearing off.

Hugs for a good day!!!

addy

Hi addy,
Yes, Trixie is doing the same thing. It's only been four days since treatment began and like you, I did not expect that to happen either, especially with such a low starting dose.

But, when you think about it, that's why it's a good idea to start off as low as you can, to see how YOUR dog will respond to Trilostane. The recommendations are just a guide line.

Going by Trixie's response, I am very glad we went with a dose that was just a touch lower that the recommended lowest dose.

I can't tell you how anxious I am to get that next ATCH test. I am so curious to know how sensitive Trixie is to Trilostane.

But, overall, she's doing fine. Her drinking and urination was reduced after the first dose, she has only had two instances of peeing in the house. Once mid afternoon, and once just before I got up in the morning, so I am not complaining. (Love my Hoover!!!)

Tuesday, April 3rd will be her ATCH and I should learn of the results in a day or two following. I'll be sure to let the forum know as soon as I know.

Thanks for the words of encouragement, and take care,
Fred.

[KarenJ]

Hi Fred,
I took the advice of this forum and I'm giving Maggie her pill with breakfast. I'm really hoping the once a day dosing works better for her. The three months she was on twice a day dosing seemed okay but looking back, I see where she was gradually declining.

We had the recommended ACTH tests every step of the way and everytime, her levels were good. Which is what scares me. Of course, to complicate matters, we found she was hypothyroid and began treating that at the same time. That's about the time when things went downhill. We stopped all meds because she was in such a bad way. She had a seizure a few days after stopping treatment so the vet had me start the Soloxine only. We saw immediate improvement in everything except her incontinence.

She was off the Trilostane for 10 days and we did a UCCR (which came back at 85). Also the other urine levels were checked and all was normal. That's when we decided to start the Trilostane back at half the dose and only once a day. We are on day 3 and so far so good. Drinking and peeing seems to have diminished (though she's still incontinent, it's no where near as bad). My only complaint is that the Trilostane causes her to tremble. It doesn't seem to bother her really, I just hate to see it.

Maggie weighs 70 lbs. so 30mg is a really low dose for her. We are due for an ACTH on April 9th. I'll be anxious to see what her levels are. I'm considering asking for a complete adrenal panel at U of Tenn to see what her other hormone levels are. I wonder if it's more than just cortisol that's causing her issues.

Thanks for your reply. It really helps having this forum. Even those who aren't "experts" are a huge help!

I'm glad Trixie is doing well on her dose! Love these Boxers!!!

Karen

[busyman370]

Today is day six, and I can see some very positive results of the Trilostane in Trixie.

She is getting stronger and is moving much better. She actually will trot to the spot where she decides to pee, then trots back to the house, and climbs the five steps with no problem.

For what seems like the longest time she would struggle her way up those steps, and I would be right there behind her in case she fell. I would have gladly carried her, but wanted her to use her muscles and remain independent minded.

Her extended periods of sleeping, which were more like being knocked out, are now what I would call much more normalized.

Her drinking and urination have been pretty good, much better than I expected when I took her off the desmopressin. Only a few pees in the house, and for most of them she has been considerate enough to pee on the tile flooring and not on the rug. My Hoover rug shampooer is parked and on the ready to quickly clean up those little spills!

So far, I am very satisfied with the Trilostane, and only have one thing that falls into the regret column. I wish we had tested her a year ago, and began treatment much sooner to have, hopefully, avoided the Calcinosis Cutis. And of course all the rest of what she went through because of the Cushing's.

The signs were there, but neither my Vet nor I caught them. I am no longer breeding Boxer's, but let me tell you all, if I was, and if I ever see an older Boxer acting "old" I would test or recommend testing immediately! Boxers don't act old by exhibiting the signs that a Cushing's dog does.

But, having said that, I am not too concerned with the C-Cutis right now. As I said before I started treating Trixie, I want to get her strong and otherwise healthy for an extended period of time, then see how the Cutis is doing, and watch for infection.

I don't think it will spread anymore now that she's on Trilostane, and I have come across cases where it did resolve in time with Trilo. If it looks like it's resolving, maybe I'll stay with Trilo, but I am considering switching to Lysodren eventually because of that hastening of the Pituitary tumor growth issue with Trilostane.

That's my update regarding day six of Trilostane.

Take care all,
Fred.

[addy]

Sounds like a really good report:):):):):):):)

Glad things are going well. Maybe you can give me some pointers on how to use my Hoover (I am not very good at it);):D

Have a wonderful weekend. Hugs to Trixie!!!

addy

[busyman370]

Unexpected update on Trixe.

Because of extensive research, and of course with the help from this forum, I thought I had covered every possible event regarding Trixie's treatment with Trilostane. I was sure that nothing could unexpectedly pop up and catch me off guard, but this afternoon, something did.

This morning I had to leave earlier than usual, and would be away for four to five hours. I completely expected to find a little puddle of pee when I returned, and was not surprised to find one when I arrived home.

Both Trixie and Trudie were resting very comfortably in their room on their loveseat, and when I saw the little puddle, I exclaimed; "OK, time to get the Hoover!"

I plugged in my trusty Hoover and began to clean up the little puddle on the 9' x 6' throw run in their room. That's when the unexpected happened.

Trixie clearly demonstrated that she has developed an attitude with the Hoover.

As I started Hoovering the area, she got up and kept standing right in front of the Hoover. I had to literally move her out of the way, then get back to Hoovering. But, she just stepped right back in front of the Hoover, blocking any progress on my end.

Maybe because it's been so long that she has been behaving like a sick dog, that that kind of thing struck me as being so out of character for her. I couldn't believe what she was doing!

After I moved her out of the way about four times, and she just ran back and stood in front of the Hoover, I did say to her; Trixie, what the heck are you doing?" It really was quite funny.

I finally got the job done, and went to turn the rug over so I could clean the back side of it, and Trixie walked over and stood on the rug so I could not move it.

I had to pick her up, carry her into the great room, and put her on MY couch so I could finish the job.

I actually think she's jealous of the Hoover! Now I have to deal with THAT new twist.

I think she's getting a little better and becoming more of her old self.

Bye the way, her name fits her. She was always the one who would steal a napkin off the table and shred it, or take the towel off the range handle and take off and make me chase after her.

I have been leaving the Hoover in her room for quick access, but as of today, I am storing the Hoover in another room to avoid any possibility of coming home one day and finding it dismantled and scattered all over the floor.

Overkill? Maybe, but from the way Trixie has been looking at the Hoover lately, I am not taking any chances

Take care all,
Fred.

[Squirt's Mom]

:p:D:p Way to go, Trixie!! :p:D:p

[addy]

Oh Fred, I think it is just wonderful Trixie want to take on the Hoover:D:D:D:D:D:D:D

Go Trixie Go!!!!!!!

[jmac]

Hi Fred-

What a great story! Trixie must be feeling really good! That's great news!

Julie & Hannah

[lauraperla]

Love Trixie's attitude!
I feel the same way about all household appliances and chores.
And I am very pleased she is showing good signs!

Laura and Saoirse xx

[busyman370]

Sounds like a really good report:):):):):):):)

Glad things are going well. Maybe you can give me some pointers on how to use my Hoover (I am not very good at it);):D

Have a wonderful weekend. Hugs to Trixie!!!

addy

Thanks addy;72940. My Hoover is the Steamvac with a 12 amp motor, and it works amazingly well. I am very impressed with its powerful vacuum. Any liquid it runs across is GONE, and the carpet, and or, bare floor, is about 99% dry. For this use with Trixie, I just use hot water, no cleaner solution, as they are quick pick up's immediately following her little puddles. Once a week, I do shampoo the throw run in her room, even though once Trixie gets past the drinking/urination, the rug is going in the trash.

I hit the initial puddle and vacuum it all up, then I begin to wet the area rather well with water from the Hoover tank, and vacuum it off, then repeat and repeat until the water runs clear through the collector tank.

Then I flip the rug over and do the opposite side.

After each use, I dump it, rinse it, put it back on the Hoover, and make sure the water/cleaning agent tank is full, and I am ready for my next adventure.

Just run it slow over the affected area to let the machine really vacuum up all the liquid. Other than that, I don't think you should have any difficulty.

If you do, give me that specifics and I'll see if I can help.

Fred.

[busyman370]

:p:D:p Way to go, Trixie!! :p:D:p

Thanks Squirt's Mom;72983!

Fred.

[busyman370]

Hi Fred-

What a great story! Trixie must be feeling really good! That's great news!

Julie & Hannah

Thanks Julie & Hannah, and yes, she has done very well in the past ten days.

[busyman370]

Love Trixie's attitude!
I feel the same way about all household appliances and chores.
And I am very pleased she is showing good signs!

Laura and Saoirse xx

Thank you Laura and Saoirse xx,

Fred.

[busyman370]

Trixie's 10 day ACTH test results were 5.9.

I am pleased with that as her Cushing's signs are being reduced an a daily basis. Even the Calcinosis Cutis is beginning to be effected. The area's along both hocks have dried up, no more bleeding. The open sores on her groin are stable with minor bleeding here and there.

I do not want to dose her any higher than I have to. I want to let her heal at a slow, gentle but constant pace.

At 5.9, she has some wiggle room before she would need an increase in the Trilo dose. Because of that, I have scheduled another ACTH test on May 1st. I did have one scheduled to be done in two weeks, but decided that as long as her signs continue to improve, why put her through another test so soon. I was surprised to see how hard that test was on her, it took 45 minutes for her to normalize after the cortisol injection. It hit her hard.

I am also keeping an eye on her for signs of hypERthyroid as she is on 0.4 mg. of Soloxine per day.

As long as she keeps improving, I'll leave well enough alone, but if she shows any negative signs, I have her right in for the appropriate test.

My plan for May 1st is to have the ACTH, a thyroid panel and a urine specific gravity done.

I must say that I am impressed by how much of her strength has been restored. She is about 60% of her old self, and that's coming from around zero before the Trilostane.

So, it's wait and see for a while, but because of what I've seen so far, I am cautiously optimistic.

Thanks again for all of you who have been there for Trixie and me.

Fred.

[lulusmom]

Hi Fred,

Can you confirm that Trixie had the acth "stimulation" test? If so, there should be two numbers, a pre and a post stimulation number. I just want to make sure that the 5.9 is the post number. If it is, it's quite possible that cortisol will continue to drop in the next few weeks, so please watch your girl for signs of low cortisol. Signs are loss of appetite, vomiting, diarrhea, extreme weakness and in serious cases, inability to walk. Did your vet give you prednisone to administer in case of emergency? Because Vetoryl has a short half life, some vets don't think you need prednisone because a dog will bounce back rather quickly by simply withholding the drug. I always have it on hand. When the pills I have expire, I get new ones. You just never know.

[busyman370]

Hi Fred,

Can you confirm that Trixie had the acth "stimulation" test? If so, there should be two numbers, a pre and a post stimulation number. I just want to make sure that the 5.9 is the post number. If it is, it's quite possible that cortisol will continue to drop in the next few weeks, so please watch your girl for signs of low cortisol. Signs are loss of appetite, vomiting, diarrhea, extreme weakness and in serious cases, inability to walk. Did your vet give you prednisone to administer in case of emergency? Because Vetoryl has a short half life, some vets don't think you need prednisone because a dog will bounce back rather quickly by simply withholding the drug. I always have it on hand. When the pills I have expire, I get new ones. You just never know.

Hello lulusmom;73314,
Thanks for asking to make sure, but yes she did have the test, I was right there, assisting and holding Trixie as the Tech was drawing the blood, and was doing the same at the injection or cortisol and again for the final draw.

My Vet gave me the results over the phone, and the 5.9 was the post number. We were both on the fly and plan to talk again this weekend when we're both at home and not busy doing something else, so all he gave was the post, and that's all I wanted to know at that time. And yes I do have some Pred on hand, although my Vet wants me to call him and let him see Trixie before I give her the Pred so he can evaluate her before hand.

I do want to talk about her being on Soloxine and how we're going to handle that. I am going to watch her for signs of hyper thyroid, but I will discuss that with my Vet to get his view on the matter.

Of course I watch Trixie like a hawk, and what happens going forward is always up for grabs, but in my opinion, I think that she may need an up in her dose rather than a reduction as she is only on 50 mg. of Trilo per day, and her post is 5.9.

That's the range where it's advised to keep her at the present dose, as long as signs are being controlled, or if not, to increase the dose if they are not.

I am happy with the 5.9 because I didn't want to see her drop too drastically too soon, but going forward, I'd rather see her post more around the 4.5 to 5.4 area. That would make me feel that we are really on a good dose.

To repeat myself, I do want the progression to take a slower pace rather than to move too fast.

But, who knows which way she will go with it. That's what her next ACTH will tell us.

She has a range of between 5.4 and 9.1 before we would need to increase the Trilo, so I decided to stay on the lower dose, go slow and wait a full month before her next ACTH, then also do a thyroid and specific gravity. But, if she begins to show negative signs, then I'll have her tested sooner.

But thank you for the reminder that her cortisol could drop significantly in the next few weeks. I will be watching for the signs.

As much as one can prepare, it's always helpful to be reminded of the important things, so thanks again for caring and helping me with this.

Fred.

[busyman370]

I have a question related to Soloxine. Today I have been wondering how soon Trilostane can effect a dog to the point where they no longer need Soloxine.

After her supper, and her usual 0.1 mg. Soloxine tablet, Trixie soon just became tired and went to sleep on her sofa. She displayed lethargy, yet would respond to my stimulating her.

Trixie is on a rather low dose of Soloxine. 0.4 mg. given at 0.2 mg. twice per day. Her thyroid levels were just below the low end of the normal range, so the 0.4 mg. brought her levels right up to a nice position with in the good range.

But with the way she has shown improvement with the Trilostane in less than 10 days, I am wondering if she needs to be taken off Soloxine.

Her post ACTH has her at 5.9, and seems to have the cortisol well under control, and I am wondering if it has also normalized her thyroid levels as well.

Of course a thyroid panel is the only way to know for sure, but I wondered if anyone on this forum has seen or experienced this issue before and would have any input on the subject.

Although the usual symptoms of hypER thyroid are of the over excited nature, a dog can also exhibit lethargy as well.

My feeling is that I am guessing that she may need to stop the Soloxine because the Trilostane has worked enough to correct her low thyroid issue, and now she is getting too much, even if only a little too much.

Your comments are most welcome, Fred.

[Harley PoMMom]

Hi Fred,

It is quite possible that when the elevated cortisol is well controlled that the Soloxine may be discontinued. Here is a link to a study I found about this: The effect of trilostane treatment on circulating thyroid hormone concentrations in dogs with pituitary-dependent hyperadrenocorticism. (http://www.mendeley.com/research/effect-trilostane-treatment-circulating-thyroid-hormone-concentrations-dogs-pituitarydependent-hyperadrenocorticism/)

Excerpt from that study:
CLINICAL SIGNIFICANCE: While treatment with trilostane did not induce a significant change of thyroxine concentrations, there was a significant increase in canine thyroid-stimulating hormone concentrations following treatment, a finding that supports thyroid-stimulating hormone suppression as one of the factors that contributes to the effects of glucocorticoids on the hypothalamic-pituitary-thyroid axis.

Love and hugs,
Lori

[busyman370]

Trixie seems to be taking a step backward.

As of yesterday afternoon she became very lethargic. She is still very interested in eating and drinking, but otherwise she is mostly out of it.

Last evening I noticed that she went through a few seconds of "drooling" which made me expect that she was about to vomit as I've seen that as the precursor to vomiting in dogs before.

She just sleeps, and when she walks, she marches again and appears somewhat unstable, and she just looks like she's not feeling real well.

My first thought was that because she was just a touch low on her thyroid panel, and only needed 0.4 mg. of Soloxine per day to bring her into the range, that she may need to be taken off Soloxine as the Trilo could have easily normalized her thyroid livels by now, and or to reduce her present low dose of Soloxine, as going hyper can bring on lethargy, but I really don't think that's the case.

It's hard to imagine that her cortisol could have shot up significantly, or that she is going Addison, in only three days after her 5.9 ACTH to cause these symptoms.

Seems that whether her cortisol went up of down, it would take longer for her to show signs of it because her ACTH showed that she was in such a middle range of acceptability.

Any thoughts?

Thanks,

Fred.

[labblab]

From what you are describing, I would be much more worried about low cortisol than high thyroid. And yes, it is possible for effects of low cortisol to come on quickly. Given that it's Saturday, can you call your vet? First and foremost, I do not think you should give her any more Vetoryl at the moment. And if you can't get ahold of your vet and she worsens, I'd give her a dose of prednisone. Withholding the Vetoryl will not be any problem in terms of long-term control of the disease, and if her cortisol has truly dropped too low, it is essential that she not receive any more medication at the moment.

It is possible that Trixie may "just" be suffering from the effects of steroid withdrawal upon having her cortisol level lowered so much so quickly. But she may truly be suffering from a cortisol level that is genuinely too low. The only way to tell the difference is by performing an ACTH and also checking her blood chemistries. So if she doesn't improve quickly upon cessation of the Vetoryl and supplemental prednisone, you'll want to do that testing. I'll come back in a moment and add a quote from Dechra.

OK, I'm back, and here's the quote from their Product Insert:


A small percentage of dogs may develop corticosteroid withdrawal syndrome within 10 days of starting treatment. This phenomenon results from acute withdrawal of circulating glucocorticoids;
clinical signs include weakness, lethargy, anorexia, and weight loss1. These clinical signs should be differentiated from an early hypoadrenocortical crisis by measurement of serum electrolyte concentrations and performance of an ACTH stimulation test. Corticosteroid withdrawal syndrome should respond to cessation of VETORYL Capsules (duration of discontinuation based on the severity of the clinical signs) and restarting at a lower dose.

Marianne

[busyman370]

From what you are describing, I would be much more worried about low cortisol than high thyroid. And yes, it is possible for effects of low cortisol to come on quickly. Given that it's Saturday, can you call your vet? First and foremost, I do not think you should give her any more Vetoryl at the moment. And if you can't get ahold of your vet and she worsens, I'd give her a dose of prednisone. Withholding the Vetoryl will not be any problem in terms of long-term control of the disease, and if her cortisol has truly dropped too low, it is essential that she not receive any more medication at the moment.

It is possible that Trixie may "just" be suffering from the effects of steroid withdrawal upon having her cortisol level lowered so much so quickly. But she may truly be suffering from a cortisol level that is genuinely too low. The only way to tell the difference is by performing an ACTH and also checking her blood chemistries. So if she doesn't improve quickly upon cessation of the Vetoryl and supplemental prednisone, you'll want to do that testing. I'll come back in a moment and add a quote from Dechra.

OK, I'm back, and here's the quote from their Product Insert:


Marianne


Thanks for the quick response Marianne,

I did give Trixie her am dose already.

Since the test results indicated that she did so well on her first ACTH, I decided to wait a month before doing another test, only because of how hard the test was on her.

But moments ago, I called my Vet's and moved that ACTH test appointment back to the original two week's following that first ACTH test.

I don't want to hit the panic button as she may be going through another period of withdrawal, like she did before, and will bounce back again in a day or two, like she did before.

But at the same time, I don't want to wait too long before taking appropriate action either.

She did go through the withdrawal during the first two days of Trilo, and after that, she seemed to be improving every couple of days, so I thought that since she was on a lower starting dose that the withdrawal period was done for now, and the possibilities of it happening again would be at some period down the road.

I certainly not expect it to happen again in such a short time.

It's time like this that present dilemmas.

Do we stay the course and keep close watch to see if the dog stabilizes, and was just going through a phase or withdrawal, or do we take an action that may or may not be justified, and could possibly skew future analysis of the actual problem?

Honestly, I feel that it is up to me to make the call as my Vet is far from being a Dr. Bruyette. He is a good Vet, but has no experience to fall back on regarding Trixie's present particular situation. He would just be guessing too.

Withholding the Trilo, then taking an ACTH on Monday would not make me feel that the results were reliable, as she was off the drug before the test.

My best judgement at this moment is to keep treating her, and see if it looks like she is crashing, then if time allows, take an ACTH as soon as I can get her to the hospital, then stop the drug until the results come back, which has been by the next day, or to take her off the Trilo at time of her crash, and re-start the whole thing from scratch.

I would say that by the end of today or tomorrow, I should be able to draw a conclusion that will be reliable based upon that approach.

I base my judgement on all the past issues I've encountered with my Boxes before, and have gained a good sense regarding when to wait and when to take action.

However, this is my first Cushing's treatment, and I am learning as I go with this one, and having the help of someone like you is most valuable and appreciated.

I appreciate your input, but because of it, wanted to take this moment to be completely open and honest with you regarding what's going on in my mind and gut as it relates to dealing with Trixie's present condition.

If anything I have said makes sense to you, or if you think I am taking too much liberty with this, as it applies to Trixie, please let me know.

Fred.

[Squirt's Mom]

Hi Fred,

These drugs used to treat Cushing's are not to be played with - they are powerful drugs. It is most certainly possible that what you are seeing means that Trixie's cortisol has fallen below that 5.9 into the "too low" range. Yes, that can happen very quickly and the signs should not be ignored. For Trixie's sake, stop the Trilo until you can make sure why she is feeling so poorly. She won't lose any ground doing this but it may save her unnecessary suffering. ;)

How is she acting now after the morning dose?

Hugs,
Leslie and the gang

[labblab]

Fred, I totally agree with Leslie and am going to be more firm this time around in my second reply -- given Trixie's behavior, you absolutely do need to stop the trilostane now. You do not wait until she has a total "crash." At that point, she can get into life-threatening trouble very quickly. All her symptoms are pointing at one or the other situation that Dechra describes: either cortisol withdrawal or genuinely low cortisol. In either case, the medication must be stopped at least temporarily. The question would only be whether she needs additional supportive care, too. PLEASE do not give her any more Vetoryl until you have a better idea as to what is going on!!!

Again, from Dechra's Product Insert:


Hypoadrenocorticism can develop at any dose of VETORYL Capsules. In some cases, it may take months for adrenal function to return and some dogs never regain adequate adrenal function.

Marianne

[busyman370]

Hi Fred,

These drugs used to treat Cushing's are not to be played with - they are powerful drugs. It is most certainly possible that what you are seeing means that Trixie's cortisol has fallen below that 5.9 into the "too low" range. Yes, that can happen very quickly and the signs should not be ignored. For Trixie's sake, stop the Trilo until you can make sure why she is feeling so poorly. She won't lose any ground doing this but it may save her unnecessary suffering. ;)

How is she acting now after the morning dose?

Hugs,
Leslie and the gang


Hi Leslie,
First, let me thank you for helping.

I do realize that these drugs are not to be messed around with, although I am not trying to pass myself off as being anywhere near those of expertise here on the forum. I have a very healthy respect for the Trilostane, and am taking every step very seriously.

Now, to how she's acting after this morning's dose of 50 mg. of Trilostane.

I gave her the Trilo, followed by her breakfast. She ate it with gusto. Then she took her usual drink and got up on her love seat and went to sleep.

A couple of hours later, I summoned her to go outside. She got up, in a tired way, came to the door and went out. She made her way around her yard quite well, peed, and trotted her way back to come back in. She soon got back up on her love seat and went back to sleep.

Although I have been monitoring Trixie's actions, I have the luxury of having her littermate as a comparison. Trixie is doing basically the same thing that Trudie is doing regarding the napping. So Trixie is not showing any signs that differ from Trudie, other than the tired look and actions.

I just summoned her again, this time on purpose to see how she reacted. I spoke excitedly about coming to get a cookie, and to go outside.

Trudie got up and quickly ran to me. Trixie woke up and looked at me, then with more excited coaxing, she got up and came over to me. I let her outside and she functioned well around the lawn and peed. She trotted to the house, came in, was eager to get her cookie and took a drink. Then both she and Trudie got back up on the love seat and began napping.

So, she's function overall better than she was last night. Still has the groggy look on her face, until I mention Cookie, then she brightens up. Not like a perfectly healthy dog, but bright for her condition.

The thing about her crashing is that she really eats very well, and drinks well also. No signs of Addisons other than the lethargy and some wobbling/unsteadiness. But when she goes outside, or comes to me for that cookie, she seems to forget about the unsteadiness.

Her reactions are still good to sharp, depending on the stimuli.

This is why I am having such a hard time pulling the Trilo. She's had Cushing's for a long time, and it has had to have taken a toll on her body and mind. I could understand how she could be going through periods of recovery as she is trying to heal, which could be an explanation of how she was last night. She exhibited similar signs, that I called "cortisol withdrawal," the first and second day after the Trilo was begun, then she began to act markedly better every couple of days. This time, she's not acting as bad as she did the first time.

However, I am less than inches from stopping the Trilo at the slightest sign that she is going Addison. I am using signs based upon the fact that she hasn't vomited yet, her appetite and drinking are still very good, and at times, such as going outside, she moves quite well and is curious over whatever dogs are curious about in the lawn.

So, she seems well enough to continue on the Trilo - MONITORED ON A DOSE BY DOSE BASIS.

Again, these are my findings upon which my assessments are formed, and are posted to you open and honestly with the desire of doing whatever is best for Trixie.

They are in no means presented as opposition to your input and suggestions.

I am trying my best to stay focused and to not over react, yet be willing to act abruptly if I feel as sure as I can be that things need to change and will change them at once.

Thank you again for helping me through this,

Fred.

[busyman370]

Thought I'd throw this in; I realized that I had been in a rather serious mood, as would be easily understood under the circumstances, and decided to stop it and set the mood for the day as it normally is around here to try to also get Trixie out of her state of mind.

I put on the music that we like and started dancing around and that always brings the dogs running to participate. They love that.

Trudie came running over with her usual gusto, and Trixie followed, but with a more subdued enthusiasm, but joined in none the less. Soon her tail was wagging, not with such vigor as Trudie's, but it was wagging, and she would bark with pleasure and play around with Trudy and me.

I wanted to add this because I don't think she would care at all, let alone participate, if she had crossed that line of illness.

However, having said all that, the dogs may think I am just having a wonderful time, and that's what I want them to think, but the reality is that I am watching her like a hawk, and testing her, now and then, with a purpose.

Fred.

[lulusmom]

Trixie seems to be taking a step backward.

As of yesterday afternoon she became very lethargic. She is still very interested in eating and drinking, but otherwise she is mostly out of it.

Last evening I noticed that she went through a few seconds of "drooling" which made me expect that she was about to vomit as I've seen that as the precursor to vomiting in dogs before.

She just sleeps, and when she walks, she marches again and appears somewhat unstable, and she just looks like she's not feeling real well.



It is this description that prompted Leslie and Marianne to post their very strong opinions and I agree with them. Everything you posted are symptoms of low cortisol and with a post stim of 5.9 at only nine days, an Addisonian crisis is a much more likely scenario than the transient effects of cortisol withdrawal. Had you had the stim test done at 14 days, I would have been a lot less worried for Trixie.

The rule of thumb with both Lysodren and Vetoryl is never give either drug to a sick dog and you yourself said Trixie appears to not be feeling well. If drooling, extreme lethargy, unstable when walking and general appearance of illness was normal for Trixie before treatment, then my concerns would much less; however, if these symptoms ar not normal for Trixie, they are not to be disregarded because she still has an interest in food and water.


My first thought was that because she was just a touch low on her thyroid panel, and only needed 0.4 mg. of Soloxine per day to bring her into the range, that she may need to be taken off Soloxine as the Trilo could have easily normalized her thyroid livels by now, and or to reduce her present low dose of Soloxine, as going hyper can bring on lethargy, but I really don't think that's the case.


Given the symptoms you described, Addison's was the first thought on my mind. You can put her hypothyroidism on the back burner for the time being. If Trixie's excessive drinking and peeing has not resolved by now, it's possible that the Soloxine has thrown her into hyperthyroidism but excessiving drinking and peeing caused by over supplementation of Soloxine is not life threatening, Addison's is.


It's hard to imagine that her cortisol could have shot up significantly, or that she is going Addison, in only three days after her 5.9 ACTH to cause these symptoms.

Cortisol shooting up significantly in three days is hard to imagine but going Addison's is not. A 5.9 post stim after only nine days of dosing is pretty low, low enough for most of us to be concerned that it was going to continue to drop.


Seems that whether her cortisol went up of down, it would take longer for her to show signs of it because her ACTH showed that she was in such a middle range of acceptability.

ACTH stim tests are only an assessment of circulating cortisol on the day of the test. There is no predictability with Vetoryl from one day to the next, which is why we should never let our guard down, stay vigilant in monitoring our dogs and follow protocol to the letter. I have read study after study on the effects of Vetoryl and it's known that dogs who have stabilized on the drug and tested within an acceptable therapeutic range for months have suddenly crashed. It is also known that dogs just starting treatment are more likely to experience adverse effects and they are certainly more unpredictable.

I'm sure you've figured out by now that there are a lot of mother hens here and we don't mind sharing our opinions. Just know that Trixie's welfare is our number concern and that our opinions are based on our own dogs' experience and more importantly, a lot of research and a whole lot of case studies we've followed right here on the forum. I think we've seen it all.

Glynda

[busyman370]

It is this description that prompted Leslie and Marianne to post their very strong opinions and I agree with them. Everything you posted are symptoms of low cortisol and with a post stim of 5.9 at only nine days, an Addisonian crisis is a much more likely scenario than the transient effects of cortisol withdrawal. Had you had the stim test done at 14 days, I would have been a lot less worried for Trixie.

The rule of thumb with both Lysodren and Vetoryl is never give either drug to a sick dog and you yourself said Trixie appears to not be feeling well. If drooling, extreme lethargy, unstable when walking and general appearance of illness was normal for Trixie before treatment, then my concerns would much less; however, if these symptoms ar not normal for Trixie, they are not to be disregarded because she still has an interest in food and water.



Given the symptoms you described, Addison's was the first thought on my mind. You can put her hypothyroidism on the back burner for the time being. If Trixie's excessive drinking and peeing has not resolved by now, it's possible that the Soloxine has thrown her into hyperthyroidism but excessiving drinking and peeing caused by over supplementation of Soloxine is not life threatening, Addison's is.



Cortisol shooting up significantly in three days is hard to imagine but going Addison's is not. A 5.9 post stim after only nine days of dosing is pretty low, low enough for most of us to be concerned that it was going to continue to drop.



ACTH stim tests are only an assessment of circulating cortisol on the day of the test. There is no predictability with Vetoryl from one day to the next, which is why we should never let our guard down, stay vigilant in monitoring our dogs and follow protocol to the letter. I have read study after study on the effects of Vetoryl and it's known that dogs who have stabilized on the drug and tested within an acceptable therapeutic range for months have suddenly crashed. It is also known that dogs just starting treatment are more likely to experience adverse effects and they are certainly more unpredictable.

I'm sure you've figured out by now that there are a lot of mother hens here and we don't mind sharing our opinions. Just know that Trixie's welfare is our number concern and that our opinions are based on our own dogs' experience and more importantly, a lot of research and a whole lot of case studies we've followed right here on the forum. I think we've seen it all.

Glynda

Glynda,
Thank you so much for your interest and candor,

Boy, I really don't want to confound things, but in response to the following, I had better comment on this;

"If drooling, extreme lethargy, unstable when walking and general appearance of illness was normal for Trixie before treatment, then my concerns would much less; however, if these symptoms ar not normal for Trixie, they are not to be disregarded because she still has an interest in food and water."

Before treatment, Trixie was not doing well at all.

I have to say that her symptoms now are almost the same as they were before treatment, and is some ways, she's doing better now than she was before treatment.

She will trot in the yard, didn't before, she can jump up on her couch, she could not before, she doesn't cry at night and in the morning like she used to, she has more strength, and areas of her calcinosis cutis are giving the impression of taking a turn for the better.

The lethargy and drooling were there, but it seems so long ago that I admit that I have a hard time remembering all the nuances before Trilostane.

Having said that, she went from crashing for two days after starting Trilostane to really looking much improved, to going back to the lethargy as of two days ago.

I really hope I am not confusing things for you. I am trying my best to be as clear and honest as I can be.

Let's get to the main point as I am very interested in your advise.

As long as she is not getting worse, should I keep her on the Trilostane and do another ACTH test right away? Right away being Monday.

Should I take her off the Trilostane as of right now?

If I take her off the Trilostane, and her ACTH can not be done until Monday, will that skew the results?

I am not worried about the Soloxine either bye the way. It was just a thought. I will have another thyroid panel done to confirm that.

"A 5.9 post stim after only nine days of dosing is pretty low, low enough for most of us to be concerned that it was going to continue to drop."

(It was at ten days, just to be clear) I wish I would have known that, and I can't help but think that my Vet should have told me that as well. I had no idea.

Fred.

[labblab]

Fred, I'm afraid I am confused now, so I am hoping you can clarify. This morning my impression was that the drooling, lethargy, and stumbling was new behavior for Trixie. Are you saying this is how she looked BEFORE starting on the Vetoryl? And that she is now reverting back to the same behavior that you had seen before?

Marianne

[busyman370]

Fred, I'm afraid I am confused now, so I am hoping you can clarify. This morning my impression was that the drooling, lethargy, and stumbling was new behavior for Trixie. Are you saying this is how she looked BEFORE starting on the Vetoryl? And that she is now reverting back to the same behavior that you had seen before?

Marianne


Hello Marianne,
Let me say that I am sorry if I caused any confusion. I want you to know that I absolutely respect the value of your time here on this forum. There are many people in need and you only have so much time to give. That goes for everyone else who helps as well.

I am trying as best I can to do this correctly, and when I see her acting one way when I am expecting to see her acting another way, I wonder what's going on, what should I do?

When I described how Trixie was acting, I wish I'd been more clear.

What I should have said was that yesterday, she was acting like she did during the first two days of Trilo. I took that as the cortisol withdrawal period, then she began to perk up. Then yesterday she seemed to be going through it again.

Having said that, I will get back to your question to the best of my ability.

"Are you saying this is how she looked BEFORE starting on the Vetoryl? And that she is now reverting back to the same behavior that you had seen before?"

The most simple answer to that question is; yes, she did. And yes she is, however those behaviors are much less severe than they were before Trilo. Even at her worst, she is much stronger and generally better overall. She still drinks allot though.

I was about to post my latest observations to the forum when I saw your post to me and wanted to respond immediately.

Here is an update that may help to clear the whole matter up;

As the day is progressing, Trixie has gotten better. No, she's not perfect, but is more alive than she was yesterday and this morning. That could just be the Trilo wearing off, but she is looking better.

So much so that, in my inexperienced mind dealing with cushing's, I really can't choose to react as if she's going addison.

Her stools are normal, no vomiting, and even though she's lethargic, as of around 3pm I would call it just a little subdued/out of it.

Although she spends most of her time sleeping, she is interacting and moving around reasonably well, gets up and down the stairs well enough, she just does it all with a lack of gusto. She has good reflexes, although wobbly, and is far from "passing out."

She is acting more toward the weaker side, but she's managing. She almost acts board, if that makes any sense.

I did just get off the phone with my Vet, who has never used Trilo before either, and we discussed the whole matter in detail.

After we discussed Trixie in detail, we left it like this; worse case if she does start to show symptoms of crashing, give her the Pred.

But he doesn't think she's crashing now, nor will by Monday. So here's the plan;

What I am going to do is to keep her on the current dose of 50 mg. for one and one half more days, then come Monday, I am going to give her her morning dose, then take her to his hospital five hours later and there will be someone available to give her an ACTH test. I usually get the results by the next day.

As long as she isn't really showing serious signs of crashing, I do not want to mess up the test results by taking her off her meds, giving pred or even reducing her dose of Trilo.

IF she takes a bad turn, I'll give her the pred, and stop the Trilo, but I sure hope that doesn't happen because I really want to get the ACTH test results based on her current status.

So, once again, I am deeply sorry that I caused this confusion.

I am not looking forward to giving her the Trilo tonight, and tomorrow morning and evening, then again Monday morning, but as long as she is looking and acting OK, then it seems to be the right thing to do regarding the test on Monday.

I do have the feeling that Trixie may need a lower dose though, I thing she's quite sensitive to the Trilo. But, we'll know by Tuesday.

Thanks again Marianne,
Fred.

[busyman370]

Hello All,
I am working to be properly prepared as I progress with testing Trixie, and I am asking the forum to tell me what blood work should I have done in conjunction with the rest of the testing Regarding Cushing's?

Thanks,
Fred.

[busyman370]

Hello to all,

The main point of this post is to tell you all that as of 10:45 this morning, Trixie began to show much improvement with her overall symptoms.

Now I will submit my story should anyone be interested in reading it.

I worked, searched and thought all day yesterday, trying to try to make sense out of what's been going on with Trixie, progressively, and hit it's peak on Friday evening........

right after I gave Trixie her supper, and....... her SOLOXINE.

Although after her two day withdrawal period, she was doing quite well for about four days, then Friday evening it was like a switch flipped inside of her, and she began to exhibit the symptoms that I posted the forum about.

(which only confused everyone, and I still feel bad about that)

I remember my gut was suggesting that I need to address the soloxine, as she may no longer need it with the way the Trilostane so quickly turned her around, but I did not make a dedicated effort to pursue it. I felt that if it were an immediate concern, my Vet would have addressed it.

I am not one to look backward, but I do regret that one.

When I first noticed that first and slight downturn in Trixie, I did mention my concern about the Soloxine to my Vet in one of our phone conversations, sort of in passing, and he commented in the same manner. The subject was dropped.

But with what I've seen already this morning, I see that it shouldn't have been.

Initially, way back before Trilostane came into the picture, he started her on Desmopressin and also 0.8 mg. of soloxine per day, and she quickly went hypERthyroid....

AND BEGAN EXHIBITING THE SAME KIND OF REACTIONS THAT SHE WAS SHOWING FRIDAY EVENING.

He dropped her down to 0.7 mg. per day, and there was no change. I knew that something was wrong.

Because of my going over her thyroid panel numbers, pouring over Dr. Dodds information, and doing my own analysis, I was convinced that he had her way too high, and after researching the drug, I decided to adjust the dose myself and reduced her dose by cutting the pills to get the amount my calculations said was correct.

I took her off it for three days, then began dosing at 0.175 mg. per day total, then by watching her reaction, stepped it up gradually to 0.35. Trixie got better and fast.

I then requested another thyroid panel and sure enough, she was at an acceptable number at the low normal end of the range. My Vet said that if a dog came in with those levels, he wouldn't even treat it.

My point to all of this is that when Trixie was started on Soloxine, she was just below the low normal range.

That chemical science would dictate that she didn't need much thyroid production to bring her into range, and once the Trilostane kicked in, her normalizing cortisol levels would more than likely take care of that, and there would no longer be a need for Soloxine.

Especially based upon Trixie's minimal need for thyroid supplementation, it would certainly be an experiment worth trying right from the get-go.

So now, the Trilostane has - more than likely - brought her own thyroid production up to where it is probably fine, or very close to it. She's not acting hypo or hyper.

To continue giving her Soloxine, I believe, pushed Trixie into hyper last Friday evening.

Because I arrived at my conclusion later in the day, I had already given Soloxine to her in the morning and at supper, and am kicking myself for it.

But, she did not get anymore this morning!

Soloxine clears the body in one to three days, and frankly, Trixie was doing so well on the Trilostane that I was expecting to see her improving quite noticeably by late this afternoon at the soonest.

She began to show improvement this morning at 10:45 AM!

She doesn't march when she walks, actually went outside and enjoyed wandering around and being in the sunshine. Her energy picked up and when I offered her and Trudie a cookie, she actually pushed her way past Trudy to be first in line.

The expression on her face is no longer the look of doom. She has just perked up overall.

I was planning on doing a thyroid and CBC panel, and another ACTH test on Monday, but if my theory is correct, and she continues to show improvement, I may want to wait a while and go back to the recommended ATCH testing protocol.

However, unless she is acting GREAT, I will at least do the ACTH.

The rest of this day, and tomorrow morning will be very telling.

Fred.

[labblab]

Fred, thanks so much for this update. And you need not apologize for the information you gave us earlier. I would much rather have the opportunity to discuss and to clarify, rather than have you wondering and worrying in silence!!

I am very relieved to hear that Trixie is showing improvement. And if she remains well today, then I don't think I'd bother with the ACTH tomorrow, either. And just remember, since you are using 10 mg. capsules of trilostane, you can easily decrease her dose down from 50 mg. to 40 mg. if she continues to lag a bit. You could then proceed with ACTH testing in a couple of weeks on the lowered dose. That could give you additional information to guide your decisions as to the ideal dose/range for her. If her cortisol has crept higher than you want, you can resume the 50 mg. dosing. But who knows, the 40 mg. might actually end up being the better long-term dose.

Marianne

[busyman370]

Quick update,
This is the first morning that Trixie hasn't already peed on her area rug before I woke to let her out. This is further proof to me that the Soloxine did have her in hyper thyroid.

Also she is just better overall, not great, but better.

She has been "marching" when she walks, and I am using it as one of the gauges of her successful progression, and I understand that is one of the symptoms of Cushing's.

She is marching much less today. Almost walking normally, but she's not there yet. I am also thinking that stopping the Soloxine may have helped the marching lessen too.

Today is day 16 on Trilostane.

Because of these things, and how she just looks better, not great, but better, I am not going to have the ACTH test done today.

As long as she keeps getting better, I will really need to decide when will be the best time to have her next one done.

Fred

[Squirt's Mom]

Hi Fred,

I am so glad to hear that Trixie is doing better! I hope the trend continues!

Hugs,
Leslie and the gang

[busyman370]

I am coming to the forum for some advise.

Now that I've gotten Trixie out that Soloxine fiasco, she has stabilized to an improved degree.

But, I am not able to be real comfortable with it, and here's why.

Bye the way, this is day #2 of no Soloxine, should that play a role in anyone's considerations of what may be going on with Trixie. She may still need more time for it to be eliminated completely, or it may not be playing a role in her current symptoms at all. Just wanted to let you know as much as I can think of that may be pertinent.

She still acts a little out of it. she's just not as "with it," as I am expecting to see her be from the Trilostane treatment. I did not expect miracles by the first day, but did expect to see her much more "normalized" than she is, sooner than two weeks after starting treatment.

To give you all a guide post to relate to, today is day 16 of Trilostane.

I will do my best to tell you how she is appearing to me;

She is steady on her feet, but not steady enough.

When she is napping, and wakes up, she looks groggy.

When going after a definite target; her bowl, the steps, she will be heading for it, and will veer off a little, but right herself and get where she's intending to go. Heading for larger targets, such as a couch, she doesn't seem to exhibit the veering.

And I don't mean she veers terribly way off, just enough so I notice it.

She still does the marching when she walks, not as bad as while on the Soloxine, but she is still marching somewhat. Enough to be noticeable.

She is becoming more demanding when she wants breakfast and supper. She whines and conveys a sense of urgency.

So it seems like a combination of neurological, groggy, or how a dog acts when they've come our of anesthesia, but are not 100% yet.

I am giving her the 50 mg. of Trilostane, and have been considering changing her to 40 mg. per day, as has been suggested to me from the forum as well, and see if anything changes.

What is also confusing to me is that on one hand, she acts like she needs a reduction of Trilostane, and on the other hand, she acts like she needs in increase.

I am not really keen on doing another ACTH right away as the last test really hit her hard, and it took her 45 minutes to come back to normal.

I want you all to know that the financial part of Trixie's treatment is not an issue. I am not restricted financially regarding my choices in treating her.

So when I talk about not doing the ACTH, it is not financially motivated.

The only reason I would mention such a thing is that I do NOT want to send any mixed signals to anyone who cares enough to help me. I want them to have as much information as they may need, and will offer whatever anyone may find necessary to know in order to come up with usable information.

And just so you all know, I admit that I am paranoid regarding the neurological possibilities (pituitary and or brain tumor), and don't want that to skew the actuality of what may be going on with Trixie because of that paranoia.

However, I am aware that it may in fact be what is going on as well.

If anyone needs any more information, do not hesitate to ask. I will be glad to supply any info that may be needed.

I await your feed back,

Thanks to all,

Fred

[addy]

Hi Fred,

I am no expert or anywhere near one. Sometimes a dog has to adjust to the lower cortisol. I know my Zoe did. You know Trixie so well. I just wonder if that is what you may be seeing.

Another thought, and this is just mine, but if it were me, I would want to do the ACTH test before adjusting to a different dose. If what you are seeing is Trixie going too low, you would discontinue the Trilostane (after confirming her cortisol with an ACTH test) for about three days and then start back on a lower dose.

Each dog is different in how they respond to Trilostane and at what rate troublesome symptoms ease up. Usually the excessive drinking and urinating is first to ease, often within two weeks. Depending on how the dog's hind leg weakness was prior to treatment, well, that can take awhile, they have to rebuild some muscle and that doesn't happen overnight.

I understand you don't want to overreact. I am going through similar issues with my pup. we just increased her dose and she also now has a scuff on her eye and started eye drops. It is hard for me to assess if she is more tired because her eye hurts, her cortisol is dropping into range or is she starting to go too low.

Is it possible she is getting up slowly because maybe there are arthritis issues being unmasked? Remember as we lower cortisol we sometimes uncover issues we were not aware of because the cortisol was masking them.

Okay, just my thoughts. The real experts will be along soon:D:D:D

hugs,
addy

[lauraperla]

Hi Fred,
I am sorry that Trixie is not responding as well as you had hoped. I am by no means an expert but I can talk about our experience with Vetoryl. Through 2 years of Saoirse taking Vetoryl, numerous dosing tweaks- and ACTH tests, we never got to a satisfactory point where Saoirse's cushings was controlled. I think it's worth bearing in mind that there are some dogs for whom Vetoryl doesn't do as well as it does with others. I think it's too early for you to feel that way about Trixie but I do think it's something worth holding in the back of your mind.
Regarding Trixie's marching, is it a stiffened gait you are seeing, with a shortened step? I am wondering if she is starting to display arthritis in her elbows, changing with her varied cortisol levels and also being affected by her muscle wasting.
Cushings is such a puzzle. And it always feels there's something else waiting round the corner.
I hope your dear girl is feeling a little better today.

Laura & Saoirse

[labblab]

Hi Fred,

I sure wish I could give you some kind of definite answer to your questions. But I'm afraid there's a lot of "it all depends..." when it comes to Cushing's treatment :o. For sure, ACTH testing will give you concrete numbers by which to plan a course of action, and that is why the periodic testing is so important. But there are also a lot of judgement calls along the way, and I think that's what you're experiencing right now. None of us know Trixie the way you do, so as much as I'd like to say, "do this or that," a lot of the decisions will just depend on your visual observations and your gut assessment as to how she's doing. And when you're in doubt, then the ACTH becomes your fall-back tool.

One other possible "interim" tool that might be easier on Trixie -- prior to your next scheduled ACTH -- might be measurement of a baseline cortisol level. As long as it is safely higher than around 2 ug/dl, it is less likely that her cortisol reserves have dropped too low (in terms of numbers) on this dose. The decrease in cortisol may be enough to make her feel "off," but not unsafely so in terms of genuine Addisonian issues. And if her baseline cortisol is a cause of concern (either too low or too high), that would propel you into knowing that you need to do a complete ACTH now rather than waiting.

But numbers can't tell you everything. It would be so much easier if Trixie were showing across-the-board improvement. But in a situation such as this, as long as her cortisol level is not a concern, I think you're stuck wih hanging in there during this first month or so. Continuing to make your careful observations and keeping a diary of the changes you see. It may just take her a bit longer to stabilize than you would wish.

Marianne

[busyman370]

I would like to diverge from the topic of treating with Trilostane for a moment, and address Calcinosis Cutis.

Can you tell me what the visual signs would be as the Calcinosis is healing, stopping, and perhaps is regressing?

I've noticed changes in Trixie's C-Cutis almost immediately after starting the Trilostane, and lately have been wondering how to judge what I am seeing, and to be prepared for what I may see as we go forward with treatment.

Thanks,
Fred.

[lulusmom]

Hi Fred,

As I recall, you are seeing improvements with the calcinosis cutus, right? I've never real had to deal with it in my two dogs but based on what I've seen here, most improvements have continued but not many were as fortunate to see improvements as quickly as you. I'd say keep your fingers crossed that you continue to see improvements and that Angela or someone with more experience will show up to share their thoughts.

[Sabre's Mum]

Hi Fred

I just have a moment ... school holidays and have to feed two hungry girls lunch.

We treated Sabre with Lysodren but the main thing we saw in the first few months was the halting of more eruptions and the ability to stop infections. Once Sabre's hair grew back in and he was within a "cushings treated" therapeutical range of cortisol he just lived with his plates of calcinosis cutis. In Sabre's case he had many hard plates on his body and they never "resolved", as in dissolved or erupted, but just stayed on the surface of his skin not ever causing any issue unless his cortisol levels went too low in which cause he would become itchy (but not always!).

Hope this helped. .... must go.

Angela and Flynn

[addy]

Hi Fred,

Zoe has the start of calcinosis cutis, she had small raised white spots filled with plaque on her sholders and plaque deposits under the skin on her tail that look like raised hard bumps. I upped her trilostane 2 weeks ago as she was not in theraputic range. The small white plaque spots started getting flatter and smaller and are almost gone but the large bumps on her tail have not yet changed. When I first dropped her cortisol last June the tail bumps cleared up pretty quickly. But this time not so much. I have to give it more time, I hope.:D

hugs,
addy

[busyman370]

hello All,
First let me thank those who've responded to my question's regarding Calcinosis Cutis.

Next, I wanted to update the latest with Trixie.

She seems stable. As I stated earlier, sometimes she looks like she could an increase in Trilostane, and at other times a decrease, so for now, I will assume she is somewhere in the middle.

She does not show any signs of crashing, nor of having an unsafe high level of cortisol. And as long as she continues, I am going to proceed as follows.

I scheduled an ACTH stimulation test and a complete Thyroid panel for April 24.

That will be the one month mark of her being on Trilostane.

Since the 24th is less than two weeks away, and since she is holding her ground, I chose to wait until then to do the tests because I believe that the results will yield more useful results than if I did them this week.

I am also aware of the brain tumor issue, as some of the signs of Cushing's are the same or similar as those of a brain tumor. The two areas of the brain I am concerned with are of course the pituitary and also the brain stem region.

One of the things I am hoping for from the ACTH test is to find out if she needs an increase, decrease, or stay on the same dose she is on, and to then have an educated idea that her cortisol under control.

Then, after another few weeks, if she still exhibits symptoms that may suggest brain tumor, I can be better prepared as we head forward.

So, as long as she stays at least as good as she is today, I will stick to the plan I described. If not, then I will make that decision at that time.

Right now, because of the wide range of possibilities regarding what's going on with Trixie, the only word that I can come up with to best describe Trixie's present state is enigmatic, with the very slightest indication that she may be showing the most minimal signs of improvement.... maybe.

Fred.

.

[busyman370]

Hi All,
You guys are going to get sick of me, I seem to be on the forum quite a bit, but I had to post this.

Trixie had a breakthrough day today!

Seems like the Trilostane finally has her at the early stages of getting caught up. I noticed it at 4:00 pm today when I let her out to pee.

She went outside alright, but when she headed back to the house, she actually tried to run! I was shocked to see that.

And her reflexes are much improved. I dropped something and she jumped a mile! And the expression on her face is almost normal.

Just an overall, minor but significant, improvement in her strength and vigor.

I realized that I really need to be careful with her so she doesn't hurt herself by allowing her mind to try to make her body do what it's not ready to be doing quiet yet.

She was really in bad shape when we started treatment, it's obvious her body has been working overtime to heal.

As we all know, things can take a turn in a heartbeat, but things are what they are, and Trixie does seem to have taken a good step forward.

In a few weeks she'll have her ACTH and blood chemistry done. I will also do a specific gravity while I am at it, and have my Vet go over her with a fine tooth comb.

I was going to do a thyroid, but she really doesn't look like it's an issue, but I will probably do one anyway when I do the blood chem, just to know what her numbers are.

I am probably overdoing it, but so far I have been measuring ten times so I can make one reliable cut. I am going to have her ACTH done, then wait a week to do the blood Chem. I don't want to do them both the same day as they would need to take the blood for the chem panel before they took it for the ACTH, and I want to make sure her blood volume is at it's normal state before injecting the cortisol. The last injection really hit her hard and I don't want that to happen again if I can avoid it.

Now I am really looking forward to how she's going to look and behave by this weekend.

Thanks for listening,
Fred.

[Squirt's Mom]

This sounds great, Fred! :)

[addy]

That is great news!!!! And we never get sick of members posting!!!

Fred, there are quite a few ups and downs and sideways with Cush pups. Two steps forward, one step back back sometimes.

You can tell us ALL of them:):):)

hugs,
addy

[busyman370]

This sounds great, Fred! :)

Thanks Squirt's Mom;73656!

[busyman370]

That is great news!!!! And we never get sick of members posting!!!

Fred, there are quite a few ups and downs and sideways with Cush pups. Two steps forward, one step back back sometimes.

You can tell us ALL of them:):):)

hugs,
addy

I seem to holding up my end rather well! LOL

[busyman370]

Hello All,

I am preparing to have a blood panel done on Trixie, and I need to make sure I get the right chem work done.

The Dechra literature only says to especially find the numbers on renal, hepatic and electrolyte.

Would I just request a complete CBC, but emphasis that the renal, hepatic and electrolytes are particularly important?

There are many many things a doctor or vet may request on those lab reports and I don't want to miss something important.

I started a new thread because I felt that the subject of blood chemistry is not the theme of my posts regarding the Trilostane. And because this is something that may be of value to many.

Thanks,
Fred.

[labblab]

Hi Fred,

I hope it is OK with you, but we've moved your reply back on to your original thread about Trixie. I know you were wanting it to stand alone as a separate thread, but your question still does relate to Trixie's own circumstances. For members to be able to give you knowledgeable feedback, they have to be able to review her diagnostic and treatment history. So I hope you'll bear with us. And I'll return myself in a little while in order to give you my own thoughts.

Marianne

[labblab]

OK, I'm back, and hoping that our lab expert, Debbie ("StarDeb55") will be by to comment. But in this instance, I think it's a Chemistry panel that you are most interested in, and not a CBC. The CBC gives you an an analysis of the blood cells (red count, white count, platelets, etc.). Certainly that info is important at times. But at the trilostane monitoring rechecks, what you are most interested in are the blood chemistries which will include information about the function of the kidneys, liver, and pancreas; glucose level; and also the electrolytes (most importantly, sodium and potassium).

It may be just as easy and not much more expensive to perform a CBC as well. But for certain, you want a Chem panel done.

[busyman370]

Hi Fred,

I hope it is OK with you, but we've moved your reply back on to your original thread about Trixie. I know you were wanting it to stand alone as a separate thread, but your question still does relate to Trixie's own circumstances. For members to be able to give you knowledgeable feedback, they have to be able to review her diagnostic and treatment history. So I hope you'll bear with us. And I'll return myself in a little while in order to give you my own thoughts.

Marianne

Hi Marianne,
Looks like I did it again!

Sure it's OK, my life's been moving at around 100 miles an hour lately, and thought that the post may call for a new thread, so I started one. But after reading your very logical explanation, I understand and thanks for moving it where it will do the most good.

Fred

[busyman370]

OK, I'm back, and hoping that our lab expert, Debbie ("StarDeb55") will be by to comment. But in this instance, I think it's a Chemistry panel that you are most interested in, and not a CBC. The CBC gives you an an analysis of the blood cells (red count, white count, platelets, etc.). Certainly that info is important at times. But at the trilostane monitoring rechecks, what you are most interested in are the blood chemistries which will include information about the function of the kidneys, liver, and pancreas; glucose level; and also the electrolytes (most importantly, sodium and potassium).

It may be just as easy and not much more expensive to perform a CBC as well. But for certain, you want a Chem panel done.

Thanks Marianne,
That makes sense. I will be probably do both, especially from what the poor girl has been through. I'd like to get update's on her physiology anyway.

I will also be looking forward to Debbie's comment.

Thanks again,
Fred.

[StarDeb55]

Fred, Marianne's comments are spot on. What needs to be done is an electrolyte (sodium & potassium) check. CBCs are done to monitor for an infection which would show as an elevated WBC, or anemia which would be a decrease in the hemoglobin.

Debbie

[busyman370]

Fred, Marianne's comments are spot on. What needs to be done is an electrolyte (sodium & potassium) check. CBCs are done to monitor for an infection which would show as an elevated WBC, or anemia which would be a decrease in the hemoglobin.

Debbie

Hi Debbie,
Thanks for the clarification and additional info. I wrote down the info that Marianne gave to me, and I will orchestrate Trixie's bloodwork based on it.

It is exactly what I needed to know, and I feel good about being able to proceed forward with confidence.

Thanks Debbie,
Fred.

[busyman370]

Hello to all,
This is just a quick note to express my appreciation for this forum.

I am well aware that Trixie and I are just getting her treatment off the ground, and we'll have the rest of her life to continue dealing with it, but I strongly feel that if it weren't for the forum, I don't think Trixie's treatment would have gone as well as it has so far.

And knowing that all you guys are here for us has given me a feeling of relief, understanding, faith and confidence, and that is something I will never forget.

I sometimes can not believe how much important and applicable information I have received in such a relatively short period of time. Not trying to sound overconfident, or to be seen as minimizing things, but I really feel that I now have a firm grip on Trixie's treatment, and my outlook as we go forward is confident.

Please don't misconstrue this statement as I am not at all taking a caviler attitude. I know how serious this is, and how crucial the proper management of it must be.

I will end by saying that the sincere level of caring I have both seen and experienced on this forum is also something that has touched me deeply.

Sincerely,
Fred.

[addy]

Hi Fred,

We are all in the same boat, pretty much walking in the same shoes. So we all understand each others plight. We all get it and we all care for each other and all the pups.

I am glad you feel more confident about Trixie's treatment. That is so important. And we all keep learning really. New studies come out, etc.

We are really glad you found us and our now part of our family.

We are always here for each other. Will always be herr for you and Trixie.

Hugs,
addy

[Squirt's Mom]

Mornin' Fred,

Your heart-felt words express what many of us here feel. There is no doubt in my mind that without our family here, my Squirt would no longer be with me. In the beginning of our journey, I talked with several groups but it wasn't until I got here that I felt any hope, any sense of true caring and compassion, and a sincere desire to see us both learn to live with the changes in our lives.

Squirt saved my life; k9cushings saved Squirt, and my sanity. I consider each and every pup and human here a blessing in our lives, an invaluable gift.

It does this old heart of mine good to hear that you have many of the same feelings about k9cushings. Thank you for taking the time to say so.

Many hugs,
Leslie and the gang

[busyman370]

Hello Everyone,
I have a question.

I am preparing to do another ACTH on Trixie, and have seen conflicting information regarding how long to wait after giving her her morning dose of Trilostane.

The Vetoryl info says to do the ACTH between 4 to 6 hours after giving the Trilostane.

Dr, Mark E. Peterson says, and I quote;

"With trilostane, it’s extremely important to give the morning medication with food, and then start the ACTH stimulation test 3 to 4 hours later."

I have been splitting the recommended Vetoryl time difference and doing test at 5 hours post Trilostane.

Now, after reading what Dr. Peterson said, I am wondering if I am waiting too long?

I would like to get your advise as to what you think is the best time to do the ACTH test post pill.

Thanks,
Fred.

[labblab]

Fred, if it were me, I'd stick with consistency and schedule this ACTH at the same time (5 hours) that you had the previous one done. That way, you'll be comparing apples to apples when it comes to evaluating the test results. At this stage, I think that's the most important criteria so long as you're still within Dechra's recommended time range.

(And thank you so much for your sweet comments above about the forum. They are VERY MUCH appreciated!!)

[busyman370]

Fred, if it were me, I'd stick with consistency and schedule this ACTH at the same time (5 hours) that you had the previous one done. That way, you'll be comparing apples to apples when it comes to evaluating the test results. At this stage, I think that's the most important criteria so long as you're still within Dechra's recommended time range.

(And thank you so much for your sweet comments above about the forum. They are VERY MUCH appreciated!!)

Marianne,
I agree with you. Keep things constant and on the same schedule = apples to apples. Makes sense.

I was just thrown when I saw Dr. Peterson's 3 to 4 hours post pill.

So far, everything I have read, including the Dechra info, says to do the ACTH 4 to 6 hours post pill. So I figured that 5 hours is perfect timing.

I understand that Dr. Peterson is a big gun in endocrinology, but I have to wonder why he thinks 3 to 4 is the way to go?

Just my opinion, based upon my life experience, but if I were pushed to choose one over the other, I'd have to go with Dechra's recommendations.

They make the drug, base their dose protocol on clinical studies, and ultimately have the most to gain from the sales. And the best way to increase sales is to recommend that it used in the way that produces the most satisfactory results.

But, that's just my take.

Regarding my comments about the forum, you are most welcome. I meant every word of it.

Thanks once again for your help,
Fred.

[busyman370]

Hi All,
I thought I'd post an update on Trixie. She has been doing better on a steady basis.

Over the last few days, I noticed that she is really starting to look and act more like her old self. She is much stronger overall, and I especially notice the improvement in her hind legs.

Her facial expression has been looking more like a happy dog. She is much more alert and her reflexes are almost back to normal.

After I took her off the Soloxine, I was giving her fiber, am and pm, both because her stools were rather dry, and she could only hold herself up just so long with those weak hind legs, so dry stools was not a good thing. Yesterday I stopped the fiber as they were starting to get a bit too loose. And sure enough, her late day potty was very good. Her body metabolism has obviously picked up as the result of the Trilostane doing it's job.

She had gotten rather skinny looking, but she seems to be putting on some weight lately. As she has gained in strength, I have increased her food just a little bit as I want to help that along and get her filled back out and at a good and healthy weight for her.

And I am very happy to see that what I called the megaesophagus-ie drinking has progressed to almost normal drinking.

She would take about 5 laps, then pause, then take another 5, and repeat until she was done. I was really worried about that.

Also, when she ate a little Mother Hubbard bone shaped treat, she would almost choke on it, and a couple of times she almost did, so as soon as I saw that it wasn't a fluke, I stopped giving them to her and instead gave her some pieces of whole wheat bread soaked with water. Now she can take the treats just fine, but I do run some water on it before I give it to her, and make her take it slowly. Pretty soon, based on her progression, I am sure that she will get past that as she really already is not, I just don't want to take any chances.

Just over the past few days, she is eating her meals much better and faster as her ability to swallow has improved dramatically. I take that as another sign of the Trilostane.

So that's it for now. Next Tuesday she gets her ACTH. I am really looking forward to the results. I just hope it doesn't hit her as hard as the last one did. If you remember, it took her 45 minutes to get back to normal after the injection. It really flattened her.

Fred.

[busyman370]

Bye the way, I have two more questions.

The last ATCH, the cortisol was cold, right out of the fridge. The Tech warmed it up in her hands before injecting, but I don't think it was really at room temp. Would you say that being cold is nothing to worry about, or should I insist that the Tech makes sure it's warm enough before injecting?

And, I was concerned by how that cortisol hit Trixie within seconds after injection. It really flattened her and it took 45 minutes before she got back to normal. Is that a normal response with the ACTH test?

Thanks,
Fred.

[addy]

Hi Fred,

I cant answer about the temperature of the drug. I do know that Zoe has had ALOT of ACTH tests. In the beginning, before we had her on Trilostane, the tests knocked her out. I usually took the day off from work. She even threw up after one. Since we started the Trilostane, her reactions have not been as strong and I think perhaps the difference may have been pre Trilostane she had the test on an empty stomach as she was fasted for multiple tests. Now she has her Trilostane with food prior to her test. I give Zoe her whole breakfast.

Many of the endocrinologists think the test is done best 3-4 hours after dosing. Trilostane peaks so fast in the pup. We have always gone 4-5 hours but I try to push the IMS to be consistent, which is sometimes a challenge:rolleyes::rolleyes:

In fact we are off this morning for Zoe's ACTH test!!!!!

It sounds like Trixie is doing well. That is happy news!!!

hugs,
addy

[busyman370]

Hi Fred,

I cant answer about the temperature of the drug. I do know that Zoe has had ALOT of ACTH tests. In the beginning, before we had her on Trilostane, the tests knocked her out. I usually took the day off from work. She even threw up after one. Since we started the Trilostane, her reactions have not been as strong and I think perhaps the difference may have been pre Trilostane she had the test on an empty stomach as she was fasted for multiple tests. Now she has her Trilostane with food prior to her test. I give Zoe her whole breakfast.

Many of the endocrinologists think the test is done best 3-4 hours after dosing. Trilostane peaks so fast in the pup. We have always gone 4-5 hours but I try to push the IMS to be consistent, which is sometimes a challenge:rolleyes::rolleyes:

In fact we are off this morning for Zoe's ACTH test!!!!!

It sounds like Trixie is doing well. That is happy news!!!

hugs,
addy


Thanks for replying addy,
Hope Zoe's test went well for her. Let us know how things went. Trixie's getting hers this Tuesday at Noon. I hope it isn't as hard on her as the first one after she started Trilostane was.

Take care,
Fred.

[busyman370]

Hello All,
I am making a prediction.

I believe that Trixie's next ACTH this Tuesday will show that she needs an increase in her Trilo dose.

She is still doing well, but over the past few days, I've noticed that she starts to regress sooner in the day than she has been. To me, it looks like the Trilo is starting to wear off a little quicker than it was.

I am really glad that she only has to wait a few more days before the ACTH test. I should have the results the next day, so I'll know where we stand with the present dose.

She is on a lower dose, just a touch over one mg per pound, so if she needs an increase, I won't be surprised.

And by how she's been looking and acting the last few days, I am really expecting that her dose will need to be increased.

Take care,
Fred.

[busyman370]

I am looking for some feedback regarding the dogs reaction to the cortisol injection given during the ACTH test.

Today Trixie had her ACTH test and did not react to the injection at all, it was a non event.

The last time the injection flattened her, and it took 45 minutes for her to get back to normal.

Either the Trilo has gotten her to the point where she can handle the cortisol better, or the Vet Tech did something different.

A different Tech did the test this time.

I'd appreciate hearing your thoughts on this.

Tomorrow I'll post her test results.

Thanks, Fred.

[addy]

Hi Fred,

Good luck with your stim results, I was thinking about Trixie today and came home to see if you had an update.

My experience with Zoe has been I thought I could tell if she would be higher or ok depending on if she was calm and/or sleeping for the hour, waiting for the last draw.

I found out for Zoe, it meant nothing. Sometimes she would sleep and still be really high with her cortisol. Sometimes I wondered if it was because she gave them problems and she was just tired after the to-do:D:D:D

Last Thursday she slept for the whole hour, we woke her up and she left with the tech for the post draw, came back raring to go, barking for treats!!!!

I dont think about it any more.:rolleyes::rolleyes::rolleyes: She has gone through so many.

Sorry I am not much help.

hugs,
addy

[Squirt's Mom]

Hi Fred,

Squirt usually has no reaction at all to the stims but on the few occasions that she has, I couldn't tell you what the possible differences were between those tests and the ones when she didn't react. Same doc, same agent, same office. Some pups seem to react and others never do.

A lot of help this morning, huh? :p

Glad Trixie is doing well and hope the trend continues!
Hugs,
Leslie and the gang

[busyman370]

Thanks addy and Squirt's Mom,
Appreciated the feed back. I did help me in trying to keep abreast of things regarding Trixie's progress, and how she act's during the process.

Thanks again,
Fred.

[busyman370]

Hi All,
Here are the results of Trixie's ACTH test.

Her first test was done on March 21st. I will show her test results in a progression from her first test up to and including this last one.

3-21: Pre ACTH-----4.0 ud/L------------Post ACTH 39.7 ug/dL

4-3: Pre ACTH-------2.1-----------------Post ACTH 5.9

4-24: Pre ACTH-----1.4------------------Post ACTH 4.3

Vetoryl says that with the 4.3 number that I should keep her on her present dose, which is 50 mg. of Trilostane once per day with breakfast.

My Vet likes this number and said to plan to stay in the current dose for the next six weeks, then do the Chem panel as he feels the Chem panel will be more accurate at that time, and depending on how she's doing, we may do another ACTH test as well.

Of course, should Trixie take any kind of turn, then the whole picture changes.

Trixie is coming along slow but sure, and this is day 32 of being on Trilo.

Going by Vitoryl's progression bar graph, I am really expecting her to really start looking much better as we progress from day 42 and onward to day 84.

So, please let me know how you feel about all of this. Your feed back means so much to me.

Thanks again for being there,

Fred.

[addy]

Im not an expert but that looks pretty good to me:D:D:D

No need to change dose now. I have read it is not unusual for a dog to be sensitive to Trilostane initially and then need increases, then plateau out. We know the cortisol can conitnue to drop those first 30days too.

Good job Fred!!!!!!! Way to go Trixie!!!!!!!!

Zoe was pre 3.7 and post 7.3 so we upped to 40mgs and she is 18 pounds:rolleyes::rolleyes::rolleyes::rolleyes:

hugs,
addy

[lulusmom]

Hi Fred.

I agree with your vet, I like those numbers too and I agree with keeping Trixie on her current dose. However, if all of her symptoms have not resolved, then there may be cause for concern that perhaps once a day dosing may not be effectively controlling cortisol throughout the day. What symptoms are you seeing right now? Do any symptoms seem to get worse later in the day?

[busyman370]

Im not an expert but that looks pretty good to me:D:D:D

No need to change dose now. I have read it is not unusual for a dog to be sensitive to Trilostane initially and then need increases, then plateau out. We know the cortisol can conitnue to drop those first 30days too.

Good job Fred!!!!!!! Way to go Trixie!!!!!!!!

Zoe was pre 3.7 and post 7.3 so we upped to 40mgs and she is 18 pounds:rolleyes::rolleyes::rolleyes::rolleyes:

hugs,
addy

Thanks addy! Yes, Trixie went through cortisol withdrawal at the beginning and then started to get better and better, so I see what you mean.

Take care,
Fred.

[busyman370]

Hi Fred.

I agree with your vet, I like those numbers too and I agree with keeping Trixie on her current dose. However, if all of her symptoms have not resolved, then there may be cause for concern that perhaps once a day dosing may not be effectively controlling cortisol throughout the day. What symptoms are you seeing right now? Do any symptoms seem to get worse later in the day?


Hi lulusmom;74497,
Well, it's good that so far we are all happy with Trixie's numbers!

Trixie has been on Trilostane for 32 days.

For the purpose of clarity, are you saying that at day 32 on
Trilo, all of Trixie's symptoms should be resolved by now?

After the first week on Trilo, and up to the last week or so, Trixie did seem to "sag a little backward" toward the end of the day, and appeared like another late day dose of Trilo would perk her back up.

But then again, on other days, she would act fine.

Lately, she has not been "sagging back" enough to really notice it. Sometimes it's a little hard to get her up and moving when it's time for her to go outside, but once she gets going, she's fine. She still shows some leg weakness, but is still much stronger than she was no too long ago.

I just figured it was more than likely the Trilo and her body have been working together to get her to the point where all her symptoms are finally resolved, and she's maybe half way there as of today.

Since it's only day 32 on Trilo, I am not expecting all of her symptoms to be fully resolved, but she has been progressing at a slow but steady pace, so I'll consider that a win for now.

The biggest thing I see with Trixie is that if I don't catch her early in the am, she'll pee on the floor, and once in a great while, she'll poop too.

It used to take her a long time to finish her meals, but lately she is basically back to her usual speed on eating.


The Calcinosis Cutis has "stopped" and has "calcified" (?) The C-Cutis on her groin is still there, but is not spreading. That too seems to have halted progression.

So, that's about it as of today.

Now that you have my update, how do you feel about the twice a day dosing? I have been considering it myself, but am waiting a while longer to see how she does in another month to month and a half, then re-evaluate.

Thanks so much for your input,

Fred.

[lulusmom]

Hi Fred,

I apologize for being as clear as mud about resolving symptoms. To clarify, the most common symptoms to resolve quickly are the excessive drinking and peeing and the appetite. Coat and skin issues, including calcinosis cutis, as well as regaining muscle mass, can take upwards of four to six months.

[busyman370]

Hi Fred,

I apologize for being as clear as mud about resolving symptoms. To clarify, the most common symptoms to resolve quickly are the excessive drinking and peeing and the appetite. Coat and skin issues, including calcinosis cutis, as well as regaining muscle mass, can take upwards of four to six months.


Hi lulusmom;74551,

Thanks for the fast reply.

If I may, when you say that most common symptoms resolve quickly, I'd like to ask you; by quickly, do you mean during the initial 14 days, or closer to 30 days, of even longer?

I am learning as I go, and have a certain curiosity as to how Trixie is, and will, fit into the averages of progress. I have been using the bar graphs provided by Dechra as a guide, and so far, regarding Trixie's various progression's, they seem pretty accurate in some ways, and not so much in others.

I am not faulting those graphs, in fact I am so glad that Dechra provided them. At least I have something to go by regarding what to expect.

Fred.

[busyman370]

Update and question on Trixie,
Since Trixie started Vetoryl she has been making slow but steady improvement.

It's been 45 days now, and she has stopped making progress.

She is not back-sliding, just not progressing forward regarding improvement of her symptoms.

The thirst and urination still are not where they should be, especially the thirst. Her urination is fine with the exception of the early am pee on floor.

I am thinking that, at the rate she's going, she'll take a couple of months more before I can make an accurate assessment.

I'd appreciate some input to help me get some understanding of, and opinions as to why, she has stopped progressing.

Thanks,
Fred.

[addy]

Hi Fred,

I dont think I have any insight for you. I wonder if they reach a plateau or perhaps in the beginning, the cortisol drops so that some improvements are very noticable and then as the pup gets used to the lower cortisol, the improvements are more subtle?

Zoe finally is controlled and under 5. When I first changed her dose to 40 mgs a few weeks ago, I could see a difference in her, not all good, really, then the second week, it was like, dose increase, what dose increase Mom?:rolleyes::rolleyes: I was sure I was looking at another dose increase this week.

How is the Calcinosis Cutis? I seem to remember you did see an inprovement with that early on. Zoe had an improvement early on as well and when I mentioned that to my IMS she told me that was "very unusual".

Sorry I am not much help as usual:rolleyes:;) But at least I was able to say hi to you and Trixie!!!!!

hugs,
addy

[lulusmom]

Hi Fred,

When you say Trixie is not making any more progress in her symptoms, what are you seeing besides the excessive drinking and accidents in the am? You mentioned that the peeing is better but not the drinking. The two are usually tied together as dogs with cushing's drink large amounts of water to keep up with the large amounts of pee so as to not dehydrate. Can you tell me if Trixie's pee is still dilute (clear like water with no odor)? If so, she is still not concentrating her urine which would explain the continued excessive drinking.

Sometimes dogs who have been drinking and peeing for a very long time, go through what is called medullary washout. In simple terms, this means the stuff the kidneys need to concentrate the urine has been washed away and sometimes takes a bit of time to normalize. This is one possibility or another possibility is that Trixie could be one of a small percentage of dogs who will eventually need twice daily dosing to control cortisol throughout the day in order to see complete resolution of symptoms.

Depending on what symptoms you are seeing that persist, you may not want to wait six weeks to address the problem with your vet. If Trixie does need a pm dose, your vet may not see the improvements he expects on the blood chemistry.

Glynda

[busyman370]

Hi Fred,

I dont think I have any insight for you. I wonder if they reach a plateau or perhaps in the beginning, the cortisol drops so that some improvements are very noticable and then as the pup gets used to the lower cortisol, the improvements are more subtle?

Zoe finally is controlled and under 5. When I first changed her dose to 40 mgs a few weeks ago, I could see a difference in her, not all good, really, then the second week, it was like, dose increase, what dose increase Mom?:rolleyes::rolleyes: I was sure I was looking at another dose increase this week.

How is the Calcinosis Cutis? I seem to remember you did see an inprovement with that early on. Zoe had an improvement early on as well and when I mentioned that to my IMS she told me that was "very unusual".

Sorry I am not much help as usual:rolleyes:;) But at least I was able to say hi to you and Trixie!!!!!

hugs,
addy

Hi addy,
thanks for the info, her calcinosis cutis seems to have stopped progressing, just charcoal gray color now. The "sores" under her groin are still pink, but as I said before, not progressing, so that's a good thing.

Thanks addy,
Fred.

[busyman370]

Hi Fred,

When you say Trixie is not making any more progress in her symptoms, what are you seeing besides the excessive drinking and accidents in the am? You mentioned that the peeing is better but not the drinking. The two are usually tied together as dogs with cushing's drink large amounts of water to keep up with the large amounts of pee so as to not dehydrate. Can you tell me if Trixie's pee is still dilute (clear like water with no odor)? If so, she is still not concentrating her urine which would explain the continued excessive drinking.

Sometimes dogs who have been drinking and peeing for a very long time, go through what is called medullary washout. In simple terms, this means the stuff the kidneys need to concentrate the urine has been washed away and sometimes takes a bit of time to normalize. This is one possibility or another possibility is that Trixie could be one of a small percentage of dogs who will eventually need twice daily dosing to control cortisol throughout the day in order to see complete resolution of symptoms.

Depending on what symptoms you are seeing that persist, you may not want to wait six weeks to address the problem with your vet. If Trixie does need a pm dose, your vet may not see the improvements he expects on the blood chemistry.

Glynda

Sorry I was so vague.

She seems to be in a holding pattern regarding what we look for regarding the signs that the dog is progressively getting back to "normal."

As I said, she's not backsliding, but her strength and animation have been at a constant state for a couple of weeks.

Her urine does not look diluted. ( believe me I've seen enough of it! )

I understand the connection between frequent drinking and frequent urination, but in her case, I think it's just that she has gotten into the habit of drinking right before bed.

I put a stop to that, and no more am pees. She goes outside and does it like normal. Same thing with her pooping.

She is not showing any symptoms of dehydration, and actually doesn't drink that much during her waking hours, I got to thinking that the drink before bed was somewhat of a habit.

She is now spending the night in her crate, as I am trying to get her as back to her normal life as I can, in small stages of curse.

I care for her so much, and it is because of it that I also have been gradually bringing back the obedience end of being a member of the household. The worse thing I could do is to spoil her in the actual sense of the word.

As I said, we're around the 40 day mark, and frankly, I had planned on waiting until we reach the 80 day mark before drawing any conclusions.

Her holding pattern may just be part of the cycle that dogs go through as the Vetoryl is doing it's work. There's allot of healing to be done, and Rome wasn't built in a day.

I just wanted to bounce this off the forum to see if "holding Patterns" were considered normal.

I'd appreciate your opinion, now that I've hopefully cleared my question up.

Thanks,
Fred.

[lulusmom]

Hi Fred.

Yes, you clarified things for me. As far as loss of strength and animation, like you said Rome wasn't built in a day. Loss of muscle mass didn't happen over night and it takes a while to regain it. My second cushdog didn't come back to life until his legs got stronger. That was a long time ago but I believe it took no less than four to six months to get there. When it finally happened, I was ecstatic to see him jumping up and down on his hind legs. That was a red letter day for me and that's when I learned that patience is a virtue. I thnk that phrase was coined by someone who shared their life with a cushdog. :D:D

[busyman370]

Hi all,
I am once again trying to figure out what's going on with Trixie.

She is on day 54 of Vetoryl, and still at the 50 mg. dose, once in am with breakfast.

She is eating very well, and the thirst and urination have improved quite a bit.

However, she is so sleepy. She has NO energy or animation. Her eyelids sag and she looks exhausted.

When I get her up to go outside she seems to have trouble waking up and getting her body to respond, and seems to have trouble gaining her balance, and her legs seem generally weak until she gets moving.

In the beginning, along with all the other Cushing's symptoms, she used to march when she walked. The marching seemed to almost go away, and now she marches quite often again.

She seems "groggy" much of the time, and sleeps very deeply, and it is hard to wake up and get her going.

And also she seems to get confused, but that's hard to explain.

Her skin has improved, and the C-cutis has halted, and seems to be in the early process of actually reversing.

It's the grogginess, weakness upon waking, the very deep and almost constant sleep, and that confusion thing that I am most wondering about.

As this is my first experience with Vetoryl, I have no idea if Trixie's symptoms fall somewhere within the window of what would be a normal course of progression by day 54.

Her next ACTH is due near the end of July.

Her last ACTH numbers on April 9 were just about perfect bye the way.

I don't want to do an ACTH test - or put her through it - at every corner just because I'm not sure how to read her.

On the subject of "crashing", from what I can find, signs include vomiting, lack of energy, listlessness, diarrhea and loss of appetite. However, these signs do often go away or lessen with time or dose adjustment

The listlessness and lack of energy fit her, but other than those, she's fine overall.

I'd appreciate some input on this.

Thanks,
Fred.

[lulusmom]

Hi Fred,

I always hate bringing up this subject but there is a possibility that a dog with a macro adenoma (large pituitary tumor) may experience accelerated tumor growth once treatment starts. Boxers and other brachycephalic breeds seem to be predisposed to larger tumors. Neurological signs can be very subtle initially and listlessness and mental dullness are some of the initial symptoms. How is Trixie's appetite? You may want to discuss this with your vet. In the meantime, I'm including a url to some good information on pituitary macroadenomas.

http://ncvc.omnibooksonline.com/2011/data/papers/SA-Peterson3.pdf

Glynda

[addy]

Hi Fred,

I will throw this out there based on my experience with Zoe. Is it possible Trixie is not hearing as well as she used to?

Last summer when we first started dropping Zoe's cortisol it became apparent that her hearing had diminshed. She would be in a deep sleep, so deep that sometimes when we would come home, she did not even hear us. But she could not hear us come in. She too would have trouble rising and it seemed she had to shake herself out of a fog. After a few minutes, she would be alert. Zoe also slept a lot and she still does. But when she is awake she is active and alert. For some reason the last few weeks, she seems to be hearing a bit better.

My thoughts were, the deep sleep was from the lack of hearing, adjusting to the lower cortisol and probably part of it a side effect from the Vetoryl. My thoughts on her difficulty getting up, I attributed to her hind leg weakness and arthritis the high cortisol masked. She has started knuckle dragging again when we walk so I am back to working one day on one day off walks.

Maybe she has a macro tumor and I am seeing the start of neurological symptoms but right now I believe it is her hearing, the drug and arthritis.

So, I am sharing what I am going through just to give you some additional thoughts.

hugs,
addy

[busyman370]

Hello All,
It suddenly became crunch time for Trixie and me.

Trixie is showing some signs that are perplexing and need immediate attention in order to correct - if possible, and I just found out that I will be having surgery soon which may either limit or completely remove my ability to take care of her.

Best case is I am hospitalized for three days, worse case is that I die. I have an aortic aneurysm and it needs surgery asap before it bursts.

I have been scrambling to try to get Trixie straightened out as soon as I can, time is a real premium now.

Here's the perplexing situation with Trixie; she has been showing classic signs of a number of possible conditions.

General weakness, lethargy, mentally dull, listless, loss of interest in normal household activities, delayed response to stimuli, and brief episodes of disorientation, occasional unsteadiness on her feet, slow to wake from a usual very deep sleep, and an overall lack of any zest for life.

Some of these signs also include trilostane overdose, which I know is not the case.

Now, if this is a "brain tumor," or other life threatening illness, then the answer is a slam dunk. I will euthanize her. I've been there before and when the dog loses complete quality of life, it's the only humane thing to do.

However, I want to concentrate on the Cushing's/Vetoryl end of the issue to be sure I've done everything I can regarding treatment.

Vetoryl says that Post ACTH of 1.45 to 5.4 to stay on current dose.

A post of 5.4 to 9.1 to stay on current dose - IF - symptoms are controlled. If they are not, then increase the current dose.

I just had an ACTH test done two days ago, and her numbers were 6.4, which is a little on the higher side.

Her priors were; 39.7 pre Vetoryl on March 21, 5.9 on April 3, and 4.3 on April 24.

Also, a complete series of blood work was taken, including the T4. I should know those numbers this Thursday.

She has been on 50 mg. once daily with breakfast, based on the start low and go slow method.

She weighs 48 pounds.

Vetoryl says that for a weight between 22 and 44 pounds, the starting dose should be 60 mg. once a day.

For a weight between 44 and 88 pounds, the starting dose should be 120 mg. once per day.

Trixie is on the high end of one, and the low end of the other.

But, doing an average, she could very well be on 90 mg. once per day and not be out of Vetoryl's range.

As each dog has their own level of sensitivity to the drug, the ACTH tests are only a very good guide to the dosing, the visual observations are also an important part in establishing the dose, and by Trixie's symptoms, she may very well need a higher dose.

This morning, I gave her 60 mg. and am going to see if she shows even the slightest sign of improvement.

My problem is that because of my own pending medical situation, I just don't have unlimited time to mess around with this kind of experimentation, and taking care of Trixie is really a full time job, more like constant nursing, and am having no luck in finding someone who could care for her during my absence, let alone death.

For the sake of this post, ruling out all other possible causes for her present symptoms, and focusing on Cushing's, do you think that my upping the dose from 50 mg. to 60 mg. is a large enough increase to show improvement, if in fact her problems are caused by being on too low a dose of Vetoryl?

And, very important, how soon should I notice any changes after this morning's dose increase? Later today, tomorrow, a week?

My Vet has had no experience with Vetoryl, so I am basically on my own.

I need your response as soon as possible.

Thanks,
Fred.

[Jenny & Judi in MN]

Fred I'm sorry about your medical crisis and hope it all works out. Is there a specialist you could email?

I have no vetoryl experience but obviously Trixie's cortisol levels are increasing so an increase in dose makes sense to me.

Wishing you and Trixie all the positive energy and healing for both of you to come through this. Please keep us posted. Judi

[Lady's mom]

Fred, I desperately wish there was something I could do to help you and trixie - my love of boxers makes me ache for you.

Is there some way your vet could provide for trixie during your medical emergency? Not just with boarding, but some special care as a friend. I don't remember where you're located - I'm wondering if there might be some special needs foster care available.

Please take care of yourself. My thoughts and prayers are with you.

[Squirt's Mom]

Hi Fred,

I am so sorry to hear about your health issues. :( This is something I fear on a daily basis - getting so ill I cannot care for my babies and my heart goes out to you during this time. BUT I refuse to believe you won't come back to Trixie and us very soon.

Lady's Mom has a good idea - talk to Trixie's vet about your situation and see if they have any solutions to offer while you are in the hospital...talk to them anyway to make sure they know what is going on and that Trixie may be under the care of someone else for a bit. Another thought - check into some Boxer rescues (any rescue groups) close by or some of your Boxer friends to see if they can help out for a little while. If you were closer, I would be glad to take her...at this point, what's one more???? :p

I question whether what you are seeing is from cortisol still too high VS too low. The lethargy, lack of interest, etc are signs of the dose being too much = cortisol too low. How is her appetite? Any nausea or vomiting or soft stools?

The most important thing here, tho, is you and your health. You have no choice but to get this taken care of today if possible. Do you and your vet think Trixie could do without the Vetoryl a few weeks while you recoup? Once you are back home, you could restart the med. This would not be optimum but it might make it easier to find someone willing to help out with her.

Now, something I would like for you to do for us - please give someone the ability to access your page here so they can let us know how you are doing. I know you will return to us but it would be nice to have a way to keep up with your progress.

Many hugs as well as prayers and healing white light flying your way,
Leslie and the gang

[frijole]

My gosh you have your hands full. :(

I would cease giving the trilo to be safe and call the vet to ask for help.

If you tell us where you live maybe one of us are close enough to help????

We are going to all pray for quick recovery - normally we are cush angels but we have the ability to pray for all ailments and trust me - we will gather and hover over you and dear Trixie.

Fred, please keep us posted. Perhaps you have a friend who can log on in your absence? We could help the friend tend to Trixie if need be too.

Sending warmest thoughts and prayers,
Kim

[busyman370]

Thanks everyone for all the good wishes.

What I am looking at here is the fact that she's not doing well and her post ACTH went up. That does suggest she could use a little increase in her Vetoryl.

I also am well aware that there may be something else wrong with her, like a brain tumor taking it's toll on her.

First things first, this morning I did up her dose of Vetoryl from 50 mg. to 60 mg. given once a day with breakfast.

Next, let's see tomorrow how her blood work looks. We did a complete work up, plus thyroid, not the full thyroid but the t4.

I would guess that by tomorrow, if the Vetoryl increase is doing any good, I should at least see some kind of sign.

Yes, my hands are full. I've been "getting my life in order" as what I am facing is very serious.

However, believe it or not, my main concern right now is Trixie, and I am doing everything I can to try to get to the core of what's going on with her.

Yesterday I noticed that she had a small facial tick on her left side of her jowl, intermittent, but still there. I see it again today. I don't like that. That suggests neurological, and that points to the brain tumor again.

I am fully aware of the brain tumor, other cancers or other issues besides Cushing's, that may be placing her at the end of her life, so I am at least grounded to the possible realities that may be present.

I will keep you all posted, and thanks again for being there.

Fred.

[labblab]

Dear Fred,

I am sorry to be so late in replying to you, but I was away from home all afternoon. I join the others with my deep regret and worry over your medical condition! As Leslie says, I greatly hope that there will be a way in which someone can update us at the time of your procedure. Please know that you have tons of well wishes being beamed your way.

As for Trixie, this is just my knee-jerk, gut reaction. But I doubt that the worrisome symptoms that you are seeing are the result of her cortisol drifting a little bit upward. I am guessing there is another cause, and perhaps it is an enlarging tumor as you fear. Much of what you describe seems to have the potential to be neurological in origin. However, like you, I will also be anxious to see her thyroid result.

I'm afraid I only have a moment to write now. But I will think about Trixie some more, and I will certainly return with any brainstorms...

Marianne

[lulusmom]

Hi Fred.

I'm really sorry that you have such a heavy weight on your shoulders. My dad had an aortic aneurysm that he didn't know he had for almost five years. He had what he thought was a heart attack and had the stupid doctors done am angioplasty they would have discovered that the aorta ripped. Most people drop dead but in my dads case, the tear created a false channel so insufficient blood was pumping to the heart. He was in and out of the hospital with congestive heart failure and the doctors finally told him that he had two choices, 1) do nothing and expect to not make it to the hospital one day or 2) have surgery with a 50/50 chance of survival. His odds were really bad because his lungs were shot from asthma and being a heavy smoker most of his life. He opted for surgery anyway.

That was way back in the 70's and he made medical history the day of his surgery. It was a 12 hour ordeal and the surgeons were not prepared for what they found. The aorta had blown up to the size of a football. It was so huge, they had a hard time finding his heart. They replaced as much of the aorta as possible, up to the arch. They filmed the procedure and as far as I know, they still show it to med student.

Medical strides in this area of medicine have been amazing in the last three decades so if surgeons could save my dad's life in the terrible shape he was in, I have a feeling that you are going to ace your surgery. Of course, all our prayers won't hurt either. :D

I second what Kim has already told you....if you are willing to let us know your approximate location, somebody here may be willing to help with Trixie and anything else you may need. I'm in Southern California, have two cushdogs and two dogs with congestive failure so I'm intimately familiar with cushing's, am a good nursemaid and have a good network of veterinary providers. If you are anywhere near So Cal, I'm more than willing to take care of Trixie until you are back on your feet.

(((Huge Hugs for you and Trixie)))
Glynda

[busyman370]

Thanks again all of you for everything.

I am going to see if my Vet will keep Trixie in his hospital while I am in the hospital. However, I am leaning more and more toward the possibility that Trixie is in real trouble, and not Cushing's related, and that won't be necessary.

Within a few days, I should have a good handle on what's going on and of what the future will be for Trixie.

Thanks again,
Fred.

[Altira]

Well there is no two ways about it. You must get better and real fast! Trixie needs you. This world needs you. You have to be fine.

[jmac]

Hi Fred,

I am so sorry to hear about your medical condition, and I am hopeful things will go well for you. I hope Glynda's is right that you will have no trouble if her dad survived the procedure many, many years ago.

I am also sorry to hear about Trixie. I hope that you will get some answers soon. Please be sure to have someone let us know how you are doing, or to even email or call one of the members on the forum so they can pass along updates. Please let us know if there is anything we can do to help.

Julie & Hannah

[busyman370]

Some interesting news with Trixie.

Previously, I narrowed down her symptoms to hypothyroid, brain tumor or Vetoryl dose issue. Of course, those could all be the cause, but one has to start somewhere.

Today I got a call from my Vet and her blood work looked very good, except her thyroid was so low that the simple t4 test could not define the number, it just said "below .4."

We are waiting for the t4 by dialysis results to come in.

I got the call at 1:35 pm. At 1:45 pm I decided to get some thyroid in her system and gave her 0.5 mg. of Soloxine.

I noticed around 3:45 she was looking just a bit more with it.

I am giving her 0.25 mg. of Soloxine with supper, and again at breakfast.

After that, I will put her on 0.2 mg. twice a day until I get the t4 by dialysis numbers.

When she was last on Soloxine, the 0.2 mg. twice per day had her right where she should be regarding her thyroid numbers, so until further notice, I'll stick with the daily total of 0.4 mg.

If she looks hyper, or still hypo, I will adjust the Soloxine based on how she acts.

But the t4 by dialysis numbers should be in soon.

I also dropped her back from the increase to 60 mg. Vetoryl back to the 50 mg. dose.

Her next ACTH was due in July and since she had been doing so well, up to a few weeks ago, we thought we'd do another full thyroid panel at that time.

I do believe that if we hadn't done this latest panel, Trixie would surely never have made it to July. She still might not, but at least this thyroid finding is a good shot at it.

So, I am looking forward to seeing how Trixie responds to the Soloxine. I should see some conformation by tomorrow night.

IF this is her problem, I felt it to be worth while to post on the forum for a possible future need by someone.

I'll keep you all posted.

Fred.

[lulusmom]

Hi Fred.

Please make sure that you give Trixie her Soloxine an hour before her meals. One of my cushdogs has low thyroid and I give her pill to her with the tiniest piece of a pill pocket. If you've been giving the med with meals, you may just see an even greater improvement when you give her the next pill on an empty stomach.

Glynda

[addy]

Dear Fred,

I have not had a chance to post to you but have been reading along.
I hope Trixie responds to the thyroid meds and you will see a difference in her before you have to go to the hospital.

I am not even entertaining the thought that I will not be here writing to you wishing you a speedy recovery. Please have seomone check in with us so we know how you are doing and when you are coming home.

God Speed, Fred, you will be back with us all, back with your K9 family who all love and care about you and Trixie, very soon.

love,
addy

[Altira]

Fred... You ok?

[Lady's mom]

Yeah. I've been thinking about you and trixie a lot too.
Hope you both are all right.

[jmac]

Me three, Fred. I hope you both are doing okay, and that we'll hear something from you soon...

Julie & Hannah

[labblab]

Me, four. :o

Surely hoping that we'll soon be hearing that all is well for both you and Trixie.

Marianne

[Squirt's Mom]

We're jumping on the band wagon, too, Fred! :)

[lulusmom]

Count me in too as another one hoping to hear from you, Fred.

[busyman370]

Hello All and thanks for your concern,
I just found out yesterday what's going on with me, and over the last few days have had some new clarity regarding Trixie.

Trixie's symptoms were both perplexing and disheartening. When I sat down and categorized her symptoms, and did some research, I found that on the overall, the probability was that she could have one of three things going on; hypothyroid, brain tumor or an over or under dose of Vetoryl - or all of the above.

I had her thyroid tested and sure enough, she was off the charts. I immediately started her on Soloxine and she soon began to show positive response.

It's been two weeks on Soloxine and she is stunningly better, about 75% normal in function and appearance.

My plan is to give the Soloxine three full weeks, then re-evaluate. If her symptoms suggest she needs an increase in the Vetoryl, I'll bump her up from the 50 mg. per day to 60, and likewise for the Soloxine.

If she normalizes, for all intents and purposes, then I'll leave things as they are and let her progress at her present gradual pace.

Her Calcinosis Cutis has not only stopped progressing but is actually regressing. The one area under her groin, which was hard as a rock, actually sloughed off and the skin below it is working to regenerate.

So, overall, Trixie seems to be on the road to recovery. She moves better and stronger, her appearance is much more bright and she has displayed a level of joy during her day, not just laying there looking half dead. In fact she's starting to get a little mouthy again! I'm waiting for her to start stealing the napkins off the table and shred them like she used to. LOL

As for me, I met with my surgeon yesterday and got the bottom line on my condition. I do have an aneurysm on the lliac artery, but it is not quite at the point where it demands emergency surgery, but having said that, if I chose to, it would be a good time to get in there and fix it.

Honestly, I have been so upset over the timing of everything that I took that prognosis with a relief regarding Trixie.

I have taken her so close to getting well, that to have to hand her off to someone else, and that includes my Vet, at this time just crushed me. This dog needs nursing care, not just feed, water and let out to pee.

I asked the surgeon if I could buy some time and he said yes. He wants to see me in December and take another measurement. If the aneurysm has enlarged, then we go in and fix it. If it has not, then we wait another six months and evaluate it again.

I feel that I will have Trixie where she will ultimately end up well before six months, so I am much relieved to have the time and freedom to do just that.

Of course there will be testing of thyroid and ACTH, but I do value what my eye and gut say also.

For example; all the way along, her thyroid was always just a bit below the low number of the normal range. A dose of 0.4 mg. of Soloxine has been established as the spot on number for her to keep her at her best without going hyper-thyroid.

The 50 mg. of Vetoryl seems to be taking her along just fine, and at a slow but steady pace.

So, I have a good and proven base to work from. All I need to do is to keep my eye on things and throw in the well timed tests, and I am sure that the near future will show where Trixie is headed.

Her blood work shows everything is very good, so as of today, I don't see why she can't get another year or two of a good and quality life.

I say that with the awareness that suddenly, something completely unrelated could pop in and end her life, and I speak from personal first hand experience on that one.

So, I am not coming from a pie in the sky outlook, but to stay with what she's been dealing with, the only real short term threat would be the brain tumor taking over, but those signs are diminishing as her overall health is increasing, so the tumor may not be as big of a player in this for the short term.

So that's the latest on Trixie, and myself.

I do appreciate the concern of all of you. I does matter, it does help and it means allot to me.

I'll keep you posted on Trixie's progress and of her treatment along the way.

Take care all,
Fred.

[Lady's mom]

Thank goodness! I love hearing good news first thing in the morning!

I'm very happy for both of you.

[Jenny & Judi in MN]

Fred what an encouraging update on you and Trixie. Sounds like she could be stealing napkins in a month or so. I'm glad you bought some time and can keep an eye on yourself so you'll know when to go in and get fixed.

Judi

[Squirt's Mom]

What a wonderful post to read this morning, Fred! I am so happy that Trixie is responding so well to the thyroid treatment and that you get a little reprieve. I can only imagine the stress you have been under! :eek:

Please, please take care of yourself. Know you have a huge family here who is willing to help you and Trixie in any way we can. So don't hesitate to reach out if needed - your family here will do all we can to help you both.

Hugs,
Leslie and the gang

[mytil]

Fred, I have been most certainly following you and Trixie's "journey" and your post today made many of us relieved :) I know you are still in the woods but at least you can see a way out for sure and have time.

Please keep us posted when you can
Terry

[Altira]

I know I haven't been very involved in all of this but I have sat here thinking ... What if we never hear from you again? What if we never know what happened? I too was very happy to see your post in the midest of all our freting. Our Cindy here on the forum just lost her cherished cousin to cancer several days ago and now she will likely loose her presious dog too in a day or two. Life can sometimes be so unfair.

[addy]

Fred and Trixie,


((((((((((((((((((((((((((((hugs)))))))))))))))))) ))))))))

[busyman370]

Hi Everyone,
Thought I'd give a quick update. As I said earlier, Trixie just wasn't right and I decided to have her thyroid checked, and it was way too low. I began giving her Soloxine, basing the dose on past experience with her, and she began to perk up, but still not where I believed she should be after 80 days on Vetoryl. I decided to up her dose from 50 mg per day to 60 mg, and after a couple of days of mild cortisol withdrawal symptoms, she began to act much better. This was a classic case where Vetoryl says that if the post ACTH is within range, but the symptoms are still there, an increase may be in order. She's been on the 60 mg for ten days, and the soloxine for 25 days, and from the way she acts I am convinced I did the right thing. I was going to zing her in for an ACTH next week, but I think I'll give her a little longer to see if she experiences a gradual but positive cumulative effect after she's been on the two drugs for a little while longer, then test for both thyroid and ACTH. If I had to make a decision today, I'd bet that she could use even more Vetoryl, but I won't do any increasing without the test, and I also want to see how her thyroid is as well. So for the time being I want to give this new course some time to hopefully yield some real improvement.

I am fine, bye the way. I spoke to my surgeon yesterday and he is comfortable with monitoring me between now and again at six months to see if there are any changes. I have some time before it becomes large enough where surgery is absolutely necessary. He also said that if there are no changes, then we can keep monitoring.

Once I get this process with Trixie at a constant, and she has a good quality of life, then I may just opt to get the surgery and be done with it. But I do really appreciate the time to work with her.

So, this was a quick post as I have to run.

Take care everyone, and thanks again for being there.

Fred.

[Jenny & Judi in MN]

glad to hear an update Fred.

[busyman370]

Hi all, been a while. Hope you all are doing well.

I wanted to give you the latest update on Trixie, and to also ask a question.

Here's the update. Long story short, Trixie was not doing well. Discovered she went hypo thyroid. Corrected that, am going to do blood panel next week to evaluate dose of soloxine.

Also, decided to up her dose of Vetoryl from 50 to 60 mg. The ACTH after 14 days gave post number of 4.6, which is close to her old 4.3, which is when she was at her best. So anything over that is too high for Trixie. Might be OK for another dog, but too high for her.

Suddenly on day 16, she appeared markedly better. More alert and robust. So the 60 mg was the right thing to do.

I will be watching her for the next few weeks, and will be relying more on how well her symptoms are being controlled rather than what the test says, at least for the short term. I want to give the 60 a good amount of time to see if it may just be enough to get her back to normal and keep her that way.

Going by her past test results, I am guessing that in about three weeks time, her post number will drop another 1.5 points, and be around 3, and my gut says that will be as close to perfect as we can get regarding Trixie in particular.

She does NOT tolerate the cortisol well at all, and needs to be in the lower end of the acceptable range. Her history has proven that to me.

If she does follow her past performance, and drops to the 3 level, I will be watching for a crash, but I am expecting instead to see her improve and continue to do so.

I want to give the new dose some real time to see if she continues to improve, and perhaps can continue on with the 60 mg dose before testing again too soon.

The reason for this thinking is that she has made tremendous progress while only on the 50 mg. Her C-Cutis is almost gone, her hair is growing back well, and now with the new dose of 60 mg, she's even better. The 60 may just be the little tweak she needed to get over the hump, if you know what I mean.

In three weeks, if she is still improving, or even thriving, I will just keep her on the 60 mg and see if she either keeps improving or actually gets back to normal, rather than test too soon. I need to know what works for her and what doesn't.

If I think, by observing her symptoms, that she needs another test sooner, I will get one. If I think she is continuing to improve, then I'll hold off for a while longer.

At this point I believe that her symptoms alone are a reliable indicator as to whether or not her dose is where it should be.

Of course, sooner than later, I will want another ACTH just for clarity, even if she's doing great.

As I said before, Trixie can test and appear to be within a good range, but her past has proven that she needs to be in the lower end of that range before she looks and acts healthy.

Once she gets over the post ATCH number of 5, she does not do well at all. It has proven that she must show post numbers in the 4.5 range at a minimum.

Based on her past test info, I am expecting her present number to be about 1.5 points lower in another three weeks, putting her in the range of around 3, and I am betting that will be her "sweet spot" regarding the post ACTH numbers.

She seems to be VERY sensitive to cortisol, and does not do well when her post number is over 4.5 range.

Now for my question:

Since the Vetoryl only comes in 10 mg increments, am I correct that each increase in Vetoryl be in 10 mg. increments?

I am now trying to plan ahead for the possibility of needing to increase her dose once again sometime in the future.

I know I can get it compounded, but my feeling is that if Vetoryl thought that a dose of 5 mg was necessary, they would offer one.

I appreciate your feed back regarding the proper way to increase the dose of Vetoryl.

Thanks,
Fred.

[Altira]

No help here... Just wanted to say hi! :o

[busyman370]

I have a question.

Please bear with me as this is a little long and wordy.

I have been treating Trixie with Vetoryl for 100 days, and she has improved, but not to the point where she looks and acts like she's past the signs of Cushing's.

Her blood work is stellar, and I've got her Thyroid spot-on.

Here's my story:

She started on 50 mg. per day, and her test numbers were; 5.9, then three weeks later, 4.3.

One month later they went up to 6.4.

She was looking better around the 4.3 but soon started to decline.

By the time she tested at 6.4 I was considering euthanasia, thinking her symptoms were caused by a brain tumor.

Checked her Thyroid, it was off the charts low. Started Soloxine and that quickly was corrected.

She was still acting too Cushinoid for me, so I took it upon myself to up her dose to 60 mg. per day.

After 14 days, she tested at 4.6 and was doing quite a bit better - BUT - was still too Cushinoid for a dog that's been on Vetoryl for 100 days.

She is now within the safe range of 4.6, but I still think she needs an increase in the Vetoryl.

I am asking for help regarding a dog being within the acceptable numbers, yet still showing signs of Cushing's.

My opinion is that the numbers are a guide, but if the dog is still showing symptoms, then an increase is in order.

How soon after the ACTH results would be the proper time to make the increase, 14 days, then test again 14 days later?

I am thinking that we need to not only go by the test numbers, but also by how the dog is looking and acting as well.

The ug/dl range of 1.45 to 5.4 is really quite a broad one. My take on Trixie is that she is overly sensitive to the cortisol, and needs to be at the lower to mid end of the acceptable range in order for her to be as free from the Cushing's symptoms as she is able to be.

Since Trixie has been on Vetoryl for 100 days, and is not nearly as being back to her old self as she should be, and since it's been two weeks since her last ACTH, I am considering upping the dose from 60 mg. to 70 mg.

I really think she is still on too low of a dose - perhaps for her particular physiology.

Going by Vetoryl's dosing suggestions, for a 22 to 44 pound dog, 60 mg. is the starting dose.

For a 44 to 88 pound dog, the dose is doubled to 120 mg.

I understand and agree that starting at the lowest dose possible is the right way to go, but consider this;

A dog weighing 45 pounds is right on the line between the 60 mg. and the 120 mg. starting dose.

This puts the dogs care giver in a tough spot. I could see how Trixie, who weighs around the 48 pound mark, could very well need a dose of at least 90 mg. per day!

Since a month is a long time in a dogs life, I don't want to waste any more of her life only going by the numbers. Her quality of life is not where I expected it to be at 100 days of treatment, and I don't want to let her go on like she is.

I am now considering upping her dose and test every two weeks until she is acting better.

Do you think that two weeks is enough time for the dose increase to show positive signs, or would it take longer to see any change?

I hope I've made myself clear on this subject.

I am really working as hard as I can to help Trixie, and my Vet is almost useless. He congratulated me on being so successful regarding making changes to Trixie's medications - soloxine and Vetoryl.

I am not flattered!

In fact I am rather let down by his lack of performance, and feel he's glad to have me carry the load instead of him having to be responsible for it. Maybe it would take too much time for him to do the appropriate research, I don't know.

And as you all know, I personally am on a rather short time line regarding my own health as well, so the sooner I get Trixie up to speed the better.

Hope you can help us.

Thanks,
Fred.

[lulusmom]

Hi Fred.

Trixie does not need another increase in dose and to do so would be putting her at great risk. She sounds like a perfect candidate for twice daily dosing. There are a good number of dogs treating with Trilostane who never see complete resolution of symptoms because of the drug's short half life. Trilostane is short acting enzyme blocker with it's effectiveness starting to wane any time after 8 to 12 hours. For some dogs, that simply isn't long enough to see complete improvement in symptoms.

I am really sorry that your vet has done so little for Trixie but I'm glad that you are here asking questions. If Trixie were my dog, I'd be talking to the vet about twice daily dosing. Since you are educating him, you may want to call the manufacturer of Vetoryl, Dechra, and ask for their guidance so that you are armed when you talk to the vet. I am also attaching a PDF version of a paper written by Dr. Ellen Behrend, entitled Update on the Use of Trilostane. Please take the time to read it and especially check out the treatment chart on page 4.
674

Here is the URL for contact information for Dechra: http://www.dechra-us.com/Contact-us-1.aspx

[busyman370]

Thanks lulusmom,
Thought I'd send Trixie's ACTH numbers history. Maybe they will help to evaluate this issue.

pre acth baseline ug/dl and post acth followed by the dose: based on 48 pounds:

3-21-12 --- 4.0 --- 39.7 ----- started on 50 mg. ---- once /day
4- 3-12 --- 2.1 ---- 5.9 ------50 mg. ---- once /day
4-24-12 --- 1.4 ---- 4.3 ------50 mg. ---- once/day
5-12-12 ---- 2 ----- 6.4 ------50 mg. ---- once/day
6-21-12 --- 1.6 ---- 4.6 ------60 mg. ---- once/day


Let me know what you think,
Thanks,
Fred.

[busyman370]

Thanks lulusmom,
Thought I'd send Trixie's ACTH numbers history. Maybe they will help to evaluate this issue.

Pre ACTH Baseline ug/dl and Post ACTH - Weight 48 pounds.

3-21-12 --- 4.0 --- 39.7 -----started on 50 mg. once per day.

4- 3-12 --- 2.1 ---- 5.9 ------50 mg. once per day.
4-24-12 -- 1.4 ---- 4.3 -------50 mg. once per day.
5-12-12 ---- 2 ---- 6.4 -------50 mg. once per day.
6-21-12 --- 1.6 --- 4.6 ------ 60 mg. once per day.


Let me know what you think,
Thanks,
Fred.

[lulusmom]

Hi Fred,

Yes, I would definitely share those stim test results so they have all the timelines and dosing changes you've made. You'll also need to tell them why symptoms are still unresolved. I'm not sure but after I posted to you, I seemed to recall that one of our members tried to contact Dechra and they were told that their vet should call. If I were you, I would still try and hope that you get a different rep on the phone. If they tell you to have your vet call, then you'll have to explain the twice daily dosing to him and ask him to call Dechra to get their opinion.

Glynda

[busyman370]

I will discuss this issue with my Vet, but the main reason I posted Trixie's test numbers was to get opinion's and feedback from you all on the forum.

Trixie was at her best, which was still not good enough, when she was at the post of 4.3.

Anything higher and she was not doing very well.

My thinking is that; going by her past performance, she needs to be at least at the 4.3 area, but I believe she needs to be closer to the 3 area to be at her best.

The way her numbers creeped up suggests to me that her dose was not high enough to control the cortisol production. In other words, the cortisol would overtake the Vetoryl and her numbers would rise.

Regarding the effect of the once per day dosing; In the early AM she is actually better than she is right before bed. This tells me that she doesn't need a second boost of Vetoryl at supper to carry her through the night to early morning period.

So, this is why I felt that her initial dose needed to be bumped up from 50 to 60 mg, and now from 60 to 70 mg.

Hope I've explained my rationale well enough here.

I hope to get some feedback on this thought.

Thanks,
Fred.

[lauraperla]

Hi again Fred,
I think twice a day dosing would be of more help to Trixie rather than a further increase. I've witnessed the difference this move can make myself in Saoirse's early days on Vetoryl. I certainly think its a step worth trying before you make any further dosing amount tweaks.
There are some differences of opinion on whether you just split the current daily dose in two or whether you add 10% to the daily dose and split that number in two. I'd consult with your vet and ask him to seek guidance from Dechra.
Best of luck Fred. For us the inconsistent control Vetoryl exerted never fully resolved and we switched to Lysodren.
Laura

[labblab]

Fred, can you describe the specific symptoms that lead you to suspect that Trixie's cortisol is still not being controlled sufficiently? Also, are these symptoms more bothersome at certain times of the day?

Marianne

[busyman370]

Fred, can you describe the specific symptoms that lead you to suspect that Trixie's cortisol is still not being controlled sufficiently? Also, are these symptoms more bothersome at certain times of the day?

Marianne

I will really try my best to be as specific as I can, and thank you so much for caring.

If I had to pick just one symptom as being the worst, it would be her urination.

She is not drinking as excessively like she used to, although more than would be considered normal. She's not urinating as excessively, but also more than would be considered normal, and does it at odd times.

After supper, she will take a drink, and that's pretty much it. Then I let her out a couple of hours after supper and she pees. Then just before bed, which is 9:30 pm, I let her out again, and she will pee, not a long one, but she does pee.

So, she pees and goes to bed at 9:30 pm. Then I hear her stirring around the 5:00 am time frame. If I don't immediately get up and let her out, she pees in her crate. And there are plenty of mornings where even if I do get up to let her out, she had already peed in her crate.

After breakfast, at 6:30 am, I will let her out to pee around 8:00 am, then again before I leave, at 9:30 am.

When I come back home, ball park 1:30 pm, she had already peed on the floor.

I can't figure that out, it makes no sense.

The next symptom in line is what I call her enjoying a quality of life.

Of course before treatment, she was a wreck in all ways, but from the beginning of treatment, she has never been close to being her old self. The one time that she started to come close was back when her post ACTH was 4.3, but then she started to back slide as her numbers went up.

Back before starting treatment, she had that Cushing's look on her face. The look has gotten better, but there is still more of that look than her old self look.

Seeing her be her old self, and enjoy a quality of life has been a very important driver in my reason for treating Trixie.

I do understand that she's 10 years old, but - in my opinion - she should be acting better than she is, regarding her quality of life. Especially after 101 days of Vetoryl.

To try to condense these symptoms, she still could be considered to show some level of aggressiveness regarding her wanting to eat and drink, and the urination issues as I have described.

To me, she "looks" like the cortisol is still harming her, restricting her ability to progress to a higher level.

As I write this, she just asked to go outside, and she peed, not much, but she did pee. THAT'S JUST 2 HOURS AND 15 MINUTES SINCE HER LAST PEE. And she came in and took another drink.

She is drinking and peeing more than her litter mate, so I have to believe that she's still drinking and peeing too much.

A urinary track infection wouldn't make her drink excessively, and she shows no outward signs of that, other than the frequent peeing.

So, regarding the increase to 70 mg, I did plan to wait until next Thursday and see if she improves, as that was the last time differential when she went from 5.9 down to 4.3. I wanted to see if she would drop from the 4.6 to a little lower this time too, and show it by starting to show improvement.

Bye the way, what do you make of those dosing suggestions on the Vetoryl info? Trixie is right on the line between the suggested starting dose of 60 mg and 120 mg. That's a big difference!

I know that those numbers are considered a high starting dose, but the ratio is still the ratio.

I did the math, and considering Trixie's weight, and that it is all muscle, using the Vetoryl suggested doses, she would be at at starting dose of 90 mg! I know that's too high of a starting dose, but I just want to point it out as an awareness - and as a curiosity.

My thinking is that we did the right thing by starting low at 50 mg, and going slow, but Vetoryl's suggested dosing tells me that I have a range to work with, and still be safe.

What I would do would be to bump her from 60 mg to 70 mg and watch for any sign of a crash, and also for signs of improvement. Then after a couple of weeks, do a ACTH to see what her numbers are.

Here is my main point; a month is a long time for an old dog, and I don't want to waste any time she may have left by under medicating out of a fear that she may crash, and never giving her the chance to actually get better. The numbers are important, but not the end all. The clinical signs of the dog are still a factor.

She seems to be trying real hard to get from Cushingoid symptoms to having a quality of life, and I want to help her get there.

As I close, I feel that I need to at least wait until next Thursday, and give the 60 mg dose three weeks to see if she improves. Then I can consider my next move; do nothing, increase to 70 mg, or do another ACTH test.

But the urination issue has me stumped! That is the one thing that has never really resolved during treatment with Vetoryl.

And that's just one reason why I am really thinking she needs to be on a higher dose.

My Vet, "Mr. Helpful" is leaving for a vacation, and when he returns, I am going to ask him to contact Dr. Bruyette and bounce this off of him. My Vet attended his seminar last spring, and did get the OK to contact him, and I want him to do just that. It may or may not be of any help, but we won't know until we try. And I've got to get him more involved in this anyway.

So I do need to hold off at least until he gets back.

Bye the way, what's your take on her ACTH numbers as I relate then to how well, or not so well, Trixie's been doing at the various doses?

I am looking forward to your input, and thanks again.

I really appreciate the help,

Fred.

[busyman370]

I have another question regarding the numbers.

Does the pre numbers mean what her cortisol level is before the injection of cortisol? If so, then when Trixie was at her height of Cushing's, her level was 4.0? And if so, that was too high.

When her post was 4.3, her pre was only 1.4. Does that mean that her cortisol was at 1.4, which is at the low end of Vetoryl's acceptable range?

She was at her best at the pre of 1.4, but it soon began to creep up to 2 in only a month. Had she stayed at the 1.4, she may have improved much more than she did.

Now that she's at a dose of 60 mg, her pre is 1.6. If it stays there for a month, then logic says that I should see some real improvement.

I'm interested in some comments on this one.

Fred.

Pre ACTH Baseline ug/dl and Post ACTH - Weight 48 pounds.

3-21-12 --- 4.0 --- 39.7 -----started on 50 mg. once per day.

4- 3-12 --- 2.1 ---- 5.9 ------50 mg. once per day.
4-24-12 -- 1.4 ---- 4.3 -------50 mg. once per day.
5-12-12 ---- 2 ---- 6.4 -------50 mg. once per day.
6-21-12 --- 1.6 --- 4.6 ------ 60 mg. once per day.
.
.
.
.

[Steph n' Ella]

THAT'S JUST 2 HOURS AND 15 MINUTES SINCE HER LAST PEE.

Fred- I hear you on this one! Even though Ella doesn't have cushings, she is recovering from a bad UTI and she drinks and pees alot still. I got lazy for a while cause I felt sorry for her...being sick and all.

I have seen some improvement by going to the basics of house training with her. She will do just about anything for a treat so she gets a treat every time she goes potty outside. I was crating her all day while I was at work (coming home for a potty break at lunch) and all night long. Taking her out for walks every hour, on the hour while I was home.

Now I have increased the area she hangs out in during the day to my (very small) den. So far she respects the "den" as part of her home and hasn't peed it...but as soon as I open the area up to include the dining room & kitchen she has an accident. She is allowed to sleep in my bed at night, but the first time she gets up, I let her out and then she goes back in the crate. In the evenings, when I am at home, I am working towards taking her out every 1.5-2 hours.

[busyman370]

Fred- I hear you on this one! Even though Ella doesn't have cushings, she is recovering from a bad UTI and she drinks and pees alot still. I got lazy for a while cause I felt sorry for her...being sick and all.

I have seen some improvement by going to the basics of house training with her. She will do just about anything for a treat so she gets a treat every time she goes potty outside. I was crating her all day while I was at work (coming home for a potty break at lunch) and all night long. Taking her out for walks every hour, on the hour while I was home.

Now I have increased the area she hangs out in during the day to my (very small) den. So far she respects the "den" as part of her home and hasn't peed it...but as soon as I open the area up to include the dining room & kitchen she has an accident. She is allowed to sleep in my bed at night, but the first time she gets up, I let her out and then she goes back in the crate. In the evenings, when I am at home, I am working towards taking her out every 1.5-2 hours.

Thanks for the words of understanding. Sounds like you are on the right track and have a good plan.

Fred,

[busyman370]

Update on Trixie - especially regarding my last post to labblab,

Yesterday, not too long after my series of posts and question's, I noticed that Trixie was showing signs of taking a positive turn.

If this turn were to come, it was not expected until Thursday of next week. That would have been the three week point after her increase from 50 to 60 mg of Vetory, and going by her prior ACTH tests, that was the number of weeks to see her post number drop from 5.9 to 4.3, which was when her symptoms were controlled the best.

Must be that this time it happened quicker than it did the last time.

She is very close to acting and looking normal in every way.

Up to yesterday, she was not making really any progress, so I was considering the bump to 70 mg. I was nervous about doing it, and really did want to wait till next Thursday at the soonest.

My Vet left town yesterday for the holiday, so I defaulted to just putting Trixie on a weeks treatment of Clavamox. I am thinking she could very well have a UTI, and since there was no time to do a culture, I wanted to be pro active and do it asap.

If she does have a UTI, I expect to see some change in her urination pattern, hopefully by day three.

Needless to say I hope she does have a UTI, that would take the Vetoryl and her Cushing's out of the picture as being responsible for the urination issue. After 102 days on Vetoryl, the excessive drinking and urination should not be the issue that it is. But time will tell.

Now, to explain why I was considering upping her dose from the 60 to 70 mg, is because of what just happened as the result of bumping up from 50 to 60.

She was not doing well at all when her post was over 4.3, and that's that. In fact, she was doing so badly that I was thinking that a brain tumor was responsible, and euthanasia may be her best relief.

But, we kept fighting to prove that was not the cause.

So that 4.3 number is a bench mark for me, at least at this point in her treatment anyway.

When I saw her last post drop from 6.4 to 4.6, I was looking for her to improve within three weeks. If she did improve, like she is today, and her post stayed at 4.6 or a little less, and especially didn't jump back up over 5, then I would keep her at the 60 mg and watch her signs. If she stopped improving and or began to regress, then I would test to see what her number was, but would expect to bump her to 70 mg. to get that post number back down to the 4.3 area again.

She absolutely has to be no higher than the 4.3 post area in order for her to get better.

Personally, I still feel that if I could get her at a constant post of between 3 and 4, that would be perfect for her, at least at this point in her treatment. But if she continues to improve and can stabilize while at the 4.6, then that's fine with me!

I'll see how she's doing, and if she keeps getting better, and holding her progress, I'll stay at the 60. If not, then I'll test, and the numbers will probably show that she went up again, then I will consider going to the 70 mg.

The increase in her food portion is starting to show. She's gained some weight and is looking quite good. I am now feeding her the same amount that I was before she got sick, and she eats it like a little piggy.

Now I am focused on this urination issue, and am really hoping that the Clavamox will fix that.

I wanted to give her some Cranberry juice, but forgot it at the grocery store. I will get some tomorrow and give her some a few times each day to try to help her along.

Update on the Calcinosis Cutis:
I have been applying coco butter to the calcinosis cutis on both her temples, and slowly it is sluffing off, leaving a thinner layer covering a smaller surface, and when I wipe all of it off that I can, an oozie blood that does not bleed. The blood just sits there, it doesn't keep bleeding. I blot it after a while and that's that. The C cutis under her groin area is GONE! all healed up. The areas along her rear hocks is still there, but keeps getting smaller and smaller, and is not a thick, flat plate like the spots on her temples are. It is going away on it's own so I'll leave it alone.

I'll keep you all posted,
Thanks again for being there, your input means allot to me. I really count on you guys.

Fred.
.
.
.

[busyman370]

Trixie's drinking and Urination issue;

She's drinking and urinating way too much. After over 100 days on Vetoryl, I just don't get it.

Other symptoms have improved, but the drinking and urination have not.

I don't think she has a UTI, and the Clavamox isn't the answer to Trixie's drinking and urination problem. She's been on it for five days and I don't see any change.

I am looking for some thoughts as to what's going on with her as it relates to Cushing's as the cause, and treatment with Vetoryl as the cure.

In the past few posts, I have listed her ACTH numbers with corresponding doses of Vetoryl, hoping they would give you something to help me sort this out, especially in regard to my going forward with Trixie's treatment.

I value and need your help, and any feedback would be most appreciated.

Thanks,
Fred.
.
.

[Harley PoMMom]

Hi Fred,

Diabetes will cause an increase in drinking/urinating and it can come on all of sudden. Maybe ask your vet about this.

Love and hugs,
Lori

[addy]

Fred, sorry to hear you are still having issues.

My thoughts are perhaps you need twice day dosing or I believe one of our moderators mentioned on a thread awhile back that it can take a while for the kidneys to start functioning normally again after all the pd/pu. I am not sure more than 100 days though, would be "a little longer".

I know diabetes insipidus can be a problem that shows up as well.

If Trixie is bouncing around a bit with her numbers- which my Zoe has a pogo problem, twice day dosing will help that. Having said that, I would think we could expect to see a little movement in those numbers, they fluctuate, as long as the movement is not too much.

[labblab]

Fred, I just want to "second" everything that Addy has just written. As she has said, I do believe there is a subset of Cushpups for whom complete resolution of excessive thirst and urination takes a long time to achieve, if ever. Trixie may just be one of those dogs. However, as other folks have suggested previously, I do believe I'd give twice daily dosing a try. More consistent control of her cortisol throughout the entire duration of a 24-hour time period may improve her outcome with those symptoms.

Marianne

[busyman370]

Hello All,
I found a study done in 2011 that suggests two or three doses of Trilo per day are more effective, and safer for the dog, than the once per day dose, and thought it would be of interest to this forum.

It is a very long read, but very informative. You'll find it posted below my signature.

I am very interested in how you feel about the suggested dose's given.

They hardly give one per day to any dog, they're mostly twice or three times a day, however, the doses are quite low in Mg. per dose.

I find this very intriguing, and am now wondering if it's not time to possibly re-think how we dose our dogs.

I did my best on the charts that appear intermittently throughout the article, hope you can figure them out.

I tried to post the link, but could not copy it. That would have been simpler for both of us! So I did it the hard way.

I am also going to go over this with my Vet.

I'm looking forward to some feedback on this one!

Fred.

JAVMA, Vol 238, No. 11, June 1, 2011 Scientific Reports 1441

Evaluation of twice-daily lower-dose trilostane
treatment administered orally in dogs
with naturally occurring hyperadrenocorticism
Edward C. Feldman, dvm, dacvim

From the Department of Medicine and Epidemiology, School of Vet-
erinary Medicine, University of California-Davis, Davis, CA 95616.
Supported in part by donations from the late Ruth Johnston, San Maeo, Calif.
The author thanks Dr. Richard W. Nelson for technical assistance.
Address correspondence to Dr. Feldman (ecfeldman@ucdavis.edu).
Abbreviations ATH Adrenocortical tumor–associated hyperadrenocorticism LDDST Low-dose dexamethasone suppression test NOH Naturally occurring hyperadrenocorticism PDH Pituitary-dependent hyperadrenocorticism UCCR Urine cortisol-to-urine creatinine concentration ratio


Objective—To evaluate effectiveness and incidence of adverse reactions to twice-daily
lower-dose oral administration of trilostane in the treatment of dogs with naturally occurring
hyperadrenocorticism (NOH).
Design—Clinical trial.
Animals—47 dogs with NOH.
Procedures—47 dogs were treated orally with trilostane (0.21 to 1.1 mg/kg [0.1 to 0.5 mg/
lb], q 12 h). All dogs were reevaluated at 2 weeks and 2 months, 38 dogs at 6 months, and
28 dogs at 1 year of treatment.
Results—9 of 47 dogs had an adrenocortical tumor causing NOH, and all had good re-
sponses after 2 months (mean trilostane dosage, 0.89 mg/kg [0.40 mg/lb], q 12 h). All
successfully underwent surgical adrenal tumor extirpation. Thirty-eight dogs had pituitary-
dependent hyperadrenocorticism (PDH); 15 dogs did not require a dose increase during the
study, and at each of 4 reevaluations, 10 of 15, 13 of 15, 14 of 15, and 11 of 11 had a good
response. Twenty-three dogs with PDH had their dose or frequency of trilostane administra-
tion increased during the study. Mean trilostane dosage at 1-year reevaluation in dogs with
a good response was 1.7 mg/kg (0.8 mg/lb), twice daily, or 1.1 mg/kg, 3 times daily. At each
of 4 reevaluations, 17 of 23, 14 of 23, 17 of 23, and 13 of 17 dogs with PDH had a good
response. Five dogs became ill because of trilostane-induced adverse effects, but only 1
required hospitalization.
Conclusions and Clinical Relevance—Administration of initial lower doses of trilostane to
dogs with NOH is effective. (J Am Vet Med Assoc 2011;238:1441–1451)

Evaluation of twice-daily lower-dose trilostane
treatment administered orally in dogs
with naturally occurring hyperadrenocorticism
Edward C. Feldman, dvm, dacvim

Naturally occurring hyperadrenocorticism is a well recognized endocrine disorder in dogs. It is estimated that approximately 85% of dogs with hyperadrenocorticism have PDH because of secondary bilateral adrenocortical hyperplasia and that 15% have ATH as a result of a cortisol-secreting adrenocortical adenoma or carcinoma.1,2 In dogs with either PDH or ATH, clinical signs are the result of chronic excesses in circulating glucocorticoids. At present, one of the most common medical treatments for dogs with NOH is administration of mitotane (o,p′-DDD); its use has been recommended for more than 3 decades.3 The effectiveness of mitotane in dogs with ATH is variable. Clinical signs are controlled in about 80% of dogs with PDH treated with this drug.1,4–6 Treatment with mitotane is, however, associated with potential adverse effects and disadvantages, such as transient hypoadrenocorticism, permanent mineralocorticoid and glucocorticoid deficiencies, drug intolerance, and relapses.4–6

The most promising new drug for treating dogs with NOH is trilostane.a Trilostane is a 4α, 5-epoxysteroid competitive inhibitor of the 3β-hydroxysteroid dehydrogenase-isomerase enzyme system that, following oral administration, actively interferes with metabolic pathways in which progesterone is involved and blocks the synthesis of end products, including cortisol and aldosterone.7–9 Decades ago, 3 to 4 daily doses of trilostane were typically administered to humans with NOH, generally with poor results.9–11 However, in dogs with PDH, the efficacy of trilostane administered once daily is reported to be similar to that of mitotane, and trilostane has been effective in diminishing hyper- cortisolemia in dogs with functional adrenocortical tumors. 12–16,b,c

Currently, the dosage of trilostane recommended by the manufacturer for use in dogs is approximately 3 to 6 mg/kg (1.36 to 2.73 mg/lb) given orally once each day. Most investigations of this drug’s treatment in dogs have involved this once-daily dose protocol. Interestingly, in some dogs with either good or poor control of NOH, the UCCR 24 hours after once-daily trilostane administration is increased, suggesting that trilostane does not consistently suppress circulating cortisol concentration for as long as 24 hours.17 In dogs for which there is an inadequate duration of effect, a twice-daily dosing regimen has been recommended.13,15,17 In a review of 8 studies13–19,d involving 191 dogs treated once daily with trilostane, 42 (22%) dogs became sufficiently ill to have their adverse effects reported. Usually, the adverse effects included anorexia, vomiting, diarrhea, and weakness. At least 6 of the 191 (3.1%) dogs were described as having died of the effects of trilostane. In the manufacturer’s package insert20 for trilostane, it is reported that 8 healthy dogs given 3 to 5 times the recommended maximum dosage of 6.7 mg/kg, twice daily, died between 23 and 46 days of daily dosing. In this same insert, results of a US field study on 107 treated dogs are reported, indicating that 2 dogs had adrenal necrosis and subsequent adrenal rupture because of the effects of trilostane and that 1 of these 2 dogs died. It is also reported that 2 dogs developed hypoadrenocorticism, a permanent condition for 1 of the 2 dogs. Further, it is reported that additional adverse reactions were observed in 93 dogs; many of these reactions were likely due to decreases in circulating concentrations of glucocorticoids or mineralocorticoids secondary to trilostane administration. This resulted in at least 4 of those 93 dogs being permanently removed from the drug. Thus, in the short-term, 97 of 107 dogs had adverse reactions, many of which were attributable to trilostane. In this same insert, it is stated that in a long term follow-up of the US field study dogs, an additional 3 dogs were described as having died, possibly related to
trilostane.20

In 4 previously published reports, the dosages of trilostane administered orally once daily at the end of the study periods were 5.3 to 50 mg/kg (2.41 to 22.73 mg/lb),15 4.4 to 16 mg/kg (1.82 to 7.27 mg/lb),14 1.9 to 8.2 mg/kg (0.86 to 3.73 mg/lb),17 and a mean of 3.2 to 11.4 mg/kg (1.45 to 5.18 mg/lb).13 In another study21 to evaluate twice-daily oral administration of trilostane in dogs, adverse reactions attributable to glucocorticoid or mineralocorticoid deficiencies were detected in 11 of 44 (25%) treated dogs, and the mean dosage at the end of the study period was 3.2 mg/kg, twice daily (todaily dose, 6.4 mg/kg [2.91 mg/lb]). In a study19 that evaluated twice-daily low-dose oral administration of trilostane in dogs, 8 and 15 of 22 dogs had a good response after 1 to 2 weeks and 4 to 8 weeks of treatment, respectively. Adverse reactions attributable to glucocorticoid or mineralocorticoid deficiencies were detected in 2 of the 22 (9%) dogs, and the mean dosages at the end of the study period were 1.9 mg/kg, twice daily (total daily dose, 3.8 mg/kg [1.73 mg/lb]), in 13 dogs and 1.3 mg/kg (0.59 mg/lb), 3 times daily (total daily dose, 3.9 mg/kg [1.77 mg/lb]), in 3 dogs.19 On the basis of the observation of a rapid but transient response (< 12 hours) to a low dose of trilostane19 and also on the basis of the incidence of serious adverse effects caused by trilostane as reported by several authors and the company distributing trilostane,13–21,d investigation of a lower-dose regimen was warranted. Further, on the basis of the experience of 1 group that used a twice-daily treatment regimen21 and previously reported results on the duration of trilostane effect,19 twice-daily administration of trilostane appears warranted. The purpose of the study reported here was to evaluate the effects of twice-daily lower-dose trilostane
treatment administered orally in dogs with NOH.

Materials and Methods Animals—The study included dogs that were initially evaluated at the Veterinary Medical Teaching Hospital of the University of California-Davis, from April 2007 through December 2008. All dogs were enrolled in the study with the informed consent of their owners. The diagnosis of NOH was suspected from a review of historical data and physical examination results. Each dog had polyuria as an owner concern, and each had at least 4 of the following 6 clinicopathologic findings: high serum alkaline phosphatase activity, high serum alanine aminotransferase activity, hypercholesterolemia, low BUN concentration or BUN concentration near the lower reference limit (low-normal value), urine specific gravity < 1.020, and microbial growth on bacteriologic culture of urine. None of the dogs had a BUN concentration > 25 mg/dL, and none had received prior treatment for NOH. Each dog underwent abdominal ultrasonography.e For each dog, results of at least 2 of 3 screening tests (ie, ACTH stimulation test, LDDST, or assessment of UCCR) were consistent with NOH. The diagnosis of PDH was made if a dog had at least 2 of the following 3 diagnostic test results: an LDDST result indicative of PDH, ultrasonographic evidence of 2 relatively equal-sized adrenal glands, or plasma concentration of endogenous ACTH > 45 pg/mL.22–27 The diagnosis of ATH was made if all of the following were applicable: abnormal LDDST result, a low or undetectable plasma concentration of endogenous ACTH, ultrasonographic evidence of an adrenal mass, and histologic confirmation of an adrenocortical tumor (adenoma or carcinoma) following examination of adrenal mass tissue removed during celiotomy.1

Treatment and assessments—Initial trilostane dosage for each dog was 0.2 to 1.1 mg/kg (0.1 to 0.5 mg/lb) administered orally every 12 hours. Capsules provided by the manufacturer (30 and 60 mg) were used whenever possible. If needed, capsules with the calculated dose were prepared by a compounding pharmacy using trilostane purchased from the manufacturer. Each owner of a dog enrolled in the study agreed to return the dog for reevaluation after 1 to 2 weeks of treatment, then at 6 to 7 weeks after the first reevaluation (approx 2 months after initiation of treatment), 15 to 17 weeks after the second reevaluation (approx 6 months after initiation of treatment), and 24 to 28 weeks after the third evaluation (approx 1 year after initiation of treatment). Dogs with a diagnosis of PDH must have been treated for at least 6 months after trilostane initiation or until illness caused discontinuation of treatment or death. If a dog with ATH was scheduled to undergo surgery for extirpation of an adrenal gland tumor, owners agreed to return the dog for reevaluation at the same intervals as for dogs with PDH or until surgery, whichever came first. All dogs with ATH must have been treated with trilostane for at least 2 months for inclusion.

On the mornings of each reevaluation, owners were instructed to obtain a free-catch urine sample from the dog, if possible, for analysis. Owners were also asked to feed their dog within an hour after urine sample collection and to administer trilostane at that morning’s meal (usually between 7 am and 9 am). Dogs were to be brought to the hospital about 3 hours after trilostane administration, at which time an ACTH stimulation test would be started and completed. Urinalysis and UCCR assessments were to be performed on the urine sample collected by the owner. If adverse reactions were observed during the first year of treatment, at times other than planned reevaluations, the event was assigned to the temporally closest of the 4 planned reevaluations. Some dogs, after 6 months of treatment, were returned to the referring veterinarian for continued monitoring of treatment. Data from dogs monitored outside our hospital were not included in this study.

At each reevaluation, owners were questioned about their dog’s general well-being, changes in clinical signs, and any adverse effects of treatment. Also, at each evaluation, a physical examination and an ACTH stimulation test were completed. A urinalysis was performed if owners were able to bring in a urine sample. For each dog at each visit, response to treatment was classified by owners as good, poor, or ill. A good response was defined as resolution of or marked improvement in clinical signs related to hyperadrenocorticism (ie, reduction in or absence of polydipsia, polyuria, polyphagia, and panting and an increase in muscle strength and activity; hair regrowth was not among the goals of treatment). A poor response was defined as persistence of unacceptable clinical signs of hyperadrenocorticism (eg, polyuria). Dogs were considered ill if signs of anorexia, vomiting, diarrhea, unusual listlessness, or unusual weakness were present. The trilostane dose or administration frequency was altered, as needed, on the basis of owner observations, physical examination findings, or test results. When possible, each dog was monitored by the same clinician throughout the study. Whenever there was discordance between test results and the owner’s opinion, the latter was given greater weight in determining whether a change in trilostane dose or administration frequency was warranted.

As an aid to resolution of clinical signs without causing illness, treatment was directed, in part, to achieve post-ACTH stimulation serum cortisol concentration ≥ 1.5 and ≤ 5.5 μg/dL. If a dog had a post-ACTH stimulation serum cortisol concentration < 1.5 μg/dL and no adverse clinical signs, the trilostane dosage was either unchanged or decreased at the discretion of the veterinarian. No change in trilostane dosage was made if a dog’s response to treatment was classified as good and test results supported that determination. If a dog’s response to treatment was classified as poor and its post- ACTH stimulation serum cortisol concentration was > 5.5 μg/dL at the first reevaluation, the dosage of trilostane was maintained or increased at the discretion of the veterinarian; if these findings were present at the second or third reevaluation, the dose of trilostane was typically increased by 10% to 50%. If a dog’s response to treatment was classified as poor and its post-ACTH stimulation serum cortisol concentration was ≤ 5.5 μg/dL, it was usually recommended to the owner that the frequency of trilostane administration be increased (q 8 h) while each dose was unchanged or decreased. If a dog was described by an owner as ill, trilostane administration was discontinued until the dog was considered well (usually 2 to 5 days) and then recommenced after reduction of each dose by 25% to 50%. If possible, a blood sample was collected from ill dogs for hematologic and serum biochemical analyses (including BUN, potassium, and sodium concentrations) and a urine sample was collected for urinalysis. If an owner could not bring an ill dog to the hospital, it was suggested that those assessments be made by a local veterinarian.

Endocrine tests—For ACTH stimulation tests, blood samples (2 mL each) were collected before and 1 hour after IM administration of synthetic ACTHf (0.25 mg) for measurement of serum cortisol concentration. Serum cortisol concentration > 22 μg/dL (607 nmol/L) at 1 hour after administration of ACTH was considered consistent with NOH.g For the LDDST, blood samples (2 mL each) were collected before and 4 and 8 hours after IV administration of dexamethasone (0.01 mg/kg [0.005 mg/lb]) for determination of serum cortisol concentration. Serum cortisol concentration > 1.4 μg/dL at 8 hours after dexamethasone administration was considered consistent with naturally occurring PDH or ATH.1,28 Serum cortisol concentrations < 1.4 μg/dL at 4 hours or < 50% of basal concentration at 4 or 8 hours after dexamethasone administration were considered consistent with PDH.1,28 Values of UCCR ≥ 13.5 X 10–6 were considered consistent with a diagnosis of NOH.29 Hormone assays—Blood samples obtained for determination of plasma concentrations of endogenous ACTH were collected, stored, and assayed as previously described.1 Serum and urine cortisol concentrations were measured by use of a commercial cortisol radioimmunoassayh that has been validated for use in dogs.28 The analytic sensitivity of this radioimmunoassay was 0.3 μg/dL (8.3 nmol/L). Statistical analysis—Data were analyzed by use of a commercially available statistical program.i To compare findings between groups, paired Student t tests as well as 1-way ANOVAs were performed as indicated. The Bonferroni method was used for post hoc analysis to adjust for multiple comparisons. A value of P < 0.05 was considered significant. Results are presented as mean ± SD.

Results
Dogs—Forty-seven dogs with NOH were included in the study. The dogs were 3 to 15 years old (mean, 10.40 ± 2.26 years). Mean weight of the dogs was 20.7 ± 12.7 kg (45.5 ± 27.9 lb; range, 4.9 to 42.1 kg [10.8 to 92.6 lb]). Included were 38 dogs with PDH and 9 dogs with ATH. Mean ages of the dogs with ATH (10.44 ± 1.42 years) and the dogs with PDH (10.34 ± 2.85 years) were not significantly different. Mean body weights of the dogs with ATH (19.43 ± 12.78 kg [42.75 ± 28.12 lb]; range, 8.1 to 38.4 kg [17.82 ± 84.48 lb]) and the dogs with PDH (20.42 ± 10.44 kg [44.92 ± 22.97 lb]; range, 4.9 to 42.1 kg [10.78 ± 92.62 lb]) were not significantly different.



Clinical signs and endocrine screening test results—The most common clinical signs initially reported by the owners of the 47 dogs were polyuria (n = 47), polydipsia (45), polyphagia (40), lethargy or weakness (35), panting (27), abdominal distention (24), and dermatologic abnormalities (eg, alopecia, thin skin, or hyperpigmentation; 21). Mean urine specific gravity before treatment was 1.009 (median, 1.009). Among the 47 dogs, 39 had abnormal results of 2 endocrine screening tests and 8 had abnormal results of all 3 endocrine screening tests. Results were abnormal in 15 of 33 ACTH stimulation tests, 43 of 43 assessments of UCCR, and 43 of 44 LDDSTs. Treatment evaluation of all 47 dogs—Mean initial dosage of trilostane for all 47 dogs with NOH was 0.86 mg/kg (0.39 mg/lb, q 12 h). The mean initial dosage of trilostane for the ATH dogs (0.89 ± 0.16 mg/kg [0.40 ± 0.07 mg/lb], q 12 h) was not significantly different from the initial dosage of trilostane for the PDH dogs (0.84 ± 0.22 mg/kg [0.38 ± 0.10 mg/lb], q 12 h). The goal of treatment for each dog with ATH was to minimize the incidence of adverse reactions associated with anesthesia and surgical removal of an adrenocortical tumor commonly encountered in dogs with NOH. Each of the 9 ATH dogs successfully underwent adrenal tumor extirpation 8 to 10 weeks after beginning trilostane treatment. The goal of treatment for the PDH dogs was long-term resolution of clinical signs. Therefore, response to trilostane treatment in the dogs with ATH was arbitrarily evaluated separately from the response to treatment in the dogs with PDH. Treatment evaluation of dogs with ATH—Initial dosage of trilostane in the 9 dogs with ATH was 0.89 ± 0.16 mg/kg, twice daily, with a range of 0.54 to 1.1 mg/ kg (0.25 to 0.50 mg/lb), twice daily. Treatment findings among all 9 dogs with ATH at each reevaluation were assessed (Table 1). At the first reevaluation, treatment response was good in 4 dogs and poor in 5 dogs. Seven of the 9 dogs with ATH underwent a pretreatment ACTH stimulation test (serum cortisol concentration, 20.9 ± 13.4 μg/dL; range, 5.3 to 42.4 μg/dL), and all had a lower post-ACTH stimulation serum cortisol concentration at first reevaluation. All 9 dogs underwent ACTH stimulation testing at the first reevaluation. For 3 dogs with a good response and 3 dogs with a poor response, serum cortisol concentrations after ACTH were < 5.5 μg/dL; a post-ACTH stimulation serum cortisol concentration ≥ 5.5 and < 12.5 μg/dL was detected in 1 dog with a good response and in 2 dogs with a poor response. The dose and frequency of trilostane administration were not changed in any of the 9 dogs. At the second reevaluation, all 9 owners classified the treatment response of their dog as good. Seven of the 9 dogs had post-ACTH stimulation serum cortisol concentration < 5.5 μg/dL, and 2 had a concentration of 8.0 and 9.6 μg/dL. All 9 dogs had a post-ACTH stimulation serum cortisol concentration at the second reevaluation that was lower than the result at the first reevaluation. All 9 dogs, after the second reevaluation, had an adrenocortical tumor successfully extirpated (4 adrenocortical adenomas and 5 adrenocortical carcinomas), and for each dog, trilostane was permanently

Table 1—Summary of trilostane dose and frequency of administration, post-ACTH stimulation serum cortisol concentration, UCCR value, and urine specific gravity in 9 dogs with NOH due to an adrenocortical tumor at each of 2 reevaluations following initiation of treatment.

Reevaluation*
Variable 1 2
All dogs
No. of dogs 9 9
Mean ± SD dose every 12 h (mg/kg) 0.89 + - 0.16 0.89 + - 0.16
Range of doses every 12 h (mg/kg) 0.54–1.1 0.54–1.1

Dogs with good response†
No. of dogs 4 9
Mean ± SD dose every 12 h (mg/kg) 0.94 + - 0.05 0.89 + - 0.16

No. of dogs with post-ACTH SSCC < 5.5 μg/dL (range [μg/dL]) 3 (2.1–5.3) 7 (0.5–5.0)
No. of dogs with post-ACTH SSCC . 5.5 μg/dL (range [μg/dL]) 1 (12.4) 2 (8.0–9.6)

Mean UCCR (X 10–6 [range]) 32 (12.1–60.6) 14.9 (8.0–30.1)
Mean urine specific gravity (range) 1.022 (1.015–1.028) 1.028 (1.014–1.037)

Dogs with poor response‡
No. of dogs 5
Mean ± SD dose every 12 h (mg/kg) 0.85 6 0.21
No. of dogs with post-ACTH SSCC # 5.5 μg/dL (range [μg/dL]) 3 (2.1–3.7)
No. of dogs with post-ACTH SSCC . 5.5 μg/dL (range [μg/dL]) 2 (7.9–11.4)
Mean UCCR (X 10–6 [range]) 18.5 (12.4–27.3)
Mean urine specific gravity (range) 1.006 (1.004–1.009)






At each visit, response to treatment was classified by owners as good or poor; no dog was considered ill.

*Reevaluations were completed 1 to 2 weeks after initiation of trilostane treatment (first reevaluation) and 4 to 8 weeks after the first reevaluation (second reevaluation). Urine was obtained 1 hour prior to the morning trilostane administration. The ACTH stimulation tests were completed 3 to 4 hours after trilostane administration. †A good response to treatment was defined as resolution of or marked improvement in clinical signs related to hyperadenocorticism (ie, absence of polydipsia, polyuria, polyphagia, and panting and an increase in muscle strength and activity; hair regrowth was not among the short-term goals of treatment). ‡A poor response to treatment was defined as persistence of unacceptable clinical signs of hyperadrenocorticism (eg, polyuria). — = Not applicable. SSCC = Stimulation serum cortisol concentration. To convert mg/kg to mg/lb, divide by 2.2.


discontinued following surgery. Clinical signs of NOH have not recurred in any dog. Treatment evaluation of dogs with PDH—Initial dosage of trilostane in the 38 dogs with PDH was 0.84 ± 0.22 mg/kg, twice daily, with an interval of 0.21 to 1.1 mg/kg (0.1 to 0.5 mg/lb), twice daily. The initial dosage of trilostane for the dogs with PDH was not significantly different from the initial dosage of trilostane in the dogs with ATH (0.89 ± 0.16 mg/kg, q 12 h). Treatment findings among all 38 dogs with PDH at each reevaluation were assessed, and after reviewing the data, the dogs were arbitrarily separated into 3 groups: dogs whose dose and frequency of trilostane administration did not change or decreased during the study period (PDH group 1), dogs that were maintained on a twice- daily dosing schedule but whose dose increased during the study period (PDH group 2), and dogs whose dosing schedule changed from twice daily to 3 times daily during the study period (PDH group 3). The mean body weights for the 3 groups of dogs were not significantly different. The mean initial dosage of trilostane for each of the 3 groups was not significantly different (0.83 ± 0.26 mg/kg [0.38 ± 0.12 mg/lb], q 12 h; 0.84 ± 0.20 mg/kg [0.38 ± 0.09 mg/lb], q 12 h; and 0.86 ± 0.24 mg/kg [0.39 ± 0.11 mg/lb], q 12 h; respectively), nor was the initial dose for any group significantly different from the initial dose for the dogs with ATH. Treatment evaluation of PDH group 1 dogs—Initial dose of trilostane did not change or it decreased during the study in 15 dogs with PDH (PDH group 1 dogs). The mean initial dosage was 0.83 ± 0.26 mg/kg, twice daily, with an interval of 0.21 to 1.1 mg/kg, twice daily. Treatment findings among all 15 PDH group 1 dogs at each reevaluation were assessed (Table 2). At the first reevaluation, treatment response was good in 10 dogs and poor in 5 dogs. Ten of the 15 dogs underwent a pretreatment ACTH stimulation test (post-ACTH stimulation serum cortisol concentration, 22.9 ± 13.7 μg/dL; range, 9.1 to 50 μg/dL), and all 10 had a lower post-ACTH stimulation serum cortisol concentration at first reevaluation. All 15 dogs underwent ACTH stimulation testing at the first evaluation. The post-ACTH stimulation serum cortisol concentration was < 5.5 μg/dL in 8 of 10 dogs with a good response (< 1.5 μg/dL in 1 of those 8 dogs) and in 0 dogs with a poor response. The dosage of trilostane was decreased from 1.0 to 0.8 mg/kg (0.45 to 0.36 mg/ lb), twice daily, in the dog with a post-ACTH stimulation serum cortisol concentration < 1.5 μg/dL. At the second, third, and fourth reevaluations, 13 of 15, 14 of 15, and 11 of 11 owners, respectively, classi-


Table 2—Summary of trilostane dose and frequency of administration, post-ACTH stimulation serum cortisol concentration, UCCR value, and urine specific gravity in 15 PDH group 1 dogs with NOH at each of 4 reevaluations following initiation of treatment.

Reevaluation*
Variable 1 2 3 4
All dogs
No. of dogs 15 15 15 11
Mean ± SD dose every 12 h (mg/kg) 0.83 +- 0.26 0.81 +- 0.25 0.74 +- 0.29 0.73 +- 0.32
Range of doses (mg/kg) 0.21–1.1 0.21–1.1 0.21–1.1 0.21–1.1

Dogs with good response†
No. of dogs 10 13 14 11
Mean ± SD dose every 12 h (mg/kg) 0.81 +- 0.29 0.81 +- 0.27 0.74 +- 0.30 0.73 +- 0.32
No. of dogs with post-ACTH 8 (1.3–5.5) 10 (0.2–5.2) 13 (1.5–5.1) 10 (1.5–4.5)
SSCC # 5.5 μg/dL (range [μg/dL])
No. of dogs with post-ACTH 2 (8.3–8.6) 3 (5.9–7.4) 1 (6.0) 1 (9.4)
SSCC . 5.5 μg/dL (range [μg/dL])
Mean UCCR (X 10–6 [range]) 26.9 (9.4–71) 17.8 (9.1–35) 12.7 (6.9–21.4) 11.6 (7.1–21.4)

Mean urine specific gravity (range) 1.014 (1.008–1.025) 1.022 (1.009–1.046) 1.027 (1.014–1.037) 1.028 (1.012–1.035)

Dogs with poor response‡
No. of dogs 5 — — —
Mean ± SD dose every 12 h (mg/kg) 0.86 +- 0.19 — — —
No. of dogs with post-ACTH 0 — — —
SSCC # 5.5 μg/dL
No. of dogs with post-ACTH 5 (8.0–19.0) — — —
SSCC . 5.5 μg/dL (range [μg/dL])
Mean UCCR (X 10–6 [range]) 22.9 (11.7–32.8) — — —
Mean urine specific gravity (range) 1.007 (1.005–1.011) — — —


ill dogs
No. of dogs — 2 1
Mean ± SD dose every 12 h (mg/kg) — 0.84 (0.74–0.94) 1.0 —
No. of dogs with post-ACTH — 1 (0.2) 1 (0.8) —
SSCC # 5.5 μg/dL (range [μg/dL])
No. of dogs with post-ACTH — 1 (6.2) — —
SSCC . 5.5 μg/dL (range [μg/dL])
Mean UCCR (X 10–6 [range]) — 23.5 (18–29.1) 27 —
Mean urine specific gravity (range) — 1.010 (1.009–1.010) 1.016 —

Trilostane dose in each dog remained static or decreased during the study period.
*Reevaluations were completed 1 to 2 weeks after initiation of trilostane treatment (first reevaluation), 4 to 8 weeks after the first reevaluation (second reevaluation), approximately 16 weeks after the second reevaluation (third reevaluation), and approximately 6 months after the third evaluation (fourth reevaluation). §Dogs were considered ill if signs of anorexia, vomiting, diarrhea, unusual listlessness, or unusual weakness were present. See Table 1 for remainder of key.

fied the treatment response of their dog as good and no owner classified the response as poor. Two owners at the second reevaluation and 1 owner at the third reevaluation described their dog as ill. Combining results from these 3 reevaluations, 32 of 38 dogs described as having a good response had post-ACTH stimulation serum cortisol concentrations < 5.5 and > 1.5 μg/dL, 1 had a concentration < 1.5 μg/dL, and 5 had concentrations > 5.5 and < 9.5 μg/dL. The trilostane dosage was decreased from 0.8 to 0.6 mg/kg (0.36 to 0.27 mg/lb) twice daily in the dog with a post-ACTH stimulation serum cortisol concentration < 1.5 μg/dL. Each of the 3 ill dogs was described as anorexic and unusually lethargic, 2 had been vomiting and weak, none had physical examination abnormalities, none had serum electrolyte abnormalities, and none required hospitalization. The ill dogs had post- ACTH stimulation serum cortisol concentrations of 0.2, 0.8, and 6.2 μg/dL, and each had its trilostane treatment stopped for 4 or 5 days, during which time each improved clinically, and then was placed back on trilostane at 50% of its original dosage (0.35, 0.50, and 0.50 mg/kg [0.16, 0.23, and 0.23 mg/lb], q 12 h, respectively). All 3 dogs received these dosages through the fourth reevaluation, and all were described as having a good response at the fourth reevaluation. Eleven dogs had no change in trilostane dose or frequency of administration. After the third reevaluation, 4 dogs were placed under the care of their referring veterinarians, all with good responses to trilostane treatment. Treatment evaluation of PDH group 2 dogs—Initial dose of trilostane increased but without a change in the twice-daily frequency of administration during the study period in 16 dogs with PDH (PDH group 2 dogs). The mean initial trilostane dosage was 0.84 ± 0.20 mg/ kg, twice daily, with a range of 0.47 to 1.0 mg/kg (0.21 to 0.45 mg/lb). Treatment findings among all 16 PDH group 2 dogs at each reevaluation were assessed (Table 3). At the first reevaluation, treatment response was good in 14 dogs and poor in 2 dogs. Eleven of these 16 dogs underwent a pretreatment ACTH stimulation test (serum cortisol concentration, 27.3 ± 13.8 μg/dL; range 13.1 to 50 μg/ dL), and all 11 had a lower post-ACTH stimulation serum cortisol concentration at first reevaluation. All 16 dogs underwent ACTH stimulation testing at the first evaluation. The post-ACTH stimulation serum cortisol concentration was > 5.5 μg/dL in all 16 dogs. The dose of trilostane was increased 25% to 50% in 13 dogs (including both dogs with a poor response) and was unchanged in 3. At the second, third, and fourth reevaluations, 11 of 16, 12 of 16, and 7 of 11 owners, respectively, classified the treatment response of their dog as good. At these same reevaluations, 5 of 16, 4 of 16, and 1 of 11 owners, respectively, classified the response as poor. Three owners at the


Table 3—Summary of trilostane dose and frequency of administration, post-ACTH stimulation serum cortisol concentration, UCCR value, and urine specific gravity in 16 PDH group 2 dogs with NOH at each of 4 reevaluations following initiation of treatment.

Reevaluation*
Variable 1 2 3 4
All dogs
No. of dogs 16 16 16 11
Mean ± SD dose every 12 h (mg/kg) 0.84 +- 0.20 1.18 +- 0.33 1.75 +- 0.82 2.0 +- 1.21
Range of doses (mg/kg) 0.47–1.0 0.73–1.5 0.75–3.0 0.75–4.0
Dogs with good response†
No. of dogs 14 11 12 7
Mean ± SD dose every 12 h (mg/kg) 0.81 +- 0.20 1.17 +- 0.36 1.9 +- 0.84 1.7 +- 1.0
No. of dogs with post-ACTH SSCC 0 3 (4.2–5.3) 9 (1.2–4.8) 7 (3.1–5.5)
# 5.5 μg/dL (range [μg/dL])
No. of dogs with post-ACTH SSCC 14 (6.7–18.6) 8 (6.6–14.5) 3 (6.2–9.2) 0
. 5.5 μg/dL (range [μg/dL])

Mean UCCR (X 10–6 [range]) 35.2 (12.2–79.2) 27.5 (8–61) 17.6 (7.2–27.4) 18.4 (7.1–29.5)
Mean urine specific gravity (range) 1.012 (1.006–1.016) 1.013 (1.006–1.019) 1.022 (1.015–1.039) 1.023 (1.014–1.032)

Dogs with poor response‡
No. of dogs 2 5 4 1
Mean ± SD dose every 12 h (mg/kg) 1.0 (1.0) 1.2 +- 0.28 1.3 +- 0.69 1.26
No. of dogs with post-ACTH SSCC 0 0 2 (4.2–4.8) 1 (4.8)
# 5.5 μg/dL (range [μg/dL])
No. of dogs with post-ACTH SSCC 2 (6.4–14.7) 5 (6.9–14.5) 2 (7.1–10.6) 0
. 5.5 μg/dL (range [μg/dL])
Mean UCCR (X 10–6 [range]) 41.5 (41–42) 46.9 (28–63) 39.9 (27–54) 54
Mean urine specific gravity (range) 1.005 1.008 1.006 1.001
(1.004–1.006) (1.004–1.011) (1.001–1.014) —
Ill dogs§
No. of dogs — — — 3
Mean ± SD dose every 12 h (mg/kg) — — — 2.86 +- 1.62
No. of dogs with post-ACTH SSCC — — — 3 (0.4–3.7)
# 5.5 μg/dL (range [μg/dL])
No. of dogs with post-ACTH SSCC — — — 0
. 5.5 μg/dL
Mean UCCR (X 10–6 [range]) — — — 16.4 (7.2–31)
Mean urine specific gravity (range) — — — 1.028 (1.021–1.039)
Trilostane dose in each dog increased over the study period, but the frequency of administration remained twice daily.
See Tables 1 and 2 for key.


fourth reevaluation described their dog as ill. Combining results from these 3 reevaluations, 18 of 30 dogs described as having a good response had post-ACTH stimulation serum cortisol concentrations < 5.5 and > 1.5 μg/dL, 1 had a concentration < 1.5 μg/dL, and 11 had concentrations > 5.5 and < 14.6 μg/dL. Three of 10 dogs with a poor response had post-ACTH stimulation serum cortisol concentrations < 5.5 and > 1.5 μg/dL, and 7 dogs with a poor response had post-ACTH stimulation serum cortisol concentrations > 5.5 and < 14.6 μg/dL. The 3 ill dogs had post-ACTH stimulation serum cortisol concentrations of 0.4, 0.6, and 3.7 μg/dL. The trilostane dose was increased from 25% to 50% in 11 dogs (including the 3 whose dose was unchanged after the first evaluation) and unchanged in 5 after the second reevaluation. After the third reevaluation, the trilostane dose was decreased 25% in 1 dog with a good response and a post-ACTH stimulation serum cortisol concentration < 1.5 μg/dL after having a 50% dose increase at the previous reevaluation. Eleven dogs with a good response had no change in trilostane dose after the third reevaluation, 3 dogs with a poor response had their dose increased 25% to 50%, and 1 dog was taken off trilostane and placed on an alternative drug because of continuing polydipsia and polyuria despite having a post-ACTH stimulation serum cortisol concentration < 5.5 μg/dL (this owner elected not to continue using a recommended 3-times-daily administration). After the third reevaluation, 4 dogs, each with a good response to treatment, were returned to their referring veterinarian for continued care.

One ill dog, about 1 year after initiation of treatment, had signs of anorexia and lethargy, had a post-ACTH stimulation serum cortisol concentration of 3.7 μg/dL, was identified as having a large pituitary mass on magnetic resonance imaging, and was euthanized at the owner’s request. This large pituitary mass was not considered an adverse reaction to trilostane on the basis of a previous study,30 in which results indicated that a reduction of serum cortisol in dogs with PDH did not contribute to pituitary tumor growth. One dog, about 10 months after initiation of treatment, was receiving 1.0 mg/kg of trilostane twice daily and developed anorexia, vomiting, and lethargy. This dog had no physical examination abnormalities, was not hospitalized, had trilostane discontinued, and improved after several days, and the owner refused to place the dog back on the drug. One dog, about 11 months after initiation of treatment, was receiving 3.6 mg/kg (1.64 mg/ lb) of trilostane twice daily and developed clinical signs similar to those of the previous dog. On physical examination, the dog was weak and dehydrated. This dog had hyperkalemia and hyponatremia documented, was hospitalized and treated with parenteral fluids, improved after several days, and was returned to the owner, who refused to place the dog back on trilostane.

Treatment evaluation of PDH group 3 dogs—Initial twice-daily frequency of trilostane administration was increased to 3 times daily during the study period in 7 dogs with PDH (PDH group 3 dogs). Their mean initial dosage was 0.85 ± 0.24 mg/kg (0.39 ± 0.11 mg/ lb) twice daily with a range of 0.48 to 1.1 mg/kg (0.22 to 0.50 mg/lb) twice daily. Treatment findings among all 7 PDH group 3 dogs at each reevaluation were assessed (Table 4). At the first reevaluation, treatment response


Table 4—Summary of trilostane dose and frequency of administration, post-ACTH stimulation serum cortisol concentration, UCCR
value, and urine specific gravity in 7 PDH group 3 dogs with NOH at each of 4 reevaluations following initiation of treatment.

Reevaluation*
Variable 1 2 3 4
All dogs
No. of dogs 7 7 7 6
Mean ± SD dose every 12 h (mg/kg) 0.85 +- 0.24 1.11 +- 0.36 5.75 6 6.01 —
Range of doses every 12 h (mg/kg) 0.48–1.1 0.48–1.5 1.5–10.0 —
Mean dose every 8 h (mg/kg) — — 2.55 +- 3.67 1.07 +- 0.43
Range of doses every 8 h (mg/kg) — — 0.48–10.0 0.48–1.5
Dogs with good response†
No. of dogs 3 3 5 6
Mean ± SD dose every 12 h (mg/kg) 0.74 +- 0.26 1.27 +- 0.25 — —
Mean dose every 8 h (mg/kg) — — 1.05 +-0.38 1.07 +- 0.43
No. of dogs with post-ACTH SSCC 0 2 (1.9–3.9) 4 (0.7–4.8) 6 (1.3–5.4)
# 5.5 μg/dL (range [μg/dL])
No. of dogs with post-ACTH SSCC 3 (7.2–10.7) 1 (7.8) 1 (8.1) 0
. 5.5 μg/dL (range [μg/dL])
Mean UCCR (X 10–6 [range]) 31.1 (1 dog) 22.5 (9.3–37.1) 12.6 (9.7–16.4) 14.5 (9.7–23.7)
Mean urine specific gravity (range) 1.010 (1.006–1.014) 1.018 (1.011–1.032) 1.024 (1.014–1.034) 1.025 (1.018–1.034)

Dogs with poor response‡
No. of dogs 4 4 2 0
Mean ± SD dose every 12 h (mg/kg) 0.94 +- 0.20 0.99 +- 0.42 1.5 —
Mean dose every 8 h (mg/kg) — — 10.0 —
No. of dogs with post-ACTH 0 0 0 —
SSCC # 5.5 μg/dL
No. of dogs with post-ACTH SSCC 4 (7.1–41.3) 4 (5.8–9.2) 2 (5.9–14.3) —
. 5.5 μg/dL (range [μg/dL])
Mean UCCR (X 10–6 [range]) 24.6 (17.9–34) 27.1 (24.7–31.8) (19.2–32.4; 2 dogs) —
Mean urine specific gravity (range) 1.007 (1.006–1.010) 1.008 (1.004–1.014) (1.004–1.010; 2 dogs) —


was good in 3 dogs and poor in 4 dogs. Five of these 7 dogs underwent a pretreatment ACTH stimulation test (serum cortisol concentration, 24.2 ± 8.9 μg/dL; range, 17.2 to 39 μg/dL), and 4 of the 5 had a lower post-ACTH stimulation serum cortisol concentration at first reevaluation. All 7 dogs underwent ACTH stimulation testing at the first evaluation, and the post-ACTH stimulation serum cortisol concentration for all was > 5.5 μg/dL (13.8 ± 12.3 μg/dL; range, 7.1 to 41.3 μg/dL). The dose of trilostane was increased 25% to 50%, but the frequency of administration remained twice daily in 5 dogs (including the 4 dogs with a poor response) and unchanged in 2.

At the second, third, and fourth reevaluations, 3 of 7, 5 of 7, and 6 of 6 owners, respectively, classified the treatment response of their dog as good. At these same reevaluations, 4 of 7, 2 of 7, and 0 of 6 owners, respectively, classified the response as poor. Combining results from these 3 reevaluations, 10 of 14 dogs described as having a good response had post-ACTH stimulation serum cortisol concentrations < 5.5 and > 1.5 μg/dL, 2 had concentrations of 0.7 and 1.3 μg/dL, and 2 had concentrations of 7.8 and 8.1 μg/dL. All 6 dogs with a poor response had post-ACTH stimulation serum cortisol concentrations > 5.5 and < 14.4 μg/dL.

After the second reevaluation, the dosage of trilostane was not changed from 1.5 mg/kg (0.68 mg/lb), twice daily, in 1 dog; was increased about 50% from 1.0 to 1.47 mg/kg (0.45 to 0.67 mg/lb), twice daily, in 1 dog; and was increased to 3-times daily administration in 5 dogs (range, 0.48 to 1.5 mg/kg, q 8 h). After the third reevaluation, 4 dogs with a good response, all receiving trilostane 3 times daily, had no change in trilostane dose or frequency of administration (range, 0.48 to 1.5 mg/kg, q 8 h). One dog with a good response had the trilostane dosage decreased from 1.0 to 0.8 mg/kg, 3 times daily. One dog with a poor response had the frequency of trilostane administration increased from 1.47 mg/kg, twice daily, to 3 times daily. One dog progressively had its dosage of trilostane increased during the interceding 4 months from 1.5 mg/kg, 3 times daily, to 10 mg/kg (4.5 mg/lb), 3 times daily. That dog was removed from the study after consistently having a poor response (severe polyuria) and was treated with surgical bilateral adrenalectomy.

Evaluation of owner opinion, ACTH stimulation test result, UCCR, and urine specific gravity—When post-ACTH stimulation serum cortisol concentrations were related with owner opinions at each reevaluation, 20 dogs classified as having a good response at first reevaluation had post-ACTH stimulation serum cortisol concentrations > 5.5 μg/dL, and 14 dogs classified as having a good response at second reevaluation had post-ACTH stimulation serum cortisol concentrations > 5.5 μg/dL, but only 5 and 1 dogs, respectively, had similar results at the third and fourth reevaluations.

The post-ACTH stimulation serum cortisol concentration < 5.5 μg/dL was an arbitrary goal. In 122 of 160 reevaluations for all 47 dogs, owners reported marked improvement or complete resolution of clinical signs. In 82 of those 122 reevaluations, the post-ACTH stimulation serum cortisol concentration was < 5.5 μg/dL, but similar results were noted in only 3 dogs classified as having a poor response.

The 5.5 μg/dL cutoff value, therefore, was relatively specific but was not sensitive because 40 of the 122 dogs with a good response had post-ACTH stimulation serum cortisol concentrations > 5.5 μg/dL. However, if the goal had been increased to a serum cortisol concentration < 6.5 μg/dL, only 4 of 40 reevaluations in which a good response was reported by the owner and in which a dog had a post-ACTH stimulation serum cortisol concentration > 5.5 μg/dL would have been added, while 3 of the 32 dogs with a poor response would also be included. If the goal had been increased to < 9.0 μg/dL, 106 of the 122 reevaluations classified as good would be included, but 19 of the 32 reevaluations on dogs classified as having a poor response would also be included. Thus, the interpretation becomes more sensitive but less specific as the ACTH stimulation test result is increased.

Neither the UCCR nor urine specific gravity was as reliable as the ACTH stimulation test results in helping determine whether a dose or frequency of administration should be changed. Of 104 UCCR values from dogs described as markedly improved or in which clinical signs had completely resolved, 41 (39%) were within reference limits (< 13.5). Of 26 UCCR values from dogs described as continuing to have clinical signs of NOH, 2 were < 13.5. Of 4 UCCR values from dogs described as ill, 1 value was < 13.5. Therefore, most NOH dogs with continuing clinical signs had UCCR results above the reference range, but this is true of 61% of the dogs described as markedly improved or in which clinical signs had resolved. Of 99 urine specific gravities from dogs described as having a good response to treatment, 50 were ≥ 1.020 and 49 were < 1.020. Of 27 urine specific gravities from dogs described as having a poor response to treatment, all were < 1.020. Thus, a urine specific gravity < 1.020 supports the concept that a dog may be continuing to show clinical signs, but this same result is seen in almost half the dogs thought to have undergone marked improvement or whose clinical signs fully resolved.

Discussion
With rare exceptions, NOH in dogs is neither a rapidly progressive nor a life-threatening condition that requires a rapid response to treatment. Typically, NOH is a chronic progressive disease that ultimately causes unacceptably bothersome clinical signs (eg, polyuria, polyphagia, weakness, and panting) in affected dogs. A primary goal in treating dogs with NOH is to reduce risk associated with anesthesia and surgery in dogs with ATH or to achieve resolution of signs of PDH, as perceived by the owners. Most owners of dogs with PDH are willing to allow a sufficient period of treatment (weeks to months) to achieve resolution of clinical signs. However, treatment may cause adverse effects that are more worrisome than signs of the disease, including death or severe illness requiring hospitalization. If their pet recovers from an episode of illness, some owners refuse to consider any further treatment (as happened in 3 dogs in this study) because of their concerns that adverse effects could recur, incurring further expense and, perhaps, similar or more serious consequences. Therefore, if possible, treatment of NOH should be benign with respect to associated adverse effects, yet effective within a reasonable time period in minimizing or resolving clinical signs.

Trilostane effectively blocks the 3β-hydroxysteroid dehydrogenase-isomerase enzyme system in dogs. This, in turn, inhibits synthesis and secretion of cortisol that occur autonomously from an adrenocortical tumor or secondary to autonomous secretion of ACTH from a pituitary tumor that, in turn, stimulates synthesis and secretion of cortisol from adrenal cortices. In either condition, by decreasing serum cortisol concentrations in affected dogs, clinical signs of NOH can be diminished or eliminated. Most published reports13,14,19,21 on the use of trilostane state that some dogs require trilostane administration more frequently than once per day to resolve clinical signs. There is also a percentage of treated dogs that become ill or die as a direct adverse reaction to trilostane. It has been documented that apparent glucocorticoid or mineralocorticoid deficiency or development of adrenal gland necrosis is associated with trilostane administration.31,32 It also appears possible that, in some dogs, trilostane may more effectively block the synthesis of mineralocorticoid than glucocorticoid. This would explain how severe clinical signs (dehydration, weakness, hyponatremia, and hyperkalemia) could develop in a dog that becomes ill during trilostane treatment despite having pre- and post-ACTH stimulation serum cortisol concentrations that may not be as low as the values in other dogs that seem to be unde rdosed or that have responded well.33 The incidence of worrisome adverse effects in our early experiences of trilostane treatment of dogs with NOH, in reports from authors at other institutions, and in our previous report,19 which included a twice-daily low-dose dosing schedule, suggested that a twice-daily lower-dose treatment plan was worthy of investigation. The goal of the present study was to control clinical signs associated with NOH while reducing the incidence and severity of adverse effects.13–19,31,32,d

One of 47 dogs in this study developed worrisome clinical signs secondary to development of a large pituitary tumor, a problem that likely developed independent of trilostane administration. Despite quite low doses of trilostane administered to the dogs in this study, 5 appeared to have adverse reactions to the drug, although unrelated conditions may have been the cause of these illnesses. Four of the 5 dogs with worrisome adverse effects were being given trilostane at dosages well below manufacturer recommendations (0.74, 0.94, 1.0, and 1.0 mg/kg [0.34, 0.43, 0.45, and 0.45 mg/lb], q 12 h). One dog was being given 3.6 mg/kg, twice daily, when the illness was considered sufficiently severe to require hospitalization and parenteral fluid therapy. On the 1 hand, it was disappointing to have 5 of 47 (10.6%) trilostane-treated dogs develop adverse effects.

However, no dog died, and only 1 had an episode of illness requiring in-hospital treatment out of 160 reevaluations. Both the incidence and severity of adverse effects were less in the dogs in this study than those reported in other studies or by the manufacturer in its insert.13–21,d Veterinarians who elect to use trilostane for treatment of NOH should be aware that adverse effects caused by the drug can occur in dogs receiving recommended or less than recommended doses. Further, such adverse effects can occur at any time after treatment has been initiated. Trilostane-induced adverse effects were documented after about 2 months of treatment in 2 dogs, after about 6 months of treatment in 1 dog, and after about a year of treatment in 2 dogs. Veterinarians should consider using low initial trilostane doses, such as those reported herein, to minimize the incidence and severity of such adverse effects.

The initial dosage of trilostane given to all 47 dogs was lower than that reported in any study to date, to the author’s knowledge. In our previous low-dose trilostane study,19 22 dogs with NOH were initially given 0.5 to 2.5 mg/kg (0.23 to 1.14 mg/lb, q 12 h; mean, 1.4 mg/ kg [0.64 mg/lb]). In that study, no dog required more than 2.8 mg/kg (1.27 mg/lb) of trilostane per treatment to control clinical signs of NOH. In the present study, the initial dosage given to 47 dogs with NOH ranged from 0.21 to 1.1 mg/kg, twice daily (mean, 0.86 mg/kg). It was assumed that the final dose necessary to control clinical signs in these dogs would be well in excess of these initial doses. However, all 9 ATH dogs responded well to the initial dose used in this study, and 15 of the 38 dogs with PDH (PDH group 1 dogs) responded well or were overdosed by similar initial doses. Further, 8 dogs whose twice-daily dose increased over the course of the study (PDH group 2 dogs) and 3 dogs given trilostane 3 times lowest (3 mg/kg/d) manufacturer’s recommended initial daily dose. Thus, 35 of the 47 (74%) study dogs never received as much as the lowest initial manufacturer’s recommended total daily dose of trilostane.

Remembering that the manufacturer’s recommended initial dosage is 3 to 6 mg/kg, once daily, it is valuable to note that only 4 of 47 dogs were given > 3 mg/ kg of trilostane per treatment. One of these latter 4 dogs responded well to 3.8 mg/kg, twice daily; 1 dog receiving 4.0 mg/kg (1.82 mg/lb), twice daily, developed a large pituitary tumor (independent of trilostane) and was euthanized; 1 dog given 3.6 mg/kg, twice daily, became ill with adverse effects requiring hospitalization; and 1 dog failed to respond to trilostane despite being given dosages as high as 10 mg/kg, 3 times daily. None of the dogs with ATH required an increase in dose, and all owners reported good responses to trilostane. These results suggested that adrenocortical tumors are quite sensitive to trilostane and that dogs with this condition, treated in preparation for surgery, should be given doses at or below those used herein.

If surgery is not planned for any dog with ATH and if trilostane is the only treatment anticipated to be used in an attempt to gain long-term resolution of clinical signs, it is assumed that the dose used should be at or below those used herein. Results indicating that trilostane may be superior to mitotane in the treatment of dogs with ATH are supportive of future studies that would compare the efficacy of these 2 drugs in preoperative treatment.

The results of the present study indicated that trilostane is both potent and effective in dogs at doses less than those recommended by the manufacturer and reported in the veterinary medical literature. In our previous report,19 it was hypothesized that the safety of twice-daily low-dose trilostane treatment might have been improved if, at the first reevaluation, fewer dogs had had a post-ACTH stimulation serum cortisol concentration ≤ 5.5 μg/dL, none of the dogs had had a good response to treatment, and the dosage needed by each dog to achieve resolution of clinical signs had been determined over a period of several months by slow adjustment of the dose and frequency of administration.

Such a slow-adjustment protocol could result in treatment of most dogs with a dose just above an established threshold that achieves the response desired, thereby reducing risk of adverse drug effects. The increase in time needed to achieve such a response would be balanced by a decrease in the incidence of adverse effects. Indeed, none of the 47 dogs in the study reported herein became ill in the first 2 weeks of treatment, and perhaps consistent with this result, only 14 of the 47 dogs had post-ACTH stimulation serum cortisol concentration ≤ 5.5 μg/dL at the 10- to 14-day (first) reevaluation. Owner opinions are not necessarily consistent.

Marked improvement in the opinion of one owner may not be so to another. Improvement in the first few weeks of treatment may not be seen as improvement after several months. Owner expectations did appear to change with duration of treatment. It appeared that owners reported a good response early in the course of treatment with minor improvements but were more critical in their assessment as treatment progressed. Closer agreement in owner observations and ACTH stimulation test results does occur with time. Despite these caveats, it would appear that owner opinion, coupled with the ACTH stimulation test result, provides the best opportunity for recognizing which doses and frequency of administrations appear satisfactory versus those that should be changed. It is suggested that the goals of a post-ACTH stimulation serum cortisol concentration ≤ 5.5 μg/dL and a urine specific gravity > 1.020 be retained, but that owner opinion remain key in evaluating treatment success or failure. Dogs with a post-ACTH stimulation serum cortisol concentration > 5.5 μg/dL and an owner who continues to observe clinical signs should have the twice-daily dose increased. Dogs with a post-ACTH stimulation serum cortisol concentration ≤ 5.5 μg/dL and an owner who continues to observe clinical signs should be considered for a change from 2 to 3 treatments/d. It would appear that there is no advantage in performing the relatively expensive UCCR evaluation on each reevaluation.34 However, reevaluating urine from dogs being treated for NOH for specific gravity is relatively inexpensive, may provide information of interest, and would allow each sample to also be assessed for glucose, protein, or evidence of infection. Such parameters have potential value in the continuing assessment of dogs being treated long-term with trilostane.
a. Vetoryl, Arnolds Veterinary Products Ltd, Harlescott, Shrews-
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b. Hurley K, Sturgess K, Cauvin A, et al. The use of trilostane for
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[addy]

Hi Fred,

Good to hear from you. I was wondering what you and Trixie were up to. I am also glad to start the discusion as I want to switch Zoe to BID.
I have read the same study. I think Glynda's computer is down this weekend but when she is back up, I know she will stop by and join in.

Another member, Terri had her Corkey on three time dosing. If you are interested in reading her story, I can find her thread for you. We considered Terri our pioneer in dosing.:)

How is Trixie? More importantly, how are you?

When I first contacted Dr. Mark Peterson about starting Zoe on treatment I asked his opinion on twice day dosing for her from the start. Zoe has colitis and I was worried about flaring it. He had no problems with me starting on twice day dosing if I thought it would be easier on her system. I also contacted Dr. Allen whom then worked at Dechra and was so great in giving us advice. At that point, Zoe had started Vetoryl, a very low dose, and her cortisol would drop some and then pogo back up. He thought twice day dosing would possibly help Zoe from pogoing back up.

In both of these incidents, the use of twice day dosing for Zoe was not discussed because of unresolved symptoms and controlled cortisol.

Are you considering switching Trixie?

[busyman370]

Hi Fred,

Good to hear from you. I was wondering what you and Trixie were up to. I am also glad to start the discusion as I want to switch Zoe to BID.
I have read the same study. I think Glynda's computer is down this weekend but when she is back up, I know she will stop by and join in.

Another member, Terri had her Corkey on three time dosing. If you are interested in reading her story, I can find her thread for you. We considered Terri our pioneer in dosing.:)

How is Trixie? More importantly, how are you?

When I first contacted Dr. Mark Peterson about starting Zoe on treatment I asked his opinion on twice day dosing for her from the start. Zoe has colitis and I was worried about flaring it. He had no problems with me starting on twice day dosing if I thought it would be easier on her system. I also contacted Dr. Allen whom then worked at Dechra and was so great in giving us advice. At that point, Zoe had started Vetoryl, a very low dose, and her cortisol would drop some and then pogo back up. He thought twice day dosing would possibly help Zoe from pogoing back up.

In both of these incidents, the use of twice day dosing for Zoe was not discussed because of unresolved symptoms and controlled cortisol.

Are you considering switching Trixie?

Good to hear from you too.

After reading the study, it dawned on me that the cortisol going up and down was not the purpose of the study.

It seemed to me that the two to three doses per day was done to get the most control with the least amount of drug, and that was interesting to me, and I am trying to find out more about that concept.

Up to now, and forgive me for being vague, but I thought that the once per day dose had some benefit to the adrenals, regarding giving "them time to rest", or something to that effect, and that twice per day was only if the once per day wasn't controlling the symptoms through the whole day.

Now, after reading this study, it seems that two to three times a day dosing is just plain safer and gentler on the dog.

So, I am at the beginning stages of attempting to learn more about this concept.

And yes, if two or three doses per day would be better for Trixie, I'd switch instantly.

Hope we can get some real usable info from the forum on this subject regarding if there is a real advantage to multiple dosing.

Take care,
Fred
.
.

[labblab]

Hi Fred,

Your ears should have been burning yesterday, because I was thinking of you and even scrolled back to find Trixie's thread in order to see whether perhaps I had missed a recent update. I am so glad to hear from you, and hope that your own health is stable right now, as well.

Thanks very much for supplying the full version of this study. I have seen summaries during this past year, but this is the first time I've been able to read the complete discussion section. I've glanced through it this afternoon, and plan to go back and review it thoroughly later.

As you can see from the citations, Dr. Feldman has been a proponent of twice-daily dosing for several years now (I think his earlier study was completed in 2008 or 2009). And as time goes on, I do think that more and more specialists will likely continue to jump on board the train. For those who continue to recommend once daily dosing, I'm guessing that their rationale may correspond with this quote from Dr. David Bruyette (posted on our forum at a time that he was a member):


...With regards to once vs twice a day dosing if we look at all the studies throughout the world you will see that about 80% of dogs do well with once daily dosing. One huge advantage of once daily dosing is owner compliance which goes up substantially when owners only have to dose once a day. While twice a day dosing may result in a lower amount of trilostane being used per day it will require closer monitoring as the ACTH stimulation tests tend to be lower so we have to look for both hypocortisolemia and electrolyte abnormalities.

So to me, there are two pieces to Dr. Bruyette's comment. The first relates to enhanced owner compliance. It is easier to stay on a consistent once daily dosing schedule than it is to introduce additional dosings during a day. So if an owner is satisfied with the degree of symptom resolution that is achieved with once daily dosing, why complicate their lives by introducing a second dose? I believe Dr. Feldman's response would be that the second (or third) dose is worth it if you can minimize side effects and decrease the overall daily dose.

Dr. Bruyette's second comment is that cortisol levels tend to be driven lower on twice daily dosing, so even closer monitoring is required. Does this necessitate even more frequent blood/urine testing? Or would Dr. Feldman's response be that if you start with much lower doses to begin with, you don't have to be so worried about dogs bottoming out. I don't know the answer to that. Maybe when I re-read Dr. Feldman's article, I'll have a better idea.

I guess the bottom line, to me, is that twice daily dosing may turn out to be preferable as long as the owner's commitment and lifestyle can support it. If people can arrange things so as to consistently medicate their dogs on a 12-hour schedule and are willing to assume the burden of extra monitoring if necessary, Dr. Feldman's research implies that is the way to go. But if people are going to blow off the second daily dose or vary the time frame each day, then a consistent single daily dose may be better. I have to give my seizure dog a dose of phenobarb every 12 hours -- as accurately as possible -- and those contraints have often really altered my evening plans so that I'm home at the right time. I have to be mindful of that dosing every single day, and it is easy to forget sometimes. I think most folks who come to this forum are already obsessed about their dogs' health and are willing to assume any responsibility necessary. But having said that, it is easier all the way around to dose only once daily.

So I guess my own preference would be for vets to take the time to discuss dosing pros-and-cons with owners who are launching out on trilostane. That way, the owner can make a more informed choice re: the schedule/expense that they are willing and able to undertake re: their dog's treatment.

You may be interested to know that when we started trilostane treatment for my own Cushpup nine years ago, we started with twice daily dosing from the get-go because it was already being discussed as a preferable option back then. In honesty, I ended up wishing we had started with once daily dosing because we ended up needing to make a lot of dosing tweaks that I felt would have been easier without trying to divide a dose. But we also started out on a much higher dosage level, too. So if I were starting out fresh today, I don't know which option I'd prefer. I've got to re-read Dr. Feldman's study and see how my thoughts play out.

Marianne

[addy]

I knew Marianne would come along if she was home.:):)

Fred, my reference to the pogoing and twice day dosing was to point out that it was a consideration other than the norm of "only use twice day dosing if cortisol is controlled and symptoms are not controlled". I realize it had no bearing on the study. I was trying to broaden our discussion in how we may benefit from twice day dosing.

My IMS has pointed out to me numerous times that quite often, because Trilostane does not "burn off" the adrenals as does Lysodren, that the adrenals can get larger, thus she has found she needs to prescribe higher and higher doses as treatment progresses. Dr. Feldman's study showed effective cortisol control with twice day dosing at lower doses. The lower doses produce less side effects. I worry about side effects at the higher doses.

I guess the glitch may be in, as Marianne points out, twice day dosing was from the onset of treatment. So what does one surmise when we switch from single day dosing to twice day? I am not sure. What are your thoughts?

You went through a lot of work for us, thank you and I hope others will benefit from reading this.

[molly muffin]

This definitely presents something to give some serious thought to in regards to not just how much to dose, but why we dose at all and what do we expect from dosing and finally, the side effects of dosing and at what levels are those side effects seen.

Thanks for posting,
Sharlene

[labblab]

For folks who would appreciate a streamlined summary of Dr. Feldman's key reasearch findings, here's a link:

http://veterinarymedicine.dvm360.com/vetmed/Medicine/Hot-Literature-Hyperadrenocorticism-Is-lower-dose-/ArticleStandard/Article/detail/743086

And here's a link to a published version of the complete study:

http://www.provet.com.br/download_especialidades.php?filename=77-Artigo_sobre_trilostane.pdf

Marianne

P.S. Both of these links have now been added to our "Helpful Resources" forum so that we can find them more easily in the future.

[lulusmom]

Hi Fred.

Thanks so much for posting the study. Like Marianne, I had only seen the summary so this is a "eureka" moment for me. There are some interesting tidbits, on of which was very interesting. It seems that in some dogs, trilostane lowers the mineralcorticoids more than the cortisol so despite having pre and post acth stimulated cortisol, what sounds like well above the danger zone, the dogs were clinically ill, showing signs of addison's. We've had members with dogs who fit this pattern so that might be why they have great looking stim tests but act sick.

Now about Trixie's continued PU/PD. Since all other symptoms seem to have abated, I think your vet needs to determine if Trixie's inability to hold her urine is due to the kidney's inability to concentrate her urine. If the kidney are still not concentrating, I think I mentioned before that it could be that the once daily dose of Trilostane isn't effective long enough and that Trixie might be a good candidate for twice daily dosing.

One of the first UC Davis studies mentioned that they had a small percentage of dogs who continued to have pu/pd despite having cortisol well controlled. I did note in this study that one of the dogs with an adrenal tumor eventually underwent an adrenalectomy because of continued pu/pd. It could be that Trixie is simply one of those dogs who will never see resolution of pu/pd, in which case raising her once daily dose of Trilostane would be risky and wouldn't be effective in the long run. If I had a dog with a pre of 1.6 ug/dl and post of 4.3 ug/dl, I would have to think long and hard about increasing the dose, especially if all other symptoms had resolved. That usually doesn't happen if a dose is ineffective.

I noted in one of your posts that Trixie seems to do much better in the early am than she does in the evening which tells you that she doesn't need a second boost of trilostane at supper time to carry her through the night. In all honesty, if you were to switch to twice daily dosing, Trixie could prove you wrong. She may not feel great on 60mg once a day. Peak concentrations are 1 1/2 to 2 hours after a dose so what you are seeing on the stim test probably isn't rock bottom for Trixie but the general malaise she might feel at her lowest cortisol level may not be instantaneous. It could take her several hours after that to start feeling better. With Lysodren, timing isn't such a big deal for dogs getting weekly maintenance doses but with Trilostane it can be everything.

My dogs have given me lots of experience with lysodren and trilostane. For their sizes, their doses of both meds were quite hefty. With respect to trilostane, I had one on once daily and one on twice daily. Lulu at 4.5 lbs was 30mg SID and Jojo at 7 lbs was 15mg BID. Lulu did beautifully, never acted sick and had consistent pre and post stim results in the 2 to 3 range; however, she never grew hair with trilostane or lysodren. Despite having consistent pre and post stim results in the 2 to 3 range, Jojo's pu/pd never resolved on trilostane or lysodren. Jojo was a shelter rescue so I didn't know his history. All I knew is that he was a walking poster child for cushing's who made Lulu's peeing and drinking look like a dribble. Jojo may not have been able to take a race horse around a track but when it came to peeing, I'd put my money on him. :D His IMS decided to try desmopressin eye drops in the hopes that he may have central diabetes insipidus but that didn't work so he was diagnosed with idiopathic diabetes insipidus and the treatment was constant availability of clean water, which was never a problem because with Jojo, water never had a chance to get dirty. :D

Desmopressin is expensive which is why those of us who've purchased it call it liquid gold. I would have gladly paid the money to give Jojo a better quality of life way from the water bowl but we dealt with it and he was happy for most of his last five years with us. You can always give Desmopressin a try if all else fails. It's a rare disorder but we've had a few members whose dogs responded well to Desmopressin.

In the seven years since our first diagnosis, I've learned that no matter how much you learn, it's not enough and never will be. It's beyond frustrating to try to analyze what is going on with our dogs and come to the right conclusion based on symptoms and the predictability of trilostane. You may be able to predict that Trilostane is going to be effective but there's no way to predict the roads you have to take to get there. And you can throw the predictability of our dogs out the window. If our dogs were predictable, a good number of us may have retained a lot more hair and the sparse hair we have left wouldn't be so gray. I've always said that cushing's is a lot harder on us parents than our dogs. I still believe that.

Glynda

[busyman370]

Hello All,
Your very welcome for the full version of the study. Glad you found it of value. I hope my Vet can improve how he treats Cushing's by reading it.

And thanks for the warm thoughts, and for advise in helping Trixie.

Here is an update; from where we were to today.


First I'll address her pu/pd.

On the once daily 7:00 AM dose, she would pee as soon as Noon, so I figured either the trilo wasn't high enough, a brain tumor was causing it, or she needed desmopressin, or any combination of the three.

Deciding that we needed to try something, rather than wait around, I tried raising her once a day dose from 60 mg to 70 mg, then to 80 mg, with ATCH monitoring, and no change at all with the pu/pd, so I ruled out the trilo as the answer to the pu/pd, and immediately started her on desmopressin, and dropped back to 70 mg, and I am planning to drop back to the 60 mg Thursday of this week, where her pre was 1.6 and her post was 4.6, then go forward from there.

Here are her past numbers, with my observations:
4- 3-12 --- pre 2.1 ---- 5.9 ------- At 50 mg. once per day.

4-24-12 -- pre 1.4 ---- 4.3 ------- At 50 mg. once per day.
• Other than the pu/pd, she was at her best at this post number.

5-12-12 ---- pre 2 ----- 6.4 ------- At 50 mg. once per day.
• She was not doing well at this post number.

6-21-12 ---pre 1.6 ---- 4.6 ------- At 60 mg. once per day.
• She was doing OK symptom wise, but the pu/pd was really bad, so as
explained above, planned to see if an increase in Trilo would correct that.


7-9-12 Bumped up to 70 mg. once per day.
• No change at all. No signs of crashing. the pu/pd was still bad.

• No ATCH at 70 to compare, but - the math says - post ATCH should have
been - 3.7.
Here's the formula I used:
@ 60 mg. post 6.4 - post 4.6 = 1.8 1.8 ÷ 2=.9 4.6 - .9=3.7
@ 80 mg. post 4.6 - post 2.8 = 1.8 1.8 ÷ 2-.9 4.6 - .9=3.7
@ 70 mg. post 4.6 - post 3.7 = .9 (half of the 80 dose) or - 2.8 + .9 = 3.7

7-17-12 Bumped up to 80 mg. once per day to give the Trilo one last shot at
fixing her Cushing's symptoms, however, gave up on the Trilo fixing
her pu/pd, and started her on Desmopressin to fix the the pu/pd.

ATCH Test:
7-31-12 --- Pre .8 ------ Post 2.8 ------- At 80 mg. once per day.
• This number is exactly 1/2 of the 6-21-12 ACTH.
• Still no change at all in symptoms, no signs of crashing, pu/pd still bad.

I knew that if the increase in Trilo had no effect on her remaining Cushing's symptoms, then I'd have to accept that a brain tumor was the probable cause, and the Trilo, even at the lower doses, was giving her all the help that it was able to give, and would go forward with that in mind.

Even though her numbers were well within range at the 80 mg, I was uncomfortable with them being that low, fearing it could suddenly drop too low without notice. And since her clinical signs were not improving, decided to drop her back down to the lower doses, 70, then eventually back to the 60 mg. once per day.

The 60 mg. once per day has shown to put her ACTH at good number, but as lulusmon said, the twice per day dosing may be worth considering.

Whether or not I go to the twice a day dose, I at least have a good bench mark to work with at the 60 once per day.

To go to twice a day, I can split that number up, as per Dechra protocol, and see how it works. I am already medicating her three times a day, so twice a day dose of Trilo would fit right into my present schedule.
My take at this point in time is that I am quite certain that Trixie is as good as she's going to get. I have her very stable, and she is quite comfortable overall. I really need to think about making another change at this point in time by going to the twice per day dosing.

That damn circling around, and always to the right, tells me that there isn't much more I will be able to do for her, and to just leave things as they are, and let her have as much good time as she can, and stop messing around with her treatment.

Again, I say this SOLEY because of the tumor symptoms. That is not going to get better, just worse.

This now qualifies as a long road traveled for Trixie and me, and through some scientifically based, albeit risky, trial and error, I believe that I have at least found the proper dose of Trilo for her - at this time in her life. The only thing I haven't tried is the twice per day Trilo.

Bye the way, the calcinosis cutis has been in remission for some time now.

However, I am no longer under any delusions regarding just how "back to normal" Trixie will ever get, no matter what I do, because of the strong brain tumor symptoms.

So, I am moving forward with the belief that the brain tumor is playing an increasing role in her overall state, and will only make her worse in time.

My feeling now is that if I can keep her within a certain quality of life window, then I am doing pretty well for her.

Regarding Trixie being "better" in the am, if I said that, either I misspoke, or that was true sometime ago. Two months treating Cushing's seems like six!

When she is "up" and does things like "jog around the yard", it is always later in the day, and usually in the evening before bed. So I really don't think that twice a day dosing is needed for her being "up." Maybe for other things, but not that.

And finally, she's different every day. Yes, she is always in that certain "state", but she's just a little better some days, and a little worse on others. I just see it as how the Cushing's, et'al, is uniquely effecting her - in particular.

Each dog must be and react differently. Plus, she's a ten year old Boxer! I have to remember that. Even if she didn't have Cushing's, she'd still be acting "older," like her Father did, and she is a carbon copy of him.

Trudie, her littermate takes after the Mom. She is still like a puppy, run's her butt off around the yard! So, the apple don't fall far from the tree.

However, Trudie has a large hyperplasia bump on her gum, but I am not going to have it removed! I've seen too many times when an older dog goes under for surgery. Every time I've done surgery on an older dog, soon after, they get mortally sick and die, I believe from the trauma, but that's another theory we can get into later.

I am going to respect that belief with Trudie. I even removed a skin tag on her temple by tying it off with thread, rather than let the Vet cut it off, and for the same reason.

In closing, after this Thursday, and she's back to the 60 mg, once per day, and on the Desmopressin, and Soloxine. I want to sit back and see how things go for a couple of weeks.

I have arrived at the lowest dose possible to control the pu/pd because I know that Desmopressin does raise the cortisol. I've seen the numbers, but can't seem to figure out just how much, as it would relate to how the dose of Trilo's control of the cortisol is effected by it. I am thinking that it won't raise it enough to require an up in the Trilo dose, as she is well within a good post ATCH range, and a little increase in cortisol wouldn't challenge it. But, we'll see.

So, that's it for now. Yet another "short note" from me. LOL

All the best everyone!

Fred.

[molly muffin]

I am sincerely impressed by how organized you are. Even in your thoughts and writings. Maybe that is a stage that a cushings "parent" is able to reach at some point. I just think that Trixie is lucky to have such a person looking out for her.

Kudos and hugs,
Sharlene

[lulusmom]

Hi Fred.

You and another member have dogs with pituitary macroadenomas and both of you have opted to treat with Vetoryl to alleviate the normal symptoms associated with cushing's. Between you and Fawni, I've done a lot of thinking about this and I just don't know if I would choose to treat a dog with already increasing neurological signs with Vetoryl or Mitotane. A study has shown that treating with Vetoryl or Mitotane can promote growth of a macroadenoma. If a dog already has increasing neurological signs, I am thinking that to accelerate growth of the tumor, neuro signs are going to get a lot worse as the cranial pressure increases. This causes a lot of pain which is why dogs head press. Vetoryl remedies symptoms that aren't life threatening nor usually painful for a dog so do think it might be beneficial to live with the problematic symptoms like peeing and drinking in exchange for allowing the anti-inflammatory effects of high cortisol to keep a dog comfortable?

I honestly don't know the answer to that question so I asked Dr. Mark Peterson's on his blog. I was lucky enough to get an answer from him on another post I made so I'm hoping he'll answer this one. I'll let you know if I here anything back.

For what it's worth, I think you've done a remarkable job with managing Trixie's illness. Your assessment of the overall picture is thoughtful, realistic and so very loving. What a lucky girl she is to have such a fabulous dad.

Glynda

[busyman370]

Hi Fred.

Vetoryl remedies symptoms that aren't life threatening nor usually painful for a dog so do think it might be beneficial to live with the problematic symptoms like peeing and drinking in exchange for allowing the anti-inflammatory effects of high cortisol to keep a dog comfortable?

Glynda

This would make perfect sense except for the Calcinosis Cutis. That in itself is a horrible thing to allow to slowly creep over the dogs body.

It's a little late now, but perhaps using Lysodren would have been the better choice in Trixie's case.

I could say more, and I plan to later, but since I'm sure we'll be talking again soon, I'll keep it short, for once!

Thanks for caring,

Fred.

[labblab]

Fred, having lost my own Cushpup to what we suspect was an enlarging tumor, I appreciate how hard it is to maintain a reasonable balance between treating the Cushing's or not. I must preface my comment with the fact that since we did not perform any brain imaging, we don't know for certain that the tumor was the cause of our dog's neurological problems. But our specialist believed it to be the case, as did we.

The bottom line was, we tried both routes: continuing to treat with trilostane versus withholding it. For us, withholding the trilo did not visibly help with the neurological problems. And when he was off the trilo, he resumed Cushing's symptoms that were making him miserable such as non-stop panting and muscle weakness. So it was a difficult proposition to try to keep him comfortable. As a compromise, we went ahead and resumed the trilostane, but at a lower dose.

I don't mean to tell you this to discourage you. But just to say that I don't think there is a single best answer in this situation. It all depends upon how each individual dog responds to the presence or absence of the medication and the best quality of life possible during the time frame that you have to work within.

One of our members has told us that her specialist even opted to treat her dog's macrotumor with both trilo and also supplemental prednisone at the same time. I've guessed that the purpose was to keep the steroid level under some semblance of direct control. In other words, the supplemental prednisone could be dosed at a specific and consistent level whereas uncontrolled cortisol could not.

I don't know whether or not it is any help to you, but I just wanted to share our experience

Marianne

[busyman370]

Fred, having lost my own Cushpup to what we suspect was an enlarging tumor, I appreciate how hard it is to maintain a reasonable balance between treating the Cushing's or not. I must preface my comment with the fact that since we did not perform any brain imaging, we don't know for certain that the tumor was the cause of our dog's neurological problems. But our specialist believed it to be the case, as did we.

The bottom line was, we tried both routes: continuing to treat with trilostane versus withholding it. For us, withholding the trilo did not visibly help with the neurological problems. And when he was off the trilo, he resumed Cushing's symptoms that were making him miserable such as non-stop panting and muscle weakness. So it was a difficult proposition to try to keep him comfortable. As a compromise, we went ahead and resumed the trilostane, but at a lower dose.

I don't mean to tell you this to discourage you. But just to say that I don't think there is a single best answer in this situation. It all depends upon how each individual dog responds to the presence or absence of the medication and the best quality of life possible during the time frame that you have to work within.

One of our members has told us that her specialist even opted to treat her dog's macrotumor with both trilo and also supplemental prednisone at the same time. I've guessed that the purpose was to keep the steroid level under some semblance of direct control. In other words, the supplemental prednisone could be dosed at a specific and consistent level whereas uncontrolled cortisol could not.

I don't know whether or not it is any help to you, but I just wanted to share our experience

Marianne

Marianne,
Thank you for sharing that experience and treatment info. I certainly can empathize with what you must have gone through.

I understand and agree with your decisions. From what I've seen it would be impossible to maintain any sort of acceptable or reasonable balance without treating the dog.

And it looks like I have the same philosophy as you did, as I lowered Trixie's Trilo back to the 60 mg. today, instead of waiting until Thursday, because I am trying to treat Cushing's without helping the tumor growth any more than I have to in the process.

I don't think I will go back to the 50 mg, especially with the desmopressin. the 60 should serve well, at least for now.

My take is that I absolutely believe in treating Trixie with whatever med's are necessary to keep her at least as good as she is at this time. As stated earlier, if only for the Calcinosis Cutis alone it's worth treating the dog.

Quote:
"But just to say that I don't think there is a single best answer in this situation. It all depends upon how each individual dog responds to the presence or absence of the medication and the best quality of life possible during the time frame that you have to work within."

Very very well said Marianne.

I'd like to add:
As you and most on the forum know, it's more than just the treatment. Between the emotion and the alterations in daily schedules and routines, one's whole life gets turned upside down when dealing with something like this. So there are at least two beings that are effected, not just the dog alone.

Plus, at least in Trixie's case, I have to watch her both get better and worse at the same time. She's beating the Cushing's and the Calcinosis Cutis, but the brain tumor is pulling her in the opposite direction.

As far as supplemental Prednisone; very interesting concept.

Trixie was never herself after her last surgery, and that was just before the formal declaration of Cushing's, and the initiating of treatment. Therefore, armed with that knowledge, and after all that I've tried, and nothing did get her back to herself, I've given up on ever seeing that in her again.

My point is that the tumor did not seem to be a big player in her initial stages, and she was not herself then. To try to shrink it with pred at this point seems futile to say the least. But interesting concept none the less, especially for a dog that did return to it's old self shortly after initiating treatment. That concept may be a real life saver for the right dog. I do see the merit, however, in reducing the Trilo with the purpose of still treating the Cushing's while at least trying to minimize the tumor growth.

To elaborate on the above; Trixie was FINE, GREAT until I had a vascular tumor removed from her chest area. When she came out of surgery, she never did return to her prior self.

The tumor had to go. It was looking pretty swollen and black purple. I was afraid it could hemorrhage at any moment.

Did the anesthesia hurt her brain function? (she never acted like she fully came completely out of sedation)

Did it hurt her kidney function? (needed desmopressin)

I say yes and yes.

And the kicker is that before her sutures were removed, she already had the start of Calcinosis Cutis on her abdomen! We just didn't know what it was. The Vet thought it was a skin infection.

So, my conclusion, once again, older dog going under anesthesia/trauma of surgery unleashed what Trixie and I are dealing with today.

Would she have gotten Cushing's anyway. Of course. But, in a perfect world, her brain and kidney function most likely would have been normal, and treatment with Trilo would have had her "back to normal." No Soloxine or Desmopressin to add to the equation.

But, that's the world of dogs. They each have their own nemeses. With Boxers, it's mostly tumors in the brain, or on the body, cancer, and heart, and not unusual to have them in combinations.

On the bright side, Trixie has done very well considering she almost made it to her tenth birthday with basically no real health issues.

I must, once again, take a moment to exclaim the absolute worth of this forum!

Without this forum I'd have been clueless, my Vet was clueless, and Trixie most likely would be gone by now.

There have been many "variations" of this disease, and many variations of treatment applications and theories.

As the forum progresses, and more posts like these are seen, I am certain that the next "Fred and Trixie," and many more to follow, will benefit dramatically from all of our experiences, and the wisdom and guidance of the sage. That will absolutely translate to the beloved dog, which is the whole point.

Take care Marianne,

Fred.
.
.

[busyman370]

Hi Fred.

You and another member have dogs with pituitary macroadenomas and both of you have opted to treat with Vetoryl to alleviate the normal symptoms associated with cushing's. Between you and Fawni, I've done a lot of thinking about this and I just don't know if I would choose to treat a dog with already increasing neurological signs with Vetoryl or Mitotane. A study has shown that treating with Vetoryl or Mitotane can promote growth of a macroadenoma. If a dog already has increasing neurological signs, I am thinking that to accelerate growth of the tumor, neuro signs are going to get a lot worse as the cranial pressure increases. This causes a lot of pain which is why dogs head press. Vetoryl remedies symptoms that aren't life threatening nor usually painful for a dog so do think it might be beneficial to live with the problematic symptoms like peeing and drinking in exchange for allowing the anti-inflammatory effects of high cortisol to keep a dog comfortable?

I honestly don't know the answer to that question so I asked Dr. Mark Peterson's on his blog. I was lucky enough to get an answer from him on another post I made so I'm hoping he'll answer this one. I'll let you know if I here anything back.

For what it's worth, I think you've done a remarkable job with managing Trixie's illness. Your assessment of the overall picture is thoughtful, realistic and so very loving. What a lucky girl she is to have such a fabulous dad.

Glynda

Thank you Glynda for the kind words.

Yes, that would be great to get Dr. Peterson's take.

I am aware of the head pressing, and try not to think of the day I will see it.

The subject of going with Lysodren vs Trilostane is an interesting one, especially when the Cushing's is of pituitary origin. I have read where the Trilo does not directly promote tumor growth, but have read more that say it does than it doesn't. Maybe some day studies will provide a more accurate answer to that issue, at least provide some numbers we could work with.

If I remember correctly, the trilo seemed the safer way to go, but that seems like a lifetime ago now.

I do agree that the Lysodren would probably have been the better choice, but we made what we thought was the best decision at the time. At this point, it's likely too late to switch gears now, but I did consider it.

I'll be looking for Dr. Peterson's reply. I am betting that he will get back to you. These Doctor's do care. It's their life.

Thanks again,
Fred.

[busyman370]

I am sincerely impressed by how organized you are. Even in your thoughts and writings. Maybe that is a stage that a cushings "parent" is able to reach at some point. I just think that Trixie is lucky to have such a person looking out for her.

Kudos and hugs,
Sharlene

Thank you so much, Sharlene.

Yes, I have to agree that Trixie is fortunate to have me around, but I must also say that I am and have been very lucky to have her, and her littermate, Trudie, in my life too. They're not just pets to me, they're family.

Take care,

Fred.