Need your advice for Tank (8 y/o Boston Terrier) looking for a vet in Roanoke, VA

[tankers]

Hello. I am so glad I am able to post finally! I have a 8 year old Boston Terrier. I have a huge story to tell, but I'll try to jump right to what is current. He has been on Vetoryl for a month now. At first he was on 10mg, now 20mg, now the vet wants to put him back on 10mg. He has had three ACTH tests in the past month. All of the beginning cortisol readings are within the 4.6 range. The first post ACTH went all the way up to 33, the next one two weeks later 14, and now this one as of yesterday went down to only 3! I swear I am noticing more hair loss and pot belly than before we even started meds, the vet doesn't seem to see any concerns. His water intake has gone from 8 cups a day down to 5-6 cups a day. He doesn't need to go out pee as often. (4-5 times a day compared to 7-8). I just don't know if he truly has Cushings at this point. What is your opinion? He has had every test in the book it seems over the past year. He would flood our apartment with urine. Two vets told me he didn't have it, but this current vet who is holistic, said he does. Of course none can be 100% sure, but with all the extreme thirst, hunger, and urination, these were are major signs. I am just worried that he will develop Addisons Disease if I keep on with the medication, even dropping it back to 10mg worries me. Thoughts?

[Harley PoMMom]

Hi and welcome to you and Tank!

Cushing disease is one of the most difficult diseases to get a confirmed diagnosis for because other non-adrenal illnesses, such as diabetes and thyroid problems, share some of the same symptoms as Cushing's. Have diabetes and any thyroid issue been ruled out?

It would help us greatly if you could get copies of all test/s that were done and post all the abnormalities here.

The starting dose of Trilostane is based on a dog's weight, so how much does Tank weigh? Were the ACTH stimulation tests done 4-6 hours after the dose of Trilostane? Is the Trilostane being given with food?

Is Tank having any adverse reactions to the Trilostane such as vomiting, diarrhea, lethargy, and/or just not acting like himself?

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

Love and hugs,
Lori

[tankers]

Yes, all other diseases have been ruled out. He has gone through 3 vets and had around 15 different tests. He originally weighed around 30 lbs. last year, then down to 26lbs. and just yesterday 25lbs. So he is losing weight, I think because of the meds. Yes the meds are given with food each morning and the tests are run 4 hours later. As for adverse reactions, not really to the meds, I think over the past year we have noticed a HUGE change in his personality. A lot of people say he seems depressed. I don't think that is it. He does shiver a lot, so he has coats, blankets, etc. He enjoys jogging and has been able to keep that up. But he is not the same dog that he use to be. He use to be very playful, energetic, and fun. Now he just seems super mellow. The post ACTH results have been 33, 14, and yesterday was 3. All the pretesting results are in the 4's. So, the vet wants to now go back to 10mg, but I am worried if I continue treatment, he could become Addisonian.

[tankers]

Also, found this online and this is what bothers me. He went from 4 ug/dl pretest, to 3 ug/dl posttest yesterday.

"To perform the ACTH stimulation test, an initial blood sample is drawn and the cortisol level is measured. The dog is injected with a form of pituitary hormone ACTH that tells the adrenals to produce cortisol. After an hour, blood is drawn again, and the cortisol level measured. Resting cortisol should range from 1-4 ug/dl in the average dog, and should be significantly higher, in the range of 6-20 ug/dl, post-stimulation. (These numbers may vary depending on the lab.) If resting cortisol is low and the dog has no or a low response to the stimulation, the diagnosis is Addison's disease. Be aware that some glucocorticoids, such as predinsone, can affect the results of the ACTH test, while dexamtheasone does not." It also mentions about shivering a lot: "Shivering or muscle tremors may also be present. The most important thing to remember is that you know your dog better than anyone."

[Harley PoMMom]

Also, found this online and this is what bothers me. He went from 4 ug/dl pretest, to 3 ug/dl posttest yesterday.

When a dog is being treated with Trilostane , according to Dechra, the pre and post value in the ACTH stimulation test should be between 1.45 ug/dl and 5.4 ug/dl with a post of 9.1 ug/dl being alright as long as the clinical signs are controlled.


Resting cortisol should range from 1-4 ug/dl in the average dog, and should be significantly higher, in the range of 6-20 ug/dl, post-stimulation.

The 6-20 ug/dl post range is for a dog that is healthy...meaning no Cushing's.

Link to Dechra's U.S. Product Insert: Dechra's U.S. Product Insert. (http://www.dechra-us.com/files/dechraUSA/downloads/Product%20inserts/Vetoryl.pdf)

[tankers]

That's good to know. His beginnings are always 4.7 ug/dl.

[labblab]

Hello, and welcome from me, too.

You mentioned above that two vets do not think that Tank has Cushing's. Is this because of test results that were actually "negative" for Cushing's, or just their general impressions about things?

Also, can you tell us more specifics about the ACTH test history? Was the first result of 33 prior to having started trilostane at all, or was it after he started on the 10 mg. dose? And how about the second reading -- what dose was he on at that time? I assume that this most recent reading of 3 was after two weeks on the 20 mg. dose?

Actually, a post ACTH result of 3 is a "good" response to the medication, and is right in the middle of the desired therapeutic range for a dog being treated with trilostane (1.45 ug/dl - 5.4 ug/dl). So if Tank was indeed accurately diagnosed with Cushing's, we would be happy with a post ACTH result of 3 along with the decrease in his thirst and urination. Although it is possible for his cortisol to continue to drift downward a bit during the first thirty days on any given dose, I'm not understanding why your vet would want to cut his dose by half right now, rather than continuing to monitor his behavior and perform another ACTH at the thirty-day mark. A lot of the changes you have described over the past year are consistent with Cushing's, and if he does have Cushing's, they won't really improve until his cortisol remains within that therapeutic range for a while.

But I'm back to wondering why at least two of the vets are questioning the Cushing's diagnosis. Can you tell us more about that?

Marianne

[tankers]

Hello and thanks for responding. The first two vets just wouldn't test him. They didn't want to believe that a dog so "young (8)" could possibly have Cushings. They never would agree to actually doing a Cushings test, even though I begged and begged. They would do all other tests instead. They did do an ultrasound once and said he had enlarged adrenals, but couldn't spot a tumor. I even went to a specialist who told me he knew what Cushings dogs looked like, and Tank did not look like one. I was getting beyond frustrated. They were not the ones having to clean up ponds of urine each morning, day after day. I even would take pictures and bring them in with data of how often he goes potty outside and how much he drank daily and they still would just brush it off. So, finally I found a vet who would test! Yes, the 33 post ACTH reading was prior to any medication. After two weeks on 10mg, it was 14, and then after 2 more weeks on 20mg, it was now 3. My vet said this is very low and doesn't want to risk it going any lower, so therefore wants to bump back down to 10 and closely monitor. That is interesting what you're saying. His water intake wasn't dropping hardly at all on the 10mg, so that is why he bumped it to 20mg, which we have seen a considerable drop (5 cups a day instead of 8-9). But he is concerned with this new reading of 3 post ACTH and didn't expect it to go that low.

[labblab]

I am wondering if your vet realizes that the desired cortisol level for a dog being treated with trilostane is much lower than that of a normal dog without the disease. Take a look at this monitoring chart that is included in the link that Lori gave you above (Dechra's U.S. Product Insert):


Table 2: Action at 10-14 day evaluation

Post-ACTH serum cortisol [ug/dl]:

<1.45 Stop treatment. Re-start at a decreased dose

1.45 to 5.4 Continue on same dose

5.4 to 9.1 EITHER: Continue on current dose if clinical signs are well controlled OR: Increase dose if clinical signs of hyperadrenocorticism are still evident

>9.1 Increase initial dose

Before decreasing Tank's trilostane dose, I would definitely print out the entire Product Insert and discuss these recommendations with your vet. Tank is right within that range in which it is recommended to "Continue on the same dose." And the initial diagnostic ACTH result of 33 is indeed consistent with a Cushing's diagnosis.

Marianne

[tankers]

I will show this to him, thank you. This was his original reply when he sent me the test results from yesterday. "Lower than expected. The baseline was similar but it did not stimulate. The post injection was 3.43. Last time it was 14. Since I expect the cortisol to keep dropping I want to play it safe."
I know he has other Bostons that he treats for Cushings and I think some of them have gone Addisonian, so that must be his concern for Tank. IDK...

[tankers]

Ok, so he just called and we spoke. I finally feel I have a better understanding of his reasoning. He wants Tank to go to 10mg again because of the drastic decrease over only a 2 week window. (Going from 14 to 3). He feels most comfortable to see a Cushings dog at @ 5ug/dl. So, to him 3 boarderline 2 is too low for comfort. With this trend that Tank is on, he feels with continued treatment of 20mg, he could become Addisonian and enter the "danger" range which he has seen happen. He would prefer to play it safe and put Tank back on 10mg to see if the water consumption and urination patterns stay the same or continue to slowly taper off. If we stay on 20mg and Tank continues this drastic decline, the outcomes can be dangerous and/or deadly. So, that is where we are. Going back to 10mg and monitoring closely.

[labblab]

It sounds as though your vet has a definite course of action that he wants to follow. Perhaps it will actually end up that 15 mg. will ba a dosage that may be optimal for Tank. That would require asking a compounding pharmacy to either repackage your existing capsules, or directly create some fresh capsules (you can ask them to use brandname Vetoryl as the base, if that's what your vet prefers).

I confess to being doubtful that the decrease clear back to 10 mg. will end up being a sufficient dose since it only lowered Tank's cortisol to 14 ug/dl the first time around. But you'll soon know whether his thirst and urination start picking back up once again after this dosing change. Our experience here is that some dogs do indeed feel better when their cortisol level is allowed to remain a bit higher. However, other dogs require a consistent testing level below 5 ug/dl in order to benefit from full symptom resolution. Only time will tell where Tank's "comfort zone" ends up to be. Since you may still end up needing a series of ACTH tests in order to arrive at the best dose for Tank, here's a hint for "stretching" the necessary stimulating agent in order to lower the testing costs:

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

You might want to print this out to show your vet. Continued good luck to you and Tank, and please keep us updated as to his progress!

Marianne

[tankers]

Interesting. I pay $200 every two weeks for the ACTH test. Is this considered high or average? I should state we live in Coral Gables and everything here seems higher than average and this is a holistic vet, so once again, higher than your normal vet. So, I am assuming $200 is on the higher end. The first time I got the Veteroyl was $60 from the vet for 1 month of 10mg. Then I shopped it around and found it for $35.99 from California. So, the past two times, I have ordered from them, and paid an extra $6 shipping and handling charges, still a lot cheaper. I have called around and asked about compounding the pills and can't find anywhere that will do it for us. I wanted to do this when he was on 20mg. The $200 ACTH tests are KILLING me since he has now had 3 in a matter of a month and a half with more to come, plus I had already spent thousands with the other two vets running their tests. I have let the vet know my concerns about this. They tell me that most dogs don't require this much testing, but until they see Tank level out with a comfortable post ACTH level, we have to keep at them every 2 weeks. I don't even want to know how much I have spent at this point, but if I had to guess, I would say around 5,000 dollars, and he has just got the correct diagnosis! Suggestions? Again, thank you :)

[Harley PoMMom]

I have called around and asked about compounding the pills and can't find anywhere that will do it for us.

Hopefully this link will help: http://www.k9cushings.com/forum/showthread.php?t=385&highlight=compounding+pharmacies

[tankers]

Thank you. Roadrunner was one of the ones my vet told me to contact and when I did, they acted like they had never heard of it. Hum...so is there just 1 that is a FOR SURE place that will do it? As of now, he doesn't need it, so no rush, but it would be nice to have that information for just in case.

[Squirt's Mom]

Any of those listed at that link are compounding pharmacies. Diamondback is one many folks here use. You might look under Apothecary instead of Pharmacy, but that may not help locally where you are either. A very small town I lived in once had an Apothecary but I haven't run across many others even in the larger cities. You might also need to tell them Vetoryl instead of Trilostane, or vice versa. Vetoryl is the brand name while Trilostane is the generic name. That might account for them acting like they never heard of it, tho that is a bit scary as they should have computers and books handy to look things up. :eek::p

[tankers]

Will do thanks. As for the pricing of the ACTH tests, what is the range? Am I getting ripped off at $200 every two weeks?

[mytil]

Hi and a belated welcome from me.

Here is a link (a poll we have set up here) and you can see what others are and have been paying for comparison. http://www.k9cushings.com/forum/showthread.php?t=1148

Terry

[tankers]

Thanks, that is helpful. Glad to know I'm not the only one paying $200 every two weeks. I asked if we could stretch it to 4 weeks, but our vet really doesn't suggest that. It sure would help my pocketbook!:)
Another question for all of you wonderful people: Tank shivers constantly, even living here in Miami where the average temp is in 80s on a daily basis. I have a coat for him, and he has tons of blankets, but he will just lay on the rug and shiver, non-stop. Is this a side effect of Cushings? The meds? Any advice is much appreciated.

[lulusmom]

Hi and a belated welcome to you and Tank.

Sorry for being late in welcoming you but I've had a sick dog and am just now catching up with everybody. You've already gotten some excellent feedback from members but as usual, I always have comments and if any are a duplication, I apologize ahead of time. You can find my comments in blue below:


Hello. I am so glad I am able to post finally! I have a 8 year old Boston Terrier. I have a huge story to tell, but I'll try to jump right to what is current. He has been on Vetoryl for a month now. At first he was on 10mg, now 20mg, now the vet wants to put him back on 10mg. He has had three ACTH tests in the past month. All of the beginning cortisol readings are within the 4.6 range. The first post ACTH went all the way up to 33, the next one two weeks later 14, and now this one as of yesterday went down to only 3! I swear I am noticing more hair loss and pot belly than before we even started meds, the vet doesn't seem to see any concerns. His water intake has gone from 8 cups a day down to 5-6 cups a day. He doesn't need to go out pee as often. (4-5 times a day compared to 7-8). I just don't know if he truly has Cushings at this point. What is your opinion? He has had every test in the book it seems over the past year.

It’s difficult to offer up an opinion without the benefit of seeing the results of testing. It would help us greatly if you would please round up all of the testing that was done to diagnose Tanker and post the results here. Standard screening tests would include a blood chemistry, complete blood count (CBC) and a urinalysis. With respect to the bloodwork, you need only post the high and low values and please include the normal reference ranges. He would flood our apartment with urine. Two vets told me he didn't have it, but this current vet who is holistic, said he does. Of course none can be 100% sure, but with all the extreme thirst, hunger, and urination, these were are major signs. I am just worried that he will develop Addisons Disease if I keep on with the medication, even dropping it back to 10mg worries me. Thoughts?

If, as you say, every test in the book has been done and the majority of abnormalities were consistent with cushing’s and presented with the usual symptoms associated with cushing’s, I’m a bit confused as to why two vets didn’t think cushing’s was a suspect. Not all cushdogs have pot bellies or skin and coat issues so that tells me those vets haven’t had a lot of exposure to cushing’s.


He originally weighed around 30 lbs. last year, then down to 26lbs. and just yesterday 25lbs. So he is losing weight, I think because of the meds.

Did Tankster have a big appetite before starting treatment with Vetoryl?

Yes the meds are given with food each morning and the tests are run 4 hours later. As for adverse reactions, not really to the meds, I think over the past year we have noticed a HUGE change in his personality. A lot of people say he seems depressed. I don't think that is it. He does shiver a lot, so he has coats, blankets, etc.

If Tank started shivering before starting Vetoryl, I would be more inclined to think it was due to pain. Cushdogs are more sensitive to heat than cold so shivering is not a symptom of the disease. It is, however, a symptom of low cortisol and tremors are also a side effect noted by the manufacturer of Vetoryl so I’m thinking the shivers came on after treatment, right?

He enjoys jogging and has been able to keep that up. But he is not the same dog that he use to be. He use to be very playful, energetic, and fun. Now he just seems super mellow. The post ACTH results have been 33, 14, and yesterday was 3. All the pretesting results are in the 4's.

I just want to clarify that pretesting results are the baseline or pre-stimulated cortisol values. For purposes of monitoring treatment, it is the post stimulated number that is most important. I have every reason to believe, based on my own experience with my two cushdogs, that you will get your sweet playful dog back. It’s a balancing act trying to find the right dose in the first few months of treatment.

So, the vet wants to now go back to 10mg, but I am worried if I continue treatment, he could become Addisonian.

I believe your vet is taking a very conservative approach but if you are still worried, make sure you ask the vet for a few rescue doses of prednisone. Vetoryl has a very short half life, meaning it’s effects wear off rather quickly. Withholding the dosing is usually all it takes for a dog to perk up so some vets don’t prescribe it when starting treatment. Many of us members always keep Prednisone on hand because you just never know when you may need it.


Also, found this online and this is what bothers me. He went from 4 ug/dl pretest, to 3 ug/dl post test yesterday.

"To perform the ACTH stimulation test, an initial blood sample is drawn and the cortisol level is measured. The dog is injected with a form of pituitary hormone ACTH that tells the adrenals to produce cortisol. After an hour, blood is drawn again, and the cortisol level measured. Resting cortisol should range from 1-4 ug/dl in the average dog, and should be significantly higher, in the range of 6-20 ug/dl, post-stimulation. (These numbers may vary depending on the lab.) If resting cortisol is low and the dog has no or a low response to the stimulation, the diagnosis is Addison's disease.

I believe the interpretation you have presented is for testing for primary addison’s disease, not for monitoring treatment of cushdogs. I believe Marianne has already provided you with information on how to interpret the acth stimulation test for purposes of monitoring treatment with Vetoryl.



Hello and thanks for responding. The first two vets just wouldn't test him. They didn't want to believe that a dog so "young (8)" could possibly have Cushings. They never would agree to actually doing a Cushings test, even though I begged and begged. They would do all other tests instead. They did do an ultrasound once and said he had enlarged adrenals, but couldn't spot a tumor.

This reinforces my thoughts expressed earlier about these two vet’s experience with cushing’s. I believe the average age of diagnosis is eight years old so what the heck are they thinking? If adrenal glands are bilaterally enlarged, pituitary dependent cushing’s is usually diagnosed, if other diagnostics and symptoms are consistent with cushing’s. It’s a given that with bilateral enlargement, adrenal tumors are not involved.

I even went to a specialist who told me he knew what Cushings dogs looked like, and Tank did not look like one. I was getting beyond frustrated.

Not all cushdogs look cushingoid and I would think a specialist would know that. Was this specialist an internal medicine specialist?

They were not the ones having to clean up ponds of urine each morning, day after day. I even would take pictures and bring them in with data of how often he goes potty outside and how much he drank daily and they still would just brush it off. So, finally I found a vet who would test!

Excessive drinking and peeing are symptoms that are shared by many conditions such as, diabetes mellitus, diabetes insipidus, liver failure, kidney failure, urinary tract infections, bladder stones, kidney stones, etc.

Yes, the 33 post ACTH reading was prior to any medication. After two weeks on 10mg, it was 14, and then after 2 more weeks on 20mg, it was now 3. My vet said this is very low and doesn't want to risk it going any lower, so therefore wants to bump back down to 10 and closely monitor. That is interesting what you're saying. His water intake wasn't dropping hardly at all on the 10mg, so that is why he bumped it to 20mg, which we have seen a considerable drop (5 cups a day instead of 8-9). But he is concerned with this new reading of 3 post ACTH and didn't expect it to go that low.

I share your vet’s concerns with a post stim of 3 on two weeks of 20mg. As Marianne already mentioned, cortisol can continue to drop even further so proceeding with caution is wise, especially if the post stim number is lower than the baseline. This is called a nonstimulatory result. My first cushdog consistently tested in the 2’s and 3’s, both pre and post for the two years she was on Trilostane and a few times she had nonstimulatory results but her vet wasn’t concerned because she had been stabilized for quite some time and the baseline was well within the norm.

Based on our experience here, I’m not that comfortable with Dechra’s recommendations to increase the dose if the post stim is greater than 9.1. We’ve seen it drop quite a bit in the subsequent two weeks. Therefore, knowing what I know now, if it were up to me to make the call, I would have waited until the 30 day acth stim to make any dosing adjustments for Tank. You know what they say, hindsight is 20/20 and I love armchair quarterbacking.


The $200 ACTH tests are KILLING me since he has now had 3 in a matter of a month and a half with more to come, plus I had already spent thousands with the other two vets running their tests. I have let the vet know my concerns about this. They tell me that most dogs don't require this much testing, but until they see Tank level out with a comfortable post ACTH level, we have to keep at them every 2 weeks. I don't even want to know how much I have spent at this point, but if I had to guess, I would say around 5,000 dollars, and he has just got the correct diagnosis! Suggestions? Again, thank you :)

My suggestion is to use the link Marianne provided earlier and print out Dr. Peterson’s blog for your vet. It has instructions on how to extend a vial of cortrosyn. Most vets do use cortrosyn as the stimulating agent and if your vet does, he can save you a lot of money by splitting the vial and storing for future use. A 20 lb dog can get 4 to 5 stim tests out of one vial. We’ve found that most gp vets aren’t aware that small dogs only need a fraction of the vial. It is well worth your while to talk to your vet.

[tankers]

Hello. Thanks for the replies. Mainly, the vets all told me 8 years old was too young to have Cushings, so that is why neither of the 2 vets would run any Cushing test. They said Cushings dogs are much older, like 12-13 and Tank was too young to have it. So, they would treat instead for UTI's and such (even when a UTI wasn't present the 2nd go round). Yes, the 2nd vet was an internal medicine specialist. I only went to him because my GP vet couldn't do an ultrasound in house. However, Tank did end up seeing him on 3 separate occassions for follow-ups, but nothing for Cushings. He finally got quite upset with me and told me, "HE DOES NOT HAVE CUSHINGS!"
Tank has always had a pretty good appetite. He eats just about eating. He doesn't seem as hungry on the medicine. He use to eat 3 times a day, now he will eat twice.
As for his shivers, he has always had them slightly. They have worsened over the past year, and now even worse since on the medicine.

Here are his test values: 1st visit:
Urinalysis, pg. 9.0 specific gravity 1.012-given Baytril injection and on Orbax

Next apt: Chem panel at antech-Alkaline phosp. at 153
CBC-normal
Urinalysis-ph at 8.0 2+ protein, spec. gravity 1.017, struvite crystals noted. Again, Orbax for another 10days.
Weight 28 lbs.
Amoxicillin 200 mg given when no longer responding to Orbax.
Protein in urine
Elevated alk. pho. levels

Urine Culture-no growth
Urine Culture 2-no growth
Urine Culture 3-no growth
Negative culture

Ultrasound-Abdominal-
Right kidney: showed no abnormalities, shape and size 5.65
Left: no abnormalities
Liver, Gall Bladder, Pancreas, Spleen, Urinary Bladder, all fine.
Prostate: unremarkable 0.90 cm
Right ADRENAL: prominent in size in the cranial pole (0.90cm); normal caudal pole (0.50cm)
Left ADRENAL: Similar to right adrenal gland (0.91cm); cranial pole (0.56cm).

Diagnosis: Proteinuria, Recurrent UTI, Increased Water Intake, Prominent Adrenal Glands. Weight 28.6 lbs.

xrays of kidneys-appear fine/normal
Urinalysis
SuperChem
CBC with Differential
Microalbumin

Total Protein 7.7 HIGH
Alburnin 4.6 HIGH
Alk Phosphates 9.53 HIGH
GGTP 25 HIGH
Upasse 1050 HIGH *these results as of 5/8/11 when I was told, "there is no way he can have Cushings"
URINE Microalbumin 14.0 HIGH

Let me know if you want to see anything else. I have loads of #s here. :)

[labblab]

I just wanted to stop back and offer a comment about ACTH monitoring results whereby the "pre" number is higher than the "post" number, as has been the case with Tank. In earlier publications, Dechra cautioned against "non-stimulatory results," which I always assumed meant exactly that situation -- where the "pre" was higher than "post." But out of curiosity, one day I called Dechra and asked to speak to one of their technical reps in order to get some clarification.

What I was told at that time is that there is not necessarily any problem when a "pre" number is higher, as long as both the "pre" and the "post" result are both greater than 1.45 ug/dl and the dog looks clinically well. Lots of transitory things can elevate the "pre" number, including the amount of stress the dog is experiencing at the time of that first blood draw. It is interesting to me that the most recent version of Dechra's U.S. Product Insert no longer includes any warning about "non-stimulatory" results.

Now, this info was conveyed to me in a telephone conversation with a rep who has retired from Dechra, and I cannot point your vet in the direction of any official written statements. But he might wish to call Dechra, himself, for further clarification in the event that this issue comes up again for Tank -- a higher "pre" than "post" number. Because if I understood that telephone conversation correctly, a lower "pre" number, in and of itself, would not be a reason to lower the dose of trilostane if everything else looks "OK" (a dog who behaves normally and both results higher than 1.45 ug/dl).

Here is a link to contact info for Dechra's U.S. Office in Kansas:

http://www.dechra-us.com/Default.aspx?ID=365

Marianne

[Harley PoMMom]

Urinalysis-ph at 8.0 2+ protein, spec. gravity 1.017, struvite crystals noted.

What did your vet say about the presence of struvite crystals? And was a course of action planned to eliminate the crystals and keep them from forming again? Crystals can lead into stone formation which can be very painful.

[tankers]

He didn't seem as concerned with the pre number being @ 4 ug/dl since all three tests have remained consistent in regards to that. He was more concerned with the post test being "so low." He prefers a post reading of 5 is what he said to me. So I'm guessing to him, 3 ug/dl was a little scary to see, hence backing down the dose to 10mg. I'm not sure really..I know it's such a # game. I am sure when we go back in two weeks for the next ACTH, if it has gone high again, he will bump back to 20mg. ???
As for the first vet and the crystals, he placed him on Orbax for two rounds and kept running urine cultures and more blood work. They didn't seem to show up again. He didn't act too concerned to me.

[tankers]

Also, two vets looked at all of that data I posted above and told me Tank did not have Cushings. What do you all think when looking at the data? They couldn't tell me that he had anything else either.

[tankers]

Hey all! Back again. So new update: My husband and I went to California for a week and we left Tank with his normal pet sitter. She kept to our normal routine and she said he pee'd A LOT, drank A LOT of water, and even once pee'd in his own BED! So, since this time frame, I have had him back home and have noticed what she said. He is drinking 7 1/2 cups of water or MORE a day. He is now down to 24lbs. He is still on the 10mg of Trilo. So, yesterday he went in for another ACTH (my God, I have no idea how many we've done at this point) and his baseline was 1.14 and then POST ACTH was 6.21. So once again in the NORMAL range. This to me is not good! How can he be testing normal, but just this week went PEE again right in front of me IN HIS BED after we had just gotten home from church and took him out. He also went to the neighbor's apt. and pee'd all on her rug this week. He will drink any type of water he can get his tongue on. He constantly shivers no matter what. He seems sleepy and grouchy. My vet is now stumped too (this is the 3rd vet by the way) and he doesn't know where to go from here either. I just want to help my dog. I feel like I have done everything and then some, but nothing works no matter how many thousands of my savings I spend on him (yes, he is worth it). Please HELP!!

[labblab]

Oh goodness, I was worried that dropping Tank clear back to 10 mg. might be insufficient to totally control his cortisol and his symptoms. And unfortunately, that seems to be the case. I just want to point out again that the "normal" post-ACTH range for dogs without Cushing's is much higher than the desired therapeutic range for a dog with the disease. If a dog being treated with trilostane is still exhibiting symptoms with a cortisol level above 5.4 ug/dl, the recommendation by Dechra is to increase the dose. And since Tank's symptoms were indeed improved when his cortisol level was lower (isn't that right?), I'm concluding that this current cortisol level is just too high to adequately control his Cushing's. I know your vet was uncomfortable when Tank's post-ACTH was down around 3 ug/dl, but am I correct that Tank's behavior was actually more normal at that time?

Granted, Tank's post-ACTH on 10 mg. is much less than it was the first time around (6.2 vs. 14+). So certainly you would not want to redouble the dose back to 20 mg. once again. Perhaps 12-15 mg. would turn out to be the optimal dose for Tank. But if I'm correct that his symptoms improved when his cortisol was lower, I do think he is in need of a dosing increase to bring his cortisol back down a bit.

Marianne

[tankers]

Yes, he did seem better on 20mg, but the vet won't go back to that. I asked about the compounding to 15mg, but he said when you do that, it is a weak dose. So IDK. If his pre-levels yesterday were at 1 ug/dl (compared to his normal 4.6ish), isn't that low to begin with before giving him the ACTH test? What do you think is the cause of the start up cortisol being so low and with this shouldn't I be seeing the opposite signs from him? I'm so lost.

[labblab]

The desired ACTH results for a Cushpup on trilostane are lower than those for a dog without the disease. A "pre" result of 1.14 combined with a "post" value of 6.21 is not too low for a Cushpup on trilostane. You've got to disregard those posted "norms" on your labsheet, because they just don't apply to a dog with Cushing's.

Within the last few days, we had a member whose dog on trilostane had a "pre" result of .7, which seemed awfully low even to me. But when I questioned it, this is what the dog's specialist had to say (the dog's post-ACTH was 7.4):



Thanks so much for the feedback. We are also concerned with the low pre-test number [.7] and did talk to the vet at Mississippi state about her results. We asked if he felt the low pre-stim results were a cause for concern. He said he was not concerned as the cortisol levels vary considerably during the day and the response [post-ACTH result of 7.4] is the critical result. He went on to say that if the suppression was too great, causing a low pre-stim level, the adrenals wouldn't respond to the ACTH stimulation...

I do understand that some vets do have concerns about the consistency of dosing when using compounded trilostane. But in Tank's case, since he did respond favorably to a lower cortisol level, I do think I'd want to give it a try before discarding trilostane altogether. Your other alternative is to start over and switch to Lysodren, the other effective Cushing's medication. But if your vet is uncomfortable with a Cushpup's post-ACTH level running any lower than 5 ug/dl, I'm afraid you're going to run into the same problems -- because the desired therapeutic range for a dog treated with Lysodren is once again 1-5 ug/dl.

Marianne

[tankers]

I see. This is the email I got today from our vet:
"Hello. The test results are normal…The fact that this is now normal and the drinking continues leads me to doubt our diagnosis… I will consult with some colleagues and get back with you. Let me know if you have any questions…Ted"

So, he is now thinking NOT Cushings AT ALL. Yikes!! What do you suggest I do?

[labblab]

I would email him this link to Dechra's U.S. Product Insert for Vetoryl. For a Cushpup being treated with trilostane, if you look at the treatment action chart on page two, you will see that it clearly states the following:



[Post-ACTH result] >5.4 to 9.1 ug/dl

EITHER: Continue on current dose if clinical signs are well controlled
OR: Increase dose if clinical signs of hyperadrenocorticism are still evident.

Here's the link:

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

Since Tank's most recent post-ACTH is between 5.4 - 9.1 ug/dl and his Cushing's symptoms have now returned, per Dechra, he needs a dosing increase. For whatever reason, your vet seems to be unaware of the treatment and monitoring norms and goals for a Cushpup treated with trilostane.

Marianne

[tankers]

Ok, I just emailed it to him with your explanation. I see what you mean now. Thank you for all of your help. Today he didn't have any meds since we are now in limbo and he drank about 10 cups of water. I just don't like that he is still losing weight and his hair has never grown back on his underbelly. I thought the drugs would have helped this by now. He just isn't the same dog at all anymore. He doesn't like to play with his ball, waterbottles, go swimming, anything. It's really sad :(
Again, thank you. As of now, he plops himself in front of his water bowl and drinks it non-stop.

[labblab]

Good for you! I know it can feel really uncomfortable to seemingly question or second-guess a vet. But it is impossible for any vet to know everything about every disorder. So I hope your vet will welcome this important treatment information. It has been our experience that the veterinarians who serve as technical representatives in Dechra's U.S. office (located in Kansas) are very happy to talk with other vets about trilostane dosing and monitoring. So if your own vet has additional questions in this regard, I hope he'll contact Dechra directly for greater clarification. Here's a link to Dechra's "Contact Us" webpage:

http://www.dechra-us.com/Default.aspx?ID=365

Marianne

[nibbles-mommy]

hi there, coming in late but, could it be possible that diabetes is involve? i read through your thread quickly and saw one reference to someone asking about diabetes but didn't find an answer. the water intake, peeing and weight lose are symptoms of diabetes.

debbie

[tankers]

This is what I got from our vet today:
Hello. I spoke with Dr. Toll and internist that does frequent consultations for me. He suspects that we may have other secondary issues as well as cushing’s..I am a little reluctant (but will ) to go up to the 20mg again…maybe 15 but we would need to compound..We could setup a consultation with him..do you have meds now? Let me know your thoughts…..Ted

**I'll be honest, I don't want to meet with any more vets or specialists. We are already on vet # 3 in Miami and more than $10,000 in the hole over it all. So, what will vet #4 tell us, that the other 3 haven't?! I don't want to go up to 20mg again either. Too scary from past results. So, hopefully he can find a place that will compound them to 12mg or 15mg. Suggestions?

[Squirt's Mom]

Hi,

Here is the key to what your vet said, IMO -


He suspects that we may have other secondary issues as well as cushing’s

This was our experience. Squirt tested positive on five tests for Cushing's BUT after the second ultrasound, I was told about a tumor on her spleen. Once it was removed, her cortisol returned to normal and has remained within that range since. It was the stress from the tumor causing the excess cortisol, not true Cushing's.

If it were me, I would pursue this avenue asap. There are many things that can mimic Cushing's and cause false-positives as well as cush signs that are not actually Cushing's. So if Tank has something else going on, it is possible that by addressing it, the cortisol and it's effects will be a thing of the past.

It is also possible that Tank has something in addition to Cushing's that is contributing to the issues you are having with gaining control of the cortisol. So this is the first conversation I would have with my vet...if possible, I would ask to talk to the specialist he consulted with or with another one in the area.

I understand very well about the financial aspect of this. Squirt has cost me enough in her 14 years that I could have build a small house :p...but I don't regret one penny of it and would do it again if I could. Today, funds limit much of what I do but my babies always get first cut after bills are paid. But, unlike many here, it is just us in our family. There are no other people depending on me. I am able and willing to make sacrifices many others can't. We all do the best we can with what we have and we have to know our limits, for everyone's sake. ;)

As for your compounding question, many here use Diamondback Drugs in Arizona. Here is a link -

http://www.diamondbackdrugs.com/

Hugs,
Leslie and the gang

[labblab]

It may indeed be the case that Tank has additional issues involved. But I'm "stuck" on the fact that Tank showed improvement when his cortisol was right in the middle of Dechra's desired therapeutic range. At that time, apparently your vet decided to lower Tank's dose not because of any observed ill effects, but because your vet was worried about that cortisol level at an early stage of treatment. Now that Tank's cortisol has risen higher, he is exhibiting symptoms again. That all seems pretty straightforward to me, and not an indication that Tank cannot be well controlled with trilostane once the optimal dose is identified.

Unless the specialist has some alternative suggestions, I personally would opt to try Tank on a daily dose of 15 mg. If you still have 10 mg. Vetoryl capsules, you could get some compounded 5 mg. capsules to add in. With the 5 mg. capsules on hand, you'd have the flexibility to come up with a variety of dosing totals down the road.

Marianne

[tankers]

Hey guys, back again. So, Tank has been on 15mg of Vetoryl in the am for two weeks now. His water intake has gone down to about 4 1/2 cups a day; which is good! Yesterday he even picked up the tennis ball and wanted to play a little bit (he hasn't done this in months) and also picked up a water bottle. So, those were good signs to us. Anyway, I got another email from the vet suggesting something else more complicated could be present, bc by now, he should be drinking less than 4.5 cups. He should be around 2 cups a day for his size (24 lbs) last time we checked his weight. So, the internist suggested we now give Tank a 10mg pill in am, and again in pm. So, we will be bumping from 15mg all at once in am, to a 10mg am dose and 10mg pm dose to see if that affects him any differently. Do any of you split dosage like this? How do you feel about this? The other choice was 10mg am and 5mg pm, but he would prefer we do 10mg and 10mg. Thanks again for all of your advice.

[labblab]

I'm so glad to hear from you, and especially glad to hear about these improvements in Tank's behavior! Since you are asking for opinions, I won't be shy in offering mine. If it were me, I would tell my vet that I prefer to wait until Tank has been on his current dose for a full 30 days before making a decision about any dosing changes. Holy cow -- a drop in fluid consumption from 10 cups to 4 1/2 cups a day sounds great to me! And the fact that Tank is again showing interest in play activities -- also wonderful. Even Dechra's own technical publications only advise that you are hoping to see "improvement" in thirst and urination after the first two weeks or so on a given dose. There is no set formula for fluid intake that dictates a dosing change.

Different specialists have different preferences regarding once-daily vs twice-daily dosing. But Dechra's literature advises a shift to twice-daily dosing when ACTH testing shows cortisol levels to be within therapeutic range on once-daily dosing but symptoms are rebounding later in the day, suggesting that the drug is losing effectiveness too quickly. If I'm understanding you correctly, your vet is recommending an overall increase and a shift to twice-daily dosing without the benefit of an ACTH test, and solely on the basis that Tank's total water consumption hasn't dropped enough in two weeks time to suit him.

If it were me, I'd be very happy for the positive changes that you are currently seeing in Tank. Since cortisol levels can continue to drift downward on any given dose, I'd wait until the 30-day mark, have an ACTH test performed, and then assess Tank's improvement at that point in relation to the test results. And THEN I'd consider whether a dosing change is appropriate.

Marianne

[Nikki]

I just wanted to pop in and say hello to you and Tank!!!
I also have a Boston Terrier, who just turned 8 that has cushings. I'm really surprised that two different vets told you dogs that young do not get cushings! Also, I'm having the same issue where my dog's dose needs to be upped and my vet doesn't understand dechra's guidelines so she is telling me to keep him at his current dose because a post ACTH of 14.1 "Is right on track" (meanwhile my poor guy is peeing in the house, losing more and more fur etc)
Anyways, just wanted to say hello :)

Nikki&Max

[frijole]

I agree with Marianne. Wait and do an acth test before doing an increase! Sounds like Tank is already improving.. leave it alone ! :) Kim

[tankers]

Thanks guys. I appreciate the responses. My husband said the same thing to me last night about at least giving this dosage of 15mg a full month before we switch it up on him. We do think he is doing better, but our vet and specialist seem to think he should be much lower in water consumption than 4 cups by this time, but I don't really know why. So, we will keep on 15mg for another 2 weeks. We could do 10mg in am and 5mg in pm to see if there was any real change, but I don't think we will see any.
Also, hey to Nikki and Max. Yes, two vets and the one vet we currently have all think 8 is way too young for a dog to get Cushings. I think most of them don't see a Cush dog until the age of 12-14 (or at least that's what I'm told). Living in a big city like Miami, I thought I would find more experienced vets dealing with Cushings, but I'm not finding that at all, which makes it all the more difficult since we rely on them so much as our "go-to" if you will. Post test of 14.1 seems kinda high right? I would think your BT needs an increase for sure. I understand the peeing all over the house often. Does your guy shiver a lot? Ours does non-stop. He usually wears a coat which helps, even though it's 90 out! Best of luck to you guys. I know it's a tolling disease.

[Nikki]

Yes he shivers!!! He was actually on pain meds for awhile before he was diagnosed, because shaking can be a sign of pain. For awhile I would wrap him up in throw blankets and he would look like a little baby when I carried him around, my mom would laugh at us. But I figured since the pain meds didn't make him stop shaking, he must be REALLY cold all the time!!! Lucky for him, he gets to sleep in our nice cozy bed right between my boyfriend and I every night, so he stays warm haha!

[tankers]

So, I spoke with our vet and told him that after talking with you guys, I prefer to keep the 15mg in the am for at least another week or so which at that point it will be a month and we can retest the ACTH. He said, "ok"

[tankers]

I am curious. On average how long is a dog expected to live with the treatment of Vetoryl? Tank is only 8, but I'm wondering how long to expect him to be able to take this medication before it starts to shut his system down or cause other ailments. Please be honest about what you know, or have read. Thanks.

[Jenny & Judi in MN]

I don't know about Vetoryl but a receptionist for a vet's office here in my town has a 14 or 15 year old dog who has been on lysodren for either 5 or 7 years. a long time. And the IMS I met with yesterday said Lysodren is a derivative of DDT :eek:

[frijole]

So long as you continue to have periodic acth tests to make sure that the dosage doesn't need adjusting dogs on either lysodren or trilostane can live a totally normal life. There is no magical number because obviously an 8 yr old dog will live longer than a 13 yr old dog.

Both drugs are strong but effective when used correctly and monitored. We have had dogs live a very long time. My Haley used lysodren for 4 1/2 yrs and she passed at the ripe age of 16 1/2 unrelated to cushings.

Kim

[lulusmom]

There is no documented evidence that lysodren or vetoryl has long term impact on internal organs so as to cause their failure. If cushing's is effectively controlled with either of these drugs, a dog can live out their normal life expectancy with a good quality of life.

Yes, mitotane (lysodren) is a derivative of DDT; however, through exhaustive studies on dogs back in the 1940's by scientists who were looking for something deadly for purposes of biological warfare, it was discovered that mitotane specifically targeted the adrenal cortex, with no effect on the other parts of the adrenal glands and little effect on other internal organs. It was a complete failure as a weapon of mass destruction but it was an incredible discovery for the medical community. When these studies were released years later, the human medical community jumped on it with eagerness to try it on their cushing's patients. Unfortunately, it was not as effective in humans as dogs.

Vets have been using Lysodren for decades with great success and it's only unsafe in the hands of an ignorant vet who doesn't follow protocol and an ignorant pet owner who takes absolutely no active participation in their dog's treatment. I've listened to numerous audios of lectures given by well known endocrine specialists and more than one has said that given the choice of Lysodren or Vetoryl, one of the reasons to choose Vetoryl over Lysodren was their assessment of the pet owner. If the pet owner didn't appear to be willing or able to take instruction and monitor their dog closely, Lysodren would be a bigger worry for them. In our experience here, I would have to agree with that train of thought. We've had members who refused to challenge their vet for not following protocol and continued to place blind faith in them, and these are the situations were we usually see most adverse reactions to, not only Lysodren, but Vetoryl as well.

I have two dogs with cushing's and both have treated with Lysodren and Vetoryl. My littlest is 4.5 lbs, being diagnosed in 2005 and the other is 6.5 lbs, diagnosed in 2007. I watch them like a hawk, I've read everything I've been able to find on both drugs so that I know what I'm putting in their mouth, including but not limited to how dosing works, the mode of action, what to watch for in the way of side effects and how to properly monitor treatment. Neither of my dogs have every had any adverse reactions to either drug. I don't just educate myself on cushing's drugs, I read up on whatever drug I am unfamiliar with before I give it to my dogs. There aren't many drugs I'm not familiar with because I've been a medically challenged dog magnet for most of my life. :D

Glynda

[tankers]

Hello all. Tank has been doing well on the 15 mg of Vetoryl, but seems to always want to eat grass. I guess his belly is upset lately with it.?? It is time to do another ACTH test and I have one scheduled for Monday. I got an email stating that Tank doesn't have to fast and I don't have to withhold water like I have done about 15 times (per DR. orders). I asked them why the sudden change and their response was, "There was a misunderstanding. Tank does NOT need to fast. He can eat breakfast with his 15 mg pills and have water prior to the test." So then I began Googling this, and found out some very interesting things. I want to know if your vets have told you the same things? Does your dog fast prior to an ACTH test? He gets his pills around 7:30am every day, so we bring him in for testing around 10:00 and pick him back up around 12:30 or 1pm. Usually at 1pm, is when he has been given his first sip of water and food. This has happened at least 10 times which I have always felt awful about. Now, they are telling me it was a "misunderstanding." WHAT?? I pay $200 per test and from what I am finding online, the results are not accurate if they don't eat in the am with their pills. Is this true? If you can please provide any helpful links that I can show my vet, I feel that I have been cheated over $2000 on tests that are not completely accurate! Please help! Thanks!! http://endocrinevet.blogspot.com/2011/03/whats-best-protocol-for-acth.html

[nibbles-mommy]

I don't post much, but I've been through many acth stim tests between 2 dogs in the last 4 years. I have always fed and given the vetoryl before testing with Nibbles as he was also diabetic. The vet said he needed to test 4 hours after dosing and to feed as usual.

As for the money...Last year Nibbles went for one of his tests, I think the 4th (?) one when starting and the numbers came back crazy high, so the vet called and told me the results and said he really didn't think they were accurate and maybe something happened at the lab so made me bring him in for a retest the next day free of charge. And yes the results were dramatically different. I just really hated the 1hr. ride there and 1hr back home but we are doing it at least once a week for glucose curves and acth testing.

[lulusmom]

I pay $200 per test and from what I am finding online, the results are not accurate if they don't eat in the am with their pills. Is this true? If you can please provide any helpful links that I can show my vet, I feel that I have been cheated over $2000 on tests that are not completely accurate! Please help! Thanks!! http://endocrinevet.blogspot.com/2011/03/whats-best-protocol-for-acth.html

Vetoryl is best absorbed with food so yes, if a pill is given with no food, it is highly likely that results of an acth stimulation test would be higher when fasted. In other words, if you don't give the pill with food, it is not effectively absorbed into the system. In hindsight, I'm thankful your vet reduced the dosage because the acth stimulation tests were not a true reflection of the effectiveness of the drug. Results were most probably higher due to fasting. :mad:

I believe you already have a link to excellent information provided by Dr. Mark Peterson. He is a renown and very well published internal medicine specialist who is intimately familiar with trilostane and the acth stimulation test. Additionally, Dechra's packaging insert specifically says to administer pill with food so one would hope that your vet would educate himself about any drug he prescribes.

Glynda

[tankers]

Thanks. I am SO very upset I could SCREAM!!! I called and talked with one of the vet techs and he got my blood boiling. He is such a cocky kid and has such a high and mighty attitude and pretty much tries to make you out like you are the idiot. He said, "It's up to you whether you feed him or not, it's whatever makes you comfortable." So, do we fast him or no? I told him I had several emails that state that we do, of course he backpeddled out of that one. I told him how I found the site about how the results can be invalid now, etc..etc..in which he then begins to say, "Don't believe everything you read on the internet and goes into a long lecture." Finally, I had to be RUDE and talk over him and request the DR. call me back. Would you all be upset too? Do you think I should find another vet or ask for a credit? Refund? Something? :mad:

[Jenny & Judi in MN]

I don't think it hurts to calmly let them know that you are questioning the accuracy of the tests due to this. Esp. if it is in the instructions for the drug.

I'm always uncomfortable asking for discounts so I'd play that one by ear. But I hear you on spending a LOT of money on all of these tests. Jenny has only had 7 ACTH tests so far but she's had about 12 curves for diabetes at the vet, etc. etc. etc.

I put off seeing a specialist because the closest one is 3 1/2 hours away. The vet I found to handle Jenny's cushings is only 1 hour away. In hindsight I should have gone to the specialist right away.

Let us know how it goes

[nibbles-mommy]

I would bring a print out of highlight the exact protocol that states that the food and meds go hand-in-hand for accurate results. Depending on you prior relationship with the vet, I would also say that you are a very concerned that all the previous tests are inaccurate because the wrong information was given to you by their office and then ask for at least a free test, done the right way, be given to reflect more accurate readings.

[tankers]

I didn't get anywhere on the phone conversation, and I was trying to remain nice and calm, didn't work, so this is the email I sent the Dr.
"Bruno/Dr.Sanchez,

As you can see from the email below and several more I have like it, I was always told to have Tank fast prior to his ACTH test. Today I was told by Bruno it was, "likely a misunderstanding" and that Tank can now have food and water prior to testing Monday. I am concerned and upset with this misunderstanding if this negates Tank's past testing results. I called my previous vet in Ocala, Fl and they too said you do not fast the dog prior to ACTH testing. After doing some additional research online, I found the possibility that the tests we have done are not conclusive, since fasting the dog invalidates the test results. We have performed numerous ACTH tests on Tank at this point, all with him fasting, which didn't give us a true reflection of the effectiveness of the drug on his system. I have included the link as well with the following:

"With trilostane, it’s extremely important to give the morning medication with food, and then start the ACTH stimulation test 3 to 4 hours later.

Fasting these dogs on the morning in which the ACTH stimulation test is scheduled should be avoided since it invalidates the test results.

When a dog ‘s food is withheld, the absorption of trilostane from the gastrointestinal tract is decreased. This leads to low circulating levels of trilostane, resulting in little to no inhibition of adrenocortical synthesis. Therefore, serum cortisol values will be higher when the drug is given in a fasted state than when it is given with food.

The higher basal or ACTH-stimulated cortisol results could prompt one to unnecessarily increase the daily trilostane dose. That misjudgment may lead to drug overdosage, with the sequelae of hypoadrenocorticism and adrenal necrosis in some dogs."


from: http://endocrinevet.blogspot.com/2011/03/whats-best-protocol-for-acth.html which is by Dr.Mark Peterson, a renown internal medicine specialist.

I know we all work together to make sure Tank has the best treatment possible. I would appreciate a phone call with a plan for moving forward for Tank as well as a plan for both the previous tests administered and future tests given. I would also appreciate if Bruno would not dismiss my cares & concerns during our phone conversation as if they were unimportant and invalid.

Thank you,

(Hope this sounds okay)

[lulusmom]

I think you did a superb job of explaining things to your vet. The vet may not give you a break on costs but I would hope he learns something from you so that he doesn't repeat this inexcusable and risky mistake with other patients. Your unfortunate circumstances are exactly why all pet owners, especially cushdog parents, need to take an active participation in their pet's treatment. Placing blind faith in a vet, especially a general practitioner, to follow proper protocols so as to insure safe and effective treatment is how many dogs get into trouble, and as in your case, money is flushed down the toilet.

Good job, mom!

P.S. I just realized that your vet also had you withhold water. Argh! You usually only withhold water for a surgical procedure and to withhold water from a cushdog who is not concentrating their urine is extremely dangerous. Dogs with PU/PD need fresh water at all times because they can dehydrate quickly and the situation can turn fatal just as quickly.

[Jenny & Judi in MN]

I think it is very well stated. good job! Now lets see what they say when they call back. hang in there

[Squirt's Mom]

Kudos to you, Mom! That is a great letter and will hopefully open a few eyes at your vet's office concerning the proper way to perform an ACTH for a pup on Trilostane (Vetoryl). If not, then yes, find another vet who will listen and is willing to learn and work with you. ;)

You are doing a superb job of being Tank's advocate!

Hugs,
Leslie and the gang

[nibbles-mommy]

I love the email!

[tankers]

"You are doing a superb job of being Tank's advocate!"

This actually made me cry...but in a good way, so thank you. :o

[labblab]

I also think you did a terrific job with the email! And I am sorry to be reminded -- after going back and re-reading Tank's whole thread -- that this is not the first time that Dechra's recommended treatment/monitoring protocol has seemingly been overlooked or ignored by your vet :(. It almost seems as though he has never taken the time to actually read through the written prescribing information :confused:.

If you want to print any of it out once again, here are links to Dechra's U.S. Product Insert, and also their Treatment and Monitoring Flowchart:

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

http://www.dechra-us.com/files//dechraUSA/downloads/Client%20Literature/47902_VETORYL_10mg_Treatment_and_Monitoring_Brochu re_Update_3_2_ps.pdf

To be fair, there are a few confusing or contradictory statements that can be found amongst all of Dechra's combined published materials, depending upon the recency of the info. But for the most part, the recommendations are consistent. And in instances where a vet has any questions, Dechra is more than happy to provide consultation via phone or email. I am willing to give most anybody the benefit of the doubt when an isolated misunderstanding arises. And this is not the first time that we've heard a vet tell an owner to fast a dog prior to ACTH testing. But it seems as though your vet has frequently relayed questionable instructions. I'm not sure where you go from here. Do you have any other veterinary options?

Marianne

[tankers]

Yes, seems to be that way for sure. He has told me Tank is one of only 3 of his Cushings dogs that he has ever dealt with, so yes, it is new to him, but then learn more about it! Yes, being that we are in a big city, there are plenty of vets. The past three we have been to have all come "highly recommended" but none by other people who have Cushings dogs, so I think that's my problem. I really need to find a vet here in Miami that has a lot of experience with it. Is there any site that you can punch in your zip code and it tells you vets with Cushing's expertise? That sure would be nice. Once again, I am caught blaming myself for just trusting him blindly about the fasting & w/holding water. I hate to beat myself up over it because Tank does seem to be doing better, but I do. Again, thank you all for taking the time to address my concerns.

[labblab]

If you plug into this website, perhaps you can locate an Internal Medicine Specialist with whom you can consult from this point onward:

http://www.k9cushings.com/forum/showthread.php?t=182

Marianne

[tankers]

Ha, the first one that comes up is vet #2 that we went to and wouldn't test him because he was, "too young to be a Cushings dog." However, in Miami, they list 2 more I could try!
So, vet just called. He apologized that his staff told me over and over to w/hold food and water bc that is what they are trained to do for normal blood tests. Obviously, they don' know about ACTH tests. But, my email got him thinking and working. HE CALLED DECHRA!! Finally. He told me everything that was said and apparently someone from Dechra is sending him a conversion chart on dogs that have fasted vs. haven't fasted and he can figure out the post ACTH from there to see if it really made a difference, he believes that it didn't and he was playing it "safe" anyway with the dose, so he feels okay (NOT THE POINT DOCTOR). As for the test on Monday, Tank will NOT fast or w/hold water, and we will see how different it is in comparison to all of the others. But no, I didn't get any $$ refunded or future credit :( He said if these numbers come back okay, he doesn't want to up his dose, but he does want me to meet with another internist about diabetes (not the typically diabetes you see in dogs) it had some odd name...never heard of it...started with an "E" He said he has only seen it once in his whole career and he doesn't even run the test for it...so IDK..I am okay with Tank drinking 4 cups a day, he told me he is NOT OKAY with it, and that is too much. He said his other 2 Cushings dogs have shown better improvement in their water intake compared to Tank, but I told him I am happy with him drinking half of what he use to! So, we are scheduled for a test Monday. Still I don't know what to do once Tue. comes and the results come back...

[Squirt's Mom]

I bet he was talking about Diabetes Insipidus. Here are some links about it -

• Polyuria, Polydipsia and Diabetes Insipidus
http://www.vin.com/proceedings/Proceedings.plx?CID=WSAVA2002&PID=2556

• Diabetes Insipidus
http://www.petplace.com/article-printer-friendly.aspx?id=3258

• Diabetes insipidus
http://www.provet.co.uk/health/diseases/diabetesinsipidus.htm

• Diabetes Insipidus
http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/40507.htm

• Desmopressin acetate (brand name DDAVP®)
A synthetic antidiuretic hormone that is used to treat Central DI
http://www.petplace.com/drug-library/desmopressin-ddavp/page1.aspx

[labblab]

Like Leslie, I'm confident your vet is talking about Diabetes Insipidus. But please excuse me for being blunt (I am nearing the end of a long and tiring day :o) -- my unprofessional, layperson's opinion is that your vet is nuts if he's worrying about DI at this point in Tank's treatment. Tank is only now nearing the 30-day mark on his 15 mg. dosing, and his water consumption has already been cut IN HALF. I think that's great. If your vet has seen more dramatic improvement in his other two Cushing's patients, he is a lucky man. Trust me, we have tons of members who would be thrilled with this kind of response.

Maybe your vet has gotten some different guidance from his phone conversation with Dechra, and if so, I stand totally corrected. But per all their written materials, what you are looking for at this early stage of treatment is "some" improvement in thirst and urination. Not a 100% return to what would be normal for a dog without Cushing's. It may take time for the kidneys to be able to resume totally normal function again. And some dogs being treated with trilostane NEVER return to pre-disease baseline.

Although Diabetes Insipidus is a rare disease, we have had a couple of dogs on the forum who have indeed been treated for the disorder. If we're still having this conversation six months from now, I'd consider the diagnosis. But if it were me, I would not be worrying about it at all at this early stage of Tank's Cushing's treatment!

Marianne

[lulusmom]

Hi again,

I'd like to validate Marianne's most recent post regarding your vet's suspicion of diabetes insipidus. All I have to say is aye, aye, aye, aye. I'd also be very interested in hearing more about that conversion chart Dechra is supposed to be sending to your vet. I've read everything I could get my hands about Vetoryl and this is the first time I have ever heard about a chart that shows the conversion of fasted post acth cortisol number to a non-fasted number. I don't want to be poop stirrer here but I think it's entirely possible that your vet is trying to pull the wool over your eyes. If he's not, I'd love to see that chart so please ask for a copy of it.

[frijole]

Just posting to let you know alot of us have had to deal with clueless vets and so you aren't alone. It is frustrating as hell but just know that as tired as you might feel - you are absolutely doing the right thing and you are a wonderful advocate for Tank.

I call BS on the diabetes insipidus talk as well as the conversion chart. Make sure he gives you the conversions and then I want you to call Dechra direct and discuss them. I bet money you will find it is fiction.

We have had lots of dogs from Florida on this site. Obviously once they are treated they don't all hang around. You might try doing searches on our site for Florida, Miami and the suburbs. I lived in Lighthouse Point for 6 yrs but my dog didn't get cushings until I had moved.

I know the U of FL Gainesville has remarkable capabilities but that isn't what you need.

Take care! Kim

[tankers]

Thanks all. By the time he called me last night, I was so emotionally drained, all I could do was listen. I really couldn't say much. Sometimes I need to just listen and not talk so much, so I did. However, today is a NEW day and I am renewed and refreshed :) That's interesting that he might just be making all of this up to cover his own tail, but it does make since. He wants to do another ACTH on Monday. Would you trust him to do it or since I have raised such a fuss lately do you think they will be rough with Tank? I drop him off in the am, and then they usually call me around 1pm to pick him up. So, in other words, I leave him for a long period of time with them! The vet is so anxious to see these results, as am I since Tank will NOT be fasting or w/holding water, but he tells me he thinks they will be "normal." So, if this is the case, do I even need to do the ACTH test or just continue on 15mg of treatment once daily? I guess as a safety, it is wise to do one since it's been a month since his last one. Silly question, but how do I find the Florida site you are referring to? I do wish we lived in
Gainesville still...I am sure at UF they have more experienced vets. Plus I am partial since that is my alma mater.

[Hstaff]

Will do thanks. As for the pricing of the ACTH tests, what is the range? Am I getting ripped off at $200 every two weeks?

I know there is a way to save money because my vet offered it. He said that when I go in for the ACTH test they can save the stuff from the vial that is unused, freeze it and use it for my next visit. I think he said it would be good up to 6 months. He said he would only charge me 100 since he would have already done the other part previously. Maybe you can ask about it or inform your vet? Go to this site and see if it explains what I was trying to say! http://www.veterinarypracticenews.com/vet-practice-news-columns/abstract/acth-stimulation-testing.aspx

[frijole]

Here you go - page ONE of Florida specialists:

Name Univ/Hospital Specialty City State
Dr. Pedro F. Armstrong Southeast Veterinary Referral Center SAIM Miami FL
Dr. Marcel Aumann Florida Veterinary Specialists SAIM Tampa FL
Dr. Ashley L. Ayoob Animal Specialty Hospital of Florida SAIM Naples FL
Dr. Cory D. Brown Palm Beach Veterinary Specialists SAIM West Palm Beach FL
Dr. Jorg Bucheler SAIM Palm Beach Gardens FL
Dr. Deborah Sue Busch SAIM Cocoa FL
Dr. Terry Carro Miami Veterinary Internists SAIM Miami FL
Dr. Kirsten L. Cooke University of Florida SAIM Gainesville FL
Dr. Mitchell A. Crystal North Florida Veterinary Specialists SAIM Jacksonville FL
Dr. Melisa A. Degen Village Animal Clinic SAIM N. Palm Beach FL
Dr. Alexander E. Gallagher University of Florida CVM SAIM Gainesville FL
Dr. Richard T. Goldston Parkview Animal Hospital SAIM St. Petersburg FL
Dr. Brenda Griffin University of Florida SAIM Gainesville FL
Dr. Rosie Henik Mobile Veterinary Echocardiography SAIM New Smyrna Beach FL
Dr. Richard C. Hill University of Florida SAIM Gainesville FL
Dr. Adam L. Honeckman Mobile Veterinary Diagnostics SAIM Orlando FL
Dr. Anthony M. Ishak Florida Veterinary Specialists SAIM Tampa FL
Dr. Jonathan J. Kreissler Miami Veterinary Specialists SAIM Miami FL
Dr. Paula Beth Levine North Florida Veterinary Specialists SAIM Jacksonville FL
Dr. Julie K. Levy University of Florida, CVM SAIM Gainesville FL

[frijole]

page TWO:

Name Univ/Hospital Specialty City State
Dr. Chris L. Ludlow Animal Specialty Hospital SAIM Rockledge FL
Dr. Brian J. Luria Florida Veterinary Specialists SAIM Tampa FL
Dr. Ronald Lyman Animal Emergency & Referral Ctr. SAIM Ft. Pierce FL
Dr. Vera Maeckelbergh Miami Veterinary Specialists SAIM Miami FL
Dr. Cathleen A. Meeks Affiliated Veterinary Specialists - Gainesville SAIM Tampa FL
Dr. Lisa Erin Moore Affiliated Veterinary Specialists SAIM Maitland FL
Dr. Sofia C. Morales Coral Springs Animal Hospital SAIM Coral Springs FL
Dr. Gary P. Oswald Tampa Bay Veterinary Specialists SAIM Largo FL
Dr. Julie R. Pembleton-Corbett Institute of Veterinary Specialists SAIM Gainesville FL
Dr. Susan C. Randell SAIM Maitland FL
Dr. Michael Schaer University of Florida, CVM SAIM Gainesville FL
Dr. Rebecca Lynn Seaman SAIM Coral Springs FL
Dr. Neil G. Shaw Florida Veterinary Specialists SAIM Tampa FL
Dr. Thomas A. Smith Animal Specialty Hospital SAIM Rockledge FL
Patti Snyder North Florida Neurology, PA SAIM Orange Park FL
Dr. Andrew J. Specht University of Florida SAIM Gainesville FL
Dr. Jeffrey Toll Adv. Vet. Med. of Miami, P.A. SAIM Miami Beach FL
Dr. Katrina Toshach Southeast Veterinary Oncology and Internal Medicine SAIM Orange Park FL
Dr. Mark Cameron Walker North Florida Veterinary Specialists SAIM Orange Park FL
Dr. Karen J. Wolfsheimer Endocrine Diagnostics & Consultation SAIM Mcanopy FL

[tankers]

Thanks! Yes, I have shown that page to my vet about prolonging the use of the ACTH test, I got nothing back. :( I assume that was his way of telling me he'd rather charge me $200 a test, but thank you for the link and information. Also, thank you very much for the detailed list. Dr.Armstrong (the first one on the list) was one of the internal med. spec. that told me Tank did not have Cushings. He also ran numerous tests (not for Cushings), but everything else under the sun, and finally told me he thought Tank's problems were all "psychological" and would not see him anymore and recommend a behavioral specialist for him to get shock collars to no longer urinate in the house (which by the way, I did not go thru with, but that was Dr.Armstrong's recommendation!!!!) Also, on that list is Dr.Toll who currently works with my vet every other Friday. He is the one who has recently suggested he thinks Tank has Diabetes Insipidus. So, my fear is that I just continue going through these vets one by one, spending thousands, and none of them know what the heck they are talking about! It's so draining as you can imagine. I really would love for someone to say they had a particular vet in S.Florida that had good experience in Cushings and I would go to him/her, because I hate to choose randomly once again. :(

[tankers]

I placed a call yesterday to Dechra. I want to see about this "conversion chart" and I also want their opinion on all of Tank's ACTH tests while fasting and w/holding water. I drop him off in the morning for his next one and I really want to tell them that I shouldn't have to pay for this one!!

[Jenny & Judi in MN]

good luck on all fronts!

[Squirt's Mom]

Hope all is well via the vet visit today and no one ends up in jail. :p;):D;):p

Hugs,
Leslie and the gang

[tankers]

Ha! No one ended up in jail. I actually decided to stay at the vet the entire time this go round. It was a long two hours, but I wanted Tank to feel better and me to feel better that I could keep him with me during the wait time. As far as I'm aware, everything went fine today. We will get a call with the actually pre and post results tomorrow and I will update this. Also, I got a call back from Dosha at Dechra. She actually was the one who spoke to my vet and sent him the conversion chart. So, I guess it is real, but I still have yet to see it. She said it shouldn't make that much of a difference fasting vs. not. And prior to the ACTH test, we should only give them 1/4 of the amount that we normally do on a typical day. It was already too late for this for me today, since she called @ 10am and he got his pills and food at 6am. So, we had a nice talk and she said really it's more the clinical signs we should watch and if we (my husband and I) are okay with Tank's progress, that is all that really matters. So, I guess I got all mad for nothing.....

[lulusmom]

We've read time and time again that food has a huge impact on absorption of Vetoryl, whether with 1/4 of a meal or a full meal, so I am absolutely flabberghasted that a vet or rep at Dechra would say otherwise. Here's a blurb from Dechra's own literature which is contrary to what you were told:
Administration with food will significantly increase the rate and extent of absorption of VETORYL Does that sound like there wouldn't be much difference if the dog is fasted?

Tank's Mom, it would really be great if you would ask your vet for a copy of that conversion chart. I know that I'm not the only one who is sitting here scratching their head trying to figure out how on earth one could come up with a fasted vs non-fasted conversion of the acth stimulation test.

The information you were provided by your vet's office was still wrong so your getting mad was justified and it mattered greatly. It prompted you to ask questions and because of that, your vet picked up the phone and learned what he should have already known about a drug he prescribed. So you've helped him with his continuing education, plus you've provided us with new information that none of us were aware of. I'm such a geek about this stuff so I am on pins and needles waiting for a copy of the conversion chart.

Glynda

[Squirt's Mom]

...she said really it's more the clinical signs we should watch and if we (my husband and I) are okay with Tank's progress, that is all that really matters.

This part is a bit frightening. There are other things that matter like proper monitoring on treatment and the ACTH results. Signs are important but so are the numbers. Many of us never knew there was a problem and even after hearing the word Cushing's and learning what to look for, our babies still didn't display all the signs many see but the testing told us their cortisol was much too high. That sounds a bit like telling someone with cancer no need to worry about anything with chemo unless losing their hair is an issue. :rolleyes:;)

[Hstaff]

Ha! No one ended up in jail. I actually decided to stay at the vet the entire time this go round. It was a long two hours, but I wanted Tank to feel better and me to feel better that I could keep him with me during the wait time. As far as I'm aware, everything went fine today. We will get a call with the actually pre and post results tomorrow and I will update this. Also, I got a call back from Dosha at Dechra. She actually was the one who spoke to my vet and sent him the conversion chart. So, I guess it is real, but I still have yet to see it. She said it shouldn't make that much of a difference fasting vs. not. And prior to the ACTH test, we should only give them 1/4 of the amount that we normally do on a typical day. It was already too late for this for me today, since she called @ 10am and he got his pills and food at 6am. So, we had a nice talk and she said really it's more the clinical signs we should watch and if we (my husband and I) are okay with Tank's progress, that is all that really matters. So, I guess I got all mad for nothing.....



I specefically asked my vet if I could feed Chloe before we did the test and he said yes it was perfectly fine...??

[lulusmom]

It's not just fine, it's what you need to do to get a meaningful acth stim test result. I think you did a great job of making sure that Tank had his last acth stim test under optimum conditions.

[tankers]

Hey gang. Here are Tank's results:

Baseln 2.7
Post ACTH 5.3

Vets notes: "Still in normal range. Slightly lower than when he was tested on 10mg. We can either stay here (at 15mg) or try to adjust the dose either to increase the once daily or switch to twice daily. Let me know your thoughts."

*I know he wants us to UP the dose. But, according to these numbers, I don't think we should. Please offer your words of wisdom. THANK YOU!! :)

[tankers]

Also, spoke with Dechra again, and Dosha is out sick today. She will return my call tomorrow. I will ask her to email me the chart so I can share it with you all. I am anxious to see it as well. I still feel it's best for us at this time to stay on the 15mg. Why up it at this point?

[Jenny & Judi in MN]

I'm no expert but 5.3 looks pretty darned good to me. What was it last time and had you increased the dose to get to 5.3?

I have no clue just wondering if the current dose brought the level down you really wouldn't want to increase would you? If you were watching trends?

Since I have a dog who's cortisol function may have been totally killed off by too much lysodren I'd be leaning towards caution and I am not one of the experienced people so if anyone disagrees with me, they are right! :)

[lulusmom]

I only have a minute but wanted to quickly tell you that 5.3 is an excellent number as long as Tank's symptoms have resolved. Since Dechra's monitoring chart indicates that 9.1 ug/dl is acceptable as long as symptoms resolved, can I assume that your vet wants to up the dose because you are still seeing symptoms? Will check back with you later. I have to run now to go bail out a poor little shelter dog who's been in jail since March. :(

[tankers]

6.21 post was where we were at last time, but that was only on 10mg, so we bumped to 15mg. He has now been on 15 mg for a solid month before we did this most recent ACTH test that came out as 5.3. As for his symptoms, our vet thinks that Tank drinking 4 1/2 cups a water a day is TOO MUCH. He says for his body weight, he should be drinking around 2 cups, therefore, this is his reasoning for suggesting the increase dosage. My husband and I think Tank is doing MUCH better and 4 1/2 cups a day doesn't bother us. Once again, this is half of what he use to drink a day, so for us, this is improvement. As for any other symptoms, I can't say that I am seeing any. He is always hungry and interested in food, but he's always been that way. Anything else I should really look for? Our issue was always the increased thirst and going pee all over our place when he has always been a house-trained dog. Those were our red flags at the beginning.

[lulusmom]

It's not about water intake but rather the reason for it. When is the last time your vet did a urinalysis to determine if Tank is concentrating his urine? Even if he isn't, I don't think increasing the once daily dose is a good idea as you don't have much wiggle room. In order for some dogs to see complete resolution of symptoms, they need to be on twice daily dosing so that cortisol is adequately controlled throughout the day.

[tankers]

Back to needing more help. I swear I feel I am losing my mind with all this. I called Road Runner to order 15mg compounded for Tank. They said they don't use Vetoryl, only the generic Trilostane. When I called Dechra they highly advised against using Trilostane and told me to find a pharmacy that compounds Vetoryl because Trilstane is not FDA approved and illegal and unsafe and there haven't been clinical trials on the usage of it, and keep scaring me why don't ya! He has been on 10mg of Vet. from one pharmacy and 5mg of Trilo from another. I was trying to save money and get just 1 pill of 15mg compounded. What in the world is going on here? I called Diamond Back, and they too only compound Trilo. They said I will not find any pharmacy that compounds Vetroyl because of the time and cost it would take to do so. Please advise :)

[labblab]

So even if you offer to buy Vetoryl capsules at their regular purchase price to be "repackaged" into smaller doses, neither internet pharmacy will do that for you? Local compounding pharmacies have done that for some of our members (involving some charge, I'm sure), and I've been wondering whether the big internet compounders would, as well.

Marianne

[tankers]

Correct, RoadRunner nor Diamond Back. So, it seems like I will just have to do what I have been doing, order the 10mg Vetroyl from one pharmacy (California Pet Meds) and the 5mg Trilo from RoadRunner. It doesn't seem like I have another choice. My vet didn't suggest any other choice either.

[lulusmom]

I'm not surprised that Dechra would recommend against using compounded Trilostane as it is money out of their pocket. I talked to Mike, one of the owners of Diamondback Drugs, on Monday for a price check on compounded Trilostane for a friend and he confirmed for me that they do not compound doses that are available through Dechra and they do not use Vetoryl to compound doses that aren't available. I was actually relieved to hear that because compounded Trilostane is so much more affordable.

To go with compounded trilostane vs Vetoryl is a personal decision but it should also be an educated one. I've done my due diligence and ultimately arrived at a decision based on no evidence that compounded Trilostane has ever killed a dog, plus my own and other members' experience with compounded trilostane. My experience was well before I ever heard of heard of Dechra or Vetoryl. Since Lulu and Jojo did beautifully on compounded trilostane purchased through a very reputable pharmacy, I can't think of a reason to pay twice as much for packaged Vetoryl and then pay more on top of that for repackaging.

Dechra is well aware that compounding pharmacies are going to continue to offer compounded doses unavailable through Dechra which is why they accelerated their plan to get FDA approval for additional doses. See excerpt from Dechra's half year financial report - 2012:


Vetoryl sales also increased by 14.0% over the corresponding period, despite continued pro-active competition from compounding pharmacies. A 120mg strength of Vetoryl has been launched and a 5mg presentation is also being developed to increase dosing options to negate the perceived need for a compounded product.

Tank's mom, since you are already using compounded trilostane anyway, if your vet is okay with giving you a script for 15mg, then why not go ahead and continue to use compounded Trilostane? Roadrunner and Diamondback are very reputable pharmacies. I don't have my notes in front of me but I think Diamondback quoted me $30 for 60 count 15mg Trilostane. Once a dog is stabilized on a dose, it's cheaper to buy 90 days worth. I think I was paying $87 for that the last time I bought 90 days worth for Lulu.

[labblab]

I totally agree with Glynda that the decision re: brandname Vetoryl vs. compounded trilostane is a personal decision that should be based upon education and the facts of the situation. It is important to know that compounded drugs are not the same thing as generic equivalents of brandname drugs. And I believe that more vets have become cautious about prescribing compounded trilostane subsequent to news of this recent study conducted by Dr. Audrey Cook of Texas A & M University. This study was funded by Dechra, so that may raise the eyebrows of those who are cynical. But Dr. Cook is highly respected internationally both as a researcher and a clinician. And these are the study results:


Compounded trilostane capsules (15 mg, 45 mg, or 100 mg) were purchased from eight pharmacies and assayed for content and dissolution characteristics. Capsules made in-house containing either inert material or 15 mg of the licensed product and proprietary capsules (30 mg and 60 mg) served as controls. Findings were compared with regulatory specifications for the licensed product. Altogether, 96 batches of compounded trilostane and 16 control batches underwent analysis. In total, 36 of 96 (38%) compounded batches were below the acceptance criteria for content. The average percentage label claim (% LC) for each batch ranged from 39% to 152.6% (mean, 97.0%). The range of average % LC for the controls was 96.1–99.6% (mean, 97.7%). The variance in content of the purchased compounded products was substantially greater than for the controls (234.65 versus 1.27; P<0.0001). All control batches exceeded the acceptance criteria for dissolution, but 19 of 96 batches (20%) of purchased compounded products did not. Mean percent dissolution for the purchased compounded products was lower than for controls (75.96% versus 85.12%; P=0.013). These findings indicate that trilostane content of compounded capsules may vary from the prescribed strength, and dissolution characteristics may not match those of the licensed product. The use of compounded trilostane products may therefore negatively impact the management of dogs with hyperadrenocorticism.

Here's the link for the abstract of this article published in the Journal of the American Animal Hospital Association:

http://www.jaaha.org/content/early/2012/05/18/JAAHA-MS-5763.abstract

The compounding pharmacies that were sampled in the study were not named. So on the face of it, there's no way to know from this study whether the compounding pharmacy you use was problematic in the past, or will be in the future. But the difficulty is that there is no mechanism in place to validate the testing of ANY compounding pharmacies in terms of efficacy or contents. Validation is not performed by the FDA, state pharmacy boards (other than Missouri), nor any other regulatory body.

Friendly pharmacists and great customer service does not guarantee the content of the compounded product. And the bottom line is, that's what you're most concerned with in terms of the treatment of your dog. So my own personal opinion remains this: if I simply could not afford brandname Vetoryl to treat my dog, or he/she needed a dose or form (liquid) for which Vetoryl is not available, then I would definitely go the compounded route. But if I could afford to pay the price for the brandname drug, I would buy it. In the long run, that might save money anyway, because I wouldn't run the risk of scratching my head and performing multiple ACTH tests because I couldn't figure out why my dog was having rebounding symptoms or suddenly crashing while supposedly being maintained on the same dose of compounded drug.

Marianne

[tankers]

You guys are so helpful. My vet sent me that same survey (he is ontop of his game now) :) He also emailed me this: " I obviously have little experience with generic trilostane…In general I like generics..I think the compounded product from a reputable pharmacy should be fine….if you see any difference in the effects over the next month then we can rethink the generic….."
So yes, he is willing to call in the 15mg of Trilo at RoadRunner or Diamond Back, or I can keep using my 10mg of Vet. and buying the 5mg compounded of Trilo. Hum....

[labblab]

In no way am I trying to twist your arm to keep on buying Vetoryl. Whatever you and your vet decide upon is the route you should go.

I just want to clarify, though, that compounded drugs are not the same thing as generic drugs even though your vet used that language. I know this sounds like nit-picking, but in the past our members have gotten really confused about this and started fretting over the use of generic drugs for themselves or their pets.

Here's a quote from the recently revised brochure published by the American Veterinary Medical Association (AVMA) that describes the difference between generic and compounded drugs. One section of particular interest in the brochure is "Questions to Ask Your Pharmacist" in the event that a compounded drug is prescribed for your pet.

http://ebusiness.avma.org/EBusiness50/files/productdownloads/2011_Compounding_Brochure.pdf


Generic drug products are very different from compounded preparations. Generic drug products are FDA-approved, which requires a demonstration of bioequivalence of safety and efficacy with the pioneer drug product. Generic animal drug products are identified by an Abbreviated New Animal Drug Application (ANADA) number on their label or in FDA drug references. In contrast to generic drugs, compounded preparations lack FDA approval.

Generic drugs are manufactured for mass sale by pharmaceutical companies in the same manner and under the same regulations as the brandname originals. Compounded drugs are prepared and assembled by the staff of individual pharmacies from ingredients they have sourced, theoretically "to-order," based on each individualized patient prescription.

I know I am obsessive-compulsive, but I'm guessing there may be a few other folks out there who also want to know the specifics about this difference. :o

Marianne

[tankers]

Thanks everyone. We decided to give the 15mg pill a try for at least a month and see how Tank responds. If he does the same as he has been doing, it saves $50 a month, which adds up quickly. If we don't see the same results as we have on 10mg of Vet and 5mg of compounded Trilo, we will switch back in July.

[tankers]

So, he has only been on the compounded Trilo for 4 days and I don't feel like it is a good thing. He seems to shiver nonstop and have no energy. Usually he enjoys jogging, and tonight, he wouldn't even walk with me. He still is eating and drinking (4.5 cups) the same as usual. He just seems to not feel good. I have contacted my vet. Any ideas? I'm thinking of NOT giving him his 15mg pill tomorrow.

[Harley PoMMom]

If my memory serves me right :eek: I think we have had a member who had a problem with their compounding medicine, can't recall if it was Trilostane or Lysodren. They did figure out it was the filler that was added, I think it was a coloring that was added. It might have been compounded locally and not prepared by one of the larger compounding companies like Wedgewood, Wycliff or Diamondback.

Maybe ask the compounding pharm. if they are adding any fillers and exactly what they are.

Hoping Tank feels better real soon, and keep us posted.

Love and hugs,
Lori

[tankers]

Hey all. I hope you all are doing well. Tank has been on the compounded Trilo for awhile now (over a month) and seems to be doing okay. The vet no longer calls/emails, so I just go on about life. I quit tracking water intake too for awhile, so I need to get back on that so I know where he is at. It still seems like a lot, but then again, it's SO hot, so who knows. I am concerned with his skin. He seems to still be losing so much hair and his underbelly is like sandpaper. It is pretty gross looking. I feel bad for him. I use lotions, oatmeal shampoos, Vaseline, fish oil capsules, etc. I don't use all of these at once or even often in one week, but I have tried them all to no avail. So, I was hoping you guys had something that you have used and worked. I thought the meds would help hair loss and their skin, but to me, it just appears to do more damage, unless that is just the disease itself speeding up.?? He also continues to lose weight here and there. He seems so small compared to what he use to be. He use to weigh 30 lbs, and now he is down to about 23 lbs. Big difference on a smaller dog. He wants people food all of the time, and really has nothing to do with his dog food. I can't find anything that he likes.

[lulusmom]

When was the last acth stimulation test done and can you please post the results? Can you tell if Tank's urine is dilute (clear)? If his cortisol levels are not in the therapeutic range, this could be why you are not seeing complete resolution of symptoms.

[tankers]

Hello. Tank's last ACTH test was at the end of May. His results were as follows:

Baseln 2.7
Post ACTH 5.3
His urine does not look diluted to me, but next time he goes potty, I will check closely.

[labblab]

Hey all. I hope you all are doing well. Tank has been on the compounded Trilo for awhile now (over a month) and seems to be doing okay. The vet no longer calls/emails, so I just go on about life. I quit tracking water intake too for awhile, so I need to get back on that so I know where he is at. It still seems like a lot, but then again, it's SO hot, so who knows. I am concerned with his skin. He seems to still be losing so much hair and his underbelly is like sandpaper. It is pretty gross looking. I feel bad for him. I use lotions, oatmeal shampoos, Vaseline, fish oil capsules, etc. I don't use all of these at once or even often in one week, but I have tried them all to no avail. So, I was hoping you guys had something that you have used and worked. I thought the meds would help hair loss and their skin, but to me, it just appears to do more damage, unless that is just the disease itself speeding up.?? He also continues to lose weight here and there. He seems so small compared to what he use to be. He use to weigh 30 lbs, and now he is down to about 23 lbs. Big difference on a smaller dog. He wants people food all of the time, and really has nothing to do with his dog food. I can't find anything that he likes.
I'm sorry to hear that, actually, it does not sound as though Tank is doing all that well right now. Skin and coat issues can take an extended period of time to resolve, but once treatment is underway, you'd hope that they would not be getting even worse. Was that previous ACTH test performed prior to the shift to the compounded medication? If so, and if some of his issues are actually worsening now since the switch, then I'm afraid this is the type of situation that makes me nervous about the dosing reliability of compounded meds because it introduces another question mark into the equation. I hate for you to have to bear the expense of another ACTH test, but it may be that his cortisol is no longer being as well controlled. It may have nothing to do with the medication itself -- his level may just be creeping upward on it's own. But without the benefit of another ACTH test, you have no way of knowing where his cortisol level is at and whether a dosing/medication change is in order. :o

Marianne

[tankers]

Yes, it was prior to him taking the compounded drug, so that does make since what you are stating. I am surprised my vet hasn't emailed in over a month to check in on him or to get his water intake. We were out of town for a week and Tank stayed with a pet sitter that we know and trust and she said he did great with her, but she fed him Gerber baby foods daily because he wouldn't eat anything else.

[tankers]

I just took him out, and yes his urine does appear very clear.

[tankers]

Hey all. It's been awhile, but I need your help/advice. Tank has been on the compounded Trilo at 15mg for two months now. He just got a ACTH test done Friday (per my request) bc he seemed skinnier and not wanting to eat much, and still a lot of hair loss. Here are his results and I am confused. Please help me figure this out.
TEST
NORMAL
ABNORMAL
UNITS
RANGES
ACTH Stim. x2
See Below
Cortisol Baseln
3.5
ug/dL
1.0-5.10
Post ACTH
3.7 L
ug/dL
5.1-17.2

[tankers]

Also, this was what his vet said: "Hello. He is thin but ok. Attached are the newest results. These are about as low as I want to get. I would stay with the dose. Let’s bring him in 1month for a quick check/weigh in. I don’t want to see him go too much lower. Ted"

Each time we bring him in, he has lost weight. So I believe that is what he is talking about. He constantly shivers and it is 100 degrees outside.

[Squirt's Mom]

How is Tank's appetite? Has he had a superchem where his glucose was checked recently? Diabetes can come up suddenly; weight loss and loss of appetite are often signs.

[tankers]

Hello. See the link I put before the last one please. It explains his appetite and levels. Thank you.

[Squirt's Mom]

I must be missing something. :confused: But that wouldn't be the first time! :D

[tankers]

Test results as of yesterday:

Cortisol Baseln
3.5
ug/dL
1.0-5.10
Post ACTH
3.7 L

*Does this seem too low for Tank, or would you guys say okay. The vet wants to continue on the 15mg once daily compounded Trilo. His appetite varies lately. He still is losing weight, down too 22lbs, from 30lbs originally :(

[frijole]

If I'm reading it right the 2nd number is 3.7 which is very good.

I am concerned about the weight loss though because cush dogs don't tend to lose weight. Is Tank eating normal quantities? Thanks. Kim

[tankers]

I didn't think the Post ACTH should be a tad bit higher than the Pre, but I guess that's okay...??
As for his eating, lately, he doesn't really eat much at all. He use to eat breakfast, lunch, dinner, now he will only eat his breakfast throughout the day and not even finish it by night. Not sure what to do about it. I've tried changing foods, adding people food to "spice it up" and trick him, it doesn't work too much. He does love people food though, so maybe I should just start buying whole chickens and cooking them, what do you think?

[Nikki]

I just wanted to throw in my input on the food thing. Because of Max's allergies, and his super non allergenic food being really expensive, and he won't eat dry food, only the wet, my vet had recommended home cooking. My boyfriend gets 4-5lbs of chicken breast when it's on sale for 1.99/lb. We throw it in the crock pot with water on low all day. It shreds so easily, and Max LOVES it!! It ends up being way cheaper to feed him that with oatmeal or potatoes than it would be to buy enough wet food cans to fill him up! (He eats A LOT)

[Squirt's Mom]

Hi,

The ACTH results look good. It is post number that matters, not the pre, and 3.7 is good! :) One of our previous admins had a real good description of what the ACTH test does. Imagine a sponge full of water. The sponge is the adrenal glands. The stim agent used with the ACTH acts like a fist that is squeezing the sponge to get as much water as possible from it. The ACTH causes the adrenal glands to empty as much cortisol as possible. So before the stim agent is given to Tank (the pre number), the results are showing how much cortisol is normally being released from the adrenals. AFTER the stim agent is given (the post number), what we are looking at is how much cortisol the adrenals were holding in reserve - we have squeezed the sponge.

However, I still don't see any test results from recent blood work that would check his glucose levels. This would be via something called a Superchem, Chem 20, Senior Wellness panel, etc, and would show things like the ALP, BUN, cholesterol, glucose and so on. The ACTH cannot check for diabetes as a possibility, or any other condition, that might be causing his weight loss. As Kim said, loss of weight or loss of appetite is not typical for a cush pup and that is why I am wondering about diabetes.

If Tank has not had regular blood work recently, that is something I would want done asap. ;)

Hugs,
Leslie and the gang

[tankers]

I have contacted the vet to see if we can schedule a superchem. I think it has been too long since we last had one. Thanks for the responses and I will continue to update you. I don't want him to lose any more weight or hair! The hairloss and dry skin still continues (along with the weight loss) even though his test results come back "good." Strange!! I don't get it ;(
Also, our vet recommended unrefined coconut oil for his dry skin, it has been helping a lot, so if anyone else is having that problem with their pup, pls give it a try. I found it at Whole Foods.

[Squirt's Mom]

ooooo, coconut oil is the BOMB! :cool: It is so good for skin, coat, digestion...just good stuff! I use it with all mine and was amazed at the difference it made in them. I pour it over their feed daily and often use it in the place of other oils when making treats and food for them.

Let us know what you learn on the labs! and, of course, how Tank is doing until then.

Hugs,
Leslie and the gang

[tankers]

So I took Tank in for a CBC on Friday along with every other blood test you can do ($200 worth) and this is the results I heard back today from the doctor when I asked about them. (They came back yesterday, not sure why I wasn't contacted. I hate that I have to stay on top of everything-isn't that their job?) OH well-
"All on the chemistry is normal except the expected alkaline phosphatase elevation. On the complete blood count the white blood cells came back on the low side with an elevation in one type of cells called eosinophils . I don't know what to make of it at this point. Would consider a fecal exam to rule out intestinal parasites. Will consult with some colleagues as well. Should probably repeat the cbc in a week to verify results."
I am not going to repeat CBC next week. I just did his ACTH last week which was $200 and then this. I can't afford to keep doing all of these tests. The reason we did the CBC is because of his continued weight loss. He is down to 22 lbs now (started at 30 a year ago) and as of now deemed "too thin." Our vet would like him @ 25 lbs. Suggestions guys please!!

[tankers]

TEST NORMAL ABNORMAL UNITS RANGES
Glucose 123 mg/dL 77-155
Sodium 147 mmol/L 136-160
Potassium 4.6 mmol/L 3.6-5.3
Chloride 107 mmol/L 98-120
CO2 24 mmol/L 15-28
Sodium/Potassium 32 Ratio 20-45
Anion Gap 21 7-35
Serum Osmolality 303 mosmo/kg 261-337
Urea Nitrogen 9.5 mg/dL 6-36
Creatinine 0.5 mg/dL 0.5-1.5
BUN/Creatinine 19 Ratio 5-43
Total Protein 7.7 g/dL 5.5-8.1
Albumin 4.0 g/dL 2.7-4.5
Globulin 3.7 g/dL 2.5-5.3
A/G Ratio 1.1 Ratio 0.6-2.0
Calcium 11.1 mg/dL 8.5-12.0
Phosphorus 5.2 mg/dL 2.2-6.6
Cl/P Ratio 21 Ratio 0-42
Bilirubin, Total 0.08 mg/dL 0-<0.5
Bilirubin Direct 0.04 mg/dL 0.0-0.2
Bilirubin Indir 0.04 mg/dL 0.0-<1.2
Alk Phosphatase 959 H U/L 0-175
ALT (SGPT) 82 U/L <120
AST (SGOT) 16 U/L <60
LDH 119 U/L 20-620
GGT 21 H U/L <21
Creatine Kinase 135 U/L 5-400
Cholesterol 283 mg/dL 115-350
Triglycerides 84 mg/dL 21-140
Amylase 486 U/L 280-1,380
Thyroid Studies
STATUS : FINAL
TEST NORMAL ABNORMAL UNITS RANGES
Free T4 9.8 pmol/L 6.0-37.0
Hematology
STATUS : FINAL
TEST NORMAL ABNORMAL UNITS RANGES
Leukocytes WBC 3.4 L 10*3/ul 6.0-13.5
Erythrocytes RBC 7.98 10*6/ul 5.5-8.5
Hemoglobin 16.3 g/dL 11.5-18.0
Hematocrit 48.0 % 37-55
MCV 60 um3 60-77
MCH 20.5 pg 19-27.5
MCHC 34.0 g/dL 30-38
Seg Neutrophils 64 % 60-77
Band Neutrophils 0 % 0-3
Lymphocytes 12 % 12-30
Monocytes 3 % 1-10
Eosinophils 21 H % 1-8
Basophils 0 % 0-1
Seg Neutrophils 2.176 L 10*3/ul 3.00-11.50
Band Neutrophils 0.000 10*3/ul 0-1.0
Lymphocytes 0.408 L 10*3/ul 1.0-4.8
Monocytes 0.102 10*3/ul 0.10-1.50
Eosinophils 0.714 10*3/ul 0.10-1.49
Basophils 0.000 10*3/ul 0.00-0.20
Platelet Est Adequate

[tankers]

Alk Phosphatase 959 H U/L 0-175
So this was very high!

GGT 21 H U/L <21 * Right at 21, should be 21 or less...

Leukocytes WBC 3.4 L 10*3/ul 6.0-13.5
So low...

Eosinophils 21 H % 1-8
So very high....

Seg Neutrophils 2.176 L 10*3/ul 3.00-11.50
so lower than acceptable

Lymphocytes 0.408 L 10*3/ul 1.0-4.8
lower than desired...

[tankers]

Any suggestions? The vet wants me to do a broad spec. dewormer. However, tank is on Heartguard, and I don't see worms in his bm's, so IDK. I feel like at this point they are just grabbing straws.

[addy]

Hi,

Hopefully someone will come along to look over your blood work. If your vet is prescribing Panacur- Panacur works on Giardi as well which Heartguard will not control. My Koko just had Giardi with no evidence of it except in his stool, it was not making him ill at all. Giardi is hard to find in the stool. Did they test for that? Do you see any food in his stool that is not digested? Are his stools okay?

Just throwing things out there until someone comes along:):)

[molly muffin]

Hopefully one of the other members who knows more about blood work results than I do will see this and comment.

I don't really worry about the ALP being high, and yours isn't that high at all compared to most of the dogs with cushings. Even Molly's is higher. The things like Gluclose, ALT's, elctrolytes, all seem to be normal, and it is the WBC's that are low. Anemic?
Like I said, I'm just not sure on the lab result stuff.

However, google is our friend and I did a search and found this site, which might
be helpful for us all to bookmark. Explaining what terms mean, etc

http://www.petplace.com/dogs/understanding-blood-work-the-complete-blood-count-cbc-for-dogs-2/page1.aspx

It might be that the high Eosinophils, which can be a sign of parasites, that makes the vet want
to check for worms, or deworm.

Hugs,
Sharlene

[tankers]

Thanks for the link. Yeah, that does make since, so maybe I should do it...

[molly muffin]

How are things going with Tank? Hope all is well. Did you decide to try the deworming?

Hang in there!
hugs,
Sharlene

[tankers]

Hello, thanks for checking in. No, I haven't done it yet. I came down with an awful stomach bug, high fevers, etc..so I am trying to get myself better so I can actually go take him to the vet to get it.

[molly muffin]

Oh no. Take care of yourself and I hope you get to feeling better soon. I'm sure Tank is very worried about his mom just like you worry about him.

Let us know how you are doing. Those stomach bugs can be just awful!

hugs,
Sharlene

[tankers]

Hello everyone. I took Tank to the vet Saturday for a ACTH test bc he is back to drinking tons of water and wanting to pee a lot, and when I take him out, he wants to urinate for much longer periods of time. Well, I just got the results back last night. His baseline was lower than 1, and his post readings were 3.29. The vet now thinks we are overdosing him at 15mg. He has been on 15mg of trilo for many months and all tests have come back fine, so this worries me. It doesn't seem to make since either! Please offer any advice you may have. Thanks!

[frijole]

? Not sure why the vet thinks you are overdosing? That test result is awesome. I have someone coming in a few to work on my pc so can't go back and read your thread... would be interesting to see if the cortisol has slowly gone lower over time? But peeing isn't a sign of overdose - it's a sign of high cortisol. Did your vet do other tests? I'd make sure you rule out diabetes by a blood panel. Thanks Kim

PS Just checking to make sure you aren't giving him any steroid medicines. Also making sure that no one Tank is around is using female hormone creams - thanks!

[lulusmom]

Tank's post stimulated cortisol of 3.29 is great but I think a resting cortisol of less than 1 is scarey low and in I personally would want to reduce the dose. I don't think Kim realized that his pre draw was less than 1 and I trust that she'll let you know.

I've read a few studies that mention that some dogs who have been stabilized long term on Trilostane can all of a sudden experience a further drop in cortisol for no apparent reason. Luckily Tank is having no adverse reactions to it but that's not to say that he wouldn't have had this stim test not caught it.

As for the increased drinking and peeing, did your vet do a urinalysis to check for a urinary tract infection?

Glynda

[labblab]

I am at a loss as far as the significance of Tank's "pre" draw that is less than 1.0. It is indeed very low, but there is nothing in Dechra's U.S. Product Insert for Vetoryl that expresses concern over a low "pre" draw as long as the "post" result is greater than 1.45 ug/dl, which is the case with Tank. In looking back through your thread, I see that his August "post" result was a tad higher ( approx. 3.9 compared to approx. 3.3). However, it is not hugely different. So I honestly don't know what to make of his low "pre" draw this time around, especially in light of his symptom profile. You might want to try contacting Dechra directly in order to see what they recommend re: Tank's current test result and dosing.

Marianne

[frijole]

Glynda was right - I focused on the post number. I also do not know the significance of the first number - I never used trilostane. Kim

[lulusmom]

Marianne may be right but if it were my dog, I would not feel comfortable with resting cortisol of less than 1. Yes, Tank has some cortisol in reserve when stimulated but I'd still be nervous. Antech Diagnostics states that when treating with Lysodren (Mitotane), basal cortisol less than 1 is consistent with hypoadrenocorticism if symptoms are consistent with such. However, they go on to recommend that if basal (resting) cortisol is less than 1 that you consider discontinuing treatment and retest in two to three weeks. Resting cortisol is resting cortisol no matter what treatment you are administering but it is possible that this is not a concern if a dog is being given Vetoryl (Trilostane). As Marianne mentioned, Dechra can give you their opinion.

[labblab]

I just want to clarify that I'm not advising you to disregard the low resting cortisol -- I just don't know what to make of it. I wish this was an issue that Dechra addresses in their product insert, but I'm afraid I'm missing seeing that info if it is there.

Traditionally, we've generally told people to disregard the "pre" readings as long as the "post" readings were in range. But the "pre" readings are more commonly larger than 1.0. And I'm starting to question my overall sense of what Dechra's current preference is as far as treatment range. Lori recently brought an article to my attention that is authored by Dr. Peterson, and he referenced a stim result as being "too low" that I would have thought was within Dechra's published range. So I am confused at this point.

Certainly, if there is ever any doubt, you don't want to overdose. Given Tank's history and current situation, I'd welcome Dechra's input if I were you. If you do decide to contact them, please let us know what they tell you!

Marianne

[lulusmom]

I figured that if anybody would have mentioned the usefulness of basal cortisol in determining adrenal function as it relates to monitoring treatment, it would be Dr. Audrey Cook. I did some digging and sure enough, her paper entitled "Evaluation of the use of baseline cortisol concentration as a monitoring tool for dogs receiving trilostane as a treatment for hyperadrenocorticism” states that baseline cortisol levels of less than 1.5 ug/dl is considered indicative of a dose of trilostane that resulted in excessive suppression of adrenal gland function. Tank's baseline cortisol is less than 1 ug/dl which I believe would definitely be indicative of excessive suppression of his adrenal gland function.

I would be very interested in hearing Dechra's assessment of Tank's stim test. It would be very troubling if their assessment of the resting cortisol is contrary to Dr. Cook's.

Glynda

[molly muffin]

hmm, isn't there something about low cortisol having many of the same symptoms as high cortisol? I think you have to go by the numbers and be concerned that he doesn't go too low. I agree, interested in what Dechra thinks.

Sharlene

[labblab]

I figured that if anybody would have mentioned the usefulness of basal cortisol in determining adrenal function as it relates to monitoring treatment, it would be Dr. Audrey Cook. I did some digging and sure enough, her paper entitled "Evaluation of the use of baseline cortisol concentration as a monitoring tool for dogs receiving trilostane as a treatment for hyperadrenocorticism” states that baseline cortisol levels of less than 1.5 ug/dl is considered indicative of a dose of trilostane that resulted in excessive suppression of adrenal gland function. Tank's baseline cortisol is less than 1 ug/dl which I believe would definitely be indicative of excessive suppression of his adrenal gland function.

I would be very interested in hearing Dechra's assessment of Tank's stim test. It would be very troubling if their assessment of the resting cortisol is contrary to Dr. Cook's.

Glynda
Glynda, I definitely agree that Tank's baseline reading is low and that per Dr. Cook's study, his baseline reading -- alone -- would be a cause for concern. But if I'm reading the study results correctly, a baseline reading such as Tank's would/should have triggered a full ACTH in order to see whether or not his "post" result was also too low. And in Tank's case, it was not, according to Dechra's recommended treatment range.

In hopes of easing the cost/demands of monitoring, Dr. Cook's study was designed to explore whether baseline cortisols, on their own, can reliably predict safe and appropriate trilostane treatment control. Per the study results, she recommends that any dog with a baseline reading that falls outside a specific optimal range should proceed to a complete ACTH stim test. Tank's baseline cortisol was definitely too low for her designated safe range, and therefore would have necessitated a full ACTH in order to make sure that he is not oversuppressed. But per the results in the study tables, the majority of dogs with "low" baselines actually proceeded to normal stimulated results, as did Tank. Out of 83 dogs with baselines below 1.3, only 17 dogs had "post" results lower than 1.5. The remainder all had normal (and even one high) stimulated results. Per statistical analysis, those 17 "low" dogs were enough for her to recommend full stims for any dogs with baselines below 1.3. But for the purposes of Tank's situation, 65 of the 83 dogs with low baselines ended up being "OK" on the full stim. Here's a link to the complete study:

http://www.2ndchance.info/cushings-monitorcortisollevel.pdf


For those dogs with baseline cortisol concentrations outside the defined target range, an ACTH stimulation test may still be necessary before adjustments in the dose of trilostane are made.
So once again, I definitely agree that Tank's baseline reading was too low for comfort. But with Dr. Cook's study in hand, I think his "post" ACTH result perhaps makes the picture somewhat less worrisome and I'd remain really curious as to Dechra's recommendation re: whether/how much to lower his dose. The study's co-author, Karen Bonds, is the Manager of Clinical Trials at Dechra. So they probably helped fund the study itself and will be very familiar with the results.

Marianne

[tankers]

Hello all, and thank you so much for all of the replies. I spoke with Dechra and also my vet did as well. This is what was said, "Hello. I spoke with a new Dr. at Dechra .He was very anti generic …Wants you to only use the Vetoryl product. Suggests to try on 10mg twice daily. He also suggest us to change the style of ACTH product that we use for testing. He likes the non compounded product. This can be more expensive because usually a one time use product unless we are doing multiple acth stim test . The other has a longer shelf life. He is suspicious of concurrent disease as well. He mentioned diabetes insipidus ( a rare disease but a possibility. Let me know if you are ok to try the 10 twice daily and we can look into the cost of the non compounded acth…."

So what do you all make of this? Tank has been on brand Vetoryl before, but in a dose of 10. When he went to 15 several months ago, we went to the compounded trilo. When I spoke to the Dr. at Dechra, I pretty much got the same thing-to reduce the dose. However, I seem to feel more comfortable just going to 10mg once a day. Am I wrong in doing this? Would it be best to do the 10mg twice a day? We have done the very through CBC panel test before (results posted in previous thread several pages back) and I believe we ruled out diabetes insipidus, so I'm not sure why that is being brought up again. Also, I have no idea what this "other" ACTH test is all about. The current one I do now is $200 each time. I have not yet responded to our vet. I am not sure what to do. I still have many 15mg tabs left, but of course don't want to keep giving them to him if I am hurting him. Ugh-what to do? :(

[frijole]

I don't think he's talking about a different acth test but rather using a different 'substance' to conduct that test. Is this what you meant? Most use cortrosyn. Not sure what he is thinking of using instead. Perhaps others can chime in. Kim

[tankers]

Yeah, I'm not sure either. I know Tank is really his only Cushs pup, so they don't really keep it on hand. They have to order it when it comes time for his test. Still with his pre results of less than 1, and post at 3.29 on 15mg of trilo once daily, going to 10mg twice a day seems too much to me, no?
As for his eating, he seems hungry often, but only likes his people food *boiled chicken* he really has NOTHING to do with any type of dog food anymore. He would rather go hungry than eat any of it. I have tried every kind known to dog. I quit wasting the $$ on it, and just buy chicken in bulk and boil it all on a Sunday and give it to him throughout the day. Also, I should mention he still enjoys his 1 mile jog each night. He meets me at the door as soon as I get in from work, ready to go. So once again, with those low results, it doesn't make since does it?

[labblab]

Well, I'm glad you and your vet both spoke to Dechra. And now, you're right -- the question is sorting out their recommendations to see which way you want to move forward. I'm going to offer out a few thoughts, and please keep in mind that I can only speculate as to whether what I'm saying actually corresponds to what the Dechra vet was saying/thinking, himself.

First, as to the ACTH testing, there are indeed different stimulating substances that can be used. Here's an article by Dr. Mark Peterson that lists the various options, and also his preference for brandname Cortrosyn:

http://endocrinevet.blogspot.com/2011/03/what-acth-preparations-should-be-used.html

It sounds as though your vet may be using a compounded ACTH gel product for Tank's testing (note that Dr. Peterson refers to this as "generic ACTH gel"). If so, it sounds as though neither Dr. Peterson nor Dechra feel comfortable with the reliability of the results using a compounded gel product. Even though the price of brandname Cortrosyn is more expensive, there are ways in which a single vial can be "stretched" and preserved for multiple testing dates with a smaller dog. I would have thought the Dechra vet would have known about this, too, but here's another article by Dr. Peterson that tells your vet how to economize in this way, as long as Tank does not weigh too much:

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

And one last thought about Tank's ACTH testing: I just want to make sure that his tests are being performed 4-6 hours after his morning dose of trilostane, and also that the trilo is being given along with some food. Otherwise, the trilo won't be metablized efficiently and the test results won't reflect the maximal effect of the drug in his system.

Next, as to the Vetoryl/dosing. It is not surprising that Dechra is encouraging you to return to the brandname drug. Obviously, they have a financial interest in wanting you to use their product. But additionally, there have been a couple of recent research studies reporting that some compounded veterinary products have resulted in inconsistent and/or less effective dosing than brandname counterparts, including Vetoryl.

If I am understanding you correctly, Dechra suggested to both you and your vet that Tank's overall daily dosing be increased to 20 mg., but by splitting it into 10 mg. twice daily. If so -- and this is where I can only speculate -- I am assuming the Dechra vet is not concerned with Tank's low "pre" ACTH result, and is instead focusing on the "post" result of 3.3 and Tank's apparently rebounding symptoms. If so, the Dechra vet's advice basically corresponds with their published literature: if you are seeing symptom rebound with a "post" ACTH result between 1.45 and 5.4, then increase the overall daily dose slightly and split it in half for twice daily administration. If you do that, you continue with the ACTH monitoring tests in exactly the same way: 4-6 hours after the morning dose.

Last but not least, the "diabetes insipidus" that the Dechra vet is talking about is an entirely different disorder than "diabetes mellitus." It is the latter that involves high blood sugar and would have been ruled out on the basis of standard lab tests. Diabetes insipidus is a totally different thing, and cannot be identified using standard lab tests. I'll try to come back later today to add a link that explains more about it. He's right that it is rare, but we've had a few dogs here who have suffered from it, and it does cause excessive thirst and urination.

I know all this new info kind of puts you in between a rock and a hard place, though. I believe the reason you shifted away from the combo of the 10 mg. Vetoryl and 5 mg. of compounded trilo was to save money. And now, switching to 10 mg. of Vetoryl twice daily will be even a bigger expense.

So what to do? I really dunno :o. I do understand your worry about his low "pre" number, but I would surely hope the Dechra vet would not have advised you to switch to the new dosing if he was concerned it would drive Tank's cortisol too low. And even though many of our members use and are happy with compounded trilo, I personally would feel more comfortable with brandname Vetoryl if I could afford the cost for my own dog. Given Tank's apparent symptom rebound at this time, if it were me, I think I'd at least switch back to brandname Vetoryl at a 10 mg. once daily dose. If his thirst/hunger does not improve or worsens, I'd then bite the bullet and add the second daily dose for a while to see how he does with that. If he improves and his next ACTH testing is OK, then you could consider returning to a compounded product, but at the same twice daily dosing regimen. At that point, you'd have a basis for comparison to see whether he still maintains well on the compounded product. And if you do end up dosing Tank twice daily and the excessive thirst/urination do not resolve, that is the point at which I'd then move to considering diabetes insipidus.

I see I've written a book here, so I'll shut up now! But these are at least a few thoughts for you to consider!

Marianne

[Squirt's Mom]

Hi,

DI, diabetes insipidus, is a disorder in which the body doesn't handle water like it should while DM, diabetes mellitus, is a condition in which the body doesn't handle sugars like it should. The DM, the common form of diabetes, can be checked via blood work as the glucose is in the blood stream. However, DI cannot be seen in the blood and is tested either via a water deprivation test or by simply starting treatment to see if it helps. The water deprivation test has fallen out of favor due to the risks and often docs simply start treatment. If treatment helps, the diagnosis is "confirmed"; if it doesn't, DI is ruled out. Here are some links on DI until Marianne gets back with more input for you.

Hugs,
Leslie and the gang

• Polyuria, Polydipsia and Diabetes Insipidus
http://www.vin.com/proceedings/Proceedings.plx?CID=WSAVA2002&PID=2556

• Diabetes Insipidus
http://www.petplace.com/article-printer-friendly.aspx?id=3258

• Diabetes insipidus
http://www.provet.co.uk/health/diseases/diabetesinsipidus.htm

• Diabetes Insipidus
http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/40507.htm

[labblab]

Leslie, thanks so much for adding those links! ;) :)

And even though I said above that I'd first tinker with the Vetoryl dosing before considering DI, I guess you could also do the reverse: stay where you are right now with the trilostane, and try adding in the DI med (I think it's most commonly in the form of eyedrops) to see whether that knocks back Tank's thirst/urination. I'd discuss this further with your vet, though, to clarify exactly what the Dechra vet recommended in terms of the timing of treatment/testing optons.

Marianne

[labblab]

And here's an important P.S. that I keep forgetting to ask!

Did the Dechra vet give you a specific answer or response about Tank's low "pre" result?

[addy]

I know every dog is different and I am nowhere near as knowledgable as Mariane and Glynda but I will offer my experience with Zoe-

When Zoe was finally in controll range (under 5) and then for 3 months was no higher than 9 but on once a day dosing, I never saw any improvement with her drinking and peeing.

Now that she is on twice day dosing but her numbers are higher, for the first time I am seeing a reduction in drinking and peeing. We cant figure out why.

I can only surmise it has to do with keeping her cortisol under better control throughout the day and night.

hugs,

[tankers]

Thanks so much for your knowledge, more so than any vet has ever given me! I need to be paying you all!
No, Dechra didn't give any indications for the low pre result. I think for now I will have Tank go back on brand name Vet. twice a day. I just hope it's not too much for his system. I also will check on that other test. Again, thank you.

[tankers]

And one last thought about Tank's ACTH testing: I just want to make sure that his tests are being performed 4-6 hours after his morning dose of trilostane, and also that the trilo is being given along with some food. Otherwise, the trilo won't be metablized efficiently and the test results won't reflect the maximal effect of the drug in his system.-- I meant to respond to that as well- Yes, I give him his pill with food at 6am, drop off at vet at 10am, do first part, wait 2 hours (I come back and sit with him in lobby), draw again at noon.

[labblab]

No, Dechra didn't give any indications for the low pre result. I think for now I will have Tank go back on brand name Vet. twice a day. I just hope it's not too much for his system.
Hi again, and I just want to make sure that the Dechra vet did know about Tank's low "pre" result?

Marianne

[addy]

I think it is important we feel comfortable with our decisions. If you do not feel comfortable and are hesitant then you could always go back to 10 mgs Vetoryl retest and see where his numbers are and then change to 10 mgs BID if his pre is higher and post is still okay. It means extra money for an extra ACTH test but sometimes if we can come up with the money it is better to follow our gut reaction.

Sweetie, you know Tank best. I do remember Corky's mom saying he had pres that low but then I also remember Cindy's pup having a low pre and it became an issue.

Every dog is different. I just wanted to give you another option in case.

[tankers]

Yes, Dechra vet did know about low pre number. I do feel most comfortable doing the 10mg once a day and test, then if that is not enough, having him take 10mg twice a day and retest. Right now it is 92 out here in Miami and he is shivering like a mad man. That means low levels of cortisol right? He woke me up in the middle of the night to go pee as well (which he doesn't ever do). I even took him out at 11pm before bed!!

[labblab]

Shivering does not necessarily indicate low cortisol. It sometimes reflects pain/discomfort. And while not in any pain, my own Cushpup shivered both prior to trilostane treatment when his cortisol was high, and also after we started treatment and his cortisol level was brought down much lower. So the shivering alone does not indicate low cortisol. Plus, in reading back through your thred, I see that Tank had problems with shivering back earlier in the summer, too, but apparently the shivering resolved at that time?

As far as a signal of low cortisol, I would be very watchful for vomiting, diarrhea, unusual lethargy, or sudden loss of appetite. Mind you, if the shivering is new, then I am not telling you to disregard it. But it does not necessarily mean the cortisol is too low.

Marianne

[tankers]

Thanks. No, not new, but seems more frequent. As for diarrhea, he has had that for today, but I'll continue to keep an eye. Again, thank you.

[tankers]

My vet said, "the pre does not concern the endocrinologist….they are more concerned with the post…he is comfortable going with the 2 day dosing"

However, I do not see why the post is so alarming, do you guys?

[Squirt's Mom]

I think he meant they look at the post and don't worry too much about the pre - not that Tank's specific post was what "concerned" them. 3.29 is a good number. ;)

[tankers]

But I think if the post was a good #, why would they be so eager to change the meds and dose? Doesn't make since to me.

[addy]

Hello everyone. I took Tank to the vet Saturday for a ACTH test bc he is back to drinking tons of water and wanting to pee a lot, and when I take him out, he wants to urinate for much longer periods of time. Well, I just got the results back last night. His baseline was lower than 1, and his post readings were 3.29. The vet now thinks we are overdosing him at 15mg. He has been on 15mg of trilo for many months and all tests have come back fine, so this worries me. It doesn't seem to make since either! Please offer any advice you may have. Thanks!
__________________



Because he is still having symptoms and he is under 5 ug/dl post with a pre under 1, my guess. Makes sense to me.

[labblab]

Just to add onto what Addy has said, here's a quote from Dechra's product information sheet for Vetoryl:


Once daily administration is recommended. However, if clinical signs are not controlled for the full day, twice daily dosing may be needed. To switch from once daily to twice daily dosing, increase the total daily dose by 1/3 to 1/2 and divide the total amount into two doses given 12 hours apart.

And here's a link to the entire information sheet:

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

I really encourage you to take a look through the sheet, and then the recommendation of the Dechra vet may make more sense to you. The bottom line seems to be that Tank's "post" ACTH result is within the desired range of 1.45 to 5.4 ug/dl, but he is still suffering from symptoms of uncontrolled cortisol. So that's why they are recommending that his medication be given twice daily instead of just once (for most dogs, the medication stays active in the body for less than 12 hours after dosing). In doing that -- shifting to twice daily dosing -- Dechra's recommended protocol is to increase the overall daily dose a bit, but split it into two doses. So they want to increase Tank from 15 mg. to 20 mg. total, but given twice daily in 10 mg. doses. They are hoping this will allow for more constant control of his cortisol level throughout an entire 24-hour time period and thereby lessen his excessive thirst/urination.

Marianne

[tankers]

But I think if the post was a good #, why would they be so eager to change the meds and dose? Doesn't make since to me.

[addy]

If Tank wasnt having any symptoms, if his drinking and peeing were under control, his post would be fine.

When you switch to twice day dosing you have to increase the dose and usually split it in two equal doses.

Ask yourself this- do you think Tank's Cushing symptoms are under control? You original post the day of testing indicated that he was still drinking a lot of water and peeing a lot.

If his post is under 5, which it is and he is still having symptoms, you dont want to increase his once daily dose, so the logical step is to switch to twice day dosing.

Make sense?:D:)

[tankers]

I see. I was getting too focused on the pre/post results and not his continuation of symptoms, so what you all and Dechra suggest make sense now. Of course my main concern is over medicating him.
Thank you for the clarification.
Best

[molly muffin]

It Is tricky getting use to all these numbers and what you want to see at what dosage with what results. It can get very confusing over all. So, it doesn't hurt to ask the questions until you feel comfortable with what your goals are and what you can and can't, should and shouldn't do. If that makes any sense. :)

Sharlene

[tankers]

Hey guys. Well Tank started the 10mg in the am and 10mg twelve hours later in the pm. My dogwalker just contacted me at work and told me there was urine all over our bedroom! I took him out as usual at 6:30am and he pee'd several times. Our dog walker arrives daily at noon and has never reported any accident in the home. So, I am not sure what to think of this. He did say there was a lot of clear urine all over the tile floor. He took him out and he went again a lot outside. Any idea why this would be? I would think the increase dose would have the opposite affect. The vet says to stay the course and just watch for loss of appetite or lethargy. This worries me either way. Would love your advice. THanks!

[tankers]

Well my husband went home from work early to check on him. He said there is diarrhea all over bathroom rugs. Poor guy. The meds made him sick. Sounds to me 10mg twice daily is too much for his little system :( so upset right now. :confused:

[lulusmom]

Definitely do not give him any more Vetoryl and contact your vet. if he continues to have diarrhea and/or continues to worsen with other symptoms, get him to the vet asap. Did your vet give you any prednisone to use in the event of emergency? If so, you may want to give him a dose but make sure you call the vet.

[addy]

Sorry to hear this, but I dont think you should give him his evening dose. When in doubt withhold the pill. I'mI sure you know, just a reminder.

How is Tank acting otherwise? Is he alert? Is he walking around? Any vomiting?

Let us know what your vet says.

[molly muffin]

Oh poor little Tank. He must have felt awful. :( I'm sure he is very upset to have had an accident in the house too, even if it is one that he couldn't control.

I agree with the others, no evening meds and take him in to get checked out.

hugs,
Sharlene

[addy]

I was reading back a few posts and Tank also had loose stools before the Vetoryl increase. Any ideas why that was? Did it resolve completely before the new dose was started?
I just wondered about what had happened with that and the shivering you had mentioned as well.

Let us know how the poor little guy is doing.

[tankers]

Thanks guys. I emailed and placed call to the vet. They don't seem that concerned like I am.
Yes, the loose stool did resolve itself prior to this increase. He was having regular stool daily.
No, the vet has never given me any prednisone. Should I ask for some next time I see him?
Yes, he is very alert, walking around, acting okay. I just got home from work and he needed me to take him out. He had more diarrhea. He was shivering too, so my husband had put his coat on him. I am waiting to see if the vet emails or calls me back tonight. The receptionist gave me an emergency vet # incase something happens tonight and I can't reach our vet. No pill tonight for sure. I don't know about tom am either at this point....

[molly muffin]

yes, i would definitely ask the vet for some pred to have on hand. Just in case. It's one of those things that you hope you never will need, but feel better because you have it and it can be a life saver in some situations.

I don't like Tank having diarrhea and shivering. I'm like you though, worry, worry. See how he does. If he stops looking alert and becomes lethargic, and vomiting, then opt for the ER number. Also print out directions to the Vet ER hospital. (I can never remember what road the dratted thing is on, each and every time I've gone, probably because by that point I'm a wreck anyway, so just do it, put it in the same place you keep copies of the all medical test results, like a folder and then can just grab that and out the door you go)
So, you'll probably be fine and hopefully Tank will be better over night, but it's one of those just in case deals. If the vet sees him, any of them, have the cortisol checked and also check for pancreatis as that seems to be one of the things that we see on here and now know we should keep an eye out for. (with or without cushings involved). oh and electrolytes, that would be the other thing to have checked.

Okay, now deep breaths. Calm is good. Just curl up on the couch with hubby and keep an eye on Tank. :)

hugs,
Sharlene

[Squirt's Mom]

Mornin',

How is Tank this morning? Hope he is doing much better!

Hugs,
Leslie and the gang

[addy]

I was wondering about Tank too:):):):)

Hope the little guy is okay. Sometimes the loose stools are not from going too low, but you never know. In the early days, Zoe's IBD/colitis flared every time I changed her dose. I subsequently learned to increase her metronidazole a bit before every dose change and she handles it well now, her stools may get a bit soft but that's about it.

Hang in there. Every dog is different. That used to drive me nuts, I guess we get used to it. Follow your gut.

[tankers]

Good morning guys and thanks so much for checking in on Tank. We skipped the pill last night, but did give it to him this am. He made it through the night okay without any accidents. He has wanted to go out several times already this morning, but just to urine. He has a good appetite and is right now sleeping. I don't think I want to give the 10mg vet. pill tonight either. The vet has not called or emailed back yet other than the first email to watch for loss of appetite or lethargy.

[labblab]

I'm so sorry that you guys had such a bad day!! Had you just now started the twice daily dosing, or have you been doing it for a while?

Marianne

[molly muffin]

Good Morning :) How did the night go? How is Tank today? Hope he's still doing good.
Happy Thanksgiving Week

hugs,
Sharlene and Molly Muffin

[tankers]

Thanks! We just had started it and he got really sick the following day.
Since then we have been scared to give him the 2 x daily dose again. He is only take one of the 10mg; which I know isn't enough because he is drinking water like a mad man, starving, and wanting to go out. However, the diarrhea is back tonight, so I am not sure what to do next at this point.. Will call vet tomorrow after work and see what he suggests. Looking back now, I wish we would have just stayed on the compounded 15mg (it seemed better than what we are dealing with now).

[molly muffin]

you could go back to the once a day compounded 15 if you think it is better. That is I guess the good thing, is that you Can tweak the dose or you could go to a 5 mg at night, compounded rather than 10. You could try the pumpkin for diarrhea too. As long as he isn't having any other low symptoms, like vomiting, lethargy, etc.

hugs,
Sharlene

[tankers]

Good idea. So our vet emailed back and wants us to give it another try to see if it was just "coincidental" We do have Thur and Fri off so are able to monitor him closely.
What do you think? It worries me! We will be out of town, but he will be with us, but if we need an emergency vet, I hope we will be able to find one in the area that is open over the holidays :/

[addy]

Well, I am wondering what is causing the loose stool since he had an episode prior to the increase and then after the increase.

So, is it a side effect of the Vetoryl and was not a side effect when it was compounded Trilostane?

Is it just something else going on but then it did resolve itself for a bit. Did he eat something outside? Did you change a treat, any supplement, did he just get a heart worm pill?:o:o:o:o:o:o

Or is his cortisol too low now?

Hopefully others will have some input. I dont know Tank's history. I would have this opinion:

1- you are going away which can cause Tank stress and I would be nervous about going back to 10 mgs BID in that situation.

2- it is worrisome to me that he has loose stool again tonight and we dont know why and we always say dont give the drug to a sick dog.

I dont want to upset you. Those are just my thoughts but I am super cautious. Dont change two things at once and taking him away for the holidays and going back to twice day dosing when he is still sick- well
IMO- that would be a no.:o:o:o:o:o:o

[tankers]

As of now, we are staying on 10mg once daily.vet is not too happy with our decision and thinks we should give 10mg twice daily one more try. I just don't want to put him through that again. You could tell he was so sick, eyes glassy, just feeling awful. He seems MUCH better now. And no, no new changes or eating anything new. He is very closely monitored.

[molly muffin]

I would be leery of going back to 10 twice a day too if that is the reaction you get. It's scary darn it! The vet should understand that.
If you do any increase, based upon his next ACTH, maybe 15 once a day. Or a 10/5, but not a 10/10.

Have a wonderful Thanksgiving, enjoy Tankers being more himself and just have fun for a bit.

hugs,
Sharlene and Molly Muffin

[labblab]

Hi, it's been a while since we've heard from you guys and I'm hoping to read an update soon!

Marianne

[tankers]

Hey all, it's been awhile since I have been on. We moved to Roanoke, VA from Miami and had to leave our great vet behind ;( Tank is still on 5mg once a day of trilostane, but he needs his levels checked. I noticed he is losing a lot more hair recently behind the legs, ears, and underbelly. He also always seems to have dry mouth and smacks his lips/mouth together to make this awful dry mouth noise. Poor guy, right? All he seems to do is sleep (he is 10 now). He does like to go out for the occasional 10-15 min walk, so that's nice. I just don't know what his levels are, and he hasn't been tested in awhile, so I am very curious. The tests are about $255-$300 each time, so we haven't taken him in awhile because he seemed to have been doing well on the 5mg for some time now. I am just noticing the new hair loss.

[Harley PoMMom]

Hi! Yes, it has been a while since you've posted, and welcome back!

I've taken the liberty and moved your post into Tank's original thread as it makes it easier for us to review his entire history. I also included in the thread title that you are looking for a vet in Roanoke, VA.

In our Resource Forum we have a link to the ACVIM site, which I will provide, where one can search for a vet/IMS in a particular State. You just need to type in the State only, nothing else: Find a Specialist (http://www.acvim.org/PetOwners/FindaSpecialist.aspx)

I did a search and there are 4 pages, I seen many are located in Blacksburg, which looks close to Roanoke.

How are Tank's symptoms? The lip smacking could be from nausea, is Tank taking Pepcid AC before his dose of Trilostane?

I am glad to hear that Tank is doing well on his Trilostane.

Hugs, Lori

[tankers]

Hi, thank you. I did access that website for specialists yesterday when I was on, and was disappointed that none were in Roanoke (it's a big city!) Blacksburg is about an hour away; which for me being almost 9 months pregnant, is too risky to drive that far for his appointments. You know in the beginning they always have you come back often to test and tweak the meds/levels, so I really must find someone here in Roanoke; which at this point, it seems it will have to be a regular vet. I have put in several calls to vets in the area to see how familiar they are with the treatment of Cushings, I might just have to trust what they tell me and go with one of them. I don't have anyone else who can take Tank out of town since all of our fam lives in FL and my husband travels for work out of state all of the time.
As for his lip smacking, I haven't noticed any nausea symptoms, so I don't think that's what it is. He is very picky about his food/water and will smell it before drinking or eating it. I can't get him to eat ANY type of dog food anymore, I have tried everything. So now, it's chicken all of the time, which I know is not good for his overall health. I need to get him vitamins, but they would have to be small, so I could roll them up in ham or cheese or he won't eat them. SO PICKY he is! Yesterday, for the first time in AGES, he pee'd a great deal in the house while we were gone (was only left for 2 hours and let out prior to leaving). This is another sign to me that his levels must now be much higher, and his dose probably needs to be increased, so I need to get him in soon for his ACTH test.

[Renee]

You can get a vitamin in powder form. Are you feeding just cooked chicken and nothing else? That would be terribly incomplete, and the lack of calcium could cause serious damage. Wysong makes a complete vitamin mix for people that feed a meat only diet. You just sprinkle the vitamin powder on his food and let him eat. The vitamin mix is flavored with chicken, so very palatable.

The Honest Kitchen makes a premix that you can use with meat in order to get the correct nutrition too. You just mix up the premix (like making instant oatmeal), add in the meat of your choice (chicken, etc), and then serve it. http://www.thehonestkitchen.com/dog-food/preference Here is a link for more information on the premix. They will send you free samples if you send them an email.

[tankers]

Thanks. Yes, he has been on a pure chicken diet for over a year now. I have tried mixing it with everything from super expensive, organic high end, to regular priced, he won't touch it if it's mixed with anything. It's insane really. Honestly, he even turns his nose up at the chicken recently. I don't know what else to do. He is down to 19lbs. I try turkey, beef, ham, etc...he will of course eat something, but you never know when or what it will be. It will never be dog food, I know that much. I can try the sprinkling of vitamins, but I can almost guarantee he will walk away from it, no matter the taste/smell, like he has done in the past...but it's worth a shot. And thanks for the link, I emailed them for a free sample. I am willing to try anything!

[doxiesrock912]

Try a layer of canned pumpkin with the vitamin powder mixed in. Or peanut butter.

[molly muffin]

I think Kenny and his Grace are in that area around Roanoke, VA. You can browse through is thread and see which vets he went to. He had a heck of a time finding one familiar with cushings, but did finally end up at an IMS somewhere in the area that is currently treating his Grace. Might give you some ideas.

http://www.k9cushings.com/forum/showthread.php?t=5290\

hugs,
Sharlene and Molly muffin

[Renee]

Thanks. Yes, he has been on a pure chicken diet for over a year now. I have tried mixing it with everything from super expensive, organic high end, to regular priced, he won't touch it if it's mixed with anything. It's insane really. Honestly, he even turns his nose up at the chicken recently. I don't know what else to do. He is down to 19lbs. I try turkey, beef, ham, etc...he will of course eat something, but you never know when or what it will be. It will never be dog food, I know that much. I can try the sprinkling of vitamins, but I can almost guarantee he will walk away from it, no matter the taste/smell, like he has done in the past...but it's worth a shot. And thanks for the link, I emailed them for a free sample. I am willing to try anything!

The vitamin powder is sold on amazon. http://smile.amazon.com/WYSONG-PET-NUTRITIONAL-PRODUCTS-858385/dp/B0006MU97Q/ref=sr_1_8?ie=UTF8&qid=1393536802&sr=8-8&keywords=wysong I think it is worth a try too. He may not even know it is on the chicken or he may like the smell / taste of it.

A whole host of problems could arise from being on an incomplete diet for so long. Most dogs, healthy dogs that is, can go for a few months on an incomplete diet.. but, an unhealthy dog even less so.

Does he eat regular people food besides the chicken? Like sweet potato, noodles, rice, etc? If it is just dog food he is rejecting, then you can home cook for him and try to meet his needs that way.

[Arizona Boston]

Hi,
I always like to say hello to all the Bostons's….which seem to be unfortunately magnets for this disease.
Did you get your new ACTH?
I'm so used to a dog that eats everything in sight…my first thought is maybe his cortisol level is too low making him less hungry and the urination problem could be from something else.
Shelly and Lucy

[tankers]

Hello and thank you guys for the continued response. I took Tank to a vet last week in Salem, VA, and I really liked them. They are holistic as well. They did almost a 2 hour exam on him and reviewed all of his records from Miami as well. The vet thinks he might have hypothyroidism. Is this common with Cushings dogs? I'm thinking it is, however, he doesn't have the "increased appetite symptom." So, he does want to do a thyroid test. We are performing the ACTH test tomorrow morning to check his levels. Is he too low? Is he too high? We will see. What is the normal range again? I need a refresher. He is on 5mg once a day, but is like a ZOMBIE dog. Even the vet mentioned how he looks to have no life in his eyes. He actually asked me about taking him off the meds, but I told him when I do, he just drinks water constantly and pees constantly and I can't be here to let him out 24 hours a day 7 days a week. So, he also mentioned doing another full CBC blood panel since he hasn't had one done in awhile. I just don't want to bomboard him with all of these tests at once, so I suggested to our new vet, how about 1 test at a time..so tomorrow is ACTH..and then get results, do thyroid on Friday, CBC next week, etc..does this make since to anyone else? As for his diet, he isn't too concerned right now since he is such a picky eater, he says feed him anything he will eat, be boiled chicken, turkey, cheese, whatever. He is skinny enough (19.5 lbs, precushings was 30lbs). His spine, bones, and ribs show, it's pretty sad actually, everyone thinks I starve my dog! I wish he would eat more.

[tankers]

Oh I found the chart:<1.45 <40 Stop treatment. Re-start at a decreased dose
1.45 to 5.4 40 to 150 Continue on same dose
>5.4 to 9.1 >150 to 250 EITHER: Continue on current dose if clinical signs are well
controlled
OR: Increase dose if clinical signs of hyperadrenocorticism are
still evident*
>9.1 >250 Increase initial dose

Also, other notes the vet made during the exam:

crusty nose (he has had this ever since going on the meds)
crust on perimeter of ears
ears cool to touch
slight odor to skin
thinning coat, mostly in inner thighs
heart rate 90, all normal
lung rate 20, all normal
slow response to pinch skin
slightly dehydrated

[labblab]

Hi again! Sorry I have only a moment to post, but if you are trying to limit the stress to Tank and you can afford it, it seems to me that it would be better to perform all the testing from a single blood draw rather than taking him back to the vet repeatedly for additional draws over the next couple of weeks. I'm guessing your new vet is suggesting a blood chemistry panel in addition to cell counts (CBC), as well as a more thorough thyroid profile. The blood chemistry panel is the one that checks a dog's electrolytes, and this is very important in conjunction with monitoring cortisol levels. Even if the cortisol itself does not seem too low, a dog's sodium and potassium levels can be out of whack when treated with trilostane.

So these additional tests all sound like a good idea to me, and as I say, I'd go ahead and order them at one time unless the vet thinks it's too much blood to draw. I'd assume the blood for all the other tests would be included in a single draw from one needle at the same time as the baseline cortisol for the ACTH. Then the only remaining draw would be the post-ACTH to check the cortisol after stimulation.

Marianne

[tankers]

Thanks Marianne. I will ask tomorrow morning when I go. I plan on staying with him and not dropping him off, so I will be able to supervise what's taking place and to help reduce his stress. The vet didn't mention if it would be all 1 blood draw, it seemed to me it was 3 different ones, but if so, that does make the most sense. I guess I was thinking more along the lines of doing the ACTH first, getting the results, moving on to thyroid, and more like process of elimination and yes, due to the high costs of each test. ACTH is around $200, thyroid is $60, and CBC is around $150. It had seemed to me the most important one to check first was the ACTH. He thought the thyroid.

[goldengirl88]

I do this with my dog in order to get it all done at once to limit stress and more draws which are hard on the dog. The only thing you need to ask about is the thyroid my vet said the dog must be fasted for this test and if you are getting cortisol checked your dog would have to have food with the Vetoryl if that is what you are using. My vet draws from the neck, so I definitely want Tipper's draws limited. Blessings
Patti

[labblab]

Oh Patti, that is such a good point -- thank you for reminding us! The ACTH should be performed 4-6 hours after dosing Tank with his trilostane along with a meal. However, some of the other tests may be better performed after fasting (such as the cholesterol reading that would be included on a blood chemistry panel). So fasting vs. non-fasting is indeed an issue to discuss with the vet, and breaking the testing into two different days may be the best way to go. In my own opinion, the blood chemistries would be equally as important as the thyroid. The manufacturers of brandname Vetoryl recommend that chemistries actually be checked alongside every ACTH test in order to ensure that the drug has not adversely affected the electrolyte balance.

Marianne

[tankers]

Good ?s to ask for sure! Thank you. I know when I was there last week, he wanted to do the thyroid and CBC following the 2 hour exam that he did, and that was at 4 in the afternoon, so he didn't mention anything in regards to fasting, so I will bring that up tomorrow. Tank does eat with his am Cushings meds dose so he will have food in his system tomorrow for the testing. He gets his dose at 8am and they want to see him at 10 for the first draw and then they said 2 hours later for the 2nd..is this timing too close? I think that's how they did it in Miami as well.

[labblab]

Dechra's official recommendation for ACTH monitoring testing is a time frame of 4-6 hours after dosing. However, some clinicians/researchers prefer the time frame your vet is suggesting: beginning the testing approximately 2-3 hours after dosing. The second blood draw is then completed either one or two hours later, depending upon the type of stimulating agent that is used. Trilostane generally reaches maximal level in the bloodstream 1.5 hours after administration, so beginning the test 2 hours after dosing should be OK. And if that is indeed the time frame within which Tank's previous testing was carried out, that is actually probably a good thing because you will be able to compare the results more directly.

Marianne

[addy]

We always had Zoe's routine blood work drawn with out fasting while she was in for her ACTH test. Our IMS knew what to discount for non fasting blood work, so if it is routine blood work, it should not matter, fasted or not. If your dog has never had a full CBC panel, etc, then you might want to fast.

[tankers]

Thanks for the comments. We just returned from the vet from doing the ACTH stem test: pre/post Cortosyn and thyroid test. The vet said he had never heard of fasting for the thyroid, so they went ahead and did it for the Total T4. We will have the results back Thursday morning. I sure hope we can get some answers. I held off on the CBC because he had already had the cortosyn injection, so I would prefer to have that done on a different day if these testing results do not yield any results (which I think they will). He has had CBC panels done last year, just not any yet for 2014. Also, our new vet does use Roadrunner for their pharmacy, but they use the liquid form of the cushings meds. Is that pretty common? Any other advice? I will of course report findings on Thursday after I get the call. Thanks for the continued support, care, and concern for both me and Tank!

[goldengirl88]

Great job you are doing! We will be waiting with you for the results. It will get better once you get this figured out. Blessings
Patti

[tankers]

So I waited until 11am and I just couldn't wait any longer, so I called the office and talked with the vet tech since the vet was busy and will follow up with me later.
Tank's pre test was 3.4
Post test result was 4.0. (Vet tech said normal range is 6-18) ?? So, he's low then...

As for the T4 thyroid test, tested at a 0.7 (LOW)
normal range is 1.0-4.0, so she confirmed Tank IS a hypothyroid dog and will need to go on medication for this. I believe she called the medication Thyroxin at 2 x daily.
Advice? Any questions to ask DR when he calls me back? Thanks!!

[Squirt's Mom]

Post test result was 4.0. (Vet tech said normal range is 6-18) ?? So, he's low then...

The tech is wrong. ;) That normal range of 6-18 is for a dog NOT on treatment. For a pup on Vetoryl (Trilo) OR Lyso, that post # of 4.0 is fine. ;)

[goldengirl88]

I just knew he was hypothyroid. My only suggestion is if it were my dog I would be conservative with the dosage. Too high and it can cause aggression, and really make their heart go. My dog was .9 and she was on half a dose of Soloxine and she just got checked and her number was fine. I know some vets give them the recommended dose and it is too much, then they have to lower it. To me that is not right, I would rather go conservatively and if more is needs so be it. If I would have let my vet give her the recommended dose, she would be off the the walls now. Blessings
Patti

[molly muffin]

Yep, Leslie is right, Tanks numbers are perfect actually.
I agree with Patti, I'd start thyroid at half med dosage instead of full. That seems to have worked well for her Tipper.

hugs
Sharlene and Molly Muffin

[tankers]

Thanks guys. Vet called and left a message. Said happy with ACTH testing results, but def is hypothyroid and wants to put on meds. I wasn't able to talk to him since he left the office after the call, but plan to in the morning. I did research throughout today, and like you both said, it said to be very conservative on dosage for a Cushings dog. Also, I am worried that if the meds actually speeds up his metabolism, he will get even skinnier, and right now, he hardly eats, and is skin and bones!! So, that part of the drug does worry me. Also, I did a lot of research on Sick Euthyroid System, so I plan to talk to the vet tomorrow about if this is just a side effect of Cushings, or if we can guarantee he actually is hypothyroid.

[goldengirl88]

Please look up Dr. Jean Dodds. She has sort of checklist to go over to determine
if your dog has sick euthyoid. You have to have a copy of the thyroid panel to compare with what she says. Do you have a copy? It is sort of a process of elimination with the information given by Dr. Dodds. Also look up Veterinary Practice News and go to how to interpret thyroid function. Glynda sent it to me about my Tipper. Blessings
Patti

[labblab]

As Patti says, it takes a more complete thyroid panel (more than just the T4 reading alone) to try to distinguish between primary hypothyroidism and Sick Euthyroid syndrome. The "free" T4 and TSH values are also pieces of the puzzle. So unfortunately, if you want a more complete picture of Tank's thyroid function, you may need to have a more detailed thyroid panel performed. And I agree with you -- before treating the thyroid, I would be hoping for more information re: Tank's actual situation.

Marianne

[goldengirl88]

That is your best shot at finding out if all these issues are being caused by the thyroid. Get the complete thyroid panel and then you will have a complete picture of what is going on. Part of the picture is not going to work, you need the whole thing. Blessings
Patti

[tankers]

Hello. I spoke with the vet this morning. He said the test that was done was a Total T4 and no other tests are really needed. He wants to place him on a 0.2mg dose twice daily (once in am/once in pm) of Thyroxine. 0.1 is the lowest, so this is conservative. Tank will continue his 5mg dose of Triolstane. Our vet said to watch for signs of nervousness or anxiety. I of course went over all of my concerns; especially NOT wanting him to lose any more weight. So for now, we will give it one month and have him go back in to measure his new T4 values. At that point, he would like to see them at 2.0-4.0.

[tankers]

So Tank has been on 2mg of Thyroxine for a week now. He seems even MORE tired and out of it, and still hardly wants to eat anything. I called the vet today and left a message. It's hard to see him like this because all he wants to do is sleep and drink water and pee...not really eat, of course not play, he will take small walks around the block with me, but that's about it...he just looks sad. I don't think he is in physical pain, but he just doesn't feel 100% either. He continues to lose hair on his tail, under body, backs of legs, and ears. His skin is all wrinkly like that of a very old man...what to do next?....Take him off meds and just continue with Cushings meds and still he will be about the same...take him off cushings meds all together and he will just pee more...so confused and have spent $400 just in the past few weeks and due with our first baby this week!

[goldengirl88]

Sometimes they have to try different thyroid medications on them. Some dog s do better on certain meds. My dog is on Soloxine, and thank God she has done well on it and ois back to walking several times a day. You need to discuss your concerns with the vet. If he does not listen to your concerns there is a problem.Just know that it takes some dogs a month on the medication to see a difference. I was lucky and could see a difference in my dog within two weeks. I would pursue the thyroid problem until blood work shows his range is normal. If that does not help with the tiredness ext. I would then be doing some more diagnostics to make sure my dog had Cushing's before resuming Vetoryl. If you cannot work with this vet you need to go elsewhere so be prepared to get your dogs file if needed. Blessings
Patti

[Harley PoMMom]

Were his thyroid levels checked recently because if he is getting too much Thyroxine this can cause increased drinking/urination.

[tankers]

Yes, just last week. He was at 0.7.

[molly muffin]

Oh my gosh you are due this week? !!
It could be a different med will work better for him. Get your husband up to speed on the thyroid/cushings aspect, because you are going to have your hands full between baby and Tank.

Don't wear yourself out!!!
hugs
Sharlene and molly muffin

[goldengirl88]

Have you checked with the vet for another type of medication? We often become frustrated when things don't work out with these babies. There are many bumps along the journey and this is just the beginning. I know you feel you have spent a lot of money on this, but it is not easy to get them on the right path, sometimes it takes a while. Talks to the vet about changing meds and keep the faith, you will get it worked out. Blessings
Patti

[goldengirl88]

Just stopping by to check and see how things are going? Blessings
Patti

[tankers]

Hi all. Sorry to not update in awhile, having a newborn sure makes you busy. Well since I last wrote in here, I ended up taking Tank 2 nights after we returned home from the hospital with our newborn, to the ER. He was falling over and in a lot of pain. Come to find out, he had ruptured his right ear drum and had a severe bacterial infection. At that point, I consulted with a new vet (completely holistic) and she took him off his Cushings meds (trilo) and off the thyroid meds. Also because he was just staring blankly into corners of walls and not getting any better. So for over a month he has been on whole food supplementation and canine adrenal support supplementation and an all natural food diet. This has been great..until now.. We did see life come back to Tank, more energy, his coat get shiny again, he wanted to eat more again, etc. But now, even after his month check up last week, he seems to be going down hill. He is urinating in the house again, drinking excessive amounts of water, yesterday he didn't want to go on our typical walk and when he did go just a little bit, had black diarrhea. And now today, I found him hiding in the back of my closet. I don't know what to do. This new vet I really like, but she doesn't want him to go back on the meds. I am so frustrated, please help!

[goldengirl88]

Unfortunately there are no holistic ways known to manage this disease. Taking your dog off trilostane and thyroid meds I can certainly understand why he is feeling badly. Did you have his thyroid checked at the 30 day period?? If so where was his level at? Blessings
Patti

[Renee]

I can understand your new vet may have wanted to take him off all meds as a sort of 'detox', possibly (as I have heard holistic vets like to do).... but, if he has legitimate cushings & thyroid, then I do not understand why she would want him off the meds permanently. Is this the approach you want to take?

It sounds like his symptoms from the cushings and/or thyroid are back. I am unsure why you would choose not to bring him some relief with any medication?

Diet can only go so far. I am a huge proponent of diet as part of the overall health of a dog, but some things just will not be cured or significantly impacted by diet alone, no matter how good and natural the diet is. The preliminary jump in energy could have been from the better nutrition of the new food, but that will not make his cushings or thyroid symptoms go away permanently.

[tankers]

Hello. The new vet would like him to remain off all meds for a total of 2 months to allow the whole food and adrenal support supplementation a chance to kick in and jump start his immune system. As of 1 month, his weight has remained unchanged (19.5lbs) but upon looking at him, he looks skin and bones, spine sticking up and out, etc. He looks like a dog who doesn't eat. This has been ongoing, not a new appearance. He did have more energy all month and actually enjoy walks, started eating more often and even began begging which he hasn't done in years..but I know Cushings makes them more hungry and more thirsty, so this is what is going on. He drinks several bowls of water a day, but since I am at home with our newborn right now, I can let him out 10 times a day. The meds were making him not have any quality of life at all, so that is why we decided to take him off. Am I against putting him back on the Cushings meds, no not at all.

[Renee]

Hmm. Okay, 2 months. I see what the holistic vet is getting at.

What are your feelings about this approach?

What is the adrenal support supplement he's on?

[Harley PoMMom]

Black diarrhea is a special cause for concern, it's usually blood that makes the stool black. If this were me I would call the vet and tell them about the diarrhea being a black color. Is Tank vomiting? Is he eating and drinking?

[molly muffin]

Oh dear that doesn't sound good at all (the black diarrhea) I second what Lori said and would definitely call the vet.

by the way, congratulations on the newest little member of the family

hugs
Sharlene and molly muffin

[tankers]

I contacted our other vet this am. He said sounds like a bleeding ulcer/internal stomach bleeding and to put Tank on 1/4 tab of Zantac. Crazy enough, our baby just got put on Zantac yesterday for acid reflux, so now I have 2 babies on it! He said being off the trilo could call for high levels of cortisol again, which in turn can cause the stomach ulcers and/or stomach bleeding, so he would suggest putting him back on the 5mg of trilo. He said to keep an eye on Tank and see if he continues to have black stool.
The holistic canine adrenal support is standard process.

[lulusmom]

I've provided a link below to Standard Process' page for Canine Adrenal Support. The key ingredients that are supposed to help normalize adrenal function are animal glandular tissue extracts. Normalize adrenal tissue seems to be a common claim made by manufacturers of these types of supplements.

https://www.standardprocess.com/Products/Veterinary-Formulas/Canine-Adrenal-Support

[tankers]

I'm sorry, so what does that mean? It's a good thing for him to be on it, bad thing? Not good to only be on that for Cushings? I'm a bit confused with your response. Thanks

[lulusmom]

Sorry, I didn't mean to confuse you. I provided the link to the product so that members could see the ingredients and I have no idea whether it is good or bad; however, it sounds like it hasn't done much for Tank. I have personally written to numerous companies who make claims that their products help normalize adrenal function and promoted those products as a treatment for both Addison's and Cushing's. This is very odd because these canine endocrine disorders are the complete opposite of each other. To normalize Addison's, this product would have to make the adrenal glands start functioning again, thereby eliminating the need for a dog to be on lifelong corticosteroids and mineralcorticoids supplementation. To normalize the adrenals in a dog with Cushing's, this product would have to have the ability to decrease the cortisol levels that are being overproduced as a result of a pituitary or adrenal tumor. There are no treatments, conventional or holistic that normalize adrenal function in dogs with Addison's or Cushing's and there are no holistic treatments that have been proven effective by way of appropriate peer reviewed clinical trials, using acth stimulation tests, low dose dexamethasone tests or urine cortisol creatinine tests. When asked if their products had been tested for safety and efficacy, I received mixed responses. Most were honest and said no, some never responded and some completely ignored my question, commending me for doing research for my dogs and then tried to sell me on their product by cutting and pasting the same bogus claims that are listed on their website. When asked what normalize adrenal function means, nobody responded to that question.

The difference between the companies I wrote to and Standard Process' product is that Canine Adrenal Support can only be purchased from a vet so this is a very good thing. It's ingredients are also quite different and unfortunately I was unable to find any evidence that this product has been put through rigorous testing for safety and efficacy.

It's pretty clear that your vet did not recommended Canine Adrenal Support as a replacement for Vetoryl (Trilostane) but rather as an interim measure to try to boost Tank's immune system in preparation to restart conventional treatment. Whether it's been effective in doing that, I have no idea. You've probably told us this already but how long has Tank been off of Trilostane? I ask because there are some dogs who simply don't do well on a particular treatment and we have seen dogs who while having excellent acth stim results, their quality of life was not great. Lysodren would be an alternative but you should never switch treatments without an appropriate washout period.

Glynda

[tankers]

Hello, so Tank's black stool was only the one day/time, so the vet said that is a good thing and he could have eaten something bad. He seems to feel better now, so at this point, there is no need to go on the additional meds. We have been off of Trilo for about a month and a half.

[Harley PoMMom]

So I waited until 11am and I just couldn't wait any longer, so I called the office and talked with the vet tech since the vet was busy and will follow up with me later.
Tank's pre test was 3.4
Post test result was 4.0. (Vet tech said normal range is 6-18) ?? So, he's low then...

As for the T4 thyroid test, tested at a 0.7 (LOW)
normal range is 1.0-4.0, so she confirmed Tank IS a hypothyroid dog and will need to go on medication for this. I believe she called the medication Thyroxin at 2 x daily.
Advice? Any questions to ask DR when he calls me back? Thanks!!

When this ACTH test was done Tank's numbers were great, and his thyroid results were low. My question is; why did the new vet take him off all his meds? His inappetence could definitely be attributed to the ruptured ear drum and the severe bacterial infection.


Hello, so Tank's black stool was only the one day/time, so the vet said that is a good thing and he could have eaten something bad. He seems to feel better now, so at this point, there is no need to go on the additional meds. We have been off of Trilo for about a month and a half.

Glad to hear that the black stool episode was just that one time. If Tank is feeling like his "ole self" and if his Cushing's symptoms are obviously strong and seem to bother him than, if this were me, I would have an ACTH stimulation test done.

If the ACTH results show that Tank's cortisol is elevated, which I'm betting it is, than I would probably start him back on the Trilostane.

Just my opinion ;)

Hugs, Lori

[Harley PoMMom]

So I waited until 11am and I just couldn't wait any longer, so I called the office and talked with the vet tech since the vet was busy and will follow up with me later.
Tank's pre test was 3.4
Post test result was 4.0. (Vet tech said normal range is 6-18) ?? So, he's low then...

As for the T4 thyroid test, tested at a 0.7 (LOW)
normal range is 1.0-4.0, so she confirmed Tank IS a hypothyroid dog and will need to go on medication for this. I believe she called the medication Thyroxin at 2 x daily.
Advice? Any questions to ask DR when he calls me back? Thanks!!

When this ACTH test was done Tank's numbers were great, and his thyroid results were low. My question is; why did the new vet take him off all his meds? His inappetence could definitely be attributed to the ruptured ear drum and the severe bacterial infection.


Hello, so Tank's black stool was only the one day/time, so the vet said that is a good thing and he could have eaten something bad. He seems to feel better now, so at this point, there is no need to go on the additional meds. We have been off of Trilo for about a month and a half.

Glad to hear that the black stool episode was just that one time. If Tank is feeling like his "ole self" and if his Cushing's symptoms are obviously strong and seem to bother him than, if this were me, I would have an ACTH stimulation test done.

If the ACTH results show that Tank's cortisol is elevated, which I'm betting it is, than I would probably start him back on the Trilostane.

Just my opinion ;)

Hugs, Lori

[tankers]

Yes, I am sure you are right, the new ACTH test would yield high cortisol.
The new vet took him off along with us deciding that too, due to the fact that he was staring at walls, not getting out of his bed all day/night, barely eating/drinking, just completely out of it. He is much more lively now.

[Harley PoMMom]

The new vet took him off along with us deciding that too, due to the fact that he was staring at walls, not getting out of his bed all day/night, barely eating/drinking, just completely out of it. He is much more lively now.

When the ear drum is perforated a dog may develop neurological problems, so this could be the reason Tank was displaying all those symptoms and it may be that the Vetoryl had nothing to do with it. Taking him off the Vetoryl while all these issues were happening, I believe, was the right thing to do.

Concurrent ear infections can be attributed to hypothyroidism, so I was wondering if the vet was going to revisit Tank's low thyroid issue.

[tankers]

Well, it's been 2 months with Tank off his meds and only on the Standard Process supplementations, and I have to say, he does seem like a happier dog, however, I noticed today, all along his spine, he has what I think is calcinosis cutis. It's all crusty and in some areas black and oozy, so back to vet tomorrow. No doubt in my mind now, that he must go back on the trilo..there just isn't a choice anymore. Now that we have yet another issue on our hands, it just complicates things. Also, I am almost positive he didn't get his hearing back in his right ear after the rupture of the ear drum. When we call him, he ends up running in the opposite direction and we will often find him in the bathroom and other odd rooms looking for our voice. Poor guy:( I hate this damn disease!

[goldengirl88]

Just wondwrednhow Tank has been doing. I think you took him off his meds? Is he having symptoms again? Blessings
Patti

[tankers]

Thank you for checking in. Tank is back on his trilostane 5mg once daily. He again is back sleepy and not wanting to do much, but he does eat well 3 x a day (still very thin with ribs showing)..but now he has developed a bad skin disease with sores. The vet treated him for 2 weeks with antibiotics, which helped, but now he is getting new spots. They couldn't really tell me what they were..just something about dogs having natural bugs on their skin and when they scratch their backs, they can irritate their skin and the bugs eat into their skin, etc...seemed crazy to me. I do put ointment on the sores daily, but still not preventing them from spreading and healing very slowly. I am going to get another opinion next Wednesday. Poor guy, he's been through so much and now this. If I could, I would upload a picture here to show you, but not sure how to do it.

[molly muffin]

Aww, poor Tank, more problems now with the skin :(

Tell them you want a skin scrapping to find out exactly what is causing the sores, yeast infection, calcium, or what exactly, so you can have it treated appropriately.

You have an album for Tank already, so just take a picture, put it on your computer. Go to your album under your profile and add picture. You just browse to your computer and select the photo (s) you want to upload.

Hang in there!!
hugs
Sharlene and molly muffin

[tankers]

Thanks. I uploaded it. Last time I went to vet, they didn't do a scrapping for whatever reason, but did clean it with medical shampoo. He didn't seem to mind. I brought up to the vet that I thought it was calcinosis cutis, she disagreed. After doing much research and looking at many photos, I still feel that it is; which it seems there is not anything you can do for it, except get his cortisol back down....when he does itch his back on the carpet or grass, it does seem to worsen/spread. Today I put coconut oil all over him, typically I use alcohol free aloe vera or neosporin. I have been reading other posters on this site who have dealt with it too, and it seems like a beast to deal with/get rid of.

[goldengirl88]

I know from what others have said this is a real bear to deal with. I hope it gets better when his cortisol goes down. Blessings
Patti

[Renee]

I posted a comment on your photo, but it does look like CC to me. Please either see a derm vet for diagnosis or have a biopsy done of Tank's sores to confirm if it is CC. You'll want to possibly change your plan of attack if it is CC.

There are a lot of things you can do in terms of managing the CC, but nothing will 'cure' it, except getting the cortisol low enough, and it can take literally months and months.

[molly muffin]

you can try a chamomile tea compress too, as that can be very soothing.

If it is cc, then not much will get rid of it other than lowering the cortisol.

CC is starts out as hard calcium bumps that break through the skin and can bleed and become crusty. You can usually tell though because of the hard bumps before they do spread, they also turn very red and angry looking at times.

There are other possibilities though, such as yeast, or bacterial infections, that need to be ruled out.

Sharlene and molly muffin

[Harley PoMMom]

When it comes to CC, I have had no experience with it but Renee definitely know her stuff, so if she thinks that Tank has CC, I would put a lot of stock in what she says.

Please do keep us updated, ok?

[goldengirl88]

Have you looked at the other threads and their pictures of it Dawn and Butters have an album documenting it, Renee and Tobey have documentation of it. Maybe you need to look at their pictures, and that will help you . Blessings
Patti