Chloe, Just starting Trilostane...Chloe has crossed The Bridge

[Hstaff]

Hi, my name is Heather. I am a owner to a 6 year old female Boston Terrier name Chloe. I started to notice last summer that Chloe was drinking more water than usual. I took her in for tests, but nothing showed up. Come the end of October 2011, I injured myself tearing my ACL and both meniscus. I underwent surgery and during my 3 months that I was laid up off work, I noticed some drastic changes in Chloe. I figured they had been going on for awhile but since I was around her all day everyday for 3 months straight I knew something was up. I took her in for urine samples and a routine blood screening. Her liver enzymes coming back high was the biggest concern. We underwent more tests, even a test for Addison's disease. Inititally thought it was something with the liver. Chloe's intital symptoms were increased thirst, increased urination (having accidents in the middle of the night or lying down on the couch in a rested state, needing to go potty every hourish) and tremoring. She was and still is having involuntary muscle tremors, primarly in her hind legs. After going around and around with testing, we almost gave up because the vet wasn't sure because Chloe was showing some mild cushing signs. She does seem to "beg" a whole lot more than she ever used to which I Know can be due to cushings. Over the course of time, Chloe has fainted or has had her hind quarters give out on her 3 times and she has had one very small seizure. Most of these were when she was in a resting state trying to get up. She also has had eye irritations and even 2 bouts where one pupil was so small, like the size of a bead and the other one was large. I took her in for testing but by the time I got there, she showed perfectly normal signs and normal reactions to light, etc. She is definitely less playful, but will still play if engaged, but not on her own. She used to be attached to her kong, no more. AN ultrasound was done, heart looked normal, liver normal and the only thing that popped up was that one adrenal gland was slightly more enlarged then the other. Finally, after many tests her test came back positive for cushings but the test could not decipher between adrenal and pituatory. My vet referred me to a specialist since he was still sort of stumped on all of the results from tests. I went to an internal medicine specialist for canines. The vet reviewed the ultrasound and all of the lab work. Coming into meet me she said "there is no way this 6 year old has cushings!". After reviewing everything, examing Chloe and talking to me she was convinced. I am on day 4 of trilostane, and no side affects have happened yet. I go in this Saturday for the first ACTH test to see if the dosing is right. She is currently 22 lbs and on 0.4 mg of trilostane. I had to get it specially compounded in liquid form for her. Im wondering when the increased urination and thirst will start to drop? She hasn't gotten back the hair yet from the shaving for the ultrasound and her skin does have some scabbed, irritable patches. She seems extremely thin for herself too. She is a tall boston but I can see her rib cage poking out. Just a few pounds too small in my oppinion. Is she losing weight from something else or from the dehydration, icreased urination scenario? I know this post is rambled, and I don't remember everything off the top of my head, but any help or advice would be appreciated as I am a worried dog owner about this disease and am not sure what all to expect. I can only research so much, sometimes it is good to just talk!

[Roxee's Dad]

Hi Heather and a big welcome to you and Chloe. :)

I am so sorry that you and Chloe are going through this. There are so many helpful and informative people on this site, I'm happy you found us!!

Please check your e-mail for a link from K9cushings and follow the instructions. I manually approved your post, once you respond to the e-mail, your posts will no longer need to be approved.

Looking forward to hearing much more about your Chloe. :)

[Somesie]

Hey there, Heather...sorry that you're here, but you definitely came to the right place! Someone with far more expertise than I will be along soon to help, I'm sure, but let me help get you moving in the right direction...

Can you please post the results of Cushing's tests you have had done? ACTH stim (prior to starting the Trilostane) and/or LDDS? UC:Cr? Liver enzymes, if they were out of range? Blood sugars?

Just from the little that I know as I have started traveling this path with our boy, the following statement...


The vet reviewed the ultrasound and all of the lab work. Coming into meet me she said "there is no way this 6 year old has cushings!"

...followed by starting your girl on meds is a little alarming. I'm wondering what the test results looked like that could have a vet saying, "Absolutely not," one minute, followed by prescribing Trilostane the next...that seems like an awfully big leap. Any detail you can provide will certainly be helpful.

If you don't have copies of the test results and lab work, I would suggest you get them and post the results here, so that the others can offer you an educated opinion.

Hang in there, hon! I know this is a scary process, but like I said, you've come to the right place for information and support. Or, like you said, just to talk!

Best,
Jenn

[Hstaff]

The starting of the medication doesn't really alarm me. Based on all of the tests I did, which was thousands of dollars later, I was informed the entire way of what my doctor said was going on. Whether I fully understood the test verbage completely though is beyond me! The specialist vet simply said the statement about there is no way she had cushings as sort of an exaggeration I felt. She said she knew it can happen in middle age dogs but she just seems too young to have it in her oppinion. She had only had some of the stuff sent to her office upon my arrival, I brought the ultrasound and further paperwork and a video of her tremoring bouts. After getting a more in depth history from me and spending over an hour with me, she agreed with what the primary vet had been telling me. She was merely my second oppinion. This specialist office collaborates closely with my vet. I am not going to the specialist anymore at the moment since her treatment can be managed (and less expensive) at my other vet through routine tests, etc. I will post her results here in a minute and maybe someone can further explain!

[lulusmom]

Hi Heather and welcome to you and Chloe,

I see that you will be posting test results for us so I'll be waiting anxiously to see them. You mentioned the Chloe is getting .4mg Trilostane. Since you have compounded liquid, I believe you meant to say .4 ml. This is a syringe measurement. To determine how many mg Chloe is getting, you should be able to find that actual mg on the bottle. 1 ml or syringe full of medication should equal the mg on the bottle. For instance if the bottle says 100mg, then .4ml would be equal to 40mg. If you can't find it on the bottle, your vet should be happy to tell you.

I see that your vet tested for Addison's as well so make sure you include the test results for that. The acth stimulation test is the gold standard for Addison's and it is also a diagnostic test for cushing's so these results will be very helpful.

I have two cushdogs and my first one displayed symptoms for year before she was diagnosed at three years old, so six years old at diagnosis won't raise an eyebrow around here.

A cushdog is more likely to gain weight than lose it because they are hungry all the times. Weight loss and excessive peeing and drinking are common symptoms of diabetes mellitus. I would think that between your vet and a specialist, they ruled out this possibility, right?

Looking forward to hearing more about your girl.

Glynda

P.S. I hope the surgery for your ACL and meniscus injury was a huge success and that you are doing well post surgery. I can't imagine how much pain you must have experienced. You poor thing.

[Hstaff]

Okay. I am going to type out as much information as possible from all of the paperwork I have recieved. When I went into the specialist I asked for ALL documents. They may not be in order either, and some things were tested more than once, sorry!

Chloe's history that the doctor noted: Tried for incontinence on meds at first because of dilution of pee, generalized shaking/trembling. Rising and elevated ALT (426, 524), and ALP (130, 253), elevated cholesteral (402, 397). Bile acids mildy elevated, pre 16.5, post 33.2. Transiently weak hindlimbs. Has had 2 episodes of collapse where she slowly sits or falls to the side. Has been treated with baytril and amoxicillin mid to end of december (which did nothing), tried denamarin and vit e to rule out liver stuff (didn't do anything) and was stopped.


Cytology Report:
Description: smears contain many large cluster of well preserved hepatocytes. No evidence of cholestasis, necrosis, inflamation, sepsis or neoplasia. Diagnosis: Moderate vacuolar hepatopathy. This is supsicious of a steriod-induce hepatopathy which could result from early hyperadrenocorticism or steriod therapy....

dexamethasone suppression test results:
Pre test result: 8.8 normal range is 1.0-6.0
Post 4 hours: 5.0 normal range is less than 1.5
Post 8 hours: 4.9 normal range is less than 1.5
There are a bunch of other random numbers that I dont understand put it came out "inconclusive" and almost everything else said consistent with pituitary dependent hyperadreocorticism and that further testing was needed to decipher between adrenal and pit.

Ultrasound results:liver normal in size, shape and echogenicity and echotexture. Gallbladder is minimally distended and thin walled. Left and right kidneys normal in size, shape, etc. Spleen is normal with exception of a small hypoechoic nodule within the body (???) measuring 6.8 mm. Caudal pole of left adrenal gland is mildly increased in size and shape with the cranial and caudal poles measuring 6.6 and 5.7 mm. Urinary bladder is unremarkable. Moderartely distended and thin walled. Pancreas is normal in size, shape. No evidence of lymphadenopathy.

Despite the normal appearence of liver, the prescence of underlying hepatopathy is suspected given the continuous rise of liver enzymes. a fine needle aspiration of the general liver was done and a coagulation test done before to see if they could perform if needed.


Blood panel:
GLU 112 mg/dl
BUN 13 mg/dl
CREA 0.7 mg/dl
PHOS 5.7 mg/dl
CA 10.4 mg/dl
TP 7.5 g/dl
ALB 4.0 g/dl
GLOB 3.5 g/dl
ALT 524 U/L HIGH normal range is 10-100
ALKP 253 U/L HIGH normal range is 23-212
TBIL 0.2 mg/dl
CHOL 397 mg/dl HIGH normal range is 110-320
AMYL U/L LOW normal range is 500-1500

BILE ACIDS:
pre meal 16.5 (HIGH) normal is <13
post meal 33.2 (HIGH) normal is <25

Cortisol sample: 3.1.

All of these tests were primarily done from NOV-JAN of 2011/2012

More tests/Blood work, anything not written was considered normal range

Protein 7.8 (HIGH) normal is 5.0-7.4
Albumin 4.6 (HIGH) normal is 2.7-4.4
ALT 426 (High) normal is 12-118
Chol 402 (HIGH) normal is 92-324
platelet count 460 (HIGH) normal is 170-400

URINALYSIS:
Total T4 (whatever that means) 2.1
Specific Gravity 1.005 (LOW) normal is 1.015-1.050
Occult Blood 1+ (HIGH) normal is negative
pH 7.5 (HIGH) normal is 5.5-7.0
None seen or negative on the rest of the results

Her urine is very clear (diluted because of water consumption)?

Thats all I have on me right now.. please let me know thoughts or anything! I could have missed some things

[Hstaff]

Yes, I specifically asked about diabetes and they said she did not have it... but I might ask again because I still wonder. She isn't gaining any weight that's for sure. And to answer your question, yes I am pretty sure I meant 0.4 ml not mg :), wh ich is indeed a syringe measurement. Expensive! Did I cover the ACTH test in all of that lab work I posted? I go in on Saturday for her ACTH test to see how the meds are working....so I might ask again what everything means. I forgot to mention that the specialist also mentioned she most likely has Myotonia, which you can't do much for from my understanding.. the tremoring stuff. She said it was possible it could subside with the meds but not for certain.

[lulusmom]

Please see my comments below in blue:


Chloe's history that the doctor noted: Tried for incontinence on meds at first because of dilution of pee, generalized shaking/trembling. Rising and elevated ALT (426, 524), and ALP (130, 253), elevated cholesteral (402, 397).

Can you please post the normal reference ranges for all of the abnormal values you posted? I've seen enough labs to know that the ALT is more than mildly elevated, which is not common in cushing's. Did your vet happen to mention anything about this. The liver enzyme abnormalities in cushing's follow a certain pattern where the ALP is usually moderate to severely elevated with a mild elevation in ALT. Are you sure you didn't switch the two?

Bile acids mildy elevated, pre 16.5, post 33.2.

These mild elevations are common in cushing's but also common with any condition that effects the bile duct.

Transiently weak hindlimbs. Has had 2 episodes of collapse where she slowly sits or falls to the side.

Dogs who have had cushing's for quite can experience severe muscle wasting due to the catabolic effects of high cortisol. Muscle weakness is not transient but persistent so I'm not sure these two episodes had anything to do with the effects of cushing's. You may want to ask your vet shy her weakness seems to be episodic.

Has been treated with baytril and amoxicillin mid to end of december (which did nothing),

Apparently your vet took a shot in the dark and prescribed baytril and amoxicillin in the hopes that it would address a possible infection and thereby normalize or lower liver enyzmes, right?

tried denamarin and vit e to rule out liver stuff (didn't do anything) and was stopped.

How long was Chloe on Denmarin. With liver enzyme elevations, specifically the ALT, I would have given it some time to work. You have two sets of tests showing ALT. Was the second one done after starting Denmarin treatment?

Cytology Report:
Description: smears contain many large cluster of well preserved hepatocytes. No evidence of cholestasis, necrosis, inflamation, sepsis or neoplasia. Diagnosis: Moderate vacuolar hepatopathy. This is supsicious of a steriod-induce hepatopathy which could result from early hyperadrenocorticism or steriod therapy....

This is a great piece of information. Fine needle aspirates are usually declined by pet owners so this is an added bonus for confirming a diagnosis.

dexamethasone suppression test results:
Pre test result: 8.8
Post 4 hours: 5.0
Post 8 hours: 4.9
There are a bunch of other random numbers that I dont understand put it came out "inconclusive" and almost everything else said consistent with pituitary dependent hyperadreocorticism and that further testing was needed to decipher between adrenal and pit.

This pattern of suppression is more consistent with pituitary dependent cushing's but the suppression was not enough to make the differentiation between pituitary and adrenal dependent cushing's. An abdominal ultrasound often makes that differentiation but I only see mention of the left adrenal. Do you know if the radiologist was able to see the right adrenal and if so, what did it look like?

Ultrasound results:liver normal in size, shape and echogenicity and echotexture. Gallbladder is minimally distended and thin walled. Left and right kidneys normal in size, shape, etc. Spleen is normal with exception of a small hypoechoic nodule within the body (???) measuring 6.8 mm. Caudal pole of left adrenal gland is mildly increased in size and shape with the cranial and caudal poles measuring 6.6 and 5.7 mm. Urinary bladder is unremarkable. Moderartely distended and thin walled. Pancreas is normal in size, shape. No evidence of lymphadenopathy.

Despite the normal appearence of liver, the prescence of underlying hepatopathy is suspected given the continuous rise of liver enzymes. a fine needle aspiration of the general liver was done and a coagulation test done before to see if they could perform if needed.


Blood panel:
GLU 112 mg/dl
BUN 13 mg/dl
CREA 0.7 mg/dl
PHOS 5.7 mg/dl
CA 10.4 mg/dl
TP 7.5 g/dl
ALB 4.0 g/dl
GLOB 3.5 g/dl
ALT 524 U/L HIGH
ALKP 253 U/L HIGH
TBIL 0.2 mg/dl
CHOL 397 mg/dlHIGH
AMML or AVVL? (cant read it photocopied) 366 U/L LOW

I'm pretty sure this should be AMYL which stands for Amylase.

BILE ACIDS:
pre meal 16.5 (HIGH)
post meal 33.2 (HIGH)

Cortisol sample: 3.1.

This appears to be resting cortisol which isn't reliable for purposes of diagnosing cushing's or Addison's. I believe you mentioned that your vet tested for Addison's and the only test done for this is the acth stimulation test, which has two numbers on it. You should have cortisol sample 1 which is the preinjection or resting cortisol and then a post injection blood draw.

All of these tests were primarily done from NOV-JAN of 2011/2012

More tests/Blood work, anything not written was considered normal range

Protein 7.8 (HIGH)
Albumin 4.6 (HIGH)
ALT 426 (High)
Chol 402 (HIGH)
platelet count 460 (HIGH)

URINALYSIS:
Total T4 (whatever that means) 2.1
Specific Gravity 1.005 (LOW)
Occult Blood 1+ (HIGH)
pH 7.5 (HIGH)
None seen or negative on the rest of the results

Her urine is very clear (diluted because of water consumption)?

No the urine is clear because the kidneys have lost their ability to concentrate the urine. Dogs drink more to keep up with the peeing or else they can dehydrate quickly, which is why you never withhold water from a dog who is not concentrating their urine.

Thats all I have on me right now.. please let me know thoughts or anything! I could have missed some things

All in all, I think you've done a great job of covering all the bases.
There are some inconsistencies like the unusually high ALT and the intermittent weakness but right now, the arrow is definitely pointing to cushing's.

[Hstaff]

Yes, when I get home I will post the "normal" ranges in comparison to the abnormal. Wasn't sure if it was needed or not. As far as the ultrasound, they looked at everything, even took a small peek at the heart which looked normal. They told me that the one adrenal was slightly enlarged but the other looked fine. I think the thing that is most scary to me is her hind leg weakness and her two episodes of falling to the side. I really feel that these episodes have happened after she had been resting or sleeping for awhile, and then getting up really fast and her body just couldn't do it. Is this cushings/the myotonia I was told about??? I did not do a test for myotonia because the specialist suggested it wasn't cheap and all it would do is tell me "yes she has that" but there is nothing you can really do for it.

Chloe was only on Denamarin for maybe a month. And this was due to him thinking it was the liver having issues before testing for the cushings. My vet suspected cushing's but I think just didn't want to go that route right away because of her age.. but obviously we think we pinpointed it now! Will right more..

[Hstaff]

Please see my comments below in blue:

Can you please post the normal reference ranges for all of the abnormal values you posted? I've seen enough labs to know that the ALT is more than mildly elevated, which is not common in cushing's. Did your vet happen to mention anything about this. The liver enzyme abnormalities in cushing's follow a certain pattern where the ALP is usually moderate to severely elevated with a mild elevation in ALT. Are you sure you didn't switch the two?




**** I added all of the reference ranges in within the message about the results!

[Nikki]

My dog has hindleg wasting, and he had several episodes of falling over, falling off the porch stairs, or losing balance and falling over. The longer he has been on vetoryl, the better he has gotten. I wouldn't really worry too much about it, it really scared us at first but he's gotten much better now.

[lulusmom]

I just want to make sure you saw my comments regarding the cortisol result you posted. If Chloe was tested for Addison's, your vet should have done an acth stimulation test. The results should have two numbers on it, the resting cortisol and a post stimulation blood draw. If you have those results, can you post them here? If you don't have them, perhaps you can get them from your vet. It's possible that your vet used the resting cortisol to rule out addison's. Any chance you can confirm that?

[tankers]

Hey Chloe. I have a BT too (Tank). He is 24lbs and on 15mg of Trilostane. I see that your vet said the same thing to you about "being too young to have Cushings" like I had two say to me. Finally the third vet was willing to actually test. Tank is 8, and yes, he has it. You have found a great site here. I wouldn't know what to do without it. So many people here are so very knowledgeable about Cushings. It helps to have the support. Best of luck with Chloe :)

[Hstaff]

I just want to make sure you saw my comments regarding the cortisol result you posted. If Chloe was tested for Addison's, your vet should have done an acth stimulation test. The results should have two numbers on it, the resting cortisol and a post stimulation blood draw. If you have those results, can you post them here? If you don't have them, perhaps you can get them from your vet. It's possible that your vet used the resting cortisol to rule out addison's. Any chance you can confirm that?

I believe that he did use the resting cortisol to rule out Addison's. I know I had that test done.. Let me filter thru and see what I can find, if not I go in Saturday for the first ACTH test since starting her on trilostane. Any questions anyone think I should ask?

[lulusmom]

If the last set of test results you posted were the most recent (I've copied and pasted them below), I would ask the vet why the ALP has normalized and there is still almost a four fold elevation in ALT which is unusual and concerning. When was this bloodwork done?


More tests/Blood work, anything not written was considered normal range

Protein 7.8 (HIGH) normal is 5.0-7.4
Albumin 4.6 (HIGH) normal is 2.7-4.4
ALT 426 (High) normal is 12-118
Chol 402 (HIGH) normal is 92-324
platelet count 460 (HIGH) normal is 170-400

On Saturday make sure Chloe gets her morning dose with food and have her to the vet within 3 to 4 hours after dosing.

[Hstaff]

If the last set of test results you posted were the most recent (I've copied and pasted them below), I would ask the vet why the ALP has normalized and there is still almost a four fold elevation in ALT which is unusual and concerning. When was this bloodwork done?



On Saturday make sure Chloe gets her morning dose with food and have her to the vet within 3 to 4 hours after dosing.


All blood work was done between dec-jan 2012. When I looked for the cortisol stuff you were talking about all it said was te result. No pre or post anything... I don't even know what alt and alp means. I think those were things he was dabbling with and sice everything didn't match up he tried to look into other "problem" areas and sent me to the specialist. She didn't mention anything else odd. What makes it so concerning? Any ideas?

[frijole]

I'm not Glynda but I'll attempt a response :D

First off - remember when testing first started you mentioned the liver enzymes were elevated and so they suspected cushings? Well the liver enzymes show up on a blood panel as ALT and ALK/ALP. On the first test they were both elevated. It is strange as Glynda mentioned that the ALT was 4 times higher than normal. We don't normally see that huge of a number with cushings. We normally see ALK readings as high as 2000 (with normal being 200). So ALK is usually much higher than the ALT in cush dogs.

So you started on the Denamarin which is used to help the liver. After being on that the ALK came back normal (if you typed it accurately) and the ALT continues to be 4 x normal. This is not at all what we see with cush dogs. Most cush dogs NEVER have ALK levels that are normal again even after years of treatment. But the ALT levels often go down.

So Glynda was asking if you could check to make sure that you didn't reverse the two.

She also asked you about the cortisol readings. When a dog has cushings it simply means their body produces too much cortisol. Typically a pituitary (sometimes an adrenal) tumor causes this. It sends messages to their body to produce cortisol (think adrenaline rush) that they don't really need.

Cortisol is measured by doing a test called the acth test. It is a couple hours long and there is a reading taken at the beginning and one an hour later. Those readings are two numbers. You should have paperwork from a lab with ACTH pre and post numbers on it. I noticed in your typing that right after the bile discussion you typed in:
pre 16.5, post 33.2

I am just guessing but I think that looks like an acth test to me. Could you double check?

Whew... hope this helped!! Kim

[Hstaff]

Hi guys. I was wondering if anyone knew or had suggestions on dog food for a cushings pup. I have two dogs that I try to feed the same food because they both have skin sensitivities. I currently feed my two bostons natural balance bison and potato. I also add fish oil as a supplement. My vet told me I didn't need or have to change it but I'm curious to others thoughts or experiences. I hear a high fiber low fat diet is good. I don't have the resources to make raw food unfortunately. I went with this food because it is grain free and also does not have flax seed (which I "heard" wasn't the best for dogs with allergies). Open to suggestions and advice on brands? Thanks everyone!

MODERATOR NOTE - I have merged this post concerning diet for Chloe with her original thread. We like to keep all info about each pup in one thread. That way it is easy to look back through the history if needed.

[labblab]

Hey Kim, I don't think those results you highlighted in red are from an ACTH test. Bile Acid tests do have "pre" and "post" numbers, just like they're written out on these lab results. They test the bile acids first before a meal is given (pre) and then again after a meal is given (post). So I think those results are accurate. And from the fact that there is only a single line for the cortisol result, I have to agree with Glynda that it looks as though only a resting (or baseline) cortisol level was measured. It doesn't appear as though an ACTH stimulating agent was injected, and no second cortisol level was drawn afterwards.

Marianne

[frijole]

Thanks Marianne! I've never had a bile test done so didn't know... Sorry for the confusion... was hoping I had found something.

[Hstaff]

Hey Kim, I don't think those results you highlighted in red are from an ACTH test. Bile Acid tests do have "pre" and "post" numbers, just like they're written out on these lab results. They test the bile acids first before a meal is given (pre) and then again after a meal is given (post). So I think those results are accurate. And from the fact that there is only a single line for the cortisol result, I have to agree with Glynda that it looks as though only a resting (or baseline) cortisol level was measured. It doesn't appear as though an ACTH stimulating agent was injected, and no second cortisol level was drawn afterwards.

Marianne

Couldn't find those test results anywhere....is it possible to have been diagnosed without that test? Going in Saturday and will ask!!

[Squirt's Mom]

Unfortunately, we have seen vets start treatment based solely on elevated liver enzymes. :eek: So yes, it is possible he was diagnosed without the proper testing. DO ask for copies of all the test results, not invoices, that have been done to diagnose the Cushing's then post them here and we can help you interpret them.

Hugs,
Leslie and the gang

[Hstaff]

Unfortunately, we have seen vets start treatment based solely on elevated liver enzymes. :eek: So yes, it is possible he was diagnosed without the proper testing. DO ask for copies of all the test results, not invoices, that have been done to diagnose the Cushing's then post them here and we can help you interpret them.

Hugs,
Leslie and the gang

In an earlier response on this thread I posted all of the test results that I had given to me prior goin to the specialist. We didn't do tests there just a consult and second opinion. I now am going in for her first ACTH test since treatment so I'll talk my ear off to him!!!

[labblab]

I'm afraid we've made things kinda confusing for you by focusing on that cortisol level. Chloe did, in fact, have a bunch of diagnostics performed, and many of the results you've given us do point towards Cushing's. Here's a "positive" LDDS blood test result:


dexamethasone suppression test results:
Pre test result: 8.8 normal range is 1.0-6.0
Post 4 hours: 5.0 normal range is less than 1.5
Post 8 hours: 4.9 normal range is less than 1.5
There are a bunch of other random numbers that I dont understand put it came out "inconclusive" and almost everything else said consistent with pituitary dependent hyperadreocorticism and that further testing was needed to decipher between adrenal and pit.

And yes, the LDDS is definitely consistent with Cushing's -- the results just don't tell you which kind. You also had an ultrasound that showed at least one enlarged adrenal gland. We're not sure whether or not the other gland could be seen. You also had a liver biopsy with results that are also consistent with Cushing's.

So I think the question as to whether or not Chloe has Addison's was laid to rest and is not an issue anymore. It's just that if your vet had indeed performed a complete ACTH stim test at that time (instead of measuring only the baseline cortisol level), we now would be very interested in the result from both the diagnostic Cushing's angle and also as a baseline before starting trilostane treatment. So that's why we've been asking about it. But Chloe has had an extensive work-up for Cushing's even without it. So it's not a big issue or a mistake if it was not performed previously.

I shouldn't try to speak for Glynda, but I think she is just still wondering whether or not all the irregularities with Chloe's liver function can be totally explained by Cushing's. The pattern of elevations doesn't conform with the usual labwork for a Cushpup.

Marianne

[Hstaff]

So I think the question as to whether or not Chloe has Addison's was laid to rest and is not an issue anymore. It's just that if your vet had indeed performed a complete ACTH stim test at that time (instead of measuring only the baseline cortisol level), we now would be very interested in the result from both the diagnostic Cushing's angle and also as a baseline before starting trilostane treatment.
After looking through all of my paper work I am pretty positive we didn't have an ACTH test done prior to the diagnosis since we had doen the supression tests, blood work and I visited the internal med specialist. I will ask though when I go in. I remember paying a lot of money, but not a $200 specifically for the ACTH test. I think I chose to do the ultrasound instead. I have the CD of the ultrasound for keeps and I did write in the earlier thread everything they saw in the ultrasound. They did say one adrenal gland was slightly more enlarged than the other but everything else looked normal

I shouldn't try to speak for Glynda, but I think she is just still wondering whether or not all the irregularities with Chloe's liver function can be totally explained by Cushing's. The pattern of elevations doesn't conform with the usual labwork for a Cushpup.

Marianne
I did get a bit confused for a while wondering if I had done everything that I needed. I am so glad I joined this forum to express my thoughts as well as to learn more and know what additional questions I should be asking my vet. I love my vet but he is more on the really Smart, socially awkward, uses BIG words/terminology that I usually have to ask for more clarification on. After all of this I feel confident with my vet as he suspected cushing's after the first blood panel but was hopeful it wasn't that. I plan to ask him if all of the blood work conforms to labwork of a cushpup or if he may thing there is underlying issues. My concern is she has lost about 3-5 lbs in the last 8 months but she is definitely not diabetic due to the testing. She isn't overly thin but definitely can see her ribs poke out a bit compared to normal. Any ideas? She poops normal, eats normal, drinks extra right now and pees alot because meds haven't set in. Normal lethargy, can't jump fully on the bed like she used to, not as playful, etc but she is pretty mild cushings and I hope I caught it as early as I could. Does anyone have issues with cush pups eyes? It did this weird dialating thing once, but then again she is also a boston and they can have those issues. Got it checked out but nothing. Thank you for all of your responses!!

[tankers]

Hope the test went well today.

[Hstaff]

Hope the test went well today.
Thank you so much! I just dropped her off and will pick her up in a few hours. Unfortunately her legs totally gve out and flipped out from under we before we left. We are looking into it but seems consistent with the cushings and myotonia. She has only been on meds for a week do haven't obviously seen a difference. How long until increased thirst and all of that should decrease? Think vet said a few weeks or do.

Heather

[frijole]

Heather, Every dog is different. Sometimes the reason you aren't seeing any changes is that the dose needs to be increased.... but that is another reason for doing the acth test... so if the numbers are still high I suspect you will make a small increase and carry on.

Remember that they are supposed to do the test 3-4 hours after you fed Chloe so hopefully they got that right this time.

Fingers crossed. Kim

[Hstaff]

Yes they did it right on time! Fed her at 5 am and gave her the meds then had her there by 9 am. They did the test by 10 and called me before noon to come and get her. I'll see the results on Monday!

Heather

[Sugar]

Maybe the fainting spells are due to a collapsed trachea.

[Hstaff]

So here is an update. The vet left a message on my voicemail. He said that the results show that we are not giving her too much of the trilostane. She is currently on compounded liquid 40ml twice daily with food. Chicken flavored..mmm! He said that she still has some elevated values and that it might still be too early to tell if this is exactly the right dosage. He said that it would be ideal to check the ACTH test again in 21-28 days and it should give us a better idea on whether to up the dose or not. This seems like good news. I haven't seen any negative side effects and she seems to be dealing with it well. She has only been on it since May 11, 2012 so when I took her in it had been 9 days. The last few days the only thing I have noticed is that she definitely is drinking less. She totally leaves water in the bowl now and when we go potty she doesn't seem so urgent. She would normally like walk as fast as she could to make it to the grass. Now she's kinda sniffing around and even one time totally didn't need to go. I come home every day on my lunch to let her out so she doesn't have to sit in an accident. Maybe soon I can stay at work and eat lunch! :) Let me know your thoughts if you know anymore! Thanks!

-Heather

[Squirt's Mom]

Hi Heather,

The decrease in amount and urgency of her drinking and peeing sounds like you are making good progress. :) I think your vet is on the mark with the testing and keeping on the same dose for now. You may see further improvements in the next few days/weeks. ;)

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

[lulusmom]

Hi Heather,

It would be great if you could post the actual results of the acth stim test. If you can't get your hands on the actual test, I'm sure your vet would be willing to give you the two numbers, resting cortisol and stimulated cortisol. Can you also find out how much Trilostane Chloe is getting? I realize she is getting .4 on the syringe but we can only figure out how much that is if we know how much a full syringe is. The pharmacy may have included the mg on the bottle.

Glynda

[Hstaff]

Hi Heather,

It would be great if you could post the actual results of the acth stim test. If you can't get your hands on the actual test, I'm sure your vet would be willing to give you the two numbers, resting cortisol and stimulated cortisol. Can you also find out how much Trilostane Chloe is getting? I realize she is getting .4 on the syringe but we can only figure out how much that is if we know how much a full syringe is. The pharmacy may have included the mg on the bottle.

Glynda

Hi there. I called to see if I could get the results emailed to me but they just said that I could pick it up for my records. They did tell me what the results were with the ACTH. The results were:

Pre ACTH- 5.7
Post- 11

Not really sure what all that means, can anyone explain it? I know how the test works and what they do but I don't know what the numbers mean exactly off the top of my head and I have not looked up what the reference range is yet. As far as the syringe goes, I'd have to go look at the bottle but this is what my vet sent me on discharge instructions: Trilostane 50 mg/ml: Give Chloe 0.4 ml by mouth twice daily with food. Will last 30 days.


-Heather

[lulusmom]

Hi Heather,

Perfect! Thank you so much for posting that information. The goal of treatment with Trilstane is to bring the cortisol levels down, both pre and post, between 1.5 ug/dl to 5.5 ug/dl. It is actually okay if the post number is as high as 9.1 ug/dl as long as all of the symptoms have resolved. Now that I know what your vet was looking at, I agree with his recommendation to hold off on any dosing changes until the 30 day acth stimulation test. How is Chloe doing as far as symptoms go?

Okay, so here's how you figure out Chloe's daily dose of Trilsotane. If the dose on the bottle is 50mg/ml, one full 1 ml syringe equals 50mg. Therefore, .4 ml on the syringe would be 20mg. (50mg x .4 = 20) So Chloe is getting a total of 40mg a day. For Chloe's weight of 22 lbs, 40mg per day is a pretty healthy dose so keep an eye on her for the next few weeks for signs that cortisol has dropped too low. It is not uncommon for cortisol to continue to drop well into 30 days and in some cases, even beyond.

Glynda

[Hstaff]

Thanks for the info! It was very helpful. I am sure the vet could tell me but he's almost too smart for his own good and he always references it in the techinical forms which I don't always get :)

Signs of cortisol being too low would be the vomiting, diarrhea, addisonian attack stuff right? Which then if I see, I give prednisone that they gave me and call my vet right away. If it subsides in an hour or two I am okay but if it doesn't...ER visit if my vet isn't open!? That is my understanding in short language. Her weight has been fluctuating. Last summer she was about 25 and now she is either 21 or 22 lbs. I would have to look at the paperwork from the specialist. The only symptoms I have seen that are new since starting of trilostane are that she has stopped peeing so much and drinking so much. Urgency doesn't seem so bad. Seems a little more playful and isn't as lethargic getting up the stairs. Still no signs of playing with her favorite toy the kong :( Maybe she is over it though. She used to greet us everyday with that thing in her mouth.

Symptoms she has had and still has, is weakness in the hind legs. She still sometimes falls to the side or almost loses balance when getting up, not every time though. This makes me the saddest. She is still tremoring when in a rested state but it stops afterwhile. Still begging when we are eating. Sometimes extra sleepy. Other than that I was told she was a pretty mild case so far. ALso, sometimes her eyes get irritated and red and it has done a weird thing with the pupils twice before. Has been looked at but not sure what it is at this point.

[lulusmom]

Signs of cortisol being too low would be the vomiting, diarrhea, addisonian attack stuff right? Which then if I see, I give prednisone that they gave me and call my vet right away. If it subsides in an hour or two I am okay but if it doesn't...ER visit if my vet isn't open!? That is my understanding in short language.

That is absolutely correct. You may not think that reciting that bit of information is any big deal but it is a very big deal and it can save a dog's life. You've done a great job so give yourself a pat on the back.

[Hstaff]

Thank you so much. I appreciate all of the words of wisdom! Hopefully I can get this figured out now because I am pretty positive my other boston has food intolerance or allergies. Gah!

[Hstaff]

Ok guys, here is an update. Not a good Chloe day today. I was at my all day training for work and my boyfriend called me saying Chloe collapsed. Luckily I had given him all the information, numbers, procedure for if something happened. He is a savior. He flew her to the vet and I left work and met him there. He said that he was laying down with her and she just peed everywhere, more than ever before. She has had trouble holding it obviously since she just started meds on May 11th. He said he went to pick her up and she was just still peeing everywhere and when he went to set her down she arched her back and collapsed. Said she was weak and wouldn't get up for 20 minutes and then that's when he took her in. Of course I was balling on my way there thinking the worst.... They took her immediately in the back to examine her. After a few minutes they had us come back. She was covered with warm blankets because her temp had dropped. They wrote 99.5 but I think that was after she had been warmed up a bit and not the initial temp read. She was so weak, she couldn't stand, her eyes were bugging out and she was so not there. They vet had me look in her eyes and said that they were flickering which could be the cause of nuerologic issues or something called vestibular neruritis (where they get nauseaus, faint, eyes are off, and dizzy). I personally couldn't see what she was talking about. They said her eye sight was good, her hearing, ears etc all of that was good. They did the foot test to see if she would lift her feet back up when the moved it and she wouldn't do it on her left side at all. She perked up after a bit when she saw treats and got warmer. They are pretty sure it was a seizure or stroke. This is her 2-3 time having a seizure... is it time for meds? Or is that associated with cushings at all. Its also been discussed that she may have myotonia (Tremoring of muscles which there isn't much to do for). They said she was not in pain and they thought she would be okay. They did a full blood panel to see if the trilostane was the incorrect dosing (But I was just in last Saturday for the ACTH test). Everything came back similar to before. Her electrolytes were fine and the numbers that were high were in the same realm. I noticed the ALT went up from 524 on 1/4/12 to 580 today. I also noticed the CHOL went up from 397 to 402 (not a big leap). Also her AKLP went up from 253 on 1/4 to 407 today. IS this because the stress of what just happened, her just starting meds and it not fully working yet or what? Ive been keeping an eye on her, Ive been told to give her small meals, lots of water, continue trilostane since results dont show it affected the collapse and to give prednisone one time and monitor. She got up and barked at the pizza man and is walking but still a little weak. Keeping an eye on her, and now time to clean the pee stained couch. Poor baby girl.... So one main question I have is what is considered neccessary to give prednisone? Any time she may fall to the side or just for these big things like today? Ive been recommended to see the nuerologist and to do a recheck tommorow. I have my limits on how much I can afford unfortunately so if they need an MRI or anything I Just don't think I can help her as far as that test goes. I asked if she had a quality of life still so I could make the best decision and 3 out of 3 vets all said yes unless something major happens..... please let me know your thoughts!!

[Hstaff]

Today took a turn for the worst. I had to put Chloe down. She wouldn't walk or drink water. She couldn't focus he was walking in circles disoriented and running into things. More happened but I'd rather leave it short. It was un related to cushings. RIP Chloe. I love you so much... You were so sick and in so much pain. You were the best dog I've ever had. Please look down on me.

[Squirt's Mom]

Oh, Heather,

It breaks my heart to hear this about our sweet Chloe. :( There is no question you did everything in your power to help her and make her every day with you one of joy and security. I know she left this world knowing she was so very loved, full of gratitude.

Her pain is ended, she is once again whole and strong, running in the Rainbow Fields with our other babies who have gone before. Chloe will watch over you just as you did her, until your job here is done and you are once again united, for all eternity. You have taken her pain and made it your own - there is no greater gift.

Please know we are here any time you wish to talk. When you are ready, we would love to help celebrate her life by sharing in your memories of life with her. We have a special section for this called In Loving Memory where you can post a tribute, or memorial, when you are ready.

Chloe's name has been added to the In Loving Memory list for 2012 where she will always be remembers and honored as a member of our family.

http://www.k9cushings.com/forum/showthread.php?t=3918

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



Love’s Final Gift
By Cheryl Goede

I know it is hard on you, there are no words that can describe
the piercing sorrow which does not lessen with time.

When you had to bring me with you, on that last car ride to make,
all the while knowing the course of action you needed to take.

I know you feel guilty, I feel your sorrow, it’s true,
I could always sense your each and every mood.

When they called my name I knew that your heart was breaking,
you carried me to the room…getting closer to my new awakening.

The friendly doctor I know gave me treats and spoke low,
he was giving you the time that you needed to let me go.

All left the room, and you gathered me close,
as you wondered how you could do this for me when you needed me the most.

I tried to convey, my last wishes to you,
I looked into your eyes with all the love you are used to,

Mom and Dad, this earthly body has served me well,
but the time has come for us to part, to no longer dwell.

You understood the signal, and knew it was time for me to go,
but before I leave there is just one more thing you should know.

I will look out for you, each day I will guide,
my spirit in some way will always be nearby.

Before I make it to the Bridge to stay,
I will return the love tenfold in hopes for my debts to be paid.

For when that new pup or dog will enter your world,
a new love will blossom and slowly unfurl.

I hope you realize that new dog is Love’s Final Gift,
sent from me, your baby girl.

That new dog was chosen by me, to lessen your pain,
like the gentle warmth of the sunshine after the rain.

When you hear him bark, it’s my bark too,
when he cuddles you close, it’s what I would do.

So open your heart when the time comes to see,
that the love he gives comes also from me.

Take comfort, hug him, and reminisce
as he gives his love freely in the form of a dear doggy kiss.

It’s what I would do, if I still could,
and what you would want that is understood.

But the time has come to let me go,
to make that unselfish choice, even though tears will flow.

Hold me, cherish me, until my last breath,
but please don’t look at this as my death,

Someday we will be together again, come close for one last kiss,
I know this it true, as it is my soul’s last earthbound wish.

Now I can feel my spirit floating it is traveling high,
as though I were a cloud in the endless blue sky.

Please find peace, you have honored my life with this,
For I have been reborn through your Love’s Final Gift.

[labblab]

Dear Heather,

I am so sorry that I somehow missed reading your post yesterday, and so much sorrier still to know that Chloe was not able to rally. There is absolutely no doubt but that you made the decision that was the kindest and most loving one for your sweet girl. But at such a price to you. On this Memorial Day weekend, please know that your sweet Chloe instantly joined our other beloved companions whom we will forever honor in our hearts.

I send my thoughts and prayers to you on this sad day. But you are right, Chloe's shining spirit has now been released from her tired, sick body. Chloe is free.

Many hugs,
Marianne

[marie adams]

Dear Heather,

I know as hard as it was to make the decision--you were doing it for Chloe. I know the feeling and it still makes me cry especially reading your last sentence. She is definitely watching over you just as the poem says from Leslie.

Take care and a big (((HUG))) to help you through the days ahead.

[Hstaff]

Thank you all. I'm still so sad and the river is still flowing down my face. I'm cuddling with my other Boston Dexter oh so close and know we can get through this together. I hope he doesn't get too sad that his sister is in a different place. I definitely will post a memorial for her when I am feeing better. Thanks for all of your love and support. I miss her so much.

[Jenny & Judi in MN]

I'm so sorry to hear this about your oh so cute Chloe. thank goodness she is out of pain but I am sorry you are missing her so much. Judi

[GabbySue]

Heather I am so sorry about Chloe. The memories will bring you happy tears but only time can put distance on the pain of losing our loved ones.}{

[Bo's Mom]

Heather,
I am so sorry to hear of Chloe. Your angel girl will forever watch over you and will keep your heart full of memories.

Belinda

[mytil]

((((hugs)))) being sent to you Heather. I am so very sorry. This is a time we never dream of when they first enter our lives, but this is a promise we make to them - to let them go. I know it is really tough Heather and my heart is with you and Dexter.

Terry

[Nikki]

I'm so sorry to hear about Chloe :(. I can't imagine how you must feel.

[jmac]

Heather,

I am so sorry to hear about your precious Chloe. I am glad she is no longer sick or in pain. You are in my thoughts...

Julie & Hannah

[lulusmom]

Heather, I am so terribly sorry for your loss. Words are so empty at times like this but please know that I understand the depth of your pain and my thoughts and prayers are with you.

Godspeed sweet Chloe.

Glynda

[Casey's Mom]

Heather I am so sorry for your loss of sweet Chloe.

Love and hugs,

[tankers]

Heather,

I just got home from being away, and read your last post. As I sit here, the tears are streaming down my face. I am so sorry you had to say good-bye to Chloe. I know you will miss her so much and I am glad to hear you have another BT to love on and to love you. Chloe was so lucky to have you as her mom and one day, you will see sweet Chloe again, I just know it. Love to you and Dexter-

[k9diabetes]

I am so very sorry to learn about Chloe's passing.... perhaps some kind of a brain tumor.

You fought hard for her and obviously loved her deeply - that's what really matters. I know it must have been traumatic for you and yours. It is hard enough to lose them without losing them so suddenly.

With deepest sympathy,

Natalie

[Somesie]

Heather...I'm so very sorry for your loss. Please know that we are keeping you close in our hearts and minds. Jordan and Barkley send you big sloppy Boxer smooches, and I'm sending plenty of hugs.

Best,
Jenn

[bgdavis]

Heather,

I'm so sorry to read about your beloved Chloe. Such a young dog! I know you are heart-broken, but you know that Chloe loved you just as much as you loved her.

Hugs,
Bonnie and Angel Criss Ann

[Cyn719]

Heather

I am so sad to hear about the loss of Chloe...a loss is the worse thing but hold on to all the wonderful memories...sending you lots of love hugs support and strength

xoxoxoxo

Rest sweet Angel Chloe

[Hstaff]

Thank you all for the kind words. Please see her memorial post in the in memory of thread.