Junior - 6 year old lab mix - Vetoryl twice daily

[Junior's Mom]

It's looking like cushings for Junior, my almost 5 year old lab mix. Like many others have written, it's confusing and scary, and hard on the brain sometimes. A definite diagnosis is not in yet. One vet says yes, the other says he is too young, and to look at medullary wash-out, thyroid, or diabetes insipidus. So here's the history so far.
Junior began drinking excessive amounts of water, and peeing excessive amounts both outside and inside the house. A urine test revealed a urinary tract infection. A course of antibiotics, and he was back to normal, for a couple of weeks. Then the drinking and peeing started again. Another urine test showed clear, but dilute. So we did a number of urines test over time, they all remained clear and dilute.
During this time, his appetite was greater than ever, and hair started falling out, and he developed small lumps under his skin. One lump had been there a while before.

Bloodwork was done lipase high 3447 reference range 0-900 IU/L
cholesterol high 10.5 reference range 3.0-9.9 mmol/L
triglycerides high 2.64 reference range 0.12-1.60 mmol/L
chloride low 104 reference range 107-123 mmol/L
rbc high 8.6 reference range 5.5-8.5 x10E12/L
lymphocytes low 0.9 reference range 1.0-4.8 x10E9/L

Everything else was in the normal range, so I didn't post it.
The ALP was at the high end of normal 137 reference range 24-141 IU/L
The Gamma gt was also high end of normal 6 reference range 0-6 IU/L

urine cortisol/creatinine ratio 129.5 It says below this <34 Hyperadrenocorticism is highly unlikely and investigation of other causes of the dog's clinical signs is recommended.
>=34 Hyperadrenocorticism is possible; however a urine sample collected from a stressed dog or dog with nonadrenal illness can have an increased ratio.

total t4 13.5 reference range 13.0-53.0 nmol/L

He was also tested for lyme (borrelia burgdorferi) ab
ehrlichia canis/ewingii ab
anaplasma phagocytophilum/pl
heartworm antigen snap
All were negative.

A urine culture was done the same time as these tests. It was negative.

There are 3 pea sized lumps, 2 on the sides of ribcage, 1 on back of neck. They are hard, and do not erupt. His elbows have always been rough. His skin is dry, and fur is thin. Lost patches are on ears at fold, on chest, and inner edges of back legs at thighs.

The tops of his paws cut easy, usually when digging, and are very slow to heal. I read somewhere this could be a zinc deficiency.
Because of suspected pancreatis due to the high lipase levels, and to check the adrenals, an ultrasound was performed. It showed no abnormalities.

A low dose test was performed. 0hr 121 high reference range 15-120 nmol/L
4hr 81 high reference range 0-10 nmol/L
8hr 174 high reference range 0-10 nmol/L

There were no specific tests for pancreatic that I know of, just the ultrasound which showed it to be normal.

I am wondering which direction to go next. He has always been a very anxious dog-loud noises, new people. I know stress increases cortisol levels, but he was pretty calm at the vets for tests as it was becoming a normal occurence to him.

I hope I answered all the questions. Thank you everyone for being so caring and helpful.

[SoggyDoggy]

Hi and Welcome to the forum! Sorry to hear that Junior has been through all of these trials lately, but it sounds as if you are on a really good track to sort him out and get him back to rights again.

I won't make any comments on the bloods listed below as I am actually still quite new to all of this myself and am still learning. I will however ask that if possible, could you edit your original post to add the normal ranges next to Junior's results? This is because apparently different labs have different ranges for some things and it affects how they can be measured (or so I understand).

The bad news is, that Cushing's can affect younger dogs as well as older, and while it is more prevalent in the older dogs, we do still have some young-uns here too. That being said, the vet that suggested looking for diabetes, thyroid etc is right. Cushing's symptoms mimic so many others, it is one of the hardest things to get a true and definitive answer on, so I would definitely be pursuing those tests if you can to rule out other causes.

Others will be stopping by shortly to add their hello's and advice too, but for now welcome and remember, if you have a question ask, ask it! There is no question too big or small here, and there is always someone will to share their experiences. Good luck with Junior, we look forward to hearing more about him. :D

[Harley PoMMom]

Hi and welcome to you and Junior,

So sorry for the reasons that brought you to us but glad you found your way here.

Cushing's can be a confusing and frustrating disease but we are here to help in any way we can.

Cushing's is one of the most difficult endocrine diseases to get a confirmed diagnosis for because not one test is 100% accurate at diagnosing Cushing's and other non-adrenal illnesses can create false positive results on all tests for Cushing's.

My boy, Harley had pancreatitis which was found on his first ultrasound. The pancreatitis was confirmed with a spec cPL test which as far as I know is the only way to validate pancreatitis.

UTI's are hard to diagnose in urine that is diluted so it is usually recommended that an urine culture and sensitivity test be performed.

Since other non-adrenal illnesses, such as diabetes and thyroid problems, share some of the same symptoms as Cushing's these should be ruled out. Has Junior been checked for diabetes and any thyroid issue?

I was wondering if you could edit your post and type in the units of measurements with the reference ranges...e.g. ALT 150U/L (5-100)....Thanks!!

Please know we are here for you and Junior so please do not hesitate to ask any and all questions.

Love and hugs,
Lori

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[Simba's Mom]

Simba and I welcome you to this awesome family, here you will find lots of info and tlc....take care and get settled in, we are here for you!

[milosmom]

welcome to you guys,you have found a wonderful forum that has many people with great knowledge on this dreadful disease.we are all waiting to read about your baby and there will be many ideas,support,love and hugs coming at you.so ask away !!! my milo was only 5 when he was diagnosed.patty(milo)meka xoxox

[Trish]

HI Junior's Mom and Junior of course!! I wanted to add my welcome to you both too, wise choice posting here. There are some seriously smart people to give advice. I look forward to you posting more about your pup and hopefully we can work out some answers for you both.

Trish xxxxxxxxxxx

[Squirt's Mom]

Hi and welcome to you and Junior! :)

More questions! YAY! :D

Were those the only abnormal values on the lab work? The ALP (same as ALKP) was normal?

Was the pancreas looked into via further testing?

Was the LDDS given while Junior had a UTI or while the pancreas may have been inflammed? If so, then it is more than likely skewed. Cushing's tests should never be performed while another illness is present because other illnesses can and do cause elevations in the cortisol skewing the results.

Any discussion of a thyroid condition? Not knowing what the normal ranges are for this lab, I can tell you that t4 looks high based on the normal ranges we are used to seeing. If it is high, Junior may be experiencing hyPERthyroidism.

Did the changes, the signs, you are seeing come on suddenly, like over a few months time?

Can you describe the bumps under the skin? Are they breaking through to the surface of the body or all under the skin layers? Do you see anything that resembles plates, or hard scaly areas? Do the bumps ever rupture/drain?

How is Junior's appetite? Any increase or decrease there?

How about hair loss or hair that has not regrown?

How is he doing with exercise? Is he showing a reluctance to take walks, play, etc? Is he having a harder time with steps or jumping on furniture?

Does Junior have any other health issues that you are aware of? Is he on any medications, herbs, or supplements?

What feed and treats are you giving?

Don't panic - HA! if you only knew who was telling you that! :p - and don't rush into treatment. Don't let your vet order any of the meds to treat Cushing's until you are convinced it is Cushing's. At this moment, based on the info we have, there are too many other possibilities that have not been ruled out to even start to think about treatment for Cushing's.

The more info and detail you can provide us, the better feedback we can offer so don't worry about writing a novel. ;) Wait til you see of the windbags we have around here! ;) ahem...just so you know, I are NOT one of them. :rolleyes::o:p I'm just nosy. :D

You have found the very best bunch of folks who have a great deal of knowledge and first-hand experience to share as well as the best support system you could ever hope for. We will be with you all the way. Never hesitate to ask questions and we will do our best to help you understand. You and Junior are part of our wonderful family now and this family sticks together in thick and thin. I'm glad you are here and hope to learn much more as time passes.

Hugs,
Leslie and the gang

[NoonelovesmelikeNorman]

Hello and Welcome to Junior and family, Sorry to hear your beautiful lab has cushings....but you've found a wonderful supportive and knowledgeable site...I am only a few monts or so into this journey and don't have advice but will send out love and prayers for you and your puppy. I have a daschound (cushings) and yorkie pooh, but my caregiver for 5 + years has a black lab...I still say she is the best dog in the world. Thinking of you and Junior!
Take care, your in good hand with this forum. wishing the best for you and Junior.

Love, Sharon and Norman

[molly muffin]

I'm just going to pop in and say hello and welcome to you and junior. :) The others have asked the most pertinent questions. All of these help us to have a clearer pictures of what junior might be going through and what direction you might want to look into next.

:)
Sharlene and Molly Muffin

[Junior's Mom]

I realized that there were a few more questions asked. His hair is very dry and brittle. It has started to break off where his collar rests, which he only wears when going for walks.
His energy level is normal, appetite increased. No vomiting, diarrhoea.
His food is a combination of Go chicken and Presidents Choice Nutrition First chicken. He gets one cookie a day at the most, broken up into 2 or 3 servings, a medium size milk bone.
He had no known uti at the time of the low dose test.
I edited my original post to includes the numbers/measurements asked for in the tests, and to add some additional information.

[addy]

bumping up


I edited my original post to includes the numbers/measurements asked for in the tests, and to add some additional information.

[frijole]

I'm sorry but this isn't screaming cushing's at all to me. The LDDS test (low dose dex suppression) is known to have false positives when something else is going on. (I had a dog with 5 false positives on it so I know from experience)

Absolutely think something else is going on based on what you have posted and I would have an ultrasound down to have the organs checked out.

What stood out from the bloodwork is the high lipase and I googled it and there are several things that could cause that and one is pancreatitis which Lori mentioned.

You mentioned you've been to two vets now. Can I ask where you live? I'm hoping maybe one of us live nearby and could help if you are looking for help.

Thanks, Kim

[labblab]

Hello and welcome from me, too!

After looking through the additional information that you inserted in your earlier replies, I'm tending to agree with your vet who is suspecting Cushing's. The profile you have presented could correspond with a dog in the early stages of the disease:

Increased thirst, urination, hunger
Skin and coat issues
Elevating liver enzymes
High cholesterol
Borderline low thyroid
Slow healing
Possibly inflamed pancreas
History of UTI
Dilute urine
Strongly positive results on the UC:CR and LDDS

One question mark is Junior's ultrasound. We would typically expect to see abnormalities in the adrenal glands with Cushing's: adrenal Cushing's presents with a mass/growth on one gland; pituitary Cushing's presents with enlargement of both adrenal glands. If both of Junior's adrenal glands appeared to be normal on the ultrasound (which you say is the case), then we can probably rule out adrenal Cushing's. But up to 30% of dogs with pituitary Cushing's will still have normally-appearing glands when the disease is early or mild.

So what to do next....? Has the vet who suspects Cushing's recommended treatment at this point?

I do think there are three more blood tests that you might want to perform. The first is an ACTH stimulation test. It is another test that can be used to diagnose Cushing's, but it is also the test that is performed periodically to monitor drug effectiveness after treatment is begun. If you do end up deciding to treat Junior, it would be helpful to have an ACTH baseline performed beforehand. Plus, if it also turns out "positive," it would be another corroborating diagnostic.

A second test could be the spec cPLI test that Lori recommended re: pancreatitis. It could confirm whether or not pancreatitis is a genuine issue for him. If so, you may want to make some dietary changes sooner rather than later. One note: it is true that other nonadrenal illnesses (such as pancreatitis) can artifically elevate the test results on the LDDS and ACTH, so we normally recommend that people hold off on the diagnostic Cushing's testing when another known illness is ongoing. However, Cushpups are vulnerable to ongoing pancreatic issues which may never resolve without Cushing's treatment. So people may have no choice but to test regardless of pancreatic elevations.

One other test possibility is an extended thyroid panel. Junior's T4 level is right at the basement of the normal range. His low T4 could be a problem in its own right, or it could be secondary to Cushing's and if so, will likely resolve after Cushing's treatment is in place. A simple T4 cannot tell you the difference, but an extended panel can give shed more light on whether or not the low thyroid is a "primary" condition or secondary to another problem such as Cushing's.

Can you tell us some more about the vets with whom you've consulted so far? Do you feel more comfortable with one rather than the others? How about the one who suspects Cushing's?

Marianne

[Junior's Mom]

Hi again. Junior had his pancreas and thyroid checked. Both were normal. I started him on adrenal gold, from pet well being. I see a noticeble difference in both water input and urine output. Not to normal levels though. His fur is still missing. I was thinking of adding zinc to his diet.

[Squirt's Mom]

Hi,

I'm sorry but you are wasting your money, doing your dog no good, and lining the pockets of charlatans who are in this for no reason other than the money they can bilk from worried pet parents. Adrenal Harmony Gold is the new name for an old product - Supraglan. A product that claims to treat two opposite conditions - Cushing's and Addison's - impossible. It contains ingredients that are directly contraindicated for cush pups so it may be actually harming Junior. Please, get to a vet and get him on the correct treatment. You are wasting precious money and time.

Hugs,
Leslie and the gang

[goldengirl88]

Welcome to the forum, this is the best place in the world for information, help, and support. Good luck to you and your baby and God Bless you both.

[addy]

I can only second Leslie's comments. I wish our lives were that simple but unfortunetly Cushings disease is not. We are not here to judge you and certainly do not mean to push you into a treatment you are not comfortable with.

We simply must point out the truths so people do not have false expectations.

[Junior's Mom]

Wow! I guess homeopathic is a big no-no on here. With all the details asked regarding initial diagnosis, I am surprised to read a blanket statement like "it's no good". Which ingredients are contraindicative, have others tried it, with no results, poor results, dire results? Has anybody tried zinc for the skin problems?
I have seen an improvement in Junior. Of course I will look into the "normal" meds if I do not see enough of an affect. Should I expect him to be normal on something like trilostane, and if so, how quickly and for how long?

[molly muffin]

I wish it was so easy. It isn't that homopathic treatment is a big no-no on here. It that we have yet to find one that does the crucial thing that causes the problems and that is to bring the cortisol levels down. With members who have been looking for that type of result for over 8 years and yes, they are still active and can answer here, the results have been that we haven't found one.
You can try zinc for skin, I'd do so with a vets over seeing though. I personally treat my dogs high liver enzymes with heppato support supplements. This is because she hasn't tested positive "yet" on an LDDS test, even though her ACTH test is high. The ACTH test is the only one that will tell you what the actual cortisol levels are and that is what is dangerous long term. So am I taking a risk? yes, I think I am, but I have her tested regularly to see where she is and where she is that even with heppato support, which is only a vitamin type of supplement, she continues to have enlarged liver, enlarged adrenal glands, enlarged lymph nodes. Eventually I will probably have to put her on trilostane to deal with that since nothing else has worked.

Acupuncture and some creams have helped with the cc, as that is hard to get control of even when the cortisol starts to come done. Once it's there it's a bugger to get hold of. Many do this in addition to the trilostane.

As far as trilostane or another treatment goes, the simple answer is that unless the cushings is due to an adrenal tumor that can be removed, there is no cure at this time for cushings. Treatment is life long. We have many dogs who have been on it for a long time and continue to do well. Again, those who can address that if you wish.

What we have found is that there are many web products that prey on the fears of pet owners, while offering nothing to back up the claim. Most of these we have been in contact with to try and get some sort of studies showing good results. Which means they would have to use the product on a pet with confirmed cushings diagnosis and monitor to see if there are any good results. So far they haven't presented that to us. If they can and will and we know that dogs are doing well on it, then you bet we would be the first to support and recommend those products.

yes we have had members who have tried other avenues, unfortunately many of them haven't come back to update if they have had success. I wish they would, since we would all love to know if something is found that would be a long term answer, even short term would be good to know. Others have come back but they usually do because something hasn't worked and they are moving on to the traditional treatments.

I hope that helps to answer some of your questions. In general though I'd say that it isn't a no-no, it's a no we haven't found one that work over all. :(

Sharlene and Molly Muffin

[Squirt's Mom]

Another point - Supraglan, Cushex and and the like are not homeopathic remedies. A homeopathic remedy is one that treats like with like, that will cause the symptoms in a well organism. Supraglan and Cushex are nothing but snake oil, pure and simple. If you want to try a more natural approach than the pharmaceuticals, then find a Holistic vet who works with herbs. ;)

Hugs,
Leslie and the gang

BTW, I am alll about as few chemicals as possible and use many herbs with my dogs and myself so it's not that I am against Holistic approaches, of which Homeopathy is just one, it's that I am against folks taking advantage of terrified parents by selling them crap. ;)

[Junior's Mom]

It seems to me, that the more I read on cushings, the more my brain hurts and the more confused I get! My vet joked that it is more difficult with an active pet parent, because they see the symptoms of anything early on.
I thought of zinc because I had read about it a few years ago, concerning Junior, and the damage his feet received regularly. It is mostly a problem with northern dogs apparently. We aren't north, but eastern Ontario has some pretty harsh winters. When all this began in the fall, and his fur started falling out, it reminded me of the zinc reading I had done previously.
From what I have learned, water needs to be monitored when starting treatment? I have 4 other dogs, so if that is the case, Junior would have to be kept separate from them. He won't be happy with that.
He has not had an ACTH test, just the low-dose test. Should he have one as a baseline before starting treatment?
Can a cushings diagnosis be made from just the low-dose test?

[molly muffin]

I think most of us feel like our brain hurts when we start thinking about the ins and outs of cushings. It's certainly not an easy disease to get hold of.
Was a pancreatic test done as a follow up to check on the high lipase results?
Personally, I would have an ACTH before starting any treatment with the normal cushings drugs as I'd want a baseline.
Monitoring of water is difficult with a full pack running around. Since this is really a life long treatment, it is not going to be reasonable to try and separate him all the time from the other dogs and he'd be quite miserable I'd think.
Some of the others who have more than one dog at the house, can probably give advice on how to go about that better than I.
I know Ontario can get bloody cold and Is cold right now. :) I'm in Ontario too. This snow and ice and salt is all very hard on their paws.

Sharlene and Molly Muffin

[Junior's Mom]

Yes, a pancreatic test as well as thyroid panel were just done. Both came back normal. I don't have the results in front of me yet, just what my vet said.
Vetoryl sounds really scary to me.

[Junior's Mom]

An ultrasound showed the adrenal glands to be normal, which suggests pituitary dependant. The low dose test had no suppression at 8 hours, but an increase of 43%. However at the four hour mark, there was suppression, but not the clinical of 50%. It was 33.1%. I am so leery of starting the drugs.

[Squirt's Mom]

Hi,

Unless there is a reason one or more of your other babies is drinking to excess, you can assume that Junior is the only one. So if the four of them typically drink 8 cups of water a day now you can use that as a gauge for Junior's decrease, as we can assume he will be the only to reduce the amount he intakes. So if month after starting treatment you see you are only giving them 6 1/2 cups a day, you can assume Junior has indeed decreased his water intake.

IF you choose to use Lysodren instead of Trilostane (Vetoryl) you may want to consider isolating Junior for the loading phase, typically not more than 7-10 days, as water intake is one of the signs you watch for to determine if the load is achieved. There is no loading phase with Trilo (Vetoryl); you simply start giving and give every day after.

Hope that helps.
Hugs,
Leslie and the gang

[Junior's Mom]

I have to ask, have there been any happy stories of dogs that started medication. Any that didn't have bad side effects, crisis, or miserableness?
At what point do the symptoms warrant medication? How do you decide?

[StarDeb55]

Here's a late welcome from me! I noticed your post about any happy stories when using meds to treat & thought I would tell you a very happy story. First of all, let me say that I have absolutely no experience with trilostane (vetoryl). What I do have experience with is lysodren which I used quite successfully to treat 2 pups. My first boy was diagnosed at about 7 years of age, treated with lysodren for 8 years. He crossed the bridge at 15 from causes unrelated to his Cushing's. My 2nd boy was 13 when he was diagnosed, so he was a little old fellow, anyway. He was on lysodren for 2 1/2 years before he crossed the bridge, again, due to causes unrelated to his Cushing's.

There are many more success stories in this group using both drugs. I'm sure other member will stop in to share the experiences.

Debbie

[Squirt's Mom]

I also consider my Squirt to have a happy story, tho not typical. She was diagnosed as Atypical in '08 and her cortisol started to rise almost 2 years ago. She has been on Lysodren as a maintenance dose since and has had no issues whatsoever with the med or the signs. At her age there are things that come up but I don't believe they are connected to the disease nor to the Lysodren. :)

[Junior's Mom]

Again, I am asking...When do the symptoms become enough to justify beginning medication?

[frijole]

When your dog is wanting to go outside to urinate so often you can't stand it anymore. When he/she wakes you up to go outside in the middle of the night constantly. When your dog urinates pools all over your carpet/floor and you can no longer take it.

I'm not being flip - that is usually what happens. Most dogs are not diagnosed early as in your case. So the cases you see here are dogs that have had it for many years.

Another thing that happens in later stages is you will note that they lose strength in the hind legs and are no longer jumping up on the sofa or walking up steps. My dog did it but only on occasion and I didn't even know what cushings was back then and I could not figure out why sometimes she would not walk up the steps. Lastly the hind legs tremble from weakness.

Trust me, you'll know when it's time. Kim

[Squirt's Mom]

For me, it was easy to decide, even tho I had missed some early signs, like hair loss and weight gain. But when that cush appetite kicked in, there was no question it was time. Squirt has always been a Miss Piggy but when her cortisol started rising it wasn't just wanting treats all the time, or just being hungrier - she thought she was literally starving. She would gulp her meal down, lick the bowl, floor and wall, then go after the other bowls. Then turn and look at me with an expression that clearly said she had not had enough and if she didn't get more NOW she was going to fade into nothing. She would wear herself out searching for something, anything, to eat inside and out. She would beg to go out just to make sure she hadn't overlooked something out there, then beg to go in only to search inside again. The worst was the haunted look in her eyes, tho. She truly thought she was staring to death. :(

Skin infections or UTIs or pancreas problems are pretty good indicators something needs to be done. Low thyroid values can also be an indicator in some cases. Treatment won't cure the condition but it can control the signs so when they become an issue for either the dog or the parent, as in frequent accidents indoors or having to go out often during the night or counter-surfing or getting in the trash, that is also a good time to start.

The key to monitoring treatment is being able to recognize when changes are occurring, either negative or positive, so you want to have signs that you can use to gauge how treatment is working. If you won't be able to tell if your baby is drinking and/or peeing and/or eating less, then monitoring treatment could be trickier. Having said that, there are now those who feel it is best to start treatment when the tests support the diagnosis whether signs are present or not.

Are you seeing more or stronger signs in Junior? Or worrying about delaying treatment?

Hope some of this helps!
Hugs,
Leslie and the gang

[Junior's Mom]

I just have a couple of questions for the amazing folks on here.
Once regulated by medication,
1.Do your dogs grow their fur back?
2.Does their pee remain dilute?
3.Does their appetite return to normal?
Thank you to all for this great place.

[Squirt's Mom]

Not always but 1) most do, 2) most don't, 3) most do. :D Not being flippant but with cushing's there are few pat answers. Each pup is different and each responds to the treatments differently. Some pups will blow their coats regrowing an altogether different one once the cortisol is under control, some simply stop shedding so much. Some will start to concentrate the urine and some never do. Most will stop the incessant searching for food and resume a more normal appetite behavior but some remain hungrier than before, some less hungry than before.

Have you decided to start treatment? With which drug?

[Junior's Mom]

It has been some time since I posted on here. I am learning from the forum on a daily basis though. Kudo's to all the pet parents who do so much for their babies, and the vast wealth of knowledge to be found.

It's been 7 months since cushings was first mentioned by my vet, but I'm still not convinced.
In Aug. 2012, Junior had a clean routine exam, and I had no problems to inquire about.
In Nov. 2012, he started having accidents in the house, I had him tested within days of this happening. He had a urinary tract infection. Antibiotics cleared it up, and he was fine for a couple of weeks. Then he started having accidents again.

I have had a low dose test done which says positive for cushings. An ultrasound showed no abnormalities. A thyroid panel, and pancreatic test showed normal.
He still peed and drank excessively, and had accidents in house and dilute urine.

I started giving him adrenal gold. The accidents stopped within a week, and have only happened since during thunder storms.
He does not drink as much as he did, but still pees for a long time. He has always held it all night-9hrs. His urine is still dilute, I may see one with some yellow to it, usually after his morning meal.

I have been giving him melatonin for a couple of years due to his anxieties. I added omega 3 fish oils due to the dry brittle coat.

The fur lost on his ears has been growing back. It has not grown back where his belly was shaved, and is thin on legs and chest. His appetite drives me bonkers. It's much more noticeable now because grass is "food" and he will drag me to the nearest patch to mow down as fast as he can.

I am thinking that whatever is wrong with him, it can't be good long term to hold a minute or more of urine in him, nor would being "starving" be much fun.

I am going to have bloodwork redone this Thurs. for a comparison to the last results, as well as an ACTH.

There is no muscle wasting, no pot belly, no lack of energy.

Sorry for the long post, I thought it would be easier to cover everything here rather than anyone having to go back and read. Unfortunately, it became a novel.

I guess I just wanted to update on where we are at, what we're doing next, and possible outcome scenarios. Maybe the biggest problem is that I don't want it to be cushings.
Huge hugs to all the wonderful people and their perfect pooches!

[Junior's Mom]

Funny how you remember more to say after you post.
At his LDDS test, I arrived before they did the 8 hr draw, so I thought having me around may have affected it.

I have also been giving him vit E. His fur is pretty shiny, but there is still some dandruff.

There has never been any panting, and he is not overweight. He has gained weight over the last couple of years, but he was on the thin side to begin with, and is just turning 6. My vet thinks he is a great size now.
Tracey

[Junior's Mom]

So Junior's latest bloodwork is back. The lower fat diet, and fish oil supplements have helped to lower lipase and cholesterol to normal levels. The triglycerides have also come down but are still high.

The bad news is alp is up to 194 now 137 last Dec.
Normal is 24-141 IU/L

The ALT is 110 now 58 last Dec.
Normal is 5-95 IU/L

GGT is 9 now 6 last Dec. Normal is 0-6 IU/L

Does anyone else see mild Lymphopenia on their babies bloodwork?

And the stim test...
Pre 134 ref 15-120 nmol/L
Post 1255 ref 220-550 nmol/L

So, with these results, the increased hunger, and the massive amounts his bladder is trying to hold, we will begin trilostane, more than likely next week. And I am very, very distraught!

[frijole]

It's interesting that the alp really isn't very high... in cush dogs we often see 4 digits so that is really not high at all. The acth test is indicative of cushings though.

Protocol is now to start trilostane on the lowest dose possible. Please tell us your dog's weight and the dosage your vet has prescribed. Thanks. Kim

[Junior's Mom]

I am in a small town. My vets office has little experience with cushings, maybe 2 or 3 cases. However, I have been going here 20 years, and find them to be very eager to talk and listen and learn. The vet I am seeing for Junior has spent at least 20min. on the phone with me on numerous occasions. She wants to do more reading up on the situation, before formulating a plan, and will be getting back to me the end of this week.
I told her I wanted to start him at the low end, and work up if need be. She said, "Of course, it is always best to start low." So I am not too worried about that end of things.
Junior weighs 50.2 lbs, so unless I had it compounded, he would be starting at 60mg.

[Squirt's Mom]

With the ALT and the GGT rising, I would want them to look into the liver before starting treatment for Cushing's. Liver disease can cause some of the same signs as we see in Cushing's.

• ALT is also important in the metabolism of nitrogen and is most
often associated with the liver. High levels indicate liver damage,
toxin ingestion, Cushing's disease and various metabolic
disorders. Low levels indicate starvation or malnutrition.

• GGT is also important in nitrogen metabolism and is found
within liver cells. High levels indicate bile duct obstruction, liver
disease, pancreatitis, Cushing's and can be caused by high levels
of steroids. Low levels indicate starvation and malnutrition.


Even tho Cushing's can cause these elevations, so can other things that are more pressing than Cushing's so I would want to be fairly sure nothing else is going on with that organ before starting the Trilo...but that's just me. ;)

[FemaleK9]

Please don't be distraught! Distraught is what I was when I took Rosie to vet because I was so afraid I was facing catastrophic disease and euthanasia, so the Cushing's diagnosis actually gave me hope!

Rosie is now doing amazingly well and I hope your Junior will be, too.

Just gather all the info you can, share it with the kind and knowledgeable people here and let them help you.

[Junior's Mom]

Thank you Squirts Mom for that information. How else would they look into the liver? I have had bloodwork done twice now-in Dec. and last week. He had an ultrasound back in Dec. which said everything looked fine.
Would you recommend another ultrasound, or some other kind of testing?

[frijole]

With the ALT and the GGT rising, I would want them to look into the liver before starting treatment for Cushing's. Liver disease can cause some of the same signs as we see in Cushing's.

• ALT is also important in the metabolism of nitrogen and is most
often associated with the liver. High levels indicate liver damage,
toxin ingestion, Cushing's disease and various metabolic
disorders. Low levels indicate starvation or malnutrition.

• GGT is also important in nitrogen metabolism and is found
within liver cells. High levels indicate bile duct obstruction, liver
disease, pancreatitis, Cushing's and can be caused by high levels
of steroids. Low levels indicate starvation and malnutrition.


Even tho Cushing's can cause these elevations, so can other things that are more pressing than Cushing's so I would want to be fairly sure nothing else is going on with that organ before starting the Trilo...but that's just me. ;)

Leslie you might have missed this. An acth test that when converted is 45.

And the stim test...
Pre 134 ref 15-120 nmol/L
Post 1255 ref 220-550 nmol/L

That and a positive ldds and the urination make me believe the dog has cushings. Why are you suggesting an ultrasound? Just curious if I missed something. Kim

[Squirt's Mom]

I'm not suggesting an ultrasound per se - I'm simply saying I would want the liver looked at more in depth before starting treatment if it were me. That might be a bile acid test, another US, whatever - but I'm not saying what testing needs to be done or that anything more needs to be done, Only that I would want the liver looked into more in depth if it were me....hence the -
but that's just me. ;)

Why? Because of Squirt's experience with the tumor on the spleen causing false-positives. And it wasn't until the second US we were told about the tumor so if treatment had been started when everyone was telling me it should be started, she would have died from that tumor. So I get nervous EVERY time someone starts treatment without extensive testing especially when something else seems "off". The ALP I don't worry about but the AST, ALT, and GGT I do. Why? Because of what Squirt's IMS told me about these values - ALP represents living liver cells, the others represent dying liver cells - so I would want to know why are they dying? Because of the cortisol or maybe something else is going on as well or instead of Cushing's?

And again, the elevations could be due to the Cushing's and nothing more. But I'm a worry wort. :o

[Junior's Mom]

Well, now I have more questions than answers. I read that tristolane is contraindicative in dogs with liver disease. Don't all cush dogs have elevated liver values though?
Now I'm wondering if I should do more tests, or a biopsy or something.

My vet left me a message today, she will be phoning back tomorrow afternoon. She said that because of his liver values, (which she is pretty sure are only do to cushings), she would want them rechecked at the acth test, to make sure the tristolane has not done more harm. I had not questioned here on this yet, so she is thinking clearly.

Vetoryl here is $154. per month. YIKES!

[molly muffin]

Hi :) Almost all dogs with cushings seem to have high liver values. That is in fact, usually one of the first things that a vet notices and starts them testing for cushings, that and the "symptoms".

The way I understand it, is that high cortisol causes a couple things, usually enlargement of the adrenal glands because they are working over time producing more cortisol than is needed and an enlarged liver, due to the liver working extra hard, due to the high cortisol. So, yes, usually there are high values.
Liver disease though is when it is the liver itself that is the problem, perhaps cancer, a nodule (can be totally benign) but something with the liver itself is the problem.

That is a pretty simplified version, but it's the way that I understand it and easily explained. So, ultrasound is one way to distinguish if there is something else going on with the liver, other than cushings, causing it to be enlarged.

I hope that helps. I would think that if it is the cortisol causing the problem then once the cortisol comes down, that things should start looking better. If it is liver disease, then it could be harder on the liver since the liver metabolizes trilostane.

Sharlene and Molly Muffin

[FemaleK9]

Vetoryl here is $154. per month. YIKES!

I shopped around online and found there are less expensive sources.
The cheapest one I found was VetApproved Rx.com (http://www.vetapprovedrx.com/shop.asp?category_id=&item_id=782#.UfM9DdLVAfV)

There is also the generic, trilostane. I just made a post on Rosie's thread that might interest you, too. I'll just put a link here (http://www.k9cushings.com/forum/showpost.php?p=115659&postcount=69).

[Junior's Mom]

Thank you femaleK9 for that info. Unfortunately they will only ship to the States, and I am located in Canada. I did find a company in Toronto, Universal Pet Meds, where I could get it for $115. That would save me almost $40/month!

I emailed my vet with questions on the liver values, and whether we should pursue more testing. Hopefully I hear back from her soon.

I would like to do a poll on how many dogs were anxious ones (it seems there are quite a few on here) before a cushings diagnosis. I'm not sure how to set the poll up though. Can anyone help? I am curious if there is a relationship between the increased levels of cortisol from stress, and a later diagnosis of cushings.

I would also like to know if anyone else see "mild lymphopenia" on the blood work results?

Junior weighs 50.2 lbs. Is 60mg low enough to start him on?

[FemaleK9]

Found this: Creating and Participating in Polls (http://www.k9cushings.com/forum/faq.php?faq=vb3_reading_posting#faq_vb3_polls)

ETA: I just tried this, and I don't see an option to include a poll. Maybe only mods can do it?

[Junior's Mom]

After some more reading-does it ever end?- I see UC Davis recommends 1mg/kg vs Dechra which recommends 1mg/lb.
Junior weighs 50.2 lbs or 22.8 kg. There's a big difference between the two. So, how much vetoryl should he be started on 22, 30, 50, or 60? Can anyone say?

[Junior's Mom]

After reading Dr. Feldman's study on low dose twice a day, that is the route I have decided to take. My vet is agreeable to that. So Junior will be starting on 20mg. twice a day. That means 120 Vetoryl capsules a month! He will be starting this Saturday morning.
My vet also recommended putting him on milk thistle. She did not see any reason to check his liver further, as the ultrasound did not show any abnormalities. We will be checking his liver values at his acth test though.

[Squirt's Mom]

Hi,

I'm sorry no one answered your previous post. We use Lsyo and I understand it better so I try to leave Trilo/Vetoryl to the ones who use it to talk about it. :o

If I have it right, you would want to start with the lowest dose possible then increase as needed. So the 1mg/kg would be the "better" starting point. So at his weight of 22.8 kg, the 20mg ONCE a day or 10 mg twice a day would be the starting point - if my math and thinking are correct. I do know you don't double the daily dose when giving it twice a day - you divide the daily dose in half. Hopefully one of the others will be along to comment soon.

Hugs,
Leslie and the gang

[molly muffin]

That is right. You don't give the dose twice, you split the dose. If you want to give 20mg per day, then you give 10/10.

Yes, I think milk thistle is a good option for liver support. I use something called Hepato Support that I get from my vet.

Sharlene and Molly Muffin

[Junior's Mom]

I want to thank everyone for all their help on here, and especially the administrators for all the hours put into collecting the valuable information to be found.

From Dr. Feldman's study "On the basis of the observation of a rapid but transient
response (< 12 hours) to a low dose of trilostane

"Treatment evaluation of all 47 dogs—Mean initial
dosage of trilostane for all 47 dogs with NOH was 0.86
mg/kg (0.39 mg/lb, q 12 h)."

I read this as the dose that is given every 12 hours. Am I wrong? Acth tests are done 4-6 hours after dosing, because it doesn't stay in the system that long.

1mg/lb for Junior would be 50mg/day.
This way, he is only getting 40mg/day. Less than Dechra's recommendation.

[molly muffin]

hmm, right, so you could actually go to 25/25 a day, but would need to get it compounded rather than the brand name vetoryl.

Yes you try to give it at 12 hour intervals, with a bit of food. Not too low fat, as you want a little bit as that helps with the absorption. Say a piece of cheese.

So if you give it at 8am, then you'd want to go in for the test around 10 (ish).

Sharlene and Molly Muffin

[Junior's Mom]

I feed my dogs twice a day as it is, so I would just need to make their supper later to keep Junior's dose at 12hrs. One night a week however, I would be going to work around that time. Would a piece of cheese be enough food for the medication, if he had his dinner 1 1/2hr before? I can't quit my second job now!

[Junior's Mom]

Day 1 of vetoryl dosing over. No side effects, definite drop in water consumption. I have prednisone on hand-just in case. Now I can breath again.

[FemaleK9]

Sounds like you're on the right track, I hope Junior continues to improve - keep us updated, OK?

[spdd]

Wow, day 1 and there is improvement already. That's good news.

[Squirt's Mom]

Sorry no one answered you about the meals - our Trilo folks are quiet the last few days! :p As far as I know - which isn't far with Trilo - giving the pill with a little cheese or meat 1 1/2 hours after the full meal should be fine. It is critical tho that on the days he has the ACTHs that he have a full meal along with the med the morning of the test. If the pup is fasted on Trilo, the ACTH is invalid so don't let your vet or the techs tell you any different. ;)

[goldengirl88]

Great job, glad your baby is doing well. I give Tipper her Vetoryl with chicken if your dog won't eat cheese give it a try. This drug is fat soluble so that is why the cheese etc. is necessary. Good Luck
Blessings
Patti

[labblab]

Yay!! I'm so glad this first day is behind you, too!

Wow, four boxes of 10 mg. capsules a month, though. That is expensive :o. For the sake of your pocketbook and also ease of dosing, I'll be hoping that Junior actually ends up needing an increase because two boxes of 30 mg. would be cheaper for you. ;)

Just to add a few more idle thoughts about initial dosing, I've had mixed feelings about the differing recommendations and honestly am not sure where I'd start myself, dosage-wise, if I was beginning all over again. Here's another quote from Dr. Feldman's study which may shed some light on why Dechra still recommends the 1 mg. per pound formula (their older printed initial dosing "range" is actually 1-3 mg/lb, but in their most current advisories the recommendation is to start at the low end of that range):


In dogs that had a good response at the one-year reevaluation, the mean trilostane dosage was 1.7 mg/kg [.78 mg/lb] given twice daily or 1.1 mg/kg given three times a day.
So the mean "good response" dosage translated into a daily total of approx. 1.5 mg/lb. Of course, this means some dogs required more than that, and others less. But in order to achieve a "good response," Dr. Feldman's study average equalled 1.5 mg/lb. Obviously, Dechra has an interest in having owners feel as though the medication is controlling their dogs' troublesome Cushing's symptoms, and there is always a danger that patients will drop out of treatment if the symptom resolution takes a long time to achieve. So I can imagine that they would endorse a dosage level that is likely to be therapeutic sooner rather than later in the process.

From my experiences here over the years, I can see both pluses-and-minuses with starting lower than Dechra's initial 1 mg/lb formula. Dr. Feldman tells us we may likely see fewer side effects when doses are started very low and titrated upwards. And obviously some dogs never need a dose as high as 1 mg/lb, and would have required a dosage decrease had that been the point where they started. But when dogs are started as low as 1 mg/kg, I've also witnessed owners who became very disappointed and worried when their dogs gained little symptom relief after treatment was started. And the low dose and slow titration upward ended up being very expensive because it necessitated repeated dosing "tweaks" and ACTH monitoring tests. I also think once daily dosing can end up being both easier and cheaper for owners, so if a dog is doing well on once daily dosing (symptoms well controlled with no rebound), I don't personally press owners to make a switch unless their dog is diabetic (for which there are additional reasons why twice daily dosing may be preferable).

So I think there are reasons to support a variety of initial dosing approaches, and that does make it a challenging choice for the owner! But no matter how an owner begins dosing, the proof of the pudding will lie in the monitoring ACTH tests in addition to symptom resolution. So theoretically, no matter which approach you begin with, your dog should end up with the optimal dose for his system once the monitoring has begun and appropriate dosing changes (either upward or downward) are made as a result. But this is why the regular testing and close observation are so important.

Here's hoping that the road will be smooth and easy for Junior!!

Marianne

[Junior's Mom]

Marianne, I did spend some time pondering once or twice daily dosing. If Junior was older and suffering from arthritis or just general aches and pains, I would probably have started with once a day to allow the cortisol to rise in the evenings.
It would definitely work out cheaper to increase the dose, and only do it once a day. 4 boxes cost me $171 plus tax, from the vet, which was cheaper than an online pharmacy. A part of me is hoping he has to increase for that reason.
My thinking was that I started treatment early on, and slowly lowering his cortisol, or not lowering it drastically off the bat would be easier for his system to adapt to.
Last night we had a storm, could be wishful thinking, but I swear Junior was less reactive to it than normal.
First pee of the morning, today, before his dose, was at least 1/3 less in quantity, and had some colour to it! On our walk, he was much less crazy about trying to chow down on the grass.
I would have to say, things are looking good so far. His acth is Aug 14.
I give him his medicine in cream cheese, after he eats his meal. He loves it. Now when I am having some of my own, he thinks he should be entitled.
Thanks for all the encouragement and well wishing.
Tracey

[labblab]

Tracey, your strategy makes perfect sense. And you are such a knowledgeable and vigilant parent -- you already know just what to watch for, and how to make changes should they be called for. Junior could not be in better hands!!

Marianne

[goldengirl88]

Tracey:
Have you tried Lambert Veterinary Supply? I get my Vetoryl there really cheaper than any where else. If you ask for Nancy and order 2 or more boxes she will ship it free. I searched everywhere and this was the cheapest I could find. Blessings to you and your baby.
Patti

[molly muffin]

Sounds like things are going better with Junior. Glad to hear it. Good job!!

Sharlene and Molly Muffin

[Junior's Mom]

I just got the milk thistle to start Junior on. Does it need to be given at a different time than the vetoryl, or can I just put it in his food? He had a pretty quick pee first thing this morning, and it was a nice yellow colour. There is a bit of colour at other times, but not like the morning yet. So far, so good.

[Junior's Mom]

Can milk thistle be given with vetoryl, or should it be at a different time?

[Squirt's Mom]

Sorry to miss this earlier! As far as I know, they can be given together.

[Junior's Mom]

To update. Junior has been doing great. His 5th day on vetoryl, his belly hair started to grow back. He drinks and pees much less. He is still pretty hungry though. We got the results back from his acth. There's been improvement, but not enough. I will be raising his dose 25%, it will be 25mg twice a day now instead of 20. I won't be changing it till I get some more meds. Either I get 5mg compounded to add to his 20 or I get 25mg compounded.
Pre 171 (up from before-134) Isn't that weird?
Post 524 (prev was 1255)
His liver enzymes were checked as well, they have not gotten worse.

[Junior's Mom]

Update on Junior. He is starting on 25mg twice daily this evening. I have 10mg vetoryl and 5mg compounded. While I have been happy with his results so far, his acth showed otherwise. I don't wish him harm, but it would be much cheaper if I have to up his dose to 30mg. eventually.
I'm glad I have learned so much from here. I like my vet, and she listens to me, but after his acth she suggested doubling his dose in the morning, and leaving his evening one alone.
I don't agree with different dosing amounts-it just doesn't make sense unless he is arthritic, and I really don't agree with big dose changes. So I straightened her out and told her what we were going to do instead.

[Junior's Mom]

Could an administrator please change my thread title? He is 6 now. Perhaps it could just say twice a day trilostane dosing, for those that might be looking for that.

[lulusmom]

Could an administrator please change my thread title? He is 6 now. Perhaps it could just say twice a day trilostane dosing, for those that might be looking for that.

I've changed your thread title per your request.

[Junior's Mom]

Thank you.

[FemaleK9]

... While I have been happy with his results so far, his acth showed otherwise. ...

I apologize if you have already posted this, but could you give us the ACTH test results? Was he given his Vetoryl within four hours of the first reading? With food or fasting?

[Junior's Mom]

Karen, no apologies necessary.
The test was to be done at 4 hrs after dosing (with food). However it ended up being 4hrs and 45mins as the office had an emergency and we had to wait.
I think the waiting is why his pre was higher than before-he got stressed out. I'm no expert though. I brought him home and then took him back for the post. In Canada it is 2 hrs later.
His results: pre 171 post 524
It's been over a week between his results, and the dose increase due to coming up with the next plan, and getting the medication in.
We will be retesting in 7-10 days.

Tracey

[Junior's Mom]

Just to clarify, I wasn't satisfied with the change in his symptoms, but happy that I saw a big change.
He is still starving, and pees as soon as he is outside.
His pee is usually yellow though, and there is much less of it. His specific gravity has come up.

[FemaleK9]

OK, I understand now. It just worries me that so many vets aren't up to date on Cushing's, and try to do ACTH tests on fasted dogs (as my vet would have if I hadn't learned better from the folks here and put my foot down) and prescribe massive single daily doses of meds and such.

But it sounds like you're on the right track and close to getting Junior's symptoms fully under control. I look forward to seeing updates with good news!

[Junior's Mom]

Hi everyone. Junior's elbows have been quite lumpy, rough and bare for a few years. My other dog's are a little bit bumpy, but nothing like Junior's. I know it is usually caused by flopping down on hard surfaces.
After the cushings diagnosis, I wondered if his elbows were a symptom perhaps as well.
4 days after increasing his dose, one elbow started to swell up. I had missed giving him his omega 3 and vit e, (which helps the elbows look almost normal) so I put it down to that. The swelling increased and decreased throughout the next day. Then the day after that his other elbow started swelling, and they were beginning to look infected.
I of course panicked, thinking it was linked to the dose increase, so I withheld his meds this morning, and took him to the vet. It is a hydronoma?, and he is on antibiotics now, and I have devised some padding for his elbows.
Long story short, I have read about a lot of lumps, bumps and fatty tumours on here with cush dogs, and am just wondering if there is a link to either the cushings, or the vetoryl that has never been explored.
As my vet said, if we end up increasing his dose again, and see it worsen, then we will be questioning that in further detail.

[Junior's Mom]

My animals have fleas. It seems to be going around on here. The vet okayed Junior for Advantage, so I purchased some and started doing all the critters. I've used it before without a problem. Now that Junior has such thin, fine hair, I realized another drawback with cushings. There isn't much to hold the drops in place. Much of it dripped down, and then off him. I'm glad the fleas don't seem to enjoy him as much as the furrier ones, because he didn't get much of a dose.

[addy]

I could see that being the case. Sorry you have to deal with fleas. Hopefully his hair will fill in a bit. It takes awhile sometimes.

[Junior's Mom]

Hi everyone. I came across a study that was done on whether just a baseline cortisol test could be used as a monitoring tool, to save time and of course expense. Only dogs with once a day dosing were studied. The recommendations were a baseline between 1.3 ug/dL and 2.9 ug/dL in healthy animals. Here is the link if anyone wants to read it.
http://www.2ndchance.info/cushings-monitorcortisollevel.pdf

I also read about testing cortisol levels at the normal dosing time (without dosing) to determine whether once a day is controlling enough, or the dog should be moved to twice a day. Unfortunately, I don't remember where I found that.

I hope everyone's babies are doing well.

[Harley PoMMom]

That article by Audrey Cook is a good read. I am pasting a post by one of Administrators, Marianne, in regards to this article:

But here's some additional information for you to have on hand when you get back. That "resting cortisol" range of approx. 1-5 (or 2-6 for some labs) is the laboratory "norm" that is given for a dog who does not have Cushing's. Historically, the baseline cortisol reading has not had significance for monitoring a dog being treated with trilostane. However, a researcher at Texas A & M who is also a consultant to Dechra, Dr. Audrey Cook, has recently performed a study aimed at investigating whether or not baseline cortisols may have predictive value in assessing whether a dog is being overdosed or underdosed on trilostane. Dr. Cook freely admits that more research is necessary to decide the true clinical significance of this study, but her initial findings suggest that baseline cortisols between 1.3 and 2.9 were associated with good cortisol control for the dogs she tested. She recommended full ACTH tests for dogs with baseline cortisols outside that range in order to insure that their post-ACTH results fell within parameters that were safe and effective. Here's a link to Dr. Cook's study:

Evaluation of the use of baseline cortisol concentration as a monitoring tool for dogs receiving trilostane as a treatment for hyperadrenocorticism (http://www.2ndchance.info/cushings-monitorcortisollevel.pdf)
Marianne

As for the timing of the ACTH test to determine whether once a day or twice a dosing is needed I found this info here: Applied Dermatology: Old or New? A Comparison of Mitotane and Trilostane for the Management of Hyperadrenocorticism (https://www.vetlearn.com/_preview?_cms.fe.previewId=9a6f9ce0-bd77-11e2-8e71-005056ad4736&ArticleURL=https://www.vetlearn.com/compendium/applied-dermatology-old-or-new-a-comparison-of-mitotane-and-trilostane-for-the-management-of-hyperadrenocorticism)

Excerpt from that article:
In my practice, dosing is often increased to twice daily, but I prefer to document the degree of variation of cortisol levels before this adjustment. For example, if clinical signs (including hair regrowth, recurrent infections, and PU/PD or polyphagia) are not well controlled, but ACTH-stimulated cortisol levels are within the target range, I ask the owners to bring the dog back for a follow-up ACTH stimulation test 1 to 3 weeks later. The test starts at the hour at which the dog would typically receive trilostane, but without giving the medication. By beginning the test at this time, we are able to document the highest level of cortisol possible for the patient during the day.

[Junior's Mom]

Thanks for those links Harley PoMMom.
I am curious about pre results in acth tests. I know Dechra says they should not go lower than under 20nmoL or .725ug/L, and that there needs to be a change between pre and post, but what is an acceptable pre if the dog is controlled?
Has anyone noticed quick changes in the pre, or is it usually only post that drops dramatically?
Junior has gone (in nmol) 134pre 1255post (before meds)
171pre 524post (on 20mg 2x day)
141pre 400post (on 25mg 2x day)

I am now increasing to 30mg twice a day. I will not increase again, regardless of the next acth test results, until a month has gone by on this new dose. So I will test in 10-14 days, and then again in 30.

I am just wondering if the fluctuation in the pre numbers are the norm? Not that there is much "norm" with our pups!

[FemaleK9]

I converted from nmol/L to ug/dL (1 ug/dL = 27.59 nmol/L) and charted Junior's results to get a feel for the numbers:

http://farm8.staticflickr.com/7417/9731691839_79fb613a5f_o.jpg

I took the reference ranges from my own dog's test results.

I think having the tests done at different times of day, different meals/mealtimes, different stress levels, etc, could explain some of the variations in the pre-test levels. I'll leave any further interpretation to the people with more experience than me.

How are Junior's symptoms doing, and how is he feeling?

[Junior's Mom]

Thanks for calculating those numbers Karen. I'm not worried, just curious about pre-numbers. Junior's is doing great. If it weren't for the numbers coming back so high, I would leave him alone for a while. He's definitely adjusting to the constant vet visits, and knows where the treats are kept now.

[Junior's Mom]

Can anyone tell me what the recommendations are for pre-acth numbers? All I can find is post. Thanks.

[Squirt's Mom]

For Trilostane (Vetoryl), they want the pre number no lower than 1.45 ug/dl.

[Junior's Mom]

As others have questioned, I am curious about the necessity of stim tests. If the pre (resting) draw is done 4 to 6 hours after dosing, it would show the lowest amount of cortisol in the dogs body. As long as the numbers were in range, then things should be fine. The post shows how much more cortisol they are capable of dumping. What does that matter?
That being said/asked the post numbers must have some special importance, because I have seen Junior's symptoms steadily improve, yet his pre has actually increased and/or remained the same since starting vetoryl. It's confusing me to say the least.
pre post
134 1255 before meds
171 524 20mg twice a day
141 400 25mg twice a day
170 392 30mg twice a day

Any thoughts on this? I will be increasing to 40mg twice a day once it arrives at the vets.

[frijole]

Typically the first number is higher than normal if the dog is stressed at the time. I had a dog that had double digit numbers for the first reading and that was bizarre. Your highest one when I convert it is 6 so I don't think you should worry.

The reason why you test is to find out where the cortisol is. If you go back to Lori's post where she copied/pasted info for you there is a range at the far right and that is your goal. Just like treating any other disease you have an objective and in this case it is to lower the cortisol.

You can't make a dosage change without doing the test because you could overdose. It sure does seem like you have done a lot of increasing - not sure over what time period. I caution you that we have seen many times where the dose doesn't kick in until up to 30 days later so I hope you are giving it time in between increases.

You said the symptoms have improved - that really is what you are looking for. I think I'd hold off on further increases after this one and see what happens. Take care, Kim

[Junior's Mom]

Has anyone ever had a dog plateau for a while, even with increases in vetoryl? While I am pleased with Junior's progress, the last 2 increases have made no difference in his stim tests. His last one was yesterday, and his number actually increased somewhat.

On a good note, my vet's office purchased a snap machine, and now the tests can be run in house, saving $35. each time. Since I have been getting them about every 3 weeks, that will definitely help.

[addy]

OMG I could probably write a book to you but will resist the urge. Has your dog's pre number been elevated or normal on the two tests? Forgive me for not reading back through your thread but does your pup have any other illnesses? Does your dog have pituitary or adrenal Cushings?

My own dog has had an increase in numbers but decrease in symptoms a few times. For Zor it usually correlates to another health issue that was on going, even surgery, once.

Stress can sometimes elevate the numbers and the numbers can fluctuate as well, those hormones fluctuate so we are given a range and also told to monitor symptoms. One test you could catch your pup on a "high" day another a "low" day.

[Harley PoMMom]

How are Junior's symptoms? If his symptoms are controlled I would not focus on those ACTH results.

Hugs, Lori

[molly muffin]

Yep, sometimes it is about the symptoms and what Junior is doing and how he is feeling, rather than the exact numbers.

Nice about the snap machine!
hugs,
Sharlene and Molly Muffin

[Junior's Mom]

I agree, I am going by the symptoms, and they are manageable. The problem is the numbers are still too high. His last 2 posts were 393 and 423. This is with 2 dosage increases. Should I just leave his meds the same for a while and see what happens.

[Harley PoMMom]

Would you do me a favor and add the timelines to those ACTH stim results? Thanks so much!


As others have questioned, I am curious about the necessity of stim tests. If the pre (resting) draw is done 4 to 6 hours after dosing, it would show the lowest amount of cortisol in the dogs body. As long as the numbers were in range, then things should be fine. The post shows how much more cortisol they are capable of dumping. What does that matter?
That being said/asked the post numbers must have some special importance, because I have seen Junior's symptoms steadily improve, yet his pre has actually increased and/or remained the same since starting vetoryl. It's confusing me to say the least.
pre post
134 1255 before meds
171 524 20mg twice a day
141 400 25mg twice a day
170 392 30mg twice a day

Any thoughts on this? I will be increasing to 40mg twice a day once it arrives at the vets.

[Junior's Mom]

I have added the dates of stim testing
Pre Post
134 1255 before meds July 19/13
171 524 20mg twice a day Aug 14/13 11 days on this dose at the time of testing
141 400 25mg twice a day Sept 7/13 15 days on this dose "
170 392 30mg twice a day Oct 12/13 33 days on this dose "
170 423 40mg twice a day Nov 11/13 17 days on this dose "

[addy]

Pre Post
134 1255 before meds July 19/13
171 524 20mg twice a day Aug 14/13 11 days on this dose at the time of testing
141 400 25mg twice a day Sept 7/13 15 days on this dose "
170 392 30mg twice a day Oct 12/13 33 days on this dose "
170 423 40mg twice a day Nov 11/13 17 days on this dose "

So the last test if I convert to ug/dl which is what members are used to seeing

pre is 6 post 15

I think I converted this correctly, if not someone let me know.

so the pre is increasing the last two tests and at a post 15 you are not within range, you want to be at least down to 248 post (9ug/dl)

What does Junior weigh?

So my Zoe has high pre numbers that I contribute to stress and her on going concurrent illnesses. I have googled my heart out to research pre numbers and did not find much written so after 2.5 years of stims and dosing I pretty much know her pattern and have drawn my own conclusions based on Zoe's history.

You may be seeing some symptoms improve but that post is still too high. Dechra says up to 9.1 ug/dl with symptoms controlled.

Just my take:)

[Harley PoMMom]

I agree, that according to Dechra, Junior's post numbers are not within the therapeutic range but since Junior's symptoms are manageable, if this were me, I would feel more comfortable letting Junior's dose as is, at least for a month. Vetoryl can continue to lower a dog's cortisol while the dosage stays the same, this is my reasoning for not adjusting Junior's dose at this time....just my opinion. ;)

Hugs, Lori

[addy]

And it certainly can, I agree with Lori, especially larger dogs can be more sensitive to Vetoryl/Trilostane.

The bottom line is you know your dog- you know what symptoms were concerning at the start and what symptoms seem better now.
You need to trust your own instincts as we dont always know the whole story.

Zoe has been on 50mgs for over a year- she has been post 6, 10, 7, 4 and 5 - all on the same dose. But durring that time she also had other health issues, including two surgeries.

Which is why I stress know thy dog above all else.

[labblab]

I agree that at this point, I'd probably just leave things alone for a month since you are seeing improvement in Junior's symptoms. At that point, you can re-evaluate.

I also agree with you, though, that it seems odd that Junior's "post" result actually increased on this most recent higher dose (all the previous testings had come down at least a little bit). Are you still using a combination of Vetoryl and compounded trilostane? If so, has the source of the compounded product changed this time around?

Marianne

[Junior's Mom]

Thanks for all the replies. I waited a month the last time, before upping his dose, I guess that's what I will do again. I still see more fur growing in, so even if the numbers don't show it, there is improvement.
His higher number this time doesn't surprise me, because we had his neurotic Dad along for the ride this visit. Junior's become pretty calm about all these trips, but having a bouncing, whining, barking buddy with him, got him a little more stressed out.
We've been checking liver values every second stim test, and they have improved all along. I think I'm going to do some urine testing, and complete bloodwork just to rule out anything else going on. He has lost a couple of lbs, but it could be due to some jogging we've been doing.
All his medication is vetoryl, no compounded right now.

Has anyone every read about cushings dogs being prone to diabetes, and this study that was done on how giving insulin may help prevent it? Has anyone done this?
http://www.ncbi.nlm.nih.gov/pubmed/21807392

Tracey

[Junior's Mom]

After Junior's last acth, my vet consulted with an endocrinologist. The specialist is of the opinion that his dose should be increased to 60mg. He is having another stim test in less than 2 weeks, so I will decide when I see his numbers. I have been trying to keep his increases close to 25%. I'm debating the 60, as I would feel more comfortable just going to 50mg. However, price is becoming a huge factor, as unless I went compounded, 60 would be cheaper then 50. It would be cheaper than the 40 he is on now, as that cost me $388 for a months supply.
Would a jump to 60mg be okay?
Has anyone looked into my post above about insulin warding off diabetes in cush pups?

[molly muffin]

Junior is on 40mg twice a day currently? I believe that is the last one we had, with a pre of 6ug and a post of 15ug.
What just Junior weigh now?
I think that how much you want to go up, would be determined what the numbers are, how he is doing, etc and of course, cost is a factor too.
If the numbers are still high and you don't feel comfortable that his symptoms are controlled then you can go up. Dechra says 9.0 if symptoms are controlled is good. Of course Junior was at 15. So, the vet wants to go to 60mg twice a day? You'd Rather have 50mg. You currently give a total of 80mg, and this would take it up to 120mg per day (60/60) but how about 60/40? or another combination? Even a combination of vetroyl and compounded to get to the number you want at a price that is reasonable would work. We have a member who is using both currently.

Yes, we have seen that study, and the administrator from k9diabetes looked it over too. The general consensus was that there wasn't enough dogs in the study, it didn't continue long enough, and that from a layman's perspective but someone who has been very involved in k9 diabetes for a long time, is that this could be a dangerous move too, with too little known of the possible long term affects.

Not all dogs who have cushings get diabetes. Some do, but I wouldn't even say a majority do so.

Hope some of that helps.
hugs,
Sharlene and Molly Muffin

[molly muffin]

Happy Thanksgiving to you and Junior!

Hope things are going well!

hugs,
Sharlene and Molly Muffin

[Junior's Mom]

Junior doesn't have cc, so I can only imagine the heartbreak many are dealing with trying to help their pups. I'm wondering if anyone has tried a vinegar and warm water solution? It may help to break up the hardness, and it would kill off any bacteria on the skin as well.

[goldengirl88]

I don't know about the vinegar part it may help with the bacteria, but the acidity may burn???? Just thinking it might.

[Junior's Mom]

Hi everyone, hope all the pups are doing well.
Question on stim tests: the pre is the amount of cortisol they are running on, the post is how much they have in reserve. As the numbers get closer together, is there a worry? Does it matter if they have little to none in reserve?
Also, when they say "with symptoms controlled", how controlled are they talking? Absolutely no symptoms, or small symptoms that can be easily lived with?
Last but not least, I have searched all over for information on cranberry and salt, and how they can affect cortisol levels. I have found nothing. Does anyone know? Any thoughts on this?
Thanks again, always grateful for the help and caring on here.
Tracey

[goldengirl88]

It was just explained to me by Dechra like this. Tipper's pre number seems to want to go low now. She was at a .7 one time not too long ago and we had to drop her dose down. Dechra said the reason they do worry about the pre number is that they have seen when the pre number drops too low the post number will soon follow. That would mean Addisons could happen. I know it has been said that the pre number is not important, but Dechra told me it is. So I am following that as I do not want an Addison's episode with Tipper, she has had enough problems. Hope this answers your question. Blessings
Patti

[Junior's Mom]

Anyone know how salt and cranberry can affect cortisol levels?

[Junior's Mom]

Dec 7/13
Pre 253/9.17 Post 281/10.18

[addy]

How is the blood work? How is Junior feeling? Are there any symptoms that are concerning you?

Was the last test was post 15 ug/dl ?

[Squirt's Mom]

I've never heard of cranberry or salt having an effect on cortisol but that isn't to say they can't. Did you read something about this somewhere? Do you have the link?

Salt in general isn't good for dogs - they get plenty of sodium in the feed. Cranberry is used by several members to help with urinary tract issues and I don't recall any problems with maintaining control of the cortisol in those pups. Interesting question!

[labblab]

Yes, I too am wondering why you are asking about possible effects of cranberry and salt? As Leslie, says, people do sometimes dose themselves and their dogs with cranberry in the hopes of lessening UTIs. But why are you asking about salt? Is Junior getting some type of food or supplement that is high in sodium?

I've never heard of a specific effect on cortisol, but I would think you'd not want to venture outside of normal salt intake so as not to upset the electrolyte balance (potassium vs. sodium) in a Cushpup taking trilostane. However, this balance is linked to aldosterone (another adrenal hormone that can be affected by trilo) rather than cortisol.

Marianne

[Junior's Mom]

After Junior had a second stim showing no drop in his post number, I went back through my notes. I had changed his diet at one point, because too often the food and cranberry supplement wasn't on the store shelf. Sure enough, I made those changes the same time he stopped dropping.
The cranberry I had been giving him daily. The food was the same brand, but the senior line. It has less fat, and slightly less protein, and salt listed as an ingredient at about # 18. That's the only differences.
I wanted to rule out diet having an effect, so I put him back on the senior food, and the cranberry. Without changing his dose, his post dropped. It can't be a coincidence.

[addy]

It may just be a matter of better absorption of the drug with the senior line food and/or time. As a side note, I cut back on fat and protein with Zoe and her numbers have been down as well. It could be they can absorb the drug better. :confused: It could be possible. Dont change the food again, keep it consistent and see what happens.

Vetoryl is strange sometimes. Zoe had been on 30/20 and her numbers have been all over the place for over a year on the exact same dose. She had a lot of other health issues going on as well, though during that time. She has also been on the drug since June 2011.

Sometimes it is just hard to know.

[Squirt's Mom]

Yeah, I don't know that you can attribute the changes in the cortisol level to the cranberry and/or salt with real confidence. The cortisol levels can vary when absolutely nothing external changes. Now that's not to say those things couldn't have had such an effect on Junior - each of these babies is a unique biological entity so it is possible they cause reactions in him they wouldn't in another. But I would be more inclined to think there was some other reason for the changes in his levels. STILL a very interesting question tho.

Brick and Trinket both experience high glucose levels when they were eating Royal Canin feed - but no other pup I've known that eats that feed has had the same thing happen and our vet was just sure the feed had nothing to do with it. But once they were off the RC, labs returned to normal....so whether anyone can prove the feed was the cause scientifically or not doesn't mean a hill of beans to me. That feed caused their blood glucose to shoot up, no question in my mind - there was no other variable.

I would do as Addy suggested and stick with the original diet for now. Once you know he is settled in on treatment, then you can look at diet changes IF needed. ;)

[Junior's Mom]

So after Junior's last stim, the original plan was to take him from 40mg twice daily to 60mg twice daily. I had 30 and 10mg capsules here, so I brought him to 50 first, for a week to use up the 10s. Then I gave him 2 30s, to up it to 60mg. After the 3rd dose of 60mg, his leg swelled up like a balloon within 2 hours.
He had swelling, just at the elbows, before during an increase, but not like this. This was sudden and extreme, and caused him to limp.
I skipped his next dose, gave him omega 3 and vit E twice daily, and dropped his dose to 30mg.
Within 24 hours, his leg was much better. Due to the holidays, and playing email tag with my vet, he ended up on just 30mg for a week, as I needed to order the 50mg, instead of the 60 I was originally going to do.
I had his leg x-rayed. It looked fine, just some small signs of swelling. So now we stick with 50 and see what happens. If his elbow starts to swell again, we will have to needle aspirate the elbow and check for bacteria.
On a slightly different note, those of you in the States are some lucky! I got a quote from Diamond back for 60-50mg trilostane (1 months supply). $63 American plus shipping. Here in Canada, I paid just over $200. Huge difference!

[molly muffin]

Wow, swelling in the leg joints in reaction to the trilostane. Well, you certainly do have a sure sign that will tell you when it is too much for junior. Might not hurt to have some smaller amounts to, like the 30mg in case for any reason he starts reacting to the 50mg.

I know, horrible the prices we get hit with here in Canada. Not to mention the amount of vet products that we need a prescription for but that can be bought on amazon.com or a pharmacy in the states. Don't even get me started on anitibiotics for dogs cost vs in the states. $20. per pill here last time Molly needed some.

wow, you hit my rant didn't you :)

I'm very sorry that junior had such a reaction, did the vet mention anything about Why or what the reaction is?

Happy New Years Eve, bloody cold in Ontario right now and the coming couple days. Stay warm!

hugs,
Sharlene and Molly Muffin

[Junior's Mom]

I had a thought, don't know if everyone would go for it though.
There are so many of us dealing with dosage changes, I'm sure we would all end up with pills kicking around in dosages we are no longer using.
What if we had a thread where people could post what they had available, and we could have a trade system going on?

[labblab]

There are so many of us dealing with dosage changes, I'm sure we would all end up with pills kicking around in dosages we are no longer using.
What if we had a thread where people could post what they had available, and we could have a trade system going on?
It sounds like an appealing idea, but unfortunately our forum rules prohibit public offers to sell or trade medication. This is because U.S. federal law prohibits the sale or transfer of prescription medication among private individuals.

Marianne

[Junior's Mom]

Thanks for that Marianne, it makes sense to have those rules in place. It is a shame though.

Junior's stim test Jan 11/14 pre 132 (4.78) post 234 (8.48)
YES! I'm happy and sticking with this dose for a while.

[molly muffin]

That is good test results for Junior. :)

How are his symptoms doing?

[Junior's Mom]

His symptoms are good, depending on what is expected I guess. There are no set guidelines that I can find.
He never got to the point where he woke me up at night. He hasn't had an accident in the house since the 3rd day on vetoryl. I don't have to take him out any more then the rest of my dogs, he just pees a little longer then them.
When we started on this journey, his first morning pit stop would last over 60 seconds. I didn't think that was good for his bladder or his mental well being. He now pees for just 20 secs in the morning, and usually 10secs other times.
He isn't acting starving any more, and his fur is starting to thicken up.
We may still have to up his dose, but for now I will leave him as is.
My vet keeps saying the target is 40-160 nmol/L for post. I tell her that I am happy with under 250 and so is Dechra.
My next order of trilostane will be coming from Diamondback, so that should save over $100.
I'm going to have a complete fasted blood chemistry done on him in Feb. I will compare that to one just over a year ago, and see what has changed.
I wish all the pups and their parents peace.

[Junior's Mom]

Junior's last stim was within range, and his symptoms were fine, so I left his dose the same. Usually it takes 2 days for him to get back to "normal" after an acth. This time he never did. Increased peeing and drinking that kept on. So I did a free catch urine sample to check for a uti. It came back with some blood, protein, and debris, so antibiotics for a week. They made no difference-still with the increased peeing and drinking, and the urine was getting less colour to it.
Off to the vet for a culture by cyntosis (sp?). It came back negative.
During all this time, he has lost a lot more fur, so we just upped his dose today to 58mg twice a day.
It seems like the stim test reset his system somehow. Have others ever run into this?

[Renee]

I wondered this same thing myself, as the last stim test my pug had (before the one we just had earlier this week), seemed to set her back. She had a strange reaction and was very different for about a week.

I just wonder if it is the cotrosyn or if this is what they talk about when they say that one day you'll wake up, and the dose that has been working will suddenly not be working anymore.

[goldengirl88]

My Tipper had really bad reactions the first couple times. It actually sent her into vestibular episodes the first so times. It scared me to death. Thank God it is better now some 15 stims later!!. She seems out of it a little and sometimes seeming confused, but not as bad as the first couple. Blessings
Patti

[Junior's Mom]

I know that managing this horrible disease is a combination of stim #'s and symptoms. Until the last set back, I was pretty happy with Junior's symptoms, and his numbers were in range. Then the stim seemed to throw all that out, so we upped his dose.
In regards to the peeing, I'm curious as to what I should be aiming for. Before meds, his first pee in the morning lasted more than 60 secs, and usually begin as we walked down the stairs outside. He now goes pretty much at the bottom of the stairs, and it's 19sec. In comparison, my other male (his father) goes for just 8sec. Should I have a goal in mind?

[molly muffin]

hmm, that is a new one for me to consider. :)

I don't think I would worry about how long junior pees, it will likely always be higher than it was before. I think more to concentrate on is being able to make it down the stairs and out the door before letting go, however long that may be.

Sharlene and molly muffin

[goldengirl88]

I would not be concerned about how long he pees, as much as I would be concerned if he is concentrating his urine, how much he is drinking, any panting, or ravenous appetite. You are doing a great job at being vigilant, which is really needed to maintain these dogs properly. Blessings
Patti

[Junior's Mom]

I believe some of you have had contact with Dr. Peterson. I'm wondering if you can clarify the following statement on his blog for me:

"For my cases, I recommend maintaining a post-ACTH cortisol concentration between 2-7 μg/dl when tested 4-5 hours after the morning dose."

In Canada, the post is drawn 2 hours after the pre. That means testing should begin no later than 3 hours after dosing. In the States, I think the post is even later. So to follow Dr. Peterson's goals, testing should begin sooner than the standard 4 hours after dosing recommended, right?

[Harley PoMMom]

The time for the post draw is dependent on the stimulating agent used. When ACTHAR gel is used the post is drawn 2 hours after the ACTHAR gel is injected. In the U.S. Cortrosyn is usually the preferred stimulating agent and when injected the post is performed 1 hour later.

Regarding the timing of the post draw, some endocrinologists recommend a 3-5 hour time-frame, Dechra states in their product insert that the post should be drawn 4-6 hours after the Trilostane is given. I believe what is more important is to have the ACTH stimulation test done within the same timelines so one can compare apples to apples.

So, using Dr Peterson's protocol of 4-5 hours, if a dog is fed and dosed with their Trilostane at 9 am the post has to be done no later than 2 pm.

Hope this helps.

Hugs, Lori

[Junior's Mom]

Jan 11/14 pre 4.78 post 8.48 on 50 mg compounded trilostane from pharmacy vet uses regularly

Never back to his normal after this stim test.

Feb. 14/14 switched to 50mg compounded from Diamondback because it was less than 1/2 the price

March 17/14 Peeing and drinking still too high, so upped to 58mg from Diamondback

April 5/14 pre 7.44 post 16.5 What the heck????!!!

My vet is going to take the weekend to think it over, but she is leaning towards quality control from Diamondback.

I think I will have to switch him back to the other compounded or the brand name Vetoryl again.

Any thoughts?

[molly muffin]

Diamondback usually has a very good reputation for quality and consistency. Strange that.
You could try, a combination of vetroyl for the majority dose and trilostane compounded in a smaller amount to make the difference for dosage. (keep costs down a little bit anyhow)

Very very weird it going up like that.

hugs
Sharlene and molly muffin

[goldengirl88]

My Tipper takes 20 mg Vetoryl and 7mg Trilostane. Her dose has changed so many times this is the only way for me to do this as I will not give her 1 more mg of this stuff than she has to have.

[Junior's Mom]

My vet decided to run the test again, for free, to rule out any lab errors. She made sure to have fresh stim agent as well. This time was definitely better.
Pre 4.58 Post 7.47
She is suggesting we increase his meds a bit, from 58 to 65 or 70 mg, in hopes of achieving results in the 2.17 to 5.05 range. I'm not sure I want to increase any more.

[Harley PoMMom]

How are his symptoms? If Junior's symptoms are controlled, then if this were me, I wouldn't increase his dose of Trilostane.

Hugs, Lori

[molly muffin]

I am with Lori, it depends on the symptoms. Dechra said if symptoms are controlled to owners satisfaction, then a post of up to 9.0ug is fine.

Sharlene and molly muffin

[Junior's Mom]

That's the million dollar question isn't it-the symptoms. I can't find a definitive answer to that anywhere.
He never has accidents in the house.
He doesn't drink excessively.
I don't have to take him out any more then my other dogs.
He isn't starving. Although I'm sure he wouldn't mind eating more.
He doesn't have a pot belly.
He never had any muscle wasting.

He pees longer than my other dogs.
His pee is still dilute-it seems to vary in colour throughout the day.
He is desperate to eat pine cones-they are all over my yard, and corn cobs left over on a farm road we walk on.
He has very sparse fur.

So I'm happy, but he can't tell me if he is, unfortunately.

[addy]

How's his blood work? Any abnormals? What about his liver values?

[Junior's Mom]

Bloodwork abnormals from Feb 8/14

ALP 192 (5-160)
Creatinine Kinase 189 (10-200) I put this here because it has been just 80-85 in the past
Urea 2.9 (3.2-11.0)
MCHC 373 (320-360)
Eosinophils 0 (0.1-1.25x..)
Lymphocytes 0.7 (1.0-4.8x..)

[Harley PoMMom]

That bloodwork looks pretty good to me. In Dechra's product insert it states that if symptoms are controlled than a dog's post number can be as high as 9.1 ug/dl. Seeing that you are happy with the improvements to Junior's symptoms, if this were me, I would not increase his dose of Trilostane.

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

Hugs, Lori

[Junior's Mom]

I went back to older blood work…
Gamma GT 9 (0-6) July 2013 For some reason this hasn't been tested again. I will have to ask for it specifically I guess.
Diamondback has decided that 58mg is too close to the available vetoryl of 60mg, so Junior's latest order came in at 57mg instead. I'm hoping that 1mg won't make a difference.

[molly muffin]

You can always get your vet to write a prescription for 1mg or 2mg trilostane if you need to make up a difference. Strange that Diamondback wouldn't give the amount ordered by the vet. I wonder if they wrote down the wrong amount or something.

Sharlene and molly muffin

[Junior's Mom]

Hi everyone. Junior has become a bit perplexing, or should I say the results of his acth's has. Junior himself is doing well I think.
58mg twice daily Pre 127 (4.5) Post 207 (7.5) left meds the same
Diamondback would now only sell 57mg instead
57mg twice daily Pre 147 (5.33) Post 342 (12.4) Huh!!!-upped dose
67mg twice daily Pre 156 (5.66) Post 420 (15.22) WTH!

So, is it lab error-these tests are run in house by my vet, or is the problem with Diamondback, or is Junior just a dog that likes to confuse things?

I don't believe I've read any post where a dog's numbers kept climbing when dosage was increased.
I am going to have the stim run again in a week or so, and have it sent out for testing. This will hopefully narrow down where the trouble lies.

In the meantime, I will keep his meds at 67mg twice daily, from Diamondback.

Anyone have any other ideas?
Tracey

[Harley PoMMom]

Is Junior getting his Trilostane with food? And are his ACTH stimulation tests being done 4-6 hours after Trilostane is given?

[Junior's Mom]

Yep, he always gets it right after his meal, and the timing of the tests is always the same.

[molly muffin]

That is rather bizarre. Diamondback has a good reputation, but maybe try some sort of combo with name brand vetroyl and trilostane to make the dosage? I know some others do that and see if there is any difference? That is the only thing off the top of my head I can think of.

Sharlene and molly muffin

[Junior's Mom]

I just had another acth done, this time sending it out to a lab, instead of doing it in house. Drum roll please….
Pre 54 (1.96) Post 57 (2.07)
It costs me $30 more, but I will be having his test sent out from now on.
I'm sure glad I double checked this, before messing with his meds. It's also good to know that Diamond Back is on the ball after all.
Junior has been on this dose for 40 days now, so I'm not too worried about it going low, but will be keeping a close eye just in case. I will test him again in a month to be sure.
Tracey

[molly muffin]

I am so glad you had this one sent out. Good call!

Hugs
Sharlene and Molly muffin

[Junior's Mom]

I thought I'd do a summary of Junior's journey for those who are newer to the forum, as he is a success story.
Junior was diagnosed at the age of 5. Symptoms were excessive drinking, peeing, and bald patches.
After blood work to rule out anything else, a low dose suppression test, and an ultrasound, cushings was confirmed.
I decided to try the "natural" route first. I had attitude about it too, when I first joined the forum. I didn't realize how very knowledgeable and caring the people here are.
He started on vetoryl about 9 months after being diagnosed. He weighed about 50 lbs, and I started him on 20mg twice daily. The twice daily dosing made sense to me, apart from the expense. I already fed him twice a day, so I just had to adjust the times a bit. And resign myself to no life, which was pretty much the norm anyways.
My vets are great, not experienced in cushings, but willing to listen and discuss things with me. With the knowledge I gained from this forum, I made the decisions about his dosages, not the vets.
Apart from his elbows swelling a couple of times, and some lab errors, Junior's path has been smooth, and trouble free. His drinking and peeing subsided the first week he was on medication. I don't know that it will ever be like it was before, or like my other dogs, but it is fine to deal with.
I never did an increase that was more than about 25% of the dose he was on, and have had numerous acth's done to know where he is at. His dose is now (after a year) at 67mg twice a day. He has been on vetoryl/trilostane for a year now.
We tested his liver values every 2nd acth for a while, and now will do full blood work twice a year.
His diet is a good quality kibble, with only 10% fat. He gets a cranberry supplement regularly. I alternate between omega 3 wild fish oil (human grade) and coconut oil a few times a week. I also smear him with coconut oil every week or 2. It has made a huge difference in his dry, flaking, peeling skin. He gets milk thistle 5 days a week. All these supplements, I just put in his food. His trilostane, which I have been getting from Diamond Back for a number of months, is in a blob of cream cheese, after he finishes his meals.
The things I have learned to watch out for-incorrect lab work, and higher anxiety. My vet can run the acth samples in house, but either the machine, or the tech has problems, and the numbers are not always correct. It's a good idea to have them sent out periodically to be sure. Junior is also more nervous than he used to be, easily frightened by noise.
As he gets older, I may switch to once a day dosing if he starts to be affected by arthritis. For now, twice a day is what works best for him.
I think that is about all the info I have right now. I will say to everyone just starting this journey, read the forum, take the knowledge to your vet, and never let them talk you into something you don't agree with.
Tracey

[Junior's Mom]

Has anyone else noticed their dog visibly age quicker after being diagnosed with cushings? Junior hasn't developed any new health issues, but his muzzle has gone grey over the last month. His dad is almost 11, and still isn't as grey as Junior.

[Renee]

I think some dogs just get grey sooner than others. My Ichiro was very grey by the time he was 6 or 7, but Tobey (who has cushings) is not very grey at all.

I love your success story recap. :)

[molly muffin]

Maybe it depends on what sort of load their bodies have had to carry for how long. I know one person whose dog had almost white hair, looked sort of grey, has cushings and now controlled on medication (trilostane) the hair has all come in dark black and the dog looks like a young pup. Crazy eh.

hugs
Sharlene and molly muffin

[Junior's Mom]

Merry Christmas to all the wonderful angels on here. I hope the holidays bring you and yours peace.

[Squirt's Mom]

Same to you and yours! I hope Junior is doing well!

[molly muffin]

Merry Christmas to you and Junior!!

[Junior's Mom]

An update on Junior, and perhaps a warning. It seems cortisol can continue to drop even after a month.

ACTH Aug 16 pre 1.96 (54) post 2.07 (57) 40 days on this dose (67mg twice daily)
ACTH Dec 27 pre 1.2 (33) post 1.67 (46) 173 days on this dose (67mg twice daily)

Yes, I was late by a month to recheck him unfortunately.
My vet prefers levels between 2.17-5.07 (60-140), and as he was doing well at a lower dose before, we have switched him back to 57mg twice daily.
His stim on that dose was pre 4.5 post 7.5 after 28 days.

I will be scheduling another stim test sometime in the next couple of months. The vets office is looking into the problem of no synthecyn (sp) available in Canada anymore.
It the tests are going to increase from $120 to $600+ I will not be having them done as often as they should. I will get a baseline done, to ensure he is not going too low, but no way could I afford all the testing I have had done in the past.

[addy]

Hi, sometimes the cortisol continues to drop even after lowering the dose. I went through that with my dog. I cut her dose in half and she went still went lower.

I say that as a warning to watch Junior carefully after lowering the dose if you have to wait to do a stim.

Are you seeing any side effects or new symptoms? How controlled are the symptoms Junior originally had?

[molly muffin]

They are going to start using the same agent that is used in the US, cortyson, and the pricing according my IMS should remain close to the same as before.
They are looking into that further too for me.

We'll see what happens though. My GP vet aid they think they will be getting that via the compounding pharmacy so I hope that the pricing won't go up, or at least not much. Cross fingers as I'm getting ready to increase molly's dose.

[Squirt's Mom]

The cortisol can go too low at any point in treatment, even after a while on the same dose. That is why it is important that we always watch for signs that things are off and do our best to keep the ACTH monitoring schedule - but we and our observations are critical. I'm glad you took him on in and the dose is going to be lowered a bit. Let us know how he is doing!

[Junior's Mom]

Just to clarify, I took Junior in for his last stim test because he was due. I would have taken him in Nov, but the vet's office couldn't fit me in.
I didn't seek the test because I felt there was something going wrong. I've been very lucky in that since day 3 on vetoryl, Junior has improved and hasn't had any complications.
I monitor him very carefully, and know that cortisol can drop at any time, but the results of his last stim were unexpected.
As Junior weighs 51lbs, splitting the dose of stim agent will probably not be possible for us, which will mean a much higher cost. Many of us struggle with the financials involved in this. I have 4 other dogs and 2 cats to care for as well. I have to spread the money where it will have the most benefit.

[addy]

Oh, I don't think any of us meant any critism so I hope you did not take it that way. We all know what a struggle it is with costs and my thoughts were mainly because of the concern of the rising cost of the stim agent. If money were no object for us, we could follow Dr. Peterson's advice and stop the Vetoryl for two weeks, restim and start over. The cost of doing that is very high to do if our pups end up with a post lower than 2. I didn't bring it up for that very reason.

I'm sorry if I my comments seemed hurtful, I did not mean them to be. My own dog dropped lower after I cut her dose in half, thus my concerun for Junior.

Dechra will advise that sometimes the dose will need to be lowered.

[Squirt's Mom]

I also apologize if my comment offended - it was not intended as a criticism in the least. :o

[Junior's Mom]

Sorry to not get back sooner.
No worries, I was not offended by any comments, I just wanted to clarify that I had not seen any negatives in Junior when I last stim tested him.

Heads up to anyone in Canada. While most of your parcels will cross the border no problem, because there are far too many for customs to inspect, there is a chance your parcel will be chosen for a further look see.
AND, it turns out that it is ILLEGAL to import any prescription drug into Canada. So Health Canada will not allow it in.
Yes, I have recently found this out the hard way. I told the health Canada guy I was talking to that things shouldn't be 3 times the price in then, if they want us to spend our money here.

So, if you don't want the hassle of an order not arriving, and having to fight to get back the money you spent on it, you are better off trying to find a decent price in Canada. Which is what I will be spending the next while trying to do. Argh!

[molly muffin]

Let me know what you find out. I've been looking into trying to get the medication cheaper here in canada too. It's tough.
One girl has recommended thepetpharmacy.ca to me as an option she uses. I've emailed them as I don't see trilostane listed on their site, but I do see vetroyl. Also checking for amolodipine as I don't see that either.

They make this so hard for us here in Canada. grrrr

[Junior's Mom]

Diamond Back, whom I have been using for about a year now, without a problem, is apparently aware of the situation. They said they are working with Health Canada to be allowed to export pet meds here.
I guess as long as it makes it to the customer, they don't care.

In my search, I have discovered VET RX Direct, on line. They are the cheapest I have found so far for the name brand vetoryl.
My vets office will be getting me quotes from a few compounding pharmacies they have used as well.

[molly muffin]

Vet RX Direct is in the US though. Would be good to be able yo use diamondback with no worries.

I have used Summit and Chiron. Both compounding pharmacies and both spendy unfortunately.

I have an email sent to the one I mentioned. Will let you know if I hear back from them.

[Junior's Mom]

Thanks for pointing that out about Vet RX. I thought I had looked closely enough at it. Ah well, back to the drawing board I guess.
Universal Pet Meds is canadian. I have used them before.

My vet has used Chiron in the past. I was not impressed with the quality from there at all.

[molly muffin]

Okay, I have a possibility here for you. :)

The place I mentioned thepetpharmacy.ca I contacted them and now admittedly my dosage of trilostane is less than yours, however, here are the prices they gave me.


Good afternoon,

The dispensing fee (like with people prescriptions) is per item each time it is picked up. If you pick up the medication monthly for 3 months then you will pay the fee three times for each different medication. If you pick up a three month supply all at once then you pay $4.99 once for each medication over the 90 days.

If you picked up 100 benazepril 5mg it would be $69.71+tax and 200 would be $134.44+tax.

Compounded trilostane capsules 11mgx30=$34.63+tax
14mgx30=$39.80+tax
15mgx30=$41.52+tax

Are you using the amlodipine already? What format do you give...capsules, liquid, chew tabs?

We request a minimum of 7-10 days advanced notice for initial filling of compounded medications for the first time to allow ordering of the required ingredients. Once a medication is on file for your pet a minimum of 2-3 days is requested.

Once I have more information about the amlodipine I can give you a price and/or let you know if it is something we can make for you.

So that beats the pricing I have had from any other compounding place the vets use.

Now I just have to convince a vet to give me a prescription. This place I think will do 3 months worth at once if you have the script for it.

[Junior's Mom]

I'm so sorry to see how many have passed. Heartbreaking.

Wow, I can't believe how long it's been since I've been on here. (There was a guy:mad:)
The past year has been a bit of a roller coaster with Junior. After not being able to get his meds from the States any longer (Health Canada won't allow it), he ended up running out of meds for a while, till I found another supplier.
It didn't take long to notice the side effects of him going without the trilostane. He started losing fur again quite quickly. He was off the meds for about a month.
I ended up using Chiron, whom I haven't been impressed with in the past. Due to the price being twice as much as from Diamond Back, and the fact that Juniors clinical signs had been so well managed, I decided to try once a day dosing, rather than twice. This did not go as well as I had hoped, so I searched for a new pharmacy, found Habers, and put him back on twice a day.

From my perspective, Junior has been doing fantastic. He looks like a new dog. So much fur! Absolutely no signs of over suppression. The only thing I've noticed is his anxiety goes up as his corisol levels go down. However his tests results have been perplexing. On 50mg of trilostane, twice a day, from Diamond Back, he was pre 1.67 (46) post 1.88 (52) My vet was not comfortable with this, so we dropped him to 43mg. It was after this that I ran into problems getting the meds. As a result, it was sometime before he had another stim test.
The next stim changed everything. It was also done differently, as the vets office was no longer using the synthetic stim agent. I expected to use that test as a base to go from, after all the changes. I was not expecting strange results whatsoever.
Pre and post were under 1(<27.6) yet he was perfectly fine. I kept him off the meds for a week, and then we dropped the trilostane dose to 33mg. Due to the increased testing costs, and again, because I see absolutely no signs of over suppression in him, it was sometime before I had another stim test done at this dose. Pre and post were the exact same-under 1. I'm now completely perplexed.

I stopped giving him the trilostane just to be safe. He is having his electrolytes tested on Monday, and we will go from there I guess. His last dose was Tues morning. Here it is Saturday, and already his pee is more dilute, and he is doing a lot more of it. My feeling is there is something going wrong with the lab, since the switch from the synthetic stim agent, but I have no way of knowing for sure. I really don't want to see him backtrack, because he has been doing so well.

[Harley PoMMom]

I'm so sorry that you are having all this trouble with purchasing the Trilostane and trying to get Junior's cortisol at an optimal dose.

Could you find out what stimulating agent the vet is using? With his numbers being indicative of Addison's you are absolutely doing the right thing in taking him off the Trilostane and having those electrolytes checked. A dog in an Addison's crisis wil have increases in drinking and urinating. How is his appetite? Any diarrhea or vomiting?

Keep us updated, ok ;)

Hugs, Lori

[Junior's Mom]

He is doing fantastic, has absolutely no signs of over suppression. Not now, not when he was tested, not ever, in the almost 4 years he's been being medicated. He is, however, already showing the signs of not being suppressed enough. It's maddening. All I can do is wait for the electrolytes results, and monitor how much he backslides into cushings symptoms I guess.

We had been using the synthetic version (Synacthen), as it was much cheaper. When the company was taken over by another, the price went through the roof. So my vet office had to switch to Cortosyn. With the synacthen, his post was done 2 hours later, and I could take him home in between. Now, the post is just 1 hour later, and as it's a bit of a drive for me, we end up hanging out walking about, or sitting in the car.
His last 2 stims have been with the newer protocol/stim agent, and those are the tests that gave extremely unexpected results.

I had his electrolytes tested the first time we switched stim agents, and they were fine then.

[molly muffin]

I agree that is very strange.
I remember when they switched to Cortosyn, here in Canada. My IMS did the ACTH test and we had not problems with it. Are they doing the vile splitting? My IMS at Mississauga Oakville Emergency Hospital said they were doing the splitting of the vile based on instructions from the lab, but I wonder if all vets are doing this or not and if it would make a difference.

[Harley PoMMom]

He is doing fantastic, has absolutely no signs of over suppression. Not now, not when he was tested, not ever, in the almost 4 years he's been being medicated.

So glad to hear that Junior is doing so well!!


We had been using the synthetic version (Synacthen), as it was much cheaper. When the company was taken over by another, the price went through the roof. So my vet office had to switch to Cortosyn. With the synacthen, his post was done 2 hours later, and I could take him home in between. Now, the post is just 1 hour later, and as it's a bit of a drive for me, we end up hanging out walking about, or sitting in the car.
His last 2 stims have been with the newer protocol/stim agent, and those are the tests that gave extremely unexpected results.



I'm a bit confused as why the vet did only a post draw 2 hours later when using Synacthen as the stimulating agent, I think an 1 hour post draw is usually done too. When researching the ACTH stimulation test protocol for Synacthen I find it is done the same way as Cortrosyn which includes a pre and an 1 hour post. :confused: And if I'm understanding correctly from the articles I've read, Cortrosyn and Synacthen are basically the same.

[Junior's Mom]

I think some vets in Canada were doing a 1 hr and 2 hr post draw with the synthecyn. Mine only ever did a 2 hr post draw. I don't know the protocols regarding the different stim agents, I'm only going by what my vets office has said and done.

Just to reiterate, Junior showed no signs of over suppression. I only had him stim tested because it had been a while. Now, I'm kind of sorry I did.
At my vets urging, do to his really low results, I quit giving Junior the trilostane, and had him tested again after 4 weeks off of it. His pre was 80 (2.899) and his post was 137 (4.965) He also had complete blood work done, and nothing was of any alarm. All his cushings symptoms are back, and my vet will not prescribe any more trilostane. I'd asked to cut his dose in half, but she refuses. She has spoken with other vets through a board she is on. They all suggest something else is going on with him, so I should spend more $ on tests, ultrasounds etc.

It's extremely frustrating to me, and I can't afford to start back at the beginning again. I know Junior's safety is of utmost importance, hence no trilostane, but his hunger, excessive thirst and peeing only reappeared when the trilostane was removed. I just don't know what to do next.

Any (cost effective) suggestions would be much appreciated.

[Harley PoMMom]

Those are perfect stim numbers for a dog on Trilostane but what has me concerned is that Junior has been off the Trilostane for over a month and although those stim numbers show his adrenal glands are producing cortisol they aren't as high as I would expect them to be in a dog that is off Trilostane.

Was Junior checked for an UTI via an urine culture? If not I would start with that so an UTI can be ruled out, and a culture is recommended when their urine is diluted because a regular urinalysis may not be sensitive enough to pick up the bacteria.

Are you seeing any other symptoms besides the increased drinking and urinating?

Lori

[Squirt's Mom]

I know some areas of Canada are really remote but if there is another vet in the area I would be darkening their door asap. Yep, finding a new vet for Junior would be my highest priority. That is ridiculous they way this one is acting. :eek::mad::rolleyes:

[Junior's Mom]

He had a urinalysis done the same time as his blood work, but not a urnine culture. That might be my next time.
Apart from the drinking and peeing, he is hungry. Constantly licking the floor looking for crumbs, munching on all the grass he can grab when I'm not looking, inhaling his meals...

I don't blame my vet. With his stim numbers, she could potentially be doing harm if she agreed to put him back on trilostane. It would mean putting her faith in me to watch him closely. It's just so frustrating. He was perfectly fine, until the meds were removed. And as I said, I can't afford to start back at the beginning, with ultrasounds, more blood work etc.