9 Year Old Maltese with Cushings [Archive] - Page 5 - Canine Cushing's Information and Support Forums

goldengirl88

04-29-2014, 01:56 PM

Kenny:
Like Leslie said you will be at this for eternity at 1 mg increases and Gracie will have white coat syndrome. I am very conservative myself with this drug. How !much does Gracie weigh now? I would think she would be safe up to 10 mg. The increments you are using as so miniscule that it is not enough all at one time to knock the cortisol level down. Tipper used to get split dose and they never worked for her. Give it to her all in one dose though and she if fine. Gracie may be like Tipper in so much as she needs a good enough dose to get the cortisol to stay at a good level all day. It may make a difference at 10 mg because you can then use brand name Vetoryl, and that could make a difference. I read a study on the compounded trilostane and it has a poor accuracy rate. So she may not even be getting a full 1 mg in those capsules and is therefore not making a significant difference in the cortisol level. You will be spending a lot of money doing this 1 mg at a time. Hope this can help her. Blessings
Patti

KennyJ

04-29-2014, 01:59 PM

Renee

04-29-2014, 02:11 PM

Gracie weighs 10.2 lbs. She gets 3 milligrams in the morning and 3 in the evening starting today. This vet is a IMS that's why I chose her. But l am getting frustrated because she is being tested a lot more than the normal protocol called for.

It's nice to see a conservative vet -- but, this is a little too cautious and must be very expensive to be running so many tests. At 10lbs for Gracie, I probably would have started at the 10mg vetoryl right off. Have you discussed with the IMS about increasing a little more aggressively?

The once daily vs. twice daily dosing depends on each dog. I have always done a twice daily dosing, and it seems more and more people are doing the same, but like Patti said, her dog does better at the once daily dosing. If she's only getting 3mg am and then 3mg pm, Patti may be correct in that she is not getting a strong enough dose to really knock the cortisol down.

Squirt's Mom

04-29-2014, 02:41 PM

Kenny, the testing schedule has to start all over with each change in dose, whether up or down. So she may not be over-testing as you think but following protocol. I think I would ask to start at 10mg and see how that does. Is this 1mg increase at a time the IMS' idea or yours...or was she perhaps responding to your fear / concerns about the med?

molly muffin

04-29-2014, 06:02 PM

Why not do 5mg/5mg? That might work.

Sharlene and molly muffin

KennyJ

05-17-2014, 09:13 AM

Gracie's symptoms still haven't improved. The 6 milligrams is way too low. I thought by going to in internal medicine specialist that she was in good hands. I also noticed the place on Gracie's leg where she chews all the time is one huge hard lump about an inch long. Not very happy right now.

goldengirl88

05-17-2014, 09:42 AM

Kenny:
As I previously said I am very cautious with the drug, but feel Gracie needs 10mg of brand name Vetoryl. That can make a world of difference. Tipper gets those hard lumps they are calcium deposits according to my vet. The IMS can't really be blamed if the dosage is not high enough. You will spend too much money in the increments you are doing this at. Blessings
Patti

Renee

05-17-2014, 01:33 PM

Kenny, I encourage you to up the dosage to 10mg brand name vetoryl. I agree, you would expect an IMS to be able to find the correct dose quicker... but, this one appears to be almost overly cautious. If Grace is getting calcium deposits, this could turn into the dreaded CC, in which case, you will need to get her cortisol under control as soon as possible.

What were the results of her last stim test?

KennyJ

06-09-2014, 10:50 AM

Well, Gracie is back at the vet for another ACTH test. There has been absolutely no improvement if anything her water consumption has increased. I am somewhat concerned about Diabetes now. She has bitten her front left leg so much that there is a large raw spot and I am not sure what to do about that. I told the lady at the front desk to make sure they checked that as well. She is 10.2 lbs and her meds were increased to 8 milligrams broken down to twice a day. I am very disappointed so far with her condition not being under control by now. Any recommendations about her leg?? I hate the thought of putting the Ecollar back on her but that may be the only alternative.

goldengirl88

06-09-2014, 12:20 PM

Kenny:
Because Gracie is on a split dose are you saying she gets 4mg in the morning and 4mg at nite? I strongly recommended last time that Gracie get 10mg in one dose. This is obviously causing problems with two low doses not being enough to knock the cortisol down. My Tipper went thru this too and from experience I can tell you , she will get more control out of one larger dose. I would be perfectly comfortable giving her 10mg at one time and I am very conservative with this drug. The longer this goes on the longer Gracie is not controlled. They sell some sprays that taste awful, but will not hurt her to put on that sore leg so she stops licking it. Could you buy a pair of little girls tights put some healing salve on her leg, and cover her leg with a leg cut out of the tights? This will keep her form licking it and let it heal. A toddlers sock would work, but would not give it as much air to heal. I am afraid of what this is doing inside Gracie with her still not being controlled. Cortisol continues to do damage until controlled. I hope Gracie gets better soon. Blessings
Patti

KennyJ

06-09-2014, 04:13 PM

Patti, I also give Gracie the compounded version of the drug, could that be making a difference as well?? So at 10.2 lbs you don't think 8 milligrams twice a day is enough?

goldengirl88

06-09-2014, 04:19 PM

Kenny:
Yes I believe it could. If you check the thread in the Everything Else page you will see it is not accurate a lot of the time. It could still make a difference if given at 10mg altogether. I give Tipper the larger part of her dose from Vetoryl and the compounded part only 5mg. Vetoryl is definitely going to be more accurate. Blessings
Patti

aceml@msn.com

06-09-2014, 05:25 PM

My dog Sophie is a lot bigger than yours, she's a Coton de Tulear, about 17 lbs. After her one dose of Vetoryl 10 mg. didn't do much, our vet doubled it to two doses, 12 hours apart. That seems to be helping (although we are still in the beginning stages.) I hope you can resolve it shortly! Ann

goldengirl88

06-10-2014, 08:43 AM

Kenny:
Any decisions on what you are going to do about Gracie being uncontrolled? Hope you get her leg better. Blessings
Patti

KennyJ

06-10-2014, 06:45 PM

Ok, I missed my Vets call so she left me a voice mail. What would cause this? The ACTH came back higher than the last time and we increased the dosage from 6 to 8 milligrams. She did tell me the other day that if it wasn't any lower she was going to switch to the name brand at 10 milligrams. They are scaring me though with the side effects and want me to have prednisone on hand just in case. Back to my original question, how could it come back higher once we increased the dosage?

goldengirl88

06-10-2014, 07:05 PM

Kenny:
Because you are not using enough even with the increase. Did you take her in at the same time of day as the last test? Their cortisol levels do fluxuate, so maybe that is why, or a combination of both. I was scared to give Tipper the 10mg too.
Honestly try not to worry, I think the 10mg Vetoryl will put her right where she needs to be. Blessings
Patti

KennyJ

06-10-2014, 07:12 PM

Thanks Patti. Yes same time as always. So you don't think 10 milligrams is too much at a little over 10 lbs?? Her leg looks really bad. Poor girl is now on antibiotics, pain pills, ursodiol, meds for ear infection, and of course her compounded Tristolane. I really thought I was doing the right thing by letting a IMS treat her but now I am not so sure.

goldengirl88

06-10-2014, 07:19 PM

Kenny:
I know how you feel. We have a mini pharmacy here from everything Tipper takes too. It does get overwhelming! I would be very comfortable with the 10 mg.
Vetoryl. It could make all the difference, and get her where she needs to be. It will be OK, so don't worry. Blessings
Patti

KennyJ

06-10-2014, 07:24 PM

Thanks again Patti. I am starting to lose faith in this vet.

addy

06-10-2014, 07:28 PM

Hi Kenny,

Do you have the results of the last ACTH test pre and post and could you post them here?

It is not unusual for some dogs to need a bigger dose. My pup was about 17.5-18 pounds and taking 50mgs of name brand Vetoryl.

But we can't just go by numbers, we have to go by symptoms as well. For my dog, sometimes other health issues raised her cortisol, even though we increased her dose. It just depends on how high your pup is now compared to her last test ad how well controlled she seems.

molly muffin

06-10-2014, 07:31 PM

Hi Kenny,

It has been awhile and I'm sorry to hear that her numbers went up. How is her gall bladder doing?

I think I would switch to the 10mg vetroyl and see if that works. I think it might be worthwhile to also add in an allergy medicine for Gracie. Benedryl can work and I know some of the members on our facebook page, have told me they are using, Zyrtec for allergies and having good luck. One dog had rubbed all the fur off on both her sides.

As she is fighting several thing, allergies from the sounds of that chewing, the gall bladder, and possible infection in her leg (is that what the antibiotics are for and the pain meds?) then it could be a combination of her body being in over drive, trying to produce cortisol to combat everything plus the cushings portion.

We have had dogs that are small, end up needing larger doses of medicine, and we've had big dogs end up using smaller amounts. You don't know till you start how they will react to meds.

I'd go for it with the 10mg. Prednisone is a precaution and hopefully nothing you will need to ever use. But Trilostane Is the ingredient in vetroyl, so basically you are going up, 2mg. (you give 8 mgs in total now correct?) and if you do end up going with trilostane again, I probably would get it from a different compounding pharmacy. We have members who have used several and your vet can call the prescription in to any of them.

Sharlene and molly muffin

KennyJ

06-10-2014, 07:41 PM

Thanks again everyone. Sharlene, we haven't tested her anymore for her gall bladder just the ACTH tests. The pain meds are because Gracie's leg has the large raw spot. The antibiotics are for the leg and she also has a yeast infection in her left ear so I have drops for that. I am little discouraged right now because I thought we were headed in the right direction. Before she started meds her ACTH was at 22. Started the meds and it dropped to 14.2. Bumped it up 6 milligrams and it fell to 11. However, her symptoms were no better so she increased it to 8 milligrams. Her water consumption may be even worse now. She could eat 24/7. 4 in the morning and 4 in the evening. Now I find out her test results were actually higher.

molly muffin

06-10-2014, 08:36 PM

Don't be discouraged Kenny. This is a long journey you are on and remember it's all for Gracie. You can do this Bump her up to 10mg vetroyl like your vet wants and lets see what happens. I don't think you need to be fearful. Just Hang in there!

Sharlene and molly muffin

KennyJ

06-11-2014, 08:03 AM

Wow, I called and got her ACTH results. She started at 22, went to 14, down to 11, and now it's back up to 18.5 and that's with the increase from 6 milligrams to 8 milligrams. So it actually increased with the dosage increase. How on earth could that happen? And I am using the pharmacy everyone recommended. Diamondback.

addy

06-11-2014, 08:14 AM

That is a huge increase. Are you sure that is not a lab error?

KennyJ

06-11-2014, 08:54 AM

Addy, that was exactly what I was thinking. How could such an increase occur when we actually increased the meds?? My IMS only works part time at the clinic so was off yesterday and today. Another vet actually called me and said she would call me today to discuss switching over to the name brand at 10 milligrams. My concern is that those meds do not stay in the system long so just giving it to her at one dose in the morning will that really work?

lulusmom

06-11-2014, 09:13 AM

Was the acth stimulation test done while Gracie had active infections on her leg and her ear? Infections and pain alone puts much stress on the body to which the body responds by secreting more cortisol. That coupled with the puny dose increases your IMS has been directing could be the reason you are seeing a post stim that looks like you never started treatment.

My dogs were treated with compounded trilostane from Diamondback Drugs for two years. My first cushdog, weighing 4 lbs, was stabilized on 30mg within 30 days. My second cushdog, weighing 6.5 lbs, stabilized on his initial dose of 15mg twice daily. Their pre and post stims were always in the 2's and 3's. They started treatment on doses well above what is recommended today. Back then, 30mg was the smallest dose without compounding and Dechra didn't recommend treating any dog under 5kg. Back then a lot of vets and specialists were starting all small dogs on 30mg a day. I am really lucky that my dogs had no adverse side effects. Is your IMS scared to death of Trilostane or is he responding to your own fear of doing harm to Gracie? Either way, it hasn't worked for Gracie and you've ended up paying a lot more for acth stimulation tests. I hope your specialist is at least giving you a break on the stim tests by letting you buy a vial of cortrosyn which he can split and store for at least five stim tests.

Glynda

KennyJ

06-11-2014, 09:18 AM

Glynda to answer your question. Yes, Gracie has a leg infection from where she has been biting it and a yeast infection in her left ear. So your dogs did fine on the compounded version of the drug?? Ok, so when the vet calls me this morning what kind of questions should I ask. And yes I feel like I am getting ripped off because I have had way too many ACTH tests in such a short period of time. The total costs for the tests including the drug they use to administer the test is $138. And wow, your dogs are smaller than mine and Gracie is only getting 8 milligrams. 4 in the morning and 4 in the evening. I am a little upset. I really thought going the IMS route was the best but now I am not so sure.

lulusmom

06-11-2014, 10:00 AM

If you are only paying $138 for a stim test, you aren't getting ripped off by the price, just the need to do so many of them. Yes, my dogs did fine on compounded Trilostane. I've used Diamondback for years and have never had a problem. To their credit, they also provide meds for most of the large zoos in this country so they are a really trusted source. Most of the vets in California I met used them so I wasn't surprised when a few new vets here in Arizona also use them.

Both of my cushdogs have passed and I don't want you to think that their dosing regimen would be safe today. I just wanted to share my experience with the drug and the pharmacy. I believe that studies have shown that small dogs are not as sensitive to the drug as big dogs. Don't ask me why because I don't know but my two pups supported that theory.

Not all specialists are created equal and I must stay that your IMS is the most cautious I've ever seen. If I were you, I would ask the new vet how many cushingoid dogs she has treated and what kind of results she's had. If you are dismayed with how things have gone so far, don't be afraid to express that and ask her if she thinks the dosing was just too low or if Gracie may be a dog that is not as sensitive to the drug. We have seen members whose dogs have had dose increases much bigger than Gracie's, yet their cortisol went up on a subsequent stim test. It happens but at this point the dosing has been so negligible that it's too soon to say if she is resistant to the drug.

You have to try to gain some level of confidence with someone so maybe this new vet is that person. If it were me, I may even want that vet to contact Dechra to discuss Gracie's case and get their recommendations on where to go from here. It may well be that they recommend 10mg once day but at least you'll have validation from the people who make the drug. Be prepared to pay a lot more for Vetoryl. The best price I could find for 10mg Vetoryl is $42 for 30ct.

KennyJ

06-11-2014, 10:31 AM

But if its true that infections can increase cortisol then why doesn't the IMS of all people understand that?? And should I still try 10 milligrams of the compounded version of the drug or go with the recommendations of the IMS and use the name brand?? Still waiting for the call from the other vet.

KennyJ

06-11-2014, 11:19 AM

Ok, I decided to try the name brand at $50 for 30 pills. Wish me luck. I did ask the vet about the infections causing an increase in cortisol. She said had it been a kidney infection or a major infection then yes it would. She said the leg and ear would not have caused this. So I really don't know what to think.

goldengirl88

06-11-2014, 12:33 PM

Kenny:
I think you are doing the right thing with the brand name to see if that makes a difference. We are crossing fingers and paws for Gracie as I know she will do well. Blessings
Patti

goldengirl88

06-12-2014, 08:04 AM

Kenny:
Did you start Gracie yet? You can get 10mg for 41.95 at Lambert Veterinary Supplies or California Pharmacy. Blessings
Patti

KennyJ

06-12-2014, 01:51 PM

Patti, started her this morning. Wish me luck.

goldengirl88

06-12-2014, 02:07 PM

Fingers crossed and paws crossed, it will be fine!!

goldengirl88

06-13-2014, 08:02 AM

Kenny:
I am guessing Gracie did fine! I hope this gets that nasty cortisol down to where it should be. Blessings
Patti

molly muffin

06-14-2014, 12:03 AM

Crossing my fingers here Kenny!

Sharlene and molly muffin

goldengirl88

06-14-2014, 07:42 AM

Kenny:
I bet everything went fine with Gracie?? I look forward to hearing an update on her. Blessings
Patti

goldengirl88

06-21-2014, 02:48 PM

Kenny:
How is Gracie doing on the new dose? How is her leg any better? Hope it is going well. Blessings
Patti

goldengirl88

06-23-2014, 04:51 PM

Kenny:
How is Gracie? Hope everything is ok.

KennyJ

06-24-2014, 09:41 PM

Good evening everyone. Gracie's ACTH came back at 8 this time after switching to the name brand at 10 milligrams. Her leg has not healed and still has an ear infection. More ear drops and antibiotics. Her water consumption has decreased but still urinating quite a bit. Overall though happy about her numbers coming down. They say stay on this for another month and come back for another retest.

goldengirl88

06-24-2014, 09:48 PM

So happy for you Kenny, aren't you glad you went to the 10MG Vetoryl? I am feeling good about her continuing to improve for the next test. Is she acting like she is feeling better? Blessings
Patti

KennyJ

06-24-2014, 09:50 PM

Patti, her legs seem to be weaker so hoping that gets better as the treatment continues and she sleeps a lot.

goldengirl88

06-25-2014, 07:59 AM

Kenny:
It may be she has some arthritis going on, were her rear legs ever checked for that? Could also be that she has had a lot of muscle wasting and it has made her weak. I think Cush dogs have a tendency to sleep more than the normal dog. Their bodies are under constant assault from this disease and they need rest to recuperate. Just keep a watchful eye on her. Blessings
Patti

goldengirl88

06-29-2014, 08:19 AM

Kenny:
Is it still going good? I am hoping her symptoms have subsided some? How are the legs doing? Blessings
Patti

KennyJ

07-03-2014, 06:45 AM

Patti I am so frustrated. When we made the switch over to the 10 milligrams of the name brand I saw some improvement in her water consumption. The ACTH test came back at 8 which was also a major improvement. I was really excited. Here lately I noticed her back to drinking large amounts of water so I'm thinking its not working again.

goldengirl88

07-03-2014, 07:46 AM

Kenny:
Hang in there as Tipper is doing the same thing. It is very hot and humid and I think it is affecting her. Gracie may be experiencing the same thing. Tipper is panting and drinking more water too. I think this will pass when the humidity goes away. Tipper is even in the air conditioning and doing this. Is Gracie in the sir too? Just keep watching until this weather leaves. Tipper is even more sensitive to the heat than last year. That could be another of Gracie's problems she has become more sensitive to the heat. Hope it turns around, which it should. Blessings
Patti

KennyJ

07-15-2014, 09:34 PM

Gracie is back to drinking lots of water and urinating a lot. Really confused over this.

doxiesrock912

07-15-2014, 09:48 PM

Kenny, the hot weather may be playing a role. Sid they rule out infections? Cushings dogs are prone to UTIs.

KennyJ

07-15-2014, 10:07 PM

She stays in a very cool house and she has been on antibiotics for a yeast infection for her ear and leg. Doubt she could have an infection. I was happy that her last ACTH had improved so much but it makes me wonder if the tumor is growing larger.

doxiesrock912

07-16-2014, 01:45 AM

Kenny,
there are bacterial infections and fungal infections. If there is another problem, depending upon which type of infection her ear is being treated for the antibiotic might not have an effect on another issue if the bacteria are different.

Might it be a reaction to the antibiotics themselves? What is she taking?

molly muffin

07-20-2014, 10:08 PM

Hi Kenny, just checking in to see when your next ACTH test will be. If she has a couple infections going on, I wonder if that would affect the cortisol levels even with treatment, or if they wouldn't make a difference since she is on treatment.

It might be that she will need an increase. You start low so there is less chance of a crash or a problem, but then it could be that she will end up needing a higher dosage to get control.

This isn't unheard of.

Sharlene and molly muffin

KennyJ

07-22-2014, 06:28 PM

I need to make another appointment probably within the next week or so. I thought we had hit a home run with the name brand at 10 mgs but she is back to drinking heavily and urinating like crazy. This is so frustrating. Her hair is so thin.

Renee

07-22-2014, 07:03 PM

Kenny, don't get discouraged (I know, hard not to). Her reaction to the name brand is good. We saw some rebound on symptoms too. We just needed a dose increase. Her initial numbers dropped rather quick, then creeped back up, so we adjusted her dose a few times to get them back down.

And, even when her symptoms are controlled, the hair growth is in cycles. Tobey has lost her entire coat twice so far. It grew back each time.

molly muffin

07-22-2014, 09:56 PM

I know this has been a long journey Kenny, but hang in there, you'll probably be upping her dosage. See where her numbers are and go from there.

Sharlene and molly muffin

KennyJ

08-04-2014, 05:40 PM

I just picked Gracie up from getting another ACTH test. The vet is somewhat concerned that maybe something else is going on like an infection or diabetes. She suggested maybe run a CBC after the results come back from this test.

molly muffin

08-05-2014, 12:39 PM

A CBC sounds like a good idea if there are any concerns. Diabetes I know can come on practically over night it seems some times in cushing pups.

Let us know how that comes out and what the latest ACTH result is.

Sharlene and molly muffin

doxiesrock912

08-05-2014, 01:11 PM

That's a good idea Kenny. Any infection and certainly diabetes can interfere with getting accurate results.

KennyJ

08-05-2014, 05:45 PM

Ok, I called and got the latest ACTH result. She jumped back up to 14. I am beginning to think now that something else is going on because her results are bouncing up and down. She started at 22 with no meds. With meds she went to 14, 13, 18, 8, and now back to 14. That's 5 ACTH tests and still not working.

addy

08-05-2014, 07:38 PM

Hi Kenny,

My Zoe was hard to control and she always had something else going on, eye issues, surgery for a ruptured growth, the list was endless. I measured her stim results along with her symptoms and adjusted accordingly. It ended up taking a whopping 50 mgs to control her. She weighed in a round 17-18 pounds. I then found a growth on her vulva. We removed it, treated her skin issues and suddenly her numbers actually stayed where they should have been for awhile.

I guess my point is- there could be something else going on, it could be her on going infections are playing a role here or it could be she just plain needs a higher dose.

What does her blood work look like?

KennyJ

08-05-2014, 07:43 PM

I haven't had any blood work in quite some time. I do believe that's the next step. She continues to have yeast infections in her ears and her skin is horrible. I asked the Vet last time if the infections like that could alter her ACTH tests and she said no. Said other infections could but not these infections. Her past blood work showed her AKLP off the charts and platelets slightly high, a certain WBC was only slightly high but everything else was perfectly normal. But that's been months ago.

molly muffin

08-05-2014, 07:44 PM

Get that cbc done and lets see what is going on with her. It might be something else, or she might be something else in combination with cushings. She might be one of those small dogs that end up needed a pretty hefty dose too, we've seen it before. Every dog reacts differently and she might be one of the tough ones who need more to keep her under control. We've had small dogs on 30mg and that is what they need to get control.

How is that gall bladder looking and her skin infections?

Sharlene and molly muffin

KennyJ

08-05-2014, 07:48 PM

She has places all over her skin. Little bumps like, almost like warts or pimples. She licks her front legs and chews on her left one until she makes it raw. The vet put her on antibiotics for about 2 months and I still notice her shaking her head as if her ear is still bothering her.

Junior's Mom

08-05-2014, 08:04 PM

Hi Kenny, I hope you are able to get answers from more blood work. I have a dog that used to get stinky irritated ears often. I found a product called sea greens, made by Holistic Blend. It helped clear things right up. After changing her food, there hasn't been any problems since.
Tracey

KennyJ

08-05-2014, 08:12 PM

I am extremely worried that she now has diabetes. That would be just so much to deal with.

addy

08-05-2014, 08:25 PM

Is she losing weight? Is she drinking and peeing a lot? I know you are worried about that but let us not go there yet. The hard white pimple like things you describe sound like Zoe's. They are filled with calcium. Zoe's would get smaller and disappear when her cortisol was lower and I always knew when she was going higher as they came back and got bigger.

If you are dealing with yeast in the ears, there could be yeast and bacteria on her paws and her skin. If she has yeast between her toes she is going to chew her paws. Zoe chewed her paws until her cortisol was controlled and we treated her skin issues. We treated her skin issues with Keto Chlor which is available by prescription and I fought to get it for her. It helped her a great deal.

So let us not think about the what if Gracie has diabetes just yet and maybe you can review with your vet and schedule a CBC blood test for her.

Ok? Do we have a plan? Are you breathing in and out?;):)

KennyJ

08-05-2014, 08:30 PM

The vet did mention that Gracie lost a little weight since her last visit. She could eat 24/7 and drinks water and urinates like crazy. I was feeling great when we switched to the name brand and increased her dosage. She is on 10 milligrams right now and it dropped to 8 from 18 on her ACTH stim test. I even noticed a difference in her water consumption so yeah I was feeling pretty good. That didn't last long.

molly muffin

08-05-2014, 08:33 PM

That could be calicunosis cutis, which is caused by high cortisol. Basically calcium deposits pushing up out of the skin. I'd get some skin scrappings done too, to verify if that is what it is. If so it is imparative to get the cortisol level down.

Next thing is, another option that Glynda uses and has had great success with, is Liquid Health K-9 Ear Solutions. You can get it at amazon or vitacost.
Getting the cortisol lower though should help with the ear infections too.

It might be that she is causing herself lick granuloma on her leg, from continuously licking of it. I know you have to usually use something like one of those soft cones and prevent them from licking it for several weeks, at least 4 or more. Ask your vet about it.

Sharlene and molly muffin

KennyJ

08-05-2014, 08:36 PM

You would think after 5 ACTH tests we would have this under control by now. She has been on enough antibiotics to kill everything possible. Her past lab work did not show any signs of diabetes but that could have changed by now.

addy

08-05-2014, 08:36 PM

I know. I know it sucks to put it plainly. It is really stressful when they bounce around and don't stay controlled. When you get the news, it is like a punch in the stomach. The drinking and peeing can certainly be attributed to her higher cortisol not diabetes.

Kenny, let me ask you, did your vet say there are concerns about Gracie having diabetes? Does your vet think that is possibly what is happening now?

KennyJ

08-05-2014, 08:38 PM

Yes, she mentioned diabetes or some sort of infection that is causing the bounce in her post ACTH tests. That's why I am so concerned.

addy

08-05-2014, 08:44 PM

Then lets do the blood work and we will deal with whatever it shows,ok?

You are not alone here. We are all here with you and we will all work it out together.

KennyJ

08-05-2014, 08:47 PM

Thank you. Just wish my little one would be back to normal.

addy

08-05-2014, 08:52 PM

I know you do, it is what we all want too. Hopefully, all these issues will be managed when her cortisol goes lower and we treat her skin problems.

I'm hoping she is like my Zoe was and just needs a higher dose to start feeling better. In fact, that is the thought I am going with!!!!!!!:):):)

KennyJ

08-05-2014, 09:04 PM

I sure hope you are right!!

KennyJ

08-08-2014, 04:08 PM

The vet called and left a voice mail. All of Gracie's lab work came back and were horrible. Her ALKP is 6700 now and even her other liver enzyme was high and it had been in the normal range. Glucose slightly higher as well. She's being treated for the gall bladder mucocele with Ursodiol but apparently that is not working. She wants to do another ultrasound on Monday.

molly muffin

08-08-2014, 04:37 PM

Absolutely need another ultrasound. When was her last CBC? This definitely sounds like the gall bladder is in bad shape and affecting her liver too. This also could be why her cortisol has been so hard to get under control. Have they not been monitoring her gall bladder situation?

I would want that checked fairly often and I thought that they were doing so. :(.

Sharlene and Molly muffin

KennyJ

08-08-2014, 05:12 PM

No, the last ultrasound showed that her mucocele had decreased in size by almost half so she then started testing for the Cushing's. The vet has NOT been monitoring the gall bladder at all.

molly muffin

08-08-2014, 10:02 PM

hmm, so it had shrunk, but now it sounds like maybe it is no longer shrinking or something else is definitely going on. That ultrasound is going to be very important.

Sharlene and molly muffin

KennyJ

08-10-2014, 06:50 PM

I am very concerned right now. Her ALP was over 6000 this time. Her glucose increased and her other liver enzymes are out of the normal range as well.

molly muffin

08-11-2014, 12:33 AM

Yes I'm concerned too Kenny. I don't like the sound of that.

Let us know what the ultrasound shows. It's tomorrow right?

Sharlene and molly muffin

KennyJ

08-11-2014, 06:51 AM

Yes, getting ready to take her now. I feel I spent all this money and not having a lot of confidence in this vet. Why didn't she continue to follow up on the gall bladder mucocele? And the liver enzymes increasing that much while she is being treated for Cushings?? This simply makes no sense.

Squirt's Mom

08-11-2014, 07:18 AM

We are with you and Gracie, Kenny. Let us know what you learn. I am praying this is nothing major and there is an easy solution.

lulusmom

08-11-2014, 09:36 AM

Hi Kenny,

Can you please get a copy of Gracie's most current blood chemistry and post all of the abnormal values and please include the normal reference ranges. The ALKP liver enzyme is not a good indicator of liver disease so I would like to see the other liver enzyme results. Any of these liver enzymes can change greatly in just 24 hours, depending on what is triggering the release of these enzymes so you may want to cut your vet some slack until she can try to pinpoint the cause. An abdominal ultrasound seems to be a good place to start.

Gracie's initial dosing, as well as subsequent increases, were the most conservative I've ever seen. It is highly likely that those inadequate doses have allowed the disease to progress so one would assume that the ALKP could possibly continue to increase. Those tiny doses have probably also cost you more for the multiple acth stim tests. This vet is an internal medicine specialist, right? Was this unorthodox dosing your vet's idea or was she acting in accordance with your wishes, based on your concerns about the drug and it's possible negative effect on Gracie?

Glynda

addy

08-11-2014, 07:27 PM

Hey Kenny,

We are all here for you. I do have to admit, Glynda just about took some of the words right out of my mouth.:o

Can you post the test results?

Budsters Mom

08-11-2014, 08:08 PM

I'm here too Kenny.

molly muffin

08-11-2014, 09:11 PM

Hi Kenny, checking in to see how the ultrasound went today and what the vet said.

Sharlene and molly muffin

KennyJ

08-14-2014, 12:16 PM

Still a lot of sludge with the mucocele. Now Gracie has an ulcer on her cornea. Always something different I have to treat. I asked about upping her dosage of the Ursodiol from 55 mgs. She did not do that. However, I called her a few minutes ago and left her a message. I do not think that is high enough for such high liver enzymes. The research I did was 2.5-7mg per pound twice a day. Anyone else used this and had to increase the dosage?

doxiesrock912

08-14-2014, 12:20 PM

Daisy was 11.5lbs and took 62.5mg once a day.

lulusmom

08-14-2014, 07:40 PM

Hi Kenny,

I'm not sure you saw my previous post so please see it below.

Hi Kenny,

Can you please get a copy of Gracie's most current blood chemistry and post all of the abnormal values and please include the normal reference ranges. The ALKP liver enzyme is not a good indicator of liver disease so I would like to see the other liver enzyme results. Any of these liver enzymes can change greatly in just 24 hours, depending on what is triggering the release of these enzymes so you may want to cut your vet some slack until she can try to pinpoint the cause. An abdominal ultrasound seems to be a good place to start.

Gracie's initial dosing, as well as subsequent increases, were the most conservative I've ever seen. It is highly likely that those inadequate doses have allowed the disease to progress so one would assume that the ALKP could possibly continue to increase. Those tiny doses have probably also cost you more for the multiple acth stim tests. This vet is an internal medicine specialist, right? Was this unorthodox dosing your vet's idea or was she acting in accordance with your wishes, based on your concerns about the drug and it's possible negative effect on Gracie?

Glynda

KennyJ

08-29-2014, 08:42 AM

Just read your post. I looked at Gracie's lab work 11/12/13 and her ALK was at 2305, down from 3700 from earlier that year. Now it's up to over 6,000. Her other liver enzymes are up as well. There is absolutely no improvement in her condition, in fact they are getting worse. I thought going with an IMS was the way to go but something has to give. I called my regular vet and he talked to me for about 45 minutes over the phone. Gracie is on 10 mgs of Tristolane, and 3 mgs of the compounded version. He says he does NOT like the compounded version and if it was him he would increase Gracie to 20 mgs of Tristolane because the symptoms have not improved. Here's the thing. This IMS has been treating Gracie for Cushings for 8 months now and we have gotten no where except I am paying her money for no results. I am really angry that she continues to increase the dosage by just a small amount each time with no improvement. Her hair is falling out, she has numerous sores on her skin, drinks and eats like a bear, and urinates all over my house. Any suggestions?

Squirt's Mom

08-29-2014, 09:14 AM

Kenny - not sure you saw this post of Glynda's originally nor the second time she posted it so I am posting it again.

Hi Kenny,

Can you please get a copy of Gracie's most current blood chemistry and post all of the abnormal values and please include the normal reference ranges. The ALKP liver enzyme is not a good indicator of liver disease so I would like to see the other liver enzyme results. Any of these liver enzymes can change greatly in just 24 hours, depending on what is triggering the release of these enzymes so you may want to cut your vet some slack until she can try to pinpoint the cause. An abdominal ultrasound seems to be a good place to start.

Gracie's initial dosing, as well as subsequent increases, were the most conservative I've ever seen. It is highly likely that those inadequate doses have allowed the disease to progress so one would assume that the ALKP could possibly continue to increase. Those tiny doses have probably also cost you more for the multiple acth stim tests. This vet is an internal medicine specialist, right? Was this unorthodox dosing your vet's idea or was she acting in accordance with your wishes, based on your concerns about the drug and it's possible negative effect on Gracie?

Glynda

Could you please respond to Glynda's post? We really need more info in order to give you insight. ;) Thanks!

KennyJ

08-29-2014, 09:23 AM

Thanks, yes I saw it but do not have the exact numbers in front of me. Her last ACTH came back at 14. I do know the ALK was over 6,000 and her other liver enzymes were also above normal. Reference range for ALP is 10-150 so they increased that much from last year. My regular vet said he wasn't crazy about ursidol as well. The ultrasound did show some signs of the mucocele still being there. Her adrenal glands have gotten larger. My regular vet said some dogs don't respond to treatment and may have to switch to the other medication but he does not like that one because of its side effects. But I was surprised that even he said he didn't think Gracie was on a higher enough dosage at 10 lbs. He would bump it up to 20mgs. Right now I feel all she has done is take my money and between this and her ruptured ACL its into thousands of dollars now. Her glucose was at 128 and reference range is 60-125.

My sweet Ginger

08-29-2014, 09:31 AM

Kenny, I think Glynda wants all of Gracie's abnormal values along with their normal reference ranges next to them from her most recent blood work and not just the ALKP values so she can see if anything else pops up. So please do that.

At this point your GP vet's suggestion sounds better to me if 13mg is doing nothing to control her symptoms. It's killing me Kenny to read your posts time after time with absolutely no positive results on poor Gracie when you've been trying so hard for so, so long. Maybe it's time you need a set of fresh eyes to look at things from a different angle.
I can tell you from my own experience that not all IMS are excellent.
I think you should be reimbursed for all the money that went down the drain by this IMS up to this point. :mad::mad::mad:
I'm really sorry for you and Gracie. Song.

Kenny, so you know I posted mine before I read your latest but I'm still :( at your IMS.

KennyJ

08-29-2014, 09:34 AM

I called and requested a copy of her last lab work and will pick them up today. Will post once I have them in my hand. Thanks to everyone for helping me through all this. I really thought the IMS was the right path for me but I don't see where she is helping Gracie at all. The only thing is causing me to be deeper in debt.

Squirt's Mom

08-29-2014, 09:45 AM

Kenny, can you tell us if this low dosing schedule Gracie has been on was your IMS' idea or yours? Your first little while here was full of fear of the drugs used for treatment so I have to wonder who / what is actually behind the low dosing - your IMS or your fears? Did you ever talk to her about these fears and perhaps that is why she started so low and has increased the dose so very slowly over the intervening months?

Squirt's Mom

08-29-2014, 09:46 AM

If your fears were behind this low dosing, talk to the IMS and let her know you are more comfortable with Trilo now and want to kick the dose up to a higher level.

KennyJ

08-29-2014, 09:50 AM

At the beginning I did discuss the fear of starting out on the high end of dosing based on what I was told on this forum. However, I completely left everything else up to her after that. We started out with the compounded version after her ACTH was at 22. After a couple of weeks at 5mgs it went down to 14. Another weeks it was at 13. Then it jumped back to 18. That's when she decided to try the name brand and it went down to 8 and I noticed less water intake. After another ACTH it went back up to 14 and that's when she said we needed to check her lab work again and another ultrasound. Everything that was abnormal at the beginning had gotten worse but the difference was her other liver enzymes were also above normal I am just now sure how much.

KennyJ

08-29-2014, 09:53 AM

I let her know that I thought we should kick it up at a higher dosage. But if she goes with one or two mgs that's not going to be a enough. And my regular vet said he would bump it up to 20mgs to see that controlled the symptoms, if not try the other med that has worse side effects.

Squirt's Mom

08-29-2014, 11:11 AM

Ok...so now we need to see those lab reports showing the liver enzymes - ALKP, ALT, and so on. If all of those values are escalating then something else may well be going on like something with the liver itself or the bile duct. So get those posted as soon as you can, ok?

You're doing good, Dad, and I know Gracie trusts you to make the right decisions for her. Keep your chin up!

KennyJ

08-29-2014, 01:09 PM

Ok here are her lab results. I will only list the abnormal ones including results of ACTH test with reference range to the right.

ALP 6744 5-160

ALT 359 18-121

GGT 131 0-13

Cholesterol 352 131-345

Glucose 119 63-114

Chloride 100 108-119

Potassium 5.5 4.0-5.4

Sodium 141 142-152

NA/K Ratio 26 28-37

Auto Platelet 750 143-448

Blood Trace Negative

ACTH STIM

Pre-ACTH Cortisol 7.0

Post-ACTH Cortisol 14.2

Reference Range

Canine 2-6 Pre-ACTH(resting) cortisol

6-18 Post-ACTH cortisol

18-22 Equivocal post-ACTH Cortisol

>22 Post -ACTH cortisol consistent with Hyperadrenocorticism

<2 Post- ACTH cortisol consistent with Hypoadrenocorticism

1-5 Desired pre and post ACTH on Lysodren therapy.

Squirt's Mom

08-29-2014, 01:20 PM

Thanks, Kenny! Now those who can interpret these better than I have something to work with. I would be asking the IMS if something could be going on with the liver and about possible bile duct blockage if it were me, tho. ;)

KennyJ

08-29-2014, 01:24 PM

Well she does have bile duct problems because she has a gall bladder mucocele.

KennyJ

08-30-2014, 11:06 AM

Any suggestions??

labblab

08-30-2014, 02:53 PM

Hi Kenny, I sure do understand why you are confused and upset! I would be, too. Can you remind us as to how long ago the mucocele was imaged via ultrasound? Those extremely high elevations in ALKP, ALT and GGT certainly are worrisome and do seem to point to something beyond Cushing's. That is what makes this situation so hard -- there may be multiple problems that are contributing both to Gracie's symptoms and also her cortisol elevation.

If those liver values were not so elevated and the mucocele was not present, I would say it's a no-brainer to just increase the trilostane dose. Like you and everyone else, I sure wish your IMS had not been so extremely conservative with earlier increases. But now the picture seems muddier to me, especially since Gracie did respond initially to the 10 mg. Vetoryl capsules prior to her symptoms/cortisol spiking again. So I am puzzling over the possibility that it is something else that is now rearing an ugly head and compounding the problems.

I know you have already spent a fortune. But if money were not an issue, I guess if it was me, I would want to be checking again on the status of that mucocele and her liver before making any other big changes. I really don't know much at all about gallbladder mucoceles, so I don't know whether imaging is the best diagnostic for that, or whether tests of actual gallbladder function and/or liver function would provide better info.

I understand that you have lost some degree of confidence in this IMS, and that you had trouble finding an IMS in the first place. Are there options for getting yet another opinion as to what is going on with Gracie? :o

It is indeed tempting to go ahead and increase her Vetoryl to 20 mg., and that is certainly the easiest thing to try. But I do have to wonder whether there is something more going on that is unrelated to the Cushing's.

Marianne

StarDeb55

08-30-2014, 03:29 PM

Kenny, even though I haven't posted to you in quite a long time, I've been following. I know what a struggle Gracie & you have had. With the severe elevations in all of Gracie's liver function tests. I'm in agreement with Marianne that I'm very concerned that there is something else in play besides cushing's. Please correct me if I'm worn but I do not remember if anyone had suggested a bile acids test
It can be pretty helpful in diagnosing liver disease. It shouldn't be too stressful for Gracie. I believe she must be fasted for 12 hours, this means no water, also. They draw blood, allow her to eat a small amount, then draw blood, again, in 2 hours. If the IMS has not mentioned this test, I would bring it to her attention.

Debbie

KennyJ

08-31-2014, 08:11 AM

I agree with all of you. You would think an IMS would have been the route to go but here it is almost 8 months after treatment and she's getting worse instead of better. She just peed on my sofa seconds ago. Something has to be done. How can a dog go from 2300 ALP to over 6000 in less than a year?? And now her other liver enzymes are way above normal. This vet being an IMS should have suggested a bile acid test. Very, very angry right now. All this money and I haven't seen anything for my money. :mad:

Squirt's Mom

08-31-2014, 08:50 AM

Cushing's is a very confusing disease, Kenny. SOOOO many things act like it and cause the testing to give inaccurate results. Among the ones that are most confused with Cushing's, and can most confound a confirmed Cushing's diagnosis, are liver disease, kidney disease, bile duct blockage - all of which could be going on along with Cushing's. Unless the vets are made to listen to us, who know our babies best of all, and unless we can clearly tell them what is going on, what our concerns are, they are almost as blind as we are with Cushing's in spite of all their training. It is so easy for us as parents and the vets to get tunnel vision and attribute everything to Cushing's. ;)

If I were you, I would sit down and make a written list of all my concerns, the things I have observed in my baby that are worrying me, questions from the lab work, anything that needs to be talked about and make an appt with the IMS asap to address your list. You worked so hard to find a vet you liked and were comfortable with I would hate to see you and Gracie have to start all over now so give the IMS a chance to listen and act - THEN if you are still dissatisfied, by all means start the search again and find a replacement very quickly. ;)

Lola

08-31-2014, 12:18 PM

Kenny, I am so sorry you are going through this with you baby, I know how it can be so overwhelming trying to decide what's best for our babies, the IMSs are not always the best judges, we are.
can I suggest you email all the lab tests and history to Dr Bruyette? he was a huge help for me so far, and he always answers my emails within an hour or so. A second professional opinion wouldn't hurt, right?

Nadia

KennyJ

09-01-2014, 09:10 PM

Lola

09-01-2014, 09:40 PM

Yes, very frustrating. Lots of money and nothing to show for it. No improvement. Just now she bit into a toad and started throwing up. I called the emergency vet here in Roanoke, Va and asked if they were poisonous and they said no. Not sure how to email the lab results without scanning them first. And adding the mucocele to the list of medical problems. Just wow, so overwhelming.

you can try emailing him a short email with her lab and diagnosis history- if you don't have access to a scanner, you can just type up the out of range values- I wish I could be of more help:(

molly muffin

09-01-2014, 10:18 PM

Yes, just type the ones that are high or low with the ranges.
Like
ALKP 6000 ug (5 - 50ug)
as an example.

My guess is that it is the gall bladder causing bile blockage that is causing those numbers to go up and affecting the liver. Just a guess of course.

Sharlene and molly muffin

KennyJ

09-02-2014, 10:31 AM

Did you include his email. I just called my IMS and she was not working today. I did find out that Gracie started her meds back on November 2013. That's plenty of time for results I would think. Really frustrated. Tried finding an email for him but could not locate one.

Squirt's Mom

09-02-2014, 10:49 AM

Dr. David Bruyette at VCA -

http://www.vcahospitals.com/west-los-angeles/our-team/veterinarians/david-bruyette-dvm-dacvim/28374

KennyJ

09-02-2014, 10:59 AM

Do I just call him with the results?? I do not see an email included on the website. Thanks. Ok, called and got his email. Sent Gracie's last lab results.

Squirt's Mom

09-02-2014, 11:19 AM

David.Bruyette@VCAHospitals.com

I did a "search" using our feature above and looked for "Bruyette email" and found it on a thread here.

Lola

09-02-2014, 11:52 AM

Do I just call him with the results?? I do not see an email included on the website. Thanks. Ok, called and got his email. Sent Gracie's last lab results.

I am so sorry I just saw your posts, I am on the west coast and a few hours behind.

here's the email address I use to contact Dr Bruyette: David.Bruyette@vcahospitals.com

I wish you the best of luck

Nadia

KennyJ

09-02-2014, 12:41 PM

Don't you guys agree that this IMS has had enough time to get the Cushings under control. And I am not a vet but looking at her pre and post numbers of her ACTH I don't see where they are that high. Am I looking at them incorrectly?

ALP 6744 5-160

ALT 359 18-121

GGT 131 0-13

Cholesterol 352 131-345

Glucose 119 63-114

Chloride 100 108-119

Potassium 5.5 4.0-5.4

Sodium 141 142-152

NA/K Ratio 26 28-37

Auto Platelet 750 143-448

Blood Trace Negative

ACTH STIM

Pre-ACTH Cortisol 7.0

Post-ACTH Cortisol 14.2

Reference Range

Canine 2-6 Pre-ACTH(resting) cortisol

6-18 Post-ACTH cortisol

18-22 Equivocal post-ACTH Cortisol

>22 Post -ACTH cortisol consistent with Hyperadrenocorticism

<2 Post- ACTH cortisol consistent with Hypoadrenocorticism

1-5 Desired pre and post ACTH on Lysodren therapy.

Squirt's Mom

09-02-2014, 01:09 PM

For a pup on treatment with either Lysodren or Trilostane (Vetoryl) the normal ranges given by the labs on ACTHs are incorrect. Those normal ranges are for a NON-cush pup or a pup who is NOT on any treatment.

The normal range for a pup on Vetoryl (Trilostane) is 1.45 to 5.4 ug/dl. IF and ONLY IF all signs are controlled the post number, the last number, can go as high as 9.1 ug/dl.

So with a post number of 14.2 Gracie is nowhere near controlled. ;)

I am leaning toward SOMETHING ELSE going on in addition to the Cushing's. I would think that SOMETHING ELSE could cause the cortisol to continue to rise in spite of treatment. So I think my first line would be to insist on the bile acid test asap.

KennyJ

09-02-2014, 01:12 PM

I think you are most likely correct and not sure why my IMS hasn't suggested that. Would the ultrasound pick up if there was a blockage? And I am guessing surgery is the only option if that is the reason.

KennyJ

09-02-2014, 02:06 PM

Dr Bruyette responded by asking me how he could help? I had already asked him what he suggested based on all the details I gave him including the latest lab results.

Squirt's Mom

09-02-2014, 02:27 PM

I would think he would need to know her history - how she got to where she is today with treatment, the mucocele and now the latest test results. Be sure to give him her starting labs, the starting dose and current dose as well as all the ACTH results to date. Ask him what he would recommend for her now...ultrasound again, bile acid, what?

KennyJ

09-02-2014, 02:33 PM

Ok, he did write me back. He asked if I was giving it with food, when the last labs where done including ACTH and mentioned since it was 13 mgs it must be a compounded version and wanted to know where I got it from. I explained on the 3 mgs were compounded that 10mgs was the name brand.

Squirt's Mom

09-02-2014, 02:46 PM

There ya go! :) Now tell him all you can think of that might help him understand your concerns.

KennyJ

09-02-2014, 03:17 PM

His response was the same as my regular vet. My regular vet told me the same thing and he is not an IMS.

It looks like we need to raise the dose. I would suggest going to 20 mg once day using the Vetoryl and rechecking the stim test in 1 week.

Dave

Lola

09-02-2014, 07:03 PM

That's a good start, you can do that and recheck in a week. You can also ask him about the off the charts numbers, if he can recommend a particular course of action based on Gracie's history.

Nadia

Renee

09-03-2014, 11:47 PM

Maybe this has been asked before..... but, why not wash out and switch to lysodren?

KennyJ

09-07-2014, 01:53 PM

Ok, started Gracie on 20 mgs on Thursday morning. So far no change whatsoever. How long does it normally take before I should see a difference?

addy

09-08-2014, 08:17 AM

That depends on the symptoms, the skin/coat issues sometimes will be the last to resolve and could take months. The hair follicles have a cycle to go through. Drinking and urinating can sometimes resolve in a few weeks. Stiff back legs can take some months. The blood work may also take sometime to show lower values or normal values.

KennyJ

09-08-2014, 11:01 AM

I guess what concerns me is that she has been on these meds for about 8 months now with no improvement. Maybe she is just one of the dogs that the meds will not work for. We bumped her meds up to 20 mgs on Thursday but she is still urinating in the house like crazy, drinking water like she is dying of thirst, hair is so thin you can see her skin, sores all over her. I feel so sorry for her but she is still greeting me at the door as if nothing is wrong with her.

My sweet Ginger

09-08-2014, 11:34 AM

Are you still communicating with Dr. B? Did he suspect any other underlying problems from the lab work you'd provided to him?
Talk to him about switching to Lysodren if this 20mg trilostane doesn't work as Renee has mentioned. Maybe she's one of those dogs who doesn't respond to trilostane as you've said.
I feel your pain that you have for your poor little Gracie and hope you will see some kind of a resolve in her very soon. Hang in there Kenny.

labblab

09-08-2014, 11:38 AM

Kenny, I definitely understand your frustration. I see that Dr. Bruyette has suggested another ACTH in a week's time, which seems pretty fast. But I'd probably want to at least see some improvement in thirst and/or urination within a couple of weeks or else I'll really start thinking that it may be something other than Cushing's that is contributing to the symptoms. A bump up from 13 mg. to 20 mg. is pretty significant and ought to be making a dent in things.

Like Song, I am wondering whether Dr. B made any comment at all about Gracie's mucocele and her extremely high liver numbers.

Marianne

KennyJ

09-08-2014, 11:42 AM

My IMS said another ACTH in 10-14 days. I was hoping with the increase in meds that I would notice at least some change in her symptoms since it was a huge bump but nothing. Dr B didn't say anything other than increase the meds to 20 mgs and test again in a week and keep in touch. Oh yeah, he did say keep a check on the gallbladder mucocele.

Harley PoMMom

09-08-2014, 11:44 AM

Hi Kenny,

It does take some time to see improvements, I believe that the elevated cortisol needs to come down to within the therapeutic ranges in order to really be able to evaluate how Gracie is responding to the Trilostane.

If it so happens that her cortisol is being controlled but symptoms still prevail then switching to Lysodren, after a wash-out period, can very well be an option for her.

Hugs, Lori

Squirt's Mom

09-08-2014, 12:22 PM

And during that month washout, have her looked at for anything else that might account for the signs and cortisol level increasing in spite of the Vetoryl - like that bile acid test. ;)

Because this has gone on for so long with so little response to treatment, I would not want to wait the 2-3 weeks the IMS suggested but insist on following Dr B's suggestion of 1 week. Like Marianne, it seems logical to me that this increase would bring some resolution of signs and a decrease in cortisol - if it hasn't in a week, I would insist on the bile acid asap.

KennyJ

09-08-2014, 12:36 PM

Thanks to everyone for your suggestions. I may ask the IMS for a bile acid test. Can this be done at the same time as her ACTH test?

labblab

09-08-2014, 01:28 PM

I do want to point out that even though this has dragged out so long, we don't yet know whether there is definitely a lack of response to trilostane. Your IMS has been so strangely slow in making miniscule dosage changes along the way that seemingly a lot of time has been taken up just spinning wheels without making the increases necessary to reach therapeutic level. It may be the case that trilostane is not a good choice for Gracie, but I'm really interested to see what this increase to 20 mg. finally does do over the next couple of weeks. And not to question Dr. B, but I'd be inclined to want to give it that 10-14 days before testing again. Who knows, it might finally turn the tide.

Also, I believe the bile acid test will need to be done at a different time from the ACTH because it involves fasting. And Gracie needs to eat her normal meal with her morning trilo dose for the ACTH.

Marianne

KennyJ

09-08-2014, 06:39 PM

I hope you are right. No changes so far. Just got home and she was starving. Drank just about a whole bowl of water and urinated everywhere. I don't believe I feed Gracie when I do the ACTH test.

doxiesrock912

09-08-2014, 07:30 PM

Kenny,. Gracie must have ner morning dose of Trilostane with breakfast 4 - 6 hours before an ACTH test. Aside from the first time one is done, this is the correct way to do all of them in order to determine proper dosage. Otherwise, you're just wasting money and risking improper dosage for Gracie.

KennyJ

09-08-2014, 07:37 PM

I do wrap the capsule up in a piece of cheese the morning of the ACTH test. You should see these two sores on the top of her head beside each ear. Is there something I can put on them?

lulusmom

09-08-2014, 07:46 PM

I don't believe I feed Gracie when I do the ACTH test.

I hope you are mistaken because you must give Gracie her Vetoryl with a meal always and most certainly before she has an acth stimulation test. The IMS should have provided you with complete instructions on this. If s/he did not provide proper counseling on dosing and acth stimulation test protocol, then shame on him/her because you have wasted even more money. If you have always fasted Gracie for her stim tests, the results are useless for any purpose other than ruling out low cortisol.

Kenny, you need to take the bull by the horns and educate yourself so that you understand your role in Gracie's treatment and are not forced to place blind faith in any vet to act in Gracie's best interest. That's what you've done and it's cost you both. Your role is to educate yourself on the drug you are putting in Gracie's mouth so that you know as much as possible about how Vetoryl works, what side effects to watch for in case of an overdose and how treatment monitoring works. In the nutshell, you need to 1) make sure you always give Gracie her Vetoryl with foods; 2) you need to watch her for signs of overdose, such as extreme lethargy, no longer eating, vomiting, diarrhea, tremoring, inability to walk and 3) on the day of an acth stimulating test, make sure you have Gracie to the vet 3 to 4 hours after you have given her Vetoryl WITH A MEAL.

All of the information you need to know is in our Helpful Resources section. I've included a handy link to the Vetoryl (Trilostane) thread below and heartily recommend you use it.

http://www.k9cushings.com/forum/showthread.php?t=185

KennyJ

09-08-2014, 07:50 PM

I am almost positive that she told me it was ok to give Gracie her pill with cheese but not to feed her breakfast. I should just make an appointment with the Vet School and quit playing around with this stupid vet.

addy

09-08-2014, 08:00 PM

Hi Kenny,

I just want to point out that you just started the 20 mgs a day or two ago, didn't you? I am not at all surprised you have not yet seen any reduction of symptoms and if you call and check with this IMS regarding her instructions about NOT feeding Gracie anything but a piece of cheese before her ACTH test, you need a different vet or you need to educate the one you have.

Just my two cents:)

KennyJ

09-08-2014, 08:03 PM

She has been on the 20 mgs since last Thursday, so 5 days now.

lulusmom

09-08-2014, 08:04 PM

Whether you continue with the internal medicine specialist, who seems to be incredibly ignorant for a board certified specialist, or whether you fall back on your gp vet, I still recommend that you educate yourself so that you understand all of this and do not place blind faith in or have to play around with any vet. Read up on the material in our library and print out those things that your IMS should have known and call her on it. Ask her why she didn't give you proper counseling and ask her why she didn't follow proper protocol, thereby wasting your money. I don't call that playing around....I call that shameful and irresponsible on her part. Only you can make sure this doesn't happen again by learning yourself. The more knowledgable you become, the easier it is to truly communicate with your vet and be the best advocate you can be for Gracie.

KennyJ

09-08-2014, 08:14 PM

Is 5 days long enough on 20 mgs to make a difference on the drinking and urinating?

lulusmom

09-08-2014, 09:21 PM

You still may see improvements in the next couple of days....or not. Every dog metabolizes the drug differently. You'll have a much better idea once you have the next acth stim test done....according to proper protocol. My heart just breaks for you, Kenny, because your IMS has drawn things out for both you and Gracie for no reason I can come up with. It's not right that all these months later you still haven't stabilized Gracie on an effective dose. :( It's just going to take a bit more to get her there so hang in there.

My sweet Ginger

09-08-2014, 09:48 PM

I don't know much about trilostane but I'm with Marianne and I'd stay on 20mg and have an ACTH stimulation test in 10-14 days as long as Gracie doesn't show any adverse side effects and go from there. Maybe it takes a little longer for her as every dog is different.

If your IMS told you to have Gracie fasted before each ACTH test, you ought to be reimbursed every penny you've wasted on all the ACTH tests that've been done.
I'm thinking what Addy said her husband told her about Drs. I think it goes something like ' Not all Drs were A students.' Probably your IMS was one of them I'm pretty sure.

I will pray and hope that this 20mg will work for poor you and poor Gracie this time.
It's so heart breaking for us to read your posts because we can all see how much you love Gracie and want to help her. Please, hang in there Kenny and keep us posted. Hugs. Song.

KennyJ

09-09-2014, 11:37 AM

Hi Kenny,
I just returned from vacation.

Gracie is a very complicated case. It is impossible to comment without examining her, reviewing the history in detail, and most likely repeating the ultrasound. Any of our medicine clinicians would be happy to see her as a second opinion referral. I am on clinics the weeks of Oct 6 and Oct 20.

Mike

Michael Leib DVM, MS
Diplomate ACVIM
C.R. Roberts Professor Small Animal Medicine
Virginia Maryland Regional College of Veterinary Medicine
Virginia Tech
Blacksburg, VA 24060
540 231 4621
540 231 1676 fax

KennyJ

09-09-2014, 02:17 PM

Ok guys I need your advice. Should I go ahead and make an appointment at the Vet School here at Virginia Tech?

Squirt's Mom

09-09-2014, 02:52 PM

Regardless of which vet you use, the most valuable advise any of us can give you has been given by Glynda in post #1165 -

Whether you continue with the internal medicine specialist, who seems to be incredibly ignorant for a board certified specialist, or whether you fall back on your gp vet, I still recommend that you educate yourself so that you understand all of this and do not place blind faith in or have to play around with any vet. Read up on the material in our library and print out those things that your IMS should have known and call her on it. Ask her why she didn't give you proper counseling and ask her why she didn't follow proper protocol, thereby wasting your money. I don't call that playing around....I call that shameful and irresponsible on her part. Only you can make sure this doesn't happen again by learning yourself. The more knowledgable you become, the easier it is to truly communicate with your vet and be the best advocate you can be for Gracie.

The single most important factor in making sure your sweet girl is getting the best care possible is YOU. ;)

As for switching vets now, I'm not sure what I would do. There will probably be extra expense for repeat testing with a new vet BUT a new vet is apt to have fresher eyes and you may be able to talk to "Mike" better than this current IMS.

addy

09-09-2014, 08:13 PM

Hi Kenny,

I was in the same boat with my Zoe. I decided to just have a "consult" with another specialist. I brought all my own records and notes. None were sent from the previous vet. I told the consulting vet I was thinking of switching and wanted to hear his take on things. It only cost me the office visit. I then went back to our original IMS and discussed our options, using the input from the consult without mentioning that info came from another IMS. I then pressed our IMS to contact Dechra.

Zoe did get better but it was not because of either vet, it was due to me putting their input to use, I analyzed both IMS vets and Dechra's input. It was I who insisted on a skin scraping. It was I who insisted on the Keto Chlor. It was I who took all the info and found a path forward.

I guess my point is that Glynda is right. Gracie's best voice is yours.
I know how hard it is. I walked in those shoes. I am sorry it is so hard.

KennyJ

09-10-2014, 08:22 PM

I know it's going to cost me more money but I decided to take Gracie to the Vet School tomorrow. My IMS wrote a referral letter with all of Gracie's lab work and ultrasounds. Just so frustrated with no improvement after all the money spent.

Squirt's Mom

09-11-2014, 08:16 AM

Kenny, have you read the info in the Resource section and do you understand what you have read?

Do you understand the things Glynda and others have explained to you?

ie - are YOU taking steps to educate yourself so you do not have to rely on a vet who may or may not be doing things according to protocol?

...so YOU know what should and should not be done, what to expect and when, what an overdose looks like, and so on?

I hope you are doing the above and that this new vet works well with you, an educated parent.

Hugs,
Leslie and the gang

KennyJ

09-11-2014, 12:48 PM

Thanks guys. I did read that dogs should NOT fast when having the ACTH test. Gracie is at the Vet School here in Blacksburg, Va and this IMS is increasing her meds to 30 mgs. He is also doing a biopsy on two of her lesions to see exactly what they are dealing with. I asked this Dr if Gracie should fast when she is doing the ACTH and he said that it shouldn't affect it. Well everything you guys showed me and what I read in this article says just the opposite. Trust me I will have a talk with him when I pick Gracie up. I also sent him the link saying just the opposite of what he said. This whole freaking time Gracie has been fasting.

http://endocrinevet.blogspot.com/2011/03/whats-best-protocol-for-acth.html

lulusmom

09-11-2014, 02:31 PM

I'm proud of you, Kenny! Keep absorbing as much information as you can and don't be afraid to challenge this new vet or any other vet if you don't agree with what they are recommending.

Squirt's Mom

09-11-2014, 03:33 PM

Good for you, Kenny! Way to speak for Gracie!

jillmst

09-11-2014, 03:44 PM

We had some trouble finding a reliable vet at first, too. It costs more money and there's more testing because you're kind of starting from the beginning each time you switch vets, but it's worth it to find a vet that is good. Knowing what to look for definitely helped a LOT. Good luck! :)

KennyJ

09-11-2014, 03:59 PM

He was actually going to increase Gracie's meds to 40 mgs but said if I felt more comfortable at 30 we would try that for a week and do a ACTH next week.

labblab

09-11-2014, 04:21 PM

Wow, wanting to jump from 13 mg. (since Gracie had just begun on the 20 mg.) to 40 mg. honestly seems incredibly aggressive! Good grief, you start with an IMS who takes months to go up a few mg., and now you've got the other extreme: essentially tripling the dose in a week's time! :eek: :eek: :eek:

Good for you for drawing the line at 30 mg., Kenny. Even that seems like a big increase mighty quickly. :o

One thing this vet needs to take into consideration is that since Gracie's previous ACTH tests were done after fasting, her actual daily cortisol levels were likely lower than the tests indicate.

Marianne

KennyJ

09-11-2014, 07:12 PM

Ouch, sounds like I made the vet a little angry at me. LOL

Kenny,
I am familiar with Dr. Peterson and this article. He is a very smart person, and so am I. I agree she does not need to be fasted, but I do believe it would be in your best interest not to feed her a full meal as lipemia (fat in the blood) can occur after full meals especially in dogs with Cushing's disease. Lipemia can interfere with the cortisol measurement.

Dr. Peterson's article states "When a dog 's food is withheld, the absorption of trilostane from the gastrointestinal tract is decreased. This leads to low circulating levels of trilostane, resulting in little to no inhibition of adrenocortical synthesis. Therefore, serum cortisol values will higher when the drug is given in a fasted state than when it is given with food." So, if you have been fasting Gracie what this means (in theory) is that if you had fed her then her cortisol concentrations would have been lower than what was measured. Lower means better control of her Cushing's disease. You don't believe her Cushing's has been controlled so if the cortisol concentrations had come back lower (better control) would you have believed she was controlled?

I hope she will start having a response to the increased dose of Vetoryl, and I feel confident if we work together we will get her up to a dose that controls her Cushing's disease. I do not believe I have ever had a patient where I couldn't do so.

DG

addy

09-11-2014, 07:13 PM

I am so glad they are going to biopsy Gracie's skin sores. Hopefully he will be able to treat that as well.

lulusmom

09-11-2014, 07:49 PM

Kenny, if you gave the vet Dr. Peterson's blog entitled "What's the Best Protocol for ACTH Stimulation Testing in Dogs and Cats?", then apparently he missed the very first sentence where Dr. Peterson states that lipemia does not appear to “clinically" affect serum cortisol values. Lipemia could affect blood chemistry values so blood for that purpose should be drawn on a different day where a 12 hour fast can be done.

http://endocrinevet.blogspot.com/2011/03/whats-best-protocol-for-acth.html

KennyJ

09-11-2014, 08:26 PM

Yep, that's the one I sent him. He didn't seem to like the fact that I questioned him.

addy

09-11-2014, 08:44 PM

He will learn to like it;);););) Sorry, we had been posting at the same time.

doxiesrock912

09-11-2014, 08:56 PM

You're paying him Kenny so you're the boss. Whether he likes it or not.

lulusmom

09-11-2014, 09:18 PM

Yep, that's the one I sent him. He didn't seem to like the fact that I questioned him.

Dang, life's a bitch sometimes, especially when you are humbled by a member of the k9c family who knows what they're talking about. Go, Kenny, go! :D

Squirt's Mom

09-12-2014, 08:33 AM

And be on your guard - a vet who gets upset at being questioned or when someone points out an error on their part can be a dangerous vet to a cush pup. BE SURE this new vet will work with you as a team, Kenny. ;)

KennyJ

09-15-2014, 06:10 PM

Ok, he called me today to see how Gracie was doing. He bumped up Gracie's meds to 30 mgs on Thursday and he thought I should see a change in her drinking water and urinating by now. No change so he wanted to bump her up to 40 mgs. I asked him to give her several more days before we bump it up. Did I do the right thing? The biopsy came back and there is no infection in the nasty looking sores on her head but instead they are caused by Cushings.

molly muffin

09-15-2014, 08:04 PM

Oh dear, so Gracie has calicunosis cutis on her head.
I would give this some time at 30mg to see how she is doing and then redo the ACTH to verify prior to increasing the dosage any further.
I hope that the cortisol is responding to this dose, but we have seen some small dogs end up on large dosage. Are you currently giving to her once a day or still doing twice a day dosing?

Sharlene and molly muffin

KennyJ

09-15-2014, 08:13 PM

Yes, two places on her head. Her skin is horrible. I am not feeling confident that the meds are going to work on her. He wanted to bump her up to 40 mgs right now. She is still gulping the water and wanting to urinate frequently.

molly muffin

09-15-2014, 08:26 PM

I think they will work once the best dose for her is found. At least I hope so.
Such a little thing but such a stubborn body. :)
Give it a bit at 30mg. Did he say when he wanted to do the ACTH test to check levels?

Sharlene and molly muffin

KennyJ

09-15-2014, 09:24 PM

He didn't want to do the ACTH test unless I saw changes in her symptoms that's why he wanted to go ahead and bump it up to 40 mgs.

Renee

09-16-2014, 12:55 PM

If she indeed has CC, then it's time to stop playing around -- wash her out on the vetoryl and get her on lysodren. The CC can very, very quickly get out of control and take MONTHS or YEARS to heal.

I just don't understand why she has been on vetoryl for a year (or longer?), and things have not improved even slightly. In fact, the presence of CC indicates things are worsening.

KennyJ

09-16-2014, 01:00 PM

Renee, the CC is really, really bad. I feel so sorry for her. It's funny you mentioned the other drug because he did as well. How long do you have to be off the meds she is on now?

molly muffin

09-16-2014, 07:40 PM

To do a proper wash out between trilostane and lyosdren, you need to really be off trilostane for 30 days.
I think you're going to need to do an ACTH test though at some point. You shouldn't switch unless you know where the cortisol is and it hasn't yet been low enough to control cc.

Sharlene and molly muffin

KennyJ

09-17-2014, 06:14 PM

Ok, I need your advice. I asked Dr Grant if this was his pet which medication would he treat his own dog with. Below is his response.

You have asked wise questions. If we switch to mitotane unfortunately I would have to recommend stopping trilostane for about a month before starting mitotane. Personally, I don't believe this wait period is necessary in Gracies situation, but "experts" in the field have given a decent explanation on why it might be dangerous to do otherwise. I don't feel like pressing the issue.

If my own pet had Cushings I would have started it on mitotane. My reasons are that mitotane is somewhat cheaper, I have much more experience using it, it only has to be given about 3 times a week after initial loading, and I find that dogs get regulated in a shorter period of time than with trilostane. I completely understand why most vets these days use trilostane and I teach my students that is what they should use; it is FDA approved for treating Cushing's, its effects are rapidly reversible in nearly all dogs when and if the medication is stopped, it uncommonly causes Addison's diease and when it does it is nearly always (not always) reversible. I tell folks that use mitotane that if their dog lives at least a couple of years that the dog will go through at least one period of having mitotane induced Addison's disease, which is usually reversible but not reversible as often as is the same problem induced by trilostane. In the scenario where a dog becomes permanently Addisonian you can look at it as a bad thing or a good thing. The good thing about it is that the dog won't ever have signs of Cushings anymore and the treatment for Addisons disease costs less than trilostane. In fact, some vets purposefully give enough mitotane to cause permanent Addisons for these reasons.

So, the two big choices for you are 1) continue to work on finding the dose of trilostane that works, or 2) take her off trilostane and start mitotane in a month. I believe we can regulate her either way, but I can't predict what the final dose of trilostane will turn out to be. Most dogs only require 1 mg/kg trilostane twice a day to control their Cushings disease and Gracie is already at around 4 mg/kg AM and 2 mg/kg PM. If you choose to continue with trilostane I recommend that you stick with 20mg AM, 10 mg PM and give me an update on Monday. If she has not had a significant reduction in drinking or eating then I will suggest giving 20 mg AM and 20 mg PM. The reason I don't want you to switch to that today is that we are now getting close to a weekend and if she is going to have an Addisonian event I don't want it to occur on the weekend as that will create unnecessary stress on you and whatever veterinarian has to deal with it. If we start 20/20 on Monday then we have 5 days to look for problems before the next weekend arrives.

As I am sure you have been told before, if she is ever showing signs of Addisons (vomiting, loss of appetite, lethargy) you should stop giving trilostane, seek veterinary help right away, and if you cannot get help then give prednisone. 5mg of prednisone is what I recommend for her. My recollection is that you have prednisone at home already.

Let me know what you think Kenny. I look forward to getting Gracie regulated.

DG

lulusmom

09-17-2014, 06:24 PM

Kenny, I love Dr. Grant! He sounds like a keeper. I think he has given you some terrific information that is spot on. I also think has presented a great plan for moving forward. My cushdogs treated with both Mitotane and Trilostane and for what it's worth, I would not throw in the towel on Trilostane yet.

Glynda

KennyJ

09-17-2014, 06:28 PM

So would you increase it to 40 mgs a day?? She is on 30 mgs right now and I do not see any improvement.

lulusmom

09-17-2014, 06:53 PM

If you see absolutely no improvement by Monday, then yes, I personally would up the dose to 40mg. My cushdog only weighed 4.5 lbs and I don't recall but I think her IMS started her on 30mg and I was very lucky because she stabilized on that dose. My other cushdog weight 6.5 lbs and started on 15 mg twice a day. He stabilized on his dose too so yay for me. That just goes to show that some little dogs sometimes need much bigger doses.

KennyJ

09-17-2014, 06:56 PM

Those places on her head look absolutely awful. Her hair is almost all gone. You would think starting her treatment Jan. 2014 we would have a fix on this problem by now. :mad:

lulusmom

09-17-2014, 06:59 PM

Did Dr. Grant confirm that the skin problem on Gracie's head is calcinosis cutis? If so, that's not going to get better until her cortisol is where it needs to be. If it is calcinosis cutis, her pre and post cortisol may need to be below 5 ug/dl. That's something you should talk to Dr. Grant about.

KennyJ

09-17-2014, 07:05 PM

Yes, he confirmed it was calcinosis cutis by doing a biopsy. He said even if we get it under control doesn't mean that will clear up all the way. Its really bad. Looks like two scabs about the size of a nickle on both sides of her head. I feel so sorry for her.

lulusmom

09-17-2014, 07:09 PM

Kenny, your vet is correct. It is tough to gain the upper hand on CC which is why I said that the normal therapeutic reference range set by Dechra may not apply to dogs with CC. It may take lower cortisol levels to see resolution.

Renee

09-17-2014, 07:44 PM

addy

09-17-2014, 08:58 PM

Kenny, I would agree with Glynda.

Even though every dog is different, Zoe's skin issues did not resolve until I treated her with Keto Chlor and her cortisol was consistently 5 ug/dl or under. Her blood work became normal once her cortisol was down even lower, closer to 2 ug/dl.

It may be Gracie needs topicals to help with the sores in addition to lowering her cortisol.

KennyJ

09-21-2014, 09:24 AM

Where do I get the topical solution you suggested because she really needs something. And I need to make a decision. Gracie has not improved even with the bump up to 30 mgs. Dr Grant said to let him know Monday what I wanted to do. Increase to 40 mgs or switch over to the other meds. Any advice?

Squirt's Mom

09-21-2014, 10:19 AM

You are in a difficult position with this decision because the treatment started with such a very, very low dose you really don't have a good idea of how this drug might have worked. If the dosing had been closer to the normal starting point with no resolution, in fact worsening, of signs I would say it's a no brainer - switch to Lysodren. BUT the Trilostane treatment was not optimal so....I'm not sure what I would do but I think I would still switch. However keep in mind, I personally prefer Lyso so I may not be as objective as others. ;)

doxiesrock912

09-21-2014, 11:23 AM

If you do switch, Gracie will need to be off meds for 30 days. With her skin issues, I would be afraid of that getting much worse during the 30 days before starting Lyso. I wouldn't make that change yet.

Honestly, try the bump to 40mg and the topical solution and see if that helps.

KennyJ

09-21-2014, 01:55 PM

Dr Grant contacted me and suggested bumping her up starting with the evening dose today. Check her cortisol levels at the end of the week. Please let them help.

doxiesrock912

09-21-2014, 03:44 PM

Kenny,

Amazon has ketochlor shampoos http://www.amazon.com/s/ref=nb_sb_noss_2?url=search-alias%3Daps&field-keywords=Keto+Chlor&rh=i%3Aaps%2Ck%3AKeto+Chlor

There are also wipes.
[URL="http://m.entirelypets.com/ketocwipes50c.html"]

KennyJ

09-23-2014, 04:39 PM

Gracie has been on 40 mgs since Sunday and no sign of improvement.

molly muffin

09-23-2014, 10:35 PM

It has only been 3 days, lets see what she does over the coming week.
I certainly would not up it again without an ACTH!

Sharlene and molly muffin

KennyJ

09-25-2014, 08:44 PM

Well I got good news and bad news. I took her for her ACTH today at the Vet School and it was excellent. However, she now has a Grade 3 heart murmur, her hair is still falling out. Those horrible skin lesions are not any better. And to beat it all, this visit was far cheaper than taking her to my regular IMS. 4.96.

Name (DOB): JARELS, GRACIE (1/4/2004)
Patient ID: 121340
Collection Date: 9/25/2014 10:48 AM
Approval Date: 9/25/2014 3:41 PM
Sex: FS
Age: 10
Patient Location: Inpatient
Sample ID: 16381
Veterinarian: DAVID GRANT
Species: Canine
Clinic: VMRCVM, VTH
Clinic Phone: (540) 231-3137
Owner Name: JARELS, KENNY (5823)
Cortisol (Post)
Approved by:
JF
9/25/2014 Reference Interval
10:48 AM
Cortisol (Post) 4.96 4.10-19.90 μg/dL
Sample ID:

doxiesrock912

09-26-2014, 12:02 AM

Kenny,
the skin issues take time to heal and will now that Gracie's numbers have lowered. Daisy had a heart murmur too. What are they going to do about it?

Glynda, what is the name of the ointment that helps CC?

KennyJ

09-26-2014, 10:52 AM

Yes if someone has an ointment that will help please let me know. They added a few other things to her visit this time in addition her heart murmur. Cornea scars on both eyes, wasn't listed two weeks ago. Not sure why they list them now. Just keeping an eye on the heart murmur right now. But what I want to know is if her levels were in the acceptable range according to him, how come her other symptoms are NOT improving. Still eats all the time, drinks a ton of water, and urinates frequently.

KennyJ

09-26-2014, 05:56 PM

I guess he sees something I don't. Her skin and her lesions look awful.

Kenny,

Gracie’s overall condition seems to be improved. Her skin appears better and she is very bright and energetic. At home she seems to still be drinking and urinating more than normal as well as wanting to eat constantly. Gracie’s medication is working well and as a result her cortisol level was within the target treatment range.

The medication Gracie is on (Trilostane) does not stay at a consistent level at all times of the day. When you give the Trilostane in the morning it takes about 4-6 hours to reach it highest effect, after that point it gradually goes down. Her cortisol concentration therefore is doing the opposite. When the Trilostane is first given the cortisol is high, and as the Trilostane reaches peak effect the cortisol goes down. However, once the Trilostane starts to be metabolized/eliminated the cortisol goes back up. The cycle restarts when Gracie gets her evening dose. These high levels of cortisol are what contribute to Gracie’s excessive drinking and eating.

As a result of the up and down levels with Gracie’s medication and cortisol, her clinical signs will be most apparent 1-2 hours prior to and after Trilostane administration. Given Gracie’s medication administration times (approximately 6am and 6pm) she is likely going to show the least clinical signs from 10 am to 2pm and 10pm to 2am. These are likely the times that you are either working or sleeping. As a consequence you may have only been able to see Gracie at times when her cortisol levels have had the opportunity to rise again.

With the current scenario it is possible Gracie may need to be given Trilostane more frequently ( 3 times a day) to effectively maintain consistent control of her clinical signs and cortisol levels. However, Gracie has only been on the current dose (20 mg twice a day) for less than a week, and other than the continued drinking and eating she seems to be doing better. At this time I think we should keep her on this dose and recheck her in a month with an ACTH stimulation test and a chemistry profile to determine whether we will change her dose or frequency. This will give her skin, muscles, and liver enough time that a measurable change can be seen, and will give you opportunities to see her at times when her cortisol is at its lowest. As you know there is always a risk of inducing Hypoadrenocorticism while taking Trilostane. As a reminder clinical signs of Hypoadrenocorticism include vomiting, diarrhea, weight loss, and lethargy.

I hope to see you in a month.

addy

09-28-2014, 09:56 AM

http://veterinarycalendar.dvm360.com/canine-cushings-case-files-ins-and-outs-detection-and-treatment-case-file-dogs-with-recurring-pyoder

http://veterinarycalendar.dvm360.com/cushings-disease-something-new-something-blue-proceedings-1

http://veterinarymedicine.dvm360.com/dermatology-challege-severe-facial-pruritus-boston-terrier

Kenny, these are just a few of the articles I researched for Zoe's skin issues. She did not have lesions. Not knowing what Gracie's lesions or skin looks like, I would still think the IMS would be suggesting something for her. I really had to push mine to prescribe a medicated shampoo.

I think you certainly could ask the vet school if a medicated shampoo like Keto Chlor would be useful for Gracie and if there is any other product they could recommend. We have had many dogs on the forum in the past two years dealing with various stages of calcinosis cutis who used many different products.

Having said that I do think what the medical school says, in the above post makes sense.

I wonder if flushing out Gracies, hair folicles may help her and if so, keep in mind it will get worse before it gets better as the folicles have about a three month cycle.

If you read the link I provided regarding the dog with severe calcinosis cutis you will see the different approches the vet team used.

If you push your IMS, specifically, perhaps, the vet school, I would think they would and should come up with something to help Gracie's skin and not just rely on lowering her cortisol.

I'm sorry it took awhile for me to get back to you, I have been pretty sick.

KennyJ

09-28-2014, 02:14 PM

Her ravenous eating, water consumption, urinating hasn't improved at all. Ok, Gracie has urinated 3 huge puddles on the floor within 30 minutes. I simply do NOT understand. How could her test results be in the normal range and still no improvement. Something is not adding up.

doxiesrock912

09-28-2014, 09:03 PM

Kenny,
Have Gracie tested for a UTI or other infection. That is not normal.

KennyJ

09-28-2014, 09:15 PM

She was tested for all that last month, all came back normal.

doxiesrock912

09-28-2014, 09:56 PM

Wow. I'm stumped.

KennyJ

09-28-2014, 10:01 PM

You and I both. I mean if the meds are not going to control that what's the point of continuing??

doxiesrock912

09-28-2014, 11:30 PM

There is no set timeline for symptoms to improve and Gracie has a lot going on.
Since the tests have ruled out infections, I'm thinking that she just might be one of the dogs whose symptoms take a week or more to improve.

I know that it's hard to be patient, but it sounds like you might finally be on the right track. Definitely insist that they give you an ointment for her skin though. The shampoo that I mentioned is also good to get through Amazon.

KennyJ

09-28-2014, 11:34 PM

She has had just about every test imaginable. I am so frustrated right now. When she urinates its like a pond. So tired of stepping in it. You guys saw the rest results of her last ACTH test and his explanation. So does that mean in between the dosages I can expect peeing all over the freaking house?

doxiesrock912

09-28-2014, 11:36 PM

Every dog is different. She's still drinking a lot so she has to get rid of it somehow. Get puppy pads in the meantime.

KennyJ

09-29-2014, 12:01 AM

I have puppy pads down on the floor but she goes all over the house. So frustrating.

doxiesrock912

09-29-2014, 12:41 AM

I know it is Kenny.
Do you have gates to keep Gracie in tiled areas when you're not home?

Our kitchen and dining room are one large room and I had to confine Daisy when she had bowel issues. Doing this at least keeps you from having to clean carpets.

Usually, the first thing to see changing are the drinking and eating habits. Remember that she also has the CC to overcome which is a lot. Also, when Cortisol is lower they will feel pain etc that they didn't feel when it was high. Her skin lesions could be hurting her making her not want to walk around alot so she relieves herself where she is.

I'm guessing at the last part, but others have said that CC lesions hurt.

Work on getting the cream please. I think that it goes by the same name as the shampoo.
Gracie's Cortisol has been uncontrolled for quite awhile and now that it is controlled, there is a lot of damage to be undone.

Be patient dear and remember that it is no fun for Gracie either and many dogs get embarrassed when they mess in the house. Do not let her think that you're angry with her. She needs your love above all else.

Hugs to both of you.

My sweet Ginger

09-29-2014, 07:33 AM

Kenny, maybe it's time for diapers for Rosie tho it won't work if she's left alone for 8-9 hours while you're at work unless you can come home on your lunch break and change diapers. They get diaper rashes very easily and quickly and you've got enough problems to deal with already. I wouldn't recommend Gracie wearing them when you are home as they need to air out the area as much as possible.
If you are interested I can give you pointers from my experience with Ginger and I tried and researched a lot trying on different ones and all.
I settled on the one she's using now and it serves our purpose perfectly. I totally get your frustration as I was there almost two years ago myself. Take a look at Ginger in that diaper (harness with a diaper inside), she doesn't look degrading in this like the other types did to her.
http://www.k9cushings.com/forum/album.php?albumid=780&pictureid=5736

Squirt's Mom

09-29-2014, 07:41 AM

Kenny, I would stop the Vetoryl, do the washout and switch to Lyso. If this were my dog, I would feel this had gone on long enough and it was time to see some resolution of signs. ;)

Renee

09-29-2014, 12:15 PM

Kenny, I would stop the Vetoryl, do the washout and switch to Lyso. If this were my dog, I would feel this had gone on long enough and it was time to see some resolution of signs. ;)

Absolutely 100% agree with this. I think this has gone on way too long already. Do the switch.

lulusmom

09-29-2014, 12:40 PM

Hi Kenny. Thanks to your vet's overly conservative dosing regimen for over the a year, Gracie has had chronic excess cortisol for a long time. It is quite possible that she has what is called renal medullary washout. To simplify things, it means all the stuff (solute) her kidneys need to concentrate her urine has been washed out for a very long time so the kidneys will take some time to recover. A UC Davis study revealed that a small number of dogs they treated dogs trilostane never saw a resolution of pu/pd so that's a possibility too.

I don't have an answer for Gracie's voracious appetite. Excess cortisol screws with protein metabolism and because Gracie is on twice daily dosing, with a perfect post stim, her cortisol should be low enough to normalize the protein metabolism. I know that with my own cushdogs, they had a huge appetites for so long, I forgot what a normal appetite was. However, once their cortisol was stabilized, they were no longer foraging or overtly begging for food but they still acted very hungry. My first cushdog was always a healthy eater so the changes were subtle but easily identifiable. Have you seen absolutely no improvement in Gracie's appetite, even a subtle one?

In my opinion, you have two choices. You can either wait another week to ten days to see if Gracie's peeing improves or you could switch to Lysodren after a 30 days washout. No matter what you decide, you need to discuss it with your vet. Did you ask your vet why Gracie is still symptomatic? If so, what was his explanation?

Glynda

KennyJ

10-03-2014, 06:56 PM

Ok, now I have another problem. I went off and forgot my refill for Grace so that means she will go all weekend without her meds. I am leaving for out of town tomorrow. Any suggestions? To answer your question, no I see no improvement on anything.

doxiesrock912

10-04-2014, 12:30 PM

Diamondback might be able to send them overnight but your vet would have to send them a prescription asap.

Squirt's Mom

10-04-2014, 12:36 PM

Sounds like a good time to start the washout to me. ;)

KennyJ

10-19-2014, 11:44 AM

Absolutely no improvement in Gracie's condition I don't care what the last ACTH test showed. So irritated right now.

molly muffin

10-19-2014, 11:51 AM

um,, what exactly Did the last ACTH show?

Are you doing the washout to switch to lysodren?

How are her kidneys? That is another thing that will cause the urinating/drinking. Any protein loss going on that sort of thing?

Some dogs the cortisol level needs to come down to post below 5ug on the ACTH to see symptoms lessen.

Sharlene and molly muffin

KennyJ

10-19-2014, 11:54 AM

Her latest results are farther up the thread. Dr Grant said it was right where it was supposed to be. I just don't believe its accurate if her hair is still falling out and none of the other symptoms have improved either. For some reason she feels so warm when she is near me.

KennyJ

10-19-2014, 11:55 AM

Name (DOB): JARELS, GRACIE (1/4/2004)
Patient ID: 121340
Collection Date: 9/25/2014 10:48 AM
Approval Date: 9/25/2014 3:41 PM
Sex: FS
Age: 10
Patient Location: Inpatient
Sample ID: 16381
Veterinarian: DAVID GRANT
Species: Canine
Clinic: VMRCVM, VTH
Clinic Phone: (540) 231-3137
Owner Name: JARELS, KENNY (5823)
Cortisol (Post)
Approved by:
JF
9/25/2014 Reference Interval
10:48 AM
Cortisol (Post) 4.96 4.10-19.90 μg/dL
Sample ID:

molly muffin

10-19-2014, 12:07 PM

So, with a post of 4.96ug on the ACTH and that was Sept 25, 2014. There should have been some resolve of the symptoms.

Did you talk to the vet about her kidneys? What does her last urinalysis and Blood chemistry show?

Sharlene and molly muffin

KennyJ

10-19-2014, 12:31 PM

Kidney's seem fine. All of her liver enzymes were off the charts though. Especially her ALP which was over 6,000.

Squirt's Mom

10-19-2014, 01:11 PM

Did she have the bile acid test done? I can't remember...

EDITED TO ADD:

Could you post those liver enzyme results along with the normal ranges? And anything else that is too high or too low on the latest lab work.

KennyJ

10-20-2014, 01:39 PM

No, a bile acid test has not been performed. Here is Dr Grant's email to me that he sent today.

I was going to email you to check on her. I will not be working in the hospital next week, so if you want to see me (or have her see me rather) then I need to see her on W,Th, or Fri this week. You are welcome to drop her off just as you did last time. My plan was to repeat the stim and her biochemistry profile so I could see if her ALP is decreasing (ie, responding to treatment). It is certainly disappointing to hear you haven't noticed an improvement. If there is also no measurable improvement then I we will have to discuss what else could be going on and further treatment options. LEt me know.

David Grant, DVM, MS, Dip. ACVIM
Associate Professor
Dept. of Small Animal Clinical Sciences
Virginia-Maryland Regional College of Veterinary Medicine
Blacksburg, VA 24061-0443