9 Year Old Maltese with Cushings

[Squirt's Mom]

Have they mentioned a condition called Diabetes Insipidus? This form of diabetes has nothing to do with blood sugar but has to do with how the body processes water. I would ask about DI ....and I would also go with Dr. Grant who wants to find out what is going on. ;)

[Squirt's Mom]

AND I would switch to Lysodren asap.

[KennyJ]

Well, they just called and Gracie's stim test had doubled. This is just crazy so I guess I will be switching over to the other meds. 4.96 last time, this time over 11.

[Renee]

Well, thank goodness you are switching her over. I cannot believe her vets have pushed using vetoryl this long, with absolutely zero results!

[KennyJ]

I'm assuming he will want to switch to lysodren. Dr Grant from the Vet School says this is the medication that he uses on dogs. Funny how they all differ in opinion. Others tell me no way to use this drug while he says he gets good results. Meeting with him at 3:00. He is at the Vet School at Virginia Tech.

[KennyJ]

Ok, doing the wash out and starting her on the new meds in a month. Scared to death. Dr. Grant said eventually all dogs on Lysodren would have Addison's.

[Renee]

Ok, doing the wash out and starting her on the new meds in a month. Scared to death. Dr. Grant said eventually all dogs on Lysodren would have Addison's.

Kenny, this is not true. Many dogs, on this very forum, have been treated with lysodren, and never went addisons. Your vet is mistaken, unless he has that opinion due to his own management of cushings with lysodren, in which case... hmmmm, that makes me wonder about him?

All aside - Gracie needs to get better, and vetoryl, for whatever reason, is not working for her. The switch to lysodren is a good choice, and if she did go addisons, it's not the worse possibility.

[KennyJ]

I know one client drove 7 hours just to see Dr Grant, I am not sure for what reason but everyone seems to think he is a great Vet. But now I am concerned since he said every dog eventually will go into Addison's on Lysodren.

[StarDeb55]

Kenny, I haven't posted to you in a long time but have been following. Let me assure you that Dr. Grant's statement about all pups on lysodren will eventually go Addison's is not correct. I successfully treated 2 pups with lyso with absolutely no instance of an Addisonian crisis. Barkley, my first cushpup, was successfully treated with lyso for nearly 8 years with lyso. The only time he even came close to going Addison was during loading because the boy didn't read the "rule book". He never slowed down eating during loading, he never slowed down eating at all during those 8 years. He would have eaten until he popped if I had let him. The only thing that caught the Addison's problem during loading was I had been measuring water intake during loading, so I used that instead of B's eating habits. He had gone in for a stim on day 8 of loading since I had seen no change. I got a call from the vet the following day, asking if I had measured water yet, I said no. She told me that she would wait on the phone. To make a long story short, there had been a 60% drop in water intake, & B's numbers on his stim were very low. He was put on prednisone immediately for 5 days, did another stim at that point, then went straight to maintenance for lysodren. This really was a small bump in the road as B never got acutely ill, & we never looked back for 8 years.

My 2nd boy, Harley, had been successfully treated with lyso for 2 1/2 years. Harley was a senior pup at 13 when he was diagnosed. We had a few small bumps in those 2 1/2 years, but absolutely nothing that was an Addisonian crisis.

You absolutely must educate yourself about lysodren & lysodren loading prior to seeing Dr. Grant. Get your questions formulated. Make sure that you are given prednisone for an emergency with clear instructions on when to use it. You also need instructions as to how to reach Dr. Grant or the vet that might be covering, if Gracie might get in trouble. I don't expect she will, but it's good to have all your bases covered.

One last thing on the off chance that Gracie does go Addison, it's actually easier to treat than Cushing's. In Europe, it's widely use protocol to chemically destroy a Cushing's pups adrenals to make them permanently Addison as the consensus is that Addison's is much easier to treat, & for the owner to deal with. Don't misunderstand, I'm not advocating this. I actually had discussed this option with my vet for Harley, & he didn't like it. I told him good as I wasn't about to let healthy tissue be destroyed.

Hope this helps.

Debbie

[KennyJ]

I love you guys!! Dr Grant is a very confident doctor and seems this should be the med for Gracie. He's just the opposite of all the other vets, they do not like Lysodren at all. He does.

[doxiesrock912]

Crossing my fingers that you've finally found the right vet for Gracie!

[KennyJ]

Wow, I was told that Lysodren was cheaper than Vetoryl. There's a pharmacy here locally that sells it so I called and got the price. They sell it in 500 milligram tablets for $170. 30 tablets. Are you kidding me?

[Renee]

Wow, I was told that Lysodren was cheaper than Vetoryl. There's a pharmacy here locally that sells it so I called and got the price. They sell it in 500 milligram tablets for $170. 30 tablets. Are you kidding me?

It's sold at walmart too, and maybe costco, and lots of other pharmacies. The upfront loading cost will be more than vetoryl, I think, but the maintenance phase should be less, because you will not be dosing every single day. Once you are in maintenance, you can order it online and get it for much cheaper.

[KennyJ]

I sure hope so. Wow!! I am already paying close to $100 a month on Vetoryl.

[Squirt's Mom]

It is also usually less expensive to use because pups on Lyso don't typically require as many dose adjustments as those on Vetoryl do. With every dose change you have to start the monitoring test schedule all over - 2 weeks, 30 days, etc. Lyso typically requires less testing to monitor than Vetoryl. Bear in mind also that you will use ONE of those 500mg tablets a day during the load then maybe 2 tablets a month on maintenance. So 30 tablets will more than likely last longer than a month. ;)

[StarDeb55]

Kenny, I've forgotten Gracie's current weight, could you remind me? The reason I'm asking is that those 500 mg tablets of lyso are whopping huge for a little girl like Gracie. You will probably have to be cutting them into quarters at the least. It may be easier if you get the lyso compounded in smaller doses so you don't have to stress over cutting those pills. Harley weighed only 14 lbs, & this is what I did. The compounded version was so much easier to deal with. Post her weight I can give you an idea of what her loading should be.

Debbie

[KennyJ]

Debbie, she lost a little weight. She is right at 10 lbs. I think Dr Grant told me a 1/4 pill in the morning and 1/4 in 12 hours. Funny thing, I come home today thinking she would have urinated all over the place and I couldn't find one wet spot on her pee wee pad. She's been off the Vetoryl since Friday. Did you get the compounded version from Diamondback?? If so how much did it cost you?? He said he didn't have a problem using a compounded version.

[StarDeb55]

Kenny, it's been a long time since Harley, so all I can tell you about price is that it didn't seem to be that bad. Yes, I used Diamondback because they're local for me.

To calculate a loading dose, you want the weight in kilos, so divide by 2.2. For Gracie, this gives 4.5 kg. You want the loading dose to be as close to 50 mg/kg body weight, so this would 227 mg. total daily which is split into 2 doses. Dr. Grant's figure of 1/4 pill twice a day is pretty close to what you want being 250 mg. IMO, I think you would be better off getting the lyso compounded with a dose of 110 mg. per capsule for a daily dose of 220 mg. The 220 works out to be 48.9 mg/kg., just about perfect.

The one thing I didn't mention about lyso & having to cut pills. You need to be wearing gloves, & have a dedicated pill cutter for this purpose. This is a very strong drug that you don't want to be absorbed through your skin. So you see. the compounded capsules, gets rid of this problem, too.

I don't want to overload you with info right now, but as you start the load with Gracie, & get her loaded, I have some other suggestions as to how to make life a little easier when dealing with these tiny babies.

I will be watching for your updates.

Debbie

[KennyJ]

This drug just seems so much more dangerous than the Vetoryl.

[Renee]

It only seems more dangerous because vetoryl has the reputation as the 'safe drug'. It's not true. Both drugs can cause a lot of damage when handled incorrectly.

The suggestion of compounded lysodren is an excellent idea. I think you'll get a much better price and less headache with splitting pills.

Are you doing a 30 day washout? How are the other symptoms?

[KennyJ]

Renee,

Yes a 30 day washout. Dr. Grant just responded to my email about doing a compounded version instead of the tablet. He said sure no problem.

[StarDeb55]

Kenny, I think several of us have mentioned this before, but it bears repeating. Both drugs that are used to treat Cushing's are very serious medications, neither of them are safer than the other one. Where problems develop is when a treating vet is not following standard protocol for dosage & monitoring of the drug, & an owner who has not educated themselves about the drug & it's protocols. This 2 things are usually what causes a pup to get into trouble. I don't want to sound like a broken record, but you really do need to educate yourself about lysodren as you are Gracie's voice & her only advocate.

Debbie

[KennyJ]

Thanks Debbie. I may bring Gracie over to your house until we get her regulated. I am so frustrated that I have been at this since Jan. and still not where we should be.

[doxiesrock912]

Kenny, every dog is different.
Daisy wasn't here with us long enough to get properly regulated. It's so tough and you have to be careful as both drugs are nothing to play with.

Be patient. Hugs

[Dixie'sMom]

Hi Kenny! Although I have not posted to your thread before, I have been following Gracie's story since I joined in July. I understand your frustration and know that you are very discouraged. The one thing that always jumps out at me every time I see your thread is Gracie's beautiful little face. She wants to please you. She wants to make you happy. So as frustrated as you may be with the lack of progress, please be patient with her. She lives for your approval and loves you to the moon.

I'm praying the Lysodren will be the answer for you and sweet Gracie to get her Cushings under control. I'll be following along to see how everyone is doing.

[KennyJ]

Update on Gracie. Started her on Mitotane last Friday and so far there has been no improvement. Drinks water like crazy, urinates ALL over the house and I am talking about LARGE puddles. Could eat 24/7. I take her in for an ACTH on Thursday but I already know the results of that test. Call me FRUSTRATED!!!:mad:

[addy]

Hi Kenny-

Are you doing a load or a maintenance dose?

[KennyJ]

I am doing a load. Started Friday November 28th.

[labblab]

Kenny, what dose are you giving Gracie?

Please try not to give up hope yet. The thing is, it is not likely that you will see any changes at all until the mitotane has eroded enough of the adrenal cortex. It can literally be overnight that you will finally notice a slight change in Gracie's behavior, and that is the signal that you've reached the dosing endpoint. So it is not like trilostane, where you may see some gradual reduction in symptoms over time as cortisol levels lower. With mitotane, it is more like a light-switch. There is nothing different at all until suddenly you reach the moment when you witness even a slight change.

Today will be Day 6 for Gracie, and that is not an unusually long time to be loading. It will be important to check her cortisol level tomorrow, but don't give up hope if she's not yet where she needs to be. Do tell us what dose you are giving her, though. And are you giving it after feeding her? Mitotane is best absorbed in conjunction with a full stomach or alongside a treat that contains some fat.

Marianne

[KennyJ]

Marianne, sorry I thought I had listed that. Gracie is on 112 MGs twice a day and yes I feed her first before giving her the Mitotane. I give her capsule in cheese.

[Squirt's Mom]

Hang in there, Kenny. Did anyone ever take DI seriously?

[KennyJ]

Who is or what is DI?

[Squirt's Mom]

uuummm we talked about DI, Diabetes Insipidus, earlier. It is a rare form of diabetes that has to do with how the body processes water and has nothing to do with blood sugars. The treatment is an eye drop. The signs are heavy drinking and excessive peeing. The test is risky so most vets simply start treating with the eye drops and if they work, there is the diagnosis.

[KennyJ]

Ok thanks for explaining. That has never been discussed. And her puddles are HUGE!!

[Squirt's Mom]

Yeah, I asked about it a while back and you posted about it when you posted about DogtorRX. I would talk to Dr. Grant about this if the Lyso doesn't seem to be helping when the ACTH is due.

[My sweet Ginger]

Kenny, when will be Gracie's last dose of Lysodren before tomorrow's ACTH stim test?

[KennyJ]

Tomorrow morning will be her last dose before I drop her off at the Vet School for the ACTH test. If the Vet Teaching Hospital can't treat this, who can??

[My sweet Ginger]

Hmm, usually ACTH is done about 48 hours after the last dose of Lysodren because Lysodren works for 48 hours although I now hear that it's not written in stone anywhere and it's ok to do it anytime before 48 hours as long as the vet takes the timing of the test into consideration. Hopefully one of the experts chimes in on this.

[KennyJ]

Here are Dr. Grant's instructions. #4 says I can give her morning dose of Lysodren before bringing her in. I am so confused.



Kenny,

I will be calling Diamondback today or on Monday to prescribe lysodren/mitotane for Gracie. The 4 week rest period from trilostane would be over next Friday. If we begin lysodren at that time then Gracie may need to have ACTH stim tests done during Nov. 26-28 when the VTH is closed and when I will be out of town. This isn’t ideal if we can avoid it. My suggestion is for you begin giving lysodren on the 28th so that Gracie will likely have her response during the following week (80% of dogs respond in 5-9 days, 10% in 3-5 days) when other veterinarians and I will be here to test her and guide you in her treatment. You will of course be able to email me at all times. Please let me know what you think about this, concerns you have, etc. Below are instructions general instructions for you to read through, which may stimulate you to ask questions.



DG





1. Starting the day treatment begins, begin feeding Gracie ½ of her normal amount of food at each of her 2 meals. This should make her exceptionally hungry, and therefore easy for you to tell when her appetite decreases. A decrease in appetite is the most common sign of a response to lysodren and that you should stop giving this medication.

2. After Gracie eats each of her two daily meals give the lysodren in something tasty.

3. A reduction in appetite can simply be that she eats her meal slower, that she walks away from it and then comes back to finish, or takes time to look around while eating. If a decrease in appetite occurs or if you notice a reduction in drinking or if she vomits, has diarrhea, or is lethargic stop giving lysodren and notify me. These are all signs that she is responding and anymore lysodren could make her very ill. She should come in for an ACTH stimulation test that day or the following day if a response is seen. If she vomits or has diarrhea multiple times or is very lethargic then she should go straight to a vet. If you are concerned and cannot get her to a veterinarian quickly then give her 5 mg of prednisone by mouth.

4. Even if Gracie has not had a response she should have an ACTH stimulation test done here on the 7th day of treatment. You can give her the morning meal and lysodren on that 7th day before bringing her in for testing.



David Grant, DVM, MS

Diplomate ACVIM (SA Internal Medicine)

VA-MD Colllege of Veterinary Medicine

[My sweet Ginger]

His instructions are very thorough so it could be the way he treats Lysodren.
I'm sorry to confuse you on this but I remember talking quite a lot about 48hour mark on here a while back. Maybe it's different now. You can also ask him about it.
Like everyone says look for any subtle changes and I hope you will see it soon. You and Gracie have been in this maze for way too long.

[KennyJ]

I also just read it should be two days after the last dose online. So yeah, this has been nothing but total confusion for me ever since Gracie started her treatments. Nothing has worked, maybe I should just keep wiping up large puddles of pee and just forget it. This guy is IM with the Hospital and even he can't get her under control. Worried that he doesn't know what he is doing either now.

[My sweet Ginger]

Trust me Kenny, I totally get your frustration at this point in Gracie's treatments but let's wait and see this time with Lysodren and let him explain his way of performing an ACTH only within hours of last dose because clearly you won't see the full effect of that last dose on the results as far as I can see. I know it's very hard for you to stay positive looking back but try to be patient a little while longer since you've started with Lyso now. Just be very vigilant watching her.

[lulusmom]

After reading the IMS' instructions to you, I am not worried about him at all. He is following Dr. Edward Feldman's protocol and nobody knows Lysodren like he does. Part of that protocol is that your vet should have started calling you on day two or three of loading to check to see how Gracie is doing. If your vet has been silent, he's not following protocol to the letter but thank goodness you have us for feedback.

Lysodren's mode of action couldn't be more different than Vetoryl. The average loading period for dogs is 5 to 8 days and the first stim test is usually done within 48 hours after the last dose but an experienced vet knows how to assess a stim test done before that time based on days loaded and last dose given. Dr. Feldman gives no more than 8 doses to his clients and if the dog doesn't show signs of loading by the 8th dose, he has them come in on the 9th or 10th day. Your vet is being conservative having Gracie come in on day 7. I personally think that's a good idea since she was on Vetoryl for so long. Lysodren targets the adrenal cortex and without having x-ray vision, you have no idea what changes were caused by Vetoryl so err on the side of caution. Your vet is playing it safe and unlike your experience with Vetoryl, you should be comfortable with conservative right now. I know you are frustrated with Gracie's severe symptoms but you need to be a bit more patient with your vet and give the drug time to accumulate and work its magic. I've treated two cushdogs with Mitotane (Lysodren) and it was certainly magic for them.

Glynda

[My sweet Ginger]

Thank you Glynda. :)

[doxiesrock912]

Crossing fingers for you and Gracie!
Hoping that the new treatment plan works!

[flynnandian]

like leslie said, if lysodren doesn't work, let them give you minrin drops to see if this is diabetus insipidus.
if it is d.i. ,your dog will be peeing normal in a few days max!
the drops are pretty expensive, but it will ''cure"' your dog!
worth the try!

[KennyJ]

He kept checking on Gracie with emails. As expected he just sent me an email and Gracie is not yet regulated yet so more Mitotane for twice daily. He will talk to me when I pick Gracie up. Glynda, are you saying Gracie shouldn't have been tested this morning since I gave her the morning dose of Mitotane??

[KennyJ]

Just received this email from him. Wow, she is back up to 17 on her ACTH. This is just crazy.


You got 30 pills so you should have plenty at home. Also, it is refillable whenever you need to. Remember, 80% of dogs respond in 5-9 days, 10% in 3-5 days. You have only given 6 full days worth. See you when you get here.

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

[labblab]

Just received this email from him. Wow, she is back up to 17 on her ACTH. This is just crazy.

Is this the result from today's test? If so, you've got to keep in mind that Gracie went for an entire 30 days without treatment, so there's no telling how high her cortisol had spiked during that time period. Within that context, 17 may actually signal a decline.

Marianne

[labblab]

Glynda, are you saying Gracie shouldn't have been tested this morning since I gave her the morning dose of Mitotane??
I'm not Glynda :D, but I don't think there was a problem with Gracie being tested this morning after her dosing. Your specialist should be equipped to assess the significance of the test results within the context of her dosing schedule.

Marianne

[lulusmom]

Kenny, I see that Gracie is getting 224 mg a day. Can you tell me how much she weighs?

[lulusmom]

Okay, I went back in your thread and see that Gracie weighs a bit over 10 pounds. The loading dose of 112mg twice daily is appropriate as 50mg/kg is the recommended max loading dose for dogs with pituitary dependent disease. Did your IMS tell you that Lysodren is best absorbed with a bit of fat? I always gave my dogs their pills with peanut butter or cream cheese. If Gracie's food is low in fat and you aren't giving the pill with any fat, she may not be absorbing the drug well.

Glynda

[KennyJ]

Good morning Glynda. Yes I give Gracie's pill in cheese. Today is the 10th day and no change in her condition. I am really frustrated.

[Squirt's Mom]

There has been absolutely no decrease in drinking, appetite, or urination? None at all, zip, zilch, nada? If not, I would be inclined to think something other than Cushing's is keeping the cortisol elevated. Perhaps the gall bladder? Perhaps DI? I am NOT saying she doesn't have Cushing's but there could be something in addition to Cushing's going on and I would want a thorough check to find out why IF the ACTH doesn't show a decrease in the cortisol level. She is scheduled for an ACTH very soon, right?

What signs are you still seeing and how strong are they compared to when she first started the Lyso?

[KennyJ]

Absolutely no change in any of her symptoms. Her ACTH last Thursday was at 17.

[Squirt's Mom]

Ok so tell me again what signs you are seeing and how strong they are?

[Squirt's Mom]

Update on Gracie. Started her on Mitotane last Friday and so far there has been no improvement. Drinks water like crazy, urinates ALL over the house and I am talking about LARGE puddles. Could eat 24/7. I take her in for an ACTH on Thursday but I already know the results of that test. Call me FRUSTRATED!!!:mad:

So Gracie has been loading since Nov. 28th? Making today the 10th day. Did she miss any doses after the last ACTH?

[Renee]

Let's do a scenario here.

Say that Gracie DOES NOT have cushings, but something else that is causing her cortisol to be elevated.... wouldn't the lysodren still lower the cortisol because it is eroding the adrenal glands?

[KennyJ]

No doses have been missed. Her water intake, excessive urinating, and eating like she is starved has not changed. Once while on the Vetoryl she came all the way down to 4.5 which was perfect. The next month she went back up to 8 so the Vet said he wanted to switch her to the other meds.

[Squirt's Mom]

I would say stay the course for now, Kenny. When did Dr. Grant want her in for the next ACTH?

I would be beyond frustrated myself at this point but don't give up just yet. I went back and reread the beginning of her thread here and in your second post you say she does have accidents. Is that worse now or simply hasn't changed?


Well she does pant a lot, drinks a lot of water but she never gets me up at night for the bathroom. She does have accidents urinating in the floor but I have always chalked that up because she is at the house at least 8 hours without a potty break.

[KennyJ]

Its worse than accidents. When she lets it loose its a bucket of urine. I believe he wants to do another ACTH this week.

[judymaggie]

Hi -- an aquaintance of mine whose dog was also diagnosed with Cushing's and who uses the same vet finally had his dog loaded after three weeks! His dog is now doing fine on maintenance. Not sure if that will be comforting to you or not but at least it is an indication that not every dog fits into the typical protocol. Unfortunately, it can be very expensive because of the necessity of extra ACTH tests.

[KennyJ]

That is encouraging. Hope Gracie will get her Cushing's under control soon.

[KennyJ]

Wow, they just called me. Gracie's ACTH was at 1.4. That is freaking low. They want me to stop the meds and start her on prednisone tomorrow. This scares me. Also, her legs are getting worse. She no longer will walk up the stairs. I have to carry her. She was shivering when I took her in this morning. They ran more lab work to see if she still had the UTI after being on antibiotics for a month and she did have white blood cells in her urine. However, they explained the type of test they ran could have caused that so they did a culture that should be back next week. I am a nervous wreck.

[Squirt's Mom]

Actually that's within range for a Lyso pup. The range for Lysodren is 1-5ug/dl. When did she have the last dose?

[KennyJ]

She took her Mitostane at 6:18 this morning. Why can't I just stop the meds for several days instead of giving her prednisone?

[KennyJ]

From Dr. Grant




Kenny, I had to leave work because my daughter was sick, & I may not make it back by the time you pick up Gracie. So, here is a summary of today's visit.
Gracie's post a cath cortisol was 1.14 micrograms dl today. This is within the range of 1-2 that we aim for. This is great news. However, because it is so close to the low end of the range she could drop lower in the next two to three days because lysodren works for that long. So, Please give her 1/4 of a 5 milligram prednisone tablet once a day starting tonight through Monday night. As long as Gracie does not have a poor appetite, vomiting, diarrhea, or lethargy (all are signs of lysodren overdose/hypoadrenocorticism) then you can give her one 112 milligram lysodren capsule next Thursday. She should not receive any lysodren before next Thursday. Then, continue to give her 1 lysodren capsule every Monday and Thursday with food. I would like to recheck her acth stimulation test in one month as long as she is doing well.
Now that Gracie's cortisol is suppressed you should see her thirst, urination volume and frequency, and appetite reduce over the next month. Her hair and skin will take many months to improve. Remember that if at any time she shows signs of lysodren overdose, do not give lysodren, and if the situation it is urgent give her 1/2 of a 5 milligram prednisone tablet and seek veterinary help.
We rechecked Gracie's urinalysis today. She had a slight increase in white blood cells in her urine so we are culturing her urine to determine if it is still infected or not. The results will take 3 to 4 days.
Gracie is limping on her left rear leg. She has a luxating patella in that leg, but it is not causing her to limp. She has some mild thickening or swelling in her hock/ankle joint on that side, which may be where she is experiencing some pain though she does not act painful anywhere I touch or stretch her. She has likely strained a muscle or ligament in this area. I recommend you not allow her to run or jump for the next couple of weeks and see if the limping resolves. The small dose of prednisone she is getting in the next 5 days may help as well. If you would like to you can hold a cold pack on her hock joint for 10 minutes twice a day for the next few days as you might do if you sprained your ankle. The knee injury she had last year was in her right rear leg.

Please stay in contact to let me know how gracie is doing. I am very happy that her Cushing's syndrome is coming under control.

[lulusmom]

Kenny, Trilostane inhibits the synthesis of cortisol and it's short acting. As soon as you quit dosing, the cortisol starts to rise. Mitotane actually erodes (kills off) adrenal tissue and has a cumulative effect for at least a day. If Gracie's post was at 1.4 yesterday and you gave her another pill this morning, it's quite possible that she is close to an addisonian crisis so you absolutely must give her the pill as your vet has instructed. She is already showing signs that cortisol is too low and it may get worse, so do not ignore your vet's instructions.

[labblab]

Kenny, your vet did a good job of explaining things so I hope his instructions will make more sense now that you've read them. The prednisone is a tiny dose and it is just temporary in order to allow Gracie to feel better in the event that her cortisol level drops any lower through the weekend. This may be why she was shivering earlier and not so perky -- because she is feeling kind of yucky from such a rapid decrease of cortisol in such a short time. The prednisone will help to ease her over the hump until her own adrenal glands start rebounding a bit on their own.

But the mitotane definitely did its job in lowering her cortisol. Hopefully you will soon be seeing some improvement in her symptoms to correspond with the lab numbers!

Congratulations, Kenny!
Marianne

[KennyJ]

So does it sound like I have a good vet this time??

[Squirt's Mom]

Sure seems to understand Lysodren and that is half the game or more right there! ;) He seems to be steering you right so far! How do YOU feel about him? How does GRACIE feel about him?

[KennyJ]

Dr. Grant is a very confident man. He took photos of Gracie today and he said in two months she would be beautiful again. LOL Just seems strange I have been battling for almost a year to get her levels down to normal now I am giving her meds to raise them again.

[doxiesrock912]

Yeah, it's a true balancing act. Add that every dog responds differently and things easily get complicated.

I can wait to see pictures of Gracie in a few months!
Maybe create an album to track her progress visually?

That would be interesting.

[Squirt's Mom]

The only thing I see is that typically you stop the drug when you see signs of the load achieved - which you never did so you continued to give the drug right up to the day of the test PLUS the following day. Usually the Lyso is stopped when you see the loaded signs, you wait a day or so, have the ACTH, and continue waiting til you start the maintenance dose. Since there was no stopping of the Lyso for Gracie, that is why the concern and need for the pred.

Lysodren is not like Vetoryl in that it leaves the body quickly. Lyso sticks around for a long time (approximately 48 hours) with each dose where Vetoryl is leaving the body just a few hours after getting it. So when there is a crisis or a chance of one, as in Gracie's case, pred is essential. Having pred on hand with a Lyso pup is NOT an option. ;-)

[KennyJ]

The problem, after I cut the pill its so freaking small for the prednisone. Even with the 1.14 ACTH test Gracie was still always hungry. No change there. I give her the last prednisone tonight and then start back one capsule of Mitotane on Thursday.

[Renee]

Kenny - in some respects, the hunger may never stop. My girl, as a pug, is always and forever hungry. Now, the intensity has decreased from when it was at it's worst, but I would still say that she is hungrier than the average dog. At her worst, she was waking me up at night to eat. Now that she is controlled, she still looks for food, still scratches the refrigerator door, still goes crazy for treats... but, she does not wake me up to eat. She has a bit more control. But she still lives for food.

[StarDeb55]

Kenny, Gracie's hunger may never really moderate. My first boy, Barkley, kept that huge appetite even when his Cushing's was well controlled. I always swore that B would have eaten until he popped if I had let him.

Debbie

[Squirt's Mom]

How are things today, Kenny? How is the urination and drinking now?

[KennyJ]

Just got a call from Dr Grant. Gracie still has a UTI. Back on more antibiotics. It never ends.

[labblab]

Kenny, I sure do understand your exhaustion and frustration at this point! Now that Gracie's cortisol level is finally down, however, she may be spared as many issues with UTIs in the future once this current one is finally eradicated. You have definitely been through the wringer over these past several months. But I am truly hoping that there is finally some light to be seen at the end of the tunnel (even though you're still not quite there, yet...:o).

Marianne

[Renee]

I hope they did a culture and sensitivity to diagnose and prescribe the abx for her UTI? Also, keep in mind, it may take much longer than the standard 7-10 days of treatment for the UTI. My Tobey has had past UTI's that took 4-5 weeks of treatment to fully eradicate. Make sure you follow up with another culture once you are done with the cycle of abx, just to be sure the UTI is gone.

[Harley PoMMom]

Since dog's with Cushing's have diluted urine sometimes an urine culture and sensitivity test is needed. A regular urinalysis is usually not sensitive enough to pick up bacteria in the diluted urine and this is where that urine culture and sensitivity test comes into play. This test will show what particular bacteria is growing and then the appropriate antibiotic can be prescribed.

Hugs, Lori

[KennyJ]

Yes, he did a culture and prescribed something different from my regular vet. Gracie was on that antibiotic for probably a month. That's why I was surprised she still had one. He wants to see Gracie again on Monday.

[doxiesrock912]

Hopefully the different med will work this time.
It sounds like you have finally found a great vet and things should start to level out now. Be patient and hug Gracie <3

[molly muffin]

Merry Christmas Kenny and Gracie.

Hoping things are going well with you both

[KennyJ]

Well once again I am so freaking frustrated. Nothing is working with Gracie. Dropped her off for more lab work and here is what Dr. Grant said.




Gracie continues to drink, urinate, and eat too much because her Cushing's disease is no longer regulated despite the fact I had her on a fairly high maintenance lysodren dose twice a week. Her cortisol is 17 micrograms/dl today vs. 1.14 a month ago. I did an ultrasound exam of her adrenals today (no charge) to be sure she does not have an adrenal tumor; I see no signs of an adrenal tumor.

At this point there are two choices. 1) take her to Los Angeles to have her pituitary gland removed surgically. 2) Near-completely destroy her adrenal cortex using high doses of lyosdren. This requires her to take prednisone and DOCP injections or a drug called florinef to replace the hormones she will not be able to make. About 25% of dogs will still relapse within a year with Cushing's using this treatment. 3) Load her again on lysodren and then give her lysodren 3 times a week to try to maintain her regulation. There is about a 50% chance she will relapse within a year with this option. I suggest option 3 given its relative ease compared to the other 2 options, and it is generally quite effective. If she relapses with either option 2 or 3 we just load again.
The good news is we saw before that she did respond to lysodren. Assuming you want to follow my suggestion, choice 2, please get a refill of lysodren and do the following:

1.Starting tonight, begin feeding Gracie ½-3/4 of her normal amount of food at each of her 2 meals. This should make her exceptionally hungry, and therefore easy for you to tell when her appetite decreases. A decrease in appetite is the most common sign of a response to lysodren and that you should stop giving this medication.
2.After Gracie eats each of her two daily meals give the 112 mg lysodren in something tasty.
3.A reduction in appetite can simply be that she eats her meal slower, that she walks away from it and then comes back to finish, or takes time to look around while eating. If a decrease in appetite occurs or if you notice a reduction in drinking or if she vomits, has diarrhea, or is lethargic stop giving lysodren and notify me. These are all signs that she is responding and anymore lysodren could make her very ill. She should come in for an ACTH stimulation test that day or the following day if a response is seen. If she vomits or has diarrhea multiple times or is very lethargic then she should go straight to a vet. If you are concerned and cannot get her to a veterinarian quickly then give her 5 mg of prednisone by mouth.
4.Even if Gracie has not had a response she should have an ACTH stimulation test done here on Jan. 19. Please DO NOT give her lysodren on the morning she will have her ACTH stimulation test done this time.

Gracie's urine culture will be complete on Monday and I will let you know the results. As during loading before, I encourage you to give me daily updates about how Gracie is feeling.

I am sorry, as usual, that Gracie is so difficult to regulate. She is one tough dog with a very active pituitary gland.

[StarDeb55]

Kenny, I don't know what to say, except that I'm literally stunned by what has happened. Gracie's adrenal glands must be able to regenerate in the blink of an eye.

I was offered the option of "nuking" my 2nd pup to make him Addisonian as most vets feel it's easier to treat than Cushing's, but I was absolutely against this idea. Harley could also lose his load in the blink of an eye, but nothing like what Gracie has shown. I do have one question, are you giving Gracie her lyso with something fatty such as peanut butter or cream cheese? Just a reminder, lyso does absorb better in the presence of fat.

I still think Dr. Grant is a good vet, even though he seems to have met his match with Gracie. IMO, I think I would go the reload route. Once you get to maintenance, definitely go to three times a week dosing. Harley's vet has always told me he prefers 3x per week for maintenance as the pup seems to do better, keeping the load.

I know you are at your wit's end but hang in there.

Debbie

[KennyJ]

I wrap Gracie's pill up in cheese. Dr. Grant I believe has met his match. He said I have hung on longer than he probably could have. So I am back giving her two capsules a day and recheck in 10 days. This time he does NOT want me to give the capsule on the day of testing. I really hope something finally works. How can she go from 1.12 and four weeks later all the way up to 17?? That's just crazy.

[StarDeb55]

The cheese may not have enough fat, I would try the p. butter or cream cheese. I even tried full strength mayo at one time. This has happened because Gracie's adrenal cortex are regenerating rapidly, & twice a week for maintenance is simply not enough. At twice per week, keep in mind that there is a 4 day gap in between doses which is plenty of time for the adrenals to regenerate which Gracie sure has demonstrated.

Debbie

[Squirt's Mom]

For a time, Squirt's maintenance was given every other day because her signs would start to rebound if given any further apart. So talk to Dr. Grant and keep a very close eye on her for any increase in signs once she is back on maintenance.

Gracie is one of a kind for sure! I was glad, sorta, to see appetite as part of the signs you mentioned to the vet as that makes me worry less about DI that is not looked into. ;)

[doxiesrock912]

Kenny, on the bright side - the fact that Grace's adrenals are regenerating so quickly means that she's fairly healthy aside from Cushings.

[addy]

The literature I read some time ago said it is not uncommon for a dog to have to be reloaded during the first year of treatment, our Gracie is just a wee bit early;)

Oh Kenny, hang in there!

[KennyJ]

Week two of twice a day and still no changes. Here was his recent email to me. He still stays confident.



Kenny,
Thanks for asking and sorry I didn't inform you sooner. Her chemistry profile was done on Friday. I didn't mention it because there were no suprises; it just looks like we expect for unregulated Cushing's syndrome. ALP around 4,000, but that isn't of concern as it does not reflect any real damage to the liver or anything else.
Her urine is still growing E. coli. Unfortunately, Cushing's syndrome is a cause of persistent urinary tract infections. It impairs their immune function. Additionally, E. coli can be extremely difficult to eliminate due to some very clever methods it has to hide from antibiotics. Since 2 rounds of antibiotics that this E. coli is susceptible to have failed to eliminate it, I doubt we will truly eliminate it until her Cushing's is regulated for a few weeks at the earliest. So, lets get her back on Baytril/enrofloxacin. We will plan to keep her on it until her Cushing's has been regulated for a couple weeks and then try to stop it. You can pick it up tomorrow afternoon. This disease can be a pain in the but can't it.
Keep giving the lysodren twice a day. Let me know when her appetite, thirst, or energy level decline.
DG

[addy]

Kim's Annie took forever to load, a few months, I think.
Hoping Grace is getting close.
Hang in there.

[KennyJ]

Ok, Gracie is due back for another STIM test tomorrow but I do not see any change in her appetite and her urinating. Here is what Dr. Grant just sent me.




On 1/19/2015 9:18 PM, Grant, David wrote:
>
> OK. If you really don't see a change in appetite or thirst yet then thete are 3 options:
> 1. Keep giving lysodren tomorrow and come in wednesday instead.
> 2. Keep giving lysodren and we can take it day by day.
> 3. Come in tomorrow but recognize if she isnt regulated you may be back again in a few days.
>
> It took about 11 days to get her to 1.12 last time.

[judymaggie]

Good luck, Kenny! My Abbie bottomed out with her mini-load -- I sure hope Gracie's numbers are right where they should be.

[KennyJ]

Judy, what do you mean by bottomed out?? I just don't understand why I can't get Gracie regulated. I have been at this for over a year now.

[judymaggie]

Kenny--both her pre and post were less than 1! Thankfully, she is not showing any signs of low cortisol so I am not giving her any prednisone as long as she feels good. Plan is to give her no Lysodren for two weeks and try maintenance again at a 25% reduced dosage. This process is so frustrating!

[KennyJ]

Yeah, when Gracie was at 1.12 he had me stop the meds and give her prednisone for several days and then give her the lysodren twice a week. Next test came back at 17 so back to loading.

[Squirt's Mom]

Kenny, what signs are you still seeing?

[KennyJ]

Still eating like crazy, urinating hasn't changed. Hair is still falling out. She's back in for another ACTH today. Continues to keep a UTI, ecoli infection. Her skin feels like she has pimples all over it. She's a hot mess. Peed in my car seat no sooner she got in my car this morning.

[Squirt's Mom]

Bless her heart and yours, too! And the ultrasound did not show cast iron adrenals, huh? :D I am very curious what Dr. Grant thinks when he sees her today so be sure to update us as soon as you can. Hang in there, Kenny! You are doing a fine job with a confusing pup.

[doxiesrock912]

Hoping that something improves soon Kenny.

[KennyJ]

Ok, Dr. Grant just said Gracie's ACTH test was 1.07. Is that good?

[addy]

The recommended target range for good control of the cortisol production is a result of 1-5 ug/dl for both the pre and post ACTH stimulation test numbers.

Kenny was that the pre or post number?

[Squirt's Mom]

She had the ACTH a few hours ago and you have the results already? Nice! But yes, is that the post or pre #? And did he have anything to say about the continuing signs?

[KennyJ]

Yes, that's the benefit of having her treated at the Vet Teaching Hospital. Results are always back the same day. I am assuming that's the post results. I never ask. I will meet with him when I pick Gracie up.

[KennyJ]

Ok, that was her post test. He did not do a pre and said it was a waste of time doing that. She will start tomorrow going 3 times a week with her meds and a recheck in a month.

[Squirt's Mom]

wow, short report! I was expecting some explanation for the continuing signs at least from Dr. Grant. Disappointed he didn't have anything to say about that. :( Wonder why he thinks the full ACTH is a waste? He is the first I've heard say that so I'm really curious as to why he feels that way. Should have saved you some money anyway. ;) VERY odd her half-ACTH shows her to be controlled but her signs show she is not. Would have been nice to hear an explanation.

Keep an eye on her because that number is low and may keep dropping over the next day or so. She may go from having full signs to a crash so watch her carefully for a bit.

[KennyJ]

I asked him why no pre results. He said a lot of vets will do that on a maintenance testing or something like that. He is a VERY confident vet. LOL I mean really confident. He thinks by giving her the meds 3 times a week instead of two she can be controlled that way. He also said in another 8-9 months her hair will be beautiful again. She is still on antibiotics for the ecoli that she continues to get.

[My sweet Ginger]

Kenny, with a post number of 1.07 Gracie is still not showing any signs improvement and she will go on maintenance. How does Dr. Grant explain this? Did he say her symptoms will disappear sometime in the future and how do you feel about it?

[KennyJ]

He seems to think that with the 3 times a week dosage that her symptoms will improve.

[Harley PoMMom]

She will start tomorrow going 3 times a week with her meds and a recheck in a month.

Usually the maintenance dosing doesn't begin that soon after the dog is loaded....hhmmm???

Also, sometimes the increased drinking/urinating will take longer to resolve due to renal medullary washout. When a dog has been urinating large volumes it can take longer to rebuild the solute that concentrates the urine.

Hugs, Lori

[KennyJ]

I must admit, he is being much more aggressive this time. When it was at 1.12 he had me stop the lysodren and start prednisone for about 3 days. Then start at two days a week on the lysodren. It jumped up to 17 by doing that.

[Squirt's Mom]

I think in light of how fast Gracie's adrenals seem to regenerate keeping her on the Lyso is probably a good idea. I also agree with increasing the days the maintenance is given and in fact would want to give it more often than 3x a week. But hopefully this will do the trick.

[KennyJ]

Really concerned about Gracie. She is having trouble getting up once she lies down. I believe her leg is hurting, the one she ruptured her ACL. She is favoring it.

[judymaggie]

Kenny--will she tolerate a warm compress? It is not going to resolve anything but might make her more comfortable. Do you have any tramadol on hand? Does your vet have Saturday hours? It might be worth a visit. Please give her a gentle hug from us.

[Squirt's Mom]

Is she eating, drinking, and pooping alright? How is she this morning? Remember - as the cortisol is lowered, inflammatory processes like arthritis can come roaring to the surface. ;)

[KennyJ]

Not sure what happened but I posted yesterday and I don't see it. Anyways, I asked for Dr Grant to check her again tomorrow. She wasn't due back until Feb. 20th. However, she is no longer gulping her food down. The limp has gotten noticeably worse as well. Now here's the big problem. This dog has always loved cheese now all of a sudden she walks away from it. That's how I got her pills down her. I tried her pills in peanut butter and she spits the pills out. I tried them in turkey today and once again she spits the pills out. I am lost. He told me I could open the capsule of the lysodren and sprinkle it on food she likes and I haven't tried it that way. All of the pills she was supposed to take tonight were wasted, including her lysdoren.

[doxiesrock912]

When Daisy wasnt feeling well somehow I swear that she knew that it was related to her meds and she refused them. A day or so off of them and she was back to taking them. The leg pain could be related.

[KennyJ]

I see a big change in her. The leg is getting worse.

[judymaggie]

So sorry to hear that Gracie is having problems--hopefully, Dr. Grant can figure things out.

I'm pretty sure that I have read on someone's thread that the capsules should not be opened. One concern I would have is that the medication might be bitter and then Gracie wouldn't get food or the medication. A couple of folks here push the pill into a piece of hot dog--maybe you could try that.

[KennyJ]

Yeah, I was surprised to hear him say I could break the capsule open and spread it over some tasty food. She just vomited up some of her food but it may be I kept trying to feed her with her meds so she would swallow them. I hate thinking she is now in pain. Her limp is so noticeable. And she can no longer climb up the stairs. Not sure what to do. Don't you think it's strange that she all of a sudden will not eat cheese. This dog loves cheese. And spitting her meds out?

[judymaggie]

I am kind of used to Abbie going through periods of spitting her meds out although it is always the ones that I have to split. If Dr. Grant thinks Gracie's limp is caused by arthritis, you might want to ask him about Adequan injections. My Maggie responded really well to them.

Wondering if Gracie is nauseous--that might make her reject foods she usually loves like the cheese. I can't remember if you are giving her pepcid before her meals.

[KennyJ]

Its really bad, I can see a big change in her. I just hope she hasn't dropped too fast. Doesn't have any energy at all. Never gets up in the chair and does not meet me at the door.

[doxiesrock912]

Stop the meds Kenny and call your vet.

[KennyJ]

Thanks Valerie. I have an appointment with Dr Grant this morning.

[Squirt's Mom]

Kenny get her in NOW somewhere! DO NOT WAIT! IF you have pred give it NOW. I think she may be crashing. Have you been giving the Lyso twice a day all this time?!

[KennyJ]

Just dropped her off at the vet school and this is the message I just sent Dr Grant.



Dr Grant just dropped Gracie off. I really think she is crashing or has already crashed. When that little dog no longer eats cheese there is something wrong. I can no longer give her meds to her because of that. I have even tried peanut butter something else she loves. Now when I feed her she doesn't seem that interested. She will eat her dog food but takes a long time now. She used to inhale everything I put before her. Her left leg is worse. The vet at Cave Spring gave her pain meds but since she is no longer eating the cheese and other goodies I can't get those down her as well. I doubt very seriously she got any of the mitotane down her because I found the moistened capsule on the floor. That may have been a good thing though. It seems like she eats on one side of her mouth now. I remember one time she had a string around one of her teeth that got infected. Sorry for such a long list of problems but I was afraid she couldn't remember everything I told her.

[Squirt's Mom]

PLEASE keep calling them and make SURE someone is watching her and tending to her immediately. She cannot sit there for hours waiting her turn, Kenny.

[judymaggie]

Thinking good thoughts for Gracie -- hang in there, Kenny!

[KennyJ]

Well, now Gracie is just the opposite. She now has Addison's. This is a never ending battle.

[Squirt's Mom]

My goodness, I was afraid of that. Hopefully the adrenals will regenerate soon. What does Dr. Grant have her taking? Is she home or are they keeping her for a while?

[KennyJ]

No, he is sending her home and I pick up some drug called Florinef from Kroger that I give her twice a day.

[Squirt's Mom]

No pred? Kenny, this may not be true Addison's disease but rather an Addison's crisis and I am concerned that she is not on Pred. Florinef to my understanding is not used in acute crisis like this but only for the permanent condition...and we cannot know today if this is permanent or not. From what I read about Florinef, it will not work fast enough for a pup in crisis and should not be used at that time. Pred is needed, asap, if the cortisol has gone too low. What were the results of the ACTH?

[Squirt's Mom]

http://www.veterinarypartner.com/Content.plx?A=536


It should be noted that an Addisonian crisis is an emergency and that, while fludrocortisone acetate is appropriate for prevention, it does not work fast enough in a crisis. An animal known to have Addison's disease who is also showing weakness, vomiting, diarrhea or appetite loss should be seen by a veterinarian and have his sodium/potassium balance checked.

[KennyJ]

The ACTH results he will have this afternoon. However, he did a chemistry profile and her potassium was extremely high and sodium low. He said even without the ACTH he knows its going to probably come back at 0 or close to that. He actually gave her a shot of something that he said would make her feel much better and she would be hungry when she got home, he wants me to give her this for a couple of weeks twice a day and then retest her.

[labblab]

Hi Kenny, I am guessing that the injection Dr. Grant gave Gracie was dexamethasone or some other form of fast-acting glucocorticoid. This would take care of the prednisone component of treatment, at least temporarily. The oral Florinef's primary purpose is to supplement aldosterone levels that have also gotten out of whack (this is the adrenal hormone that regulates sodium and potassium levels). So it is primarily a mineralcorticoid, but it also has some glucocorticoid activity, as well. Without asking Dr. Grant, there's no way to know for certain about his gameplan. But perhaps his thought is that the fast-acting emergency injection today will get Gracie over the hump as far as her cortisol, and then the oral Florinef will be sufficient to replace both the lost aldosterone and cortisol on a daily basis until there is proof that all her adrenal hormone production has rebounded.

Like Leslie, I am more familiar with folks giving their dogs both Florinef and prednisone when the adrenal hormone activity has dropped too low -- or at least, I think that is the case. But maybe that is more often the situation when injections of Percoten are given instead of oral Florinef, because Percoten functions solely as a mineralcorticoid. I honestly haven't paid that much attention to the difference between the two -- oral Florinef vs. Percoten injections.

I am guessing that all the bases are covered for Gracie for the next 24-48 hours, but like Leslie, I'd want to double-check with Dr. Grant about the need for any supplemental prednisone in addition to the Florinef. And you know, Kenny, if Gracie does end up being permanently Addisonian, it may actually turn out to be OK and in her unique case, actually easier to handle than the Cushing's. Remember, Dr. Grant even talked about Addison's as a possible purposeful goal with her since she has been so incredibly difficult to control with the trilostane and Lysodren. So even if she has gone permanently Addison (although probably that is unlikely), she may end up being easier to control after all...

Marianne

[KennyJ]

Her ACTH was below 1. This is wonderful, the meds she will be on will most likely cause excessive drinking and urination. All that money to get rid of that now I am right where I started from. Are all my vets just crazy and don't know what they are doing?? Two times a week and she went back up to 17 on lydrosen, 3 times she is now below 1. I can't beat this.

[Renee]

Wish I had some words of wisdom Kenny. I can only imagine how incredibly frustrating this has been ... but, like Marianne, I was actually thinking that being Addison's may not be such a terrible thing for Gracie.

Besides all the numbers and test results - how is Gracie herself doing? How are her symptoms?

[KennyJ]

Even with the shot she hasn't changed any. Limping badly. She's starting to look like the cat with no hair.

[judymaggie]

Kenny--I really don't have any words of wisdom but wanted to let you know I am thinking of you and Gracie. What did Dr. Grant think was causing the limping?

[KennyJ]

Well I just returned from the Emergency Vet and I really thought I had lost Gracie. This is the email I just sent Dr Grant. It's now about 1:44 am.


Dr. Grant, I had a major scare tonight with Gracie. At around 12:00 tonight she woke me up yelping. I picked her up, she urinated on the bed and then she was out like a light for a couple of minutes. I thought she had died or was dying. I rushed her to the Emergency Vet and by then she was doing much better. They ran another chemistry profile and her potassium was at 6.9 and glucose was at 224. I am not sure what other lab work they did on Gracie this morning. What do you suggest?? Should I bring her back in this morning and you take another look at her?

[Squirt's Mom]

Please find out what was in that injection and ask about the pred, please. I am very worried about our sweet Gracie.

[labblab]

It sounds as though Gracie may have had a seizure. Was that potassium level of 6.9 still really high (I don't know what the normal range is off-hand)? If so, I think that could cause a seizure. Her glucose level was also high, but that may have been secondary to a seizure, perhaps? Did the ER vets give her any treatment? What did they say they thought was going on?

Marianne

[KennyJ]

The Emergency Vet also mentioned seizure. If so, she has never had one before. They only ran a chemistry profile which makes two in one day. Dr. Grant said I could bring her back in if I would like if she wasn't still at the ER. She vomited all over me in the bed at 4 am so needless to say this was not a good night. I haven't given her morning meds yet but I guess I should. Dr Grant said the 6.9 was higher than it was when she was with him yesterday. I really thought she died in my arms. All I could feel was a faint heartbeat.

[labblab]

Is he not concerned that her potassium level is even higher??? Does he not plan to do something to address that? I am totally confused as to why he is leaving it up to you to decide whether or not to take her in to be seen again today -- how is her potassium level supposed to come down if he doesn't change or add anything?? Poor little girl and poor you!!!!

[KennyJ]

I totally agree, I sent him an email back and still waiting for a response. Should I give her the med he gave me yesterday?

[Squirt's Mom]

Kenny, I would be on the road with her to see someone NOW. This is not right. Did Dr. Grant intentionally make her Addison's? Did he tell you he was going to do that to her? Is that why he's not alarmed at her current condition? I would be screaming at him by now in your shoes!

[Tina]

Kenny,
In my opinion, Gracie needs to be hospitalized and on IV fluids to get the potassium lowered. Like others have said, the Florinef is not fast acting and will not be able to get the potassium lowered within a normal range quick enough. IV fluids are necessary to help with that, and also to increase the sodium. Did the emergency vet give any IV fluids, or provide any treatment based on her lab results? And is her sodium still low?

In addition to seizures, elevated potassium can cause cardiac arrhythmias, which can be very dangerous. I am not convinced that her cortisol has been stabilized either, and she may need more injectable or IV dexamethasone. And now that you said Gracie has vomited, to me this is more evidence that this is an emergency situation and that she needs to be seen and/or hospitalized right away.

I'm sorry I just have a minute to post, I have to head into work, but I'm going to be monitoring the forum today as I'm able to. I can't tell you how sorry I am that this is happening. You and Gracie are in my thoughts today.

Tina and Jasper

[doxiesrock912]

Kenny,
I would find another specialist.
Praying for you both.

[Squirt's Mom]

How is she, Kenny?

[My sweet Ginger]

Praying for you and Gracie. Hugs.

[addy]

Thinking of you both, Kenny.

[judymaggie]

Sending healing thoughts and prayers for Gracie and you!

[Renee]

Kenny, we are all checking in. How is Gracie?

[Tina]

Checking in here too, Kenny. Thinking of you and Gracie, and hoping for some good news.

[Dixie'sMom]

I'm here too, Kenny sending prayers and strength for you and Gracie.

[molly muffin]

Checking in on you and Gracie here too.
I do hope someone is addressing these issues. Each of which separately can be serious, together can be catastrophic.
Hoping for the very best. Tina, btw, has a dog who went Addisons, and still is, she knows quite a bit about what she is talking about.

[judymaggie]

Very worried about Gracie -- will continue to send prayers.

[molly muffin]

Kenny how is Gracie doing?
We're worried.

[Renee]

Kenny, I am checking in too. Please let us know how Gracie is and how you are.

[KennyJ]

She may be doing a little better but not eating very much now. Dr. Grant just sent me this email. What do you guys think?



If she isn't feeling better in the morning give her 1/4 or 1/2 of a 5 mg prednisone tablet and see if she feels better when you get home. You are also welcome to give her that prednisone right now and see if she feels better in the morning. If it helps then give it to her once a day. Keep giving fludricortisone.

[labblab]

Kenny, I would go ahead and try giving her the prednisone tonight in the hope she will feel better tomorrow.

Marianne

[KennyJ]

He wrote me back and said go ahead and do it tonight, said it would cause me to worry less and it certainly won't hurt her. He also wants me to continue the baytrill and ursodiol. That's a lot of meds for such a little dog. Don't you think?

[molly muffin]

Well she has a lot going on. I would give her the pred. It really isn't even a question in my mind that she needs it.

[Dixie'sMom]

Kenny, the prednisone also may help stimulate her appetite. Hang in there.

[KennyJ]

Gracie did seem to feel better this morning. I gave her a 1/2 of a 5mg prednisone last night. I sent Dr Grant an email telling him that seemed to be feeling better. Here is his new set of instructions for me.



Ok. Its sounding like Gracie’s Addison’s is going to last a while. I had hoped that fludricortisone would be enough and that she would bounce back fairly quickly, but I was being overly optimistic. You should plan to pick up more prednisone from me on Monday or this afternoon if you prefer. To summarize, here is what I want you to do.

1. Give ½ of a 5 mg prednisone tablet once a day

2. Give ½ of a 0.1mg fludricortisone tablet twice a day

3. Keep giving ursodiol and baytril/enrofloxacin

4. If Gracie is doing well, on 2/14 start giving her ½ of a 0.1 mg fludricortisone once a day in the morning and stop giving enrofloxacin. Keep giving prednisone and ursodiol.

5. On 2/16 give Gracie her prednisone only (no other medications) and drop her off at the VTH to have a chemistry profile and urine culture done. I can make more recommendations then.


DG

[doxiesrock912]

Praying still Kenny.
I have no experience with Addison's. Hugs

[KennyJ]

She woke up this morning like a puppy dog. Running up the stairs and was once again barking for her food. Now she is dragging again and urinating in the floor just like she did with the Cushings. :(

[labblab]

Kenny, were you able to get the prednisone to give her over the weekend? It seems as though the pred may really help her feel better right now.

Marianne

[KennyJ]

Yes, I have always had it on hand. I started giving it to her the other night. He wants me to give it to her everyday along with the other meds.

[KennyJ]

My message to Dr. Grant this morning.


Dr. Grant, yesterday was a pretty good day for Gracie. She ate her breakfast leaving a small amount that she came back and finished. Ran up the stairs like a puppy. Started limping badly later but still was in good spirits other than sleeping a lot. This morning she was really limping and walked away from her food without touching it. Should I increase the prednisone or is this something that will get better as time passes? I gave her the meds for pain.

UPDATE: I placed Gracie's food on the chair next to me and she ate every bite. This is gross but she vomited a little bit of it up and ate that too. Sorry for being so graphic.

[doxiesrock912]

I wonder if her leg needs to be examined again?
It sounds like she's improving otherwise.

Sometimes when they eat too fast, some food comes back up. Since she hasn't eaten all day, I'm sure that she was hungry and ate too fast. Daisy did this occasionally and I added a bit of water to her food which made her eat slower. It never happened again after that.

[molly muffin]

Checking in to see how you and Gracie are doing. Hope she is continuing to improve.

[KennyJ]

Wow, yesterday I had a totally new dog. She was like a puppy again. Playing, was even on top of the chair waiting for me to come home. Today is totally different. She is shivering uncontrollably. Would not eat her dinner and was ready for me to put her to bed. Not sure what to do.

[Dixie'sMom]

Do you think Gracie may have over-did on her good day yesterday and is having some pain today? Poor little sweetie. I hope she feels better tomorrow.

[KennyJ]

I can't get her to stop shivering. I mean it's worse tonight.

[doxiesrock912]

Call the vet Kenny. Shivering can be a sign of pain.

[Squirt's Mom]

Has anyone checked her gall bladder lately? I am worried sick about Gracie, Kenny. :( I have been suspicious for some time that something other than Cushing's or in addition to Cushing's is going on with our sweet girl to cause her to react the way she has to the medication yet no improvements.

Please let us know how she's doing.

[KennyJ]

She is no longer eating her dry dog food. Maybe a bite or two. Should I switch to a can dog food?

[Squirt's Mom]

Has anyone checked her gall bladder lately? I am worried sick about Gracie, Kenny. :( I have been suspicious for some time that something other than Cushing's or in addition to Cushing's is going on with our sweet girl to cause her to react the way she has to the medication yet no improvements.

Please let us know how she's doing.

Call the vet and let them know she is not eating and do not give any Lyso for now. Is she showing any signs of loose stool or lethargy?

[KennyJ]

She is no longer on the mitotane because her levels dropped below what it should be so now she has Addison's. Last night I had another scare with Gracie. She was crossing the sofa to the chair which I fixed to where she no longer has to jump and hit the floor. Her legs are not very stable so I thought she just slipped and fell. I am starting to think Gracie is now having seizures. She couldn't walk after the fall and screamed again like she did a couple of weeks ago when she passed out. Here is what I sent Dr. Grant.



Dr. Grant, I really believe Gracie suffered another seizure. I first
thought she fell off the chair but when I went to pick her up she was
thrashing about as if she had broken something and couldn't get back up.
She landed hard. I picked her up and she had that same look as if Mike
Tyson had knocked her out. She yelped just like she did the other time
as if she was in a great deal of pain. I put her on the floor and she
couldn't walk at all and all four legs spread out to the point she
looked like a rug on the floor. I really thought she had broken her
back. The one thing I did notice different this time was that she stuck
her front left leg straight out as if it was injured but it was stiff.
This morning she is walking and eating. Her left leg of course is still
giving her major problems but she doesn't seem to suffer from anything
that happened last night.

[doxiesrock912]

Kenny, that definitely sounds like seizures! I would bring her to the vet asap.

[KennyJ]

This Dr. Grant's response. Sorry but she never had anything like this while she had Cushings. This just started when the mitotane pushed her into Addison's and different medications. She is now no longer taking her pills in the pill pockets anymore. She has gone from eating everything in sight to being a finicky eater. I have to admit, I liked her better when we were treating her for Cushings. These are a whole set of problems that are not enjoyable to work with.



Grant, David wrote:
> It is possible, though doubtful, that her electrolytes (sodium, potassium, calcium) are altered and causing this. It is possible she has developed epilepsy or that the tumor in her pituitary gland has grown and is causing seizures. The first thing to do is check her electrolytes. One of my colleagues can see her any day this week.

[molly muffin]

Did you take her in to get her electolytes checked?

Are you still giving her pred?

Let us know how things are going.

[KennyJ]

I drop her off in the morning at the vet school. I found a couple of her meds on the floor, I wonder how long she has been spitting them out. I thought I had hit the jack pot with the pill pockets after she stopped eating the cheese, now she won't eat the pill pockets. She has gone from bad to worse. I mean, I thought for sure taking her to a hospital she would have the best treatment now I am not so so sure.

[Dixie'sMom]

Kenny, how is Gracie feeling?

[KennyJ]

They gave her a shot instead of me giving her the tablet, it's supposed to least 25 days. I just give her the prednisone now. Her kidney function has worsened and her potassium is still high and sodium low. Her RBC was low as well. Here is his response because I was pretty upset over this.



Grant, David wrote:
> Kenny,
> While kidney injury is a possible cause of the changes in her bloodwork it is much more likely that her Addison's/hypoadrenocorticism is causing them. You will just have to wait until her sodium and potassium return to normal and we get her prednisone dose reduced to tell the difference. Gracie has certainly been a difficult one to regulate, and as always I commend you for sticking in there for her. I remain confident that we can get her regulated and keep her feeling well (unless she develops new problems in the future). I also have complete confidence in Dr. Ziglioli. His recommended treatments today are spot on. It will be nice to have someone else that can take turns with me in caring for Gracie.

[molly muffin]

Did they do IV fluids or anything to try and address the potassium and sodium values?

It is good to have a couple docs that are all on the same page for treating gracie if you need them.

I'm very worried, it sounds like her cortisol is still very low.

[Dixie'sMom]

Kenny, my best friends Dad had trouble keeping his sodium balanced. It caused him to have symptoms very much like dementia. The fix? Salt tablets. Give Gracie a few sprinkles of salt in your hand to lick or on her food a couple of times a day. Regular salt. Lite Salt is mostly potassium and Gracie's potassium is already too high. I'm hoping your sweet girlie feels better tomorrow.

[Squirt's Mom]

If those doctors aren't giving her something to get those electrolytes back in line, she is going to be, if she's not already, in very serious trouble, Kenny. I am worried SICK about this girl and you tell us VERY FEW details. :(:(:(

[doxiesrock912]

You can buy unflavored Pedialyte for Grace.

[labblab]

Hey Kenny, just to reconfirm, it sounds like they gave Gracie a Percoten injection yesterday in order to address the electrolytes? I think people may have missed seeing you write about an injection. If she did get one, I don't think you should be giving her any supplemental oral salt or any liquid containing extra sodium right now without Dr. Grant instructing you to do so. There is a specific balance they are trying to achieve right now with the injection, and you don't want to throw things off the other way, either (too much sodium). I am so sorry you are having such a tough time getting things straightened out!

Marianne

[doxiesrock912]

Yes, I missed the injection. Is Grace improving now?

[KennyJ]

Wow, that injection made a tremendous improvement in Gracie. I wish they had done that before the oral meds they gave me. She has been playing with her stuffed animals and eating. She still limps with that back leg but that's never going to improve and I can live with that. Knock on wood but she looks and feels much better.

[Squirt's Mom]

Oh what a relief! I am so glad to hear that she is finally acting as if she feels better. ~~whew~~

[Dixie'sMom]

Great news Kenny! I'm so glad she's turned around and is feeling better. :D

[My sweet Ginger]

I'm so happy for you and Gracie too that she finally feels better. A long overdue.
Questions, do you still give her daily dose of prednisone and do you know the name of the shot they gave her 4 days ago? Thanks.

[doxiesrock912]

That's wonderful Kenny!

[KennyJ]

Well I was so excited because Gracie was doing so much better until this morning. Although her eating is back the way it was when she had Cushings.



Dr. Grant,

Gracie has been doing wonderful until about 30 minutes ago. She's back playing with her stuffed animals and her appetite has increased drastically, like she is back on the Cushings end of the disease. However, this morning after I took her out to potty we got back into bed and she had another spell of yelping and having the Mike Tyson knockout look. She fell back on the bed with the same dazed look and was unable to move for about 5 minutes. I managed to get some video but was unable to send it using my phone. I guess the file was too large. She seems to be doing okay at the moment and ate her breakfast. She was doing great!! I was so excited to see the improvement in her condition although like I said she back to wanting to eat constantly again.

[judymaggie]

Kenny -- I am so sorry that Gracie had another "episode". What you are describing sounds like a type of seizure called a "tonic" seizure. My Maggie had seizures (tonic, grand mal and later cluster seizures) and I found an invaluable source of information at the Epi Guardian Angels website at http://www.canine-epilepsy-guardian-angels.com/default.htm. Just like I read everything I could have on this forum after Maggie's Cushing's diagnosis, I did the same on the Epi website.

One of the most important things to do is start a journal -- your video will be great but it is also necessary for you to make notes about how long the episode lasted, what happened before and what happened after.

I am concerned that Gracie's episode lasted five minutes. That is a very long seizure if she was, indeed, seizing the whole time. I did learn on the Epi website that a dog's blood sugar can drop drastically during a seizure. I would give Maggie a small amount of Haagen Dazs vanilla ice cream after a seizure to bring her blood sugar back up. I am wondering if maybe Gracie's seizure (if that is what it was) was short but that she was sluggish due to a sudden drop in her blood sugar.

Hang in there -- hugs to you and Gracie!

[KennyJ]

She has since had another one. That's two within 5 hours. This concerns me. She was doing great!!


https://www.youtube.com/watch?v=Y4FFrRSLB-o

[Squirt's Mom]

That video reminds me of how Squirt was after her seizure or stroke whatever it was. It took her about 3 months to regain as much as she could. I hope they can find out what is causing these episodes in Gracie and offer some help for her and you both. Let us know what Dr. Grant has to say!

[judymaggie]

Kenny -- here is the emergency info from Epi website: http://www.canine-epilepsy-guardian-angels.com/emergencycare.html.

I looked at the video and it is hard to tell what is going on. You are the best person to judge since you are right there with her. If I were in your shoes, I think I would head to the ER vet just to be on the safe side. If you do go, be sure to take her history with you, especially info about her meds.

[KennyJ]

From Dr. Grant


Good video Kenny. Yes, she seems like she was experiencing or recovering from a seizure. She may be having what are called transient ischemic attacks. I will check out her electrolytes tomorrow, and if they are normal then we will need to think more about her actually having a central nervous system problem as the cause of these attacks.

[KennyJ]

Ok, I am really worried. Gracie has had 3 seizures today. She has never done that before.

[judymaggie]

Kenny--I am going to try one more time to encourage you to take Gracie to the ER vet/clinic. She is having cluster seizures and she needs supportive treatment.

[KennyJ]

Ok, I just got back from taking Gracie to the Emergency Vet Hospital. Her potassium was high at 7.0 and her sodium was only slightly low at 131. Her glucose was at 147. The vet said nothing there would cause her to have seizures. So I really don't know what to do now.

[molly muffin]

I would tKe her into emergency. Her electrolytes could be off and she would need iv fluids like before. Sodium potassium that are not within normal ranges can cause seizures and be life threatening. She might need another shot too.

[KennyJ]

That's where I just took her. Nothing in her lab work would be causing the seizures according to that Vet.

[molly muffin]

They know her history and the low cortisol issue? What did they do or suggest?

[molly muffin]

Did you ask them about OTC seizure possibility.

Sorry just now had read your message that you had taken her I to emergency and what her. Levels where.
Did they check baseline cortisol?

[KennyJ]

Yes, and they said I may have to have a full neurological profile run maybe even an MRI which is big bucks.

[KennyJ]

What is OTC?

[molly muffin]

Sorry. iPad typing. Tonic seizures I meant to say.

[molly muffin]

For any knd of seizures I guess they would suggest a neuro consult.

[judymaggie]

Kenny--I am glad that you took Gracie to the ER. Did the ER vet give her any valium? I hope that Gracie had a peaceful night and that you were able to get some rest.

I remember that, when Maggie started having seizures, I found it very difficult to sleep--I thought that every little noise she made was the onset of another seizure. Since I lived by myself I could not administer rectal liquid valium so my vet gave my valium tablets. Maggie's seizures were not frequent enough to treat her with phenobarbitol.

I did take Maggie to a neurologist who then worked together with my vet. I opted not to do an MRI.

[doxiesrock912]

Kenny,
how are you and Gracie!

[Squirt's Mom]

Kenny, how is Gracie doing?

[Squirt's Mom]

Kenny? Would love to hear from you!

[Squirt's Mom]

Would love to hear from you, Kenny!

[Squirt's Mom]

You and Gracie remain on my mind, Kenny.