11 y/o Doxie in Chester County, PA – New to Cushings and concerns while on Trilostane

[Hanna's mom]

Hello everyone and thank you for being here.

I'm new to the forum and new to Cushings. My husband and I rescued an older (we think she's 11 years old) Doxie about 2 years ago which shortly after got sick. After some blood work and an ultrasound we go diagnosed with a bad liver. Not sure of the details, though they said it was bad, but could improve some after taking care of it. She's been on Demimarin and Hepatic food ever since.

She did not seem to get better until finally we got extremely concerned with her symptoms, which we now know was from the Cushings. She had every symptom. After numerous trips to the vet thanks to the Doxie Rescue, they were able to identify the symptoms and asked us to have the vet (a different one at emergency) test for Cushings. The positive results was a relief. We knew that we could possibly treat her now instead of watching her slip away.

The vet obviously did not have much experience with Cushings but seemed very willing and confident to keep her in his care. He started her off on the recommended 30mg of Trilostane. She was/is about 16lbs. After about a week I honestly thought she was dying. We took her to emergency one night and the same vet, offered to do either surgery, which neither of us thought she would live through or just try to keep her comfortable, I guess while she was dying. Our hearts were broken.

After being off the Trilostane for a few days, she improved tremendously. She was able to walk again, had her energy back, she wanted to eat, still wasn't dying of thirst and wanted to go for walks again. It felt like a miracle.

After doing a little research and talking to the Rescue again, we asked the doctor if we could cut her dose in half. He did, and now she is taking 5mg 3x a day. She appears to be doing pretty good with that, but I still have some concerns...

After being on this new dose, we did the blood work again after about 20 days in. The vet called to say everything looked good. Not exactly sure what all that means or what exactly he tested for. I don't have a whole lot of confidence in this vet after the 30mg mess and sending her home to die.

After doing a little bit of research on this forum I read that I should look out for muscle tremors and diarrhea while on Trilostane. Well, Hanna has had diarrhea on and off since we've had her. I've also contributed this to her liver. I can get it under control after one day on prescription food for diarrhea. For the last couple of weeks I have noticed her gagging (not very ofter at all and her heart x-ray looked good before the Trilostane other than a small heart murmur). Also I've noticed some muscle tremors, which also are not very strong and noticeable. She has some days where she wants to eat great and some days I have to encourage her. Some days she wants to walk and play like never before and then some days she lacks energy. One day this week she threw up, but quickly recovered by following it up with a meal. I'll also mention that after the Trilostane she started loosing MUCH MORE hair than before. She also constantly has sores between her toes that fill up and pop, oozing blood and puss. Sometimes this is the reason she does not want to walk. Her feet hurt.

My dilemma...
Of course now I'm scared about the tremors, diarrhea, vomiting (only once). Let me point out that today was a "good" day. She's eating, playing, has had two good firm BMs. I want to go to a specialist but now it's Friday and I'm sure I would not be able to get her in until next week, if even that. Plus I'm going to have to get her records from three other vets. If I take her to her current vet, I'm not confident that he will think anything is wrong since her blood work was "good." If I go to another vet all together, just to get her in before the specialist, I'm not sure they will know what they are doing either.

How concerned should I be right now? Do you think it would be okay to wait for the specialist? Should I take her off of the Trilostane until then? Should I be running to the emergency vet? Does anyone recommend a vet in Chester Counter or near by?

Another thing, is that ever since we've had her, we have been constantly going to the vet. Our funds are depleted. I'm tired of spending our money on the wrong thing. This was one reason I was excited to know what she has so we can stop wasting money and time on treating the symptoms. We are not going to be able to afford a $5000 surgery. At least not anyway soon and I'm not sure that would be the best for her anyway. I really want this Trilostane to work for her. I know it's not a cure.

We love our Hanna Banana! I know she is happy to finally be with a permanent family, I just wish I could make her feel better. She has been an awesome dog! She deserves to feel better.

Thanks for any advice. Also, I don't have any information about her blood work.

One more thing I forgot to add... When we mentioned the gagging to the vet, he suspected Kennel Cough, plus her feet did not look good and she had a swollen eye that was draining too much. He put her on an antibiotic she had never been on before and gave us some eye ointment. She didn't react very good to the antibiotic at all! I did some research and decided to take her off. She improved. Right after that, we also ran out of her Trilostane and was having a hard time getting 5mg so she went without it for 6 days. She did fine during this time. She now been back on it again for 1 1/2 weeks.

[Budsters Mom]

Hello and welcome:)
I am sorry for the reason that brought you here, but so glad you found us. You have come to the right place! There are many K9Cushing's angels standing by to help and stay with you every step of the way. They love details, test results, any information you can get your hands on. The more the better. We will do all we can to help. Others will be popping into welcome you shortly. Be ready for tons of questions, because we are a very nosy group.:D So again welcome Hanna Banana and mom.:D Hugs,

[Trixie]

Oh dear...so sorry to read what you've been going through with little Hanna. There are many people here on the board who are so helpful when it comes to figuring this all out and they give great support.
Is there any way to get hold of the tests you have had so far so you can post that info for the experienced people here?? What tests were performed to give you the positive Cushing's diagnosis? Maybe if you have a copy of your bill you can see what tests they charged you for and post that info here. If you can bear to look at it...I can't stand seeing those bills from the vet, it gets too scary! :eek:
The starting dose of the Trilostane was rather high for a dog weighing 16 pounds. The recommended dose would be 1mg per pound...so half the 30mg dose would have been a safer starting point. The 30mg start is an old dosing which has since been changed.
I will let the others chime in here and I'm sure they will be on to welcome you and help out.
It sounds like you started with this the same way I did..high liver enzymes. We also started Denamarin for the liver and then the Cushing's symptoms became more pronounced so we tested.
How have Hanna's symptoms been lately since the cut in dosage? It sounds like she is definitely better since being overdosed with the Trilostane.
You mentioned surgery...did the vet say that Hanna had an adrenal tumor?
I'm going to let the others get on here as I am still a novice here. I'm still working at getting my dogs dose tweaked. We started very low and are working our way up to a dose that will control her symptoms. It's work in progress..and like you mentioned an expensive one.
I'll let the experts get on here with their questions and hope you can get some answers. Hanna sounds like a sweetie and it's so nice you were able to give her a forever home. :p
Barbara

[Roxee's Dad]

Hi and welcome to you and Hanna Banana,

I am so sorry for what you and Hanna have been going through. :( I see you came to the conclusion that she was being overdosed on the Trilo... Good job !! You most probably saved her life. :) It is a shame the Vet couldn't figure it out though. :(

You mentioned that in the ER the vet wanted to do surgery, What knd of surgery was he proposing?

At the moment what concerns me is it the right testing that was performed. Like an UC/CR, ACTH, LDDS. Please ask your vet's office for copies of all the test that were performed and post the cushing test results along with the normal values and any other testing results that were abnormal. It will help us to see the bigger picture.

You mentioned an Ultrasound was performed and they found an enlarged liver, was any mention of the adrenal glands, pancreas, spleen, gall bladder? Usually a cush pup will have 1 or both adrenal glands a bit plump or enlarged.

Another concern I think many of us would have is if the cushings test were performed while Hanna was ill. Many non adrenal illness's will produce a false positive for cushings.

You mentioned that Hanna had every symptom, excessive appetite, excessive thirst, excessive urinating, loss of hair, pot belly... anything else? Has she been tested for diabetes?

Okay, I'm am sorry for so many questions :eek: , but it will help the members here see the bigger picture.

Oh... one more question,:o what was the ointment that was being used for the eye? Does it contain any kind of steroids (cortisone)?

[goldengirl88]

Hello:
I wanted to welcome you and your baby to the group. One thing I want to say is knowing what I know now I would insist on going to and IMS or a very qualified vet. You will save time, money and heartache. Unfortunately a lot of us are in the same boat as you. We spend thousands of dollars on finding the problem and run out of funds. You can apply for Care Credit and use it only when needed, it is very reasonable, please look into it in case you need it for an emergency. Start a daily diary of your dog, it is important. If you use the name brand Vetoryl call Dechra and start a file on your dog. They have vets there on staff to help you. The number is 866-933-2472. I cannot stress enough that you need someone who knows Cushings to treat your dog or bad things can happen. I am not trying to scare you, but save you heartache. You need to get copies of all test results and post them. I don't understand what your dog is going to be operated on for, what is the diagnosis?? Lastly, you never, never ever start with a high dose of Trilostane. You start with the lowest dose possible and inch up if you have to. The dogs body will be better able to adapt to the drug that way. I know from experience with my Tipper. The tremors etc. you speak of I am convinced are either side effects of trilostane, or from muscle wasting from Cushings. I only say that because once you get the Cortisol stabilized the muscle wasting is supposed to stop, and it hasn't in my dog. So I am guessing it could be either. God Bless you and take care of your baby.
Patti

[Hanna's mom]

Wow! Thank you everyone! This morning I made an appointment with an internal medicine vet in the area for Monday. I found them by going to the site this forum recommended. I have all her records being sent over. Hopefully this will get us on a better track and also will allow for me to get a hold of her test results so I can post them as we move forward. For now, I have found a couple things people have asked for. (Having just moved, I'm having a hard time finding things).

Her last test (after going on the 5mg of Trilostane (3x a day):
The bill says "Acth Response Test." Vet said this "looked good."

As for her liver ultrasound:
This was done before the Cushings diagnosis. Here's the entire report....

10/31/2012
A complete abdominal ultrasoungraphic examination was performed.

Liver: Small in volume, mottled parenchyma. Blunted and tortuous intrahepatic portavascular arborization. The portal vein and portahepatis are larger than normal for age and breed.

The gall bladder is normal volume with mobil, echogenic sludge filling 35% of the total volume. The rest of th biliary system is normal.
Gastro-intestinal tract: the stomack and small bowel are empty. The colonic wall is normal filled with scan volume normal feces.

Pancreas: Normal echostructure.

Peritorneal Cavity: No effusion, no lymphadenopathy. No omental changes.

Spleen: mild splenomegaly.

Kidneys: Normal size and echostructure.

Adrenals: Upper limits of normal size, no masses.

Differential Diagnosis: The liver changes are compatible with chronic active hepatitis and atrophy. The enlarged portal vein and mild splenomegaly could indicate early portal hypertension. Gall bladder bile stasis, no prediposition for a mucocoele at this time.
The adrenal glands could indicate adrenal hypertrophy from non-adrenal axis disease (liver). This was probably an acute exaceration of chronic process.
No evidence of neoplasia.
No evidence of IBD in the bowel or lymphangiectasia in omentum at this time.
***

As for the eye ointment that she was on:
05/31/2012
Neopolydex 3.5 gm 2-3x a day

At the same time he put her on Cephalexin 250 mg every 12 hours I had to take her off of this, she was not wanting to eat, had no energy at all, did not have strength to walk. After she went off, she was back to normal)


Diabetes testing:
She DID get tested a while back before the Cushings diagnosis. Maybe close to a year ago. No diabetes then.

I'm receiving the Trilostane from Wedgewood Pharmacy. They are compounding it to the 5mg chewables.

As for the surgery option:
This was only the vet's suggestion for the future after doing an ultrasound that we chose not to do at the time because of cost. We wanted to get her on the Trilostane first and get her stronger. She has. Now we probably need to get that ultrasound done. He mentioned that if a tumor was found that we could take it out. He probably said some other things that I couldn't comprehend at the time. It was a very hard week that week. I just knew we were going to loose her. Surgery any time soon was definitely not going to be an option.

Her symptoms:

Before Trilostane:
Over drinking and eating. Urinating all the time. Sores on her feet. Not able to walk or run. She would try to run and it was like her back legs would not work for her. Also just simply falling over a lot. Loosing the hair on her feet. Big pot belly. We could also tell she was loosing muscle around her neck and chest. She still has not grown back the hair from her ultrasound from Oct 2012. Thin skin. She had a really large bladder stone removed before we got her.She also had to get many teeth pulled before we got her. She had the calcified lumps under her skin, under her front arms. Dark pigmented skin, which seemed to get worse after the Trilostane. Frequent diarrhea. Her voice had also changed with her bark getting very weak and loss of muscle.

After Trilostane:

Occasional diarrhea. Threw up once this week with a quick recovery. Occasional gagging. Dark skin that has gotten worse after Trilostane. Worsened hair loss. Sometimes I have to convince her to eat by adding chicken broth to food. (I honestly don't know how much food is normal. When I got her, she could have eaten a cow and not been satisfied.) Occasional weakness. She still seems to not have very good balance. She can run a little bit. This is a huge improvement from where she was before. Very slight and suddle tremors. So little in fact, my husband hasn't seen them. And of course super cuteness and sweetness (this is not new):p!! Overall she is doing so much better but there are still some lingering things obviously.

That's all the info I have for now. I'm going to try to find the original bill that had the initial testing for her Cushings. I'll post as soon as I do. I'll also give an update after our Monday visit. I'm praying hard this appointment goes well.

Thanks again for your time!
~Stella
(P.S. I posted a couple of photos if interested ;))

[Simba's Mom]

Hello and welcome to you and Hanna, I have a Doxie too, his name is Simba, and this place has been awesome...he is also 11, but weighs 21 pounds, he just started a new dose 18.3mg...the people on this site have helped me ,so ,much with info and encouragement too..Simba has a touchy tummy so I give him plain yogurt with meals, seems to help when his trilostane dose is right...hang in there and keep asking questions, info is power.....

[spdd]

Welcome to the forum. This is the most amazing place I have ever found on the internet. Volumes of good information.

[Roxee's Dad]

As for the eye ointment that she was on:
05/31/2012 Neopolydex 3.5 gm 2-3x a day


What is Neo-Poly-Dex Ophthalmic?
This prescription eye medication treats bacterial infections of the eyes and eyelids in multiple species including dogs and cats. It contains neomycin, polymixin B, and the corticosteroid, dexamethasone.

The highlighted ingredients of the eye meds are steroids, which the Trilostane and your vet are trying to reduce.

We are looking forward to the ACTH results which may be incorrect because of the steroids in the eye meds.

Edited to note: I am trying to work out the time line of symptoms, Ultrasound and eye meds...

[Squirt's Mom]

Could you get copies of the actual testing that was done to diagnose the Cushing's in the first place and post the numbers here? All tests with names like LDDS, HDDS, ACTH, UC:CR as well as labs that show blood values like ALP, ALT, BUN, CHOL, etc. We need to see the actual numbers with the little letters that follow along with the normal ranges. Only the abnormal values on the blood work are needed but everything on the other tests.

From what I see on the ultrasound report, there is absolutely no mention of Cushing's, nor do her adrenals present as a cush pup, yet liver disease seems a real possibility. Why did your vet home in on Cushing's and not liver disease? Am I missing something? Entirely possible! :D

[Roxee's Dad]

Leslie, I am wondering if the cush type symptoms started after the eye meds which contain steroids.

[Roxee's Dad]

When did Cush symptoms start that led to testing and a diagnosis of cushings?

5/12/2012 - Started eye meds that contain steroids.

10/31/2012 - Ultrasound really only found issues with the liver and Adrenals are Upper limits of normal size, no masses.

What was the time frame on this?
Over drinking and eating. Urinating all the time. Sores on her feet. Not able to walk or run.

When did she start Trilostane?

Sorry for so many questions, but we are trying to understand if the eye meds containing the steroids may have caused the symptoms of cushings. "IF" that is the case, then Hanna has Iatrogenic Cushing’s. This is cushings induced by prescribed steroids.

Is she still on these eye meds?

[Hanna's mom]

Thanks again! Sorry if this this is confusing and thanks for being patient with me. I'm slowly finding more information to provide you. I'm still working on getting her complete records. That may not happen until Monday though. I realize that without this, there's not a whole lot of feedback you can give me.

Timeline:

Date unknown: Doxie Rescue received Hanna and had to have a "huge bladder stone removed."

Jan 28, 2012: Adopted Hanna knowing that she still needed surgery to remove several teeth. The rescue did this for us:

Feb. 25, 2012: Dental surgery

During the summer 2012 she appeared to be pretty normal other than a ravenous appetite (we thought was normal) until October 2012 when she began to drink obsessively and was having frequent diarrhea. This is when the 1st vet ran some test for several things including Diabetes and her live came back abnormal. She sent us to get an ultrasound.

Oct. 31, 2012: Ultrasound - Results posted on an earlier post.

We started her on Denamarin (still on) and Hepatic food (still on) along with 80 mg of Ursodiol from the natural pharmacy (We stopped this for now). I also remember having her on Clavamox quite a bit because this is when her foot sores started appearing and popping open.

She showed slight improvement for a little while, mainly getting the diarrhea under control but the drinking and peeing all the time was way out of hand. She also started to have trouble walking and loosing her balance. The (1st) vet suggested physical therapy. I thought she might have IVDD. Her walking was getting really bad really fast. After setting up this appointment for physical therapy, in the meantime we contacted the Rescue for advice. This is when they mentioned the possibility of Cushings and to have them test for it when we went to the new (#2) doctor. So that is what we did.

April 29, 2013: We saw the 2nd doctor thinking we were going for physical therapy and ended up with a Cushings diagnosis. On the initial visit, this vet took many x-rays. First to check her heart which appeared to be fine other than the small heart murmur, but saw that another x-ray was needed because a some kind of mass that was showing up. She took another one to get a closer look but could not tell exactly what it was. She only could tell that is was large and pushing her intestines to the way side. She wanted to do ultrasound but first decided to get Cushings test results back, then go from there.

I have to mention that this 2nd vet was a "visiting" vet. :( So we ended up working with a 3rd vet after getting her positive Cushings result back.

April 30, 2013: Positive Cushings test. The bill says "Dexamethasone Suppression Test"
He also remove a very small tumor that turned out to not be cancerous on her belly. Later I found out that this was not a good idea to do until we got her Cushings under control. She pulled through fine though.

May 2, 2013: Started on the 30mg of Trilostane. At the same time she went on Clavamox 125 mg tablets

We have been with this 3rd vet ever since.

She overdosed on the Trilostane. Kept her off for 7 days. In the meantime Hanna improved greatly. She appeared healthier than we had ever seen. So we did some research, talked to vet and got a pharmacy to compound the 30mg into 5mg tablet that she can take 3x daily. This seemed to be working.

May 31, 2013: Hannah's foot sore got pretty bad, along with her eye swelling up, so back to the vet. This is when he put her on the Neopolydex eye ointment for 10 days and the Cephalexin antibiotic.

June 10, 2013: Acth Response Test - Vet said was "good."

June 20ish 2013: We ran out of the 5mg and found out that the vet could not get it in that dosage. We finally found Wedgewood Pharmacy and ordered but Hannah had probably been off Trilostane for 6 or seven day. She did fine during this time.

July 6, 2013: The past couple of weeks has been on and off for her. She's had diarrhea, vomited once, very slight tremors. After the vomiting I didn't give her last 5mg dose. The next day she was fine, playful, wanting to walk. Tremors seem to appear more in the evening. She's still loosing her hair. Her skin is still getting darker. She was playful last night but I had to convince her to eat when I got home at 5, but then at 8:00 she was begging for more. Maybe I'm feeding her too much.:rolleyes:


Again I'm working on more information and will provide them ASAP.

Take care everyone!

[Hanna's mom]

I have one question for now, should I hold off on giving her any more Trilostane until we can see the new vet on Monday? I don't want to screw up any test results by doing it but I'm also scared to give her any more. Any suggestions? I understand that without her records no one is going to have a concrete confident answer, but also don't want to prolong getting a good readable test or cause it to cost us any more money.

@GoldenGirl: thanks for the advice and your support! We already have CareCredit, it's been a blessing, but we are getting close to our limit on that! We've already had to use it on several appointments.:eek:

[frijole]

I would withhold due to vomit and diarrhea and shivering- the risk of low cortisol is too great. The only test done to diagnose cushings is the LDDS test which is prone to false positives when something else is going on. We see this frequently. The ultrasound really didn't indicate that the adrenals were enlarged which you typically see in cushings dogs.

Is there any way possible to call them and get the June 10th acth test results? You want the two numbers on the test. That is real important. Saying it is 'fine' is meaningless. Normal for a cush dog is not the same as normal for non cush dogs and we see these mistakes alot.

Since you are going to a specialist I would make sure you get all records to save from retesting and also type up a summary like you have already done with as much detail as possible (include symptoms that led to tests and then what happened after each drug was given etc) This will help the IMS as well.

Kim

[Roxee's Dad]

Just based on her not feeling well, we have a rule of thumb around here, when a cush pup is not feeling well, we stop the meds.


May 31, 2013: Hannah's foot sore got pretty bad, along with her eye swelling up, so back to the vet. This is when he put her on the Neopolydex eye ointment for 10 days and the Cephalexin antibiotic.

June 10, 2013: Acth Response Test - Vet said was "good."

I am not saying Hanna doesn't have cushings, but this eye med that contains steroids may have contaminated the ACTH test results.

Is Hanna still on those eye meds? They are steroids, so she will need to be weaned off slowly. If the meds were stopped abruptly, she may be feeling pretty lousy.

Sorry for so many questions again :o

[Hanna's mom]

Please stop apologizing for the questions. This is the only way to get answers :o Also this is allowing me to hopefully have a great and successful appt. on Monday. This is good to get all my thoughts straight and the facts written down as suggested.

We gave her the ointment for the suggested 10 days. That would have made her last dose on June 10th or 11th. And no, we were not told to take her off gradually. :(

[Roxee's Dad]

So basically she was just off of the meds the day of last ACTH. That may have skewed the results of the June 10th ACTH.

Just my opinion, I wouldn't trust the results of that test that the vet called good and I would request a new one. My thinking is the steroids in Hanna's system may have shown up in the ACTH giving a higher reading that what it really was and in fact may have been too low. Thus her feeling not well. By stopping the trilo, her cortisol should have started to rise and hopefully she will be feeling better.

We have had a few cases where the cush pup was overdosed on Trilo, recovered but didn't need to be restarted on Trilo again. I wish I could remember who it was.. Maybe one of the other members might remember and can point you to her thread.

I wouldn't give Hanna nay more Trilo until she is feeling good.

Sorry for the questions... Oh wait, I didn't have any questions this time :D LOL Give that Hanna a belly rub from us :)

[Hanna's mom]

Thanks John. I'll definitely mention this on Monday.
Belly rubbing now..

~Stella

[labblab]

Hello and welcome from me, too! I'm glad that John has clarified the use of the eye ointment, and it does seem unfortunate that the ACTH monitoring test was performed right at the time that Hana was finishing up the eye ointment containing the steroid. I don't know whether the amount of steroid was strong enough to actually skew the ACTH result, but if so, it would have skewed it upward. Meaning that Hanna's cortisol reserve was actually lower than the test would have shown. And in conjunction with her current problems, it does make one wonder whether even this dose of trilostane is too high for her. We have a number of dogs who are dosed twice daily with trilostane; we have had very little experience with dogs dosed three times daily. Is there a particular reason why your vet opted to go that route? We've been told by an endocrinology specialist who is a past member here that dogs dosed multiple time daily may have a greater tendency for adrenal oversuppression than do dogs who are dosed only once daily. Presumably this is because the cortisol level never really rebounds to any significant extent throughout an entire 24-hour time period. I mention this only because it may be another reason why this current dose may turn out to be too much for Hanna to comfortably handle.

Another possibility is that if Hanna's new problems have corresponded with the introduction of the Wedgewood chewable, perhaps there is an issue with the drug itself or with some sensitivity that Hanna may have re: the chewable binder with which the drug has been prepared. So unfortunately, that is yet another variable.

What especially strikes me, though, is that it sounds that in recent months Hanna actually has looked healthier during the time periods that she has not been taking the trilostane at all. Under the circumstances and given the fact this is a holiday weekend, I do think I'd discontinue the trilo again, too. You are right in fearing that stopping the trilo now will render an ACTH performed on Monday far less useful in assessing the true effect of her current dosing. So that is unfortunate. But the alternative is risking pushing her into an Addisonian state if you continue dosing her through Monday. So if she were mine, I'd probably opt on the side of safety.

One cheaper alternative to performing a full ACTH on Monday might be to just perform a baseline cortisol measurement at the same time that blood is drawn to check the blood chemistries ("electrolytes"). I've been writing on some other threads over the last couple of days that I have read that as long as a dog's baseline cortisol is higher than 2.0 ug/dl, there seems to be little danger that the dog has gone Addisonian from the standpoint of cortisol. If the baseline cortisol is lower than 2.0, you would still need to proceed with a full ACTH. But if it is higher and the electrolytes are OK, then you may have saved yourself some expense.

Going back to the eyedrops, John is certainly right that we often feel concerned about proper weaning off of steroid use. But I believe this is more of an issue when steroids are given orally and in higher doses. I have personally used steroid drops and topical ointments for less than 2-week courses, and I have never been told that I needed to worry about weaning in that situation. So I am hoping that is the same situation for Hanna, too.

OK, I've probably written enough to totally confuse things by now. So I will close and keep checking back to see how you guys are doing.

Marianne

[Roxee's Dad]

Thank you Marianne, :) yes, I was thinking oral steroids needing weaning.

[Hanna's mom]

@ Simba's mom - Funny you should mention the yogurt. Hanna has been given yogurt as a treat ever since she got a yeast infection in her ears from being on so many antibiotics. She LOVES it!

@Marianne - Thanks for the brain storming. It all makes sense to me. I'll mention these things to the vet also.

As to why the 3x a day, this was suggested by my husband and I after we did some research learning that it would be better to give Trilostane in smaller doses throughout the day. Not sure where we read this. The vet had no objection to our suggestion, so that's what we did.

Thanks again!
~Stella

[Hanna's mom]

Okay, finally have enough to report...

First of all, Hanna is doing GREAT! She is better than I have ever seen her! It is such a relief.

Second, thank you Marianne for suggesting the baseline cortisol test instead of the full blown expensive test. You saved us hundreds!

Third, thank you John again for your thoughts. Vet said it is very possible the eye ointment messed up her testing. Some dogs respond more to the steroid than others so it's possible.

Lastly, I have no clue how to summarize what the results were so I'm going to simply copy/paste the emailed report that the vet gave us. I feel so very confident in this new vet. I'm so glad you guys encouraged me to see a specialist. It has added a few years to my life, I'm sure :D and Hanna's also. I'm not going to include the vets info because I haven't seen that done on this forum, but if anyone is in the area and is interested, you are welcome to message me privately.

I should also mention that the vet that did her last testing has not sent over the results (last I heard anyway) so I still do not have those, but it doesn't seem necessary at this point. We will be doing a follow-up in about 14 days.

Here's the report...

History:
Hannah presented for evaluation of Cushing's disease, abnormal muscle movements, and dermatologic issues. Hannah was adopted in 2012 after being a bitch at a puppy mill. In Oct 2012, Hannah was evaluated for diarrhea. Her ALT was 488, ALT 1616. An abdominal ultrasound performed by Dr Schelling on 10/31/12 showed microhepatica with mottled parenchyma, blunted and tortuous intrahepatic portovascular arborization, enlarged portal vein and portahepatis. There was sludge in the GB and mild splenomegaly. She was started on Clavamox and Denamarin and recheck lab work on 11/17/12 showed a ALT 521, ALP 865, and GGT 39. Hannah was started on Royal Canin Hepatic diet. She was treated with ursodiol but this was discontinued at some point.

Hannah was diagnosed with Cushing's disease on 5/1/13 after presenting with PU/PD, muscle wasting, pot belly, pigmented thin skin, decreased energy, change in bark, diarrhea, and falling off the steps. Hepatomegaly was noted on abdominal radiographs. Lab work showed increased ALP, ALT, and, GGT with USG 1.002.Her LDDS test was 14.1, 19.4, 22.3. She was started on trilostane 30 mg PO SID after which she became lethargic and recumbent. Her trilostane was stopped and her symptoms resolved. The following week, the trilostane was restarted at 5 mg PO TID. After starting this new dose of trilostane, Hannah's symptoms resolved other than her dermatology concerns (including thinning fur and dermal pigmentation). A recheck ACTH stimulation (Antech) was performed on 6/11; pre 2.2 (1-5), post 5.8 (8-17). The trilostane dose was held steady.

Hannah has intermittent periods of large bowel diarrhea that tend to improve with switching to EN diet. She tends to be a picky eater. Hannah had a mixed mammary adenoma in May 2013 based on histopathology. Hannah had conjunctivitis with periocular crusting on 5/31. She was placed on cephalexin and Neo poly dex, which resolved the issues, although she had diarrhea and lethargy on the cephalexin. For the past few weeks, Hannah has been having muscle twitches intermittently. Ms Ziegler seeing the episodes 5-6 times a day. She has periodic gag episodes. Hannah is pee paid trained.

Hannah overall is significantly improved at home. She is playing for the first time since she was adopted. She is not PU/PD, although she gets up to drink once a night. She vomited on 7/3 or 7/4 but has not vomited since that time. She was scratching her face over the weekend. Due to concerns about the vomiting and then muscle twitches, the last dose of trilostane was given on 7/6.

Medication:
Denamarin 225 mg PO SID
Trilostane 5mg TID (chicken flavored chews)- last dose given 7/6

Physical Examination:
T: 101.7
P: 140
R: 36
Wt (kg): 7.6kg
BCS out of 9: 4

Mentation: BAR to QAR

MM: pink, moist, CRT<2
Ears: Clean AU
Eyes: Clear OU, no discharge
Cardiac: No arrhythmia, pulses strong and synchronous, II/VI systolic murmur
Respiratory: Normal respiratory rate and effort. Lungs clear. No upper respiratory noise or discharge
Abdomen: Compliant and non-painful. Hepatomegaly with mild pot belly. Rectal examination normal
Lymph nodes: Mandibular, prescapular, and popliteal lymph nodes normal
Neurologic: Normal cranial nerves. Normal gait. Normal CPs x 4. Normal mentation
Musc/Skel: Ambulatory x 4. No neck or back pain.
Derm: Per Dr Palmeiro - Interdigital furunculosis affected all 4 feet but worse on the hind feet (tops and bottoms) with swelling, erythema and self induced alopecia. The left hind foot has a focal draining tract (between the 3/4 space). She has generalized trunkal scaling with multifocal thin serous tan crusts.

Diagnostics:
* USG 1.010
* Superchem: Albumin = 2.6 (2.7-4.4) L, AST (SGOT) = 21 (15-66), ALT (SGPT) = 86 (12-118), Alk Phosphatase = 103 (5-131), Total Bilirubin = 0.1 (0.1-0.3), Creatinine = 0.4 (0.5-1.6) L, Potassium = 5.9 (3.6-5.5) H, Otherwise WNL
* Baseline cortisol: 5.1 (1-5)
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* Dermatology consult by Dr Palmeiro:
Diagnostic tests:
1) Skin cytology: Marked pyogranulomatous inflammation, moderate cocci
2) Trichograms: Broken hairs, no parasites
3) Bacterial culture: pending

Summary/comments:
A consultation was performed while Hannah was here during an internal medicine visit. She has evidence of a superficial skin infection on her trunk and deep skin infection (furunculosis) between her toes. As we discussed, skin allergies and Cushing's are likely both contributing to her recurrent skin issues. We have obtained a skin culture to further guide antibiotic therapy. Occasionally, we will see atypical infections (fungal etc) in patients with Cushing's disease. If there is no improvement with culture based antibiotics, skin biopsies may be needed.

Treatment:
1) Clindamycin 75 mg:
Give 1 capsule orally twice daily pending the culture results

2) Chlorhexidine shampoo (that you already have):
Increase bathing to twice weekly.

Follow-up:
Please call Dr. Palmeiro for skin culture results in 7 days. Please schedule a follow-up appointment with dermatology in 30 days (while still on culture based antibiotics) to discuss further evaluation/treatment of the underlying cause for Hannah's recurrent skin infections (allergies etc).

Assessment/Plan Summary:
* Cushing's disease: Hannah has a history of Cushing's disease. She was on trilostane 5 mg PO TID. Her initial ACTH stimulation 20 days post starting the trilostane looked good. Her cortisol concentrations have not been assessed since that time. Based on her behavior at home, her family was worried that she was going into an Addisonian crisis. Therefore, they stopped her trilostane on 7/6. Since that time, they feel that she has clinically improved. I recommended an ACTH stimulation to assess her adrenal status. Due to financial concerns, a baseline cortisol was performed to assess the adrenal status. The baseline cortisol concentration was high, suggesting that Hannah was not in an Addisonian crisis. Since the family felt she clinically improved with the cessation of the trilostane, we will restart the trilostane at 5 mg PO BID. I recommend an ACTH stimulation in 7-14 days.

* Muscle movements: We submitted a baseline cortisol to assess for iatrogenic Addison's disease. The baseline cortisol is not supportive of this diagnostic. A Superchem was submitted to evaluate for hypocalcemia, renal disease, or liver disease that could be contributing to this issue. There were not significant abnormalities. I cannot rule out that the muscle twitches are in response to the derm issues.

* Skin disease: I recommended a dermatology consult for recommendations for the skin issues. Dr Palmeiro has submitted a bacterial culture of the interdigital lesion, which is pending. He Rx clindamycin and chlorhexidine shampoo in the meantime. He recommends a recheck appointment in 1 month with him.

* Liver disease: Previously, Hannah has a period of increased liver enzymes (ALT>ALP). She has been on Denamarin and a liver diet since that time. I do not feel that Hannah needs a liver specific diet. While I cannot say for sure that Hannah needs the Denamarin at this time (based on the current status of her liver), the Denamarin will not cause any issues.

* Diarrhea: Hannah has intermittent diarrhea that tends to resolve on EN diet. Her family says that sometimes metronidazole has been added, which also causes significant improvement that there has been nervousness to use metronidazole based on her previous hepatic concerns.

[Budsters Mom]

I am thrilled that Hanna is doing so well!:D Keep that good news coming!;) There is a big smile on my face right now!:D:):D

[molly muffin]

I think this was an excellent consultation and I am hopefully that they can get the skin problems cleared up.
She was definitely Not in a too low situation with a base cortisol of 5. or over. Some dogs just do better with a tad bit higher than others. Some need to be lower. It will be interesting to see what the cultures come back with for skin. I wonder if there is a yeast infection that will show up. We've seen that before.
Also the dermatologist consult should be interesting too.

It's a good write up! I'm glad you had it done.
A happy Hannah is a happy home. LOL

hugs,
Sharlene and Molly Muffin