New here with my Sheltie Isabel

[Karen_Izzy]

My name is Karen and I have a 12 year old sheltie Isabel (Izzy for short) I have been reading this forum for a few weeks and have learned so much. I can't thank all you generous kind people for the information and support you share with each other. Isabel got her official diagnosis yesterday of Cushings. Today I am at that scarey first stage of the beginning dosing. I am nervous, like most of the others at this stage. Of course.. it's Saturday of Labor Day weekend and my vet is not in the office for questions till Tuesday. My question is pretty simple at this point. I know I have to dose 12 hours apart with food. Right now she is on seizure meds (she had a stroke 2 months ago) and I give them at 10am and 10pm. this schedule works for me. However since this new medication has to be done with meals 10pm is a bit late for her dinner meal. Can I give her half her dinner meal at anywhere from 5-7pm and then give her the other half of her meal with the cushings meds at 10pm? Is this enough food to go with the meds? My other question is if I'm giving her the AM dose at 10am.. on the days she has to be tested, can I move that dose up for that day only to around 8am? so the vet has enough time to do the test at the right time during that day.. or do I have to stick strictly to the 12 hours schedule? I'm so afraid of screwing this up.

Just for info.. she weighs 22.5 lbs. Her prescribed dose is Vetoryl 20 mg in the morning and 20 mg at night. Her diagnosis test was -pre acth 5.1 and post acth 34.4

thank you in advance for all your advice.

me and Izzy ..a little freaked out today!

[Junior's Mom]

Hi Karen, welcome to you and Izzy. I know nothing about the seizure meds, so I can't comment on that. I do know that dosing should be as close to 12hrs apart as is possible, and must be given with food. I don't know if it should be given at a different time from the other medication.
The acth test should be done within 4-6 hrs of dosing, so if Izzy was getting her medication at 10am, you would need to be at the vet for 2pm. This should be possible.
Did your vet give you prednisone to have just in case, and tell you everything to watch for?
Others will be on here to comment. You will be asked for copies of all bloodwork/testing done on Izzy. It's a very thorough and knowledgable group.

[Karen_Izzy]

I thought when she went back for the first testing after starting the medication..it was blood work throughout the day? Is it just once that day?
and he didn't give me prednisone..he just said if she has any reaction..vomiting loose bowels..to stop it immediately. Now I'm scared..what else should I be looking for? what if I don't have the prednisone? yikes. I gave her all her meds together too. He didn't mention separating them.

feeling so overwhelmed!

[spdd]

Don't worry. Everyone on here as I'm sure you know is so well educated, they can tell you exactly what to do.

Others will be on here telling you exactly how to treat your pup, but I also know they will want the test results, so if you have them, post them and if not, get them from your vet.

We all feel overwhelmed, you are in good company. Welcome to the forum.

[Squirt's Mom]

Hi Karen,

What drug is she taking for the seizures? Do you know the cause of the seizures?

The all day test is the LDDS - which is used in diagnosis only, not for monitoring after diagnosis has been confirmed and treatment started. Was the ACTH the only test Isabel had to diagnose the Cushing's? Did your vet run regular blood work that shows things like ALP (sometimes seen as ALK or ALPK), CHOL, BUN, etc? If so, would you post the abnormal results from that - just the values that are too high or too low. If your vet did not do labs, I would ask for that to be done asap and not give any more of the Vetoryl until they are done.

There is usually no rush to start treatment so if you are still unsure and not comfortable then stop for now. We can help you understand things a bit better, raising your comfort level. One of the good things about this drug is that it is very easy to stop and restart. ;)

We do like to know that all our cush parents are given pred just in case. You just never know if the cortisol may go to low and it always seems to happen on weekends, holidays and when the vet is unavailable. With Vetoryl, because it is leaving the system so quickly (within 2-12 hours of dosing), most pups on this drug will bounce back if the drug is withheld. HOWEVER, there is also the chance they will need help - hence the pred and hopefully directions from your vet as to when, how and what dose to give. If that info isn't given to you or isn't clear, let us know and we can help with that as well.

There have been some changes to the recommended starting dose of Vetoryl. UC Davis recommends starting at 1 mg/kg once daily. At a weight of 22.5 lbs, Isabel weighs 10.23 kg. So her starting dose would be closer to 10mg once a day or 5mg twice a day. You do NOT double the dose when using the twice a day dosing schedule. ;) Have you noticed any changes in Isabel whatsoever since giving her the meds?

We use Lysodren and I have a hard time keeping up with Vetoryl but I'm sure some of our Vetoryl/Trilostane parents will be along to share their experiences with you.

I want you to know you and Isabel are not alone on this journey. We will be with you all the way. We will ask lots of questions and hope you will as well. I'm very glad you are here and look forward to learning more about the both of you as time passes.

Hugs,
Leslie and the gang

A good link on Vetoryl/Trilostane from our Helpful Resource section -
http://www.k9cushings.com/forum/showthread.php?t=185

[Karen_Izzy]

Below is a chart of bloodwork she had 1 month after she had her stroke and MRI (7/25/13 date of bloodwork). She had a stroke (confirmed by the MRI) and had a 2 slight siezures afterwards and was put on Zonisamide 100 mg every 12 hours. At the time of the MRI they thought she had a brain tumor as well, but were not sure. Now it's been 2 months since the stroke and they think it may have just been a major stroke and no tumor since she is doing so well (neurologically speaking). I don't have the most recent blood work from my local vet. (the one below if from the Neurologist) I don't know if these results below tell you anything. From doing a lot of reading over the past 6 months I was thinking in the back of my mind all along she might have cushings. She had a few accidents in the house and when Urine was tested it was dilute. Her fur has been thinning out (not real noticeable to anyone else, just me) and recently she started panting, drinking water quite excessively and urinating every two hours. In the past week she woke up twice in a puddle of urine. So clinical symptoms alerted my vet to the possibility of cushings and the test results in the first post, he said confirmed it. I thought the dose was high too, and I questioned him on it. But he assured me this was the right dose. I will get the most recent blood work, but won't be able to contact him till Tuesday.


HEALTHCHEK - CHEM 25
ALK. PHOSPHATASE 583 10 - 150 U/L High
ALT (SGPT) 63 5 - 107 U/L
AST (SGOT) 17 5 - 55 U/L
CK 122 10 - 200 U/L
GGT 6 0 - 14 U/L
ALBUMIN 3.8 2.5 - 4.0 g/dL
TOTAL PROTEIN 7.4 5.1 - 7.8 g/dL
GLOBULIN 3.6 2.1 - 4.5 g/dL
TOTAL BILIRUBIN 0.1 0.0 - 0.4 mg/dL
DIRECT BILIRUBIN 0.0 0.0 - 0.2 mg/dL
BUN 25 7 - 27 mg/dL
CREATININE 0.7 0.4 - 1.8 mg/dL
CHOLESTEROL 727 112 - 328 mg/dL High
Comment RESULT VERIFIED BY REPEAT ANALYSIS

GLUCOSE 93 60 - 125 mg/dL
CALCIUM 10.8 8.2 - 12.4 mg/dL
PHOSPHORUS 3.8 2.1 - 6.3 mg/dL
TCO2 (BICARBONATE) 13 17 - 24 mEq/L Low
CHLORIDE 116 105 - 115 mEq/L High
POTASSIUM 4.3 4.0 - 5.6 mEq/L
SODIUM 145 141 - 156 mEq/L
A/G RATIO 1.1 0.6 - 1.6
B/C RATIO 35.7
INDIRECT BILIRUBIN 0.1 0 - 0.3 mg/dL
NA/K RATIO 34 27 - 40
HEMOLYSIS INDEX +
Comment Index of N,+,++ exhibits no significant effect on chemistry values.

LIPEMIA INDEX +++
Comment Index of N,+,++,+++ exhibits no significant effect on chemistry values

ANION GAP 20 12 - 24 mEq/L
HEALTHCHEK - CBC COMPREHENSIVE
WBC 6.0 5.7 - 16.3 K/uL
RBC 6.58 5.5 - 8.5 M/uL
HGB 15.5 12 - 18 g/dL
HCT 42.9 37 - 55 %
MCV 65 60 - 77 fL
MCH 23.6 19.5 - 26.0 pg
MCHC 36.1 32 - 36 g/dL High
% RETICULOCYTE 0.6 %
RETICULOCYTE 39 10 - 110 K/uL
NEUTROPHIL SEG 69.2 60 - 77 %
LYMPHOCYTES 21.7 12 - 30 %
MONOCYTES 9.1 3 - 10 %
EOSINOPHIL 0.0 2 - 10 % Critical Low
BASOPHIL 0.0 0 - 1 %
AUTO PLATELET 399 164 - 510 K/uL
REMARKS
Comment SLIDE REVIEWED MICROSCOPICALLY.

ABSOLUTE NEUTROPHIL SEG 4152 3000 - 11500 /uL
ABSOLUTE LYMPHOCYTE 1302 1000 - 4800 /uL
ABSOLUTE MONOCYTE 546 150 - 1350 /uL
ABSOLUTE EOSINOPHIL 0 100 - 1250 /uL Critical Low
ABSOLUTE BASOPHIL 0 0 - 100 /uL

[Karen_Izzy]

I realized I have an older blood work result from June..This was when she first show neurological signs of left side weakness, confusion, sight loss, hearing loss. Took her in to the vet and he did this bloodwork and said take her to a neurologist who diagnosed the stroke with the MRI. I dont know if it helps but I'm posting it in case it makes sense to anyone. This was before the vets thought of Cushings.




Special notes:

Isabell's blood results are basically very good. The ALP is elevated but all other liver values are normal. Her ALP was at 308 in January and so, has increased, but is an unlikely cause of her current neurologic condition. The cholesterol is elevated, but the Thyroid level is normal; so may be just a non-fasted blood change. There is no indication of infection or inflammation in the cell counts

Patient: ISABELL VAIL
Species: Canine
Breed: SHETLAND SHEEPD
Gender: Female
Year of Birth: 2001

Panel/Profile: Senior Profile
Hematology
6/18/2013 (Order Received)
6/18/2013 @ 10:35 am (Last Updated)
RBC 7.28 5.5 - 8.5 M/μL
Hematocrit 53.0 37 - 55 %
Hemoglobin 17.1 12 - 18 g/dL
MCV 73 60 - 77 fL
MCH 23.5 19.5 - 26.0 pg
MCHC 32.3 32 - 36 g/dL
% Reticulocyte 0.5 %
Reticulocyte 36 10 - 110 K/μL
WBC 5.7 5.7 - 16.3 K/μL
% Neutrophil 61.8 60 - 77 %
% Lymphocyte 21.3 12 - 30 %
% Monocyte 8.7 3 - 10 %
% Eosinophil 8.2 2 - 10 %
% Basophil 0.0 0 - 1 %
Neutrophil 3.523 3 - 11.5 K/μL
Lymphocyte 1.214 1 - 4.8 K/μL
Monocyte 0.496 0.15 - 1.35 K/μL
Eosinophil 0.467 0.1 - 1.25 K/μL
Basophil 0 0 - 0.1 K/μL
Auto Platelet 235 164 - 510 K/μL
Remarks SLIDE REVIEWED MICROSCOPICALLY.
NO PARASITES SEEN
Chemistry
6/18/2013 (Order Received)
6/18/2013 @ 10:35 am (Last Updated)
Glucose 94 60 - 125 mg/dL
BUN 13 7 - 27 mg/dL
Creatinine 0.7 0.4 - 1.8 mg/dL
BUN / Creatinine
Ratio
18.6
Phosphorus 3.7 2.1 - 6.3 mg/dL
Calcium 11.2 8.2 - 12.4 mg/dL
Sodium 144 141 - 156 mmol/L
Potassium 4.8 4 - 5.6 mmol/L
Na / K Ratio 30 27 - 40
Chloride 109 105 - 115 mmol/L
TCO2
(Bicarbonate)
19 17 - 24 mmol/L
Anion Gap 21 12 - 24 mmol/L
Total Protein 7.4 5.1 - 7.8 g/dL
Albumin 3.8 2.5 - 4.0 g/dL
Globulin 3.6 2.1 - 4.5 g/dL
Alb / Glob Ratio 1.1 0.6 - 1.6
ALT 47 5 - 107 U/L
AST 14 5 - 55 U/L
ALP 413 10 - 150 U/L H
GGT 5 0 - 14 U/L
Bilirubin - Total 0.0 0.0 - 0.4 mg/dL
Bilirubin -
Unconjugated
0.0 0 - 0.3 mg/dL
Bilirubin -
Conjugated
0.0 0.0 - 0.2 mg/dL
Cholesterol
a 852 112 - 328 mg/dL H
Amylase 481 450 - 1240 U/L
Lipase 329 100 - 750 U/L
Creatine Kinase 58 10 - 200 U/L
Hemolysis Index +
b
Lipemia Index +
c
a
Printed from VetConnect® PLUS:
June 18, 2013 4:58 PM Page 2 of 4
Atlantic Veterinary Services
Patient: ISABELL VAIL
Chemistry (continued)
RESULT VERIFIED BY REPEAT ANALYSIS
b
Index of N,+,++ exhibits no significant effect on chemistry values.
c
Index of N,+,++ exhibits no significant effect on chemistry values.
Urinalysis
6/18/2013 (Order Received)
6/18/2013 @ 10:35 am (Last Updated)
Collection FREE-CATCH
Color DK YELLOW
Clarity CLOUDY
Specific Gravity 1.049
pH 6.0
Protein 3+ (300-500 mg/dL)
a
Glucose NEGATIVE
Ketones NEGATIVE
Blood / NEGATIVE
Hemoglobin
Bilirubin NEGATIVE
Urobilinogen NORMAL
White Blood 0-2
Cells
0 - 5 HPF
Red Blood Cells 0-2 0 - 5 HPF
Bacteria NONE SEEN HPF
Epithelial Cells 1+ (1-2) HPF
Mucus NONE SEEN
Casts NONE SEEN HPF
Printed from VetConnect® PLUS:
June 18, 2013 4:58 PM Page 3 of 4
Atlantic Veterinary Services
Patient: ISABELL VAIL
Urinalysis (continued)
Crystals 4+ CA OXALATE (>10) HPF
Other AMORPHOUS DEBRIS
NON-CRYSTALLINE DEBRIS PRESENT
a
Protein test is performed and confirmed by the sulfosalicylic acid
test.
Endocrinology
6/18/2013 (Order Received)
6/18/2013 @ 10:35 am (Last Updated)
Total T4
a 1.8 1 - 4 μg/dL
a
Interpretive ranges:
<1.0 Low
1.0-4.0 Normal
>4.0 High
2.1-5.4 Therapeutic
Dogs with no clinical signs of hypothyroidism and results within the
normal reference range are likely euthyroid. Dogs with low T4
concentrations may be hypothyroid or "euthyroid sick". Occasionally,
hypothyroid dogs can have T4 concentrations that are low normal. Dogs
with clinical signs of hypothyroidism and low or low normal T4
concentrations may be evaluated further by submission of free T4 and
canine TSH. A high T4 concentration in a clinically normal dog is
likely variation of normal; however elevations may occur secondary to
thyroid autoantibodies or rarely thyroid neoplasia. For dogs on
thyroid supplement, acceptable 4-6 hour post pill total T4
concentrations generally fall within the higher end or slightly above
the reference range.
Printed

[frijole]

Others have offered you good advice and asked good questions. Please don't start until you have confirmation that the seizure med Zonisamide is safe to take with trilostane. Are you located in the US? Because you can contact the manufacturer directly and ask them.

Also it is normal to start with once a day dosing and lastly I agree that the dose is high to start with, particularly given the other health issues and meds you are on.

I wouldn't give a single pill until I spoke with Dechra. (manufacturer) Kim

[goldengirl88]

Karen:
Glad to see you on the forum, and welcome to Isabel too. I use Vetoryl and can tell you some ideas from my experiences. First of all call Dechra 899-933-2472 and establish a file on your dog. They have vets there that can help you and answer questions. You really should get prednisone from you vet. Just in case you need it you have it on hand. Like Leslie said 2X a day dosing does not mean to double the dosage. You should start your dog on a low dose so her body has time to adjust to the drug. This can prevent potential problems. Some vets start them too high and the dogs have problems. Start low not matter what. You can always go up if and when she needs adjustments. As far as giving her the Vetoryl early one time to get the testing done, I would not do it as it may skew her test results. On any other given day some time if you must give it early, it is ok as I checked with Dechra on this because I had a situation where I had to leave Tipper with a sitter. I would not make a habit of it. About the meals. I would split the last meal. When you ask is it enough to give her half with the Vetoryl, how much is contained in her last meal?? It needs to have something with a little fat in it as this drug is fat soluble. Maybe a small piece of cheese or something. That makes the drug work more efficiently. Always get a copy of all test results from your vet, then post the numbers on here for help. Keep a daily doggie diary to refer back to, it will really help. If your vet is not very experienced in Cushings and it's treatment you should seek out another that is. It will save time, heartache, and money. Most vets familiar with Cushings would not dispense Trilostane without prednisone. Please check this out. Also if you keep a copy of all testing etc. and decide to change vets you already have the file. Some on here have had trouble getting their dogs info. off of vets, this will save you from doing that. There is no harm in waiting until the holiday weekend is over to start your dog on these drugs. That way you have a vet in in case you need them, that is a safe way that I would use. As far as you giving other medications with the Vetoryl, I never do that. I always give the Vetoryl alone, and wait a good hour even to give supplements I do it this way. I don't want anything to interfere with the drug absorption. I hope you have a good weekend, and don't worry too much as we are all here to help you whenever you need us. These are powerful drugs so never open them, and wash you hands good after handling them. You may find getting them from a reliable source online is much cheaper than your vet. Lambert Veterinary Supply is wonderful, ask for Nancy she is great and helpful. Blessings
Patti

[Trixie]

Hi Karen,
You remind of of myself 6 months ago starting our first day of medication! I was so nervous and scared to give that first pill. I would heed the advice of others, who know more than I, on checking about the other medication and Vetoryl.
We started on a very low dose so I never saw any adverse reactions in my dog. We were not even at 1mg per pound so when I say very low...it was. I give Trixie her Vetroyl on 10am-10pm dosing too. The morning dose goes with breakfast (I give her pills balled up in some food) and with the 10pm dose I do the same,-pills inside some food balls, and then I give her a couple bites of food and a couple treats too..she has an appetite at all hours of the day so getting her to eat at 10pm is not a problem. So, it's not a whole meal but it's enough in her tummy as the medication is better absorbed with food.
Everyone is here whenever you need to post!! I hated that first weekend of medication I was watching my dog constantly and driving myself crazy. I;m still watching all the time...I guess that just comes with the territory. :)

Barbara

[Karen_Izzy]

Thank you for your suggestions. I am in a fairly rural area and there aren't many vets to choose from. I had to travel quite far to get her to a neurologist. So I am pretty much stuck with this vet. He is open to discussions and very cooperative with any of my input. I feel pretty confident in his abilities, so that is why I agree to the dose he recommended, even tho I thought it was a little high. Should I give her only 10mg tonight? and then give her 10mg in the am and 10 in the pm? instead of 20mg and 20 mg? I can talk to him Tuesday. I did call the drug manufacturer( Dechra) and they said there were no known side effects with the Zonisamide .

[Trixie]

I am no expert at the tests and numbers. All I can say is that there is no harm in starting lower...if your dog is 22 pounds then 20mg a day would be a conservative starting dose. So- you could start with 20 a day in 2 doses of 10mg...instead of 20mg at each dose.
After many weeks of increasing we are now at 14mg twice a day (28mg) for a 17 pound dog.
Your dog may tolerate the 40mg a day and may need that much to control the cortisol, but if you are nervous then you can play it safe and go with the low and slow dosing. There were times it was frustrating for me as I did not see improvement in symptoms for awhile with the low dose but I also didn't have any scary overdosing either. If you had a crystal ball dosing would be a no brainer.
By the way Izzy is a beauty!! :):) Forgot to mention that on my previous post...she's such a pretty girl. Does she exhibit many Cushings symptoms...drinking, peeing, panting etc....??

Barbara

[frijole]

I live in a pretty rural area too and went thru multiple vet changes when i first was dealing with cushings. Its a shame but the tests and drugs are too expensive to "practice" on your dog. Also overdosing can lead to big issues and is life threatening so don't mess around.

Any vet starting a dog on these drugs needs to be available 24/7 by phone in case of problems so to have you start on a holiday weekend is just crazy, particularly at that dosage and with them not being open... and no prednisone to give in case of emergency.

Glad you got ahold of Dechra. There are some meds that do interfere so better safe than sorry. If it were my dog I'd either wait til Monday when a vet is available the next day or simply go with 1/2 the dose because that is what most vets nowadays are doing. Kim

[Karen_Izzy]

Does she exhibit many Cushings symptoms...drinking, peeing, panting etc....??

Barbara

Thanks Barbara, Izzy is a sweet girl. Yes, she is drinking a lot, peeing every 2 hours. Has had some incontinence here and there, she pants and her fur is thinning(not really noticeable to anyone else, but I groom her, so I can see even a small difference). I hate to go against my vets advice, only because he went to school..I didn't..so maybe he sees something in her results that require this dose? I have till 10pm tonight to decide whether to go to the 10 or stick with his 20mg. why don't all vets just start really low? is there a reason?

[Karen_Izzy]

If it were my dog I'd either wait til Monday when a vet is available the next day or simply go with 1/2 the dose because that is what most vets nowadays are doing. Kim

I probably will back down to the 10mg on tonights dose. That's what my gut is telling me to do. I hate that this decision is in my hands...I'm no doctor.. How often do people get into a life threatening position with this medication? Is it rare or common?

[Squirt's Mom]

why don't all vets just start really low? is there a reason?

My guess is because the product insert and brochure for Vetoryl says to start at a higher dose. However as this drug has been used more, it is the "new kid on the block" in Cushing's treatments, it has been discovered that many pups do better starting at a much lower dose then increasing as needed.

[frijole]

I am not a vet so I didn't go to school for it but trust me they spend very little time on this stuff which is the problem. Especially in small towns - they just don't see it or don't treat it because they are 'farm dogs'. I came here 8+ years ago because of a clueless vet and I guarantee you I have seen more cases and read more about this disease than most small practice vets. That is why this site exists. If dogs didn't constantly get in peril there would be no need.

I don't mean to scare you but as Leslie said Dechra's packet has dosing info that even THEY no longer support - they just haven't reprinted the insert. Scary huh but true.

Go read on other's threads if you want to see what I'm talking about - dogs misdiagnosed on a regular basis, dogs doses too high on a regular basis, wrong instructions given for dosing/testing on a regular basis. Sometimes errors are made because owners don't take the drug seriously and aren't paying attn to vet's instructions.

You obviously care about Isabel and are wise to read up and ask questions. There is a reason why the manufacturer and UCLA Davis (researchers in this area) drastically reduced dosing from what is on the insert. If you are concerned just phone your vet and tell him you decided to only give treatment in the morning at 10 mg.

Note if you only give once a day you must give it in the am. Also don't even think about splitting a dose from a capsule - that's a no no. Just making sure. :o:) Kim

[Karen_Izzy]

Thanks Kim..yes ..I am even more scared now than I was ..but that's ok. I believe in getting info and making informed decisions. I am going to back down to 10mg in the AM and 10mg in the PM. this is Half of what he recommended and I feel more comfortable with that.

I also cannot say enough- that this forum is so important for so many people, including me. It really makes us newbies not feel like we are flying alone. That is HUGE help. I feel so alone in all this, and I feel so much better being here. thank you!

[frijole]

Do you have 10 mg pills? Just make sure you don't take a 20 mg pill and pour out half and half.

No problem. Don't mean to scare you but vets tend to take trilostane way too lightly - like prescribing an antibiotic. I've been here way too many weekends where a parent comes on distressed as there dog has overdosed/gone too low. No prednisone on hand and the vet office is closed.

So yep that is why we are here. Your vet is making big money off of a cush dog because there are repeat visits, tests, etc and the least they can do is study up on it. Dechra doesn't help things by not changing their insert.

The way it works is you start low on trilostane and if after several weeks to a month on it the numbers aren't where they need to be you slowly increase. You can't do it the other way around without having problems. Take care. Kim

[Karen_Izzy]

thank you Kim.. yes,I have 10mg capsules. he said 2 capsules in the morn, 2 capsules at night. But like I said, I am going to do 1 in the am and 1 in the pm.

[Trixie]

I understand how you feel Karen..I do think many people on this board are more expert on Cushings than many vets are!! Not saying this in relation to your vet who may know plenty, but some stories I've read here boggle the mind and you can't believe it but some vets seem to need a refresher on the Cushings chapter of thier textbooks...or even Cushings 101!!!

Your vet may look at the number from your test and prescribe the 40mg because he thinks that is what it's going to take to control Izzy. The thing is that it may be better to build up to the higher dose than to overdose at the beginning. So starting at 1mg per pound of your dog would be approx. the 20mg a day dose vs. the 40mg. Izzy may need 40mg or even more...but maybe she may need less than that. It's a tweaking game and I know because we've been tweaking since April.
So- yes I saw very little change in Trixie's symptoms the first 4 weeks as we steadily and conservatively moved up the dose in small increments...but I would still choose to do it the way we did because starting and getting adverse reactions would have freaked me out and could have been dangerous to Trixie. So slow and steady...and finally after many increases we finally have reached a dose that seems to be good. We may still need to come up a bit-maybe to 15mg 2x a day..but for now we're holding at 28mg. We had zero bad reactions so it took a lot of the fear out the whole thing for me.
The basic thing is this-- going in low just can't hurt...going in high can.
If you see a decrease in symptoms with only 20mg a day then you know you made a good choice. You'll then do an acth and see your dogs levels and make adjustments if needed. It's just not as risky going in low.
Your 40mg dose is higher than recommended based on the 1mg per pound starting dose. I believe if you politely tell your vet you were uncomfortable with the original dose and prefer to start lower and build up if needed I would hope he would understand.
At one point my vet wanted to increase the dose a little more than I was comfortable with and when I just said how about a little lower he was fine with that. Turned out I was wrong and we still needed more but hey-better safe than sorry.
I was brought up in a house where doctors (human or animal) were not questioned and I'm not so sure that's a good thing, they are not always right...sometimes you just have to go what your comfortable with-so go with your gut.
I know this is hard, everyone here has been through this guessing game and unfortunately it doesn't really end with the start of the medication, but Izzy is going to be okay and if you go with the lower dose you will have a little less worry starting out.
Barbara

[Junior's Mom]

Hi Karen, I am also in a rural area, so I know it can be difficult. I did lots of research on this forum before starting my dog on vetoryl. My vet is willing to work with me, and listen to my wishes. It's sad that we have to direct the medical team some times, but if that is what is best for our babies-so be it.
After reading that vetoryl usually leaves the system within 12 hours, I decided to go with twice a day dosing. It made sense to me. I also figured it would be best to start low, so the sudden cortisol drop was not a shock to his system, and there would be less worry about side affects. I made my vet give me prednisone. I have not had to use it.
Junior weighs 50lbs. I started him on 20mg, twice a day. I saw positive affects almost immediately. We are still tweaking, but I have insisted on small amounts at a time.
If you got the vetoryl brand, then it should be 10mg capsules. It would be better to start with just 1capsule.
Waiting, to have more bloodwork done, and a urine culture if it has never been done, will not hurt your dog. This is a slow progressing disease. I waited a year before I started Junior on the medication.
Don't worry, you are in good hands here.

[Karen_Izzy]

thank you so much. I hope I didn't do too much damage already with the 20mg dose this morning. I'm wondering whether I should even give her any dose tonight. and then tomorrow give her 10 in the am and 10 in the pm. Since she has had 20mg today already. aaacckkk so confusing!!!!!

I am literally sitting here all day watching both Izzy, and this forum..and worrying.

[frijole]

You're fine. Skip tonight's dose (for all the reasons discussed earlier) and then start tomorrow at 10 mgs. Kim

[Trixie]

I did the exact same thing the first day I gave the medication! :D Watching every little thing and checking in with the board..a common day for many on the forum!!
You're doing fine...it's going to be okay for you and Izzy. :)

Barbara

[Simba's Mom]

Hello and welcome to you and Izzy, she's a beauty, so glad you found this forum, it's the best, take care, hugs....

[molly muffin]

Hello and welcome to the forum.

Just from what I have seen here on the forum, dogs that start low and even if they have to build up, do seem to tolerate and do better on vetroyl. I think it is a matter of the body adjusting to the cortisol being lower. It can make them feel really yucky when it goes down too fast.
That is just one of those things that we have noticed in addition to the UDavis and now Dechra recommendations. This was also confirmed by our Specialist as the way she likes to start treatment for cushings, and I think that it would be easy enough to tell your vet that this is what you feel comfortable at.

While they are serious drugs used for treatment, there is no need to be scared of them.
Knowledge is your best friend, the more you know about it, the more comfortable you'll feel. You will always worry, this is just the nature of this disease, but it won't feel as scary as it does right now.

Like Barbara said, you could end up at 40mg or even higher total daily dose, but I like the idea of giving the body time to make the adjustment slower personally speaking.

Welcome again!
Sharlene and Molly Muffin

[LtlBtyRam]

Welcome! We started with a low dose then went to a very very low dose. The first 2 doses were on the low side, but Shasta got really really sleepy those first 2 days. Since our vet was new to Trilo although she didn't seem new to Cushing's at all, she was calling our house everyday to check on her, then had a tech doing it daily, then every other day etc. Shasta's records have grown 40 pages in the last year.

I'm rambling. Another reason to start low is their Cortisol levels can continue to drop months into this process. We were on a dose and got her levels into range, but I think they were a little low for her. Rest assured we are working on it.

In short you have nothing to lose by starting low.

[Karen_Izzy]

Just wanted to let you all know that the first day I gave her 20mg in the am with food. After talking to you all, I didn't give her the PM dose (of another 20 as prescribed). The second day I gave her 10mg in the am and 10 mg in the PM. We are now on day 3 with 10mg this morning. This was the dose I thought he was going to prescribe and the one I felt comfortable with. With no vet on a holiday weekend, and no prednisone to help in a emergency, I thought this was the way to go. She is doing fine so far, no leaks in the house, no vomiting, nice stools. She is still panting and drinking and peeing every 2 hours, but she does make it through the whole night without having an accident.

I can't thank you all enough for your support. Having you all here gave me the courage and sense to cut back on the dose he prescribed. I feel much better today (the third day) and trying to enjoy the time I have with my girl. Since her stroke, I've thought everyday would be her last, so everyday is a blessing. Thank you ALL!!!

[Harley PoMMom]

So glad to hear that Izzy is doing so well. The increased drinking/urinating may take a few weeks to subside. Has Izzy's next monitoring ACTH test been scheduled?

Keep up the great work!!

Love and hugs to you both, Lori

[Karen_Izzy]

As far as her next ACTH test..no..it isn't scheduled yet. My vet wasn't there on Friday when I went to pick up the meds. I will talk to him on Tuesday via phone and tell him about my decision to lower her dose, and to schedule her ACTH. (probably the 11th or 12th which would be her 11th or 12th day unless something happens before then). I will make sure they do these ACTH follow ups at the same time after her morning dose (with meal-930am) each time they test. I know it's early to see results, I'm just glad there are no negative results so far!

[goldengirl88]

You are doing well, and I am proud of you for taking the advise of the panel and going with a lower dose. You are the best advocate for your dog so use your gut feeling. Just remember this is your dog, the vet won't be sitting home crying like one of us would if something happened. You have the most to lose in this situation, so you must question every little step being made by someone else. I am not trying to scare you, but always come on here and ask questions, as the knowledge you gain will benefit your baby. I check, check and recheck everything my vet tells me or wants to do, before I let him proceed with anything. You will get confident enough to rely on yourself through the help of all the wonderful members on here. Blessings
Patti

[frijole]

Thanks for giving us an update! Glad you decided to start low - it's hard to trust total strangers but we really have seen many hundreds of cases and there is a trend. Take care and keep us posted. KIm

[Budsters Mom]

We are NOT total strangers Kim. WE ARE FAMILY! Everybody sing now!:D xxxx

[LtlBtyRam]

We are NOT total strangers Kim. WE ARE FAMILY! Everybody sing now!:D xxxx
Singing with Kathy :D

[Trixie]

Sounds like you're doing great Karen!!
I did find it hard to give the medication and still see tons of drinking and panting. Thankfully everyone here listened to my many posts about Trixie's water intake. I was impatient and thought she would improve faster than she did. For my dog it was awhile before I saw improvement..and she still drinks more than she used to but it's not crazy like it was. Some people will see changes in just a few days...all dogs are different. I hope you won't have to wait too long before you see Izzy's symptoms decrease.

After our 1st acth we did increase the dose. Each increase was small and conservative so again symptoms did not just disappear one day but gradually got better as we slowly increased the dose.
You are doing great! I hope your vet understands your decision to start with a lower dose. I can't believe he would fault you for wanting to start a little lower.
Hope Izzy continues to do well and have no adverse reactions. :)

Barbara

[Trixie]

Hi Karen,
How has Izzy been doing? What did your vet think about your lower dosing? Did he want you back on the higher dose for Izzy?
Any changes so far? Hope all is going well and that you'll check back and let us know how it's going.

Barbara

[spdd]

Singing with Kathy :D

Singing kum ba yah...

[Karen_Izzy]

I spoke to my Vet the minute the office was open on Tuesday. I explained my reasoning for the lower dose and he was fine with that. He said he prescribed the higher dose because her post Acth was so high, and I understood why he did it, and he understand why I wanted to start lower. So we agreed to stick with the 10mg AM and 10mg PM till the next test. (in a few days from now). I also asked him for an emergency dose of Prednisone to have on hand for emergencies and he quickly agreed. So all went well, and we are on the same page for now.

As far as Izzy, she absolutely has more energy and actually asked ME to play yesterday. I haven't seen that behavior in about 10 months or so. She is more alert and responsive. She is still drinking a lot and peeing frequently, but her panting has definitely stopped. She has had a few urination accidents while taking daytime naps, but she has been making it through the night without wetting her crate.

Although progress is slow, I am happy with the positive direction at this point.

A representative I spoke with at Dechra had an interesting insight that I'd like to share. I'm sure it has been mentioned on this board somewhere, but I thought it bears repeating. She said if the Cushings is caused by a Pituitary tumor, as the Vetoryl decreases the cortisol, it may cause the tumor to become larger (because the anti inflammatory properties of cortisol). If this is the case, you may see more neurological symptoms appears as the Cushing's symptoms disappear. (she mentioned trouble chewing, balance problems, trouble seeing). If that is the case you may have to find a happy medium with the meds - instead of getting rid of one or the other symptoms entirely, but balancing it in the middle with a little of both symptoms you can live with or think is best for your dog. She said not many vets think of this, and it was something to watch for.


thank you all again for the support you give. It is amazing. :)

[Squirt's Mom]

The tech at Dechra told you correctly. FYI -

Trilostane-induced inhibition of cortisol secretion results in reduced negative feedback at the hypothalamic-pituitary axis. (causes growth of macros)

http://www.ncbi.nlm.nih.gov/pubmed/19041802

[Squirt's Mom]

It is entirely logical that Lysodren would work the same way but as far as I know, no studies on this have been done with Lyso yet.

[frijole]

Given the fact that you are seeing changes in symptoms on the lower dose I would NOT change the dosage even if the numbers are still high on the next test. The reason is that the drug is known for it's cumulative effect - people who have been on a certain dose all of a sudden see a drop after months. So 7 to 10 days is not enough time. Stay the course and it is fantastic you are seeing changes. Good job. Kim

[Karen_Izzy]

I am on day 7 and I am a bit concerned. Izzy is losing interest in eating. She has always had a good appetite, since she was a pup. She nibbles and walks away.. looks at the food like she wants to eat it.. then walks away again. She is still drinking a lot and urinating every 2 hours or so. Her panting has gotten better, but I'm really worried about her lose of appetite. :(

[Trixie]

Hi Karen,
It is worrisome that Izzy has little appetite..in the couple weeks before starting the medication was she eating normally or even more ravenously than normal?
Since she is still drinking and urinating a lot it sounds like she's not all the way controlled but the appetite issue shouldn't be ignored. Her tummy could also be off because of the Vetoryl,I think some dogs may get tummy upset from it. How is her energy level? She hasn't had any diarrhea or vomiting, right? You know if you see any of those to just stop giving the med.

In case she is getting a sour tummy from the pill you could try giving her a Pepcid A/C and see if there's any difference...it can't really hurt her. I give my 17pound dog one half of a 10mg tablet each night.

Luckily right now she doesn't have any other signs of going too low, but I would also feel worried like you. Maybe you can move up your acth test to next week if she continues to be uninterested in eating. You're giving her dose with food aren't you? Hopefully some others who know more than I do will have a suggestion about Izzy's loss of appetite.

Barbara

[Harley PoMMom]

I agree with Barbara that Izzy's inappetence is a bit worrisome. If this were me, I would skip her next dose of Vetoryl and see if her appetite perks up. And as Barbara has suggested, giving the Pepcid AC 20-30 minutes before her Vetoryl dose may help.

Hugs, Lori

[spdd]

Your post is interesting. It's almost a replica of what I went through, so I'll be watching to see what your resolution is.

[Karen_Izzy]

She's alert, no vomiting, no loose stool. I give her her meds with food.
I'm watching her like a hawk now. I will keep you all posted on how it goes this morning. Of course it's Sunday and I can't just phone the vet.. why do these things happen on the weekend all the time??? :eek:

[Karen_Izzy]

Your post is interesting. It's almost a replica of what I went through, so I'll be watching to see what your resolution is.

What did you do? stop medication? try different foods? I'm interested in any input you might have.

10:10am - gave her her morning dose at 930am. she had no interest in her regular food. Tried sardines which I normally give for a meal once or twice a week. She picked at it..ate a little. I was going crazy with what to feed her. I also give a tablespoon of plain yogurt with meals (all her life) and when I put a spoon of yogurt in her bowl she ate it like crazy and looked at me for more. ??? so she has an appetite but I'm stumped. Anyone have any suggestions on what I can feed her? Maybe it's the texture? the temp? I told her she's driving me crazy :)

[Trixie]

Hmm...well it's a good sign that she lapped up the yogurt and also good that she shows no other signs of going too low. Maybe you could experiment by putting some of her regular food along side a couple spoons of yogurt and see if she eats everything or just the yogurt.
I guess I would try and offer things that she usually thinks of as a treat and see what happens. Guess you're probably already doing this. I know my dog is extremely tempted by raw (very lean) chopped beef. I only give her a little bit but she stares right through me begging for more. Anything like that for Izzy that you could test her appetite with? Does she usually scarf up the sardines?
What we don't know about medications and dogs is if perhaps the med changes how things taste to them. Maybe what usually taste good doesn't taste the same on medication. What you really want to determine is if her appetite is there at all.
You're doing a great job keeping the eagle eye on her. I would continue to be vigilant just like you are doing. The good part of this medication is if you notice any of the things that mean too low a drop, you can just skip a dose. I think monitoring the water intake is a good way to see how quickly her level might be changing...it is in our case as excessive drinking was the most prevalent symptom. You will feel better once you can do the acth and see where Izzy's level is.

Barbara

[Karen_Izzy]

I bought some Merrick Chicken 96 (high protein, low fat) food that Izzy ate, both at breakfast and dinner. About 2 1/2 hours after dinner she vomited it up.

Needless to say I am upset and worried. Her next dose of 10mg is due at 930pm and I am going to skip that dose. I hope I am doing the right thing. She is on 10mg in the am and 10mg in the pm. She is about 20lbs.

She doesn't seem overly sleepy, she is still peeing and drinking a lot and today she was panting a bit. She had a stool this evening that was half formed and the last part was loose. It doesn't seem that she is going too low, but why the vomiting and loose stool. Maybe from the change in food? I will call the vet in the morning, but I'm so scared at this point. She was supposed to have a ACTH stim on Wednesday.

[Harley PoMMom]

I'm thinking, too, that the new food is what's causing her vomiting and diarrhea. And, I also believe withholding her Vetoryl is a good idea. You are doing a wonderful job, Karen!!!

[frijole]

Agree - withhold the trilostane. Go back to the other food if you can get her to eat it. If the appetite is OK and the soft poops are gone then you can go back on the trilo. Hang in there. Kim

PS oh yes and definitely talk to your vet! :D

[Karen_Izzy]

Thanks so much for the encouraging words. I did not give her her 10mg dose tonight. I will call the vet first thing in the morning. --it's going to be a long night.

Question- If I take her off the meds, what happens to the scheduled ACTH stim on Wednesday? Does she still have that done?

[Trixie]

I understand how worried you probably feel. I would also withhold the evening dose. It is probably the new food but why take a chance?
This is an instance that makes it hard to know what's going on.
Your dose is low, there's no lethargy, still drinking, some panting...probably not too low, but once there is vomiting and loose stool you should hold the dose. See what happens with her tonight and tomorrow morning talk to the vet.
Try not to be scared...she could have a regular old stomach upset caused by the food or something she picked up outside, whatever it is you don't want to give Vetoryl for now.
Before she got sick did she seem to get her appetite back?
Don't be scared..you can't hurt her by withholding the night time dose.
Barbara

[molly muffin]

I bet it was the food change. When I changed molly, she immediately got the runs and an upset tummy. I had switched her to a can natural food, this was some years ago, and I had to go back to the kibble, which suits her stomach much better it seems.

Of course that can be an issue with her not eating. I'd try her regular food tomorrow morning with a morning dose of trilostane if she is fine through the night. Give it with some cheese perhaps so it can be absorbed properly.

If she is doing fine, and back on the trilsotane, she could probably go forward with the ACTH test, but check all of this out with your vet in the morning before doing anything.

You are doing wonderful.
hugs,
Sharlene and Molly Muffin

[Karen_Izzy]

Well..it's morning..I have a call into the vet, waiting for him to call back. No more vomiting during the night..and no poop. She is drinking water, and appears hungry this morning. I used to give her the pill in cheese, until she decided she didn't want to take it that way any more! Now I've been cooking up some chicken liver and putting it inside that. I used to feed her raw (her entire life) then when she was diagnosed with the stroke, I switched to cooked home diet. I just thought if she was weakened maybe raw wasn't the best at the moment. She has been on that for a few months. about 4 days ago she started just picking at it at meals and then Saturday morning she wouldn't eat it at all. That is when I went out and bought the can..which she ate immediately. (breakfast she kept down ..dinner she vomited) So I don't know where to go with her food now. Back to raw??? I'm so confused with all this. It's become my full time job and it's really stressing me out.

update- haven't heard back from the vet, so I fed Izzy her breakfast. Back to the home cooked diet. I gave her half her breakfast portion with NO Vetoryl. She ate it all quicker than she has eaten in the past 5 days. I am now waiting to see if she keeps it down. I saved half her breakfast in case I should give her the 10mg Vetoryl this morning. Should I give it to her? I'm thinking now I should. What do you all think? I hate to miss the timing for the morning dose if the vet doesn't call soon I will miss her 930am dose (she is on 10mg am and 10mg pm).

update again.. I waited 15 past her regular dosing time. I didn't hear from the vet so I had to make a decision. She seems perky this morning, and hungry. No problems during the night. She kept the first half of her breakfast down, so 1/2 hour later I gave her the 10mg morning dose with the second half of her breakfast. She ate it all quickly, like she was hungry for a change. I am still waiting for the vet to call.. but I really really hope I did the right thing.

[Harley PoMMom]

Glad to hear that Izzy was feeling more like her normal self and had no other vomiting episodes, I think she will be fine with her dose of Vetoryl.

Also, since Izzy did so well on the raw diet, I would see no reason not to feed her the raw diet...just my thoughts. ;)

Looking forward to hearing what the vet says, please do keep us posted.

Hugs, Lori

[Trixie]

I agree that you were ok to give the vetoryl this morning. Now you're back to watching her and seeing how her appetite is and how her poops are. It is sometimes a tough call to make...you know her best and I think your intuition will guide you most of the time.
Hope all stays well with Izzy today. Maybe sticking with the diet she's most used to will be best for now.

Barbara

[Karen_Izzy]

about her raw diet. I was always confident in feeding her raw and started her as a pup. At first both my shelties (I have another one besides Izzy) ate chicken wings just as they are, with other meals making up some veggies, healthy oils, etc. When Izzy broke a tooth at about 8 years old, she had an expensive root canal and a cap. AFter that the dental specialist said no more bones. Well.. that didn't suit me so I began grinding the chicken wings in a heavy duty grinder and mixing it with pumpkin, kale, wheat germ, yogurt, eggs, oatmeal, quinoa etc. etc. 12 years ago raw feeding was in the minority and there weren't as many healthy choices in premade food. When she had the stroke, and I knew she was going to need consistent blood test, I thought maybe I should switch her to a store bought food for consistency. I was never worried before, but I read so much about having not enough of certain vitamins and minerals affecting both blood tests, and her Cushings I began to question whether the raw was meeting all her needs consistently. Then I read that in a dog with a compromised system the raw might lead to salmonella or a diet too high in something for her.. fat or whatever..and my confidence in the raw started to falter. That lead me to starting the cooked diet, but with no bones (and a calcium supplement) Then I read you can really screw them up with too much calcium or not enough and I got scared of the home cooked too. (sometimes I think I read too much!! lol) Anyway.. that is what led me to buying Honest Kitchen Zeal and trying both Merrick and Blue kibble (no grain varieties). But I just don't know what to do anymore. I may just go back to grinding the wings and doing like I was with a multi vitamin.. I'm still unsure what to do.

[Trixie]

I can see your dilemma. Now that she has started on the medication it would be best if diet remained the same...whatever is usual so that you don't have to second guess if she has a tummy upset, not the best time to start something new because then you're left to wonder what made her sick-food or pill?
If her system was consistently good on the cooked ground wings plus whatever you add then maybe that would be best. I am not at all sure about adding calcium but perhaps some of the expert members of the forum will chime in on that.
Has Izzy been doing fine today since she's had her pill?

Barbara

[addy]

awww- I feel for you. Thing is it is hard to make changes when you first start treatment because you don't know cause and effect. My Zoe was on commercial raw when we started our journey (long story) I slowly decreased her raw and added Honest Kitchen Zeal to her meal slowly, bit by bit. She could not eat their other foods without them flaring her IBD. I knew she could not do any kibble.

Just a thought for you, maybe put her back on her regular raw diet and then slowly replace some of it little by little. Do you think that may work?

[Karen_Izzy]

You are absolutely right.. I really didn't want to be changing her food up at this point. I knew it was going to cause me to question what was causing any upset should it arise. and lo and behold..that's where I am. ugh!

and so far today.. she is doing fine with the 10 mg dose this morning. She hasn't vomited her breakfast. No bowel movement today yet. I'm still waiting for the vet to call me back. She is schedule for her ACTH stim tomorrow.

[Karen_Izzy]

If her system was consistently good on the cooked ground wings plus whatever you add then maybe that would be best. I am not at all sure about adding calcium but perhaps some of the expert members of the forum will chime in on that.

Barbara

She was on ground raw wings (with the bone), so no calcium was needed with that. When I switched to home cooked ..it was a mix of chicken and lean beef with no bones..hence the calcium supplement.

I swear you have to be a chemist!! I'm leaning towards going back to raw ground chicken with the bones.

[Trixie]

I'm clueless about what's the best choice of nutrition for Cushings, my dog is on low fat everything. It sounds like you know what you're doing with the food...sounds like your dogs have done well on what you make for them.
I am glad to read that Izzy is doing fine today.
I always think "no poops" is a good thing after a day of bad ones...her system is probably getting back to normal which is always a relief. :D
Good luck with tomorrow's test.
Barbara

[Harley PoMMom]

I know near to nothing about canine nutrition, so when I decided to home-cook for my dogs I had Monical Segal formulate a diet for my boys. Monica also does diet analysis, in case you're interested here's a link to her website: http://www.monicasegal.com/about-us.html

Hugs, Lori

[Trixie]

How is Izzy doing? Did she have the acth today? How about her appetite and digestion? Hoping all is going well with her. I know it's hard to be positive when you still see some symptoms but things will even out eventually.

Barbara

[Karen_Izzy]

Hi Barbara, Izzy is doing so-so. She ate ok, no vomiting, I'm on day 2 of waiting for a bowel movement. It was nice out this evening so I was walking back and forth in the back yard trying to get her system moving, but no luck. She did not have the ACTH today. I spoke to the vet, and we decided to wait a few days so that we make sure we get an accurate result since she was off the meds for a day. Since she's on so low a dose, I agreed (she also is still panting and drinking/peeing..although it is decreasing a little)

Besides all this, I get the feeling something else is going on with her. The stroke really took a lot out of her and she is continuing to lose weight. She has been wobbly since the stroke..she has a few neurological problems ..and we still don't even know if she, in fact has a brain tumor or not. (the MRI was inconclusive). So I am sadly watching my baby decline. They did tell me she had 6 weeks to live back in June, so every day is a gift.

Everyone here gives me a lot of comfort, making me feel like I'm not alone, and I so appreciate that. Hugs to you all.

[Trixie]

I'm glad you are waiting for the acth...it is best since she was off the med for a day. I'm sorry you feel like there's more going on, I hope maybe it's just Cushings that has her off, but of course you know her best.
Good news that she's not vomiting though, hope she does fine on the medication.

Barbara

[Squirt's Mom]

Two days without a BM is concerning to me. If she doesn't poop today, I would want this checked out. Have you tried giving her some plain pumpkin (NOT the spiced for pies)? That may get things moving. Oils can help too, like mineral oil or a high dose of fish oils. Is her water intake high enough? Normal water intake is around 1 oz per pound, or 1 cup per 10 pounds.

Let us know how she is doing as you can.
Hugs,
Leslie and the gang