My girl pug (confirmed Cushings & confirmed calcinosis cutis) / Tobey has passed

[Renee]

Updating on my girl. She's doing good. Symptom control is great and CC is in 'remission', as I like to say. Her weight is up. Steadily been increasing over the last year, sadly. She's just under 20lbs. Ideal weight should be 17. I've been cutting back food, but with our horrible weather, she's not going outside, except to potty.

So... next question is: has anyone purposely tried weaning down the vetoryl, after getting good control, just to see how far they can push it?

Right now Tobey is on 20mg am / 20mg pm. Her last stim result was 2.3, 4.0.

I have cortosyn to waste (yay me), so I kind of thought about dropping 10mg off her nightly dose and seeing what impact it has on her cortisol levels.

Am I being too scientific at Tobey's expense?

[labblab]

Renee, my big worry would be allowing the CC to start back up again. You may be more of a gambler than I am, but after all you've gone through to get that under control, I'd sure hate to see it start flaring again. Right now, Tobey's stim results seem just about perfect. It's too bad that the Vetoryl is so dang expensive, because really, I'm not thinking of any other good reason to alter the dose right now other than the cost. Is there some other reason why you want to cut back?

Marianne

[addy]

Hi Renee, unless you are seeing some odd new side effects that worry you, I would not rock the boat because you don't want to upset the apple cart.

Keep in mind that at some point you may have to adjust the dose up.
Dechra warned me that Zoe might need her dose lowered at some point.

If I remember, the stim before this last one showed pretty tight control. These numbers look good.

I agree totally with Marianne.

[Renee]

Yes, what you all say is true.

I'm not seeing any symptoms of concern (either too low or too high), but I am thinking that if she can have good control on a lower dose, then it's a win.

The truth is, I have cortrosyn to waste. I purchased an entire bottle and have four doses remaining that need to be used up in the next 5 months. With her numbers as good as they are, I'm not looking to need another stim test for 3 more months. Why not drop her dose by 1/4 and see how much her cortisol rebounds? The cost of her medication is not the motivating factor. Yes, it's expensive, but it doesn't hurt to buy it. Her numbers are very good right now, but I wonder (based on her previous stim test before this one), how much they will continue to drop? Keep in mind, her most recent stim test was after being back on her full dose for only 3 weeks. The CC is probably the only true issue that is giving me a reason not to try a lesser dose.

I'm just pondering at this point. Wish I could send or donate some of the cortrosyn to someone else. It makes me a little crazy to think of wasting it!

[addy]

I can see you thought process, that she may go lower as before or even lower and then you wind up adjusting the dose anyway and then your cortrosyn will be expired.

[labblab]

If Tobey was only on that dose for three weeks before testing, then I would leave the dose alone and retest in another month. If her cortisol is lower, then you would have actual justification to make a dose adjustment at that point. But I honestly do not think it makes any sense to alter the dose now, when the numbers are perfect and the symptoms are well-controlled. Most people here would give anything to be in your position right now. :o

[Squirt's Mom]

Wasting the cortrosyn is nothing compared to the pain Tobey will experience if the CC rears its ugly head again. ;)

[Renee]

Bumping up my thread so new people can find it, just in case anyone is dealing with CC.

I've decided to follow Marianne's recommendation and run another stim test in a few weeks to see if the cortisol comes down any more, then decide about lowering the dose or not.

Symptom wise, doing pretty dang good. I've had her into the vet to check for UTI, which has come back negative (culture done), but yet, something with her lady parts is persisting. She had some bloody type discharge for a day or so, and the hair around her lady parts got gunky... but, no UTI and it kind of cleared up. I have not seen any blood since. She is spayed, FYI, so I have no idea what's going on. At this point, the vet said the only next step would be to scope her, which we are both not inclined to do. So, I'm just waiting and watching. I'll probably retest for a UTI when she goes in for her next stim.

My other pug, Ichiro, is going in tomorrow. He's been having a lot of mobility issues. :( He's had a weak back end for years now, but this week just seems much worse. It's like he can hardly control those back legs anymore. He walks, but something is worse. I think the time is coming to order him a cart, but I'll see what the vet thinks.

[judymaggie]

Renee -- just one thought re the discharge/possible UTI. Did the vet use a free flow for the UTI culture? Abbie had a similar sounding discharge. Because of the possibility of contamination from the discharge, our vet did a cystocentesis to get a sample. She did have a UTI which we then treated.

[Renee]

Renee -- just one thought re the discharge/possible UTI. Did the vet use a free flow for the UTI culture? Abbie had a similar sounding discharge. Because of the possibility of contamination from the discharge, our vet did a cystocentesis to get a sample. She did have a UTI which we then treated.

We always do cysto when running a culture, which is why I am confused. This girl. I swear, something weird is gonna happen, and it will be her!

My two boys, who are fixed as well, sure like sniffing around her parts too. It's like she has some infection or blood, but it is not from the urine. This is why the scope was mentioned. To see if anything else could be causing / leading to the blood or irritation.

[Harley PoMMom]

Renee, I do believe I remember reading where Trilostane may have some effects on a girl's private parts...let me see if I can find that.

Aha!
Other adverse reactions included: nocturia, corneal ulcer, cough, persistent estrus, vaginal discharge and vulvar swelling in a spayed female,

http://www.dechra-us.com/files/dechraUSA/downloads/Product%20inserts/Vetoryl.pdf

Do you think that this is what's happening with Tobey?

[Renee]

Lori - you are UNBELIEVABLE!! Yes, this is exactly what is happening! I can't wait to talk to my vet about this.

I cannot thank you enough for even thinking of this. A side affect of the vetoryl was the last thing I would ever, ever have thought of.

It seems such a crazy and completely unrelated symptom.

[addy]

Renee, Zoe had vulva swelling and then ended up with a small tumor on her vulva.

[Renee]

Talked to my vet on Saturday about the possible side effect of vetoryl and Tobey's vaginal discharge. She was pretty surprised and said she would definitely call our local IMS to talk about it.

The discharge is continuing, but sporadically. She's not displaying signs / symptoms of UTI, but I'll probably run her in for another culture anyway, just to check... again. Sheesh! I need my own home culturing lab to keep up!

[Renee]

Tobey goes in for another stim test this friday, so we will see if the numbers have continued to drop at her current dose.

The vaginal discharge has continued, so the vet is going to check things out on Friday too. I'm so confused about whether this could be a symptom of UTI (no other symptoms currently), or if it is a side affect of the vetoryl or something else entirely? I asked her to consider running a culture on the discharge itself. We will see what she thinks after she sees her.

[labblab]

Sorry to hear about the mystery of this discharge! And yes, doing a culture might be a good idea, I think. We'll see what your vet thinks.

Good luck on the stim test, though. It will be really interesting to see how it turns out! ;)

Marianne

[Renee]

Friday stim results: baseline 3.8, post 3.2. So... just a bit up on the baseline and a bit down on the post from the previous test. Not sure why the baseline is higher than the post, but, even if the numbers were accidentally switched, they are both still in good range. I'm happy with these numbers, so barring any major changes, I will run another test in 6-8 weeks.

As for the mystery discharge - my vet felt it would be a waste to culture it, since it would be very contaminated with bacteria anyway. What she did do was a free urine catch (no blood, no abnormal cells), a swab of the discharge (again, no blood and no abnormal cells) and an external examination. She tried using a scope to look, but Tobey was getting upset so she stopped. Nothing appears out of the ordinary, so at this time, we are going to assume it's a side effect of the vetoryl.

I do want to get a dental on Tobey some time in the next few months, so if the discharge persists, then while she's under, my vet will have a chance to do a more thorough exam, including looking inside with a scope.

[Dixie'sMom]

Those are good results! Yay! I love it when the babies are doing well. :)

The discharge makes me shake my head. I swear this little cush babies have it rough. I wonder if Vagisil or Monistat or even a topical antibacterial would help any.

[molly muffin]

Excellent results and a good plan of action for the future too.

Way to go Renee. :)

hugs

[ShibaMom]

Hi there... when my grandpuppy got an infection of her vulva during her first heat, the vet had us use stridex-type pads once a day (in addition to anti-fungal cleaning pads for yeast infection, but that was separate) to keep things cleaner. He had us get the type that had both salicylic acid and benzoyl peroxide.
Maybe ask about that?

Hope things clear up! Poor baby!

Regards,
Samantha and Zanya and crew

[Renee]

Hi Samantha, thank you for the suggestion. She is spayed (and has been since a puppy). I don't think this is an infection, so much as just discharge, like a side effect of the medication. But, my vet did say we could use epi-otic to cleanse her lady parts as needed. Thankfully, the discharge has dropped off a bit.

Pugs had an exciting day today, since I was baking, I put together some cookies for them too. They won't leave the kitchen now, heehee!

[ShibaMom]

Ah, Reneé, I wasn't meaning it was necessarily an infection, but that it may be good for keeping it clean? Might be too drying, though.
What's epi-otic? Some sort of ear cleaner?

I should ask my vet as well, since Zanya is so prone to UTIs (hopefully that will improve with her Cushing's getting under control!), may help to keep the area a bit cleaner.

Oooh Cookies! I'm sure they were thrilled!

Cheers,
Samantha

[judymaggie]

Hi, folks! I have found that baby wipes are a great (and inexpensive) way to clean the vulva area. I use Charmin Freshmates which have no aloe (or other additives in them).

[Renee]

Hmm, all good suggestions.

The epi-otic is an ear cleaner, but I suspect it has many of the same ingredients your vet suggested for the stridex pads, plus anti-fungal.

Maybe I'll try baby wipes first, just to keep it clean and then watch for any increase in irritation.

Oh, Samantha, I do think the UTI's will decrease. May not go away for good, but as her immune system strengthens, she likely won't get them as much. Here's hoping!

[molly muffin]

Baby wipes are a good idea. I have some I use with molly occasionally when she has had UTI's as I just don't want any yeast spreading around causing problems. She hasn't needed them in quite some time, but they did seem to help when I used them.

[Renee]

Interesting happenings at our house... lol

Ichiro (one of my male pugs) has a back injury that we are treating with prednisone. He's been on it 2 solid weeks and begins the tapering off phase tomorrow. What an eye opener to watch him develop prednisone induced cushings symptoms! He's drinking so much water that his little chin is red and chapped (drink a bunch of water, run outside in 10 degree weather), and his appetite is monstrous! It makes me feel a bit sad for Tobey that she went through this for a while before I realized what was happening.

And.... I'm going to cuddle a 7 month old boston terrier baby tonight. He's new to rescue. I may foster him, but I am afraid of foster failing, haha. I don't want four dogs (never even meant to have three!), so that is really what would prevent me from keeping him. But, I can dream for a while! :p

[Renee]

Just posting an update -- the discharge has dropped off. So strange why that even happened!

Everything else is going good. No news is good news, right?!

[addy]

No news is great news when you are dealing with a Cush pup!

I sure am glad the discharge is gone. How is Ichiro doing? I hope things are going better for him.

Are you still cuddling the puppy?

[molly muffin]

Yep, no news is good news :)

ohhh, puppy still? I'm with Addy I want to know too.

Hope that all the dogs are doing well.

huggers

[Renee]

Okay, it sounds bad.... I did cuddle the puppy and even brought him home for a few days, but he was way too much work! :D I haven't had a puppy in 10 years. Boy did I forget! Give me an old dog any day!

He's so adorable, he has hordes of people that want him.

Ichiro improved on the pred, but we are tapering him off now. He was starting to get the cushings symptoms, and I wouldn't treat him long-term on the pred anyway. I think he's just an old pug man and I need to find a way to help him manage.

[addy]

I don't think I could handle a puppy either:D They sure are adorable and fun to cuddle though. The puppy will find a home.

[Dixie'sMom]

I just dropped in to see how you and your crew were getting along. I'm with you... puppies are adorable but waaaay too much work.(I'm just too darn old for a high energy puppy.) LOL. Dixie and Buttons keep me busy enough.

I hope Ichiro's prednisone is helping his injury. I'm sure it is strange for you to watch the Cushing's symptoms begin. Luckily, they should go away when the Pred stops.

Hugs to you and your babies!

[molly muffin]

uh oh, we're all getting older. I don't think I could handle a puppy's energy any more either, but darn, yea they are cute and that energy they have is a joy to behold.

Oh yea, at some point it is definitely important to get away from the pred as much as possible. My golden was on it most of her life and I hadn't a clue then what was wrong with her, now i know ,introgenic cushings. Not one vet mentioned it to me. It's horrible what it does to them when on it so long. I don't think vets (most anyhow) are as prone to put animal on it long term as they use to be. Owners are a whole lot more educated about it's adverse affects too now. It's a great drug but it pops a wallop of a punch to the body.

huggers

[Renee]

Whew, we were way back on page 5!!

I want to get a dental on Tobey, and she has recovered from her pancreatitis in December, so my vet is good with moving forward too.

Should we have a stim test done before, or just normal bloodwork?

[molly muffin]

I think that usually just blood work is needed. See where her numbers are, if there is any concerns, etc

Great to hear she has made a full recovery from the pancreatitis

hugs

[Renee]

Thanks Sharlene. She's not due for a stim test, but I just wanted to be sure.

Yes, I am very glad she recovered, and that scare was good enough to scare my hubby too. He's much more careful about feeding her food she shouldn't have. :)

[Harley PoMMom]

I agree, since a stim test is not due, I see that one was just done on the 2nd of Feb. I would have only the chemistry/CBC blood panel done.

Man, that darn pancreatitis, sometimes it sure can be a devil to work with so I'm glad to hear she has recovered and is doing so well.

Hugs, Lori

[Harley PoMMom]

Hey Renee, it's been a while since we heard from you, how are you and Tobey?

[Renee]

Hey Lori -- thanks for digging my thread out of the trenches. I'll bet I was at least 10 pages back.

A lot going on that has been keeping me from active. Work this year (I'm a tax accountant) has been busier than ever. My partner running rescue went on vacation, so it was a one-man show for a few weeks, and just life in general.

Also, my Ichiro pug has been struggling with age related decline and back issues. I just got back the results of his DNA test for the genetic markers for DM, which came back negative. I'm back to square one on figuring why he can't really use his back legs very much and is displaying the classic neurologic symptoms associated with that (knuckling, legs crossing). I need to get him a cart, but have not yet. He has been on a decline for a few years, but kinda of took a big step in the last few months with his decline. I've had to focus a lot on him lately.

The update on Tobey - she is getting her 3 month stim test done tomorrow. I should hopefully have results Saturday. Her CC is well controlled, as is the drinking / peeing. She is panting quite a bit though and seems very bloated. I think she is not digesting her food very well, so I may go back to homecooked for a bit. She has turned down her food a few times in the AM only, but perfectly happy to eat in the evening and have treats. I really think it was the food though, because I bought some canned Wellness for mornings only and that has stimulated her appetite. I feed The Honest Kitchen, for those wondering.

Bless him, my Skeeter is the last healthy pug I have!

I promise I'll try and be more active!

[Harley PoMMom]

So sorry to hear that movement in Ichiro's legs hasn't improved :( but very glad that Tobey is doing well and that that dreaded CC is under control.

Hey, we all understand how life gets in the way :) so do not worry about being around on the forum, I saw that there wasn't an update for a while and, you know how we are here, we get worried. So, hey, when it is convenient let us know how things are going.

Hugs, Lori

[molly muffin]

awww, poor Ichiro. I bet a cart would work wonders for him. Seems so weird doesn't it, for no reason to be found.

Great about Tobey. Hope her numbers are good for this next test.

Skeeter is in charge of wellness for the group. LOL

Yes, that life stuff sure does interfere with all the other things we want to be doing. I can totally relate.

Hugs! Great to hear from you.

[Trish]

Hi Renee

Just popping in for a catchup and to say Hi!! :D Sorry to hear about Ichiro and hope you can help feel a bit more comfy, might be his back giving him discomfort too? Great news about Miss Tobey though :D

Pug hugs to you all xx

[Renee]

ACTH results from yesterday:

3.0 baseline
1.3 post

Much lower than I was expecting. I'm going to withhold the dosing for a few days, then start back up at half. (currently on 20mg x2).

[Renee]

Next concern - she's having a dental on Thursday. Any thoughts to whether I should reschedule it?

[labblab]

Hi Renee,

In situations where the "post" is lower than the "pre," Dr. Peterson tells us this usually means that there has been a testing problem: either the samples were mistakenly reversed or the stimulating agent was bad. Since Tobey is basically doing well, I really do have to wonder whether the results are backwards. If so, I don't know that you would want to cut her dose in half.

I don't remember what her last ACTH numbers were, but if these were reversed, would there be a big departure from last time?

I'll try to find the relevant quote from Dr. Peterson and come back and repost it.

Marianne

Edited to add: here's the quote:


Q. I recently rechecked a dog on VetorylR. The post-ACTH stimulated cortisol concentration was lower than the pre-value. What does this mean?

A. There are several explanations for discordant results, i.e., those in which the baseline cortisol is greater than the post-ACTH value. These include laboratory error, mislabeling of samples in the clinic, interference by exogenous steroids, and use of an ineffective ACTH product.

If the patient is clinically well and both results are between 2 - 7.5 μg/dl, it is appropriate to continue VetorylR at the present dose and recheck as usual. If both values are below 2 μg/dl or above 7.5 μg/dl, or if the dog is not clinically normal, the test should be repeated as a dose adjustment may be necessary.

[Harley PoMMom]

ACTH results from yesterday:

3.0 baseline
1.3 post

Much lower than I was expecting. I'm going to withhold the dosing for a few days, then start back up at half. (currently on 20mg x2).

That is a low post number, a bit too low for my comfort. I would not restart the Vetoryl until either the Cushing's symptoms return and an ACTH stimulation test has shown that her adrenal glands are producing a sufficient amount of cortisol for her body, this is what Dechra recommends also:
If the ACTH stimulation test is < 1.45 μg/dL (< 40 nmol/L) and/or if electrolyte imbalances characteristic of hypoadrenocorticism (hyperkalemia and hyponatremia) are found, VETORYL Capsules should be temporarily discontinued until recurrence of clinical signs consistent with hyperadrenocorticism and ACTH stimulation test results return to normal (1.45-9.1 μg/dL or 40-250 nmol/L). VETORYL Capsules may then be re-introduced at a lower dose

Regarding the dental, you may want to discuss this with the vet, however if this were me, I would reschedule because I'm not sure how Tobey's system will respond to the anesthesia. An extra amount of cortisol is needed in times of severe stress or surgery.

Hugs, Lori

[labblab]

I just checked back and see that in February, Tobey's "post" was lower than her "pre" back then, too. That seems really, really odd to me. At that time, both results were 3+ so you were not too worried. If her true "post" is still at 3, I don't know that the 1.3 is that big a worry if that is actually her "pre" now.

I am baffled by these results and really don't know what to make of them. But I still don't know if you really want to cut her dose in half if she otherwise seems to be doing well. I still have to wonder whether there is an inconsistency/problem with your vet's testing protocol.

I can't remember, is your vet freezing the stim agent in order to get multiple tests from a vial? If so, I wonder if the agent is somehow being degraded...

[molly muffin]

That is very strange that it would be consistently lower post than pre.

Has your vet contacted a specialist to get their take on the low pre numbers?

[Renee]

First, thank you so much for dropping by and helping me with this, even though I haven't been active lately.

Yes, this is the second test in a row where the pre number exceeded the post. With the post being 1.3 this time, I'm worried.

My vet follows Dr Peterson's protocols for diluting the cortrosyn and we schedule the exams at the exact same time. No changes there.

As for the dental, I figure that withholding her dosing from now until surgery (Thursday), she should have sufficiently rebounded by then. She is displaying NO symptoms of low cortisol. They are doing preanasthetic bloodwork, so I can have her cortisol tested that morning too, in order to make sure that is high enough.

As much as it pains me... I may end up buying an entire new bottle of cortrosyn. I still have 4 doses left too! :( :( I don't want to risk relying on a bad agent though.

My vet has not contacted a specialist, but it's Memorial Day weekend, and those test results just arrived today. She was nice enough to check her email for me and forward results, even though she's out of town.

[labblab]

Was the previous test the first draw out of the bottle, or had the Cortrosyn already been frozen at that time? If it was the first draw out of a new bottle, then the freezing can't be the problem. But if not, I seem to remember some discussion somewhere as to whether using a frost-free freezer may be an issue -- that going through the freeze/thaw cycles might affect the agent's efficacy.

Just grasping at straws here, but something has to be goofy for you to be getting these results twice in a row. Given your description of how she's doing, I just feel skeptical that Tobey's cortisol is really too low and I'd hate to see her symptoms rebound from a dosing decrease if it isn't really warranted -- especially the CC. :o

Did your vet advise you to go ahead and totally stop the trilo altogether right now? I am thinking that you might want to keep up with at least a half dose until you can start sorting this out on Tuesday?

Marianne

[molly muffin]

Doesn't dr. Peterson answer question online? I asked him about Molly and he answered within a day or two I think it was.

Maybe either you or your vet could ask him directly his thoughts or even about the protocol itself.

[Renee]

Marianne - what a good question. I do believe the feb stim test was before the medication had been frozen. That is when I bought the entire bottle, they diluted it down, used one right away, and then froze the rest. I believe we got 6 doses from a bottle, so that would be one used Feb, one used this week, and four remaining.

I swear, this disease is so difficult!!

I haven't heard back from my vet, but I didn't expect to, since it's a holiday weekend. I am still going to withhold dosing until she gets through her dental. Past experience shows that symptoms, for Tobey, take about a week to 10 days to reappear. I'm okay with having some rebound, because getting her through the dental is more important to me than dealing with cushings symptoms. Even if the CC recurs, it won't have a chance to really set in, as it's unlikely her cortisol will get as high as it was pre-treatment, and as soon as treatment starts again, it knocks it out quickly. At least, that's how it was when she had the pancreatitis and we stopped dosing for 3-4 weeks.

UGHHHH, so many variables, it's hard to be decisive.

[Renee]

Just spoke with my vet.

I purchased the bottle of cortrosyn in January, used one then before freezing, one in Feb, then the most recent one last week.

She did use one of the doses on another dog in the clinic in April (and reimbursed me), and that dog had a perfectly normal response (14.1 base, 20.4 post). So, given that it produced a normal response in another dog, it's much more likely that Tobey's results are accurate, odd as they are.

I asked about the possibility of an error in labeling the samples, but she said she did the test and it was not mixed up.

She's going to consult with an internist and let me know their thoughts.

Plan is to keep Tobey off the meds for another week. Go forward with the dental, pending blood panel (to include checking electrolytes), then start back up on a reduced dose. I can always work my way back up to her most recent dose, if it's needed.

[molly muffin]

Well it sounds like it isn't a mix up in labeling then and if the other dog was fine on their tests with normal type of results, it doesn't sound like a freezing issue. Tobey is just "special" . :)

It is worth asking the speicalist about for their thoughts I think and I would write to Dr. Peterson too. Maybe it is something he or Dr. Bruyette has come across in their years with cushings.

[Renee]

Woop Woop! I LOVE MY VET!!

She managed to get personally in touch with Dr Peterson about Tobey's results!!! :) He even talked to her on the phone!!

He said that it's not as uncommon as we used to think for a post to be lower than the baseline when a dog is on vetoryl, but it's generally a result that is specific to the dog, not necessarily a result of the drug. He did feel her latest result was a bit too low for comfort.

He suggested exactly as we had already planned. Take a break for 2 weeks on the vetoryl, then start back at the 1mg per 1lb of weight and follow the protocols for monitoring. Maybe I'll get lucky and Tobey will stabilize at a lower dose.

I feel much better! Tobey is at the vet now for her dental and her bloodwork was all normal and electrolytes are perfect.

[Harley PoMMom]

Renee, that is so awesome that your vet took the initiative and conferred with Dr. Peterson...WOW!!! I love your vet too!!!!! I believe the plan for Tobey sounds excellent.

Hugs, Lori

[Trish]

I love your vet too, now that is doing her job!! Wish a few more would do that eh! Yay for the excellent blood results! Hope Tobey is home tonight with her new pearly white gnashers all sparkling! x

[Renee]

Her pearly whites are all polished up and she even had a beauty mark zapped off her leg, hehe.

All is well. She went out and had a nice long pee and now she's inside resting.

[Renee]

Well, her cortisol appears to be rebounding a bit quicker than I thought. Or, at least her water consumption has dramatically increased.

Today is one week off her medication. I'm not sure if I will wait until the 2 week mark, given how quickly she seems to be rebounding.

This disease! Something is always changing!

[labblab]

He said that it's not as uncommon as we used to think for a post to be lower than the baseline when a dog is on vetoryl, but it's generally a result that is specific to the dog, not necessarily a result of the drug. He did feel her latest result was a bit too low for comfort.
I agree that's awesome your vet called Dr. Peterson directly, and thanks so much for reporting back to us, Renee!

I admit, though, to wishing I understood the reason why any individual dog will end up with a lower "post" value. I just don't understand why a dog would consistently not respond to the stimulating agent. I don't know whether Dr. Peterson gave a more extensive explanation to your vet, but maybe you could ask her more about it when Tobey is next in for a check-up. We've had the same thing happen with a couple of dogs here, and since Dr. Peterson's current answer differs from his older published answer, it sure would be great if we could better understand the dynamic involved.

Thanks in advance from us all!
Marianne

[molly muffin]

I kept meaning to come reply to your thread, but gads I am so awful on the ipad typing.

Your vet is definitely awesome! Good on her to go direct to the source for the information. I had emailed him using his webpage and got a response, so I do think he is accessible for information which is great.

Interesting that he seems to be saying that this is just how Tobey is, the post lower than the pre and it need not mean much.

So glad Tobey had a good cleaning and now can be flashing those pearly whites around. Good to find her in the dark! :)

You know Tobey best and if you feel it the cortisol is going up, then reintroducing the medicine might be well worth it, especially if there is a risk of the cc coming back.

hugs

[Renee]

I started Tobey back up on a half dose (10mg am / 10mg pm). Her cushings symptoms have started to subside somewhat, especially the water consumption.

CC remains 'dormant', so YAY!

I'm going to stick with her current dose for a few weeks and run a stim test. Maybe I'll get her stabilized at a lower dose??

[Renee]

Hi everyone,

I apologize I'm not as active as I'd like to be.

Update on Tobey - she developed a cough about 10 days ago. I stopped her vetoryl (she was on 10mg x2 per day). We went to the vet, who thought it may be kennel cough or just some tracheal irritation. She agreed with me to stop the vetoryl and gave us some cough tabs. Lungs sounded clear and her heart was good. Absolutely no other symptoms but coughing.

The coughing has not gotten better, so we went in for x-rays yesterday. Her x-ray came out clear, but sadly, my vet and her colleague both think Tobey has laryngeal paralysis. :( :(

I am waiting to hear back from my vet on scheduling surgery. This is not a surgery she can do, so she is coordinating with a veterinary specialist (only 2 in Alaska).

Surgery is the only option. The cough has progressed to the point that she'll eventually choke herself to death. I am not about to let that happen.

So, that's my tale of woe for now. I am so mad right now. Isn't cushings enough?!

[scoora]

So sorry to hear what is happening with Tobey.
Please keep us informed on what is happening and how she is doing.
Prayers and hugs to you both.

[Harley PoMMom]

OMGoodness Renee, I am so sorry to hear this news about our sweet Tobey, my oh my, you've certainly have had a lot on your plate and I so admire your strength through it all. Sending positive energy your way and keeping you both in my thoughts and prayers. Keep us updated, please.

Love and hugs, Lori

[molly muffin]

oh my gosh Renee! Sorry I haven't been around as much lately either and just now seeing this.

I do hope they can do something for tobey. Are they positive it is paralaysis?

Sending all the positive vibes I can your way!

Let us know how she is doing

[Renee]

Update on my girl:

Sorry for the delay. It's been crazy this past week.

We are in limbo right now. Specialist #1 (my choice) is not available until Sept 9th. The second specialist does not think Tobey has laryngeal paralysis, so he wanted to just wait a while to see if her cough improves. He thinks she just has irritation or swelling. He's also blaming it on her breed, which ticks me off.

We had her xrays sent to a radiologist. The radiologist reported back that Tobey has a mildly enlarged heart and mild/moderate collapsing trachea in the thorastic area. No heart murmur. It is not felt that her heart is contributing to the cough, but it could be the trachea.

Given this information, we are not going forward with surgery yet. I have had her off the vetoryl, and on codeine cough syrup.

The cough is somewhat improved, but definitely still present. She does not appear to be losing oxygen, so I'm definitely not as freaked out that she is going to suffocate. I am trying not to be mad that between 4 vets, no one has an answer. First, two of them freak me out that she's going to die any second, then the specialist dismisses it all. What the heck?!

Without her vetoryl, her cushings symptoms are back, especially the drinking and peeing. So far, no CC eruptions.

I am so confused about what to do. I want to restart her vetoryl, although I know that is going to start the dosing and monitoring protocol all over again. I don't know if it's been helpful or not having her off, so I am having trouble making a decision.

I think I am going to wait for my preferred specialist to be available and schedule her to be scoped. While she's under, he can do surgery, if needed.

Any clear-headed advice is greatly appreciated.

[labblab]

Hi Renee, I'm so sorry, too, about Tobey's new problems. Since you are seeing a rebound in the Cushing's symptoms and you have no clear evidence that withholding the Vetoryl has been helpful, I believe I'd resume the treatment if Tobey were mine. If the cough suddenly worsens again, you can always stop the trilo until you see your preferred specialist. But if not, I know you'd hate to see the CC re-emerging after you've worked so hard to control it.

And if, by chance, Tobey suffers from a condition that would benefit from a temporary elevation in corticosteroids, it may be the case that the specialist would still want her to continue on her Vetoryl simultaneously with adding in a bit of prednisone. As contradictory as that may sound, we've been told that maintaining the trilo even in the face of supplemental steroids may be helpful because you are able to more precisely manipulate the steroid level in the body. If a Cushpup's natural cortisol goes unchecked, you really have no idea what the circulating steroid level is at any given time. We have had a couple of Cushpups with lymphoma treated in this manner (trilo and pred simultaneously), and also a couple of dogs with macros.

Also, since she's only been off the Vetoryl for a short while, I'd think you can just resume her dosing and her monitoring testing at the same point that you were at beforehand. In other words, there would be no need to lower her dose and work upwards all over again.

Just my two cents worth, and I'll surely be hoping for some positive news to come out of the scoping!

Marianne

[scoora]

Glad to hear you're not so worried Tobey is going to suffocate and that her cough is somewhat better.

Hopefully your preferred specialist will take care of what needs to be done to help Tobey.

Thinking of you and Tobey. HUGS!

[Squirt's Mom]

How is Tobey today? What did you decide about restarting the Vetoryl? I think my concern would be the CC taking hold again - you have fought so hard and done so well getting that under control.

It would be disconcerting to have so many different views on what could be going on with her. But you know her best and I know you will do what is right for our sweet girl just as you always have.

Hugs,
Leslie and the gang

[Renee]

I started her vetoryl back on Tuesday evening. Her cushings symptoms were just getting too prominent for me to keep her off the meds.

Coughing has gotten worse though. I am psyching myself out wondering if her cough is worse because I started the vetoryl back up, or if it's just a coincidence? The coughing waxes and wanes, but there has been absolutely no change in how it sounds or the onset of any other symptoms. It's isolated to just a cough. No mucous, no sneezing, no runny nose.

I am waiting for my vet to call me back, hopefully today. I left her a message yesterday asking her to see if the specialist can do a consult, so I don't think I'll hear from her until she's had a chance to get in touch with him.

I hate not knowing.

[molly muffin]

Did you hear from your vet yet? Has there been change since you started her back on vetroyl?

Sending you big hugs Renee

[Renee]

Update on Tobey:

Coughing still persists. It seems a bit worse now that she's back on vetoryl, but I am second guessing everything and cannot be certain if that is the cause or not. She does not seem in oxygen distress, so I am keeping my spirits up about that.

She is scheduled for scope / surgery on 9/18. I'm pretty ticked off that it's so long away... but, it is what it is, and I am just keeping her comfortable until then. Fortunately, it is with my specialist of choice.

[scoora]

I know it has to be hard waiting when you know something has to be done.
If the vet thought Tobey was in need of immediate attention wouldn't he have scheduled it sooner?
Hoping the week passes quickly and everything will be fine.
Hugs to you and Tobey.

[Renee]

Update (again!)

Things are just so up in the air and I am having trouble keeping my spirits up.

The coughing has not gone away. It does come and go though. Last week was pretty good, but since yesterday, it's been pretty persistent again.

Last Friday was her appointment with the specialist, Dr Priddy. Due to some unfortunate miscommunication, he was under the impression that he was coming to do a laryngeal flap surgery. We have basically ruled that out though, and after his assessment of her, he thinks it highly unlikely too. We took xrays a second time. No change. He didn't do surgery, because he was not prepared and does not have a scope small enough. She's at the vet now for bloodwork and stim test.

We are rescheduled for a bronchoscopy and bronchoalveolar lavage (BAL) on Wednesday of this week. Dr Priddy and my regular vet are planning to be there, but they won't be leading the surgery, as it's not their machinery and they aren't trained in using it. The BAL will yield cells in order to run pathology and culture, which will hopefully give us some answers, on top of whatever visual is provided by the scope.

Frankly, I am just scared she's going to die from this. Not the coughing per se, but the risk of the surgery and whatever they may discover. I don't think I can do this again. Come what may, I think this will be the last time I anesthetize her. I don't want to keep risking her life.

I hate this. I just hate this. :(

[labblab]

Aww Renee, I am so sorry for the mix-up and for your added worry. I totally understand where you're at. At this point, though, there is still hope that that once they finally do get her scoped on Wednesday, you'll get an answer that offers some solutions. That is surely what I'll be hoping for!!

If only they could talk!!!!! How many times have we all said or thought that?????????????? It would help so much if only Tobey could tell you exactly how she's feeling, and what she wants to have done. :o

Anyway, I think you are doing a great job in a very stressful situation. We'll all be sitting alongside you during the procedure, and anxiously awaiting news.

Try to hang in there, OK?
Marianne

[Squirt's Mom]

I am so sorry about the mixup Fri. and hope they find the answer Wed. Then offer a plan of action so she is feeling better soon. I hope your bug is better soon as well!

[Harley PoMMom]

Sending huge and loving (((hugs)))

[molly muffin]

I too am sending out best wishes and positive vibes your and Tobey's way.

Hopefully she will come through this all okay and they will be able to figure out the problem and resolve it even, or get her to a better point (more good days)

All that said, I know you are going to be worried very much until she is through this procedure.

I know the last thing you wanted was more delays, so really, really hoping Wed does the trick and she will be fine.

Sending you big hugs

[Renee]

Ugh. The saga continues.

The vet that does the scope called yesterday. After reviewing Tobey's file, she flat out said she was not comfortable doing the surgery until we had run a course of doxycycline for a minimum of a week to rule out bacterial infection (which may have been an outcome from the pathology / culture anyway). So, the procedure, yet again, was cancelled. I'm not a vet, and I now have three solid vets with conflicting opinions... so, I am at a loss of what to do. On the one hand, I am very glad to not be doing the procedure, as there is always risk with anesthesia, on the other hand, I hate to delay finding an answer. I am starting to feel a bit guilty, like my vet must be tired of me and all this back and forth. I believe she rearranged her own schedule to be at the procedure, then had it cancelled the day before, even though I pushed and pushed.

We started the doxycycline last night. I don't know if it's a coincidence or not, but her coughing was very bad last night. I really hope we see some solid improvement over the next week though.

Could it be all this time that she just has a secondary infection from kennel cough? Wouldn't that be a kicker?

Also, of interesting note, her stim results were baseline 5.6, post 4.1. Third time in a row where the baseline exceeded the post. And, these results are at half the dose she originally controlled at. I do believe she may be one of those dogs that will eventually not even need vetoryl, or will need a very small dose.

[addy]

Renee so sorry to read all these developments. Most of Zoe's stim had a higher pre than post. I searched high and low for answers and never found any as to why that occurs.

I hope the antibiotics kick in and the cough improves.

Big hugs

[scoora]

How's Tobey doing?
Has there been any improvement in the coughing?
Keeping my fingers crossed the antibiotics are helping!

[molly muffin]

Has Tobey's cough improved at all Renee?

[Renee]

Hey everyone.

First. HAPPY BIRTHDAY TO MY GIRL! 12 Years Old today. :)

The coughing has diminished and changed somewhat in it's sound. It's a lot more 'wet' or mucousy sounding now, with gags at the end. I wonder if whatever infection or bacteria she had in her lungs is breaking up with the abx? Before, it was a lot drier and breathier, if you know what I mean. She's definitely still coughing though. I have another week of abx, which I am going to finish up, then see where she's at.

Thanks so much for all the support around here. It seems I come on here panicking, just to back off and head in another direction. It's good to have this sounding board full of such knowledgeable people!

[molly muffin]

Hmm, definitely seems to be a respiratory infection from what you say it sounds like. Be aware that some of those can be like any bacteria, a toughie to get rid of. Especially if she is showing improvement on the abx, if it is still going on after you finish the current dose, she might need to be on it longer.

now for the important part! :)

HAPPY BIRTHDAY TOBEY!!!!

[scoora]

HAPPY BIRTHDAY sweet Tobey!

Hope another week on the antibiotics clears up that cough!

[judymaggie]

We hope you are having a wonderful birthday, Tobey! :D

[Renee]

UPDATE:

You guys, I feel like I need your advice more than ever right now. I am so completely lost on what to do next with Tobey and where things are going to go.

Here is a recap, so no one has to read back:

On 8/15/15, Tobey developed a cough. I suspected it could be kennel cough, although she had not been exposed that I know of. I stopped her vetoryl, thinking the natural steroid could help and decided to wait the weekend.

On 8/17/15 we saw the vet. Her heart sounded good and lungs sounded clear. We took home cough tabs for a week. The tabs helped somewhat, but the cough was definitely persistent.

On 8/24/15 I took her back and had chest x-rays done. Her lungs were clear and nothing else of note by my vet. We did send these x-rays to a radiologist for a second look. The radiologist noted some heart enlargement, but that may be consistent with breed, and mild thorastic collapsing trachea. We switched to codeine cough syrup and waited for an appointment with the vet specialist. My vet and her colleague thought it could be laryngeal paralysis.

On 9/1/15 I started her vetoryl back up, because cushings symptoms were returning. 10mg am/pm. No change in the cough.

On 9/18/15 we met with the specialist. He had a few possibilities, but no definitive opinion on what it could be. X-rays were repeated, with no change noted. He did feel it highly unlikely she has laryngeal paralysis. His only suggestion was to schedule her to be scoped and perform a BAL (tracheal wash).

On 9/21/15 basline cortisol 5.1, post 4.6. All other bloodwork in normal range.

I *was* scheduled for the scope on 9/23/15, but the vet that does the scope (only vet with one small enough), told me she was not comfortable going forward until I had run a course of doxycycline. I agreed to this and started them on 9/23/15. Since being on the abx, she's had a few good days, and as I noted in a previous post, her cough did get more 'wet' sounding, which I thought could be fluid breaking up out of her lungs. It has still persisted, and as of 2 days ago (9/30/15) it has definitely come back strong.

Today, 10/2/15, Tobey's cough is NO better and she has completed 10 days of the abx.

The symptoms are:

Coughing. Some wheezing. Some occasional gagging. Some occasional vomiting, from the coughing, not vomiting her full meal. No sneezing. No runny nose. Appetite is good. The coughing, while painful to hear, does not appear to be restricting oxygen.

I see my regular vet again on Monday morning at 8am. Mostly just to reconvene and plan what's next. I was all for doing the scope a few weeks ago, but now I am hesitating. Money is not the issue. Tobey's quality of life is.

Feedback?

[Harley PoMMom]

Man, Renee, I'm not really sure what I would do....what really throws me is that she has a wet cough but nothing shows up in the xrays and her lungs sound clear.

What all are they planning to scope?

[molly muffin]

Hi Renee sorry to hear that Tobey isn't much better. I'd hope that the coughing would have lessened by now. The only thing I could think of is to keep her on antibiotics for a longer period of time in case it's a tough bacteria. I don't even know for sure how they would determine that.

I know you are worried about anthesia and scoping, so I'd discuss that with the vet. What the risks are etc, vs how long can she just go on coughing like this.

It is tough and I really don't know at this point what I'd do. :(

[Harley PoMMom]

The only thing I could think of is to keep her on antibiotics for a longer period of time in case it's a tough bacteria. I don't even know for sure how they would determine that.



If I'm understanding what I read correctly, it seems a sample is collected using the tracheal wash. Maybe that would be the route to take??

[molly muffin]

That sounds like a possiblity Lori. Maybe something you could ask your vet about Renee?

[Squirt's Mom]

I have to ask...is she exposed to cigarette smoke?

[Renee]

Leslie - that's a fair question. The answer is absolutely not. No one in my family smokes, and if they did, they certainly would not be welcome to smoke in my home.

Yes, the BAL would be used to collect samples for culture & pathology, so we could determine if there is a need for continued abx. They would do that at the same time as the brochoscopy.

[Renee]

Quick update!

No scope, as of yet. I'm still debating.

My vet feels we have ruled out: kennel cough, pneumonia, bacterial infection, and cancer. Also, since she's not been losing oxygen and no aspirating, the chance of laryngial paralysis (as originally thought) has greatly diminished. Lungs clear and heart good as of this morning. I looked at her bloodwork from last week, and nothing is out of range (except Alkphos, as expected). White blood cells were not elevated.

Soooooo, where does that leave us?

We are going to treat her like she has COPD / asthma. Nebulizer treatments, bronchodialator (theophylline), and cough suppressants. Basically, our last ditch effort. If this does not bring any relief, then I'm not sure I can avoid the scope. I'm a little scared on trying the theophylline, as it contradicts cushings, so we are going with a very conservative dose.

Any thoughts?

[labblab]

Renee, this sounds like a reasonable approach to me. I sure hope it gives Tobey some relief! I just checked and saw theophylline contraindicated alongside low thyroid, but nothing about Cushing's. Do yo know what the worry is in that regard?

[Renee]

Renee, this sounds like a reasonable approach to me. I sure hope it gives Tobey some relief! I just checked and saw theophylline contraindicated alongside low thyroid, but nothing about Cushing's. Do yo know what the worry is in that regard?

It's actually not an FDA authorized medication for use in canines, so I don't think there is anything saying it contradicts cushings for human use. My vet called the local IMS to get her take on it. The IMS said it can contradict, but the contradiction is the same as using pred in the face of treating cushings. It can cause recurrence of symptoms. I'll gladly trade increased cushings symptoms if it relieves the cough! Of course, I read the side affects of the medication and went straight to the worst-case scenario, lol, but I'm staying positive!

[scoora]

Sure hope this new treatment brings Tobey some relief!

[Squirt's Mom]

Trinket has been on Theophylline since May with no side effects. It has helped her a great deal in regulating her breathing and making it easier on her. She has COPD. She also has a drug called Guaifenesin that we use when the coughing gets worse even with the Theophylline on board. We battled pneumonia for 3 months before we got it finally knocked out with injected ABs at home...and I firmly believe part of what made it so hard to get rid of was her fighting the pills so very hard. She was aspirating on her own saliva! :eek::( The Guaifenesin must taste god-awful because she doesn't fight just the Theophylline as hard as she does both. Add an antibiotic pill and all hell breaks loose! :D I swear this itty bitty girl has Bengal tiger and Moray eel DNA! :p

[Renee]

Leslie, thank you for letting me know Trinket is taking this medication and hasn't had negative affects. That is very reassuring!

First nebulizer treatment was last night. Thank goodness she's a pug, so the mask actually fits pretty good on her face. It's a pediatric mask, lol.

It did help for a few hours and she slept deeply.

[Renee]

And, update #1,582, right?!

The medication has not helped at all. She's still coughing. In fact, it seems worse. The nebulizer treatments do give her some relief though. Yesterday, when I got home, I took her outside and realized she had diarrhea. I stopped all medications last night. I am sure it's the theophylline, but without knowing, I think it safest to just withhold everything. Once she's feeling better, I'll start her vetoryl back up, but I'm not doing the theophylline anymore. What's the point, when it's not helping?!

I have rescheduled her to be scoped on 10/14. I feel like we've done everything conservative that we could do. Of course, like every major decision, I am kicking myself for putting this off and making her suffer for the last two months coughing. I always tell myself I'll be more aggressive when one of my pugs gets sick, but then when it comes down to it, I hesitate.

Are there ever decisions where one does not second guess every step along the way!? :confused:

[addy]

Aww Renee, I stop by and follow what is going on. I'm not familiar with asthma drugs and dogs, I just know how they affect me. It takes awhile for the drugs to kick in for me and if I have a bad cough it can sometimes get worse before it gets better.

I'm not advocating starting up the drugs again just wanted to share how they sometimes affect me.

Second guessing, that becomes our middle name i think.

[Renee]

I cannot believe I am posting this again.. but, the procedure was CANCELLED. Yet again. This time, due to a failure on the part of the vet clinic that owns the scope. This vet examined Tobey and her file this morning, and said she was not comfortable doing the surgery without Dr Priddy (specialist) being there. Tobey is too inflamed and it's not safe putting her under without a specialist present that can fix any abnormalities. And, of course, even though I told them to coordinate with him when scheduling, they failed to do so, and he's out of town.

:mad:
:mad:
:mad:
All the mad faces!

I am trying to be gracious and keep in mind that no matter what bad communication has taken place, all these vets are just trying to be cautious and safe with Tobey, but this is ridiculous. I had myself all worked up, all night, worried about her dying under anesthesia, and now it's postponed. She's been coughing for a solid 2 months. I feel terrible guilt about it and I don't want her to keep suffering. I should have never cancelled that last appointment.

[Harley PoMMom]

Hey girl, there is absolutely no room and especially no reason for any guilt...my goodness you are doing everything humanly possible for dear Tobey. Dam them vets for not scheduling things correctly :mad::mad:

Huge loving hugs are coming your way ;)

[scoora]

Renee, Please don't feel guilty. You have no reason to. You always do what you feel is the best thing for Tobey. I'm so sorry things did not go as planned.

Hugs

[Renee]

Update again - a lot has happened over the past 2 weeks.

Firstly, I took a break from her vetoryl again, for about 5 days, then started back up at 10mg am only. This is where she's been since 10/26. It seems to be working well, with a moderate amount of rebounding cushings symptoms. I will be having a stim test run in 2 weeks, at this dose and make a decision about increasing or staying.

The good news is that over the past week (since 10/22), her cough has improved dramatically. To the point that I am no longer afraid she's going to die! She still coughs daily, but it's not disrupting her quality of life anymore, and she is just as likely to pant or breathe heavily as she is to cough. YAY!!! I have NO idea what caused the sudden onset of her cough, nor what has caused the remarkable improvement. She is ONLY on vetoryl.

Now for the update from the surgeon we saw (yesterday): basically, after all is said and done, no vet here, even a specialist/surgeon, is willing to risk putting her under, and with the improvement in her cough, I am not convinced it's worth pushing at the moment. The surgeon was quite frank and honest, and said he was not willing, at all, to put her under and that my only option, if I must, was to fly her out (assuming a flight doesn't kill her) to a vet university. When he listened to her breathing and coughing, he said she seems to have a 'snap' in her lungs upon exhalation. This is contrary to most conditions, which are related to inhalation (collapsed trachea, laryngeal paralysis, etc). He had no answer, but suggested that I pursue a consult with a cardiologist, as it often crosses over to pulmonary too. He also gently reminded me that whatever triggered her may happen again, and there is likely not a surgical 'fix' to be had.

I checked in with my regular vet (bless her), and she suggested, as long as the cough is improved, that we wait and run her stim test, then consider the consult with a cardiologist.

So, that's where we are! Thank you for bearing with me. Anyone have any idea if this could be a cushings complication or symptom? One of the rare ones?

[molly muffin]

I haven't heard of this associated with cushings, but heart issues Can be associated with cushings. So I wouldn't rule it out as being one of the rare issues.

I am glad to hear that the cough has improved though. It just all seems so strange doesn't it.

[flynnandian]

interesting blog; http://www.instituteofcaninebiology.org/blog/brachycephaly-its-more-than-just-the-pretty-face

[Renee]

Hey everyone - time for an update.

As suddenly as the cough came about, it has also dramatically decreased. For no apparent reason. We still have occasional coughing, especially during periods of excitement, but it no longer wakes her up or dominates her every move.

Who the heck knows what happened or why it went away when it did. What a horrible 2 months that was though!

I had briefly stopped her vetoryl in the hopes of helping control the cough. We started back up at 10 mg in the morning only on 10/26. I just had her stimmed last Friday. Results were:

baseline 4.2
post 5.3

Now, this is not what I was expecting and I'm actually not very happy with these numbers. I feel the post cortisol is too low to increase her dose, but I also do not feel it's controlling her symptoms enough, as her water consumption and hunger have both increased quite a bit. I was honestly expecting her post cortisol to be some where around 8-10 and had planned on bumping her up to 10mg am 10mg pm. Given that her post is only 5.3, I think that's too risky and I fear it could make her crash. At numbers this low, I really would think her symptoms would be controlled, but they are only mildly controlled. She has had much better control in the past, even with similar numbers.

I have a trip coming up next month. I'll be gone from Dec 21-30. Tobey will be boarding during that time. I'm not too keen on messing with her dose right before I leave the country, so I agreed with the vet to leave things as they are and revisit an increased dose when I return. I think it is safer to ask the boarding facility to deal with increased cushings symptoms rather than risk an addison's crash.

I swear, this disease!

[Renee]

interesting blog; http://www.instituteofcaninebiology.org/blog/brachycephaly-its-more-than-just-the-pretty-face

Thanks for posting this. It is very interesting! I do love the breed, but yes, it has been distorted over the years.

[molly muffin]

I wonder if what ever it was that caused her coughing, also might have affected her cortiso production naturally. In that, her body had something wrong with it, and cortisol increased due to that, which increased symptoms, then the vetroyl tries to knock it down so you do get lower number on the test but not lower symptoms, to what you would expect. I do hope that made some kind of sense.
If so then it is possible that the symptoms will also decrease to what they would be expected to be with those numbers. I know that sounds weird and could be totally off base, but it's just a thought. Something strange was going on inside of her and it never really was determined what the root cause.
What ever the cause though, super glad that it is resolving.

Yea I can't do testing right now due to work issues, so I'm not doing an increase till Jan or Feb. I just don't want to do that either, when I can't be around to do testing.

So glad for the good update on Tobey and it IS good. That cough was scary!!!

[Renee]

Hi everyone!

I keep lurking, and try to check in on the CC threads - but I haven't updated on Tobey in a while.

On 11/20/15, taking on 10mg in the morning, her stim numbers were 4.2 baseline, 5.3 post.

I was still seeing symptoms, and after much back and forth, I upped her to 20mg (10 am/10 pm) and had her stimmed 2 weeks later, on 12/21/15 and her baseline was 4.5, post 4.8.

Those numbers are perfect for her, and her symptoms have lessened quite a bit. :) No active CC lesions, but I can feel a few bumps under the skin or right at the surface. I think if her cortisol were to go above 10, those things would erupt.

I find it so fascinating that for a solid year she was stabilized on 40mg total of vetoryl per day, and now she is stabilized on 20mg total. I wonder, and hope, if one day she can take even less vetoryl?

We had a bit of a scare over Christmas holiday. I went out of the country for 10 days, and she didn't adjust to the change very well at first. She got very stressed out and stopped drinking water, which caused her to get sick with diarrhea and vomiting. My very best pug friend that was watching her (owns a boarding facility) was very attentive and took her to pet emergency right away. She spent that night and the next day on fluids for dehydration and infection. After that, Tobey did much better and no more issues while I was gone. Lord, it was so hard being halfway across the world, in another country, with her being sick!

I have noted that her cough, while no where near as bad as it was, still does trouble her sometimes. I think the surgeon we saw was correct - whatever the source of the cough, she will likely always have it, be it mildly or severe at times. At the moment, it only bothers her once or twice per day.

She is seeing a vet ophthalmologist next week, as I think she has developed cataracts now. Vision is definitely lessened and her eyes are blue and cloudy, but not completely covered.

Temperament and personality wise, I think she's very happy. She never plays or anything like that, but she seems very happy and has moments of excitement where she runs around a bit and barks happily. I cherish the moments when she snarks her brothers because it lets me know she's still her sassy self. :)

Anyway, that's the update. Things are going well!

[judymaggie]

Hooray for good updates!! :D I have not had to leave Abbie for boarding but have a feeling she would not do well. My Maggie would refuse to eat for several days when she was boarded. So glad that Tobey was able to get necessary treatment so quickly and recover!

[molly muffin]

Awww, Toby. I have a real problem with molly and boarding. She does not want to eat, or do much of anything if she is not home with us. Just is very unhappy and shows it. I am a bit worried that this is getting worse as she gets older and will have the same sort of thing happen as what Toby went through. I think it is the same, stress related.

Good that cough is more under control and not affecting her as badly as it was. Strange there was never a definitive answer about what caused it. Harder to figure animals out I think as they can't tell you, it feels like this, it hurts right here, I cough because I'm gagging or whatever it is. Sure would be easier if they could. (how many times do we all say that!!!).

[Renee]

Well, bad news.

It's been over a year since Tobey had an active CC lesion. I just found one today low on her back that has officially broken through the skin. :( :(

I haven't had her cortisol tested since 12/21/15, which is only a month ago. It was in perfect range. Her symptoms have been well controlled, I think. She did miss meds for a week or so right around Christmas when she got sick while boarding. She has only missed a dose or two in the last few weeks.

Why is this happening??!!

[molly muffin]

Oh sorry to hear there has been a new break through.

If I had to guess I would say maybe the calcium built up during the time she was off trilostane and has taken this long to push through. Just a guess but the principle would be the same as clearing up I'd think. If it takes awhile for all deposits to clear up and skin to cycle through then it would take awhile from the time a new deposit formed to work it's way up.

The plus is that she is controlled again so only deposits that formed earlier when she went higher will be coming through but no new ones being formed now.

I wonder if once a dog has had cc if they are always more susceptible to them reforming at the least increase in cortisol. Or if it is a breed that is more prone to them or something.

[labblab]

Yes, I would tend to agree with Sharlene. In re-reading your thread, I see you were noticing deposits under the skin surface even a couple of weeks ago. So my best guess would be that the stress of boarding plus the week without the trilo might have allowed her cortisol to spike enough to cause a more active cc flare. But hopefully this will remain an isolated lesion now that everything is stable again.

[Renee]

Yes, the bumps have always remained under her skin, but have not moved or changed for a long time. I guess the stress and time off her medication must have allowed enough cortisol to rebound and allow one of them to develop far enough to break through.

I'm just so frustrated! I am praying this one shrivels up and goes away. I would hate for another full on lesion to develop. I've been checking the rest of her body and nothing has broken through.

[molly muffin]

How is it looking today Renee?

[Renee]

Well, I can feel another one coming up, but it's still under the skin. She's not too keen on letting me look real close. I think she's probably sick of being bothered all the time, lol. The one that erupted last week is definitely still there, but it has not grown or changed much. It's still relatively dry.

Symptoms have not rebounded in any other way. She generally acts hungry, but not more than any pug would for the most part. Peeing and water intake is normal.

I am seriously stumped on the reoccurrence of her CC!

[Harley PoMMom]

Oh shoot, that darn CC :mad: Are her phosphate and calcium levels normal?

[Renee]

Oh shoot, that darn CC :mad: Are her phosphate and calcium levels normal?

I was thinking that could be a possibility. I know CC is generally presumptive for cushings, but if she has something else at play, it could account for the lesions appearing now. Hmmm. She had bloodwork done in December while I was out of town. I'll see if I can get those copies.

[Renee]

Seeing the vet this afternoon. The lesion has grown a bit. :( Putting aside the CC, her symptoms are so well controlled that I sometimes wonder if she's drinking enough water at all. And, she's starting to limp when getting up from the floor, making me think she's got a bit of arthritis / stiffness. I was actually giving thought to dropping her down to the 5mg dose in the evening ... but, the re-emergence of her CC contradicts that. Seriously, what the hell. :mad:

And, to add insult to injury, I do believe she has an infected or impacted anal gland.

[Harley PoMMom]

Oh Renee, man you guys just can't catch a break :( Let us know how Tobey makes out at the vets, and wishing you both good luck.

Hugs, Lori

[molly muffin]

Oh gads no, not cc and an impacted anal gland and arthritis. Maybe they can do another biopsy and see if this one is truly cc or something else? If it isn't cc then dropping her might be alright.

[Renee]

The anal duct was just clogged. Vet was able to work it out. Thank goodness it was nothing worse. I must admit, I have rarely had to deal with anal gland issues with any of my pugs.

We talked about the CC and cannot come up with any reason why it would be making a reappearance. It's just the one small lesion, so we are going to watch it. Unfortunately, I won't be lowering her vetoryl dose due to this.

She had bloodwork done in Dec, so we reviewed those results. Other than the expected elevations in liver function testing, the only out of range item was phosphorus. It was 6.9, with the range being 1.4-6.8. So, very, very mild elevation. But, it has been elevated for a good 2 years now, right around that upper normal-high range. BUN and creatinine are good, so no other indication of kidney issue. I am stumped. I still think it's her kidneys, but not sure. Would she have kidney disease that shows elevated phos, but no other elevations?

[molly muffin]

Renee, if you have concerns about kidney disease, then I recommend the newer SDMA kidney test which can catch kidney disease much earlier than the older tests.

https://www.idexx.com/small-animal-health/solutions/articles/sdma-diagnose-kidney-disease.html

We had it done on molly due to her labs and the urine protein loss. I think it might be worth it for you to look into.

[Renee]

Renee, if you have concerns about kidney disease, then I recommend the newer SDMA kidney test which can catch kidney disease much earlier than the older tests.

https://www.idexx.com/small-animal-health/solutions/articles/sdma-diagnose-kidney-disease.html

We had it done on molly due to her labs and the urine protein loss. I think it might be worth it for you to look into.

Sharlene. :) I just spoke to my vet about this. She is able to run the test, so I'll be stopping by for a blood draw this week.

[molly muffin]

Oh so good to hear that!!

[Trish]

Hi Renee

Just popping in to say HI to you and Tobey, that new test is interesting. Been considering having it done for Flynny next time he has bloods done. Not much help on the cc and cushings but with the arthritis Flynn has cartrophen and a supplement and I find in summer he does not need the injections monthly but in winter he does so might be the weather causing her some extra discomfort in her joints. He likes a heat pad when they a bit sore too but you probably already onto my suggestions as you such a good Pug Mom! xxx

[Renee]

Just posting an update.

SDMA test came back with numbers perfectly in range. She was at 8, and I believe the range is up to 14.

That said, she is back in the ER on fluids and pain medication. She presented last night with signs of pancreatitis again. I only waited a few hours before taking her in. Vomited 4 times, but the diarrhea has not kicked in yet. She just could not settle herself though, because she was in too much pain. After watching her try to lay down and then sit straight back up for a few hours, I knew it was pretty bad, and took her in.

We did xrays at the emergency vet, to rule out obstruction or anything else obvious. Nothing abnormal, except her enlarged liver and heart. They suggested we see the cardiologist, as a side note.

Interestingly, the xrays clearly showed many of her calcium deposits (CC) under the skin. I could count 5-6 along her back, and, never before seen, she has a cluster of them low on her abdomen.

And, it was interesting that another cushings dog happened to be there that night too, but sadly for him, he was in addison's crisis. :( I didn't hear much more, just the techs and vets commenting about having 2 cushings dogs in at the same time and how uncommon that was.

I called this morning to check on her and they said she's doing well. They have her on fentanyl right now and she has been able to rest most of the night. Ate some breakfast, but has not gone to the bathroom yet. They want me to call again later this afternoon.

I can't pinpoint what may have triggered this episode. :(

[judymaggie]

Renee--sure hope Tobey continues to improve. My Abbie just came from a hospital stay so I know how hard it is to be home without our pups. Sending healing thoughts to Tobey!

[scoora]

Renee, Sorry to hear about Tobey's pancreatitis! How's she doing now?
Still improving, I hope!
Love and hugs to you both.

[molly muffin]

Oh no, poor Tobey, not pancreatis again. :( I'm sorry to hear this. I wonder if once they've had it once it they are more prone to getting it again or susceptible I should say to getting it.
I hope she is feeling better real soon.
Wow, you could see the calcium on the xrays. What does that mean? That they are bigger? more solid? about to erupt? I'm sure those are the questions that you are asking the vets too.

[Harley PoMMom]

Oh Renee, So sorry Tobey is having a rough time right now :( That pancreas sure is a fickle organ and anything can set it off. Give her some gentle hugs and kisses from me, sending huge and loving hugs your way.

[Renee]

Tobey came home last evening. She is doing much, much better. Able to lay down and rest, able to keep down some scrambled eggs. I've been giving her tramadol every 8 hours. Withholding vetoryl for now.

This episode hit quickly and I'm not certain what set it off. I don't think I've ever seen her act so painful either. Dogs are so stoic, but she was trembling in pain.

I'm not sure what to think of the CC being visible in the xrays. I think these xrays at the emergency clinic are of better quality than my own vets. I suppose those deposits under the skin will either stay there, or eventually make their way to the surface and out. I'm just not sure. I don't think I ever had her xrayed while she had the worst of the lesions.

Either way, I am glad to have her home and feeling better.

[scoora]

Glad to hear Tobey is home and doing much better!

[molly muffin]

What awesome news to hear that Tobey is home and doing so much better. Maybe that is true that it was always able to be seen but just needed a higher power xray machine.

I hope she continues to do well and get stronger every day.

[Harley PoMMom]

So happy to see that Tobey is home!!

I found some interesting information it seems in humans there are cases of pancreatitis causing a form of calcinous cutis:
Patients with pancreatitis or pancreatic cancer release pancreatic enzymes that cause lipolysis of subcutaneons fat. Fatty acids formed in this process combine with calcium to form calcium soaps.


This info is found under Panniculitis at this link: https://books.google.com/books?id=A78BaiEKnzIC&pg=PA730&lpg=PA730&dq=pancreatitis+causing+calcinosis+cutis&source=bl&ots=-Zhh7yD_lf&sig=R7MsZEHktX_Eagu4d41CVq22pTw&hl=en&sa=X&ved=0ahUKEwjI046olo_LAhUK2B4KHaA0BlgQ6AEITDAH#v=on epage&q=pancreatitis%20causing%20calcinosis%20cutis&f=false

[Joan2517]

Such good news, Renee...I know how happy you are to have her home.

[Renee]

Well, the diarrhea has hit bad. :( I was just thinking she had turned a corner and was ready for regular food / vetoryl. But, not yet I guess. She's not acting painful, drinking a lot, and excited to eat for the most part, but definitely has liquid diarrhea. I picked up some prostora and we are going back to rice / pumpkin / scrambled eggs for now.

I'm just really hating cushings today. :mad:

Lori, that is fascinating about the correlation between CC and pancreatitis. I'll definitely read up more about that!

[Renee]

She's doing pretty bad today, actually since last night. I have her back at the vet, but she's with my vet instead of the emergency clinic. I am so grateful that she's with my vet this time.

She started with diarrhea yesterday, but by this morning, all that was coming out was liquid blood. :( She's not acting as painful as she was over the weekend, but still she's not good. She ate a bit of food last night, but threw it all up over the next few hours.

My vet just called with an update on the bloodwork. Low red blood cells, high white blood cells, severe dehydration (but electrolytes are not out of balance), snap test for pancreatitis is NEGATIVE. They are letting her rest on fluids for a while, then going to xray and ultrasound. It's a low quality ultrasound, but should still provide some information, hopefully. I have no idea where her cortisol is at the moment (last stim test was in Dec), but she's been off her vetoryl since last Friday. I asked them to give her a shot of steroids anyway, regardless. I could care less if her cortisol is too high right now.

I'm just so frustrated and terrified. My vet looked at me this morning and said that she absolutely would not let Tobey die. I know she means it. I just hate this and I hate cushings.

[Joan2517]

Oh, Renee...I hope she starts to feel better. I know how frightened you are. I hate Cushing's every day! I am thinking of you and Tobey and praying that she will be alright.

Love,
Joan

[labblab]

Oh Renee, I'm so sorry, too!! I'm really glad Tobey's with your vet this time around. I know how scared and worried you are -- I'd be a basket case right now. But you know she's in good and caring hands. I'll keep watching for any updates. In the meantime, sending tons of healing thoughts and prayers your way.

Marianne

[Tina]

Renee,

I am so sorry to read what is happening with Tobey. I am at work so just have a second to post, but wanted to chime in because this sounds almost exactly like what happened to my boy Jasper a while back.

He ended up being diagnosed with Hemorrhagic Gastroenteritis (HGE). I think the exact cause of HGE is poorly understood, but it can be stress related, and for Jasper, I feel certain that is what caused it. He was hospitalized and on IV fluids, and I can't remember what else the treatment was, I would have to look back in his thread. But I remember it was an emergency. He had bright red blood actually just dripping and leaking out of his little bum! :eek: :(

I'm so glad that Tobey is in the hospital with your usual vet. I just wanted to share since I see that Tobey was recently hospitalized for pancreatitis, and I wonder if maybe the stress of all of that contributed to the current issues. I completely understand how worried and scared you are, it was terrifying. I about had a full blown panic attack when this happened to my boy. Sending tons of positive thoughts and prayers to you and your baby.

Big hugs,

Tina xo

[Renee]

Tina, thank you so much for sharing with me. My vet did bring up HGE as a possibility. It's not something I have familiar with, so I'll have to do some online research.

Yes, her poor little bottom is just dripping blood. Heartbreaking does not even come close.

[molly muffin]

Oh my gosh Renee, how terrifying. I'm glad she is with your vet too. I know they will do everything possible to get this sorted out.
I couldn't agree more, vetroyl, cushings is the last thing to worry about with this going on .
Weird eh if it's not pancreatis. Tina's comment does make one wonder about HGE, but I don't know anything about it really either.

I hope she starts to do better soon and your vet can figure this out.

[Renee]

Update from the vet -- it's probably HGE. They xrayed her earlier this morning and she was huge with gas, but no visible torsion. They xrayed her about an hour later and the gas bubble was moving through. They are going to give her some barium and xray again. Hopefully the barium will help the gas move along as well. The blood seepage has slowed, but still there. She did show a bit of spirit and bit the vet tech for making her take a tramadol.

I should be hearing from the vet around 430-ish and making a plan to transport her to the emergency clinic for over night.

[Harley PoMMom]

She did show a bit of spirit and bit the vet tech for making her take a tramadol.


Glad to hear she showed some spunk, that's a good sign and she's a fighter for sure. Keep us updated, sending positive energy with huge loving hugs.

[Joan2517]

Thinking of you and Tobey, Renee.....

[scoora]

Renee, So sorry to hear about what has happened with Tobey.
Hopefully she will be feeling better real soon and back home with you.
Love and hugs!

[Tina]

Renee, just checking in this morning to see how Tobey is doing. Hopefully she had a quiet uneventful night and is feeling better this morning. Sending continued positive thoughts and big hugs.

Tina xo

[judymaggie]

Renee--I, too, am hoping Tobey had a restful night and that you were able to get some sleep.

[Renee]

She spent the night at the emergency clinic, and I just transported her back to my regular vet this morning.

She is showing a lot of improvement. I think my little fighter is still in the game, thank god. I won't hear from my regular vet for a few more hours, but they are keeping her going with IV fluids and abx. She was able to walk on her own this morning and go pee. She is coughing again, which is a good sign. She was too lethargic and depressed to cough the past few days.

Thank you everyone for your continued thoughts. I think she's going to get through this.

[Joan2517]

Good news, Renee....

[labblab]

Thank goodness!!!!!! WHEW!

[scoora]

So glad to hear the good news! Continued loving thoughts and hugs to you both. Hope she continues to improve,

[molly muffin]

So glad to hear this Renee!!!

[Harley PoMMom]

Glad to read this news too!!

[Renee]

Update from my vet (love her!):

My girl gets to come home this evening. She is doing much, much better. No more blood. Her demeanor is good. She held down some canned i/d. I'll be bringing her home with subq fluids, and a few different meds. My vet recommended to get her back on her vetoryl soon, but I think I'll take my time on that one. I'm in no rush to bring her cortisol down quite yet. I'll risk the CC for now.

Dr Jen did admit to me that she thought I was going to lose Tobey yesterday. I know when I first took her in she said she would not let her die. When I spoke to her later in the day, she said she couldn't promise me anything. An angel must have been watching over my girl, because she made a big turnaround over the last 12 hours.

Nothing like facing down mortality to remind you how precious things are. I feel like everything from this day forth is a gift.

[Joan2517]

It sure is, Renee, so embrace it!

[scoora]

Great news Renee

[Renee]

just updating on my girl.

Cough is back and bad as ever, unfortunately. But, she is recovered from the HGE and has been doing well.

Stim test results from yesterday (3/11) Baseline 2.2, post 2.0. This is on 10mg am and 10mg pm. Continued pattern of her baseline exceeding her post figure, lol.

I thought she was a little over-suppressed as her water consumption has dropped off. I'm going to stop the vetoryl for a week or so and let her rebound, then start back at just 10mg morning only.

[molly muffin]

Dang, that cough! Was hoping that wouldn't come back as bad as it was. :(

How is she doing now? Is she off the vetroyl now for a couple days?

How is her CC?

[Renee]

I stopped her meds Saturday night. This morning was the first time I actually saw her drink water. So, it took about 48 hours for her to rebound just a little bit.

CC is the same. It's hasn't progressed at all. Just that single lesion that is kind of open, the rest of the deposits under the skin. She does have a bump, which I thought was a CC deposit, but I've been feeling it lately, and it feels different. I think it may be a tumor of some sort. Small and perfectly round. I haven't take her into see my vet yet about it. I'm sure she is sick of the vet!

[molly muffin]

Maybe a lipoma?

Good she is drinking better. 48 hours. whew, sounds like her body doesn't care much for that range for her cortisol.

[Renee]

She's not rebounding as fast as I would like her to, but I'm probably just being overly nervous. It's weird how my mind goes crazy when she drinks too much water, but then when she doesn't drink enough, I make myself just as crazy. :confused:

The bump is most definitely not a lipoma. It's much too solid. I am hoping it's just a folicular tumor (can't remember what those are called).

[molly muffin]

oh a hard lump, yes not lipoma then as those aren't usually hard at all.

Since they don't want to put her under anesthesia (with that cough I probably wouldn't go that route either) then hopefully it doesn't bother her.

Worry seems to be the name of the game when it comes to our cushing furbabies. They eat too much, they don't eat enough, they drink, they don't drink, they pee a lot, are they peeing enough, sleeping too much, no wait, they are restless. It's like being on a roller coaster that never stops to let you off. Sometimes it slows down but I'm sure that's just a trick, as it always speeds back up again.

This is our lives. LOL I'm actually used to it most of the time now.

[Renee]

Update on my girl. She's doing so good right now. Hope I haven't jinxed myself, lol!

Her cough is still bad, but her demeanor is good, water intake is going up a bit, and her digestion has been really good (no diarrhea, gas, vomiting, etc). I'm still not giving her any vetoryl and I'm okay with that for now.

It feels calm for a change. It's nice.

[Harley PoMMom]

It feels calm for a change. It's nice.

So glad to hear this, you two have been put through the wringer and so deserve a break.

[scoora]

So good to hear! You do deserve some calm for a change!

[molly muffin]

So glad to hear that your girl is doing well for awhile and some peace has settled in at your house. :)

[Renee]

A little update on my girl.

We started back up on 10mg am only on 3/22.

Her cough is still bad, so I went to refill the torbutrol, which I have not purchased since Nov 2015 ... well, the price skyrocketed! It was $80 for 36 pills in Nov. Three months later, and the same number of pills is now $196. YIKES! I decided not to purchase them locally and try to get them online. The only reputable online pharmacy that sells them is Diamondback Drugs. I'm getting 60 pills of the generic (butorphanol) for $139. Quite the savings.

Anyway, now that I am using the torbutrol more regularly, I decided to call Dechra and ask them about interactions. They said that there should not be any interaction, but that they do not have trials or research about the two drugs specifically.

Even more so, they were very interested in talking about her cough and said they would start a file on her and would be calling me to check in regularly on it's progression. They are listing her cough as a potential 'adverse' reaction or something similar. So, that was interesting! The rep I talked to, Kim, was very knowledgeable and asked all about Tobey's history.

Here's a question I never even thought of, until my hubby asked: the torbutrol is an opoid Class IV narcotic. He was wondering if Tobey would get 'addicted' to it, since I am dosing her with it every night. Man, I don't think she needs an addiction on top of every thing else! Thoughts?

[molly muffin]

okay, wow, never thought about it, but I guess she Could? get addicted. Maybe check with your vet and see how other dogs that she has prescribed it for have reacted long term, especially at any point when they withdrew it. I'd think like pred, it would be tapered down rather than just stopped if you are using it regularly.

So, that is very interesting about Dechra's response. They are thinking a possible reaction to the trilostane and I wonder if this means they have other dog whom a cough has developed in and if so how many... enough to try and track it I am guessing. hmmm..

Hopefully her cough will improve on the medication though.

[Renee]

Hey everyone!

Update on my girl. Dang, if she isn't doing so good right now!

She's currently on 10mg once per day (morning). She's been on this dose since 3/22. I'm a bit late on her ACTH, but that is scheduled for this upcoming friday. I'm expecting her to be right in range, as her symptom control is about as good as it's ever been. Her cough is very minimal again, so she recovered from whatever the trigger was. I'm sure it will be back, at some point, but who knows!

Dechra called me back following up on her just a few days ago, but I have not returned their call yet. I think I'll wait until her stim test on Friday, that way I have results for them too. They were very interested in hearing about her cough.

Personality-wise, she's doing so great. She's getting back to some of her old shenanigans (getting into bathroom trash, lol) and being peppy. She still sleeps a lot, of course, but she seems very happy right now too.

I feel like all her stars have aligned for now. It's so nice having all these good days. It feels like a gift.

[Joan2517]

Good news, Renee~

[Harley PoMMom]

Oh Renee! What a great update!!! So glad that Tobey is doing so well!!!!!

[labblab]

Awww, this is such great news, Renee!! :) :) :)

Thanks so much for the update, and may these good days keep on comin'! ;)

[scoora]

So, so happy to hear Tobey is doing so well!

[molly muffin]

This is wonderful news Renee!!!! What a journey it has been lately, so I'm super glad to hear that things are on the up/up!

[Renee]

Okay experts, riddle me this one.

Baseline 1.1
Post 1.6

10mg once per day only

What the hell? She is not acting over suppressed at all! No signs of low cortisol. We did not run blood chemistries, but I just emailed the vet and said I would bring her in Monday to check her electrolytes, etc, and see where she's at.

I've already dosed her this morning, but I guess I'll stop for now. I am completely baffled by these results. She has been doing so amazing these past few weeks, I really did not expect this.

Her last stim test was 2.2 and 2.0 on 10mg twice her day. That was on 3/12.

[judymaggie]

Renee -- I definitely don't have any explanation for what's happening with Tobey's numbers but I saw a similar thing happen with Abbie when she was on Lysodren. Her numbers registered <.01 on pre and post and she showed no signs of low cortisol -- her electrolytes were all normal. This whole disease process can be a mystery, that's for sure!

[molly muffin]

Wow. That Is a surprise. I don't know why that would happen either. I guess all you can do is wait for cortisol to go up on its own and see if she needs medication going forward.

[labblab]

Count me in as being totally surprised, too, Renee. Maybe Tobey is just one of those dogs who end up experiencing physiological changes to the adrenals such that overproduction is no longer an issue. We know it does happen every once in a while. Whether this will be only temporary or permanent, obviously only time will tell. But heck, maybe you guys will get to enjoy a lengthy vacation from trilo at any dose! :)

[Renee]

Yes, Marianne, I was thinking that too. Back when she was first regulated, it was at 40mg per day. Now we are down to 10mg and it's too much. I've stopped the meds and will let her rebound for a bit, then probably order the 5mg capsules, assuming she even needs them. I really, really hate to rock the boat, since she's been doing so well, but I cannot risk her dropping any lower.

[Renee]

I spoke with Dechra today. One of their reps, Kim, has been following along for the past few months. She agreed with the approach to stop the meds, even though their 'cutoff' is 1.45 ug/dl, and Tobey's post was 1.6.

She brought up the same thought as Marianne, that Tobey may end up being one of those dogs to go into 'remission' and not need the medication. It would certainly be very nice to take a break from the medication for a while. Time will tell!

[Joan2517]

Wouldn't that be awesome~

[DoxieMama]

Did you get her electrolytes tested today? I'm just curious what those levels are now. It would be great if she doesn't need the meds!

[labblab]

Renee, I just finished posting a reply to another member that made me stop and think again about Tobey's situation. You know, if/when you do see the need to restart her trilo, you might try shifting to once daily dosing. Her adrenal function may have altered such that she would do better and run less risk of oversuppression if her cortisol is allowed to rebound a bit more within a 24-hour cycle. Just a thought for you to consider in the coming days...

[Renee]

I wasn't able to make it in for her electrolytes to be tested, and now I wonder if I'm past the window of testing them any way? Symptoms have not returned, which it's only been 3 days off the medication. She's acting perfectly normal. I've decided this time around to run a stim test when symptoms do recur, but before starting any dosing back up. I'll get her blood chemistries run at that time too and see where she's at.

Marianne, she was on once daily dosing (10mg) for this last stim test. It's a good thought though, and one I completely agree with. If I do end up putting her back on the medication, it will be 5mg in the morning only. More the pity, I have 3 unopened boxes of 10mg. :(

[molly muffin]

Wow, that would be great if you never had to worry about high cortisol again and all the problems for Tobey that go along with that.
That is a good suggestion that Marianne has and something to think about. Dechra might be able to comment on that too if the cortisol does go up.

[Renee]

Well, Tobey's symptoms have rebounded over the past 2-3 days, so we are scheduled for another stim test this friday, which is 2 weeks from her last one. Am I jumping the gun and getting it a bit too early? I have no idea how high the cortisol will have climbed in relation to the symptoms. She's drinking a lot of water again and ravenously hungry. All her other stim tests (except the initial diagnostic one) have been on medication, so this will be the first time she's had a test without any medication in her system.

I went ahead and ordered a few boxes of 5mg in anticipation of starting her back up on vetoryl. I still have 3 boxes of 10mg, but given her last stim results on the 10mg, it was over-suppressing her.

Hmm, this disease!

[Joan2517]

Oh, pooh Renee...

[Renee]

Oh, pooh Renee...

Yeah, I was hoping she wouldn't need the medication at all, but I figured it was wishful thinking. Still, 5mg a day is not bad! It's a very low dose, considering she weighs 17 pounds. I'm okay with it. I only stopped the 10mg based on the stim results. Judging by her symptoms, she was doing perfect.

I'll be getting her bloodwork / electrolytes tested this time around too.

[DoxieMama]

Aw darn.

I don't think there's any harm in getting those results now. Then you'll have a baseline for where she's at before you start again. I know others recommended that I have an ACTH done on V. before starting him again (electrolytes were off which is why we stopped) but I chose to only have electrolytes tested since that was the reason we stopped. Since you stopped due to lower cortisol, it's probably best to make sure she needs it, though the symptoms are a good indicator.

I'll be interested in seeing her electrolyte numbers, so I'm glad you are doing that too.

[Harley PoMMom]

Sounds like Tobey may have some fast regenerating adrenal glands :) This dratted disease sure is a roller coaster ride :( I'll be anxious to see the results of that ACTH stim test.

[molly muffin]

Sounds like Tobey may have some fast regenerating adrenal glands :)

Isn't that the truth, Tobey goes up and down faster than most any dog I've heard of. She will be low, then take her off and bham! she is back to symptoms again in what seems a very quick turn around.

I wonder what she is at now too.

Yea I guess it was too much to hope that she could just be a normal dog without cushings for a long time. It's what we all wish for anyone we know dealing with cushings though, so doesn't hurt to have hope.

[Joan2517]

Can't live without hope...

[Renee]

Isn't that the truth, Tobey goes up and down faster than most any dog I've heard of. She will be low, then take her off and bham! she is back to symptoms again in what seems a very quick turn around.



Sharlene, I was thinking the exact same thing. She doesn't appear to need very much vetoryl overall, but clearly she still needs it, as her symptoms almost always rebound within about 7-10 days.

[Renee]

Stim test done. Results should be in tomorrow.

Blood work was unremarkable.

Now for the electrolytes - I don't have the individual numbers for sodium and potassium, but the ratio was 26, which is the very last low part of normal. 24 being indicative of addison's.

She has been off vetoryl since 5/1. Her cushings symptoms are strong right now. She is not acting much different though, and certainly not acting like a dog in cortisol crisis.

Any feedback?

[labblab]

Can you get the individual numbers for the potassium and sodium? One of the issues with ratios alone, of course, is that you cannot pinpoint the source of the possible abnormality. The individual numbers may not be all that worrisome when viewed in isolation.

[Renee]

Okay, here are the electrolytes and lab abonormalities

EOS (Low) .03 (.06-1.23)
PLT (High) 562 (148-484)
PCT (High) .58 (.14-.46)
CREA (Low) .4 (.5-1.8)
ALT (High) 243 (10-125)
ALP (High) 227 (23-212)
GGT (High) 11 (0-7)
CHOL (High) 392 (110-320)

Na 146 (144-160)
K 5.7 (3.5-5.8)
Na/K 26
Cl 110 (109-122)

[molly muffin]

we have seen cortisol be within in range and electrolytes be affected. Doxiemom just went through this and they lowered the trilostane dose. You want those electrolytes in range even if cortisol has to be higher as it is expected to be based on symptoms. It is worrying because of the cc. If it goes too high that would return probably. Much depends on what the values show on the ACTH.

[Renee]

Stim test results:

Baseline 6.0, post 9.5.

Funny how quick her cortisol spikes. In exactly 2 weeks she was able to go from post cortisol 1.6 to 9.5.

[Renee]

Bumping up, in case any experts have thoughts / feedback. :)

[molly muffin]

Tobley is not going to just stay any one thing from what it looks like.

I suppose the worry is that on 10mg she would go too low again, so the option is to try the 5mg and see if that will put her at a good place for the cortisol, cc and electolytes.

I think that is what I'd do.

[DoxieMama]

Her sodium and potassium are in range, though just... which puts that ratio low. Chloride is low too. But her cortisol is up and she is symptomatic. Is it possible for a dog to have too much glucocorticoid yet not enough mineralocorticoid?

[labblab]

I'm guessing you can possibly end up with some trilostane effects that would not be commonly seen in naturally-occuring Addison's, especially if the dog was additionally taking other medication that also has an aldosterone-lowering effect. Maybe the trilo is having a more lingering effect on her aldosterone, for some reason. Renee, I can't remember, is Tobey taking any other meds, too, that might affect aldosterone?

I don't know whether you've already thought of this yourself, but I do wonder if she might be a girl who'd end up doing better on Lysodren. Given what seems to be her great sensitivity to trilo now, it might be kind of a scary prospect to load. But maybe she could handle a low, maintenance Lysodren dose that would keep cortisol in check without experiencing the same aldosterone disruption that she seems to be getting now. Just an idle thought...

In the meantime, yes, I'd first try the 5 mg. of trilo, too.

[Renee]

She's not on any other medications.

I actually had not thought about lysodren at all.

Frankly, her bloodwork is baffling to me. Never would I have thought her electrolytes were out of balance, or even that she was over-suppressed 2 weeks ago the way she was. I mean, at that time, I thought she was doing amazing. She was perfectly controlled.

She is definitely symptomatic now, so I would like to get some medication going, but I am scared about the electrolytes being how they are.

I guess I will try the 5mg and have her cortisol tested at the 2 week and 4 week mark. I may do the electrolytes weekly though.

[lulusmom]

As I mentioned to you earlier, we've seen a few dogs who seem to be doing very well on a particular dose for long enough to think they are stable when out the blue, a scary low post stim cortisol pops up. I've never been able to find a credible explanation for why that happens but I do know that's why UC Davis recommends that dogs treating with trilostane have acth stimulation tests every 90 days.

I do know you have concerns about the Na:K ratio being lower than you are comfortable with and I don't remember any members presenting us with such a mind bender. Be sure to thank Tobey for us. :p I personally wouldn't be too concerned, especially if your vet is experienced and didn't mention any concern. However, as promised, I did a bit of research to see if I could bring something to the table that might calm your nerves.

The most likely suspect for driving down the Na:K ratio is the mildly elevated platelets which is common in uncontrolled cushdogs. I discovered that platelets contain large amounts of potassium and because Tobey's platelets are elevated it stands to reason that potassium would also be mildly elevated. Had the platelets been normal, Tobey’s potassium level would have probably been more in the middle of the range. The resultant ratio would have been much higher, making you feel much more comfortable with everything. I asked about the fasted sample because if a specimen is taken too soon after a meal, there could be a lot of fat in the blood which can falsely lower sodium. Since electrolytes are routinely checked at the same acth stim test appointment, I’m not sure that is a legitimate concern but it still could account for a negligible decrease in sodium but only if the test results shows that the sample was lipemic. I wish I could have provided a definitive answer for you but I could not find anything that would suggest that dogs being treated with trilostane can have acceptable pre and post cortisol concentrations and concurrent electrolyte imbalances.

I do want to mention that it is highly recommended that electrolytes be checked at every acth stim test appointment. I would have been most interested to see what the sodium and potassium levels were at the time of the last stim test that was scary low.

Glynda

[Renee]

Glynda, I cannot thank you enough for spending your time putting some thought into Tobey's results.

We have, for the most part, always abided by the 90 day ACTH rule. I can think of possibly a few times that it has been stretched to 4 months, but not often. I must admit though, we have not checked electrolytes every time. But, thanks Tobey, I have learned my lesson there!

My vet is perfectly comfortable with starting the 5mg dose. She wasn't overly concerned about the electrolytes and felt that it could just have been a fluke or anomaly, especially given the results of the stim test. The boxes of 5mg arrived today, so we will be starting those tomorrow morning.

As I said in my earlier message, I did call Dechra about this and they had no definitive explanation, other than to say the same thing you (Glynda) mentioned about certain dogs developing sensitivity to the drug and needing less and less of it over time.

The correlation between elevated platelets and potassium sounds plausible. It gives me a lot more peace of mind than not having any explanation.

This pug keeps me guessing, that is for sure!

[labblab]

Renee, when you spoke to Dechra, did you ask specifically about the combination of high potassium but normal cortisol? Apparently the researchers are aware it can happen, given the wording of the warning that is placed in the Vetoryl a Product Insert:


If the ACTH stimulation test is < 1.45 μg/dL (< 40 nmol/L) and/or if electrolyte imbalances characteristic of hypoadrenocorticism (hyperkalemia and hyponatremia) are found, VETORYL Capsules should be temporarily discontinued until recurrence of clinical signs consistent with hyperadrenocorticism and ACTH stimulation test results return to normal (1.45-9.1 μg/dL or 40-250 nmol/L). VETORYL Capsules may then be re-introduced at a lower dose.

I'm just wondering how often Dechra has actually seen this to be the case. Glynda's suggestion about the platelets is an interesting one and that may be exactly what's going on with Tobey. But I'd also be curious to know how common it is for trilo dogs to experience over-suppression of aldosterone while cortisol levels remain normal.

Marianne

[Renee]

Marianne - I did ask them about it. I read off all of her results and went over the last 2 months of stim test results and dosing changes. They didn't really have a good answer or explanation. I think because I had already withheld the vetoryl for 2 weeks and her cortisol had rebounded enough (which they would have advised anyway).

Honestly, while I have found Dechra support to be helpful in some respects, I also found them to be less than helpful this time around. They are good at giving instruction / advice, but not so good at providing useful feedback or explanations for results.

Tobey started the 5mg yesterday morning. I'll be getting her electrolytes checked on Friday, but her stim test isn't scheduled until June 3rd.

[lulusmom]

Marianne, who was the awesome internal medicine specialist on staff at Dechra and retired. It seems like when he retired, we lost an amazing resource. Nobody since him seems to possess his knowledge so I wonder if the resumes of the current reps are anything close to his.

[labblab]

It was Dr. Allen, I think. :o

Yes, he was wonderful, and I sorely miss him. One difference, I think, is that he originally fielded all the U.S. technical calls personally and he knew all the research (and traveled to the U.K. to powwow with the home office). Now, I think techs are frequently the initial frontline responders, and although they are obviously trained, they just don't have the wealth of research knowledge that he did.

Losing him at Dechra and losing Dr. Oliver at UTK have been two hits that we've never really recovered from. :( :(

[lulusmom]

I'd also be curious to know how common it is for trilo dogs to experience over-suppression of aldosterone while cortisol levels remain normal.

Marianne, I am not sure how common it is but it definitely happens. Here is verbatim excerpt from my 4th Edition Canine and Feline Endocrinology text by authors, Edward C. Feldman, Richard W. Nelson, Claudia E. Reusch, J. Catharine R. Scott-Moncrieff and Ellen N. Behrend:


Although as an enzyme inhibitor the effects of trilostane were expected to be fully reversible, adrenal necrosis can occur with resultant prolonged or permanent cortisol deficiency with or without aldosterone deficiency. Decreased aldosterone secretory reserve can occur (Winger et al, 2004; Siever-Ruckstuhl, et al, 2006); it is common regardless of level of control of PDH and cannot be predicted by measurement of electrolyte concentrations (Reid et al, 2014). Aldosterone concentrations are best measured before and 30 minutes after ACTH if using cosyntropin for the ACTH stimulation test (Reid et al, 2014). Aldosterone deficiency can be life-threatening.

I've attached a copy of Reid, et al, 2014 study entitled, "Effect of Trilostane and Mitotane on Aldosterone Secretory Reserve
in Dogs with Pituitary-Dependent Hyperadrenocorticism"

882

P.S. Yes, it was Dr. Allen and I agree he and Dr. Oliver were irreplaceable. Both were delightful, giving of their time and their wealth of knowledge is immeasurable. We were fortunate to have them for the time we did but I sure do miss having them to turn to in tough times.

[Renee]

Forgive me, I'm getting myself a bit panicky now.

How can I test her aldosterone levels? And how would I know if they are safe or not?

[lulusmom]

How can I test her aldosterone levels? And how would I know if they are safe or not?

With a little research, I found a lab who provides aldosterone on an acth stimulation test. My dogs treated with mitotane and lysodren and I never recall seeing a test result with aldosterone included.

http://thehormonelab.com/handbook/adrenocortical-function/aldosterone

[Renee]

Well, the lab my vet uses is able to order the aldosterone test, but it would take 7-10 days to produce results and I would need to run another stim test at the same time.

I guess at this time I am in a bit of a quandary.

Symptomatically, she has active cushings symptoms. PU/PD, extreme hunger, dilute urine.

Her cortisol is elevated, as shown by the stim test, but her electrolytes are showing mild imbalances, although not technically out of range.

Maybe I am over-thinking? I cannot recall anyone else here that had 'normal' cortisol readings, but concern about aldosterone levels.

Maybe the answer is that I just need to re-check her electrolytes again and see what information that provides?

[Renee]

I have myself a little too nervous. We are going in tomorrow to see the vet and get electrolytes rechecked.

[lulusmom]

Renee, sometimes I think we do overthink things and freak ourselves out. Hopefully tomorrow's appointment will alleviate some of your concerns. I'll be checking for your update.

[Joan2517]

It's a nerve-wracking disease, that's for sure, Renee.

[DoxieMama]

I am anxious with and for you, and will be waiting to hear the results of today's tests.

[Renee]

Electrolytes from today.

Potassium 5.0
Sodium 146
Ratio 29
Cl 107

Better, but not where I want them at. :( My vet and I agreed to run the electrolytes again in a week.

[DoxieMama]

Better is good! It will be interesting to see what the numbers are after a week+ of the new dose. Which reminds me, I need to schedule an electrolyte test for V to see how his numbers look on his lower dose.

[molly muffin]

Getting there, but it does take time often to see a turn around in values.

I get it Renee, I'm a wreck about things too when I get tests back that throw me for a loop. I just keep trying to figure it out, why why why is this like this or that like that. What is causing it, what can I do to change it.

I think we are all like that honestly. How can one not be to some extent with cushings.

[labblab]

I totally get it, too, Renee! (So says the Queen of Fret...! :o).

I'm really sorry Dechra hasn't been able to provide a better perspective on things. The only other suggestion I can think of is to either send an email to Dr. Bruyette or to post a question on Dr. Peterson's blog. They have both tended to so many Cushpups that perhaps this is a scenario with which they've had some experience.

This has got to be so wearing and so frustrating to sort out, especially since Tobey was outwardly doing so well on the higher dose.

Marianne

[Renee]

Marianne, do you happen to have Dr Bruyette's email? Is he fairly responsive? I think your idea is excellent. We no longer have an IMS here in AK, so resources are limited.

[labblab]

Renee, here's his email address:

David.Bruyette@vca.com

I have found him to be amazingly responsive. He has replied to some inquiries of mine within a half an hour, even on a weekend. I hope he can be helpful to you!

[lulusmom]

Marianne, I've never written to Dr. B so I'm wondering if you identified yourself as an admin on this site or just a pet owner with a question? I'm asking because he knows who we are and it may make a difference as to whether Renee gets a response.

[labblab]

Yup, he knows I'm an Admin here. Other members here have reported amazingly quick responses, though, too. I'm assuming they may identify themselves as K9C members, but I don't know for certain about that.

[judymaggie]

Hi -- just wanted to pipe in that I have e-mailed Dr. Bruyette as a "regular member" and received very quick responses from him. I did advise him that I was a member of the forum and was aware that he had provided assistance to other members.

[Renee]

Shoot, email already sent. I did not identify myself as a member here. But, I provided a very detailed account of Tobey's history. Hopefully he will see my dedication to her care and take the time to provide a meaningful response. I would certainly be willing to pay for his time if he wants to consult with my gp vet.

We shall see.

[labblab]

Renee, I don't think you need to worry. I honestly don't think it will make any difference whether or not you identified yourself with K9C. I think Dr. B pretty much lives and breathes canine Cushing's, and I'm guessing he treats everybody with the same interest and enthusiasm, regardless of who they are.

I'm betting that if he's available now, you'll be hearing from him soon.

[scoora]

Renee,
I had contacted Dr. B with questions about Scoop.
That was 3 years ago. He was very responsive to my emails.
He seems like such a wonderful person and doctor caring about all our fur babies.
He was very easy to talk to.

[Budsters Mom]

Dr. B. Helped me out with Buddy too. Buddy had a probable pituitary macro tumor in the mix. Buddy's neurosurgeon and GP vet, based Buddy's treatment plan on Dr. B's recommendation. It was free. Dr. B was very down to earth and happy to help in any way he could. He even emailed me a few days later to see how things were going. He always signed his emails "Dave", not some stuffy doctor title, but much more personal.


Renée, this man truly has a good heart and love for dogs. When I contacted him, he emailed me back within a half an hour. He has helped many of us out here. I agree with Marianne. I don't think it matters whether you label yourself as K9C or not.


Kathy

[Renee]

No reply. :( I can only assume he must be very busy or my email has been spammed.

[labblab]

Don't give up hope, Renee! He may just be at a conference or something right now.

[Budsters Mom]

You could try sending it again?????

[Renee]

I'll wait until Monday, then re-send it.

[molly muffin]

hmm, yea I'm thinking he must be away or something because he has always in my experience been very good about answering emails promptly.

Don't give up hope!!

[Renee]

Okay, I got my reply.

I'm a bit underwhelmed, as it was a very short answer .. but, I guess he's super busy!

Here was his reply:
I suspect the electrolyte imbalance is unrelated to the medication given the cortisol levels but it would be easy to test by running an ACTH stim test and measuring aldosterone pre and post.

So. I am nowhere closer than where I was. I'll continue on with my course of action. Electrolyte check weekly, stim test 6/3, to include aldosterone test only if the electrolytes do not improve.

Incidentally, I started adding a bit of salt to her food. Salt is not an ingredient in her food, so I am wondering if she's just not getting enough in her diet?

[Renee]

Update on my girl. Friday is her stim test at the 5mg dose. We will recheck electrolytes too.

Symptomatically, I am fairly pleased with how she is doing. I would not say she is 'perfectly' controlled, but for my own peace of mind, I really don't mind seeing a bit of cushings symptoms. She drinks more water in the evenings and is definitely more hungry then as well. But, overall, I think she's in a good place.

[molly muffin]

Being in a "good place" is definitely a good thing. Tobey bebops around enough that those good place times can be hard to come by. :)

[Renee]

Electrolytes - no change.

Stim results:

Baseline 3.5, post 4.3. This is on 5mg am only, started on 5/17.

I'm actually really happy with these numbers, and continuously astounded that she is able to get this level of control on such a small dose.

[Harley PoMMom]

Stim test results:

Baseline 6.0, post 9.5.

Funny how quick her cortisol spikes. In exactly 2 weeks she was able to go from post cortisol 1.6 to 9.5.


Electrolytes - no change.

Stim results:

Baseline 3.5, post 4.3. This is on 5mg am only, started on 5/17.

I'm actually really happy with these numbers, and continuously astounded that she is able to get this level of control on such a small dose.

Those stim numbers look great to me, and I agree, what good control on that 5 mg dose....from 9.5 ug/dl to 4.3 ug/dl, awesome job, Renee!

Hugs, Lori

[molly muffin]

That is great stim results. Toby continues to be amazing and defy what is expected from her on the Meds. Yay

[Renee]

Well, Tobey's CC seems to be flaring up. :( :( All her old CC spots are raised, rough, and pink. I'm not sure what they are going to do, but they are much more prominent. ALL of them, not just one or two.

I talked with Dechra and they weren't much help at all. Just told me that the CC can get worse before getting better. Yeah, thanks for that.

She's still on just 5mg per day. Her last stim on 6/3 had good numbers, so I don't think I can increase her dose. I'll have to run another test. If the lesions stay like they are, then I'm fine. But if they all break through, we will have a problem.

[molly muffin]

Oh no. I hope they don't pop through.
I wonder what is causing them to come back. Dechra didn't have any thoughts eh. How frustrating. grrrr

[Renee]

Well, I find myself in the position of having to take my own advice.

Tobey's CC erupted as of last night. Every single spot she previously had is flared up, right under the surface, but one spot opened last night. :(

She's on 5mg vetoryl once per day, and according to her last stim test, she was in range. I have a few hypothesis about what may be going on, but I will be meeting with the vet this afternoon to make a plan. I believe, if I can get it, I will try the abx that Jana is trying for Bubbles. I need to find the articles first though. Seems I read one a year or two ago and most of the study was about CC being secondary to non-cushings causes.

Other than the CC, her symptoms are good. I would say she is well controlled, which is baffling. Maybe she really does need to be as low as is safe? She never appeared to be too low, even when she was clinically too low.