French bulldog w calcinosis cutis - Qs on Cushings diagnosis & treatment

[lola's mom]

Hi Everyone,

The info here has been very informative, I'm still sifting through a lot of it. I'm sure I'll have some more questions beyond today...thank you to everyone who created this forum and to those who are active in it.

A few days ago my frenchie was diagnosed with calcinosis cutis - she has CC patches in several spots on her body and unfortunately one of them (just above her shoulder blades) is oozing and severely infected which we are trying to get under control - it is very scary-looking. She is on Zeniquin, Chloramphenicol, Mupirocin, Silvadene, and Trizchlor shampoo & spray. She doesn't seem to be in pain except for certain spots when I apply the ointment, and she doesn't try to itch too much - she's such a good-natured dog.

They gave her the ACTH Stimulation test to confirm Cushing's and it came back negative. The vet is certain that she has Cushing's and so she wants to run the Low Dose Dexamethasone Suppression Test to see if it returns positive for Cushing's. Given that CC pretty much is synonymous with Cushing's, is it even worth running this additional test?

Either way, it sounds like an ultrasound would be beneficial to help determine pituitary vs adrenal cushing's?

As for treatment, it sounds like there are really three options to choose from, is that right?:
- DMSO (that's what my vet is already leaning towards for some reason)
- Vetoryl (Trilostane)
- Lysodren

Is the choice between these dependent on whether the Cushing's is pituitary vs. adrenal? What other factors impact which treatment to choose?

FYI, my Lola is about 8 years old. I adopted her from a rescue group about one year ago, so I don't know if she's had prednisone in the past - definitely not in the last year. Since she is a frenchie, she is also very prone to skin allergies.

Thank you in advance for your advice and caring concern,
Lola's mom

[Renee]

Oh dear, yes, the dreaded CC can be quite painful to look at and hard to control. If it causes her pain, definitely see about getting her some tramadol. Please tell us how the CC was diagnosed? Biopsy? Does she have any other symptoms that would lead you to suspect cushings?

Can you please post the ACTH results including the reference ranges and any other bloodwork results? I know you said the ACTH was negative, but they may be dependent upon the lab. For example, the normal range for my lab is up to 22 for the post cortisol, but in many other people's results, their labs use a max of 18... so, you may be just on the border line for the ACTH results.

An LDDS is a good idea, as is the ultrasound. I would not say either of those are a waste, in my opinion.

As an aside, with her being on so many abx, I would urge you to add some probiotics to her diet. That much medication can really get her system out of whack.

[lola's mom]

Thanks for your note, Renee! I was sent to a dermatologist for the weird growths that the specialist immediately recognized as CC and confirmed via biopsy. Lola has also been drinking much more recently and having increased accidents inside which isn't like her. She has also battled UTIs for the last few months, thinned skin and weakened hind legs which I thought was the beginning of arthritis. Also a slight decrease in energy.

I will post the ACTH numbers when I'm able to receive them from the vet, and yes Lola has been on probiotics for a few weeks now. Her liver/kidney (?) values were slightly elevated - nothing that my two regular vets flagged, but the specialist really put all the puzzle pieces together.

Unfortunately Lola had a terrible reaction when I gave her tramadol combined with her other meds a few days ago (all require to be given with food and some are required three times a day, so I can't give her any more food!). She was shaking about 30 min after I gave it to her, I had never seen her do that before, so the vet recommended I omit the tramadol since she generally didn't seem to be in pain...

[Renee]

Poor girl. :( I am so sorry the tramadol gave her a reaction.

It sounds like you are on the right path. And, I am glad you saw a specialist about the CC.

There are a number of us (my pug included) that are dealing with CC. Please find our threads and read them. You can get some good information on how we have been treating them. Of course, the only true 'cure' for CC is lowering the cortisol. Everything else is just management.

I look forward to seeing the test results and seeing what the LDDS and ultrasound reveal.

[lola's mom]

Renee - I just read your entire thread about Tobey from early December through to your latest post. It has really helped me set expectations for the long and winding road ahead, thank you so much for all of that documentation (and for everyone else's care and advice!). It sounds like things have been improving for Tobey, how is she doing now?

Thanks again to everyone who is active in this forum - I hope to return the favor over time as I gain more knowledge and hopefully as Lola gets better.

[Renee]

Bless you for reading my thread! I remember when I first came here, I was reading threads from start to finish too. Its helps to not feel alone, and it is reaffirming to see that all of us have gone through similar experiences from the very start to wherever we are now.

It is a long and winding road, but the path gets easier and easier for many of us.

Symptom wise, Tobey is doing very well. I think we have hit her perfect dose, but I have not gotten an ACTH done yet, and that will tell some of the story. I was supposed to do it last week, so I thought I would do it this week, but her vet is out of town, so.... I have put it off another week. I know it's a break with protocol, but I feel okay with it at this point.

Her personality is still a bit off, but I am just giving that some time.

[lola's mom]

It really does feel better to know that others are going through this with their pets and that things can and do get better over time.

That's great to hear about Tobey, fingers crossed the numbers are positive.

[molly muffin]

Hope that you can get the cortisol lowered and then you should see things start to improve with the cc too. Eventually, it takes time.

Not all dogs react well to tramadol, sounds like Lola is one of them. They can maybe have it in a very, very small dose, if you need to try that.

Sharlene and molly muffin

[lola's mom]

Thanks so much Molly Muffin and Renee!

We had the LDDS test yesterday, so I'm hoping to receive the results today or tomorrow which I'll post here. In the meantime, here are the ACTH results:
Pre: 2.5 ug/dL (Reference range = 1.0-5.0)
Post 15.2 ug/dL (Reference range = 8.0-17.0)

I've read mixed things about DMSO and the risks associated with it - Lola is a french bulldog with a sensitive system so I'm conflicted on whether to try it out or not...thoughts?

Also, I'm having trouble finding the thread on here - is the general thought that Lysodren is better for resolving CC, or is it Trilostene? I just read that there were some sudden death cases with Trilostene, which is alarming.

[Renee]

Okay, the ACTH results do rule out cushings.. but, again, we know those can be wrong, so other diagnostics and analysis of symptoms will help lead to the diagnosis.

I personally had zero success with DMSO, and the smell of it was just horrible. It is often prescribed, and some dogs (Cosmo on here, who has passed) did have success with using it, in conjunction with vetoryl. If you are already on abx and using trizchlor spray, then I would not waste time with the DMSO.

Some people say that vetoryl is not as effective at controlling CC, while others (my Tobey included), are doing well using vetoryl.

Don't get scared away by the side effects of vetoryl vs. lysodren. They both are equally as effective and equally as 'dangerous'. You won't be able to choose one over the other based on which is safer. Neither one is safer than the other.

[lola's mom]

Thanks for the advice, Renee! I'll post the LDDS results as soon as I receive them.

[lola's mom]

Good info, thanks Renee.

Here are Lola's LDDS results, indicating Cushing's:
Cortisol Sample 1 (Pre) 2.0 ug/dL (Reference range = 1.0-5.0)
Cortisol Sample 2 Dex (4hrs) <0.7 ug/dL (Reference range = 0.0-1.4)
Cortisol Sample 3 Dex (8hrs) 2.5 ug/dL (Reference range = 0.0-1.4) HIGH

The lab results also said the following:
If the 8hr post dex. cortisol level is greater than 1.4 ug/dl, the following can be used to differentiate pituitary dependent hyperadrenocorticism (PDH) from an adrenal tumor:
1. Cortisol level less than 1.4 ug/dl 4hrs post-dex is consistent with PDH.
2. Cortisol level less than half the baseline level at either 4 or 8 hours post-dex is consistent with PDH.

The wording is confusing, but based on the above, it sounds like it is a pituitary-caused case of Cushing's. Given this, is it still worth getting an ultrasound?

My vet is inclined to go with vetoryl over lysodren given the potential damage to the adrenals with lysodren...

[Squirt's Mom]

My vet is inclined to go with vetoryl over lysodren given the potential damage to the adrenals with lysodren...

You and your vet need to be aware of the fact that Vetoryl can and does cause the exact same damage to the adrenals as Lysodren. They can both cause permanent Addison's and even death - they simply work differently and stay in the body differing lengths of time. Make sure your vet is up to date on all the changes with Vetoryl since the drug insert was printed, too. ;)

[lola's mom]

Thanks, Squirt's mom, good to know.

FYI, my dog is about 22/23 pounds - and I've been reading here low and slow is the best way to start either medication. Any thoughts on suggested initial dosing for either medication?

[Renee]

Leslie is correct - while vetoryl does not erode the adrenals in the same fashion as lysodren, it can and has caused spontaneous addison's.

If your pup is 22-23 pounds, I would start at a max of 20mg vetoryl, and give it at least 30 days before adjusting the dose (if needed).

You're doing good!

[Renee]

As to your question re the ultrasound --- my personal opinion, and what I did, was to wait. I knew she (Tobey) had cushings, and I knew what treatment I was going with (vetoryl).... so, I saved the money and delayed doing imaging until later into treatment. We ended up getting a CT, and it confirmed PDH.

[lola's mom]

Great, thank you!

After starting the vetoryl, my vet wants to run the ACTH tests after 1, 3 and 6 months to see how Lola is doing. Do you think we need to be testing more frequently than that?

[Squirt's Mom]

The "start low and go slow" applies more to Vetoryl (Trilostane) than it does Lysodren. Lyso is loaded at 50mg/kg/day and maintenance is 25-50mg/kg/week. There is no loading nor maintenance phase with Vetoryl - you start giving it and give every day. Vetoryl is often more expensive to use because it often requires frequent dose changes and with each dose change, the ACTH monitoring schedule starts all over.

[lola's mom]

Got it!

I'll be sure to let you all know what we end up going with for Lola and how she and the CC are progressing with the treatment.

Thanks again, all!

[labblab]

I "second" Renee's recommendation that you start off with 20 mg. if you are opting to treat with brandname Vetoryl. With that dosage strength, you could easily have the option of giving the full 20 mg. once daily in the morning or instead 10 mg. twice daily. There are pros-and-cons with both dosing options, and different specialists have different preferences in that regard so there is really no right or wrong approach. If once daily dosing fits more conveniently into your daily schedule, I'd see no reason to start out differently. Down the road, if it turns out that you are seeing a rebound in symptoms later in the day, you may want to try giving twice daily dosing a try.

As far as monitoring ACTH testing, Dechra's official published protocol is to conduct an initial test at the 10-14 day mark. Then, as long as the cortisol level has not dropped too low, the recommendation is to remain at the same dosing level until the one-month mark. This is because cortisol levels have a tendency to continue to drift downward during the early days of treatment, even when the dose remains unchanged. In this way, you have a better idea as to the maximal effect of that initial dose prior to making an increase.

We are finding that some specialists are holding off until the one-month mark to perform the first full ACTH test (omitting that first two-week test). I can only speculate that it may be because they don't intend to increase the dose until a month has passed, regardless. And as long as the dog is behaving normally and looking well, they are assuming that the cortisol has not dropped too low. One "twist" I have sometimes seen added is to perform a simple baseline or "resting" cortisol at that initial two-week mark. This involves only a single blood draw and is less expensive than a full ACTH. While not an accurate indicator alone of the need for a dosing increase, a baseline cortisol can give you some added reassurance that cortisol is not dropping too low (which is the issue that is most important for a dog's safety). As long as a baseline cortisol is higher than 2.0 ug/dl, there is some reassurance that the dog is not bordering on an Addisonian condition.

Of course, all bets are off if a dog is acting unwell at any time. Then the monitoring testing becomes a necessity.

It is true that we have seen many dogs here who have required periodic and even frequent tweaking of their Vetoryl doses. But we have also seen dogs taking Lysodren who have experienced lengthy loading periods or Addisonian scares that have also required a great deal of monitoring. We have seen very large dogs who ended up taking relatively small doses of Vetoryl, and vice versa (small dogs requiring larger doses). So in advance, I think it's hard to say which drug would end up being more expensive for any given dog. There are many times when a crystal ball would sure come in handy! :o

Marianne

[lola's mom]

Thank you so much, Marianne, this is very helpful info!

Based on what I've read on this forum, lysodren requires a loading time with ongoing maintenance after. Presumably that is dosed via weight as well? Any recommendations on what that would be if we took the lysodren route? Once again, Lola weighs 22-23 pounds.

My regular vet isn't familiar with lysodren and my dermatology specialist didn't feel too strongly about going with either vetoryl or lysodren - she just recommended that whichever vet I go with should be well-versed in the treatment they prescribe and test often. Reading through an overwhelming (and helpful!) number of threads here, it seems that on the whole, lysodren has been more helpful in clearing up CC than vetoryl for most dogs, so I'm more inclined to go that route.

My regular vet has been wonderful and has gone well out of her way to help diagnose Lola, and while she has been reading up on Cushing's treatment to ensure she is taking the correct route I am feeling like she isn't as well-versed in treating Cushing's as I'd like her to be, so I've found an internal medicine specialist (one who works closely with and is in the same building as the dermatologist) who treats many Cushing's cases and is equally familiar with both vetoryl and lysodren. I was able to get an appointment with him tomorrow, so we'll see exactly what he recommends - I'll report back on that here, stay tuned!

[Renee]

Thank you so much, Marianne, this is very helpful info!

Based on what I've read on this forum, lysodren requires a loading time with ongoing maintenance after. Presumably that is dosed via weight as well? Any recommendations on what that would be if we took the lysodren route? Once again, Lola weighs 22-23 pounds.

My regular vet isn't familiar with lysodren and my dermatology specialist didn't feel too strongly about going with either vetoryl or lysodren - she just recommended that whichever vet I go with should be well-versed in the treatment they prescribe and test often. Reading through an overwhelming (and helpful!) number of threads here, it seems that on the whole, lysodren has been more helpful in clearing up CC than vetoryl for most dogs, so I'm more inclined to go that route.

My regular vet has been wonderful and has gone well out of her way to help diagnose Lola, and while she has been reading up on Cushing's treatment to ensure she is taking the correct route I am feeling like she isn't as well-versed in treating Cushing's as I'd like her to be, so I've found an internal medicine specialist (one who works closely with and is in the same building as the dermatologist) who treats many Cushing's cases and is equally familiar with both vetoryl and lysodren. I was able to get an appointment with him tomorrow, so we'll see exactly what he recommends - I'll report back on that here, stay tuned!


Awesome job mom! You are doing everything right so far. Lola is very lucky to have you. I look forward to hearing what the IMS has to say.

[lola's mom]

Thank you, Renee :-)

The IMS felt strongly about an ultrasound to rule out any adrenal growths, so Lola had that done today and the adrenals were all clear. He felt that vetoryl was the best route to begin with since he feels it's easier to adjust as needed and is FDA-approved for Cushing's, whereas he feels lysodren is a bit trickier when adjustments are needed (and apparently not FDA-approved for canine Cushing's even though it's used widely for that). He's used both for Cushing's patients and typically prefers to start with vetoryl as the first approach unless there are other hormonal issues going on, in which case he said lysodren would be the better one to start with. He said that if the vetoryl isn't working over a period of time, we can always switch to lysodren and feels the unmedicated time in between that switch doesn't need to stretch out to 30 days, but can be 10-14 days...let's hope that vetoryl just works for her and no switch is needed!

While he wants to start out dosing low and slow, since Lola has such severe CC which is spreading quickly, he wants to start her out at 30mg and he wants me to bring her back in within 2 weeks for the ACTH test to see how things are going. I'm a bit nervous about starting at 30mg instead of 20mg but he feels very confident about that amount and he has many Cushing's patients...We start her first dose tomorrow AM and I'll be keeping a close eye on her and logging everything. I'm nervous but cautiously hopeful that she'll begin to turn around in time.

We go back to the dermatologist in one week, and at that time if her infection is much improved they want to take Lola off the antibiotics and put her on DMSO so that the calcifications can begin to reabsorb into her skin (antibiotics won't do that presumably). The IMS agrees with that approach. I'm nervous about all that too, but we'll see.

Does all this sound kosher to you all? Thanks for your thoughts!

[labblab]

I'm glad you've had the ultrasound performed and are receiving the benefit of additional consultation. Yes, for the most part, things sound kosher to me and given Lola's rapidly spreading CC, I do understand why he is wanting to be a bit more aggressive with the dosing. Since you are starting at about 1.5 mg. per pound, I'm glad that he is recommending ACTH testing at that initial two-week mark. I know you will be watching her really closely and will be poised to nip any problems in the bud. I'll be watching anxiously for updates!

Marianne

[Harley PoMMom]

I agree with Marianne, Lola's treatment plan sounds right to me, however; I do disagree with his statement below:
He said that if the vetoryl isn't working over a period of time, we can always switch to lysodren and feels the unmedicated time in between that switch doesn't need to stretch out to 30 days, but can be 10-14 days...let's hope that vetoryl just works for her and no switch is needed!



On the dvm 360 (veterinary medical information) website they have a Q&A Cushing's article with Dr. Feldman. Dr. Feldman is a renown Cushing's expert who has published in many peer-reviewed, high-quality journals, he had this to say about switching from one drug to another:


Any dog switched from one to the other should receive no medication for at least six weeks.

Full article can be found here: Cushing's disease and other adrenal gland disorders (http://veterinarynews.dvm360.com/dvm/article/articleDetail.jsp?id=672663&pageID=1&sk=&date=)

I am sure Lola's vet has heard of Dr. Feldman and I bet has read many of his published articles.

Will be watching for updates about Lola, and I am sure you'll do an excellent job, and remember we are here to help. ;)

Hugs, Lori

[lola's mom]

Thank you so much, Marianne and Lori! I will be sure to share the link to the Dr. Feldman Q&A with the IMS.

I have to say the more I think about it, I'm waffling on the 30mg vs 20mg start given the potentially scary side effects...The capsules I was given to start tomorrow AM are 30mg capsules.

[Harley PoMMom]

Trilostane, which is the active ingredient in Vetoryl, has a short half life, so if Lola would start having any adverse effects, stopping the Vetoryl should perk her back up. Adverse effects to watch for (although I really don't think this will happen) are: vomiting, diarrhea, lethargy, or Lola just not acting like herself. Remember too, when in doubt don't give the Vetoryl, and we are here to help. ;)

[doxiesrock912]

Some of the ladies here have used a spray that is quite effective in treating CC. Maybe your IMS would consider a combination of 20mg Vetoryl and the spray. Trizchlor spray conditioner(smells nice) and mupirocin ointment for spots that crack open.

[labblab]

Val, Terry tells us that Lola is already being treated with these medications, as well as some others, but control has been difficult.


A few days ago my frenchie was diagnosed with calcinosis cutis - she has CC patches in several spots on her body and unfortunately one of them (just above her shoulder blades) is oozing and severely infected which we are trying to get under control - it is very scary-looking. She is on Zeniquin, Chloramphenicol, Mupirocin, Silvadene, and Trizchlor shampoo & spray. She doesn't seem to be in pain except for certain spots when I apply the ointment, and she doesn't try to itch too much - she's such a good-natured dog.
Terry, I surely understand your concerns about the trilostane dosing, and without that handy crystal ball that I already mentioned :o, it's impossible to know what will end up being the best dose for Lola. However, I also understand your vet's sense of urgency as far as getting her cortisol down relatively quickly. CC is a terrible condition that can explode when untreated or undertreated. Sadly, during our years here, we have had a couple of owners who were faced with end-of-life decisions for their dogs when unmanageable CC rendered quality of life unbearable. I do not tell you this to scare you unnecessarily, but to offer a bit more context for your IMS's recommendation. I cannot tell you what the "right" dose will end up being for Lola, but as Lori says, if you do opt for the 30 mg. you can simply stop giving the drug if Lola seems to be reacting badly. Plus, the fourteen-day ACTH will give you valuable info re: the drug's effect on Lola's system and I'm sure your vet would decrease the dose at that time if it seems to be higher than is optimal.

Marianne

[goldengirl88]

I don't have any experience with CC thank God, but know many on here struggle with it, and I just wanted you to know you can lean on us for support to get thru this. Blessings
Patti

[lola's mom]

Thank you all so much for the pep talks!

The thing that scares me most is the rare sudden death issue, but there's just no getting around the need for the medication. I'm going to buckle down and go with the 30 mg dosing. Thanks again, all!

[labblab]

Good luck, and I'm betting that Lola will do just fine! But as Lori says, we are always here for you to talk to. ;)

[lola's mom]

Thank you all! I started her this AM and gave her the trilostane with her zeniquin and chloramphenicol along with her breakfast. Unfortunately, she had the same reaction as when I gave her the chloramphenicol + tramadol. About 30-40 min after her meal she started shaking, and it lasted for about 20 min or so. Then she napped for a few minutes, and then she was completely normal. She had some water and excitedly accepted a treat. She's been perfectly ok since. Do you think she just had an upset tummy with that combo of meds at one time? I'm waiting to hear back from the IMS to see what he thinks.

[labblab]

Terry, can you describe the shaking in greater detail? Did it involve her entire body, and was it constant or more in waves, etc.?

Marianne

[lola's mom]

It was upon her exhaling. I took a short video so that I could send it to the vet. Am I able to upload that here?

[labblab]

Unfortunately, no. But if you upload it somewhere like Youtube, you can then give us the link.

[goldengirl88]

I am so sorry your baby is having these troubles, and I too am anxious to we what you have on video, as it is sort of hard to visualize I know. I hope everything turns out ok and not more shaking. Blessings
Patti

[lola's mom]

Thank you.

Here's a link to the very short video - you'll see my poor girl's CC...

https://www.dropbox.com/s/z6g8oa21fq5cxc8/2014-04-10%2013.17.28.mp4

[goldengirl88]

I watched the video. It is definitely a shivering your baby is doing. My God that CC has to be the very worst part of Cushing's. Your poor little baby, I am so sorry this is happening to you. I wish someone would make some progress with this disease and find a cure. These babies do not deserve this. Blessings
Patti

[lola's mom]

Thanks Patti. It's actually really warm in my apartment, so she wasn't cold...

Thankfully, she's been ok for the rest of the day. I haven't heard back from the IMS yet, so not sure what to do for tomorrow's meds. Hopefully he will call before he leaves for the day.

[goldengirl88]

I think the shivers are not because of the cold I didn't mean it that way, I think because of pain or something. I am wondering how painful the CC is?? Maybe you could ask the vet. God Bless you both.
Patti

[labblab]

I have only a moment to post right now, but take a look at this conversation on Pansy's thread -- I believe there are similarities with what you are seeing in Lola:

http://www.k9cushings.com/forum/showthread.php?p=142905#post142905

Marianne

[lola's mom]

Thanks Patti. And thank you Marianne for that link - it looks like a few dogs including yours have had those same shivers on inhale or exhale, how odd! I feel a bit better about it though now that it is also a shared experience, but so sad to have read that Pansy ended up passing away after reading through that thread :(

I have not heard back from the IMS today, which is concerning, but I think I'll continue to give the next dose of trilostane in the morning and will call him again tomorrow AM. I will also send the link that you sent along so that he can see that a number of other Cush dogs have experienced this too.

Lola and I just came back from a short walk and she had some serious pep in her step! I'm not sure if it's the warmer weather here today, the new thundershirt I got for her, or the trilostane...

[lola's mom]

Hi All - I hope everyone's dogs are doing well! Today is day 5 of Lola on trilostane. I didn't hear much back from the IMS re: the shivering, they just asked me to continue to monitor her. I actually found a study online that showed that the shivering was a side effect for some dogs on trilostane.
http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=11916
I saw her do it once more, but no real changes for Lola in any other way (that pep in her step was very short-lived).

Unfortunately Lola now has diarrhea and just seems miserable, I feel so sad for her. Did anyone else experience this with their dogs? I'm going to call the IMS in the morning to discuss and in the meantime will withhold any further meds just in case...

[doxiesrock912]

Absolutely withhold meds and if she vomits or becomes lethargic let them know, if she vomits more than once, consider that an emergency.

I am going through the same thing with Daisy right now and our IMS said to stop. Thankfully, she only vomited once.

Anytime they are sick, stop the Trilostane.

[lola's mom]

Thank you, Valerie. I was just reading your thread and I really hope things clear up for Daisy soon. It's so frustrating to have progress only to then experience a few steps back. Thinking of you guys...

[Renee]

Thank you, Valerie. I was just reading your thread and I really hope things clear up for Daisy soon. It's so frustrating to have progress only to then experience a few steps back. Thinking of you guys...

Such is cushings, I am afraid. Lola may be reacting to the vetoryl, or it may be unrelated, but best to withhold meds and let her clear up.

She is on 30mg, correct? That may be a bit too high, and you might consider dropping down to 20mg, or splitting the dose up one in the morning, one in the evening.

[goldengirl88]

Valerie:
If you have anyone that does cold laser therapy around where you live it may be an option for the CC. I go to one for my Tipper's leg and back problems, but have read it is good at healing the CC. It energizes the cells and gets them working again, so that would be good for healing purposes. Blessings
Patti

[Harley PoMMom]

Unfortunately Lola now has diarrhea and just seems miserable, I feel so sad for her. Did anyone else experience this with their dogs? I'm going to call the IMS in the morning to discuss and in the meantime will withhold any further meds just in case...

Withholding the Trilostane along with a call to her IMS are absolutely the right decisions. Hoping Lola is feeling much better soon, if she still seems off an ACTH stimulation test should be done.

Hugs, Lori

[doxiesrock912]

When we first started, Daisy was on meds once a day. She didn't tolerate that well and we opted for twice a day. I hope that Lola feels better soon and thanks for the well wishes for Daisy.

[lola's mom]

Thanks, all. The IMS didn't think the diarrhea was related but he told me to continue to monitor her closely (thankfully I work from home). She's actually been perfectly ok today, so he ok'd me moving forward with a very late breakfast (think brunch) including all of her meds. She hasn't pooped at all today despite our many trips outside (and despite the freaking SNOW outside) and she is still eager for food and gladly accepting treats (still drinking lots of water).

So, with day 6 of trilostane nearly over, I just gave her another medicated bath with the trizchlor which I've been doing about once to twice per week in addition to the trizchlor spray and other ointments which I do daily. I don't know who the baths and ointment applications are more painful for, her or me. I'm sure it's not helping her cortisol levels at all, particularly the baths since we need the shampoo to stay on her for about 5-10 minutes. And, her CC continues to spread - I can really see it best in spots where she hasn't been shaved yet while I bathe her.

I really hope this minor bout of diarrhea last night was nothing and that the trilostane will begin to kick in soon to help improve or at least prevent further spread of the CC. I have a check in appointment with the dermatologist on Thursday to see if we should switch / add DMSO. I will also look into the cold laser therapy, thank you for that suggestion.

[Renee]

The CC will get worse before it gets better, and it goes through some very nasty stages. It seems the worst part, before I saw improvement, was when the large scabs would peel away and the skin underneath was very raw like it was recovering from a burn. After we got through that stage, the cortisol was low enough (not in therapeutic range, but lower) that the sores began to dry out more. Even as it was healing up, new spots were coming up too, but I believe the seeds for those spots were already planted while the cortisol was higher and they just needed to run their course.

[lola's mom]

Thanks, Renee. That's what her CC is like now - big scab, portions of which are crumbling off (helped by the baths), with angry raw red skin beneath. The spots that are spreading thankfully aren't oozing anything, they are just red and puffy. I really hope those don't become gooey, but I am preparing myself if they do. Renee, did all of the new spots turn oozy for you or just some?

[Renee]

The worse spots, when her cortisol was not controlled as well, were very angry, raw, red and oozy. :( So heartbreaking. There are some pictures of them in my album. The newer lesions, which popped up after her treatment was started, were less angry and seemed to stay drier. They aren't healing any quicker, but they also aren't nearly as bad as the others.

I didn't bathe Tobey a lot when her CC was bad, because I didn't want to get them wet. I don't know if that is right or wrong, I just didn't want them wet. Personal choice.

[lola's mom]

Your pug is the cutest thing, Renee. Thanks for posting all of those pictures.

[lola's mom]

Good news, no more diarrhea, just some soft poop! What a relief!

[goldengirl88]

Yeah!!!!!!!!! Better Poops!!!!!!!!!!!

[molly muffin]

Soft poops over diarrhea we'll take! :)

Might have been an upset tummy. The cortisol dropping can make them feel yucky. Some dogs get an upset tummy from the medication. (you can try pepcid ac about 30 minutes before to see if that helps)

hugs
Sharlene and molly muffin

[goldengirl88]

Checking in on Lola to see how the poop are? Hope she improves. Blessings
Patti

[lola's mom]

You're so sweet, thanks for checking in Patti!

Still soft poops, no diarrhea, but she had a bit of fresh blood in both of her poops yesterday. This happened once before about 3 weeks ago - my regular vet didn't seem too concerned about it and it went away the next day. I'm not sure if this is related to the Cushing's or something else. Has anyone seen this in their dog's stool?

We are going to the dermatology specialist today for a check in and I spoke with the IMS folks who are in the same building - I'll be bringing them a stool sample for them to check out.

Incidentally, late yesterday I saw the pet insurance submission my IMS's office made and they listed a few things that I hadn't heard directly from my IMS, which is concerning (!):

Cushings disease - known to me
Calcinosis cutis - known to me
Pyoderma - known to me
Small pancreatic nodule - He did mention this to me from the ultrasound, but said he wasn't concerned.
Mild left renolithiasis - This wasn't discussed...not sure if I should be concerned here! I will be following up on this!
Elevated liver enzymes - Presumably this is related to Cushing's?
Hypercholesterinemia - This wasn't discussed, is this something I should be concerned about? Look like high cholesterol in her blood based on my google search. I will be following up on this too!


I'm going to ask about these things when I stop by the IMS office today...

[lola's mom]

Hi all - Here's what I learned during my appointments with the derm specialist and the IMS yesterday:
- The mild left renolithiasis is so minor, and she presents no clinical symptoms so I just need to keep a lookout to see if she strains while she urinates.
- Apparently the high blood cholesterol is also related to the Cushings.
- She has clostridium bacteria in her poop so they gave me panacur granules to sprinkle over her food for 5 days, plus metronidazole for 7 days (in addition to all the many other meds she's on!).

As for her CC, the derm would like us to continue with the mupiricin and silver sulfadexine (sp?) ointments and trizcolor spray on the infected area on her neck, plus continuing with the oral antibiotics (zeniquin & chloramphenocol), plus the trilostane. For the new CC spots that have popped up (they're just red and puffy at this point, no discharge or infection) - they want me to begin to apply DMSO on those to prevent further spread/worsening of those new spots and hopefully some begin to reabsorb with the DMSO and the trilostane over time. So far, the DMSO isn't too smelly.

I'm worried about having ALL of this stuff in her system, frenchies in particular are typically very sensitive to meds. We'll see how all this goes, fingers crossed!

[Renee]

I can't remember if I asked this or not? Do you have her on some good probiotics? With so many different meds, especially the abx, her good bacterias can get out of whack. A good probiotic can help keep things healthier.

[lola's mom]

Yes, she's been on probiotics for at least 3 months now :-)

[lola's mom]

Hi All,

Just wanted to post an update on Lola. Her CC has continued to spread, however here are her ACTH test results after being on 30mg of Trilostane for 2 weeks:
pre:1.3 ug/dL
post: 3.4 ug/dL
(Desired(?) pre and post range on Trilostane treatment is 1.5 - 9.1 ug/dL based on what was listed in her first test results)

Unfortunately they listed the desired range on the lab results for Lysodren treatment (1-5 ug/dL ), and she's not on Lysodren! I'm waiting to hear back from the IMS on this issue and his interpretation.

You may recall that her initial ACTH results didn't indicate that she had Cushings, however the LDDS test confirmed that she does, plus she has the CC. For reference, her initial ACTH test results were as follows:
Pre: 2.5 ug/dL (Reference range = 1.0-5.0)
Post 15.2 ug/dL (Reference range = 8.0-17.0)

Any initial thoughts on her 2-wk pretest level being at 1.3 ug/dL?

Thank you!
Merove

[Renee]

If it's only been two weeks, then I would caution you to watch her very, very close over the next 2 weeks, as the cortisol can continue to drift down for the first 30 days. With her post figure already being so low, at 3.4, she could be at risk of going too low in the next few weeks.

Honestly - you may consider dropping back to 20mg to be safe.

The range you are in however, is a good range, I just worry about the cortisol continuing to drop.

The CC will continue to spread, as the sores underneath the surface of the skin still need to bust out (they were there long before they appeared above the skin surface). You'll know it's improving when the oldest sores start to heal, and the newer ones aren't as angry as the original sores. My pug continued to get lesions coming up for a few months after starting vetoryl, but none of them ever got as bad as the original lesions from before treatment. They still have to run their course though.

[lola's mom]

Thanks so much, Renee. I'll also let you know what the IMS says once I hear back from him.

[molly muffin]

The range for vetroyl is 1.5 - 5.0ug or up to 9.0ug if symptoms are controlled, so where she is now is doable, you don't want to go any lower on the pre though, as 1.5 is optimal. You could easily increase I meant decrease! a tad with room as Renee mentioned and stop immediately if she goes too low. As far as the cc, Renee is right about that too and she too is going through it, so hopefully the worst is over now and you'll see improvement, but cc and hair, usually the hardest ones to get over. Just keep an eye on her that she doesn't go too low.

Sharlene and molly muffin

[Renee]

Sharlene - I was actually thinking a potential decrease in the vetoryl, as she has already dropped down to 3.4 in just the first two weeks. I worry that with such low numbers, while in an ideal range, she does not have much room to drop any lower and still be safe within the next two weeks. That cortisol may continue to drop down, and it could get too low.

[molly muffin]

I meant decrease, not increase! :eek:
Good catch Renee!! I edited :)

Sharlene

[lulusmom]

I agree 100% with Renee's assessment. You don't have a lot of wiggle room and it's only been two weeks. While Dechra says a post stim of 9 is okay as long as all symptoms are resolved, I don't believe calcinosis cutis is included in the usual symptoms. Unless he's changed his opinion, Dr. Edward Feldman of UC Davis does not use the Dechra guidelines and uses a therapeutic range similar to Lysodren. I listened to one of his lectures and he states that if a post stim is above 6 or 7, the dog may have resolution of all symptoms but it will never be normal. To achieve normal, you have to get the post stim in the same range as the basal (resting) cortisol. Most labs show this range as 1 to 6 ug/dl. If I had a dog with cc, that would certainly be my goal so as to ensure resolution. Just my two cents.

Glynda

[lola's mom]

Thank you, all. Glynda - perhaps that's why the Lysodren range was listed on the lab results instead of Dechra's range???

I finally heard back from the IMS just now and based on his experience he is standing very firm on keeping Lola at 30mg until our next ACTH test, with me keeping a very close eye on her in the meantime (I work from home for the most part right now thankfully). It's already been one week since the last ACTH test, so 3 more weeks to go. I'm very nervous...I don't know what the right answer is here - keep her at 30mg or insist she be decreased. OR, keep her at 30mg and get the next ACTH test sooner?

Other things to note:
- Lola is still having those shakes/shivers as I shared in that video from before, but now they are becoming more frequent. The IMS confirmed that does happen to some dogs on Trilostane, and he'll be calling someone from Dechra today to see if they can provide anymore detail on that. Apparently Dechra staff is offsite for all of today & tomorrow for some training, so it will take a few days to receive a response, which I'll post here once received.

- Over the last week I've noticed Lola drinking slightly less water than the gargantuan amounts she used to drink. I don't think it's at her normal rate yet, but definitely a bit of a decrease.

- Sometimes when I take her out now, she won't pee at all, whereas she used to pee every single time I took her outside, even if it was only an hour in between trips. I assume this is because of the slight decrease in drinking...but she's still drinking a lot so I'm feeling like this might be a little bit weird? The vet said they didn't think it was anything to be worried about since her urgency to urinate might be less now...

- Her appetite is still great.

- Her energy is still up (periodic bouts of play and speed walking) and down (moments of looking miserable) throughout the day.

[Renee]

Okay, I can see how you are kind of stuck between a rock and a hard place, trying to decide between going with the IMS or dropping back a bit on the dosing.

My personal instinct would be to drop back to 20mg, but in place of that, I would at least want another ACTH done within 2 weeks of the last. Waiting a month is too long, as the cortisol may continue dropping. I just fear she may drop too low, and waiting an entire month to find out would make me crazy.

If you are home with her most of the time, and vigilant, as we know you are, you will be able to immediately stop the medication if she displays any adverse reactions.

Remember with cushings, the peeing causes the drinking, not the other way around. My pug decreased on peeing before she did on the drinking. she still drinks more than what I would consider 'normal', but her peeing is greatly reduced.

[goldengirl88]

Good job by Renee as that is also what I would do. The numbers are getting low lets face it. From others going thru Addisons crisis on here it scares me to death so much I will avoid it at all costs. I therefore would also drop back to the 20 mg. I have no time to read what your vet said, but please this forum has the experience where many of the vets sadly do not. This will not hurt your dog, but help to ensure it's safety which is the paramount objective here. Blessings
Patti

[lola's mom]

Hi All,

Please pardon the lag in my posts! I hope everyone's babies are doing ok.

Here's the recap and latest with Lola (FYI, she weighs 23 lbs):

Severe and rapidly spreading bloody and pussey CC in March was the first indication of potential Cushings, which was then confirmed via various tests in March & April.
She started on 30mg vetoryl for 3 wks and while her numbers went down, a tinsy bit less drinking/urination, bit more energy, her skin dried up (still looked terrible but no more blood/puss), and no more spreading of CC, she was unfortunately experiencing the shakes (Dechra confirmed this happens to some dogs) and blood in her stool so we decided to decrease her to 20mg (the bloody stool is still a mystery, but now it's gone).
After about 2.5wks at 20mg, it was clear that that was the wrong choice for Lola - her energy went WAY down, the CC began to spread again (thankfully still dry though), very very weak and shaky in her hind legs and she had a few accidents in the house. Her ACTH test at 3 wks on 20mg showed her post number increase to 5.2, whereas it had gotten down to 3.4 after 2 wks at 30mg.
Given the severe spread of the CC and everything else, we put her back on 30mg and it's now been 3 weeks since we've done that. Starting about 10 days ago, I noticed a huge increase in her energy, less shaky in her hind legs, and her urination has nearly normalized, which is awesome. Also no shakes (she had minimal blood in her stool at the beginning, but no more). Unfortunately though, her CC has continued to spread very very rapidly. She's due to have her next ACTH test in one week.


Here's the dilemma:
Despite the dramatic improvements in her energy, urination, being less shaky in her hind limbs, and no shakes/bloody stool, the dermatologist is so concerned with her CC and believes that Lysodren may be better for the CC than the vetoryl. I also saw this mentioned on a few posts here, particularly one from Gladys. The dermatologist has been debating this switch with the IMS (who has experience with both vetoryl & Lysodren) and he is open to switching her over to Lysodren. Given the severity of her CC he would want her to do a quick washout period of only 6-7 days. I've seen the posts on here and elsewhere about providing 30 days washout, but we don't think we have that amount of time here at all given how rapidly her CC is spreading. The dermatologist's concern is that it could spread to spots where it will make her have difficulty walking (paws), urinating/pooping, etc - basic function. The IMS feels confident that if Lola develops Addison's then we'll just switch over to begin treating that which he is very experienced in as well...not sure how I feel about that.

Over the last 3-4 weeks, I've seen existing CC spots expand or new ones pop up nearly every day. However, I don't believe I've seen any new ones/expansion over the last 3-4 days. So, given this and my nervousness about switching to Lysodren in general and with such a short washout period as well, we talked about giving her another 2-7 days to see if the vetoryl will kick in to stop any new CC growth. We're fighting against time in either scenario and I feel very uncomfortable with either scenario...what are your thoughts on these or options?

I will post pix of her CC over time shortly...

[lola's mom]

Here is a link to a photo album showing her CC progression over time. Despite how scary it looks, and her being a bit itchy, she doesn't seem to be in pain (except for when I need to apply her antibiotic ointments in certain spots). She is such a sweet and forgiving trooper.
http://www.k9cushings.com/forum/album.php?albumid=889

On another note, I wanted to mention that she has lost one or two teeth and the IMS specialist said that can happen due to weakened ligaments as a result of the Cushings. Has anyone else experienced tooth loss in their dogs?

I also failed to mention that about a week ago the IMS specialist recommended that we also give her lignan and melatonin supplements as those have also been shown to help with various Cushings symptoms according to a study from the University of Tennessee...She's been on those for a few days now. Has anyone seen any positive/negative results from those supplements?

[molly muffin]

The pictures in Buttercups album was before and after her radiation therapy for the macro tumor. As the cortisol went down it did improve and continues to improve last we heard.

CC is one of the hardest things to get rid of. I think they used a triacholor spray (not sure if I spelled that right) Didn't give her very many baths as you're trying to dry it out, wipes I think were used quite often.

Yes, Dechra does recommend a longer wash out period, but it sounds like they are very concerned about the cc continuing to spread. It is of course in the end up to you, we did have one dog I think do a week or two week wash between vetroyl/trilostane and lysodren, which went okay. I'd want the IMS to be very experienced with both, which it sounds like yours is.

I don't know that I have heard of tooth loss specifically due to cushings, but yes the ligaments do become weaker.

I do hope that you can get this under control. Some of our more experiences hopefully will be by soon or tomorrow even.

hang in there
Sharlene and molly muffin

[lola's mom]

Thank you, Sharlene! Yes, we've been using the trizchlor spray and shampoo too.

[goldengirl88]

Here is my suggestion. If it were my dog I would take her to a laser therapist, it has done wonders for Tipper's leg. I was told by the laser therapist that cold laser can be used to heal skin problems. I would try that. The next thing I would do is go to 15mg of trilostane. You said 20 was too low and 30 seems to have helped. Have you had an ACTH on the 30 mg yet? I would do that first. Then I would get 20 mg Vetoryl and a 5mg of trilostane from Diamondback Drugs. I would use the 25mg dose. You can ask you vet to order you some 2mg trilostane also. The reason I say this is from experience with Tipper. She can no longer take 30 mg as it makes her pre number go low. 25 mg is not enough to control her symptoms so I added 2 mg of trilostane. So she now gets a dose of 27mg. When you have the trilostane in 2mg increments it is easy to go up or down a few. I do not want to give Tipper 1mg more than she needs of this stuff so that is how I work it. There are others that combine Vetoryl with Trilostane. I like the comb as I know Vetoryl is true to the dosage where compounding is not as true. Hope this helps you somehow. I would definitely want to know about the blood in the stool though. Blessings
Patti

[Renee]

Even as things come under control - the CC will go through a period where it is working it's way out. You may be seeing parts coming up and through the skin that were there long, long before, and are just now erupting. If they aren't as angry, and they are staying relatively dry.... I wouldn't be so quick to jump to lyso. If you read my thread, you'll see that Tobey continued to have CC come up for months, she still has a few spots, but the nature and character of the spots was quite different once her cortisol was under control.

I think it sounds like 30mg is working very well.

I don't know about the cold laser therapy, as no one here has personal experience using it on CC, so it's a shot in the dark.

[goldengirl88]

It would never hurt your dog. In fact you may get a whole session and your dog will feel like a puppy after a few times. It helps their arthritis, and any musculoskeletal issues going on as Tipper had those in her back and it helped her.

[goldengirl88]

My laser therapist is highly trained and skilled, she told me she has used this for skin issues and it rejuvenates the skin well. She has been working with Tipper for over a year now, and has not reason to tell me something that is not true, so I would not consider that " a shot in the dark." That is my suggestion and I stand by it, it has worked wonders for my Tipper.