My Boston's symptoms...need advice

[Kim C.]

My 8 year old Boston Terrier, Sunny, has lost muscle on her back and hind legs over the last year. The vet did blood work and x-rays, even sending the x-rays to Texas A & M for a look. Her white blood cells were slightly elevated, and her spine looks 'stiff' in the x-rays, but she really has no other symptoms. She moves just fine. Her activity has slowed down, but she doesn't seem to have any other issues. I feed her well. She has a good appetite and has always drank a lot of water. 4-5 of her vertebrae are showing, but it doesn't seem to be getting worse. Does this sound like Cushings? The vets haven't diagnosed her with anything and are puzzled. She is my baby. Any thoughts?

[Harley PoMMom]

Hi and welcome to you and Sunny!

To me, the symptoms that Sunny has do not point to Cushing's. If you would tell us more about Sunny, hopefully we can help you figure out what is going on, ok? Could you get copies of all tests that were done on Sunny and post any abnormalities that are listed with the reference ranges and units of measurement? How much does she weigh? Does her weight fluctuate? Does she have any other health issues? Have tick-borne diseases been ruled out?

I am sorry for the circumstances that brought you here but glad you found us as we will help in any way we can.

Hugs, Lori

[molly muffin]

Hello and welcome to the forum.

I agree with Lori, this doesn't really sound like cushings. Perhaps a disc, vertebrae issue as a root cause?

Sharlene and molly muffin

[Renee]

My pug Ichiro has the same issues. His vertebrae are fusing together. I think this may be a form of myelothapy (sp?). As the back weakens, muscle is lost and it seems the back end gets quite thin and can start to slope down.

Ichiro gets quite stiff as well, and his tail is permanently down (pugs have high, curly tails). We have really helped his discomfort by using methocarbomol. It is a muscle relaxer.

[Kim C.]

Thanks so much for your responses! The only abnormality found in her blood work was slightly elevated white blood cell count, indicating infection. He gave her antibiotics but found no other signs to indicate infection. She weighs about 25 pounds. No other health issues that I can see. She's just looking thin, eating and drinking a lot, having a few accidents in the house from all the drinking, and losing muscle tone. Recently she's had a few bumps under her skin around her neck. This has happened before and they've gone away, so I'm not sure if there is a connection. My vet is puzzled and never mentioned Cushings. Would a hormonal imbalance show up in a CBC? (I'm thinking if it was a pituitary or adrenal issue...) Should I just take her back and insist he look again?

[molly muffin]

A hormonal imbalance would not necessarily show up in a CBC as you are looking for the sex hormones, but what you could do is to have a complete test for Atypical Cushings, sent to the University of Tennessee. This would show all the hormone levels, including cortisol.

If it is Atypical then a couple of the sex hormones would be elevated, the cortisol would be normal. Treatment is lignans and melatonin to start with for 4 months. so that is something you can look into.

Sharlene and molly muffin

[Kim C.]

I took Sunny for a 2nd opinion and she was confirmed as having Cushings. He is starting her on Trilostane. She is at the higher end of the 'possible/likely' numbers (20.3 with 22 being absolutely positive). I am glad to finally know what the problem is and be able to treat it. Anything I should watch for with this medication?

[Squirt's Mom]

Was that from an ACTH? Is this the only test she has had to diagnose Cushing's? Did she ever have the special ACTH from UTK?

Just me, but no way I would start my baby on such powerful drugs as Vetoryl (Trilostane) nor Lysodren based on a "possible/likely" especially since her profile, from the little we know so far, does not fit with Cushing's.

[Squirt's Mom]

Here is a link to our Helpful Resource sections thread on Vetoryl (Trilostane). It will tell you all about this drug. ;)

http://www.k9cushings.com/forum/showthread.php?t=185

[Kim C.]

I have been reading about the drug. I'm not sure what tests were done, but I can find out. Thank you for the link. I'll look at it, too. This vet is a small animal only doctor who has dealt with Cushings dogs before. I know his tests were much more extensive than the first vet I used. He talked about the results in great detail but I can't remember all of it. He's putting her on it for two weeks and will then do blood work again. He said that the extensive water drinking (even that showed up in her blood work), the new skin issue, how the results showed something about the liver, and other areas that were 'kind of all over the place' being typical for the disease. I'll ask him lots of questions and get back to the forum.

[Squirt's Mom]

PLEASE PLEASE PLEASE get copies of the actual test results and post them here before you start the treatment. PLEASE.

[Kim C.]

Sunny started Trilostane today. He gave her 50 mg tablets, which is 10 less than the recommended for her weight. I'm glad to at least have something to give her that can help her. At least this vet has knowledge of the disease and treatment.

[Renee]

50 mg is much, much too high. If Sunny weighs 25 pounds, then 20mg would be the max to start at.

I sincerely hope your vet has at least instructed you what to watch for in terms over overdose, etc. Do you have prednisone on hand, just in case?

I am afraid you've jumped into this too quickly. If her post cortisol was only 20.3 on her ACTH, then she's not in even in range to have cushings. Why would you and your vet give her vetoryl, if her test does not even indicate for certain that she does have cushings?

[Kim C.]

I had to jump into something quickly. She needs help. I am not an expert and must trust someone to diagnose her. She has taken it since Saturday and her water intake has gone back to normal. She played for the first time in a while yesterday. No, I don't have prednisone. He seemed confident in his diagnosis and has experience with the disease. He said that the tests he did were far closer to a confirmation than to eliminating the possibility, so he wants to try the medication. The dosage is slightly less than what is recommended for her weight when I look at several reputable online sources, including the manufacturer. Why would I give her the medicine? Because it is the first real option I've had to try to make her better. I will call the vet today and ask about it. He's obviously trying to help her, but I do not want to hurt her while trying to help. Thank you for your warning. Do you have a vet who specializes in this? Would he/she be willing to talk to my vet?

[Squirt's Mom]

Even tho the information from the manufacturer in their literature recommends a starting dose of 2.2-6.7 mg/kg, more recent studies performed by UC Davis have determined the starting dose should be 1mg/kg. Dechra has not changed their literature and is not likely to any time soon but this information has been available for some time now. Here is a link to our Helpful Resource section on Vetoryl (Trilostane) -

http://www.k9cushings.com/forum/showthread.php?t=185

[Kim C.]

Thank you.

[Kim C.]

I have a copy of her most recent blood work. ALKP was high (1009 U/L). It says normal range is 23-212. ALT is on the line between normal and high (150(U/L). Other high numbers were BASO, PLT, and PCT. RDW was 20.6 (21.8 would be high). ACTH Stim <2. Is there anything else on the test I should look at/share?

[labblab]

Just to muddy the water further, an alternative dosing schedule to the one that Leslie has mentioned as being advocated by UC Davis (1 mg. per kg.) is one that is now promoted by Dechra themselves and by many other specialists worldwide: 1 mg. per pound. Here is a quote from a Dechra publication that is more recent than the dosing chart contained in the U.S Product Insert.


Ideally, the starting dose to aim for is 1.0 to 3.0 mg/lb (2.2 to 6.7 mg/kg) once a day based on body weight and capsule size. When calculating dosage, it is suggested to round down. Start at the low end of this range. If you have any questions on dosing, contact Dechra Technical Support at 866-933-2472 or support@dechra.com.


http://www.dechra-us.com/Cushings-Syndrome/Veterinarians/Prescribing-VETORYL-1.aspx

Having said all this, however, every dog may metabolize the drug differently, leading to the need for individual dosage increases or decreases once the treatment has begun. That is why the subsequent monitoring tests are so important. If your girl has been taking the drug for five days now and you are seeing only positive results, then it may be "backdoor" validation for the diagnosis and it may be the case that this higher dose is indeed suitable for her and may be where you would have ended up, anyway. But you will want to continue to watch her very carefully, though, and proceed with another monitoring ACTH within a couple of weeks in order to get a clearer picture of this dose's effect on her cortisol level.

Marianne

[Kim C.]

Thank you for your post, labblab, and especially for noting that the diagnosis could be correct and that the medicine might actually help her. I will continue to watch her very, very closely. She goes back a week from Saturday for retesting. I will post how that goes and will talk to my vet about the new dosing schedule.

[Kim C.]

Day 10 of Sunny's treatment. Saturday I started giving her half a pill (it's not a capsule and has a line drawn down the middle), the recommended dosage, just because I kept thinking about what was said on this forum. She's pretty much the same, except her skin spots have started flaking. I don't know if that's a sign that it's getting better or not. I'm spraying it twice a day with Genesis Topical Spray I got from the vet.

[molly muffin]

So you are giving her 25mg and she weights 25lbs.

That is interesting that it is a tablet that can be broken in half and not a capsule Not sure I've heard of that before. Is it compounded trilostane or is it vetroyl tablet (from Dechra) if trilostane, which pharmacy is doing the compounding.
I'm curious as this would be a new format for the pill than I am use to seeing and could be handy for many other members if it can be split safely down the line.

It takes the longest time I think for the skin to clear up, so don't get discouraged and keep treating with the tropical spray. Hopefully it will clear up sooner than later.

Sharlene and molly muffin

[Kim C.]

Just another update on Sunny. She's on 25 mg of Trilostane per day. I'm giving her half in the morning and half in the evening. Everything seems good except her skin problem. The vet gave me first a spray, then switched to antibiotics and a special bath shampoo and rinse to be used twice a week. She's not itching terribly, though I don't see how! I think it's better...not infected at all...but it just isn't going away. They're little raised places on her back and sides, and the skin is kind of hard in those places. She goes back for blood work again Saturday, so we'll see if the Trilostane is keeping her level and what he thinks about her skin.

[molly muffin]

It takes a very long time for cc to clear up. There are hard little deposits under the skin and those all usually have to come up and out with no more developing.
Let us know what the vet says

hugs

[Kim C.]

I will and thank you!

[Kim C.]

I just saw this post! The bottle the pills come in is a vet office bottle, and it just says Trilostane. The pills are tan and have a line drawn through the middle for easy breaking. There's a symbol on one side, but I can't see what it is. I'll ask more about them Saturday.

[molly muffin]

Yes, if it says trilstane then it is compounded. I just wonder which pharmacy does the compounding into pill form as that would be very handy for some of the members to have.

Mine are capsules and can't be split.

hugs

[Kim C.]

The pharmacy is Wedgewood. Hope that helps! Sunny's blood work was good Saturday...in the normal range. I got a refill for the antibiotics for her skin, and I'll keep using the medicated shampoo and rinse twice a week.

[molly muffin]

Yay for good bloodwork!
I think wedgewood also has trilostane in dog tablets and treat form.

[lulusmom]

Hi Kim. Can you please post the actual results of the acth stimulation test that was done on Saturday? If you don't have a copy of the test results, your vet's office should be happy to give you the pre and post stimulated numbers. There's only two number and all you have to remember is which is the pre stimulated number and which is the post.

Glynda

[Kim C.]

Sorry it's taken me so long to get back. The numbers I'm looking at show CORTO6 to be 20.3 in September. October was 6.4, and November was CORTO8=6.2. She's still taking 25 mg per day, split into morning and night. If she seems to feel a little bad, I sometimes skip a dose (which is really a half dose). Are those the numbers you mean? I have the lab reports. If that's not right, are there codes on the report I can look for?

[Renee]

There should be a baseline (pre) figure, and then a post figure for her cortisol, so two numbers.

If the post is 6.2 ug/dL, then she is in a good range... except that controlling CC (assuming she has CC) requires tighter control. How are her other symptoms?

[Kim C.]

Her skin has gotten better. She has stopped losing hair, though the calcifications are still there. I'm still bathing her twice a week with KetoChlor shampoo and using the leave-in lotion. She doesn't seem bothered by it at all. She is eating and drinking normally. We stopped the antibiotics. She looks a little rough, but seems to be doing well. I'm taking her back for the vet to look at her skin when I refill the Trilostane, and we'll talk about when to do another blood test. I'm wondering if I should try to give her just 1/4 of the 50 mg tablet once each day instead of 1/4 twice a day. I don't want her to go backwards, but I don't want to give her more than she needs.

[labblab]

Kim, with these positive results I would definitely not cut back on the trilostane dose. You really will risk a rebound in symptoms, and as difficult as managing CC can be, I cannot imagine risking going backwards again at this point. This is all assuming that the ACTH results remain within a safe and good therapeutic range. If that 6.2 represents a "post" ACTH result, then as Renee says, you are already on the high side of maintaining ideal control. I really, really don't think you want her cortisol to go even higher at this stage. And if that number represents only a single, baseline cortisol draw, then it is also a high reading rather than a low reading. If it was me, I would stay the course right now and not risk decreasing the dose at all.

Marianne

[Kim C.]

I will continue that dosage, then. Thank you!

[Kim C.]

Just an update on Sunny. Her last test showed 4.2. I had reduced her Trilostane to 12.5 mg a day. She's done okay on that for a bit, but the last few days she seemed very lethargic, somewhat shaky on her feet, and just seemed to feel bad. Knowing the dangers of too much Trilostane, I did not give her a dose this morning. She was better when I checked on her at lunch. I'm thinking of switching to an evening dose, so she will be sleeping when the medicine is at its strongest, because she appears to get better in the evenings. The other alternative is to reduce it again. Any thoughts on this?

[Renee]

You don't want to switch to an evening dose only, as the testing protocols require a stim test 4-6 hours after dosing.

The only way to know if the cortisol has dropped too low and account for her shakiness would be to run another stim test. She could just be a dog that requires a bit higher level of cortisol. If she's been acting lethargic and off for the past few days, then I think a stim test may be in order. You were smart to withhold her trilo for now.

Depending on her numbers, dropping the dose down might be advisable.

[labblab]

Hi again, Kim. Can you please tell us the date of this most recent ACTH and also the date Sunny started on the reduced dose? If the current dose is too much for her, the solution needs to be reducing the dose again as opposed to giving her the medication in the evening. All monitoring ACTH tests have to be performed 4-6 hours after dosing with food. If you give Sunny her once daily dose at night, there will be no way to proceed with accurate ACTH testing from that point onward.

Please do let us know about the timing of the most recent test and also the dosing change. Thanks!

Marianne

[Kim C.]

You are right about the evening testing time. I didn't think about that. She was tested Tuesday the 23rd after about 2 weeks on that dosage. Her number had dropped 2 points even after the reduced dosage.

[Renee]

If her numbers continued to drop, even after reducing her dose, and you are seeing some questionable symptoms, then I think it may be wise to get anther stim test and consider taking a break from the trilo for a short time, then start back up on a reduced dose.

My girl was off her vetoryl for 3 weeks when she came down with pancreatitis. I was worried about getting her cortisol back into range and how long that would take. It only took a month to get her back into perfect range. So, I don't think you have too much to worry about in terms of 'messing up' your progress, if you choose to just stop the trilo for a while.

[Kim C.]

Sounds good. It's good to know I have a little room to work with the dosage.

[RemiCash]

Remi (boston terrier) has been on 60 mg. once a day for 2 years now. Perhaps it is just me, but I would not consider playing around with his dosing. I do know the testing should be done around the same time of day, each time it is done (for me, it is every 4 months). Vetoryl is out of their system in 13 to 18 hours each day.

[Kim C.]

I have to make adjustments based on the way she feels and acts. If I had kept it at the original 50 mg a day for her, I'm pretty sure she would have gone from a Cushings dog to an Addisons dog very quickly. The vet told me I did the right thing by reducing it. It's great that the first dosage tried worked great for him! I hope to get Sunny settled in soon, though everyone says it's not unusual to make adjustments along the way.

[Renee]

You are doing good Kim. You absolutely have to make dosing decisions based on symptoms, and Sunny appears to be quite sensitive to trilostane.

[Kim C.]

Thank you, Renee. It's quite scary!

[Kim C.]

Sunny has been on about 6 1/2 mg of Trilostane in the mornings for about 3 days. After a few days without any medication, she started to drink more water, though overall she seemed to feel better. She seems good on this dosage for now. The excessive drinking stopped after two doses. I hope this works for awhile. I'll take her for testing again in two weeks, unless she develops issues before then.

Do you use heartworm prevention on your Cushings dogs? Sunny was on Advantage Plus for years, but I stopped when she became ill because the package says not to use it on ailing dogs. My vet told me to go ahead, but I haven't yet. I hate to put a pesticide on her, and the oral preventatives worry me as well.

[judymaggie]

Kim--I live in Florida and it is essential that heartworm treatment is used year- round. My Abbie was heartworm positive when picked up by animal control. She was treated prior to coming home with me. Fast forward five years-- yes, she has Cushing's but I honestly don't consider her as "ailing". Neither her vet nor her IMS have ever suggested I stop heartworm preventative. I give Abbie Heartgard Plus (used generic Heartgard until no longer available). In my mind the possibility of Abbie getting heartworm totally overrides any concerns about side effects (if, indeed, they exist) because of Cushing's.

I am confused by your reference to Advantage Plus as it is my understanding that is just for flea treatment.

[Squirt's Mom]

I used Advantage Multi on Squirt with no problems. It covers heartworms, fleas, and several other parasites but not ticks. Our area is high in heartworm occurrence as well.

[Kim C.]

I was referring to Advantage Multi. My mistake. Side effects do exist for both topical and ingested worm prevention. The information on the package says: "Not for use in animals hypersensitive (allergic) to imidacloprid or moxidectin. Do not use in animals who are sick, debilitated, or underweight." I just wanted another opinion before I put something like that on Sunny. I live in East Texas, so heartworms are a huge problem. Of course I do not want Sunny to have to try to deal with that in addition to her Cushings, so between the vet and y'all, it looks like that's what I should do. Thanks for the advice!

[LauraA]

My Cushing's girl still gets her yearly heartworm injection, and we use Avantix or frontline for flea treatment. However my vet did stop giving her vaccinations after her diagnosis.

[Kim C.]

So no rabies shot, too? I was worried about the heartworm preventative but hadn't thought about vaccinations...

[judymaggie]

In some states you can get a waiver for the rabies shot based on medical conditions; other states you can't. We have racoons in my neighborhood so I will still have Abbie get a rabies shot. My vet pre-treats Abbie with a Benedryl injection to help avoid any negative reaction.

[Kim C.]

I will ask my vet about that. I want her to get everything she needs but not suffer because of it.

[LauraA]

Being in Australia we don't have to worry about the rabies shot fortunately :)

[Kim C.]

Sunny has been doing well on 5 1/2 mg of Trilostane for a few weeks, but yesterday she had a crash. Wouldn't eat or drink, just lying there...it was quite scary. I gave her water with a syringe and watched her closely, ready to take her to the ER. Shortly after the meds would have peaked in her system (a little over 6 hours), she perked up, ate, drank, and walked around. I didn't give it to her this morning, and I'm planning on taking her for blood work again this week. Should I try a different medication, like Lysodren or Veterol, or are they pretty much the same? Is Veterol pretty much the same thing? I don't mind continuing the Trilostane, but I hate seeing her feel so badly. Thanks in advance for your advice!

[molly muffin]

Oh goodness. That sounds like a very scary episode. Vetroyl is the same things as trilostane just a brand name. Lets see what the levels are like now.
That is a very profound sensitivity. Are you using the liquid trilostane? Would that be easier perhaps, as you could control the dose and take it even lower if need to?
How is Sunny doing now?

[Kim C.]

She is better! I hope to take her Thursday for a level check. I'm still giving her water through a syringe occasionally when her mouth is dry so she won't be dehydrated. She's decided I should hand feed her now. I was already feeding her with a baby spoon, but now she thinks I have to literally use my hands. She's gotten a little quirky. :/ I'll post test results when I get them.

[Kim C.]

Sunny was at 10 Saturday. After 5 1/2 days without any Trilostane, it had gone up 7-8 points. She was drinking more water but not feeling as badly as before. Frustrating, but the vet on call Saturday couldn't advise me and I can't talk to my vet until sometime this morning. I went ahead and gave her 5 mg Saturday and am waiting to hear what the vet suggests. I'm thinking every other day might be something to try. What do y'all think? She felt good yesterday and this morning. She's more active and is eating and drinking fairly normally.

[Harley PoMMom]

Sunny was at 10 Saturday. After 5 1/2 days without any Trilostane, it had gone up 7-8 points. She was drinking more water but not feeling as badly as before.

I'm not sure what test those results are from, was an ACTH stimulation test performed, and if so could you post those results here?
with a full ACTH stimulation test there will be two numbers we need to see, a pre and a post.



Frustrating, but the vet on call Saturday couldn't advise me and I can't talk to my vet until sometime this morning. I went ahead and gave her 5 mg Saturday and am waiting to hear what the vet suggests. I'm thinking every other day might be something to try. What do y'all think? She felt good yesterday and this morning. She's more active and is eating and drinking fairly normally.

If you could get those ACTH results for us to see we may be able to help. If those results do show low cortisol than the Trilostane should not be restarted until her cortisol has rebounded.

Every other day dosing is not recommended as it leaves the cortisol fluctuating too much.

Hugs, Lori

[Kim C.]

They are supposed to fax me the results but haven't. Since I haven't seen them, I'm just going by what the vet told me on the phone. The level that originally was in the low 20s, then dropped with medication, even after adjustments, to 2...is the number we talk about. Hers confused him because it came back simply >10, so he called the lab and talked to one of their vets. All they did for Saturday's test was draw blood, waited until it clotted, and then ran it. He's going to have them make her 2 mg tablets because he felt her level was higher than it should be without the Trilostane, but he is more afraid of it dropping too low. He said we wouldn't try every other day unless we had to...for the same reason you mentioned. She just doesn't seem to need much. When they fax me the test result, I'll scan and attach it if I can.

[Renee]

I'm afraid your vet may be basing decisions on the resting cortisol (baseline). If he is, then he could be making some very big assumptions. That resting cortisol can fluctuate quite a bit and is not an appropriate tool for judging trilostane / vetoryl affects.

The fact that he said her number was confusing because it was >10 means he is looking at the baseline. The in-house labs generally cannot compute a baseline above 10.

I really hope I am wrong, but if your vet has not run a full ACTH, then I would demand one immediately before moving on.

[Kim C.]

I believe he's only done that test once, when she was diagnosed. The rest have been baseline tests. Do you think the low dose test would be sufficient?

[Squirt's Mom]

The low dose dex, or LDDS, has no value once treatment has started. It is a diagnostic test only. ;)

[Kim C.]

I was reading about the ACTH test and it said there were three methods: low dose, which takes about an hour, and two others that took longer. Do they do a baseline, then give an injection, then another baseline?

[Kim C.]

Wow, that is a lot of great information. It helps so much to be informed when you go to a vet because, unfortunately, all vets don't know what they should about the animals/illnesses they are treating. I really like this new guy I've taken Sunny to, but if I don't know what to look for/ask for, then I can't help Sunny by being sure she's getting what she needs. Thanks very much!

[Harley PoMMom]

The length of time it takes to do the ACTH depends on which stim agent is used and I don't know which one takes the longest. When Squirt was having them it took 4 hours - they drew her blood (where the pre number comes from), gave her the injection of stim agent, waited four hours and did another blood draw (where the post number comes from).

I'm not familiar with an ACTH stimulation test that takes 4 hours to perform. When using Cortrosyn as the stimulating agent, the pre blood draw is taken, and then the Cortrosyn is injected, than the post blood draw is done after a hour.

When Acthar gel is used as the stimulating agent, after it is injected the post blood draw is taken at 2 hours.


An endogenous, or baseline, ACTH is the pre blood draw; no stim agent is used so there is no way to measure how much cortisol is in the adrenals to know if the med is working correctly or not - it measures how much cortisol is flowing in the blood at that particular moment which can change in five minutes, up or down. The post draw, after the stim agent is used, tells the tale on how treatment is working.

The Endogenous ACTH test is used in trying to differentiate between the adrenal or pituitary type of Cushing's. It measures how much ACTH (adrenocorticotropic hormone) is in the blood. If the Cushing's is caused from a tumor on the pituitary gland the ACTH concentrations will usually be elevated.

If the Cushing's is adrenal related the ACTH concentrations will generally be decreased.


As for a "low dose" ACTH, I can't answer that but maybe one of the resident gurus can. To me "low dose" means the Low Dose Dexamethazone Suppression Test, or the LDDS/LDDST. ;)

I believe what she may be referring to is the dose of Cortrosyn used in the ACTH stimulation test. Cortrosyn is supplied in vials each containing 0.25 mg (250 μg) of synthetic ACTH (cosyntropin).

For years that whole vial (250 μg) was used for one ACTH stimulation test, however, studies now show that only 5 μg/kg is needed to perform an ACTH stimulation test, which can be referred to as a low-dose ACTH stimulation test.

Intramuscular administration of a low dose of ACTH for ACTH stimulation testing in dogs. (http://www.ncbi.nlm.nih.gov/pubmed/16910850)

Hugs, Lori

[Squirt's Mom]

Thanks, Lori! But it did take four hours for Squirt's ACTH. ;)

[molly muffin]

And it takes 3 hours for molly's, and 3 blood draws currently, base, 1 hr and 2 hr.

[Renee]

I'm in AK and all the stim tests we've had done have taken 1 hour (for synthetic cortrosyn) or 2 hours (for the gel).

[molly muffin]

2 hours is what I should have said. 3 draws, 2 hours.

[Kim C.]

After tests and adjustments, Sunny has been on 2 1/2 mg of Trilostane daily and is doing well. I'm also bathing her with Ketachlor and using the rinse about twice a week. Her skin is still extremely calcified, but it has not gotten worse. My concern now is that she is so thin. She has a good appetite, though I've spoiled her to hand feeding, but she looks so thin. Her normal, healthy weight was 25 lbs. and now she weighs 21. Any suggestions for adding some healthy weight to her little body? She will only eat meat and occasionally a piece of cheese.

[Harley PoMMom]

Carbs can definitely put weight on, do you think she would eat carbs? You can mix them with the meat to make like a meatloaf. The carbs I'm thinking of are: pasta, rice, oatmeal, potatoes. Hey, what about baby food?

There is one supplement I can think of too:
Nutri-Cal High Calorie Palatable Dietary Supplement For Dogs 4.25 oz Tube : http://www.1800petmeds.com/product.jsp?id=prod1340&sku=1340&AFFID=GG&ID=1327711090&adpos=1o2&creative=45746555666&device=c&matchtype=&network=g&gclid=CJyVmrfl1cQCFQpk7AodynQAVg

Hugs, Lori

[Kim C.]

Thanks, Lori. I will definitely try the supplement and mixing her food with some carbs!

[judymaggie]

Hi! I used Nutri-cal with my Maggie (Cush pup now at Rainbow Bridge). I got it from the vet but it is now available on-line at a much better price. I think I've also seen it at PetSmart and/or PetCo. It is a strange consistency -- very pasty and can get pretty messy. Maggie would just lick it off a spoon. Hopefully, Sunny will like the taste and do the same.

[Kim C.]

Thanks, Judy. I'm going to try it!

[Kim C.]

I have another question for y'all. Sunny is acting strangely about drinking water. She will occasionally stand in front of it and paw at it, like she's afraid to drink it. Not all of the time, though. I bought a stand that puts it up to her shoulder level, but sometimes she will knock it over even if it's full. I'm wondering if it's just a Boston thing because of her push face. When she puts her face down, her nose is close to the water. She is having a little allergy stuff right now, and I think it makes it worse. She is also having fairly long periods of time walking randomly around the house. She will end up standing in a corner or between two pieces of furniture...just looking a the wall. When she comes in from outside sometimes, she goes to the corner of the porch instead of the door and just stands close to the wall. She's about 10 years old and is doing great as far as Cushings symptoms goes. Do you think it's just an aging Boston's eccentricities or does it sound like something you have seen before?

[Squirt's Mom]

That sounds sadly like a neurological issue, either a macro, other brain tumor, or something like doggy Alzheimer's. I would take her to the vet and explain what I was seeing. ;)

[Kim C.]

Her symptoms are definitely those of Alzheimer's, or Cognitive Dysfunction Syndrome. I'm reading that melatonin can provide some relief from the stress she feels and will help her sleep at night. I have not slept all night in weeks because she moves around a lot and I am constantly on watch for her. (It's like having an infant again!) She's never been crated, and she is adamant that she will sleep in the bed with me. I don't want to cause her more stress. Can I give her low doses of melatonin if she's taking Trilostane? I'll talk to my vet, but I trust y'alls opinion, too. In many ways, this forum has been more informative than he has.

[labblab]

Hi Kim, I'm not aware of a problem with combining melatonin with trilostane, so I think you can safely give that a try. However, I have a couple of different worries about Sunny. Do you know whether she has ever had an ACTH stimulation test to check her adrenal reserves? I've just now looked back through your thread, and it earlier sounded as though the only monitoring testing that your vet was doing was to check Sunny's baseline cortisol levels. Since she is acting so abnormally right now, I really think it is crucial that a full ACTH stimulation test be run in order to make sure that her adrenal function is not being oversuppressed by the trilostane, even at this low dose. Low cortisol can definitely cause worrisome behavior of many kinds.

In the alternative, if the ACTH shows that Sunny's cortisol level is fine, I am worried that Leslie may be right about the possibility of an issue in her brain. I don't think it has ever been determined whether Sunny's Cushing's is caused by a pituitary tumor or an adrenal tumor. But if she does have pituitary Cushing's, the tumor may be enlarging and placing pressure elsewhere in her brain. Unfortunately, dogs with smushed faced like Bostons seem to be at greater risk for this problem due to the shape of their skulls and their brain configuration. Loss of appetite and/or ability to drink, and aimless wandering are often associated with enlarging tumors. I watched the same thing happen with my own Cushpup, and although we never did have confirmation via imaging of this head (CT or MRI) that his tumor had expanded, we do believe that was what had happened.

If an enlarging tumor is the problem, treatment is a possibility which we can talk about some more. But first of all, I agree with Leslie that these are symptoms that you need to talk over with your vet so that he is also aware of what is going on. And as I say, performing an ACTH stimulation test is probably the first thing that should be done, regardless.

Marianne

[Kim C.]

The ACTH stim test was done early on, but he has not thought it necessary to repeat it. When I asked for another one, he just did the single draw test. Can you tell me why he needs to do that instead of just the one draw test? That way I can help him understand. He determined that she does not have a tumor. She hasn't had the main symptom she had when she was getting too much Trilostane: diarrhea. She is eating well and moving around okay. She has not lost any more hair, though he told me he has never seen a case of cutis calcinosis as bad as hers. I spoke with him today and he said it could be cognitive dysfunction. He described her symptoms before I could list them for him. She's always had issues with drinking when she has allergy-type symptoms. She gets very croupy. She has a small hernia in her esophagus that was found when my first vet checked her out. (He did multiple xrays and blood tests but apparently didn't know to check for Cushings... thus my search for a new vet for her.) It caused her to throw up frequently. Since I hand feed her and stop when she starts having trouble swallowing and breathing, she's done much better. I feed her slowly and hold it so that she holds her head up to eat. She will let me give her water with a syringe (I don't want her to get dehydrated.) and does better if she drinks with her head up. I bought a crate waterer (the kind that hangs with the ball that releases the water) and hope that will help, too. I'll talk to him again about the STIM test, and I'm going to try melatonin this evening. From what I've seen, 1 1/2 mg is what I should give her (she's 21 pounds). Do you think I should stop the Trilostane until I can talk to him about a STIM test? I was thinking she was doing well on this dosage, but I don't want to hurt her. Thanks so much for your help!

[Squirt's Mom]

He determined that she does not have a tumor.

Sweetheart, true Cushing's with elevated cortisol always, always, always involves a tumor. Either on one or both of the adrenal glands or on the pituitary gland. The pituitary gland is in the skull. You're vet simply cannot, must not, dismiss the possibility of a macro. That is not what we want but the correct treatment is crucial.

[labblab]

Kim, when did she last have the single cortisol draw, and do you know what the number was? As long as that test was done fairly recently and the number was safely above at least 2, then probably low cortisol is not the issue with her right now. However, the baseline draw alone is only giving you one piece of information about Sunny's adrenal function. You usually cannot rely on baseline cortisols alone when making decisions about increasing the dose, but that is a different issue. I'll try to come back later to give you more information about that.

As far as a tumor, I'm afraid your vet is somehow confusing you about that. If Sunny truly has Cushing's (and it is not being caused by giving her supplemental steroids which you are not), then she has to have a tumor either in her head (on the pituitary gland), or in her abdomen (on an adrenal gland). Cushing's is caused by a tumor in one place or the other. The way to find out for certain is by doing an abdominal ultrasound to see if there is a tumor on one of her adrenal glands, or to perform a CT or MRI scan of her head to see if there is a tumor on the pituitary gland. It doesn't sound as though your vet has done any of this imaging nor a LDDS blood test, either (this blood test can sometimes help identify whether the tumor is on the pituitary).

By far, the majority of Cushing's cases are caused by tumors on the pituitary gland. More often than not, they remain small enough to not cause neurological problems. But sometimes they do enlarge enough to negatively affect other areas of the brain. So that is why I am worried about this possibility with Sunny.

Marianne

[Budsters Mom]

Hi Kim,
I have been reading along. Yes, approximately 85% of all regular Cushings (not Atypical) is caused by the pituitary type. The other 15% is Adrenal. Both are caused by tumors. It is only when a pituitary tumor starts to grown significantly and puts pressure on the brain that neuro symptoms occur and the tumor becomes a macro. Many pituitary tumors remain small and the dog's Cushings can be successfully managed. I have learned much more than I ever wanted to know about pituitary macroademas ( macro-tumors). I lost my little Buddy almost two years ago. Although the news was devastating at the time, I am still grateful that I knew and could prepare the most comfortable treatment option available for him. We are not trying to scare you. We are just suggesting that you talk with your vet and voice your concerns. Neuro signs can definitely point to a macro as there is limited space for a tumor to grow in the brain, but something else could also be going on.

My recomendations for now would be....

A possible referral to a vet who has more experience dealing with Cushings

Getting an ACTH test ASAP. You need to know what is going on with Sunny's Cortisol.

A Neurology Consultation for peace of mind.

The Neuro consultation was $$$$ well spent. $130 for a two hour appointment. They had all of Buddy's history. He was seen by a neurosurgeon and team of neurologists. The neurosurgeon managed Buddy through his regular vet free of charge until he passed on, monitoring him daily. Yes, 24/7. His regular vet didn't charge either. There are people who will help and care. I paid for meds only and got those at Walmart or Costco.

I don't know a fraction of what the others know around here Kim. All I can tell you is my own experience. For me, it was better to know.

Kathy

[Kim C.]

I should know that, with all that I have read. Now I'm not sure what he meant by that, unless he meant that she did not have the kind that could be removed? I hate to appear ignorant when I've tried so hard to understand this issue. :(

[Kim C.]

Thanks, Kathy. I wish I knew of a vet with more experience with Cushings. This one has dealt with it but is definitely learning with me on some of the things that have come up. That frightens me but I don't know of anyone else in the area. If her cortisol is showing within the normal range, does that mean that the tumor and it's effects are under control?

[Kim C.]

Marianne, her level has been between 2 and 3 the last few times she has been checked. I appreciate the clarification I am getting here. He based his decision about the tumor on the original Stim test results. It seems like he referred to her liver showing healthy numbers. More confusion. He has not done any ultra sounds or scans. I think he is trying but just doesn't have enough experience with Cushings. Any suggestions on how I can find a vet with Cushings experience? I don't know anyone locally who has a dog with it. I went to this one because he only works on small animals (most of ours in the area handle horses and cows as well), and I thought he'd be more knowledgeable with a narrower focus.

[Kim C.]

Kathy, was the neurologist you took him to at a university? Was he an animal neurologist? The closest university we have with a vet school is Texas A & M. It's about 5 hours away, but I would take her if I can.

[Budsters Mom]

Yes, the Neurology department was part of an animal specialty hospital. They do cutting edge treatment there including transplants. The consultation was well worth it, but otherwise, the prices were far beyond my budget. Without the neurosurgeon's willingness to help, I would still be second guessing some of my decisions. She and my vet (since retired) are truly Angels.

I live in an area with many resources and choices of care available. 5 hours is very far to go for some answers. Many of out members have driven long distances to go to a vet school for help, but are glad they did. I am truly sorry that this is all so hard and frustrating.

You do not appear ignorant with regard to Cushings. I had never heard of it before Buddy came down with it.;)

Kathy

[labblab]

Kim, I hate it that you would feel badly about still having questions or confusion. Cushing's is a very, very complicated disease and you are doing a great job taking care of Sunny. It sounds as though you are trying to get the best help for her you can, living in an area where there are not a lot of small animal vets available. I have many relatives who live in very rural areas, so I really do understand your dilemma.

I agree with Kathy that five hours is a long way to drive. Plus, the tests that provide images of the head are very expensive. That is one reason why my husband and I did not have it done, either. But it is good to know that you have Texas A&M as a possibility in case Sunny worsens and you really want an expert's opinion. If an enlarging pituitary tumor is causing the problems, I think the problems will keep getting worse and you can then decide if you want to take her. But maybe, hopefully, this is a temporary issue that will soon normalize on its own.

As far as the baseline cortisol being in normal range, that does suggest that Sunny's cortisol is not dropping too low on the trilostane. But it does not tell us whether or not the tumor is growing and pressing on her brain. It is the neurological symptoms that would tell us that.

Also, the baseline cortisol does not give the whole picture as to whether Sunny's adrenal glands are still over-producing cortisol in response to stimulation (that is characteristic of Cushing's when the dose of trilostane is not high enough). That is why the ACTH stimulation test is important in deciding whether the drug dose should be increased. But right now, given Sunny's behavior, I don't believe you would want to increase the dose, no matter what.

So let's see what the next few days bring, and whether or not things change for her in any way. Please keep updating us, OK?

Marianne

[pansywags]

Kim, learning about Cushing's and how to be my dog's advocate felt like getting a crash veterinary course. It's a lot of info and it's really complex and even many (most?) otherwise quite competent vets don't have the knowledge base to deal with it, so you are doing great!

I am someone who traveled to a veterinary medicine teaching hospital (UC Davis) with my dog because I couldn't find good Cushings diagnosis and treatment competency in my area. In my case, I only traveled 2 hours (each way), but I did stay overnight for two days of diagnostics that were recommended after our initial consult. It was the first time I found Cushing's knowledge that matched this group.

[Kim C.]

Thanks so much for your encouraging words. Last night I noticed a small, hard knot on the top of her head. It's not fluid, so it's another thing to try to figure out. I recently read that Trilostane could cause growth in pituitary tumors, though I'm not sure that's proven. I think it was in a university study I found online. My vet tries really hard. During my last visit I was asking him about Anapryl, and he went and got his drug book and was going through it to find information for me. He told me I'm really making him dig! He meant it in a good way. :) He has learned more through my sharing the information I've found here, and that will surely help him treat other Cushings dogs that come along. I am going to request he do another 'real' stim test, and I want to talk to him about knowing which type of tumor she has. She is such a trooper. She's been promoted to sleeping in the bed with me (insists on her head on the pillow beside me). I've given her Melatonin for the last few nights, and I think she's sleeping better and maybe even not pacing quite as much. I will keep you posted on what we find out and how it's going. I am very grateful to have access to the knowledge you have here.

[molly muffin]

Hi Kim, checking in to see how you and Sunny are doing? Good grief, a knot on the head to add to the mix. Has that gone away?

[Kim C.]

Thanks for checking, Sharlene. She is doing well. The knot is tiny and still there. It hasn't grown or changed any. I took her to Austin with me for a library conference last week, and she loved it. I wasn't sure how she'd handle the ride and hotel, but she did great. I couldn't leave her with anyone. That would have stressed us both out! She ate really well, which she's never done on trips. I'm currently trying to find a local vet with more Cushings experience, and am going to take her for a 'real' Stim test asap. I'll update as soon as I can do that. She felt good all weekend, and I think the Melatonin is helping her sleep at night. She's even playing with the cat a little!

[Squirt's Mom]

She has not seen anyone concerning the possibility of a macro tumor yet?

[Kim C.]

No. I'm afraid my vet is not informed enough to proceed further with this, and I do not want his inexperience to cause more problems. I have touched base with two other local vets, but have not received a response.

[Squirt's Mom]

How very sad. :( I pray you find someone asap, today if possible. It pains me to think of her suffering if something could be done to help her. :(

[Kim C.]

I have an appointment for next Thursday (soonest I could get) with a vet who says he has several Cushings patients now. I'm going to talk to him and show him the paperwork I have. If he seems knowledgeable, I will schedule tests with him asap. Other than a new Stim test and tests to find the location and size of her tumor, what else should I expect him to want to do? If I have an idea of what someone who knows about the condition should request, then I can better judge if he knows what he's doing.

[labblab]

Thanks for checking, Sharlene. She is doing well. The knot is tiny and still there. It hasn't grown or changed any. I took her to Austin with me for a library conference last week, and she loved it. I wasn't sure how she'd handle the ride and hotel, but she did great. I couldn't leave her with anyone. That would have stressed us both out! She ate really well, which she's never done on trips. I'm currently trying to find a local vet with more Cushings experience, and am going to take her for a 'real' Stim test asap. I'll update as soon as I can do that. She felt good all weekend, and I think the Melatonin is helping her sleep at night. She's even playing with the cat a little!
It sounds as though Sunny is actually doing significantly better than she had been doing previously? If so, I think that makes a macro less likely since it is a progressively deteriorating condition. Unfortunately, the only way to definitively diagnose a macro is through imaging of the head (CT or MRI) which can be very expensive. So I would not expect the new vet to be able to offer you an alternative means to test for that. But a full ACTH will be important, as well as a clinical evaluation of basic neurological response.

But going back again to the question of how she's behaving right now -- is she truly doing better?

Marianne

[Kim C.]

She has really done better, but the last few days she's been really croupy. She gets that way every now and then. It makes her hesitant about eating and drinking. She's eaten well today, though, so I'm hoping it goes away for awhile. She's done that all of her life, typical push-face issue, but it scares me more now. I don't think her cognitive issues have gotten worse. I would pay for a CT or MRI if he can do that, though. I'm anxious for her to see him, and hopeful that he knows what he's doing.

[molly muffin]

He sounds promising so I have high hopes too. :) Answers are always good to have.

[Kim C.]

Shortly after reporting that she was doing really well, Sunny seemed to reject the Trilostane once again. Pretty much the same symptoms as before. She seems to do great for a while and then her body just doesn't like it. She becomes confused, lethargic, and refuses water. And that's on 2.5 mg per day! I stopped it 2 weeks ago, knowing I had an appointment with the new vet last Thursday. I went through her history (took the original diagnosing test and copies of later bloodwork) with him. He has quite a few Cushings patients and has treated many. I know that doesn't mean he's an expert, but he has formed opinions on treatment and can measure his own success/failure. He does not like Trilostane and, after going through the pros/cons/odds of the various possibilities, suggested Ketoconazole. I take her back for an ACTH test (a real one) late this week to see if it's helping. He said it will either help her or won't have any effect, but she at least won't suffer side effects like with the Trilo. She is down to 20 pounds (her healthy weight was 25). After 3 days on the Keto. she is drinking a lot (confusing because I read that is common with this medication but it's also a symptom of too high Cortisol numbers). I was surprised he didn't want to test her when I first took her in because that was with no medication in her system. I asked him about the possibility of a pituitary tumor swelling, and he said that he has seen that happen before. He also said the cognitive dysfunction symptoms are textbook. The thing is, though, those symptoms have been reduced drastically (if not completely) since stopping the Trilo. His answer was to try this, test her, then go from there. If it doesn't work, he's suggesting Selegiline (Anipryl) or Mitotane (Lysodren). He says the Keto's helpful effects are actually a side effect of the antifungal drug, and there's probably a 60% chance it could help her. What do y'all think? I just started giving her Flaxseed Lignans just in case that will help, too. He looked at her skin and said that the cutis calcinosis is almost always caused by being given too many steroids, but Sunny has never had a steroid shot in her life. The only procedure other than spaying her has been one teeth cleaning a few years ago. I thought that was interesting...

[molly muffin]

Cortisol increased in the body (cushings), is the same effect as giving steroids. He should know that. Without an ACTH, having been done at the point of symptoms or thereafter, there is no actual way to know how the trilostane affected the cortisol or what her readings where (was she going low or what)

How is she now?

[Harley PoMMom]

Ketoconazole is rarely used for Cushing's any longer due to it's lack of efficacy and it's adverse effect on a dog's liver which is already being overworked from Cushing's.

I am also including a post made from Marianne to another member with regards to the ketoconazole:



Moving on to the ketoconazole, I checked with an endocrinologist specialist, Dr. David Bruyette, who has been very helpful with answering some questions for us here. We are just not that familiar with ketoconazole treatment, so I wanted to get some guidance from him. He has confirmed that it is an older treatment that preceded trilostane and as Lori has said above, in countries where trilostane is available, trilo is now prescribed more often because it is effective for more dogs and carries less risks of side effects such as the liver dangers associated with keto.

Keto treatment does require the same ACTH monitoring as does trilostane and Lyosdren because cortisol can be driven too low, but you do not have the same worries about electrolytes (potassium and sodium levels) going too low with keto because it does not affect aldosterone production (another adrenal hormone) in the same way as do trilostane and Lysodren. The trade-off, though, is that you have to watch the liver values very closely with keto due to the potential for liver damage. As far as the ACTH monitoring, you are looking for the same 1-5 ug/dl post-ACTH range as for Lysodren. So Belle's recent ACTH result is therapeutic (assuming she truly does have Cushing's), and it is certainly a good thing if her symptoms seem to be improving since starting the drug.
Marianne

Hugs, Lori

[Kim C.]

Sharlene, so I have two concerns about this vet: the fact that he did not want an ACTH test to start, and the comment he made about her skin being affected only by too many steroid shots. Also, he referred to his prescription book more than listening to me describe her symptoms. We were up all night Saturday. She was restless and drank a good bit. Yesterday after some napping she was better, and this morning she was very alert and almost peppy.

Lori, he told me Keto. is rarely used but said in his experience it has worked well for quite a few dogs. He told me it might not work but wanted to try it since it she is not handling the Trilostane well. I do not like hearing that it can hurt her liver, though. I don't want to go back to the Trilo, though, because I think it will kill her. Her negative response to it is frightening. So I'm thinking I will continue it through the week, take her Friday for the ACTH, and go from there. I'll talk to him about the liver issue and see what he has to say about that. If we stay on it, how often will she need to have her liver checked and is it something that will happen slowly enough we can stop it before it is too late?

One thing that has been consistent no matter what the medication, and even when her numbers are excellent, is that she has dry-mouth almost all the time, which means she must be dehydrated. I make sure she drinks often, but is there anything I can do to alleviate that? Is there an electrolyte for dogs that you suggest? I used to give my horses electrolyte powder but have never had the need for it with my dogs.

Thank you both so much for taking the time to respond to my posts!

[molly muffin]

Only if the elctrolytes are not in range would I give a supplement for that. Dogs are so sensitive to changes in sodium and potassium that I don't think I would do that unless it was needed.
I'm not sure what can help with the dry mouth.

[Kim C.]

The new vet did a Stim test and she was at 13. He said that was within a normal range, though I thought the target range was 2-6. He doesn't want to change her medication. She's doing okay...eating well and getting around without too much shakiness. She is drinking a lot, but I can deal with that if that's the only symptom. She had a brief flare-up of calcinosis cutis after the test, but it has not spread anymore. Could the Stim test cause that?

I'm very interested in finding out what y'all think about the test results. This vet seems confident in his decisions/opinions, but I've learned to question vets more through this process.

[Squirt's Mom]

13 is not within range unless he is using a scale I am not familiar with. The optimal range for a pup on Vetoryl is between 1.45 ug/dl and 5.4 ug/dl with the post acceptable up to 9.1 ug/dl if, and ONLY if, all signs are controlled. So if the "13" is in ug/dl units, she is not within range. ;)

[molly muffin]

Exactly what Leslie said, the lab prints the normal range of a pup NOT on medication. That range changes if they are being medicated and most labs will add a note at the bottom saying so. (as they don't know if the blood submitted is for a pup on treatment or not, the Vet should know this)

I think if she had a flare up of the cc after the stim test, then she needs to come down a bit more. When they do the test, the stimulating agent causes a dump of cortisol from the adrenal glands storage into their bodies. She reacted to that with a cc flare up which means she is right on the cusp of it flaring with any increase.

You want her at least under 9 ug with symptoms controlled, especially with cc involved.

[Kim C.]

She had the stim test only 8 days after starting the Ketoconazole, and she had been without any meds for at least 2 weeks. When I went home for lunch a few minutes ago, she actually ran to meet me. I haven't seen that in a while. I was hoping since the number is much higher to diagnose Cushings (23 or more, right?), that this would be acceptable. I would like to give this medication a bit longer since she is feeling okay. I could have her tested again in another few weeks and if the number is high, try the only other drug left, Selegiline. If she couldn't handle Trilostane even at 2.5 mg per day, then I'm thinking I should not use it. Do I try to direct this vet or try vet #4? I hate to start over again, but I want to do what's best for her.

[Harley PoMMom]

Since she is being treated with Ketoconazole (which is hard on the liver), also since she is feeling/doing well along with her symptoms being controlled except for the increased drinking, I wouldn't worry too much about that post of 13 ug/dl, that was the post number, right?

Hugs, Lori

[Squirt's Mom]

ahhhhh, she's on Keto not Vetoryl.....never mind. :D

[Kim C.]

Yes, that was the post number. I've read about the danger to the liver, and of course that scares me. I'll need to have blood work done to keep an eye on that.

On another note, one of my rescues just went completely blind in a week. We believe it is SARDS. After dealing with rescues' heartworms, amputations, deafness, tumors, and just about every other malady you can imagine in the last 28 years, I'm wishing I had the fortitude to become a vet.

[labblab]

I would love to say I thought that an ACTH result of 13 is OK, and in the short run maybe it is. But given the fact that CC is an issue for you, I think the cortisol should be consistently lower on a long-term basis. Here's a reminder that a noted endocrinologist, Dr. David Bruyette, tells us that the target therapeutic "post" range for dogs being treated with keto is identical to that for Lysodren: 1-5 ug/dl. So Belle is quite a bit higher than that right now, and I do worry that you may lose control of the CC with a cortisol level that is still that high.

I am not saying you should move on to another vet, but I would encourage you to discuss your treatment goals in greater detail. I don't remember whether increasing the keto dose is an option? If Belle's cortisol still hasn't come down any further by the next test -- and especially if the CC starts spreading -- I'd want to know for certain whether an increase is a possibility.

Marianne

[Kim C.]

That sounds good, Marianne. The next test should tell us a lot about how the Keto is working and if we can continue the current dosage. Her cc has stopped spreading for now, but I'm watching it carefully. She amazes me with her tolerance of it...doesn't show that it bothers her at all.

[molly muffin]

Hopefully the next test will show that she is reacting appropriately to the Keto. Glad you are keeping an eye on that cc, that is the real tell symptom. As you know already if the cortisol goes up the breakouts will start up and spread.

[Kim C.]

Yes, and she has so much of that already. Thanks for your help!