Stanley - 16.5 yo Maltese w/ Cushings + Bladder Stone/ Stanley has passed

[l4d44]

Hello. My name is Mike and I'm a new member here. I discovered this great site and community after doing some research on cushings disease - which my 14 year old maltese, Stanley, was recently diagnosed with along with bladder stone.

I would appreciate any advice/feedback/suggestions regarding his current regimen and treatment for both cushing and the bladder stone. He does not appear to be in pain from the stone (no surgery as of yet; will be treated with diet) and has the usual signs of cushings (panting, pot-belly, restlessness at night, difficulty climbing and getting up from sitting position, etc.)

First of all, Stanley weighs 11.5 lbs. According to my vet he's about 2 pounds overweight. Just this week his new "diet" consists of Royal Canin Urinary SO (moderate calorie) wet/canned food. I feed him a total of 2/3 cup per day.

I have added the following supplements:

-milk thistle (1 ml, about 28 drops) with his morning meal
-liquid glucosamine (1/2 tsp), twice per day mixed with each meal

Also his vet prescribed TRILOSTANE (1 ml per day w/ evening meal) to treat his cushings. This is in a liquid/compound form since he is very difficult with pills (even hidden in treats/pill pockets). He will need to have another complete lab work done again in 3 weeks to check if the medicine needs to be adjusted.

I have the results of his blood work and urinalysis (from a couple of days ago). Please advice on what results I should post for the community to look over and review.

Are there any other SUPPLEMENTS that is strongly recommended besides the milk thistle and liquid glucosamine?

Also is Trilostane the best form of treatment for cushings?

Thanks in advance for reading this posts and for your help.

[Harley PoMMom]

Hi Mike,

Welcome to you and Stanley! So glad you found your way here, and we will help in any way we can.

Regarding the tests results, from the chemistry/CBC blood work,which may be called a senior wellness or geriatric blood panel, could you post any thing that is marked abnormal along with the reference ranges and units of measurement...e.g...ALT 150 U/L (5-50)...thanks. From the urinalysis we would like to see those results too. Also if you would post the results from all tests that were done to diagnose the Cushing's that would be great. Was an ultrasound performed on Stanley? If so, could you post those findings too?

Does Stanley have the adrenal or pituitary type of Cushing's?

Dogs with Cushing's generally have a ravenous appetite, drink copious amounts of water and pee lakes, does Stanely have those symptoms too?

I see you have posted that the vet prescribed the Trilostane at a 1 ml dose, it should also show how mg are per one ml of liquid Trilostane, could you post that for us? I also see that the vet wants Stanely's Trilostane to be given in the evening, which is not the proper protocol. When treating with Trilostane it should be given in the morning with food, this is because the monitoring ACTH stimulation test has to be done 4-6 hours after the Trilostane dose.

Lysodren/Mitotane and Vetoryl/Trilostane are the two medications that are generally prescribed for dogs with Cushing's disease. In deciding which medication to use is largely dependent on the vets experience in using and knowledge of. These are strong medicines but are life savers for dogs that have Cushing's. Cushing's is a treatable disease, however, success in treatment does depend on a few things; keen owner observation, a pet parent willing to educate themselves about Cushing's, and a vet/IMS that has experience treating Cushing's and is knowledgeable about the protocols for Cushing's.

I am providing links from our Resource thread that have a wealth of information regarding Cushing's and the medications:

Links to Cushings Websites (especially helpful for new members!) (http://www.k9cushings.com/forum/showthread.php?t=180)

Trilostane/Vetoryl Information and Resources (http://www.k9cushings.com/forum/showthread.php?t=185)

Lysodren loading Instructions and related tips (http://www.k9cushings.com/forum/showthread.php?t=181)

If you have any questions at all please do not hesitate to ask them ;)

Hugs, Lori

[l4d44]

Hi Lori. Thanks for your reply and for the helpful links.


Does Stanley have the adrenal or pituitary type of Cushing's?

I'm pretty sure my vet mentioned it when first telling me but I honestly do not recall. I can find out Monday morning when the clinic opens up. Which one is worse/more serious?


Dogs with Cushing's generally have a ravenous appetite, drink copious amounts of water and pee lakes, does Stanely have those symptoms too?

Yes but not that bad. When he urinates on his wee-wee pad (indoors), it is pretty massive in size though. He does have this habit of wanting to go outside more often than usual but not necessarily to do "bathroom" stuff. Mostly to bark in the open air. :)


I see you have posted that the vet prescribed the Trilostane at a 1 ml dose, it should also show how mg are per one ml of liquid Trilostane, could you post that for us?

10 mg/ml suspension


I also see that the vet wants Stanely's Trilostane to be given in the evening, which is not the proper protocol. When treating with Trilostane it should be given in the morning with food, this is because the monitoring ACTH stimulation test has to be done 4-6 hours after the Trilostane dose.

I was told that the Trilostane needs to be given AFTER food, once every 24 hours at the SAME time.

Evening fits that guideline the best because he has a bigger/better appetite in the evenings and sometimes I leave for work in the morning prior to him eating his meal. I wanted to make sure that he gets his dose with his food at the same time everyday.

Can I give him the Trilostane in the morning BEFORE he eats his food?


Regarding the tests results, from the chemistry/CBC blood work,which may be called a senior wellness or geriatric blood panel, could you post any thing that is marked abnormal along with the reference ranges and units of measurement...e.g...ALT 150 U/L (5-50)...thanks. From the urinalysis we would like to see those results too. Also if you would post the results from all tests that were done to diagnose the Cushing's that would be great. Was an ultrasound performed on Stanley? If so, could you post those findings too?

X-ray was done on his abdomen. NO ultrasound. His urinalysis came out completely clean (negative and with-in range). Below are his "out-of-range" numbers along w/ the reference range as requested. Thanks again for your help. IF I missed to post any results, please let me know and I'll look for it.

COMPREHENSIVE CHEMISTRY PROFILE

TOTAL PROTEIN: 8.3 (5.4 - 7.6)
ALBUMIN: 4.5 (3.4 - 4.2)
GLOBULIN: 3.8 (1.3 - 3.2)
ALK. PHOS. 894 (1 - 142)
GLUCOSE: 116 (71 - 113)
BUN: 37 (9 - 33)
BUN/CREAT RATIO: 28.5 (4.0 - 27.0)
PHOSPHORUS: 7.6 (2.4 - 6.4)
CA: 13.1 (9.7 - 12.1)
CL: 104 (107 - 120) *LOW
OSMOLALITY (CALC): 320 (285 - 315)
CHOLESTEROL: 320 (285 - 315)
LIPASE: 160 (17 - 152)
CK: 395 (101 - 328)


COMPLETE BLOOD COUNT (CBC):

MONO#: 1.4 (0.1 - 0.8)
MONO%: 17.2 (2.0 - 9.0)
RBC: 8.7 (5.5 - 8.5)
HGB: 19.6 (12.0 - 18.0)
HCT: 61 (37 - 55)


ACTH RESPONSE (STIMULATION) TEST (CORTISOL 2):

CORTISOL (PRE): 9.4 (1.0 - 6.5)
CORTISOL (POST): 21.5 (6.5 - 18.0)

[l4d44]

A few more Things/questions:

I've noticed last night that Stanley was restless. He kept moving positions around the bed; going up and down the bed; pacing the apartment.

Usually he sleeps really well at night. Could the TRILOSTANE med be causing this? Or could it be that I'm giving it to him in the EVENINGS that's causing him to be hyper at night? Or what about the MILK THISTLE?

Also Lori you recommended that I switch giving him the Trilostane from evenings to mornings.

a) How do I go about this? Do I skip an evening dose and give it to him in the morning instead (which would be 36 hours in between doses)? Or do I continue with the evening dose and give it to him again in the morning (12 hours between doses)?

b) Is it mandatory that he gets Trilostane with/after his meal - or can it be given standalone?

c) He's do for another ACTH test at the end of the month. I read that for accurate results, this test needs to be performed no later than 4-6 hours after him taking his Trilostane med. The vet wants him to be brought in at 8AM (first blood test done) and then to be picked up 2 1/2 hours later (after his second blood test). They tell me no food past 8PM the previous night (water is okay).

So do I give him his Trilostane before taking him to the vet (on empty stomach) - or is there another method of doing this on days when he's about to be tested?

Thanks again.

[lulusmom]

Hi Mike and a belated welcome to you and Stanley.

I've just read your thread and I am a bit concerned that your vet diagnosed cushing's based solely on borderline acth stimulation test. Additional tests such as abdominal ultrasound or an endogenous acth test should have been done to determine whether Stanley has pituitary or adrenal dependent cushing's. An abdominal ultrasound would have been preferable to validate the acth stimulation test as well as differentiate between pituitary and adrenal disease.

Please see my additional comments in blue text below:


A few more Things/questions:

I've noticed last night that Stanley was restless. He kept moving positions around the bed; going up and down the bed; pacing the apartment.

Usually he sleeps really well at night. Could the TRILOSTANE med be causing this? Or could it be that I'm giving it to him in the EVENINGS that's causing him to be hyper at night? Or what about the MILK THISTLE?

Dogs who get once daily dosing in the am are more likely to be restless in the evening hours. Every dog responds differently to Trilostane so anything is possible. I've never heard that milk thistle can cause restlessness at night so sorry I'm not much help on this issue.

Also Lori you recommended that I switch giving him the Trilostane from evenings to mornings.

a) How do I go about this? Do I skip an evening dose and give it to him in the morning instead (which would be 36 hours in between doses)? Or do I continue with the evening dose and give it to him again in the morning (12 hours between doses)?

Your first guess was correct. You skip the evening dose and start dosing the following morning. You could overdose Stanley if you give him his evening dose followed by a dose 12 hours later.

b) Is it mandatory that he gets Trilostane with/after his meal - or can it be given standalone?

Trilostane must be given with food so you need to give it with food pr directly following a meal. It's going to be a change of routine for both of you but you will adjust. You may want to split Stanley's meals, half in the am and half in the pm starting the night before you start dosing in the morning. That way he is more likely to be hungry.

c) He's do for another ACTH test at the end of the month. I read that for accurate results, this test needs to be performed no later than 4-6 hours after him taking his Trilostane med. The vet wants him to be brought in at 8AM (first blood test done) and then to be picked up 2 1/2 hours later (after his second blood test).

Trilostane peaks at 1 1/2 to 2 hours so it's okay if they do the stim test 3 hours after dosing. Just make sure Stanley has his dose at 5:00 or 5:30 am.

They tell me no food past 8PM the previous night (water is okay).

This is absolutely incorrect information. Stanley must get his morning dose with his regular meal. If you fast him, the results will be useless and you will have wasted a lot of money. By the way, since Stanley is so small, you can save lots of money on your stim tests if your vet will learn how to dilute and store cortrosyn, which is the stimulating agent. That stuff is ridiculously expensive and even though the instructions on the vial say to use the entire thing, small dogs don't need the entire vial. As a matter of fact, if Stanley is 20 lbs or less, you can get at least four or five stim tests out of one vial. I would highly recommend that you print out Dr. Mark Peterson's blog for veterinarians entitled How to Dilute and Store Cortrosyn. I have provided a link below. You have nothing to lose and everything to gain by asking your vet to do this.

http://endocrinevet.blogspot.com/2012/03/how-to-dilute-and-store-cortrosyn-for.html

So do I give him his Trilostane before taking him to the vet (on empty stomach) - or is there another method of doing this on days when he's about to be tested?

No, you MUST give Stanley his dose of Vetoryl with food ever morning, including the day of the stim test. Never give Vetoryl on an empty stomach and never do an acth stimulation test (for purposes of monitoring Vetoryl treatment) on a fasted dog.

Thanks again.

I hope I've been of some help to you and Stanley.

Glynda

[l4d44]

Thanks for your insight Glynda. I will switch his Trilostane from PM to AM tomorrow by skipping it in the evening and giving it to him the following morning after he eats his meal.

I will also follow up with my vet tomorrow regarding an abdominal ultrasound and to find out if he has pituitary or adrenal cushings.

Also I'm curious to find out what his lab results (post #3) mean? Are his numbers decent or does something suggest a serious cause for concern. I would appreciate some feedback regarding Stanley's test results.

Thanks. :)

[labblab]

Hello from me, too! I'm sorry I have only a moment to post right now, so I do not have time available to review your lab results. I will try to come back later for that, or hopefully somebody else will be able to comment.

But I just wanted to add a link to substantiate Glynda's info re: the peril of fasting a dog before a monitoring ACTH test. This will be a good article to share with your vet. As Glynda has said, when the ACTH is being used to initially diagnose Cushing's, fasting is not an issue and may be preferred by vets when other diagnostic blood panels are being performed at the same time. But once treatment has begun and the ACTH is being run for monitoring purposes, fasting will invalidate the results because the effectiveness of the trilostane will be decreased if given on an empty stomach.

http://endocrinevet.blogspot.com/2011/03/whats-best-protocol-for-acth.html

Marianne

[l4d44]

It's 4 AM right now and Stanley has barely slept for consecutive nights. He's pacing the house again and appears to be hyper/restless - not typical signs of Cushing's (from what I've read). Correct me if I'm wrong.

Could it be that he has an active thyroid or possibly dementia? This all started as soon as he began taking Trilostane. Coincidence?

Since I'm switching him up to Trilostane in the AM on Tuesday (not getting his dose tomorrow).... I'm also going to halt the milk thistle and glucosamine supplements as well and monitor his sleeping habits tomorrow night.

I'm going to call his vet in the morning as well. I've barely slept the past two nights and neither had poor Stanley. I don't know if he's in distress or what. I want to make sure that I'm doing everything possible including getting proper diagnosis and treatment.

Marianne, thanks for your reply and for the link.

[LauraA]

Hi Mike. Just wanted to say that the roaming can be a sign of Cushings. My girl used to pace around the house in the middle of the nigh and there was nothing I could do to settle her. Went I started the Vetoryl (trilostane) many of her symptoms did get a little worse before they got better. But all dogs react differently.

[Squirt's Mom]

Personally, with that ACTH result combined with the bladder stones, I would not be treating with Vetoryl (Trilostane) or anything else right now. I would be insisting on further testing and on giving my baby time to deal with the stones as the internal stress from that condition can skew the cushing's tests giving false-positives. I would insist on an abdominal ultrasound performed on a high resolution machine, and I would want the kidneys looked into with that BUN, BUN/CREAT ratio, and abnormalities in the electrolytes. Just my thoughts on what I would do in your shoes. ;)

Bear in mind, that at 14 Stanley is a geriatric pup and as such subject to mental decline. Elderly dogs get a condition called Canine Cognitive Dysfucntion/Syndrom, or CCD/CCS. They will act much like humans with Alzheimer's. Restless at night, loss of housetraining, confused, stuck in corners and behind doors, etc....BUT there are things you can to do help with this as well should that ever become a real concern. But don't let yourself get Cushing's tunnel vision where everything we see that is a bit off is attributed to Cushing's. ;)

Hugs,
Leslie and the gang

[l4d44]

Hi Mike. Just wanted to say that the roaming can be a sign of Cushings. My girl used to pace around the house in the middle of the nigh and there was nothing I could do to settle her. Went I started the Vetoryl (trilostane) many of her symptoms did get a little worse before they got better. But all dogs react differently.

Hi Laura. His roaming did not start until he started taking Trilostane. Previously he would sleep throughout the entire night.

I'm switching his dose to AM and I'm hoping that it would solve this issue.

[l4d44]

Personally, with that ACTH result combined with the bladder stones, I would not be treating with Vetoryl (Trilostane) or anything else right now. I would be insisting on further testing and on giving my baby time to deal with the stones as the internal stress from that condition can skew the cushing's tests giving false-positives. I would insist on an abdominal ultrasound performed on a high resolution machine, and I would want the kidneys looked into with that BUN, BUN/CREAT ratio, and abnormalities in the electrolytes. Just my thoughts on what I would do in your shoes.

Hi Leslie. Thanks for your advice. I did schedule an appointment with an internal specialist to have an abdominal ultrasound this Saturday. That facility also does "microscopic" and laser stone elimination - which is what I was hoping for because I do not want to put Stanley through a general surgery procedure considering that he's 14 y/o. I was also advised to continue his Trilostane up until that appointment.


Bear in mind, that at 14 Stanley is a geriatric pup and as such subject to mental decline. Elderly dogs get a condition called Canine Cognitive Dysfucntion/Syndrom, or CCD/CCS. They will act much like humans with Alzheimer's. Restless at night, loss of housetraining, confused, stuck in corners and behind doors, etc....BUT there are things you can to do help with this as well should that ever become a real concern. But don't let yourself get Cushing's tunnel vision where everything we see that is a bit off is attributed to Cushing's.

Noted and Thanks again.

[l4d44]

My vet said that it's safe to give Stanley 1/4 - 1/2 dose of BENADRYL at night to help him (and me) sleep.

Can someone confirm that Benadryl is safe for older dogs w/ Cushings (and stones)?

Thanks.

[molly muffin]

Benadryl should be safe for Stanley. Many use it with their cushing dogs, especially if allergies are involved. Melatonin would also work. 3mg, no rapid release or anything different than straight melatonin.

It is possible that switching to the morning dose will help with this too.

I don't know where you are located, but your specialist should be able to recommend a place that does the surgery the way you want it done, via laser, etc. Sonic ultrasound too, although only a few places do that. Usually a vet hospital or specialty vet ER hospital/clinic might do the surgery the way you want too. I understand and am the same way. Molly too has been on SO food for gads, 7 or so years now. Key is getting them to drink enough water.

I've looked over your lab results and the main things I see are, one) dehydration - Stanley needs to be drinking more water, this contributes to the ph being off, the stones, and hopefully the food will encourage him to drink more. Your CBC is consistent with dehydration. Your chemistry profile, is either consistent results with dehydration and mild increases attributable to cushings.

I would ask that they take a look at gall bladder, kidney, liver, adrenal glands, pancrease, spleen when they do the ultrasound. Those areas should all be covered and you should get a comprehensive report on the results. This will give you a much better idea of what is going on over all and I'm very glad you have one scheduled.

Sharlene and molly muffin

[l4d44]

Thanks Sharlene.

I live in the San Fernando Valley (Los Angeles) and I'm going to a facility called ACCESS ANIMAL HOSPITAL in Woodland Hills, CA (per recommendation of my general vet)

Here is a link to the doctor I've scheduled the appointment with.

http://accessanimalhospitals.com/our-doctors/dr-domenico-bianco/

Consult fee is around $110 and the actual ultrasound is $385. I'll be spending close to $500 in total on that visit. I've already spent close to $700 with the xray, ACTH test(s) along w/ the blood and urinalysis tests.

*** If anyone in the Los Angeles area knows of a good facility/doctor that performs ultrasounds and deals w/ cushings at a more afordable rate, I'm up for suggestions. ***

I will note to have him check all of his major abdomen organs. If you or anyone else think I should ask specific questions regarding his cushings or bladder stone (or any particular test numbers from his lab results) - please advice me on what to ask.

Thanks.

[Budsters Mom]

Yes, Benadryl is considered very safe. My Cushing's dog used it to treat allergies throughout his lifetime. The standard dosage is 1mg. Per pound every 8 -12 hours. Do not exceed 3 dosages per day. The generic for Benadryl is called Diphenhydramine HCI. Buddy weighed 15-16 lbs, so I gave him 1/2 a 25mg. Caplet.

I have another allergy baby now. She weighs 10.4 lbs. I give her about a 1/3 of a caplet when needed. She is 17 months old.

[l4d44]

Thanks Kathy. I give him 1/2 Benadryl last night and it worked great. Stanley slept throughout the entire night. First time in the past 3-4 days that he an adequate amount of sleep. I'm cutting his dose to 1/3 tonight and I'll see if I get same results as last night.

Also I switched Trilostane to the mornings. Time will tell.

[Budsters Mom]

Buddy always had his Trilo with breakfast in the morning. That worked out well when it came time for his ACTH test, since it needed to be started approx. 4 hours after receiving his meds with food.

I'm glad the Benadryl helped. It used to drug Buddy too. Really knock him out. It has the opposite effect for Rosie (Buddy's little sister). It makes her hyper. Go figure.

[molly muffin]

Did Stanley do okay on the morning dose and how was he last night?

No I don't know of any place necessarily cheaper in the area. :(

Sharlene and molly muffin

[l4d44]

The Benadryl has been working wonders! I've settled @ 1/3 tablet and Stanley has been sleeping like a champ all night.

Also switching the Trilo to AM seems to be working better too. He loves his Royal Canin Urinary SO canned food (surprisingly) since he's somewhat picky with food.

I hope we get some good news on Saturday w/ his abdominal ultrasound. Will update afterwards.

Thanks again to this amazing community.

[molly muffin]

This is great to hear. I'm sure you are both better for getting a good nights sleep. :)

Sharlene and molly muffin

[l4d44]

Update on Stanley:

Took him today to get an abdominal ultrasound. His internal organs are very good - No damage or anything serious. It confirmed that he has pituitary cushing. Numbers from last week's lab indicate that his numbers are just a little out of range.

He has 2 small stones in his bladder. He may or may not need to have them surgically removed. Will wait about a month and continue on the Royal Canin Urinary SO diet to see if it might dissolve them. He doesn't believe that those stones are large enough to be causing Stanley any pain.

He has a ACTH re-test in a couple of weeks but I can definitely see an improvement in the short amount of time with just the Trilostane and diet modification. Not bad for a 14 y/o geezer. :)

[l4d44]

Can someone tell me if they following are related to Cushings, side effects to Trilostane or something else (old age, bladder stone, etc):

1) I've noticed recently that when Stanley sleeps, his eyes are partially open. Previously when he used to sleep his eyes were closed shut.

2) During the daytime hours, he's constantly pacing around the house. He seems restless/hyper. If this is related to Cushings, will the Trilostane (once the proper dose is set through future ACTH tests) help calm him down?

If someone can shed some light on these two issues I'd greatly appreciate it. Otherwise Stanley seems to be doing great.

[molly muffin]

hmm, I'm not sure about sleeping with eyes partially open.
But pacing around and in general discomfort, are symptoms we often see associated with cushings. A lot of times this happens at night and them and everyone has a hard time sleeping.

This usually gets better with controlled cortisol!!

hugs
Sharlene and molly muffin

[flynnandian]

my ian has the same thing with his eyes whilst sleeping since on vetoryl.......i've noticed it too...weird side effect.....

[l4d44]

my ian has the same thing with his eyes whilst sleeping since on vetoryl.......i've noticed it too...weird side effect.....

Is this something to be concerned about?

[flynnandian]

he has it for 9 months now and his eyes are ok.
he still has a good vision for a 13.5 year old, so i don't think it is harmful.
you can look if your dog has dry eyes or loss of eyesight, but my dog looks fine.

[l4d44]

Stanley has become very hyper/active the past couple of days several minutes after talking his Benadryl pill. I'm going to switch him to melatonin instead starting tomorrow. Where can I purchase melatonin for dogs and is 1.5mg the correct dose for a 10 pound dog?

Also I'm starting to think that his bladder stones are bothering him. However I'm hesitant to put him through surgery since he's 14 y/o and don't want to risk it - but if he's this uncomfortable I might just have to.

Can someone please advice me in what I should do regarding his bladder stones. My vet doesn't think surgery is a huge risk but I need some reassurance I guess.

[Budsters Mom]

Melatonin can be purchased at any drugstore. It does not have to be specifically for dogs. I'm not sure of the dosage for a 10 pound dog. Sorry I can't help you with that. Hopefully someone will be along soon with the dosage.

Benadryl knocked my Buddy out. He took it for his allergies. Benadryl makes Rosie hyper. You just don't know.

[lulusmom]

Most pharmacies, health food stores and some grocery stores carry Melatonin. They don't make it specifically for dogs. You want to buy 3 mg and make sure it's not extended release or rapid release.....just plain old Melatonin.

[Harley PoMMom]

My non-cush dog, Bear, had to have 2 surgeries (approx. 5 years apart) to remove his oxalate stones. He came through both surgeries with flying colors ;)

With bladder stones you need to find out what kind they are, they are usually sent out to be analyzed, from knowing this information one can take steps to stop their formation.

Hugs, Lori

[l4d44]

Stanley has an appointment @ 8:30 am this Monday for his 2nd ACTH test.

What is the best time in the AM to give him his Trilostane dose (w/ food) prior dropping him off for his test?

I've read 1-3 hours and 4-6 hours prior to testing. Is there a recommended time?

Thanks.

[lulusmom]

I've had two cushdogs and fostered another cushdog, all of whom were treated with trilostane. I always had them to the vet within 3 to 5 hours of dosing. If Stanley's appointment is at 8:30, I'd dose him at 5:00 or 5:30.

[Silliam]

Just wondering it was probably already mentioned but I am only 2 pages into your post, what kind of stones does Stan have?

[l4d44]

Just wondering it was probably already mentioned but I am only 2 pages into your post, what kind of stones does Stan have?

Not sure until they operate to remove them.

Results came back for Stanley's 2nd ACTH test. Numbers looked good and his vet is keeping him on the same dose of Trilostane (10mg, once per day).

She recommends to hold off on his bladder stones removal until his 3rd ACTH test next month.

It's been 2 1/2 weeks between his first and second ACTH test and it will be 4 weeks between his second and third tests.

Does that sound about right?

[Silliam]

I think testing for cushings right at the time of surgery is not gonna work as their stress hormone goes up to help with the anesthesia and recovery which is why she probably wants to hold off.
Sometimes the type of crystals if any in the urine will indicate the stone. Is your dog having trouble peeing? Do stones block the urethra? I heard to late but they can redirect the urethra away from the OS penis so they pee like a girl. For dogs with alt of stones this means they can pass them easier. It is no coincidence that male dogs have more problems with stones then female.
Also my dog didn't start a S/O diet untill they had the analysis back because some stones like oxalte cystine and rate need the U/D food which alkalises the urine to prevent new stones.
It might be a question to ask your vet.

[lulusmom]

I am very familiar with oxalate stones and had two dogs, one with cushing's, who had surgeries to remove these stones. My cushdog, Lulu, had two surgeries within 11 months of each other. She had her last surgery in the middle of being diagnosed for cushing's. My little male Maltese, Buster, also had speedy surgery as he had stones blocking the urethra and the vet had trouble flushing them back. I didn't know anything was wrong until I saw the drops of blood in his urine. They had been on grain ladened kibble for most of their lives and Buster's vet recommended I change to a moist diet and try to get him to drink more. That was when I put all my dogs on a commercially prepared raw diet and became a believer. After his surgery, the vet prescribed potassium citrate as well. Lori mentioned on this thread, or possibly another thread, that she used Pala Tech brand which is what I purchased online. I would never feed my dogs UD as it's low in protein, high in fat and the ingredients are simply awful. I am certainly no expert on canine nutrition but I don't understand how Hills can possibly call this a balanced diet.


Water, Egg Product, Corn Starch, Chicken Fat, Pork Liver, Sucrose, Rice, Soybean Oil, Powdered Cellulose, Soy Fiber, Potassium Citrate, Choline Chloride, Iodized Salt, vitamins (Vitamin E Supplement, Thiamine Mononitrate, Niacin Supplement, Calcium Pantothenate, Vitamin B12 Supplement, Pyridoxine Hydrochloride, Biotin, Riboflavin Supplement, Vitamin D3 Supplement, Folic Acid), Calcium Carbonate, Dicalcium Phosphate, Taurine, L-Lysine, minerals (Ferrous Sulfate, Zinc Oxide, Manganous Oxide, Copper Sulfate, Calcium Iodate, Sodium Selenite) , L-Tryptophan, L-Carnitine, Magnesium Oxide, Beta-Carotene.

Water intake is key so is it any wonder, the first ingredient is water? If you increase a dog's water intake by changing to moist food and/or adding home made chicken broth to the water bowl, and add Potassium Citrate to their food, this crappy and expensive food is not necessary. You will notice that potassium citrate is also an ingredient in UD.

Glynda

[l4d44]

Is your dog having trouble peeing? Do stones block the urethra? I heard to late but they can redirect the urethra away from the OS penis so they pee like a girl.

Stanley is not having trouble urinating. His vet says that the stones are not blocking the urethra. Also he's been urinating by squatting both legs (like a female dog) for a while now.

Is having him on the Royal Canin Urinary SO (canned/wet) a good diet for him? He seems to love the food which is surprising since he's a super picky eater.

[lulusmom]

I personally would not feed my dog Royal Canin SO, especially if my dog had cushing's. It does not dissolve calcium oxalate stones and whether it helps prevent them remains to be seen. It's low in protein, high in fat with pork and chicken by-products, ingredients I consider to be disgusting. It's also high in calories which will make a dog fat over time and obesity is a factor that is thought to predispose a dog to oxalate stones. High fat diets contribute to increasing the risk of pancreatitis, especially in a dog with cushing's. I've provided a link below to some good information on the subject found at dogaware.com. Here is an excerpt from that article that addresses Hills and Royal Canine formulated diets.


In February 2002, The American Journal of Veterinary Research published a study conducted at the University of Minnesota College of Veterinary Medicine’s Minnesota Urolith Center that compared dietary factors in canned food with the formation of calcium oxalate uroliths in dogs, with surprising results. Canned diets with the highest amount of carbohydrate were associated with an increased risk of CaOx urolith formation. Contrary to commonly accepted beliefs, the study concluded that “canned diets formulated to contain high amounts of protein, fat, calcium, phosphorus, magnesium, sodium, potassium, chloride, and moisture and a low amount of carbohydrate may minimize the risk of CaOx urolith formation in dogs.”

In contrast, both Hill’s Canine u/d and Royal Canin Urinary SO, often prescribed for dogs prone to forming CaOx stones, are extremely low in protein, and restrict calcium, phosphorus, magnesium, and potassium (Royal Canin is less restrictive than u/d). See The Side Effects of Low Protein Diets for more information.

http://dogaware.com/articles/wdjcalciumoxalates.html

[l4d44]

Thanks for the info lulusmom.

I'm going to get Stanley off the RC. Can someone please recommend me a brand of canned/wet dog food that is suitable for a senior dog with Cushing and bladder stones.

EDIT: a rep from an online pet food delivery service recommended the following brands:

Nature's Variety Instinct

Natural Balance

Wellness Core grain free weight management formula

Any of those 3 any food or is there something better?

[Harley PoMMom]

Here's a couple of links to websites that rate dog food: http://www.dogfoodadvisor.com/dog-food-reviews/brand/

http://www.dogfoodanalysis.com/dog_food_reviews/showcat.php/cat/3/page/1

Hope that helps.

Hugs, lori

[l4d44]

Here's a couple of links to websites that rate dog food: http://www.dogfoodadvisor.com/dog-food-reviews/brand/

http://www.dogfoodanalysis.com/dog_food_reviews/showcat.php/cat/3/page/1

Hope that helps.

Hugs, lori

Helped a lot. Thanks Lori.

After checking those 2 sites + online reviews + talking to a very knowledgeable pet store rep, I have settled on this food to replace the Royal Canin SO.

Hopefully the ingredients meet the standards for premium dog food?

http://www.amazon.com/Instinct-Grain-Free-Limited-Ingredient-Duck/dp/B008YDSQ2Y/ref=pd_sim_petsupplies_8?ie=UTF8&refRID=12S8W7KEG97D6YAA2EAW

DUCK FORMULA

[l4d44]

Stanley is not liking the Nature's Variety Instinct food. I switched him back to the RC so he can eat in the AM in order to give him his Trilostane dose.

If anyone knows of another brand of canned food recommended for a senior dog, please let me know.

[molly muffin]

Sometimes you have to introduce it slowly, mixed with the kibble. A transition phase. Try mixing just a tiny bit in at a time, gradually increasing it.

Sharlene and molly muffin

[l4d44]

The past couple of days I've noticed that Stanley's panting is getting more excessive than previous weeks.

Is this to be expected/normal w/ cushing - or possibly a sign that his Trilostane dose needs to upped (or something else)?

[l4d44]

I was giving Stanley a cut and bath today and I noticed a pretty large red and blackish spot/bruising on his upper chest/bottom neck area. I've never seen it before and I have to ask if this is Cushing's related or possibly something else (other disease, food allergy or maybe a tight harness)???

Here's a picture link for reference. Thanks

http://i59.tinypic.com/33vf8du.jpg.

[lulusmom]

Dogs with cushing's bruise very easily and I suspect that Stanley's bruise is from the blood draw taken from his jugular last Monday for the acth stim test. My little cushdog, Lulu, was bald so you couldn't miss the huge bruise she would get after after acth stimulation test. It would take several days to fade.

[l4d44]

Dogs with cushing's bruise very easily and I suspect that Stanley's bruise is from the blood draw taken from his jugular last Monday for the acth stim test. My little cushdog, Lulu, was bald so you couldn't miss the huge bruise she would get after after acth stimulation test. It would take several days to fade.

They draw blood from the chest area for the ACTH test? I never knew that.

He had his ACTH test on Monday (6 days ago) and as you can tell from the picture I posted, the bruise is still pretty bad/dark. Should I be worried?

[lulusmom]

They draw blood from the jugular in the lower part of the neck and the bruising can extend into the upper chest area. Here's a picture of a jugular blood draw (venipuncture):

829

If you are concerned, I would recommend that you call your vet and email them the picture.

Glynda

[l4d44]

Thanks Glynda. You've eased my nerves a bit. I'll give it a couple of more days and then I will email the pic to my vet if they bruising doesn't subside.

[Squirt's Mom]

My Squirty had spots very similar to that once or twice from exactly what Glynda said- blood draw from the neck. It is scary as all get out to see for the first time! :eek:

[molly muffin]

I think Molly had a bruise once from a blood draw. It definitely was scary when I first saw it and it was only because she'd just had a grooming and the hair was so short.

Is the spot going away?

Sharlene and molly muffin

[l4d44]

I think Molly had a bruise once from a blood draw. It definitely was scary when I first saw it and it was only because she'd just had a grooming and the hair was so short.

Is the spot going away?

Sharlene and molly muffin

Thankfully the color is fading. Is the bruising a result of a bad blood draw or does it usually occur every time?

Just something to possibly discuss with the vet before his next test.

[molly muffin]

I only noticed it that one time on Molly.

I'd mention it to the vet so they are aware.

Sharlene and Molly muffin

[l4d44]

Is it safe to feed FRUIT to dogs with Cushing?

Stanley loves watermelon and apples (without skin of course). Is this okay to feed him?

[molly muffin]

yes, watermelon and apples should be fine. My dog loves bananas.

Sharlene and molly muffin

[labblab]

Just be sure not to give any grapes, because grapes and raisins are both very toxic to dogs.

Marianne

[l4d44]

Got the results today from Stanley's 3rd ACTH test. His pre was 6 and his post was 9. According to the vet, it was higher than what out should be. She's upping his Trilostane dose from 10mg to 20mg total daily. She said to give him 10mg in the AM and 10mg in the PM.

Question: do you think it's better to give him the FULL 20mg dose at once (in the morning) or is it better to have it split like how the vet suggested?

[Renee]

How long has he been at his current dose of 10mg?

A post of 9 is actually not too high, assuming symptoms are controlled. That said, if Stanley has been on the 10mg for at least 30 days and you are not satisfied with symptom control, then a dose increase is probably a good idea.

I always dose twice daily. Some dogs respond better to once daily, but it appears from most of the people using vetoryl on this board, twice daily dosing is more common. I notice Tobey's cortisol spikes in the later afternoon, which is why I think having her dose split up helps with overall symptom control.

Also - Tobey always bruises badly from her blood draws. :(

[l4d44]

Stanley has been on 10mg of Trilostane since he was first diagnosed 2 months ago. This is the first time his side has been adjusted/increased.

[Renee]

How are his symptoms? With a post of 9, I would rely on symptom control in determining to increase or not.

[l4d44]

He seems fine. Nothing unusual. He's due for a recheck in a month.

I'm a bit confused.... Should I do as the vet suggested and double his daily dose or keep him on his current dose?

[Renee]

What I am trying to say is: When using vetoryl, you can have an acceptable post cortisol figure of up to 9 ug/dl, assuming you are happy with symptom control.

If you are not happy with symptom control, then you can increase your dose in order to bring that post cortisol figure lower.

At a post of 9, you have some decision making in regards to increasing or not since you are right at the highest point for the acceptable range. I would base the decision on symptom control. If all Stanley's symptoms are under control and you are happy with the results, then I would not increase. But, if you feel there is room for improvement, then you should consider the increase.

If you decide to increase, you'll need another stim test in 2 weeks, not a month.

[labblab]

I'd encourage you to discuss the dosing increase further with your vet. Per the published recommendations of Dechra, the company that makes Vetoryl, here is the action to take when a post-ACTH monitoring result falls between 5.4 and 9.1 ug/dl:


EITHER: Continue on current dose if clinical signs are well controlled
OR: Increase dose if clinical signs of hyperadrenocorticism are still evident*

If the dose is to be increased, they further warn to do so slowly.

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

With a post-ACTH of 9, Stanley is right at that upper limit. But as Renee says, I think the key here is whether or not he still has remaining symptoms. If not, and he is otherwise doing well, at his age I agree that it seems as though the better choice would be to leave things alone until/if symptoms rebound. Even if you do increase, doubling the dose seems excessively high.

So I do encourage you to look at the monitoring chart in that product insert and then get back with your vet for a further duscussion of the wisdom of an increase at this time.

Marianne

[l4d44]

Just spoke to the vet, she said that it was fine keeping Stanley on his current dose of 10mg once daily since he's not showing any symptoms.

Also she said that the post level numbers/range differs from manufacturer to internal medicine. IIRC, the range is something like 2 pre, 6 list for internal medicine.

Stanley's panting has all but disappeared and his thirst frequency has also decreased. Any other "symptoms" I should keep an eye for to monitor his Cushing?

Thanks y'all.

[jas77450]

Glad He is doing better.:)

[Squirt's Mom]

I'm not sure what your vet means by "IMS normal ranges" - that range is set by the manufacturer, Dechra, and researchers like UC Davis. If IMS's have their own range and GPs have their own range and the labs have their own range and the manufacturer has its own range.....how confusing and extremely dangerous for our dogs that would be! EEEEKKKKK!!!!! :eek::eek::eek: That statement makes me very uncomfortable so I hope I am missing something vital. ;)

[lulusmom]

Also she said that the post level numbers/range differs from manufacturer to internal medicine. IIRC, the range is something like 2 pre, 6 list for internal medicine.


That is true in many cases but not all internal medicine specialists agree . Dr. Edward Feldman of UC Davis is one who believes that if you want the dog to be "normal", you need to get the pre and post stimulated cortisol within a range of 2 ug/dl and 5 ug/dl. That's pretty much the same therapeutic range used for lysodren.

Dr. Mark Peterson, another renown endocrine specialist, feels differently. Here is an excerpt from one of his papers that reflects his treatment monitoring recommendations:


Monitoring and Goals of Trilostane (Vetoryl) Therapy

The combination of the owner’s evaluation of the dog’s clinical response and the results of the ACTH stimulation test are the keys to monitoring dogs on trilostane (Vetoryl) therapy. There are 3 published therapeutic ranges in the veterinary literature. While the recommended resting cortisol levels are similar, the “upper” post-ACTH cortisol values recommended in these 3 studies vary considerably —5.5 μg/dl, 7.0 μg/dl, and 9.1 μg/dl.

We recommend maintaining a post-ACTH cortisol between 2-7 mcg/dl when tested 4-5 hours after the morning dose. Lowering serum cortisol values to <5.5 μg/dl is not needed in most dogs and increases the risk of adverse effects. In contrast, most dogs with post-ACTH cortisol values > 7.0 μg/dl will show persistent signs of Cushing’s disease. However, if the ACTH-stimulated cortisol value is too high (> 7.0 μg/dl but the dog looks great and the owner does not report any clinical signs, we do not recommend increasing the dose. However, these dogs should be monitored closely, since many will show relapse of clinical signs within a few weeks.


You can find the complete article on Dechra's website at http://www.dechra-us.com/Files/dechraUSA/downloads/Articles/Canine%20Cushings%20Syndrome-%20Some%20%20Old%20but%20Everything%20New%20NAVC%2 02014%20Dr%20Mark%20Peterson.pdf

We have another specialist, Dr. Ellen Behrend, who also contributes to Dechra's veterinary continuing education program, seems to to agree with Dr. Feldman's protocol. You can also find her paper, entitled "Update on the Use of Trilostane" on the Dechra website where she includes an acth stimulation test graph where she indicates that the ideal range is between 1 - 5 ug/dl. You can find that article at http://www.dechra-us.com/Files/dechraUSA/downloads/Case%20Studies/Clinicians%20Brief-trilostane.pdf

Dr. Behrend also stated in that same chart that you should check with the lab for ranges and if you look at IDEXX Labs, they pretty much mirror Dechra's recommendations: You can find the IDEXX chart at https://www.idexx.com/pdf/en_us/smallanimal/snap/cortisol/trilostane-dosing-monitoring.pdf

So who is right? We moms and dads are. We need to make that call based on what we know about cushing's, how the drug works and what our pups are telling us. My first cushpup had a history of oxalate bladder stones, had black skin disease and alopecia so I agreed with her internal medicine specialist to keep her pre and post below 5 ug/dl. She never grew hair but she did great with lower levels. We kept my other cushpup under 5 ug/dl in an effort to resolve his PU/PD. It never resolved but he also did beautifully in the 2 to 3 ug/dl range. He also had arthritis and if it had been debilitating, I probably would have chosen to allow his cortisol to run higher.

I hope this helps.

Glynda

P.S. I believe you can find the papers I cited, including other valuable reference material in our Helpful Resources sub-forum. I highly recommend that you surf that forum and use the material to your advantage. Our ultimate goal is to be the best advocate we can be for our pups and the only way to do that is through education. A knowledgable vet and an educated pet owner is a force to be reckoned with when dealing with canine cushing's.

[l4d44]

After reading the links and everyone's suggestions - I have to admit that im confused.

I'm not sure wether to increase Stanley's dose (per the initial recommendation from his vet or keep him on his current dose as some has suggested here).

Seems like the vet is just going off the numbers from internal med and others are going by the numbers from the medicine manufacturer.

I just want to do what's best to properly treat his Cushing but doing it in the safest and most effective way.

With his post being "9" - should I just keep him on his current dose of 10mg daily once per day or should I bump it up a little (maybe around to 15mg) instead of the vet's dose of doubling-up (20mg)?

[steiny]

I'm a newer member dealing with the same issues you are with my Bichon. I totally agree with Lulusmom that we know are dogs better than the vets! Based on my experience, if your dog is doing well on the dosage he is on, leave the dosage alone. You can always have him retested and adjust down the road if his symptoms change.

I was always one to never challenge a dr. or vet. but I've learned that they don't know everything and they can be totally wrong at times. Like Lulusmom says....educate yourself as much as possible and you'll be the best advocate for your dog! It looks like you already are doing a good job at questioning and reading a lot!

Kelly

[labblab]

I'm a newer member dealing with the same issues you are with my Bichon. I totally agree with Lulusmom that we know are dogs better than the vets! Based on my experience, if your dog is doing well on the dosage he is on, leave the dosage alone. You can always have him retested and adjust down the road if his symptoms change.

I was always one to never challenge a dr. or vet. but I've learned that they don't know everything and they can be totally wrong at times. Like Lulusmom says....educate yourself as much as possible and you'll be the best advocate for your dog! It looks like you already are doing a good job at questioning and reading a lot!

Kelly
I "ditto" the things that Kelly has said :), with just one difference: if you start seeing Stanley's symptoms rebounding in the near term, I'd probably get permission from your vet to go ahead and up the trilostane even without another ACTH beforehand. But as I said above, I'd feel more comfortable first increasing to 15 mg. total rather than doubling the dose right off the bat. If you are using brandname Vetoryl, this does create a bit of a problem since it does not come in capsules smaller than 10 mg. But you can special-order smaller doses from compounding pharmacies (which we can talk about later should the need arise).

Marianne

[l4d44]

The Trilostane pills were too big for Stanley, so he had to have it made in compound down since day one.

Besides panting and excessive thirst, what other Cushing symptoms should I be on the look out in order to determine if I should up his Trilostane dose in the near future?

[labblab]

Other classic "external" Cushing's symptoms include excessive appetite, skin and coat issues, seeking out cool places, and pot belly. "Internal" problems can include worsening of high blood pressure, protein leakage from the kidneys, and elevated fats in the blood.

Since Stanley's original presenting problems were excessive thirst, urination, and panting, I think you would probably first notice them rebounding once again.

Marianne

[l4d44]

From the looks of things, I'm going to take my vet's advice and bump Stanley's dose up a little before his next ACTH test in about 3 weeks. Some of the symptoms are starting to rev up again.

However I'm not going to double the dose from 10mg to 20mg as the vet suggested. That seems too extreme as some have suggested here.

What would be a good number to go up to? 12mg or 15mg???

If either of the above, would it be best to split the dose in 2 or just keep it 1 dose in the AM?

[Squirt's Mom]

It would be best to have an ACTH prior to any dose change, up or down. ;)

[labblab]

Normally I would agree with Leslie, but since Stanley's ACTH results two weeks ago were high enough to prompt discussion of an increase then (pre of 6 and post of 9), I think I'd raise the dose now if you are seeing rebounding symptoms.

This is totally personal opinion, but I think I would just add the 2.5 mg. to the once daily dose for at least a week and see whether there is improvement from that 25% dosing increase. If not, I'd rethink again. Whatever you decide upon, do notify your vet, though. ;)

Marianne

[l4d44]

I've raised the Trilostane to 13mg the past few days and I'm not sure if it's a coincidence or not but Stanley's appetite has increased and he seems much more hyper in the late evenings (frequent pacing).

I'm not sure if this is due to the increase of his dose or of possibly he needs more than the extra 3mg I added?

Any suggestions?

[labblab]

I'm very sorry that nobody replied to you yesterday. Hmmmmm...dunno exactly what to make of Stanley's behavior. Guess I'd give it another few days "as is" in order to better judge whether or not this is truly a consistent change.

Marianne

[l4d44]

Got back the results from Stanley's 4th ACTH test and his post was 8.3 (down from 9.0 last month).

His vet would like to see his post number at around 5.5. She did recommend to slightly increase his dose (currently at 13mg once per day). She said that either 14mg or 15mg is fine and that she recommends splitting it up in 2 doses (morning and evening) instead of the current 1 morning dosage.

My 2 questions:

1. Should I increase his Trilostane dose to 14mg or 15mg (from 13mg)?

2. Is it better to give it once in the morning or twice per day?

Thanks.

[lulusmom]

If Stanley is still symptomatic, you still have some wiggles room so I'd definitely increase to 15mg. I treated two cushdogs with Trilostane. One was on once daily dosing and the other on twice daily dosing. Both did beautifully. Every dog is different and yes, some dogs may eventually need twice daily dosing to control cortisol over 24 hours b ut I think it may be too soon to tell if once daily dosing is not going to be effective for him. It's certainly more convenient to dose once a day so you may want just up the morning dose to see if symptoms resolve.

Glynda

[labblab]

If Stanley is still symptomatic, you still have some wiggles room so I'd definitely increase to 15mg. I treated two cushdogs with Trilostane. One was on once daily dosing and the other on twice daily dosing. Both did beautifully. Every dog is different and yes, some dogs may eventually need twice daily dosing to control cortisol over 24 hours b ut I think it may be too soon to tell if once daily dosing is not going to be effective for him. It's certainly more convenient to dose once a day so you may want just up the morning dose to see if symptoms resolve.

Glynda
I say "ditto" to everything Glynda just wrote. ;)

Marianne

[l4d44]

I say "ditto" to everything Glynda just wrote. ;)

Marianne

Great. Thanks Gals. :)

[l4d44]

I would like to wish everyone here (and your pets) a Safe, Healthy, Blessed and Happy New Year!!!

In the past week I've noticed that Stanley's appetite and urination have both increased. I bumped his Trilostane dose from 13mg to 15mg (once daily) last month.

He is due for another ACTH test in about 3 weeks. Since he is showing the above mentioned "symptoms" - would it be wise to slightly increase his Trilostane dose by another 2mg (up to 17mg total) or is this not recommended?

His last ACTH test about 4 weeks ago had his post number @ 8.3

Please advice. Thank you

[Harley PoMMom]

I would always rather error on the safe side than the sorry side, so, my answer would be to not increase the Trilostane dosage with out a recent ACTH stim test, especially since his dosage has already been adjusted upward.

Hugs, Lori

[molly muffin]

Just want to wish you and Stanley a happy new year too.

I too would wait to bump up till after the next ACTH test. I like to know the numbers before making any changes.

hugs

[l4d44]

Will do. Thanks ladies.

[l4d44]

I'm taking Stanley in next week for another ACTH test. About 2 weeks ago, his vet suggested that I split his Trilostane dose in 2 parts, which I have done. I'm giving him 7.5 mg once in the AM and 7.5 mg once in the evening.

When I take him in for his test, do I still stick with this schedule or should I skip the evening dose and give him the full 15 mg dose 4 hours prior to dropping him off at the vet?

What is recommended for better/accurate pre and post results? Thanks.

[labblab]

You most definitely stick to your normal dosing schedule. You do not change things in advance of the test.

You are still looking for the exact same therapeutic range as for once daily dosing.

Can you tell us why your vet asked you to switch to twice daily dosing? Is Stanley getting both doses along with food?

Marianne

[l4d44]

You most definitely stick to your normal dosing schedule. You do not change things in advance of the test.

You are still looking for the exact same therapeutic range as for once daily dosing.

Can you tell us why your vet asked you to switch to twice daily dosing? Is Stanley getting both doses along with food?

Marianne

Yes he gets both his doses with food. The vet switched it up because Stanley started showing some symptoms like increased shaking, increased appetite hyper activity during late night hours.

She stated that certain dogs respond better to AM and PM doses instead of just once a day. Thus far I have seen some improvement since I switched it up - but his ACTH test on Tuesday will obviously be more telling.

[l4d44]

Just got back the results for Stanley's latest ACTH test from yesterday. The vet is out until Monday, so I was unable to discuss adjustment of his Trilo dosing.

His Pre was a (4.1) and his Post was a (6.9) - that's down from his previous test about 7 weeks ago which was 8.3.

Currently he's getting 7.5mg of Trilo (liquid compound) TWICE per day.

I'm hoping someone could shed light on his latest test numbers and if it's an improvement from a couple of months ago.

Also I recently started mixing SWEET POTATO with his canned food (about 1 teaspoon) per meal. Is this okay for senior dogs with cushing or is Sweet Potato a "no no?"

[addy]

Hi, sweet potato isn't a bad thing, my dog has it in his food. Is it fresh?

As for the test results, I think the results are fine. You just started the twice day dosing, how are the symptoms that caused you to go to twice day dosing?

Each dog is different, some will do well with a bit higher numbers, some need to be lower. I think under 5 for a post is great and you are almost there.

It depends on how you feel your dog is doing, if you are satisfied with how well controlled the worrisome symptoms are.

[Harley PoMMom]

I'm with Addy, those numbers are great as long as his symptoms are controlled, is he still having to drink/pee a lot? How's his appetite?

[l4d44]

Yes the Sweet Potato is fresh.

I've definitely seen a noticeable improvement since switching to twice-a-day dosing. Stanley's urination and appetite are about the same.

I have noticed slight increase in tremor symptoms, especially when he's resting all by himself. Not sure IF this is related to Cushing or not - but this is something that I will discuss w/ his vet on Monday as we go over his latest ACTH results.

Ideally I would lie to get his post # down to around 5. I'm going to assume this is would require an increase in his daily Trilostane dose.

You guys are obviously more knowledgeable about his sort of thing than I am but is a 5mg increase (from 15mg to 20mg daily) too drastic?

[Harley PoMMom]

When you say that Stanley's urination and appetite are about the same. Does this mean that he is still drinking/urinating a lot and that this has not decreased?

I am a believer in that how a dog is feeling and if symptoms have improved are a better gauge in how treatment is going rather than basing it solely on ACTH numbers.

Also, in some cush dogs, even with treatment, the PU/PD may not resolve, which is called renal medullary washout. This means that all the stuff (solute) the kidneys need to concentrate their urine has been washed out for a very long time so the kidneys will take a while to recover.

Muscle tremors is a side effect associated with Vetoryl, and is listed as such in Dechra's product insert. http://www.dechra-us.com/files/dechraUSA/downloads/Product%20inserts/Vetoryl.pdf

Adding 5mg isn't a massive dose increase unless the dog is sensitive to the Veyroyl/Trilostane.

Hugs, Lori

[addy]

I tried to go back through you thread to see if I could see the history of doses and stim results, maybe if you have those handy you could post them for us.

The thing is, every dog is different. Boy that statement used to drive me crazy but it is so true. How well our dogs respond to Vetoryl depends on so many things; are their concurrent illnesses, are their illnesses that benefit from running higher cortisol (like arthritis or other inflammatory diseases), what is the blood work history of the dog.

I consulted with two different specialists in our city. Both shared their experiences that dogs they treated that had posts under 5ug/dl showed improvements in their blood work. Whether there are studies proving that, I cant say. I do know that once my own dog was consistently under 5ug/dl, things normalized in her blood work. As her coritsol got even lower, other problems arose, but my Zoe had other health issues. Dosing and treating can sometimes be a balancing act.

So, if your dog has a tendency to pogo back up and not stay controlled, or if the blood work has not improved or if you still see symptoms that bother you then perhaps an increase is in order. I personally do not think a bump of 5mg split into twice a day is not excessive but I really need to see the history of the stims and dosing.

I have now written a book, sorry:o:o:o:o

[l4d44]

Sorry for the late reply. I was severely under the weather the past few days.

What I meant by saying that Stanley's urination and appetite are the "same" is it hasn't really changed all that much since he's been steady on the Trilostane. I've slightly increased his dose but I don't think it's a significant bump to warrant any noticeable changes in his urination and appetite.

The vet dis suggest to bump him up a little, going from 15mg daily to 17mg to see if we could get his post # to under 6 for his next ACTH test.

[l4d44]

Hi guys and gals. It's been a little over 5 months since Stanley's last ACTH test and he's been doing just fine until about a week ago when I noticed some symptoms (excessive thirst, slight panting, increased appetite, etc).

I have him scheduled to be re-tested tomorrow morning and I have a question regarding his medication.

Currently I have him on 2X per day of Trilostane (mornings and evenings). Do I continue with this cycle (2x per day) or should I give him a FULL dose tomorrow morning (5 hours prior to his ACTH test)?

Not sure how this works when doing an ACTH test.

[labblab]

You continue dosing Stanley as normal prior to the ACTH test. You maintain your normal twice daily dosing, with the usual dose both the evening before the test and the morning prior to the test. You want to know exactly where his cortisol level is on the dosing amount and schedule that he's on everyday.

Marianne

[l4d44]

Thanks for your reply Marianne.

Since I'm giving his Tuesday morning dose around 3AM (instead of the usual 8AM) for his ACTH test....should I also give his Monday evening dose earlier or keep the same daily time?

[labblab]

I guess I'd give his Monday evening dose a bit earlier, too.

So will the vet be starting the ACTH right at 8:00 a.m.? According to Dechra, the testing window for the ACTH is 4-6 hours post-dosing, so if so, you could wait even an hour longer in the morning to feed and dose him if you wanted to. He does need to take the trilo with food, even at 3 or 4 a.m. :o

Marianne

[l4d44]

Results from Stanley's latest ACTH test:

Pre: 3.5
Post: 4.4

Vet says those numbers are within "range" and look really good. Also said to maintain current dosage of Trilo.

Opinions welcomed regarding those ACTH numbers please. Do the numbers look good and is staying w/ current dosage a good idea?

[labblab]

Those numbers look GREAT!!! :) :) :) :)

As long as Stanley is behaviorally doing well, too, I would not change a thing!

Marianne

[l4d44]

His previous ACTH numbers from about 5 months ago were pre 4.1, post 6.9.

I upped his dose since from 15ml to 20ml (current dose). I'm trying to figure out if it's normal for his numbers to drop to today's ACTH results from that slight Trilostane dose increase?

[Squirt's Mom]

Yes, that is what the drug is supposed to do. How long ago did you make the increase?

[molly muffin]

The numbers look really good.

I never go up more than a few mg on an increase because it can make a big difference.

Congratulations. :)

[labblab]

Upping from 15 mg. to 20 mg. was adding 30% more of that original dose, so that actually isn't as tiny as it might seem.

Like Leslie, I'm wondering how long ago you made the change. If Stanley has been on this dose for 30 days or more, I would now expect him to remain stable at this level.

Marianne

[l4d44]

Yes, that is what the drug is supposed to do. How long ago did you make the increase?

After his last ACTH test, I bumped it from 15mg to 18 mg (after talking to the vet). Then about 6 weeks ago I increased it from 18mg to 20mg (on my own :p) and he's been on that dose ever since.

[l4d44]

Hello. I'm hoping someone can help me with this question since my vet is out of town until late next week.

Stanley has been doing great but recently I've noticed that he's getting these dry, yellow, crusty, scab-like sores on certain areas of his back and neck. They usually come off his skin area after moistening it (clean w/ water + apply Neosporin) for a couple of days and then cutting them off his hair. They do leave a pinkish halo-like impression.

From what I've been able to find on the net, this is either yeast infections (due to cushing?) or possibly ringworm.

I have included a link to pictures of the scab and one after it is cleaned up. http://imgur.com/a/xriLq

For those with doggies w/ Cushing - have you seen this with your pet?

If so, how is usually treated?

Thanks.

[labblab]

Hi, I just looked at your photos and they resemble a bacterial staph infection that I've been battling for several months with my non-Cushpup Lab. Before culturing my dog's spots, I had also narrowed down the possibilities to ringworm, yeast, or bacterial infection. So Stanley could have any one of the above, but I just wanted to add a bacterial infection to the list :o.

Since Cushing's does compromise the immune system, Cushpups are more vulnerable to infections of all sorts, including skin infections. However, other types of problems such as allergies can also weaken the skin's defenses, as well. If the lesions continue to spread, you may want to go ahead and perform a culture/sensitivity in order to have a better idea as to how best to treat the lesions themselves. I will mention that there is another type of skin disorder, Calcinosis Cutis, that can plague dogs with Cushing's. But from looking at your photos, my layperson's impression is that Stanley's spots look more like infection than CC.

Bacterial and yeast infections can be treated with medicated/antiseptic shampoos, sprays, and topical ointments. Many medicated shampoos and ointments contain the combo of both antifungal and also antibacterial properties. If the spots are generalized and the topical agents aren't controlling things, oral antibiotics can also be prescribed in the case of bacterial infections (and perhaps oral antifungals for chronic yeast infections, as well).

We don't yet know what is at the root of my own dog's skin problems, but for the moment, the outbreaks are pretty well-controlled with frequent antiseptic baths and topicals (she's been on-and-off oral antibiotics). I waited a while to go ahead and have a culture done -- if I had it to do over, I would have cultured sooner so that I really knew what the problem was. So that may be something you want to talk with your vet about immediately upon his return, so that you don't let things get out of hand quickly.

Marianne

[molly muffin]

Definitely thinking you'll want some antibiotics on top of what Marianne has suggested and she is going through it currently so has an idea of what has worked for her. I'd say they need to culture to find out what kind of infection it is for certain, as there can sure be a lot of different ones and not all medications work with all infections.

[l4d44]

Thanks Marianne and Sharlene. I picked up a bottle of Vetericyn spray from my vet's office today. Never heard of it before but I hope it works well.

The staff told me that if the problem persists that I need to bring in Stanley for an exam/culture.

Hopefully this spray will help.

BTW if anyone can recommend me a good natural/organic shampoo for a Maltese with dry skin- I'm open for suggestions please.

Thanks y'all.

[l4d44]

Here are the numbers for Stanley's most recent ACTH test (10/27/15):

Pre: 3.1
Post:4.2

In comparison to his previous test back in June:

Pre: 3.5
Post: 4.4

I have not spoken to the vet (out of town until Monday) but I've noticed in the past couple of weeks that Stanley has started to pant and more thirsty than normal.

But according to the most recent test his numbers are better than his last test but I'm noticing a rebound of Cushing symptoms.

Should I increase his Trilostane dose a bit? Currently he's getting 20mg per day.

Any advice is greatly appreciated.

[Harley PoMMom]

I would rule out any non-adrenal illness that could be causing the increased drinking such as diabetes, UTI and/or, a bladder/kidney issue (stones, crystals), regarding the panting, pain can cause a dog to pant, does Stanley have arthritis?

Hugs, Lori

[l4d44]

Hi Lori. Stanley does have a history with bladder stones but he's been on a specialized diet for a while now, so I don't believe it would be that. He does also have issues with his front arms. They often collapse when he's walking or running and he falls flat on his face. It might be arthritis related but most likely due to old age, according to his vet (he's 15 1/2 yo).

However I believe it's most likely due to the yellow, crusty scab-like marks on his skin (which I described in page or so back in this thread) that seems to be bothering him. I'm taking him in on Monday for the vet to take a sample and send it in to the lab for analysis and for him to be put on antibiotics.

One last thing regarding his Cushing, I did speak to the vet a little while ago and she recommended that I go down in his Trilostane dose (from 20mg daily to 17mg daily) based on his most recent ACTH test.

Can someone who knows better about this give me their opinion/feedback regarding if this is recommended?

[Harley PoMMom]

When ACTH results show that a dog's cortisol has dropped too low than the Vetoryl/Trilostane has to be stopped for a while and than restarted at a lower dose. Since his most recent ACTH stim numbers are great - Pre: 3.1 ~ Post:4.2 - I'm not sure why she wants to decrease his dose. How is Stanley behaving? There hasn't been any episodes of vomiting or diarrhea? How about his appetite, still good?

Those yellow, crusty scab-like marks on his skin could be Calcinosis cutis (CC), and can be determined with the biopsy the vet is taking. If Stanley does indeed have CC than keeping his post number below 5 ug/dl is usually required to gain control of it, and it can be a bugger to control.

My noncush pom, Bear, had to have 2 surgeries to remove oxalate stones. With oxalate stones a diet alone can not dissolve that kind of stone formation, now with struvite stones a special diet can help to dissolve those type of stones. What kind of stones does Stanley's body produce?

[l4d44]

It's the latter (struvite) and I've taken him a few months ago for xrays. The doc said it's not a pressing issue.

My hunch also tells me to stick with the current Trilo dose. I think I will indeed do that. Thanks for your advice.

I definitely need to keep those scab "thingys" under control. I can tell that he's very uncomfortable at times because it seems like it itches like crazy.

Will find out early next week.

[SandyH]

For shampoo I can highly recommend the Quadruped line. It is a natural, yucca based line which has medicinal properties. I use the All in One but I do not have skin issues with my crew. They do have medicated shampoos which probably have additional stuff for skin issues. Yucca is also a natural flea repellant and killer, and yes, it does kill the fleas dead on contact-I can attest to that from others that have used it with their flea infested dogs. I would call them and see what they would recommend for you, customer service is very nice. It is also economical as the bottles you buy are concentrated so you have to mix 5:1 or 15:1 ratio, can't remember exactly. It also gets white dogs very very white and clean. You can buy thru them or Amazon, you won't find their line in stores like Petco. They also have leave in conditioners. I buy it by the gallon, usually go thru a gallon of shampoo and conditioner a year for my 3 cocker spaniels, makes grooming easier and also cuts down on mats. Hope this helps with Stanley's skin, I love this stuff!

http://quadrupedpetcare.com/wp/products?cat=15

[Harley PoMMom]

If it does turn out that Stanley has CC, Renee, one of our members here, is the resident expert on treating and controlling that CC. So if the biopsy comes back positive for CC I am sure Renee will be along to help guide you.

In the meantime here is a link to her and Tobey's http://www.k9cushings.com/forum/showthread.php?t=5908thread:

Hugs, Lori

[molly muffin]

There is also a trichlor shampoo made by Dechra the manufacturer of vetroyl that might work, although the one that Sandy mentioned sounds good too.

[l4d44]

I purchased the shampoo/conditioner from the site SandyH recommended (thank you).

Stanley's lab work came back as a staph infection. The vet recommended that I completely change his diet (novel protein) and put him on some anti-biotics (Baytril).

Unfortunately Stanley had really bad reaction/side-effects from the Baytril (loss of appetite, super lethargic, depression) so I had to immediately discontinue use after 1 day and 2 doses. He was basically a zombie yesterday. I will be discussing other medicine options w/ the vet tomorrow morning.

I switched up his food to "The Honest Kitchen" brand (grain-free turkey recipe). It's a dehydrated-type food/meal. After much research, I found this to be the best food for his age (15 1/2 yo) and for his skin condition.

I don't know if he likes it or not because he's been refusing to eat due to the Baytril med. I'm hoping he will regain his appetite later this evening.

I also removed a living room rug I recently purchased as I'm unsure if he might be allergic to it (ruling out all possibilities). And I also washed all of his towels and blankets with a hypo-allergenic/dye-free detergent.

Sigh. Here's hoping that he no longer gets those super-itchy skin scabs.

IF anyone else has any suggestions - I'm all ears.

[molly muffin]

Did you get an alternate type of antibiotic? Unfortunately, just like in people, staph infections don't clear up without an antibiotic usually, and can be quite resistant and spreading. The antibiotic spray should help but I do think he'll need some internal too. There are other kinds of anitibotics out there other than Baytril, so let your vet know.

[Harley PoMMom]

Marianne's (labblab) dear Luna is going through a staph infection too, here's her post telling what she is using:


Overall, Luna's skin generally looks much better. I thank you so much for the Douxo and Allerderm recommendations. I really think the Douxo shampoo is superior to what I was using previously and I am going to recommend it to my vet.


Hugs, Lori

[labblab]

Hi again from me! And yes, Lori is absolutely right that we have been challenged for over a year now with a recurrent staph infection on the skin of our non-Cushpup Lab. We have tried both oral antibiotics and also medicated topicals, and actually, my Luna is now doing very well using only medicated topicals alone <knock on wood!>

After ten days of rain, I think I can finally take my dogs out for a "dry" walk this morning :), so I am headed out the door! But I'll stop back by later today and share some info about our experience and the products we have been using.

Marianne

[labblab]

OK, I'm back again after basking in a day filled with sunshine. :) :)

One of my non-Cushing's Labrador retrievers, Luna, has had recurrent staph infections ever since last January. We are clueless as to the underlying cause, but we are now guessing it's most likely an allergy of some sort since we haven't uncovered any other obvious disease or abnormality. Like you guys, we've switched to a novel-protein food and we also give her oral Omega fatty acid capsules to help support her skin health.

Initially, she just sprouted a few isolated "goopy" red spots and her hair pulled out in those areas. In honesty, we pretty much just ignored it because the spots seemed to quickly heal :o. But by late spring, she developed a really widespread outbreak across her back. The vet cultured it, and it came back as antibiotic-sensitive staph. The outbreak was really spreading fast, so we put her on oral antibiotics in addition to using antibiotic ointment directly on the spots. She responded really well, her skin cleared up, and we stopped the antibiotics. All was good for a month, and then the spots came back. Instant replay of all the above, but a longer course of oral antibiotics this time. All was good for a month, then a spot reappeared. :(

During this time, we had also been bathing her with a medicated shampoo. But by this time, I was really anxious to come up with some better options for topical treatments because I realized she couldn't live on oral antibiotics forever. Thankfully right at that time, another one of our members, Saskia, shared some treatment suggestions and they have ended up really helping Luna.

First, I decided to switch to a shampoo that contains chlorhexidine (our first shampoo had a different antiseptic). There are several studies that suggest that chlorhexidine seems to be the most effective against staph (although there are some new shampoos on the market that are highly praised and instead contain sodium hypochlorite, the active ingredient in bleach). Saskia recommended a product line made by Douxo, and I have been using their chlorhexidine shampoo and spray (they make lots of different products). I have also been using a spot-on product that she also recommended, but unfortunately, it is no longer being manufactured in the U.S.

Anyway, if an owner is willing/able to bathe their dog as frequently as 2-3 times weekly during an outbreak and to administer antiseptic spray, wipes, lotions, or ointments in between, there is now research to demonstrate that many antibiotic-sensitive and antibiotic-resistant staph infections may be controlled as successfully through topicals alone as through the use of oral drugs. This saves the dog from the side effects of oral antibiotics, and also helps decrease the development of antibiotic-resistant bacteria. So it really is a win-win situation. But it does require commitment to keeping that skin clean!! If you're interested, here's a link to brand new study that documents the success of aggressive topical treatment:

http://www.ncbi.nlm.nih.gov/pubmed/26140535

So, bottom line, since Stanley has been diagnosed with staph infection, at a minimum I'd recommend switching him to a medicated shampoo that contains an antiseptic that specifically targets staph, and I would bathe him frequently while he is having active lesions. Since switching to the new shampoo and spray, Luna's skin has been so much better. Initially, we were bathing her twice a week, but we now space it out to every ten days. She still sprouts a small spot every once in a while, but she is much, much better than she was before making the switch. And we are hoping we can keep her outbreaks sufficiently under control that we won't need to return to the oral antibiotics.

Marianne

[l4d44]

Wow, thanks for the useful info. This past weekend I ordered a shampoo line recommended by fellow member SandyH called "Quadruped." I'm hoping that it will help his skin issues. If not then I will definitely try "Douxo" next.

The vet switched Stanley's anti-biotic to SIMPLICEF. However she stated that the side effects are similar to Baytril. I have not given him the new pill yet - still waiting for him to get adapted to his new food and to regain his appetite.

I'm feeding him ZIWIPEAK Venison recipe canned food, mixing it with fresh steamed peas and squash (for taste and flavor since he's super picky).

Also the vet gave me an "wound & skin" spray called VETERICYN VF. I've used it a few times but I don't think it's really working.

[labblab]

Simplicef is the oral antibiotic that we gave Luna, and it did effectively clear the infection both times we gave it to her. She was on a two-week course the first time, and I believe a month-long course the second time. For us, the problem was that the staph infection returned each time after we stopped the Simplicef. For Stanley, however, it may turn out that the antibiotic will clear the infection for good. I'd have to assume that his Cushing's is the underlying condition that has left him more vulnerable to the skin infection (with our Luna, we don't know what the cause is). If so, the longer his cortisol level is kept well-controlled, then hopefully the less likely it will be that he will continue to have skin problems. Also, I don't mean to suggest that there is never a need for oral antibiotics; these studies are all talking about clearing "superficial" infections with topicals alone. Deep or widespread infections may still need the oral meds.

The Quadraped shampoo may turn out to be an excellent choice for reinforcing Stanley's skin health once the infection is under control. However, I do think you may need to shift to a shampoo with an antiseptic agent that is known to effectively kill staph while you are dealing with active infection. Also, here's some info about Vetericyn that even your vet may find interesting. I have been using it for a couple of years to clean wounds, etc. (it also contains a bleach derivative), but when I went to buy a new bottle during the summer, I noticed there had been a change in the labeling. When I Googled more about that, this is what I found. So the new product may just not be as effective as the old one.

http://www.k9cushings.com/forum/showthread.php?t=7340

Anyway, I certainly wish you good luck with getting this infection under control. It has definitely been a journey for us. :o

Marianne

[l4d44]

Quick update: switching Stanley's food seemed to have solved the skin staph infection problem. I decided not to give him his oral antibiotics med because of the side effect and I'm glad that it worked out. I'm also bathing him once every 5-6 days now. He has not had a break out since and he is much more relaxed and comfortable.

Happy Holidays to everyone!

[molly muffin]

This is wonderful to hear! So glad the outbreaks are clearing up and the antibiotic wasn't needed. Good news!! :)

[l4d44]

Stanley has been doing great for almost 1 1/2 years after first being diagnosed with CD (on Trilo) with very little adjustment and hardly any symptoms.

However about 3 days ago, he started showing ALL of the symptoms (out of nowhere) and it was pretty drastic too. Drinking water excessively, always hungry, frequent panting and restlessness throughout the day and mostly during the night (I haven't slept for more than 2 hours the past 3 days because of this).

I took him in today for an ACTH test. Most likely his dosage would need to be adjusted.

Is it normal for the Cushing's symptoms to all-of-a-sudden bounce back like this (and not gradually)? He was literally doing fine one day and the next day he was exhibiting strong signs of CD.

To help him rest at night, his vet gave him 0.25 mg of ALPRAZOLAM (generix for Xanax) to be used on "as needed basis."

Since Benadryl doesn't work for him (makes him hyper actually) and I've had poor results with Melatonin - his vet recommended this since it was limited/low side effects.

Since Stanley is almost 16 now, is this a good idea? Does anyone else give their dogs Xanax to aid in their sleep?

Please advice.

Also I will post his ACTH results when I get them on Saturday. Thanks y'all.

[labblab]

It is not at all uncommon for dosage changes to be made over time due to rebounding symptoms, but your description of such an overnight change does raise some red flags for me. I hope that in addition to the ACTH, your vet is also running a blood chemistry panel. Diabetes can come on quite suddenly, and there does seem to be increased vulnerability to diabetes in Cushpups. So I am especially hoping that Stanley's glucose level is being checked. Also, at his age, you'd also want to make sure that there hasn't been a sudden change in his kidney or liver function. So once again, a blood chemistry panel can give you some important indicators or those types of changes.

It may well be that he just needs a bigger dose of trilostane. But I'd want to make sure that there isn't a problem other than Cushing's that has suddenly surfaced.

Marianne

[Harley PoMMom]

I agree with Marianne, it does sound more like diabetes.

[molly muffin]

Yes definitely need a blood test but one question. You mention getting the ACTH results on Saturday. Did these symptoms come icon right after the ACTH test was done?
There something I call the ACTH spaz. My dog is nuts after the test. Eating. Drinking. In general spazzing. Having symptoms she doesn't have at any other time. J

So that could be a culprit too if the timing works out.

[l4d44]

I really wish I would have made my post PRIOR to his vet visit this AM. The vet suggested to do a blood panel but I declined since it was a little expensive and all his symptoms seemed to be cushings related. Hindsight is always 20/20 but it appears that was a poor decision on my part. I will call tomorrow and schedule a blood test on Saturday (his vet is off on Fridays).

Molly: no, his symptoms do not increase after he has his ACTH test(s).

I appreciate everyone's insight. I don't know what I would do in this situation without this great community.

I will post any updates in the next few days.

[l4d44]

Update:

I took Stanley in this morning for a full blood panel test. He does NOT have diabetes. Kidney, Liver and Thyroid results are due on Monday.

Also got back in ACTH results (CURRENT):

Pre: 1.4
Post: 1.5

As compared to his previous ACTH (10/26/2015):

Pre: 3.2
Post: 4.1

Since his numbers were really low, his Vet recommended to cut his Trilo intake by 50% (from 0.6ml to 0.3ml - liquid compound of Trilo, FYI).

I forgot to ask the vet but I'm hoping someone might know the answer to this.....can a dog show Cushings symptoms if they are being over-medicated by Trilostane?

[Harley PoMMom]

I forgot to ask the vet but I'm hoping someone might know the answer to this.....can a dog show Cushings symptoms if they are being over-medicated by Trilostane?

Absolutely, if a dog's cortisol is too low increases in drinking and urinating can be seen.

His ACTH stimulation numbers are too low for my comfort too, so dropping his dose is needed. If this were me I would with hold the Trilostane for at least a week than evaluate his symptoms and if feasible have another ACTH stim test done to make sure that his adrenal glands are producing enough cortisol. I know those ACTH tests are expensive so an option could be to have just the resting cortisol (pre number) done.

[labblab]

Hmmm... Stanley's ACTH results are certainly of interest, and given how low and "flat" they are, you might want to talk to the vet about withholding the trilostane entirely for a few days before starting back at the half-dose. Some dogs who experience oversuppression of adrenal function due to trilostane overdosing actually need to take a complete break until such time that it's established that cortisol is being produced sufficiently once again.

One of the confusing issues is that both Cushing's (too much cortisol) and Addison's (too little cortisol) can share overlapping symptoms such as excessive thirst and urination, panting, lethargy. One oddity here, though, is that Stanley's hunger has really accelerated again, and that is more typical of a dog whose cortisol is running high rather than low.

Given those ACTH results though, as I say, I'd be tempted to ask about withholding the trilo altogether, at least until the rest of the blood panel results are back on Monday. With cortisol that low, it's also possible that Stanley's aldosterone has also dropped too low. That's the adrenal hormone that controls the balance of sodium and potassium in the bloodstream, and if that balance is "off," then some of these same types of symptoms could be the result. Information about the potassium and sodium balance should also be included in the results you'll be receiving back on Monday.

So the picture is still a bit of a puzzle, but I think you'll know more by Monday.

Marianne

[molly muffin]

I don't like results that low either and would let them come up a bit before restarting trilostane. Just to be on the safe side and then start back at the lower dose once you know that the cortisol is coming back up.

[l4d44]

Thanks for the advice everyone. So Stanley has been off Trilostane since Friday. I've definitely noticed an improvement the past 24 hours.

[l4d44]

Stanley's ACTH test results came back:

Pre: 4.6
Post: 7.2

These numbers are with him being OFF Trilostane for a week prior to testing.

Since Stanley is still showing some symptoms (excessive thirst, restlessness and slight panting) and due to the concern of getting Addison's Disease - his vet recommended to start him up on a low dose of Trilostane and do a re-check of his blood in 2 weeks (Pre/Resting only).

She suggested to give him 3mg twice per day (6 mg total daily). Previously he was on 18mg total daily.

I trust this community immensely and I would love some feedback regarding what the vet recommended. For his numbers...is 6mg too much or too little (or should he not be on Trilostane at all)???

Thanks.

[Harley PoMMom]

Those ACTH stim numbers are showing that Stanley's adrenals are producing an adequate supple of cortisol...YAAA!!! Since he is still showing symptoms of Cushing's I agree with the vet and would feel comfortable restarting the Trilostane. The 3mg BID sounds like a good dose to start with and instead of having only a pre draw done I would have a full ACTH stim test performed.

You're doing a great job!!

Hugs, Lori

[molly muffin]

I'd try the lower dose and see how he does on it if it were me.

[l4d44]

You mean the 6mg daily that the vet recommended or going even LOWER?

[molly muffin]

I meant what the vet suggested. :).

[l4d44]

Thanks for your input Lori and Sharlene! I really appreciate it.

[molly muffin]

Okay, checking in to see how Stanley is doing! Did you go with the 6mg dose? If so how is he doing on it?

[l4d44]

Okay, checking in to see how Stanley is doing! Did you go with the 6mg dose? If so how is he doing on it?

Hi. Thanks for checking. Stanley had another ACTH test yesterday and here are his numbers:

Pre: 2.9
Post: 5.3

This is with him on the 6mg of Trilostane daily. He looks to be doing better. In regards to the numbers above, is any adjustment of his dosage recommended?

His vet said to keep him on the same dosage but I'm interested to see what this community says.

Thanks.

[molly muffin]

As long as the symptoms are controlled and considering he is sensitive to the drug. I think that is a good result. I'd leave the dosage alone for now

[l4d44]

Hello. Stanley has been really lethargic the past few days. His appetite is still the same but all he does is sleep and he looks "out of it."

I noticed that his water consumption is drastically down - to the point where he is hardly drinking any water whatsoever.

I began giving him a water/pedialyte (clear) mixture (1-to-1) with a syringe, several times today. He is not drinking water on his own though. I ordered a water fountain that is arriving tomorrow to hopefully stimulate his thirst.

I know it's a shot in the dark but I'm almost sure this has nothing to do with his Cushings. I scheduled an appointment with his vet for Tuesday.

Anything specific test I should request to be done?

If anyone has gone through a similar thing with their dog or have any have suggestions - please let me know. Thanks.

[labblab]

I'm afraid you need to request another ACTH test ASAP. These symptoms are commonly associated with adrenal oversuppression and could very well signal that Stanley's cortisol has dropped too low once again. In looking back, I see that low cortisol has been an issue before, and Stanley may be a dog who is just particularly sensitive to the effects of the trilostane.

Can you possibly take him in for testing today? Even if not, I believe you should call your vet first thing this morning to tell him what is going on. The safest thing to do is to stop giving any trilostane until Stanley is tested, but I want your vet to be aware of what you are doing in that regard. If Stanley continues to refuse water or worsens in any way, this can signal an emergency situation and he may need to be given some prednisone in order to supplement his natural cortisol production if it has dropped too low.

Also, I would only offer him plain water without the pedialyte unless your vet instructs otherwise. If Stanley's adrenal glands are being oversuppressed by the trilostane, the balance of potassium and sodium may be messed up in his system. The pedialyte may alter that balance even further. In order to check that balance as well as the status of his kidneys and liver, he should have a blood chemistry panel drawn in addition to the ACTH.

Please keep us updated, OK?
Marianne

[DoxieMama]

Hi, I second Marianne's suggestions to not give him any more trilostane until he is tested with both an ACTH and a chem panel.

My boy was also lethargic and "out of it", his appetite was good, though he also drank a normal amount of water. His ACTH results were good but his electrolytes (potassium and sodium) were not optimal. We kept him off of trilostane for a week until we got a lower dose. Next week will be the first tests on this dose so I don't have any results yet other than to say his behavior is a lot better now... no more lethargy or spaced-out looks.

Hope Stanley is feeling better soon! Hugs!
Shana

[molly muffin]

Always check cortisol levels when there is activity that like not eating, not drinking, excess lethargy, diarrhea, vomiting, wobbly. All of these can be signs of over suppression and are serious. If any doubt at all, stopping trilostane to see if it makes a difference is an an option.

[l4d44]

Hi again. I took Stanley yesterday for an ACTH test along with a blood panel test was well.

Pre: 4.6
Post: 6.1

These numbers are with him off Trilostane since Monday. His vet suggested to keep him off the Trilo for 2-4 weeks until re-testing or if his symptoms rebound, which I'm almost certain they will in the next few days. If that's the case then she wants me to call her and we'll probably start him on a lower dose and re-check.

His blood work came back mostly great. His thyroid levels were a little low (0.6) but the vet said that it could be due to his Cushing's and he might need to have it checked out again in a few weeks for a more accurate reading.

His kidney BUN number is 33. She said it was a little off but I recently switched him to a "lightly cooked" meat diet made by MY PERFECT PET. It's the only dog food that her would eat and since he's almost 16 yo now, I want him to eat what likes. Supposed to be real healthy with fruits, veggies, fish oil and vitamins.

Anything from those numbers look off?

[Harley PoMMom]

I believe the plan of action that your vet is taking is spot on.

Hugs, Lori

[l4d44]

Update: Stanley has been completely off Trilostane for 16 days now and he's doing great. Exhibiting no symptoms whatsoever.

Kind of strange that he's been on Trilo for this long and then all of a sudden he doesn't need it anymore. Is this somewhat common with dogs or is it a unique case?

[Harley PoMMom]

Update: Stanley has been completely off Trilostane for 16 days now and he's doing great. Exhibiting no symptoms whatsoever.

Kind of strange that he's been on Trilo for this long and then all of a sudden he doesn't need it anymore. Is this somewhat common with dogs or is it a unique case?

On the forum we have seen some dogs go into a Vetoryl/Trilostane "hiatus" but usually this was after the dog's cortisol went too low.

[molly muffin]

Yes Stanley wasn't actually too low, so it would be different if he is stable for a very long time with no medication at all for cortisol.
Are you planning to have the levels rechecked at some point or only if symptoms return?

[l4d44]

Yes Stanley wasn't actually too low, so it would be different if he is stable for a very long time with no medication at all for cortisol.
Are you planning to have the levels rechecked at some point or only if symptoms return?

It's been a little more than 2 months and Stanley has been doing great being off the Trilostane.

At first sign of symptoms rebound - I will have him rechecked. Is this okay?

[labblab]

Wow, this is great news that Stanley is doing so well! Especially given his age, if he were my own dog, I think I'd wait until/if symptoms rebound before rechecking cortisol, too. At this stage of his life, daily quality is the single most important thing. So even if his cortisol was running a bit higher, I probably wouldn't restart treatment, anyway, unless you were seeing symptoms that were making him uncomfortable.

So I would probably just carry on for now, and please do continue to update us either way. As you know, Stanley's experience is somewhat unusual for us here, and it helps us to have you share his experience!

Marianne

[Whiskey's Mom]

Hi! Happy to hear Stanley is doing great off the Trilostane. It's almost one month off for my Whiskey and his symptoms haven't returned yet either. I've been worried about not giving it to him so I'm glad to see I'm not alone in this situation. thanks for posting! :)

[l4d44]

Hi everyone. I took Stanley in today for an ACTH test because I believe his symptoms are slightly rebounding (lethargy, increase thirst, sleepless nights, noticeable panting, etc). I also did a senior blood panel test as well.

I won't receive his results until Monday afternoon but I was wondering if it's okay/safe to start him on a very low dose of Trilostane in the meantime - until I get his results to get a "jump start" or is that a no-no?

Thanks.

[DoxieMama]

I would wait, but I am curious what others suggest.

[labblab]

Since you will only be waiting one more day to get the test results, I'd also hold off on restarting the trilostane until you know exactly where things stand. Please do let us know how things turn out -- we'll be very anxious to hear!

Marianne

[l4d44]

Here are Stanley's latest numbers from his tests:

Pre: 6.4
Post: 5.2

His vet said that he's right at the "border" and recommended to NOT give him any Trilostane at this moment. Is this the right call???

Also his blood work came back really good for his age (16.5 yo) - with the exception of his BUN, which is slightly elevated at 48. Previously it was 33 when it was tested back in late May.

She recommended food/meat with low nitrogen levels or switching him to the KD/Renal prescription food.

However Stanley has skin allergy issues with most commercial dog foods and he's a super picky eater.

I've recently switched him up to homemade food consisting of ground turkey, kale, apples, oats, peas, lentil, eggs and Olive oil.

I'm not sure if this is good for him with beginning stages of kidney problems?

Help. :eek:

[Harley PoMMom]

Those are pretty good stim numbers! If his Cushing's symptoms seem to be bothersome, if this were me, I would restart the Trilostane but at a lower dose. I see that his previous Trilostane dose was 6 mg so I would cut that dose in half and only give him 3 mg daily...just my two cents worth! ;)

[labblab]

Hmmm...here's another couple cents worth to throw into the mix. :p

If I were to begin the trilostane at all, I definitely agree with Lori that I would give a lower dose than before. But honestly, I think I'd side with your vet on this one and not restart the trilostane at all right now. There are a couple of reasons why.

First, Stanley's post-ACTH result is even lower now than it was when he was last tested at the end of May. It was 6.1 in May, and now only 5.2, and this is while being totally "off" the trilostane altogether for the last four months. So in reality, this means his cortisol production really hasn't rebounded at all throughout the entire summer. So actually, I would be rather nervous about restarting the trilostane and risking additional adrenal suppression at this point.

Secondly, the symptoms you are seeing may not really be the result of cortisol production. Especially if he is now experiencing some renal insufficiency -- which would not be at all unexpected given his age -- some of the changes you are seeing may be related to that or to other geriatric issues.

However, the increase in Stanley's BUN may be related more to diet or hydration than anything else, especially if his creatinine is still within normal limits. But if there is a chance that his kidneys are no longer working as efficiently, I think this would be another reason to be cautious about restarting the trilostane because his body may not be able to clear the drug as efficiently, either. This could lead to a build-up of the metabolites in his body.

So if it was me, I think I'd wait and see a while longer before starting back on the trilostane again. As far as your dietary questions, I'm hoping that some of our other folks who have dealt with renal dietary changes will be able to stop by and offer some tips. Although, I have to say that I also agree with one of your earlier statements, too. At age 16 1/2, I think I'd tend to just give Stanley the things he wants to eat and that won't disturb his allergies.

Marianne

P.S. I've taken the liberty of editing your thread title to reflect the fact that Stanley has celebrated a couple more birthdays since you first joined us! ;)

[l4d44]

Yeah I don't think his recent symptoms are related to CD either. Recently it's been super hot and very humid out here and I think that might be a result of his slight increase of water consumption and the infrequent panting.

Surprisingly, Stanley is doing well for his age - minus your typical geriatric things like staring at himself in the closet mirror, loss of hearing and sleeping a lot more, etc.

I went through renal failure with my previous dog and it wasn't easy on myself and especially my dog, who required daily fluid injections.

I just want to make sure that Stanley gets early treatment and enjoys a better quality of life towards the end.

Any advice regarding this is greatly appreciated. You guys are so helpful and supportive. Not sure what I would have done had I not stumbled upon this site.

[molly muffin]

I would not restart the trilostane at all, since there has been no change except for decrease while off the trilostane this summer .
I also at 16.5 wouldn't necessarily switch him to renal perscription food if he isn't good on kibble. Rather you might talk to a dog dietician about making some low phosphorus home made food and what nutrients would need to be added to that to keep him healthy and his kidneys functioning optimally.
Thats my two cents. :)

[l4d44]

...........

[Harley PoMMom]

Dearest Mike,

I am so very sorry for the loss of your beloved Stanely, he's such a special boy. I will be keeping you in my thoughts and prayers and I wish there were someway I could help you though this very difficult time. Please know we are here for you and always will be.

With my deepest sympathy, Lori

[molly muffin]

Oh No Mike, I am so very sorry. My sincerest condolences. :( how very heartbreaking it is to hear this news.

[Joan2517]

I'm so sorry for your loss...

[Squirt's Mom]

Dear Mike,

I am so sorry to learn about our precious Stanley. You are a great dad and I have no doubt Stanley was so very grateful to you for all you did on his behalf. The two of you fought many battles together but when this last fight proved to be just too much, you gave Stanley the greatest gift of all - freedom from a failing vessel. For this last gift, I know Stanley is most grateful.

Our deepest sympathies,
Leslie, Trinket, Sophie, Fox and all our Angels



The Rainbow Bridge
inspired by a Norse legend

By the edge of a woods, at the foot of a hill,
Is a lush, green meadow where time stands still.
Where the friends of man and woman do run,
When their time on earth is over and done.

For here, between this world and the next,
Is a place where each beloved creature finds rest.
On this golden land, they wait and they play,
Till the Rainbow Bridge they cross over one day.

No more do they suffer, in pain or in sadness,
For here they are whole, their lives filled with gladness.
Their limbs are restored, their health renewed,
Their bodies have healed, with strength imbued.

They romp through the grass, without even a care,
Until one day they start, and sniff at the air.
All ears prick forward, eyes dart front and back,
Then all of a sudden, one breaks from the pack.

For just at that instant, their eyes have met;
Together again, both person and pet.
So they run to each other, these friends from long past,
The time of their parting is over at last.

The sadness they felt while they were apart,
Has turned into joy once more in each heart.
They embrace with a love that will last forever,
And then, side-by-side, they cross over… together.

[l4d44]

I'm literally tearing up typing this but unfortunately I had to put Stanley down last Tuesday from complications due to cancer. He had deteriorated really bad the past 2 weeks and it was time for him to go peacefully and not when he reached an uncomfortable point in his life. That was really important to me as I did not want him to suffer.

As I told Lori (via PM), this was literally the hardest thing I've ever had to do. I was so attached to my baby boy and his presence will be greatly missed. My home and my life is so empty without him now. I took better care of him than I did myself.

I guess time heals but this feeling really sucks right now.

I would like to thank this wonderful community for all your love and support from day 1. The journey has been amazing and I can't thank each and every one of your enough for your insight and help. I have learned so much. Thank you again.

Have a blessed and safe Holiday Season to you and your loved ones (including your beloved furry babies of course).

-Mike

[molly muffin]

Mike. I understand exactly what you mean when you say the hardest thing you ever had to do. It just sucks and yet we do it for them anyway because it is the right thing. Seems that seldom is the right thing, the easiest thing. Often the opposite.
Stanley was lucky to have such a wonderful dad to take such good care of him, just as you were lucky to have him to being you such joy throughout the years. It's always a two way street they being so much to our lives.

Take care of yourself.

[Budsters Mom]

Hi Mike, I am so sorry to hear about your beloved Stanley. We know exactly what it feel like to end our babies's pain. Their pain becomes ours. You are exactly right. It does suck!

Fly free Stanley, fly free!

Hugs,
Kathy


I guess time heals but this feeling really sucks right now.