My little 'mister' has been diagnosed with cushings

[innotu]

Hello,

I'm thankful that I stumbled onto this site. It has been a wealth of information. A little bit about my boy....

Mister (Mr.) will be 8 years old on or around Jan. 28th (he's a rescue). We think he's a Maltese poodle mix. We can't remember a time when he hasn't been ravenous with hunger so no sudden increase in appetite to forewarn us. He's also had pancreatitis 6 times since Nov. 2010 - cause unknown. No recent bouts of pancreatitis as I'm now making his food (bland low fat diet). Over the past several months he's been slowly losing his hair on his tail and torso and recently (the past 2 months) we've noticed a marked increase in thirst. He was always so good about not peeing in the house and since his increased water intake, he's had a few 'accidents'. We now take him out every 2-3 hours. At night, he's restless and every few hours scratches the side of our bed to get our attention - he wants food and/or to go pee. I did some research on the internet and came to the conclusion it was probably cushings.

I took him to the vet on Christmas eve and the vet said just by looking at him and hearing his symptoms, he was 99% sure it was cushings. He then did the 2 hour test. He phoned me on Dec. 27th to confirm the diagnosis - his levels were 'off the chart'. Apparently the test measures up to 1300 and Mr.'s numbers were well above that. I'm now waiting for a call to bring him in for an ultrasound. And barring an adrenal gland tumor (which he says are very rare - he's only seen 2 in his 9 years), he'll start him on Lysodren. He explained the process and how he would be closely monitoring Mr. during the induction phase.

I'm fairly comfortable with my vet. He seems to be quite knowledgeable and says he treats several cushings dogs. He has 9 years of experience and diagnoses about 1-2 new cases each month.

My question is what should I be asking the vet during our next appointment? I'm quite worried about the medication and the risk of an overdose given that Mr. has always been hungry. I don't want to miss the signs of when to stop the meds.

Sorry for the long post.....I'm a worried Mom.....

Thanks

[addy]

Hi and welcome.

If you could ask for copies of all tests and post the results here that would be great. Just any abnormal readings with the reference range.

The symptoms described can be associated with Cushing's and I am glad you are also doing an ultra sound. Actually we have had a few members that have gone through surgery. We also have members currently treating with Lysodren.

We have loading instructions in our reference section. I am typing on my new iPad and I am not good at stopping and adding links yet so I do apologize for not posting the links for you.

We would want to know the loading dose and instructions your vet gives you. Also provide how much Mister weighs.

You are not alone in your journey, so deep breaths and others will be along soon.

Glad you found us,

[Harley PoMMom]

Hi and welcome to you and Mister from me as well!

Like Addy mentioned, getting copies of those tests and posting all abnormal values here would help us to provide you with more meaning feedback, we are especially interested in the results from the tests that were done to diagnose Mister's Cushing's.

Having an ultrasound performed is a really good idea, it has the ability to take a look at all the internal organs to check for any anomalies that may be present. Also if the adrenal glands are visualized than the ultrasound may be able to differentiate between pituitary or the adrenal form of Cushing's.

The two medications generally prescribed for canine Cushing's are Lysodren/Mitotane and Vetoryl/Trilostane. They are strong drugs and one drug is no safer than the other, adverse effects are usually not seen unless the proper treatment protocols are not followed.

If a dog does have an adrenal tumor, Lysodren may not be the drug of choice because adrenal tumors are extremely resistant to Lysodren and normally require doses greater than what is generally used to load a dog, which is 50mg/kg.

We understand that you are fearful but we will help you and your dear furbaby in any way we can, we will walk this journey with you, ok?

Here's a handy link from our Resource thread that has a wealth of information regarding Cushing's and treatment: Links to Cushings Websites (especially helpful for new members!) (http://www.k9cushings.com/forum/showthread.php?t=180)

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

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

Hugs, Lori

[innotu]

Thank you so much for your supportive and knowledgeable replies. I am so thankful I found my way to this site. I know I will be supported throughout this journey.

Mister weighs 8.1kg (approx. 18lbs). He is overweight and we've struggled with his weight for the past 6 years.

I will make sure to get copies of the test results when we go in for the ultrasound and will post them here.

Thanks again for your support.

Inno and Mister.

[innotu]

Hi there,

Mister had his ultrasound yesterday (Jan. 9th) and although the official results are not in yet, the vet tech says he has 'normal' Cushing's and no tumours to worry about. I will speak directly to the vet on Monday to get the 'official' results from the ultrasound and to talk about next steps.
I asked for the test results from the blood tests (Oct. 28, 2014) and stimulation test (Dec. 24, 2014). Below are the 'out of range' results:

Oct. 28, 2014 - blood tests done for suspected pancreatitis:

MCH - 20.3pg - (21.2-25.9) LOW
NEU - 12.26x10^9/L (2.95-11.64) HIGH
MONO - 2.09x10^9/L (0.16-1.12) HIGH
EOS - 0.02X10^9/L (0.06-1.23) LOW
BASO - 0.22x10^9/L (0.00-0.10) HIGH
PLT - 576 K/ul (148-484) HIGH
PCT - 0.59% (0.14-0.46) HIGH
CREA - 34 umol/L (44-159) LOW
CHOL - 2.68 mmol/L (2.84-8.26) LOW
AMYL - 431U/L (500-1500) LOW

Urea - 2.8 (3.2-11.0) - units mmol/L
Na/K Ratio - 27 (28-37) - units mmol/L
Chloride - 105 (108-119) - units mmol/L
ALT - 147 (18-121) - units IU/L
ALP - 366 (5-160) - units IU/L
GGT - 14 (0-13) - units IU/L

Comments:
BIOCHEMISTRY:
low urea-normal variation likely; rule out diuresis
Chloride consistent with loss or sequestration
ALP, ALT, AST - hepatobilary disease vs. Cushing's. Monitor.

Cortisol Test - Dec. 24, 2014:

Cortisol (pre) 227 (28-120) - units nmol/L
Cortisol (post) >1380 (220-550) - units nmol/L

ENDOCRINOLOGY:
Stim supports Cushing's given compatible signs and chem
T4 looks okay.

I will be speaking with my vet on Monday and mister will likely be going on lysodren .....what should I be asking.... Thanks for your help!

Inno and Mister.

[innotu]

I also wanted to ask any Canadians out there about costs. Where is the best place to buy lysodren? Also the cost for the cortisol stimulation test was $305.00 and the ultrasound was $405.00. Are these costs reasonable? I'll do what's necessary for Mister, however I don't want to pay more than is necessary.

Thanks in advance for your help!

Inno and Mister

[Harley PoMMom]

The test generally performed to confirm pancreatitis in a dog is the spec cPL, was this test done? Here's a link to info regarding this test: http://www.idexx.com.au/smallanimal/reference-laboratories/testmenu/innovative-tests/spec-cpl.html Also, usually the pancreas is visualized on an ultrasound and any anomalies are noted, so if this were me I would ask the vet about the pancreas and mention about getting the spec cPL test done.

[innotu]

Hi there,

The blood test results posted were from October 2014. Yes they did test for pancreatitis and he didn't have it (I don't have copies of this test).

Thanks

[Harley PoMMom]

Hi there,

The blood test results posted were from October 2014. Yes they did test for pancreatitis and he didn't have it (I don't have copies of this test).

Thanks

I'm a bit confused here because in your first post you mentioned that Mister has had 6 bouts of pancreatitis, is this correct? There is acute or chronic pancreatitis. Acute is like a sudden assault and may go away suddenly, chronic is when it lingers on and on with periods of time of the dog not showing any signs. My boy Harley had chronic pancreatitis and he never did show any symptoms of it, his pancreatitis was found on an ultrasound and was confirmed with the spec cPL test.

Lysodren is known to cause gastric upset, so if the Lysodren is the choice of treatment I would ask the vet about giving Mister Pepcid AC 20-30 minutes before the Lysodren dose.

For Mister's weight of 18 lbs, a loading dose would be around 409 mg being split and given twice daily, so that would be approx. 200 mg given twice a day. Is this the vets plan for the Lysodren? Is the vet prescribing prednisone for you to keep on hand? Also is their office open 24 hours in case of an emergency or has the vet given you instructions of where to go in case Mister would need after hour care?

I'm also providing that link about Lysodren from our Resource thread and I do urge you to print it out and memorize it, just in case ;)

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

Here's another link to a really good article regarding Cushing's and Lysodren, it is a bit long: http://www.k9cushings.com/forum/showthread.php?t=199

Article on how to save money on those ACTH stimulation tests: How to Extend Your Supply of Cortrosyn and Lower the Cost of ACTH Stimulation Testing (http://endocrinevet.blogspot.com/2011/03/how-to-extend-your-supply-of-cortrosyn.html)

Remember we are here for you both and will help in any way we can.

Hugs, Lori

[innotu]

Thanks for your reply! I will be sure to ask these questions during the appointment (in a few hours). I will also be reading the information you provided - I've printed the pages and will be reading as much as I can prior to the appointment.

Thanks again for your help Harley PoMMom!


I'm a bit confused here because in your first post you mentioned that Mister has had 6 bouts of pancreatitis, is this correct? There is acute or chronic pancreatitis. Acute is like a sudden assault and may go away suddenly, chronic is when it lingers on and on with periods of time of the dog not showing any signs. My boy Harley had chronic pancreatitis and he never did show any symptoms of it, his pancreatitis was found on an ultrasound and was confirmed with the spec cPL test.

He did have pancreatitis the last confirmed bout was the summer of 2011. Since then, I've been giving him 10 mg of Pepcid/day as well I make his meals. We found that no matter what type of food we purchased (vet prescribed for sensitive tummies, top end dog food, special blends, i.e. low fat) nothing worked for long. It seemed that after a few months, he'd get sick - he'd stop eating, vomit, diarrhea. Since this time he's been great, with the exception of last October when he had a garbage party thanks to the raccoons who got into our garbage. Before I could stop him, he'd cleaned up after the raccoons and of course became sick shortly thereafter. I took him to the vet and they checked him over, gave him IV fluids, and he was fine by the end of the day.

Lysodren is known to cause gastric upset, so if the Lysodren is the choice of treatment I would ask the vet about giving Mister Pepcid AC 20-30 minutes before the Lysodren dose.

Should I worry about his tummy issues? Is the cure worse than the disease? I don't want him getting sick from the Lysodren.

For Mister's weight of 18 lbs, a loading dose would be around 409 mg being split and given twice daily, so that would be approx. 200 mg given twice a day. Is this the vets plan for the Lysodren? Is the vet prescribing prednisone for you to keep on hand? Also is their office open 24 hours in case of an emergency or has the vet given you instructions of where to go in case Mister would need after hour care?

I will see him today and ask these questions. Our vet is not open 24/7. They are open from 7am - 7pm Mon-Sat. There is an emergency vet about 1 hour away, that I'm aware of. I will have to which one they recommend.

I'm also providing that link about Lysodren from our Resource thread and I do urge you to print it out and memorize it, just in case ;)

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

Here's another link to a really good article regarding Cushing's and Lysodren, it is a bit long: http://www.k9cushings.com/forum/showthread.php?t=199

Article on how to save money on those ACTH stimulation tests: How to Extend Your Supply of Cortrosyn and Lower the Cost of ACTH Stimulation Testing (http://endocrinevet.blogspot.com/2011/03/how-to-extend-your-supply-of-cortrosyn.html)

Remember we are here for you both and will help in any way we can.

Hugs, Lori

[Harley PoMMom]

Thanks for your reply! I will be sure to ask these questions during the appointment (in a few hours). I will also be reading the information you provided - I've printed the pages and will be reading as much as I can prior to the appointment.

Should I worry about his tummy issues? Is the cure worse than the disease? I don't want him getting sick from the Lysodren.

Thanks again for your help Harley PoMMom!

Both Lysodren and Trilostane are capable of causing a gastric upset, but with the Trilostane one can taper slowly upward so a tummy issue may be less likely to happen or if it does it may not be that bad. With Lysodren the loading dose generally prescribed is 50 mg per kg of a dog's weight, if one tries to load with less than that it can take a long while for the loading phase to complete and then there would be more of chance for a tummy issue to happen.

[molly muffin]

I'll let you know the cost of the ACTH test here in Ontario after Wednesday when we are due to redo ours. I don't have the invoice handy at the moment.

I know our ultrasound was expensive the first time around, but recheck ultrasounds have been around $75. I think it was.

I don't know about the cheapest place to buy lysodren as we are trying trilostane.

[innotu]

Thank you Harley PomMom and Sharlene!

Well, what a day! I spent over an hour with our vet today (at no additional cost!) and he walked me through what to do and expect when Mister goes on lysodren.

I asked him about the ultrasound and received a copy of the report. Here are the 'abnormal' results everything else was 'normal':

The left and right kidneys measure 4.5 and 4.4 cm in length respectively. They are more hyperechoic than normal and there are a few very tiny calculi within the collecting systems, particularly on the left.
The left and right adrenal glands are enlarged, both measuring 8.6 mm in dorsal ventral width
The liver is larger than normal and more hyperechoic than normal. The margins are rounded. The parenchyma is mildly heterogenous but no mass lesions or nodules are identified.
The gallbladder is distended and there is a moderate amount of hyperechoic debris dependent within the lumen. There is no evidence of biliary obstruction.
Conclusion: both adrenal glands are plump and there are diffuse liver changes present as described. Primary consideration would be given to pituitary dependent Cushing's disease. There are mild chronic renal changes present.

The vet indicated that the kidneys and liver issues were part of the Cushing's disease and he said he wouldn't be surprised if the liver issues resolved once we got his Cushing's under control. He also said the kidney issues were mild and consistent with Cushing's. I asked him about the pancreas issues and potential tummy issues with lysodren and he seemed to think that this would not be an issue and if it was, we would switch meds if need be. The pancreas was normal on the ultrasound.

I have been given instructions on the lysodren. We won't start until Friday because the Vet wants to time any potential issues with the clinic being open. They have given me the prednisone in the event he needs it and also the number to the emergency clinic. They are open Mon-Sat, 7-7. They will be calling me daily, even on Sunday. The vet himself will call me on Sunday. I feel well supported.

Also, one of the vet techs spoke to me at length about Cushing's as her dog has it. She recommended going to Costco for the lysodren. I have filled the prescription at Costco and the cost for 15 pills was $70.00 - not too bad given what I've heard. The prednisone was $0.64.

Mister will start his lysodren on Friday. The dose is 375mg. 1/2 tablet in the morning and 1/4 tablet in the evening. I will have to cut the 500 mg pills myself. I purchased a pill cutter and thank goodness the pills are rather large and easy to cut. I was advised to wear gloves when doing this.

Wish us luck!

Inno and Mister.

[judymaggie]

Inno--it sounds like you are very ready! I am impressed with your vet and am glad you have a good partner going forward. My Abbie is on Lysodren so I know well the anxiety you might be feeling as you prepare for loading. Keep Feldman's protocol close (Lori gave you the link earlier). Are you going to give Mister pepcid ac before his meals? I think you got a great price for the Lysodren--the lowest price in my area is $5.60 a pill. Be sure to post to let us know how loading is going and don't hesitate to ask about any changes you might see in Mister.

[innotu]

Thanks Judy,

Yes, I am very nervous. I'm trying to get everything ready for Friday. I've cleared my calendar so that I can keep a close eye on him. I've split the lysodren into the required sizes, and I've got his favourite treats ready so that I can hide the lysodren in them. I've been giving him pepcid because of his previous tummy issues and I will continue doing this.
I love him so much, he's the sweetest, most gentle boy. I don't want to make a mistake and miss the signs. I try not to worry, but I'm a worrier and he's my baby.
I am so thankful to have this site and my vet's office to help guide me and Mister through this journey. I hope the process goes smoothly.

Thanks again.

Inno and Mister

[Squirt's Mom]

I'm sure you'll do just fine! We will be here if you have any questions or just simply need to talk.

[molly muffin]

I think you have an excellent vet who seems to be on his A game with the loading phase.
Loading is the most nerve wrecking time, once you are through that and out the other side and into maintenance, it will all feel much better to you.
In the meantime though, we are all here with you.

:)

[molly muffin]

Okay so back from the vet and the ACTH test was 145.90 and the synacthen (the agent used to do the test) was 72.86 for a complete test of $218.76. There is also a charge of 32.50 for blood collection.

[innotu]

Thanks Sharleen,

My vet charged $232.20 for the test and $59.50 for the consult. With taxes, the total came to $306.29. So, it looks like my vet charges are in the ballpark. I'm hoping that next time I'm not charged for the consult.

[molly muffin]

I also had a 40. recheck fee and a bunch more in there, so yes sounds like your vet is in the ballpark of what we are charged here in Canada.

I usually try to just get a vet tech appt, so no need for a consult. This time though for whatever reason they wanted a full recheck by the specialist.

[innotu]

Day 3 on lysodren and no change in mister's behavior. I'm a nervous wreck. I don't let him out of my sight. I am worried about Tuesday however, I have to go to work....I will probably take him with me. He's quite a laid back little guy and nothing stresses him out, so I'm hoping that he will be ok with coming to work with me.

[Harley PoMMom]

The loading part with Lysodren sure can be nerve-wracking! Remember to breathe....in..out..in..out ;)

Sending soothing and huge hugs, Lori

[Dixie'sMom]

How is Mister doing?

[innotu]

Hi Dixie's Mom,

Mister's about the same. Day 5 going on day 6 and he's still begging for food, ate his dinner like he's starving, drinking and peeing large amounts. I keep watching him for signs but nothing yet. The vet's office calls every day and so far there's not much to report.

Could he be fine one day and then crash the next? I'm so worried about overdosing him because I miss the signs....he's calm as can be sleeping beside me. I, on the other hand, am a nervous wreck.

Thanks for checking in on us!

Inno and (currently snoring) mister

[Harley PoMMom]

Could he be fine one day and then crash the next? I'm so worried about overdosing him because I miss the signs....he's calm as can be sleeping beside me. I, on the other hand, am a nervous wreck.


Unfortunately yes this could happen, but I truly believe with your eagle eye on him that you will notice any subtle sign of Mister being loaded, remember it can be just a slight hesitation when eating, or he pauses and looks at you instead of having his head buried in the food dish.

I, too, was a mess when I was loading my Harley :eek::eek: Another thing if you suspect that he may be loaded no more Lysodren should be given and an ACTH stim tests needs to be done.

Hey, we are here for you, ok?

Hugs, Lori

[innotu]

Today (day 6 on lysodren) when the vet called to check in, I booked a stimulation test for Friday (sooner if he shows signs). I would then have the test results on Saturday. I will feel much better going into the weekend knowing what's going on with his levels and before the vet closes for the weekend on Saturday night. Until then, I am to continue with the lysodren unless of course, he starts showing signs.

I feel better now that we have a plan.

Inno and Mister.

[Harley PoMMom]

Sounds like a good plan to me ;) Keep letting us know how it's going, ok!

Hugs, Lori

[judymaggie]

So glad loading is going smoothly--it sounds like your vet is familiar with protocol which is reassuring.

[innotu]

Ugggh! I'm so scared. I just knew I'd somehow miss the signs! I feel so guilty. The vet just called to say mister's stimulation test results show his levels are too low. And to think the vet wanted to wait until Monday because he wasn't showing signs. I brought him in this morning and he was running around the office begging for treats so they said maybe we should wait until Monday. I said no, if we waited that long, I would have a heart attack.

The vet said to give him 1/2 a prednisone which I've just done. I now need to look for symptoms like vomiting, diarrhea, lack of appetite, etc...and head to emergency if this happens. Hopefully he'll be ok. So far he's continued to be his usual self.

The vet says no more lysodren for 14 days, then another stimulation test and if his levels are okay we'll start him on maintenance. Does this sound right?

I'm so scared and worried.

[Spencersmom]

Bless your heart! Don't be scared....you are being such a good mom! Just keep a close eye on him and you will immediately know if you need to take him to emergency. Your gut will tell you!

Your support system is fully in place here....you are in awesome hands

[My sweet Ginger]

Hi Inno,
I know you are very scared right now after hearing from the vet but going by what you've described of Mister today he may just be ok now that he's off Lysodren. Can you please post the pre and post numbers for us so we can see how low they are and if you don't, please get them for us from your vet.
I read that Mister wasn't exhibiting any signs of being loaded so don't think you missed any signs.
I'm glad you got ACTH stim test done today.
I wouldn't worry too much at this point as long as Mister is behaving his usual self. A break from Lysodren maybe all he needs for now.
Keep a watchful eye on him tho. You will know more by tomorrow going by his behavior but as long as he feels ok don't be too scared, k? Hugs.

[innotu]

Thanks for your reassurances. I will be watching him closely. Right now he's getting a tummy rub from Dad and snoring contentedly.

Tomorrow when I call the vet, I will ask for the test results and post them.

Does waiting 14 days to do another stimulation test and stopping the lysodren for that long make sense? I don't want to do this all over again and most importantly, I don't want to take this kind of risk again with my little mister.

[Spencersmom]

Awww...... Just hearing that he's getting lovings and is content is a good sign!

Keep up the good watch mom!

[My sweet Ginger]

Maybe we don't want to wait 14 days if his adrenal glands are stimulating but once we know the pre and post numbers along with Mister's behavior we will know better. For now tho just enjoy your together time with lots of hugs and kisses. Nite.

[Squirt's Mom]

We need to see those test results and we need a detailed post explaining the signs you are seeing now. Eating and playing does NOT sound like a pup who has gone too low and nothing in your prior posts indicated that could be possible. So I am a bit confused and need more info! :D

[My sweet Ginger]

Hmm, it will be interesting to see Mister's ACTH numbers. :rolleyes:

[Harley PoMMom]

Ugggh! I'm so scared. I just knew I'd somehow miss the signs! I feel so guilty. The vet just called to say mister's stimulation test results show his levels are too low. And to think the vet wanted to wait until Monday because he wasn't showing signs. I brought him in this morning and he was running around the office begging for treats so they said maybe we should wait until Monday. I said no, if we waited that long, I would have a heart attack.



Don't be so hard on yourself, on the forum we have had more than one dog that loaded on Lysodren and didn't show any signs. You scheduled the ACTH stimulation test for Friday and even when the vet didn't think one was needed you insisted that it be done, YOU did good!!

Will be anxiously waiting with you for those ACTH stim results. ;)

Hugs, Lori

[judymaggie]

As Lori said, you are doing great! Just keep on being Mister's advocate and we are right there with you!

[innotu]

See my post below.

[innotu]

Sorry, I'm having problems with the posts. I meant to say:

Hi everyone,

Thanks so much for the reassurances. I'm feeling better today. Mister had a good night - nothing out of the ordinary. He's eating, still begging for food, no vomiting or diarrhea. He's just his usual self. I do notice less drinking of water and less time spent going pee.

I phoned the vet this morning to check in and to get his test test results. They emailed them just now. Here are his ACTH results from yesterday (this was a 1 hour test).


Cortisol (pre) <27.6 (28-120) nmol/L
Cortisol (post) 39 (220-550) nmol/L

These look very low to me....the test was done about 1 hour after a 250mg dose of lysodren. His test was done between 9:30 - 10:30 am. He had another dose of lysodren at 4:00 pm (125mg). The vet called at around 7pm to let me know about the test results and advised a 1/2 prednisone tablet and no more lysodren for now. No more prednisone is to be given unless he shows symptoms.

Do you think stopping the lysodren for 14 days and doing a retest then is too long to wait, too short, just right? I don't want to put him in harm's way by starting all over again.

Thanks so much for all of your help. You've talked me down from the ledge. ;)

Inno and Mister.

[My sweet Ginger]

Yea, those are low with a very slight stimulation.
When you convert those numbers to ug/dl they are pre 1.0 post 1.4.
What was your vet's instruction regarding pred? Is he to get more today or how many days?
He may be feeling better from the pred he got yesterday.

[My sweet Ginger]

Ok, I just saw your post regarding pred. I think we have to wait and see how Mister (love his name) does for next few days without pred.
As to when he should start matenance, we have to wait for our most experienced experts to weigh in. But I'm so glad he's doing pretty good.
I'm worried about the two pills he took yesterday and hope they won't bring his cortisol even lower than his already low numbers as Lysodren works for 48 hrs. When you notice any of the adverse signs, give him the pred and call the vet.

[Harley PoMMom]

From my calculations that pre number comes out to <0.97 ug/dl. So with his ACTH stim numbers being that low I would suggest waiting at least a week to start the maintenance dose.

Forgive me for not looking through your thread (I'm being lazy), what dose of Lysodren did Mister load on?

Hugs, Lori

[flynnandian]

found this;
Mister will start his lysodren on Friday. The dose is 375mg. 1/2 tablet in the morning and 1/4 tablet in the evening.

[innotu]

His dose was 375mg per day. 250 in a.m. and 125 in p.m. He weighs 8kg.

Should I be asking for a stimulation test to be done 7 days from the last one (that would be Friday January 30)?

I can't begin to express my gratitude for all the help and support I'm receiving.

[judymaggie]

Inno: My Abbie's latest post-loading ACTH had both pre and post below 1. One of the knowledgeable folks here (I think it was Lori) pointed me to the most current IDEXX dosing and maintenance protocol for Lysodren:

https://ca.idexx.com/pdf/en_ca/smallanimal/snap/cortisol/cortisol-mitotane-protocol.pdf

Pertinent to Mister's recent numbers would be the following:


If dog is clinically healthy, do not start prednisone, but start low maintenance dose of mitotane in two weeks.

In order not to totally lose Abbie's load, my vet has recommended we start her on a low dose after 10 days (rather than the full 14). I will be giving her a much lower dose than she was on previously and gradually increasing the number of days (and thus the dose) based on how she handles it. I know Abbie's situation is different because this was her second loading but I think there are parallels.

I would be interested in having our experts here chime in with regard to a maintenance dose for Mister. The 325 mg. would be the high end of the 25-50 mg./kg range. The low end would be closer to 200 mg. The pills could easily be split to dose with 250 mg.

I also am not sure why another stim test would be necessary before starting Mister back on Lysodren, especially if waiting the full 14 days.

[innotu]

Thanks Judy. I've looked at the chart before, but in my distress forgot about it. That's why this forum is so valuable. According to the chart another test at 14 days isn't required.

I'll talk to my vet on Monday. I think I should talk to him about starting a maintenance dose between day 7-10? Thoughts?

Thanks again.

[Harley PoMMom]

I totally agree with Judy with the 250 mg maintenance dose. And , hey Judy, you definitely know your way around with Lysodren so to me YOU are an expert. ;)



I would be interested in having our experts here chime in with regard to a maintenance dose for Mister. The 325 mg. would be the high end of the 25-50 mg./kg range. The low end would be closer to 200 mg. The pills could easily be split to dose with 250 mg.

I also am not sure why another stim test would be necessary before starting Mister back on Lysodren, especially if waiting the full 14 days.

I don't think I would wait 14 days to start the maintenance dosing unless Mister does start to show any adverse symptoms, if this were to happen than I would have an ACTH stimulation test done. If Mister is doing well with his new maintenance dosing than I would have another ACTH stim test done, in say, a month.

Edited to add: I think starting Mister's maintenance dosing regimen in 7 days would be ok.

Hugs, Lori

[innotu]

Thanks Lori and Judy.

Mister is doing well. No symptoms and still begging for food. He's a tough little guy.

I will be speaking with my vet tomorrow. There are 2 vets in the practice. One works Monday to Wednesday and the other Thursday to Saturday. I have a better rapport with the Monday to Friday vet. I've been dealing with him this whole time with the exception of this last stimulation test.

To recap: start mister on 250mg weekly maintenance dose at 7 days (January 30) and do a stimulation test at 30 days after that (unless he's showing symptoms).

Thanks again!

Inno and Mister

[innotu]

Well I spoke with my vet today.- the one I feel more comfortable with. I must admit I am sad and confused.

He admitted to me that he thought I was being premature in bringing Mister in on Friday for his stimulation test. He felt that as he was showing no symptoms, he was going to be one of those dogs that would take about 14 days of loading. When he came in to work this morning, he was surprised to see Mister's numbers as low as they were. He now thinks he's one of those dogs that will not show symptoms until its too late.

He did agree with me that we should start the low dose (250mg) maintenance with mister earlier than 14 days, (he thinks 10 days), but he want to do a stimulation test first. I'm ok with doing another stimulation test for my own sanity.

I am a bit concerned about what he said afterwards. He thinks that perhaps Mister will be a 'problem' Cushing's dog and will have wildly fluctuating numbers. If this is the case, he talked about making him Addisonian using the Utrecht Protocol. I think he said that this would mean putting him on a high dose of lysodren for a month as well as another drug (I think a steroid). The lysodren would destroy the adrenal glands and the other drug would help him to not become ill. This scares me and I'd have to educate myself on this before I made any decisions.

He also mentioned that the company that sells the stimulation test has just been sold. The purchasing company intends to make it exclusively for humans and that the price is expected to be in the $800/vile range. He's now sourcing out other alternatives. He mentioned cortisyn (sp) however he did say that even this would be more expensive than what he's using now. Apparently mister's name is on the last vile they have in stock. He feels that stimulation tests for a 'problem' Cushing's dog will become cost prohibitive.

For now, he wants to test him at the 10 day mark. If he's low/normal we'll start him on a maintenance dose. If he's jumped back up to high levels he says we'll have to talk about next steps.

Thoughts?

I'm so worried about my little mister ;_;

[labblab]

Hmmmm...well, I will let the other Lysodren users give you their thoughts, but I am totally puzzled by your vet's conclusion that Mister will be a problem child with wildly fluctuating cortisol levels. I just don't understand where that is coming from at all. As others have noted, he is certainly not the first dog here who has surprised us by loading in the absence of obvious signs, and I don't recall that as having any impact on ultimate control of cortisol. I think it seems as though you are in a very good place right now with a fully loaded dog on your first go-round who is feeling and behaving very well.

Beyond that, if for some reason Mister does not end up responding well to Lysodren, I don't understand why your vet would not first try switching to trilostane as opposed to leaping ahead to pushing Mister into Addison's. Some dogs do better on one drug; some do better on the other. If Mister was my dog, I would want to try the alternative Cushing's med before making such a drastic move as your vet is suggesting. However, it doesn't seem to me that trilostane has ever even been considered as an option for Mister -- do you know if there is a reason for that?

I'm really sorry that your vet has bummed you out in this way, because I think you have a lot to feel good about right now! Also, thanks for the heads-up about the ACTH stim agent there in Canada. That's info that we will try to explore further.

Marianne

[Squirt's Mom]

:mad: For me, there would be nothing to think about but finding another vet. That he would assume something like this without any history of the little guy on Lyso,, OR ANY OTHER TREATMENT, for any period of time sounds like he has something to gain from doing this to your baby...and that is what it would be - DOING a horrible thing to Mister. Why on earth totally destroy glands that are otherwise healthy?! Does he thing the ONLY thing those glands are good for is causing Cushing's?! They do serve other purposes that would also be destroyed. No. I would get Mister's records and RUN from this man as fast as I could. That is insane in my book, flat insane to intentionally destroy organs, ESPECIALLY with no history to base such a drastic move on. No. :mad:

[labblab]

He also mentioned that the company that sells the stimulation test has just been sold. The purchasing company intends to make it exclusively for humans and that the price is expected to be in the $800/vile range. He's now sourcing out other alternatives. He mentioned cortisyn (sp) however he did say that even this would be more expensive than what he's using now. Apparently mister's name is on the last vile they have in stock. He feels that stimulation tests for a 'problem' Cushing's dog will become cost prohibitive.
Just wanted to add a bit more about this part of things. I'm guessing your vet is referring to the stimulating agent Synacthen, which was sold last year by Novartis to another rival company. That stim agent is not used in the U.S., but I believe it is used in Canada. We do know that for a time after the sale, there was a shortage of the agent in the U.K. and Europe. But I think that problem has been resolved, at least there. I don't know about the price going up. Our staffer Sharlene, Molly's mom, also lives in Canada and is having ACTH tests routinely performed. She is on holiday right now, but once she returns, I'm sure she can check with her own IMS and help get some answers/solutions for you and your vet, as well. I have not heard her voice any worries about this, so I am hoping your vet is suffering from some misinformation or lack of information that can be remedied.

Marianne

[innotu]

Thanks Marianne. I'm taking a positive outlook that Mister will have good levels on Monday and that all goes well on maintenance.

[molly muffin]

I am away currently but I have sent an email to both my IMS and my gp vet inquiring about anyo potential concerns about the stimulating agent in regards to ACTH testing. I will let you know if and when I hear something back from either of them.

If I don't have a reply to my emails I will have to wait till I return from holidays to pursue further.

[Spencersmom]

I'm kinda jumping in here really late....and my thoughts may not apply.....but my experience with Spencer is that not all dogs present text book symptoms. You just have to work with your vet, any other specialists as well as these guys here to work thru what is going on! My Spencer was such a challenge! If you have a gut feeling about anything....ask....push for answers...fight for your baby!

[molly muffin]

I have had a response back from internal medicine department I use for Molly's testing.


Hi Sharlene;

Unfortunately, your information is correct. The Synacthen is still technically available to us, but it will be much more difficult to obtain, and the cost increase implemented during the transition between companies would make testing much too cost prohibitive for our clients. When our current stock runs out, we will be transitioning to a different synthetic ACTH agent. This other agent has been on the market for some time, and while the dose and testing protocol is slightly altered, we do not anticipate that the switch from one to the other will result in any changes to Molly’s trilostane dose or treatment plan. We are currently looking into any potential cost difference to our clients, but preliminary investigation indicates that the cost will be very similar to the Synacthen.

I hope that is helpful! Feel free to contact me with any other questions or concerns.
Regards,

It rather sounds like they will be moving to cortrosyn but I have replied asking if this is what most vets in canada will be moving to. If. So then I expect pricing will be similar to what're spend nowadays sounds like my IMS thinks so also

Hope this helps and do let your vet know. If he needs to contact an internal medicine practice for clarification I use the Mississauga/ oakville ER vet in Ontario.

Index laboratory might also be able to help with information. They are world wide and should be familiar with the agent he mentioned.

[molly muffin]

Hi Sharlene;

Yes, it is the Cortrosyn that we will be using in future. The OVC has kindly shared their protocol so that we may safely use the same vial for multiple patients, which is the only way to keep the cost similar!

So yes this what we are moving to in canada

[innotu]

Thanks Sharlene,

This is great info. I will talk to my vet about this on Monday when I bring Mister in for his test. I'm praying that all goes well and he begins his maintenance dose that day.

He's been really sluggish the past few days and is limping at times. He's always been reluctant to go for a walk but now it's almost impossible to get him to go out. Is this because of the reduction in cortisol levels?

[innotu]

Sharlene,

Forgot to ask, what does OVC stand for?

[innotu]

Sharlene,

I googled OVC (Ontario veterinary college) our equivalent is the college of B.C. veterinarians. What did we do without Google? :)

[Dixie'sMom]

Good luck to you and Mister tomorrow! I'll be cheering you along hoping for great results. :)

[judymaggie]

Inno -- I know you will be anxious about Mister's test but all should go smoothly. Remember that there will be a break in Lysodren before you begin maintenance -- we had talked earlier about a 7 day break.

The lowered cortisol could definitely be the reason for Mister's reluctance to go for a walk/limping as it will cause any arthritis to be more significant. Even if not previously diagnosed, it may have been present.

[innotu]

Hi everyone,

I need help.

This morning mister goes in for his stimulation test. We stopped lysodren 10 days ago. Over the past 3 days he's had diarrhea on and off, he has weakness in his hind legs, and is very restless. He's panting and whining quite a bit as well.

He's still eating and drinking as usual however he's not begging for food as before. I'm wondering why he showed no signs or problems until 7 days after stopping lysodren? Why is this happening now? What is happening? I'm so worried about my little mister. We have to carry him up and down the stairs to get him outside to do his business.

Any help/advice would be appreciated.

[Squirt's Mom]

I would get him asap this morning. Let us know what the vet says. Hopefully this is just a bug and not the cortisol going too low. ;)

[innotu]

Thanks. He's going in as soon as the vet opens -7:30. His symptoms escalated rapidly since about midnight. He's now just thrown up.

We're leaving for the vet now.

[Squirt's Mom]

Ok, let us know! The vomiting is concerning. Prayers go with you!

[molly muffin]

Checking in to see how your little mister is and what the vet said.

hugs

[innotu]

Thanks everyone.

Mister is still at the vet's. I just got an update. He's perked up a bit. No stimulation test today but they did do blood tests. His cortisol levels are still low (after 10 days!). He's been given prednisone, anti-nausea meds, and something for diarrhea. He's on I've fluids as well. Poor little guy. Of course no one can tell me why this started so suddenly and why symptoms started 7 days after his last dose of lysodren. I'm so confused.

They want to keep him until closing (7:30) at which time they will inject him with the IV fluid bag and send me home with instructions and meds. I'm so sorry to have put my little guy through this. I have to really think through next steps for him.

Inno

[molly muffin]

oh dear, poor baby. I do hope he does much better as the day goes on and gets past this.
Thinking of you both.
hugs

[innotu]

Mister is home!

He's happy to be home and resting comfortably.

He's on prednisone for 10 days and metronidazole for 5 days. So far so good. I hope he has a good night and is on the mend.

His blood levels were within range. His cortisol levels are worrying. Today's baseline cortisol level is < 14 nmol/L. This is lower than his pre stimulation test results from 10 days ago (<27.6 nmol/L) when he was still on Lysodren! Has anyone else experienced this?

I will be talking to the vet tomorrow.

[Squirt's Mom]

Has he been getting pred all this time? Did they check his electrolytes? If not have that done asap today.

Is there ANY question about the diagnosis? He did have an ultrasound?

[My sweet Ginger]

Wow, that's very low which is <0.5ug/dl.
Are you supposed to get his post number today?

Evidently his cortisol went down after his ACTH on Jan. 23rd which he took his last Lysodren that morning (I hope I got it right) and the drug worked for another 48hrs. One reason I'd rather wait 48 hrs to perform an ACTH so you get more accurate readings rather than get it done prior to 48hrs and have to take things into consideration.

I'm glad prednisone is helping him right now and his electrolytes are in the normal ranges assuming that's what the blood work was about.
Please, do not rush into maintenance phase. He's going to need a break from Lysodren for no one knows how long.
He's going to tell you when he needs next ACTH stim test by his clinical signs like I've been suspecting that finally my pup's cortisol level maybe rising and her last dose of Lysodren was in Nov. of 2013.

This could the case that he just needs a break from Lysodren and no permanent damages were done to his adrenals as many other cases here. Hugs.

[innotu]

Thanks for the responses. Yes he was "off the charts" on the stimulation test to confirm Cushings. Tests to confirm Cushings: blood, stimulation, and ultrasound. He also had outward signs: hair loss, hunger, thirst, accidents in the house. Answers to the questions:

1) He started taking prednisone yesterday AFTER the blood work.
2) His electrolytes were checked and were fine.
3) They did not do a stimulation test yesterday just a blood test.
4) Vet wants to wait 10-14 days before doing another stimulation test.

I'm new at this and just can't wrap my head around why this happened 10 days after stopping lysodren??? He was doing great all throughout the loading and we did a stimulation test before the vet thought he was ready - his results were low but still no side effects until now. Even more bizarre, why are his cortisol levels lower now?

[Squirt's Mom]

When he was first judged to be too low, the pred should have been started then and kept up until he could produce enough cortisol on his own. He should have been getting the full ACTH, too. If you can't afford it or if the stim agent is available that is understandable but otherwise a full ACTH should be done ANY time low cortisol is suspected.

So he never had an ultrasound? Was the ACTH the only test he had done to diagnose? Cushing's is VERY hard to correctly diagnose and if some other problem is in play, that can cause elevated cortisol as a natural response and false-positives on the testing. It is always best to do as many tests as one can afford to be as sure as possible that everything else has been ruled out. A tumor on Squirt's spleen caused her to test positive for the pituitary form on FIVE different tests but she did not have it at that time - it was the tumor causing her cortisol to elevate and causing the positives on the tests. ;)

[labblab]

Les, I'll let Mister's Mom correct me if I'm relaying any wrong info, but he was not technically too low on the first testing ten days ago, which did consist of a full ACTH. His results at that time were 1.0 and 1.4, so you would not want them to go lower, but in conjunction with the fact that he was behaving normally and still begging for food, I don't think anybody saw a need to give daily prednisone at that point. I think the big question was how long to wait before starting maintenance dosing.

Given the shortage of the stim agent and a baseline cortisol as low as it was yesterday, I don't really fault the vet for not proceeding with the full ACTH at that time -- with a baseline that low, you already know there's a problem with cortisol production that has to be addressed. So perhaps it was better to save the stim agent for the next testing, as they are suggesting.

As to why his cortisol is crashing now, ten days later, I am stumped. Even though many of us staffers have warned folks for years that cortisol can continue to drop for 48 hours after dosing, we are currently unable to find any research that confirms that fact. In fact, there is actually some research that points in the opposite direction -- that cortisol levels will rise again as quickly as 48 hours after the last dose. So I am unaware of any documented study that would suggest that the Lysodren itself would have a lingering effect that would carry over to this point in time. So I am thinking that there must be some change in the adrenal glands themselves, secondary to the treatment. At least Mister's electrolytes are OK, so that's definitely a positive.

I see that Mister did have an ultrasound. Plus, the fact that he was so sensitive to the Lysodren does not really support a false diagnosis because, paradoxically, dogs without Cushing's seem to actually be more resistant to the effects of Lysodren rather than more sensitive to it. So I am puzzled, puzzled, puzzled, too! :confused:

Marianne

[labblab]

Just wanted to add that I surely understand how worried you are, and why. But it really is a good thing that his electrolytes are normal, because that means his aldosterone production has not been negatively affected. And even if, for reasons unknown, Mister has backed into a lengthy time period of needing supplemental prednisone, you can take care of that and he will still be fine. So either way -- Lysodren or prednisone -- his needs can be taken care of so that he feels well.

Marianne

[Squirt's Mom]

Thanks, Marianne!

[Tina]

Hi Inno,

I have been following along pretty much daily with Mister’s journey and have been meaning to post , but haven’t had a chance. I only have a few moments now, but wanted to tell you that what is going on with Mister sounds very much like what happened to my boy Jasper when we started on our Cushings journey. He became over suppressed during Lysodren loading and his cortisol level crashed but he did not show any severe symptoms. His cortisol bottomed out again only worse after we started maintenance. I think his pre and post levels were less than 0.4 ug/dL. Again he did not show any of the severe Addison’s crisis symptoms at the time. However, several days later the crisis happened, even though he had not had any Lysodren for days. I remember feeling like it was a delayed reaction or something to his cortisol being low for a while. If I remember correctly, Jasper’s electrolytes weren’t abnormal at first, but after a few days they became out of whack. He was very sick and was hospitalized for a couple of days for IV fluids, steroids and other treatments.

Here is a link to our thread:

http://www.k9cushings.com/forum/showthread.php?t=4372

I glanced back and think on page 4 is where he started having some problems. I am at work and can’t take time to go back through our thread right now to find the exact posts. But I just wanted to get a quick post off to you to let you know that this happened to my baby also.

I am in complete agreement with Marianne’s last post -



So I am thinking that there must be some change in the adrenal glands themselves, secondary to the treatment. At least Mister's electrolytes are OK, so that's definitely a positive.

This is what I would suspect also, as this is exactly what happened to Jasper. I would definitely caution that just because the electrolytes are ok today doesn’t mean that they can’t get out of balance at any time, even though no more Lysodren is being given. This needs to be monitored very closely, and if he starts vomiting, it could indicate an emergency and he should be seen immediately.

I will try to be back on the forum tonight after work, but wanted to at least get this information for you and also let you know that you are not alone. My Jasper hasn’t read the textbook either, and unfortunately has proven time and time again that he travels to the beat of his own drum. We have managed to get him to a stable place now, and he seems to be feeling good. Hang in there.

Hugs,
Tina and Jasper

[innotu]

Hi Marianne,

Yes you are correct in your post as far as tests and results go. Thanks for the information and I very much appreciate the help and support.

[innotu]

Tina,

Thanks so much for posting your response about Jasper's case. This does sound like my Mister. I am keeping a close eye on him. He's with us 24/7. Thankfully I work from home most days and when I'm out my husband and/or son are around.

I will take a look at your thread and see what I can learn. I am so worried about the little guy and his 'delayed reaction'.

Thanks again.

Inno

[innotu]

Also, forgot to ask: What type of changes to the adrenal glands would have caused this reaction?

Thanks

Inno

[Tina]

With Jasper, he proved to be very sensitive to the Lysodren for whatever reason. After the second cortisol crash during maintenance, his adrenal glands were not able to regenerate adequately, even after stopping the Lysodren. It is rare, but sometimes this happens with treatment, even though every precaution is taken to guard against it.

How is Mister feeling today?

Tina and Jasper

[innotu]

Hi Tina,

Thanks for your posts. I've read some of Jasper's story - my goodness, he really didn't read the textbook! Both of you have been through the wringer. I feel better about Mister, having learned about Jasper's journey. I know it's still early in Mister's journey, however when did they decide that Jasper was permanently addisonian?

Today Mister's doing well. Almost back to normal. He's a bit lethargic and constipated but otherwise okay. His appetite is great and he's able to get up on his hind legs and climb the stairs. The prednisone is doing its job.

I'm checking in with the vet daily. So far so good.

Inno and Mister

[innotu]

I'd like some advice/help please.

I'm worried about the tapering down of the prednisone for Mister. :confused: and that his body still isn't able to produce cortisol. His simulation test is scheduled for Feb 16 at which point he will have tapered down to 2.5 mg every other day. Could he have Addison's permanently? How do I protect him? His body has been through so much already.

[molly muffin]

Gosh, sorry we didn't get a response back to you. To begin with you do want to taper down the prednisone, so as to gradually allow the adrenal glands to recover if they can. You'll know if the tapering down isn't working and he starts to seem like he is low again. Keep in contact with your vet and let them know if for any reason, it seems that he isn't producing cortisol.

You don't know till you go through the entire process whether or not the adrenal glands can or will recover or not. I know we've had some go permanently Addison and some who maybe months or a year later will start to produce again. It depends on how much erosion there was to the gland itself.

How are things going now?

[ShibaMom]

I hope Mister's doing ok!! Hope to hear from you soon, inno.

[innotu]

Thanks for the replies. Mister is doing well. We're tapering his dose of prednisone and he's now on 1/2 a tablet per day until Friday. Because his next stimulation test is on Monday the 16th, I have to stop the prednisone on Friday. I'm hoping he will be okay without it for a few days. Fingers crossed my little guy won't have a negative reaction.

[molly muffin]

Oh good, glad to hear from you. Well, if he doesn't do good, then you call the vet and tell them and you will have pred on hand, just in case you need it for him.

Hoping for a good healthy non pred needed ACTH on Monday. :)

huggers

[labblab]

There is an alternative steroid replacement, dexamethasone, that does not interfere with ACTH results in the same way that prednisone does. So just for future reference, dogs who cannot tolerate going without supplemental steroid support prior to testing can be given dexamethasone instead.

Marianne

[innotu]

Well Mister had his stimulation test yesterday. Here are the results:


Cortisol (pre) 51 (28-120 nmol/L)
Cortisol (post) 115 (220-550) nmol/L
Comments: previously cushionoid, loading dose lysodren given, became addisonian, no meds at this time.
Comments: Reflects that adrenal function is returning. Suppression is present but not in range for Addison's

The vet tech told me no prednisone for the time being and to monitor him for any changes. If changes occur (i.e. cushings symptoms or Addison's symptoms) to call them. So for the time being I'm in a holding pattern.

Does this make sense? I'm to do nothing until I see symptoms? Do I wait for him to go full cushionoid again? Isn't that a real possibility and then do I start over again? I don't think I can put Mister through all of that again. I'd really appreciate any advice you could give me. I'm hoping he stays 'normal' for Mister's sake.

Thanks

Inno and Mister

BTW: Mister is his usual self and hungry as always....

[addy]

I think yes, you wait for symptoms to come back. We had one member who's dog was symptom free a year later and the cortisol never came back high enough to treat.
It just depends, every dog is different.

[molly muffin]

Yes, you wait to see if any symptoms return. This can take weeks to months.

If you Do notice any increase in symptoms, you can go in and get an ACTH to check his levels and see how quickly they are coming back. Or you can really at any point, have them checked when you want to.

You wouldn't start any kind of medication though until those adrenals have rebounded fully as it would be very easy to send him right back into crisis.

So glad to here he is doing so well though. Whew!
hugs

[Harley PoMMom]

I'm thinking that you may want to start maintenance dosing, on 2/2 his pre was < 14 nmol/L ( .5 ug/dl) and now, 2 weeks later, it has climbed up to 51 nmol/L (1.8 ug/dl) with his post at 115nmol/L (4.2 ug/dl). So to me it seems that his adrenals are rebounding quickly.

How are his symptoms? How does he seem to be feeling?

[innotu]

Mister is feeling well. Nothing unusual. As usual, he's always starving, so that hasn't changed. I don't see an increase in either water intake or urination. He's bounced back quite well from his Addison's crisis. He's been off prednisone since Friday, 13th.

Can you explain, what is the downside to not treating him if he becomes Cushing again? I feel that for Mister, the cure may be more dangerous than the disease. I want what's best for him. This journey, so far, has been very hard on my little mister.

Thanks for your help and support.

Inno and Mister

[Harley PoMMom]

The medications used in treating Cushing's are not a cure but given to control the symptoms. Also, when a dog has Cushing's it means that their body is producing excessive amounts of cortisol and overtime that elevated cortisol will cause systemic damage, so treatment helps keep that cortisol down within therapeutic ranges.

I don't want you to think that I am trying to persuade you into continuing with the Lysodren, I am not, that choice is totally up to you. We as pet parents are the ones that know our furbaby the best.

[Squirt's Mom]

From the Helpful Resource section -

Complications for an untreated cush pup:
http://www.k9cushings.com/forum/showthread.php?t=195

[innotu]

Thank you. Those are sobering complications of the disease. It looks like in Mister's case, both the disease and the cure, are trouble.

I have left a message with the vet to discuss the next steps. At one point he suggested making Mister Addisonian in a controlled manner. I'm going to discuss all three options with him: 1) do nothing, 2) treat for Cushing's and 3) make him Addison's

I'll have quite a bit of thinking/worrying to do. I cried myself to sleep last night worrying about him. I just don't want him to go through anything like he's been through the past several weeks. I feel such guilt for putting him through this - it feels like we played a game of Russian Roulette and I almost lost him.

Thanks again to all for your help.

Inno and Mister

[Squirt's Mom]

You are doing wonderfully, Inno. Many would have already folded up and given up but you keep fighting for your baby boy. That is all any of us can do...and you are doing a fine job. Talk to the vet, talk to the pros here, think things over, research on your own...and whatever you decide will be right for little Mister, I am sure. ;)

[labblab]

Inno, try to take heart, because as an ousider looking in, I don't think you are in as bad a place as you may be thinking. I know, easy for me to say, but I do believe that's true. Mister's cortisol is rebounding, so his adrenals were not permanently damaged, so that is good. And we also know that he does respond to the Lysodren, so it can be a useful tool for controlling his cortisol.

I am glad you will be talking things over with the vet in more detail, because I am kinda on the same page as Lori. With a post-ACTH of 4+, I am thinking this might be a good time to start back with maintenance dosing, before his cortisol elevates a lot further such that you are seeing severe Cushing's symptoms and you'd have to reload all over again. I dunno, but this is definitely something I'd want to discuss further with the vet.

I know you are so worn out and so worried. But try to hang in there, OK? I really do think that things will work out for you two.

Marianne

[innotu]

Hi everyone,

I have learned so much from this site. I know this added knowledge has and will help my Mister. Although this knowledge and subsequent questions for my vet may not be welcome. Having said this, I feel that I may have outgrown my vet.

I haven't spoken with him, or more accurately, he hasn't returned my last 3 phone calls - I've spoken to vet techs only. For the past 2 visits (blood and stimulation tests), I've had to call for results and each time I feel that the vet tech couldn't answer my questions and the vet was 'too busy' to come to the phone. I'm not even sure that the vet was involved in Mister's care for these tests. They are an extremely busy practice and he is by far the more popular of the two vet's, but having the vet techs responsible for this hard to control disease is unacceptable. I've tried to catch him when I drop Mister off and pick him up, but he's always busy.

I'm asking myself why did we do the expensive stimulation test if now we're just going to wait and see?

Yesterday, I phoned as soon as they opened at 7:30a.m. and then again at 5:00p.m., both times I was assured the vet would call me back. He did not. I feel this lack of communication is putting mister at risk. I think my questions, phone calls, etc...are not welcome and it may be time to find a new doctor.

For any Canadians out there, do you know of any internal medicine vets in the Vancouver area?

Thanks again.

Inno and Mister

[Squirt's Mom]

See what I mean? Right there. Not everyone is willing to take a hard honest look at the vet they use from the perspective of what is best for their baby. Just another sign that you are a good mom and not failing your sweet boy at all. ;)

[innotu]

Well I finally spoke with my vet today. I'm still not happy with his lack of response - I know he's busy and that he's a very popular vet, but he has to take care of his patients. I keep wondering, what would happen if I wasn't such a nag?

After some discussion and review of his history since having been diagnosed with Cushing's, we decided that Mister should be on a low maintenance dose of Lysodren - 125mg, twice a week (250 mg per week). I've started him on his first dose today. We'll do another stimulation test in 4 weeks to check his levels.

I hope things will go well for Mister this time. We're both pretty worn out.

Inno and Mister

[Harley PoMMom]

His dose was 375mg per day. 250 in a.m. and 125 in p.m. He weighs 8kg.


Since that 375 mg loading dropped his cortisol too low I think a maintenance dose of 250 mg is a good plan, and hopefully will hold that cortisol within the therapeutic ranges....fingers and toes all crossed. ;)

Hugs, Lori

[innotu]

Mister is doing well so far on his low maintenance dose of lysodren. He has another stimulation test on Mar. 16.

My question is: the hair on his tail is growing back and his skin is no longer pink, this is good. However, his skin is dry and flakey, particularly on his tail. Is this part of the Cushings or should I be worried?

[leahdan]

I believe Canada West Veterinary Specialists have an internist. They are in Burnaby I think. We used to live in Victoria and used them to diagnose a liver problem in our Boston Terrier. They were very good and extremely knowledgeable but I'm not sure if you are going to find a better personal experience there. It was a long time ago, but they were also very busy and I found the specialist we had wasn't really willing to listen. It was also EXPENSIVE - even by Canadian standards. To be fair, they seem to work on a triage basis and we had better contact with the vet the sicker our dog was. It may be worth giving them a try - this was just our personal experience and it was almost 9 years ago.

Leah

[molly muffin]

We've heard of some dogs having dry and flaky skin. Have you tried adding in omega 3 supplements?

[innotu]

Thanks Leah- I've heard of Canada West. I'm going to wait until the next stimulation test to see how Mister does and then decide.

Thanks Sharlene - I haven't tried any supplements yet. I may try the omega 3.

[LauraA]

My girl has battled with dry and flaky skin pre and post Cushings diagnosis. She has always been on omega 3 since her ACL surgery many many years ago but she still suffers from it. I have tried many different shampoos and potions (not going to add up the cost on that hehe). The thing that works best for her is to keep her hair clipped, a bath every 6 days - if I wait 7 days then the flaking and itchy is really bad, 6 seems to be the magic number for her, and a coconut oil based shampoo. I also put QV oil in a spray bottle and spray it on her after her bath or if her itchiness increases before bath day.

Some cheap things to try are the the QV oil, or rubbing coconut oil into his skin and then washing off. If her skin is really itchy I smother her in a skin conditioning creme with has been the best thing I have found that really works for her. I did it everyday for about 2 weeks and now I cover her about once a month as a preventative. Different things work for different dogs so it can be a matter of trial and error.

[innotu]

Thanks Laura,

We gave Mister a bath with oatmeal shampoo and conditioner and we've just started applying coconut oil. So far so good, his skin is looking better.

Inno

[molly muffin]

Yay, glad it looks better!

[LauraA]

I am glad he seems to have got some relief :)

[innotu]

Mister had is 4 week stimulation test yesterday. He's been on 125mg of lysodren twice per week (250mg/week).

Today's results show his cortisol levels have more than doubled since his test on Feb. 16th. So, we've increased his dose to 125mg three times per week (375mg/week). The vet doesn't want to go any higher given his previous 'crash'.

Here are his latest results (March 16):

Cortisol pre - 137 (28-120) nmol/L
Cortisol post - 386 (220-550) nmol/L

As a reference, his Feb. 16 results were:

Cortisol pre - 51 (28-120) nmol/L
Cortisol post - 115 (220-550) nmol/L

His dry, flaky skin continues, although it is improving. The vet says this is normal when the skin starts to recover after a reduction in cortisol levels. He sent us home with sebolux shampoo. We're to bathe him with it twice per week. His hair has also started to grow back. His little tail is now covered in jet black hair - looks funny given the rest of him is somewhat grey :D

Thoughts?

Inno and Mister

[molly muffin]

I'm not as knowledgable about lysodren, but it does seem that sometimes rather than do a mini reload, the vets opt to increase the maintenance dose.
You'll want a follow up ACTH to see if that is working or not.
I know his crash was so scary, so don't want to risk that ever again and I'm sure the vet doesn't either. This would be consider I think the conservative route to take.

I've heard that some dogs hair comes in as different colors or textures even after the cushings loss. You'll have to take a pic for us! :)

[innotu]

Mister had his latest stimulation test on Tuesday April 28:

Cortisol pre: 159 (28-120) nmol/l
Cortisol post: 389 (220-550) nmol/l

This is up from his last test (5 weeks ago). His lysodren has been increased from 375mg/week (125mg 3x/wk) to 500mg/week (125mg 4x/wk).

The vet thinks we're getting close to the ideal dose. We go for another stimulation test in 6 weeks. Mister is feeling okay and his hair has grown back. Fingers crossed that we hit the sweet spot this time.

[molly muffin]

Oh I do hope this one will be the perfect dose for him. He just keeps escaping it seems and the cortisol coming back up.

Glad his hair is looking good again and has grown back in. Yay!

[innotu]

Poor little mister collapsed today. We thought it was a reaction to the increase in lysodren. We rushed him to the vet and after observation, checking him out, and an X-Ray, it looks like he has a torn cruciate ligament in his right knee and severe arthritis in both knees. He's on anti-inflammatory and pain meds and will have surgery the week of May 24.

He has been having difficulty walking and climbing stairs but today he just couldn't move any longer. My poor little guy has had a rough time lately.

[Bonnie0420]

I'm so sorry, I don't know the history with mister but sure hope he is feeling better soon, nothing worse then seeing our fur babies in pain..

[molly muffin]

Oh no. Poor little guy. Do hope he will be okay. Sure it is quite painful.

Big hugs.

[innotu]

Mister has had a very painful few days. He has pancreatitis. At first I thought maybe his cortisol had dropped too low again, however after several tests it turns out he has acute pancreatitis (again). He hasn't had an attack for a few years and this one is pretty bad. It's been three days and he's still at the vet's. He has started eating, but he's pretty lethargic, has bloody diarrhea, and is in pain. He was due for a stimulation test, so I had that done while he was there. The levels are perfect, so at least his Cushings is under control (for now). I've put his cruciate ligament surgery on th he back burner for now. He's been through so much and seems to be managing okay on the bad leg.

My poor little mister. Please keep him in your thoughts and send positive vibes his way.

[molly muffin]

Oh dear, so sorry to hear that Mister is having a bad case of pancreatis. :( I do hope he'll get over it very soon and be out of pain, and home.

Keep us posted. Sending good vibes your and Misters way.

[Harley PoMMom]

Thoughts and prayers being said and sent. Are they giving him pain medication? If not, they really need to do this, pain can keep a dog from eating, and with pancreatitis it is important for them to eat.

[innotu]

Yes, they are giving him pain meds, anti-nausea meds, antibiotics, and fluids. He seems to be getting better however its been a slow process. He comes home tonight and I hope he continues to do well.

Thanks for your thoughts and prayers.

Inno

[judymaggie]

Sending healing thoughts to Mister! Hopefully, the recovery process will go smoothly and quickly so you can address his ligament issue.

[innotu]

Well it was too good to be true! Mister is relapsing. His panting has increased and he's having accidents in the house again.

The last 2 stimulation test were not great and we've increased his dosage to 750mg lysodren per week (125mg x 6/week). He only weighs 8kg so this is a high dosage. I'm concerned that the lysodren is no longer very effective in controlling the Cushings.

Here are the results of his last 2 stimulation tests:

Nov. 10th:

Cortisol pre: 226 nmol/L (normal range 28-120)
Cortisol post: 361 nmol/L (normal range 220-550)
Notes: poor control. Post should be less than 100nmol/L for good control.

Dec 12:

Cortisol pre: 195 (normal range 28-120)
Cortisol post: 458 (normal range 220-550)
Notes: poor control. Post should be less than 100nmol/L for good control

The vet says his dosage is already too high and that if symptoms persist we will need to change medication.

Advice/thoughts would be appreciated.

Thanks

Inno and Mister

[judymaggie]

Hi, Inno! So sorry that Mister's cortisol levels are rising again. A couple of thoughts based on my experiences with my Abbie. Because my vet only had experience with Lysodren, that is what we started Abbie on. Loading went well but cortisol was not controlled during maintenance. We tried several increases and then tried a mini-load--all to no avail. My vet then had no choice but to suggest switching to Vetoryl. Based on what I have learned here as well as getting guidance from Dr. Mark Peterson, we waited a month after stopping Lysodren and started Vetoryl. Abbie's cortisol has been controlled after one increase. So ... I think you could try a mini-load with Mister to see if that helps or you could consider switching to Vetoryl. With Mister's cortisol already high and symptoms returning, I think you could probably reduce the waiting period between the drugs (one of the reasons you wait is to make sure the adrenal glands have started producing cortisol again). You should have an ACTH done right before starting Vetoryl in order to have an accurate baseline.

[innotu]

Thanks Judy. I'm going to have to do something soon. The vet told me to 'wait and see' if symptoms increase. I think I have seen enough and it's time to do something other than small increases in his Lysodren dosage.

Happy New Year

Inno and Mister

[molly muffin]

Let us know how it goes and what you decide to do.

Remember you want a 30 day wash out between switching between lysodren and vetroyl.

[innotu]

Hello,

It's been quite some time since I've been on this site. Mister had been managing quite well with his cushings. Lately he's been quite ill and my vet (it's a revolving door of vet de jour) has been unable to help him. I am in the process of interviewing new vets and will take my 3 furry babies to a new vet once I find the right one.

He's stabilized now but only because I've started him on prednisone and drastically reduced his lysodren. The vets have tested him for everything and X-rayed his stomach - all is normal.

HOWEVER, I believe his latest stim test was low when they told me it was within range. Below are his last 2 results:

2016:
Pre: 195 range: 28-120nmol/L
Post: 458 Range: 220-550 nmol/L

We then increase his Lysodren from 1/4 tablet 6/week to 1/4 everyday. He was fine for over one year on this dose.

Mar. 31, 2017:
Pre: 42.7 Range 0-280 nmol/L
Post: 72.5. Range 221-650 nmol/L
The lab reported him as adequately suppressed.

I brought him in for a stim test because he was lethargic, having trouble walking, and not very food motivated. He would need to be cajoled into eating when previously he was always ravenous. I have been trying to figure out what's wrong and spending $$$$ getting tests done when he stopped eating all together. I phoned the vet's office and got yet another newbie. I asked if I should start him on prednisone and reduce his lysodren and he said yes - this was last Thursday. Note: within 12 hours he was back to his usual self. I'm still waiting for them to 'confer' with the head vet on what to do with him. It dawned on me that I hadn't asked for the last stim test results. When I got them it made me suspicious...what are your thoughts?

[Harley PoMMom]

Those stim results are perfect for a dog on Lysodren but it certainly sounds like his cortisol dropped too low especially since the Prednisone has perked him up. Have his electrolytes been checked?

Just for clarification, was an ACTH stimulation test done after the March 2017 one and if so, was it performed when he acted like his cortisol was too low and without having any Prednisone?

[innotu]

Thanks for your reply.

The stim test was done while he was sick and before prednisone. We've had a number of blood and urine tests done in the past 2 weeks. What would I look for to see about his electrolytes?

Thanks again.

[Harley PoMMom]

Electrolytes are found on a chemistry blood panel which are: sodium (Na), potassium (K), chloride (Cl), calcium (Ca), and PHOS (phosphorus). The sodium and potassium are the two levels I'm really interested in knowing.

How much time passed between his Lysodren dose and the performance of the ACTH stimulation test?

[Squirt's Mom]

Has he lost weight since starting the Lyso?

[innotu]

Thanks so much for your help,

1) his stim test was about 2 hours after his lysodren dose.
2) electrolytes from 4/24/2017 test:

Na - 144 (142-152)
K - 5.3 (4-5.4)
Cl - 111 (108-119)
Ca 2.73 (220-280)
Phos 1.7 (.08-2.0)
Na/K ratio 27 (28-37)

Thanks again for your help! Much appreciated....

[Harley PoMMom]

Mar. 31, 2017:
Pre: 42.7 Range 0-280 nmol/L
Post: 72.5. Range 221-650 nmol/L
The lab reported him as adequately suppressed.


I also wanted to add that dog's being treated with Lysodren the therapeutic ranges are between 30 nmol/L - 138 nmol/L, which for our U.S. members that is 1.09 ug/dl - 5.0 ug/dl.

So that would put Mister's stim numbers at a pre of 1.5 ug/dl and post of 2.6 ug/dl. So I am just wondering if his cortisol continued to decrease and it dropped too low and that would make sense that the prednisone helped.

I'm relieved to see that Mister's electrolytes levels look pretty good, the only one I'm just a bit concerned with is his potassium so you may want to keep an eye on that.

Hugs, Lori

[molly muffin]

Electrolytes look good, but it does sound like his cortisol has gone low. I'd decease the lysodren and I too wonder if his cortisol continued to drop after that last ACTH test.