Zoe-Our journey together

[Crystal&Zoe]

I've been lurking here and the FB page for awhile and thought I would introduce myself and my Zoe to the group and ask a couple of questions. I apologize in advance for the book but just want people to know our history. Perhaps it will give some insight to help you all give us tips, suggestions and advice. Zoe is a Maltese that I got from a byb back before I knew better. She is not the typical Maltese in conformation or temperament. She has always been a high anxiety dog with OCD tendencies. Her food dish must be in the same place. She will only drink out of the water bowl on the right, not the left. She is the reason I've learned that only true positive reinforcement training is best. I feel like I failed her miserably the first couple of years I had her before I did my homework and became a student of all things dog related in behavior, training and holistic health care. However she is the smartest dog that both I and the trainer who did classes at my store have met to date, and has brought me so much joy. Out of my 3, she is the one who wants to please me more than anything and it's frustrating to her and upsets her when she can't figure out what I'm asking of her or she knows what I'm asking and simply can't give it. She will be 11 tomorrow.

Our cushings journey started in the late fall of 2011 when she was 8. My parents were getting older and I was beginning to be called to their house in the evenings after work more and more to help with various things. It was exhausting and draining to try to keep up my place as well as theirs. So I sold my house and theirs and we purchased a house where we could all live with separate areas and I could help out more easily. Zoe did not transition easily to this move. I had a pet supply store (just had to close it the end of 2014) and due to Zoe's temperament she did not do well at the store. So I would take her to my parents home and she would stay with them for the day while I took the other 2 with me to work. The place we moved to is a planned community where we pay a HOA fee and they maintain the outside. So rules are strict here. Zoe went from being able to run free in a 3 acre yard chasing squirrels and chipmunks and exploring adjacent fields and even a creek running through the yard to a place where she had to be leashed when we go outside and we had to implement a 3 bark rule. A huge change for her and one she still to this day struggles with. She has a history of back pain and right after we moved she was in so much pain she would tremble uncontrollably in her bed and would not move. Everything we tried to manage the pain did not help. I was still trying to find a good vet that would work integratively with me. I'm in a small town and most vets here still have the farm animal, pets are pets mentality. It finally became a quality of life issue and she had to be put on Prednisone a few times. She was diagnosed at that time with IVDD. Also at that time she started to drink large volumes of water and having to go outside to pee a lot. Side effect of the Prednisone, right? Well it didn't stop. So I took her to my then vet and we ran a full CBC, Chem Screen and urinalysis and everything was WNL's but her AlkPhos was slightly higher than it had been the previous year and at the high end of normal. Then dad was diagnosed with cancer and died very unexpectedly in February, just 3 months after we moved. Dad was her person and was always in his lap. We had to call the ambulance in the middle of the night and she refused to leave his side. She truly grieved and went into depression. And she continued to drink large volumes of water and pee a lot, as well as lick the kitchen floor incessantly before and after dinner for at least 30 minutes if not more. My then vet was telling me it was all behavioral because she would go drink large amounts of water when she was over excited and didn't know what to do with herself or frustrated. At that time I also noticed she was no longer able to jump up on furniture. It was thought it was due to her IVDD. She has always been a grouchy girl but she was acting grouchier when I would touch her lower back area. So I found a holistic vet a couple of hours away who specializes in movement and does chiropractic and acupuncture in horses as well as small animals. We were doing acupuncture and noticed some areas of thinning hair. He helped me find a really great integrative vet closer to home and we ran a thyroid test and it came back wnl's. Next we ran a Urine Cortisol:Creatinine Ratio. It came back positive. But we did a urine catch there at the vet clinic and she's a high anxiety girl. So we did the Low Dose Dex Suppression test which also came back positive. But her hair was for the most part still thick with only a few areas on the tops of her feet that were thin. And she had no pot belly and her weight was good. She was really in good condition and both my integrative vet and holistic vet said she's the most atypical looking dog they've yet met if she truly has cushings. Neither could really believe she had cushings so we ran the ACTH Stim. Yes, she has cushings. So we treated holistically and managed her cortisol levels well. She would have times where we needed to adjust her TCHM meds and lost most of her hair at one point but it came back in nicely. Then about 5-6 months ago she started to lose her hair again, lost more muscle mass and developed a pot belly. And her grouchiness got worse to the point of aggression. So we started her on Trilostane about 4 1/2 months ago. She was 10 lbs when we started her on 10 mg. once a day. She's also on 3 mg. melatonin twice a day. Her aggressiveness got worse. She lost even more hair to the point of practically being bald. Her skin started to become paper thin where I could see veins and flake. And she was dropping weight and losing her pot belly. She was drinking normal amounts of water again and all peeing accidents stopped. And she was acting like she was feeling better. In her 3rd month of being on the Trilostane she was continuing to lose weight to the point of being too thin. She was under 9 lbs at that point and I couldn't put weight on her and I was increasing her food a lot. And she was beginning to shake uncontrollably when over stimulated. We were trying to spread out the Stim tests a bit for financial purposes but her symptoms were all over the place. Some indicating she was on too high of a dose and others that she was on too low of a dose. We ran another Stim Test a few weeks ago (the same week her symptoms seemed to finally resolve) and her cortisol levels are being very well managed and all of her others levels look good. I'm a firm believer in preventive medicine as well as integrative medicine so I do yearly cbc's and urinalysis on my dogs. We haven't done any flea or tick meds in over 7 years and they've not had fleas or a tick in those 7 years. They get heartworm prevention with no other wormers that is compounded for their sizes every 60 days. They are raw fed with what would be considered 'cold' or 'neutral' meats in TCHM and we rotate often. Zoe is back up to a good weight of 9 lbs and gets in addition to her trilostane and melatonin daily: glucosamine/chondroitin, cold pressed organic coconut oil, fish oil and an immune support blend. I've always given my dogs a 30 day detox with a milk thistle blend every quarter as well as every weekend a homeopathic detox that works on a cellular level. I've also started to give her a preventive dose of an herbal blend for bladder health. So far her liver enzymes have all been wnl's and she's not had a UTI.

So these are my questions:

1) Is her reaction to starting Trilostane typical?

2) I'm reading more and more that it's better to give Trilostane twice a day. She's always been grouchy but I'm noticing in the evenings she's more grouchy than in the mornings. I give her Trilostane at breakfast. Should I ask my vet to compound it and give it to her twice a day?

3) Did the stress/anxiety of our move and the loss of dad trigger this? Again she's always been high anxiety but her adrenal system took a huge hit at that time. And do I try to keep her manners in check even if it causes her stress? The 3 bark rule (not literally 3 barks but I'm ok with them alerting me of something, thank them for it and acknowledge it and then they have to stop) is very hard for her. She can't give it to me at times even though she knows it's what I'm asking of her. I can see she wants to do what I'm asking and just can't. Her barking is getting worse. I'm guessing due to cataracts that are also developing. Do cataracts go hand in hand with cushings or is it that cushings dogs are typically older and so they also have cataracts?

4) Are dogs who are more high anxiety dogs more at risk of developing Cushings?

5) Both vets are skeptical that Zoe will regrow her hair. Any thoughts/experience on this? I'm ok with her being bald but when we go for walks people don't want to touch her or give her attention like they used to; or if I have the other 2 with us, they give them all the attention and that frustrates her.

6) Has anyone been able to successfully lower the dose of Trilostane after a period of time while supplementing holistically?

7) Is there anything more I should be doing? Or is there something I'm doing that raises red flags for those with more experience?

For those that have read our book ::blush::, thank you!

(I wanted to include a photo of Zoe that was taken before she got sick and one that was taken last week. She was begging me to fill up her treat ball again. :p But I don't think I have permission to do that yet. I did upload a few pics into an album I created for any that would like to meet her.)

[Dixie'sMom]

Hello and welcome to you and Zoe! I loved reading your book(haha) and found it very interesting. :) You obviously care deeply for your pups and strive to give them the very best care possible. It sounds like they are very well behaved even with Zoe's tendency to be high strung. I'm glad you uploaded pictures and I will go look at them. It is one of my favorite parts of this forum.

Unfortunately, I am a fairly new Cushpup Mom and can't do much to advise you. The gurus on this forum will be along soon to welcome you and offer their support.

The one thing I do know that they will ask of you is copies of Zoe's recent test results (blood work, urine, ACTH or any other test specific to Cushing's) to help them get a clearer picture of Zoe's health. They will be able to give you more meaningful feedback after looking over the labs so if you do not have copies, could you request them from your vet?.

My Cushpup, Dixie, is also very high strung and always has been, so I can relate to your experiences with Zoe. Dixie was the only female in her litter, was the runt and was the bully. LOL.

I look forward to getting to know you and your precious Zoe. Again, welcome! :D

[labblab]

Welcome from me, too! We're so glad you took the plunge and started posting! ;) :)

I have to "second" what Suzie has written above -- you sound like a super conscientious and caring mom, and we will do whatever we can to try to be of help to you. Also as Suzie has said, probably the most helpful thing you can do for us is to get your hands on copies of actual test results, especially the diagnostic tests for Cushing's and any/all subsequent monitoring ACTHs. The combination of specifics re: Zoe's trilostane dosing history and the associated ACTH results will really help make sense of the things that have been going both right and wrong for her. Until we get that info, there's a limit to the amount of feedback we can offer. But I'll take a first stab at answering at least some parts of your questions below (my answers will be in blue).




So these are my questions:

1) Is her reaction to starting Trilostane typical?

You need to be a bit more specific as to what "reaction" you are wondering about. It sounds as though Zoe has gone through a range of behaviors/symptoms over time, and I'm not exactly sure as to which things you are associating with trilostane. This is an instance where the dosing history and monitoring test results will be invaluable to us, so that we can better assess where her cortisol level was at a given point in time and in conjunction with specific issues that you are concerned about.

2) I'm reading more and more that it's better to give Trilostane twice a day. She's always been grouchy but I'm noticing in the evenings she's more grouchy than in the mornings. I give her Trilostane at breakfast. Should I ask my vet to compound it and give it to her twice a day?

There is still disagreement among researchers and clinicians as to whether twice daily dosing is preferable for all dogs. Some clinicians prefer to dose twice daily right from the get-go. Others (including the manufacturer of Vetoryl) recommend starting first with once daily dosing and only switching over if symptoms are rebounding at night even though the daytime ACTH level is within therapeutic range. Twice daily dosing is more of a hassle, since it needs to be given at 12-hour intervals and trilostane always needs to be given along with a meal. But it does keep cortisol levels more consistently lower throughout the course of a 24-hour time period. For some dogs this is a good thing; for some, it actually has a greater tendency to drive their cortisol too low. So my personal opinion (and that's all it is, an opinion), is that if my dog was doing well on once daily dosing without noticeable symptom rebounding at night, I'd probably leave well enough alone.

3) Did the stress/anxiety of our move and the loss of dad trigger this? Again she's always been high anxiety but her adrenal system took a huge hit at that time. And do I try to keep her manners in check even if it causes her stress? The 3 bark rule (not literally 3 barks but I'm ok with them alerting me of something, thank them for it and acknowledge it and then they have to stop) is very hard for her. She can't give it to me at times even though she knows it's what I'm asking of her. I can see she wants to do what I'm asking and just can't. Her barking is getting worse. I'm guessing due to cataracts that are also developing. Do cataracts go hand in hand with cushings or is it that cushings dogs are typically older and so they also have cataracts?

I'll start backwards with the cataracts question first. I honestly don't know whether cataracts are more common in Cushpups, so thanks for asking the question because I am interested in looking that up myself! But yes, it does seem logical that cataracts may happen to appear in Cushpups simply since more dogs are diagnosed with Cushing's at a later age.

As far as stress/anxiety causing Cushing's (I'm answering your next question as well), I am not aware of any research that supports this. Cushing's is caused by tumors of either the pituitary gland or adrenal gland. While chronic stress is believed to have unhealthy effects on various aspects of the whole body, I don't think there is any direct relationship between stress and the development of these particular tumors.

4) Are dogs who are more high anxiety dogs more at risk of developing Cushings?

See answer above.

5) Both vets are skeptical that Zoe will regrow her hair. Any thoughts/experience on this? I'm ok with her being bald but when we go for walks people don't want to touch her or give her attention like they used to; or if I have the other 2 with us, they give them all the attention and that frustrates her.

This is an example of why it will really help us to see Zoe's actual monitoring test results. If Cushing's is the cause of her hair loss, once Zoe's cortisol level is truly within the desired therapeutic range, hair regrowth should be one of the general benefits of her treatment. So I am unsure as to why your vets are pessimistic about this improving. What is the status of her thyroid function, however? Low thyroid also commonly affects skin and coat. Low thyroid results often occur hand-in-hand with Cushing's. Sometimes the thyroid levels normalize with effective Cushing's treatment. Sometimes the low thyroid level is a primary problem in its own right and needs to be addressed with supplementation.

6) Has anyone been able to successfully lower the dose of Trilostane after a period of time while supplementing holistically?

Trilostane dosing often requires tweaking over time, both upwards or downwards. That's why the monitoring tests are very important on an ongoing basis, especially if there is a rebound in symptoms or a decline in health. However, I am not aware of any holistic supplementation that can take the place of the physiological activity of trilostane. In other words, we do have dogs for whom dosing is reduced over time, but this is due to their response to the trilostane itself, and not because another drug or supplement is performing the same pharmacological action.


I hope these answers are at least a start to the conversation. Once again, we're really glad you and Zoe have joined us!

Marianne

Edited to add: On rereading your post, I see that Zoe's thyroid level was normal at the time of her initial diagnostics. So that answers one of my questions above. Has her T4 level remained within the normal range subsequent to that time, however?

[Crystal&Zoe]

Hello and welcome to you and Zoe! I loved reading your book(haha) and found it very interesting. :) You obviously care deeply for your pups and strive to give them the very best care possible. It sounds like they are very well behaved even with Zoe's tendency to be high strung. I'm glad you uploaded pictures and I will go look at them. It is one of my favorite parts of this forum.

Unfortunately, I am a fairly new Cushpup Mom and can't do much to advise you. The gurus on this forum will be along soon to welcome you and offer their support.

The one thing I do know that they will ask of you is copies of Zoe's recent test results (blood work, urine, ACTH or any other test specific to Cushing's) to help them get a clearer picture of Zoe's health. They will be able to give you more meaningful feedback after looking over the labs so if you do not have copies, could you request them from your vet?.

My Cushpup, Dixie, is also very high strung and always has been, so I can relate to your experiences with Zoe. Dixie was the only female in her litter, was the runt and was the bully. LOL.

I look forward to getting to know you and your precious Zoe. Again, welcome! :D

Thank you! I look forward to getting to know you and your sweet Dixie as well. I just wish it were under better circumstances. ;)


Welcome from me, too! We're so glad you took the plunge and started posting! ;) :)

I have to "second" what Suzie has written above -- you sound like a super conscientious and caring mom, and we will do whatever we can to try to be of help to you. Also as Suzie has said, probably the most helpful thing you can do for us is to get your hands on copies of actual test results, especially the diagnostic tests for Cushing's and any/all subsequent monitoring ACTHs. The combination of specifics re: Zoe's trilostane dosing history and the associated ACTH results will really help make sense of the things that have been going both right and wrong for her. Until we get that info, there's a limit to the amount of feedback we can offer. But I'll take a first stab at answering at least some parts of your questions below (my answers will be in blue).



I hope these answers are at least a start to the conversation. Once again, we're really glad you and Zoe have joined us!

Marianne

Edited to add: On rereading your post, I see that Zoe's thyroid level was normal at the time of her initial diagnostics. So that answers one of my questions above. Has her T4 level remained within the normal range subsequent to that time, however?

Thank you Marriane. We've tested Zoe's thyroid now on multiple occasions and send it to Dr. Jean Dodds' lab. So far it comes back normal. However the last time we sent it off was when we were struggling to manage her cortisol level holistically and test results were indicating an underlying kidney issue and there were some notes from her lab. I'm sitting her thinking, 'I can't believe I don't remember!'. It was a stressful time and she was not only having many piddle accidents (which she never has, but she had a terrible gastric upset and was having liquid diarrhea every 2 hours for almost a week. I got very little sleep at that time and we were even thinking she may have diabetes insipidus. Thankfully once the cushings was managed again, that went away. But during that time she was not dehydrated but I'm guessing her electrolytes were out of balance because she truly seemed unaware that she was peeing in the middle of the room right in front of me. I will go back and pull records. How far should I go back? I've not received copies of her latest stim test and work up yet. I can have her email me copies but it's usually easier to pick them up when I go to pick up her next supply of Trilostane.

And yeah....I probably just need to admit it. I'm a crazy dog mom. I was never blessed with skin kids so they are truly my kids. I owe so much to Zoe. She really helped me through a very dark time when I realized I would never have children of my own. So please forgive my over the top crazyness. :(

Edited to add: My understanding is that stress, whether it's good stress or bad stress if her body doesn't know how to deal with it causes major fluctuations in her cortisol levels. I guess I was wondering if having chronic fluctuations could possibly cause tumors either on the pituitary or adrenal gland. We've been thinking Zoe's is pituitary but her last ultrasound did reveal that at this point in time one adrenal gland is slightly larger than the other. No tumors could be seen. Due to her size, I know it really takes an expert to be able to see them and I've not been able to take her to a specialist. My vet is certified and recently took a CE course specifically to help her with ultrasounds for the tiny patients.

And good to know the thought process on once a day vs. twice a day dosing. Thank you!

[Dixie'sMom]

I checked out Zoe's pictures and she is just beautiful! If you want to make one of these pretty pictures your avatar, just go to User CP, Edit Avatar.

I see Marianne has dropped in on you. You are in excellent hands. :) :D

[Squirt's Mom]

Edited to add: My understanding is that stress, whether it's good stress or bad stress if her body doesn't know how to deal with it causes major fluctuations in her cortisol levels. I guess I was wondering if having chronic fluctuations could possibly cause tumors either on the pituitary or adrenal gland. We've been thinking Zoe's is pituitary but her last ultrasound did reveal that at this point in time one adrenal gland is slightly larger than the other. No tumors could be seen. Due to her size, I know it really takes an expert to be able to see them and I've not been able to take her to a specialist. My vet is certified and recently took a CE course specifically to help her with ultrasounds for the tiny patients.

Hi and welcome to you and Zoe! :)

The fluctuation in cortisol levels due to stress is a NORMAL function of the body, canine, human, feline, equine, etc. Cortisol is vital to our survival. It's only in Cushing's where the levels are so very high that this hormone turns on the system.

At this time, no one knows the cause of Cushing's. Studies have been done on feed, environments, genetics and no correlation has been proven. It seems to just be a fluke that some develop this disease. It presents differently in different species, too. In dogs, Cushing's is caused by tumors, either on the pituitary or the adrenal gland(s). What causes those tumors is unknown but stress is not the culprit or we would have proof of that from the scientific community by now.

Stress is MUCH more of a concern for pups with Addison's, a disease the opposite of Cushing's in which the body can no longer produce cortisol or not enough cortisol to deal with any stress. These pups must be supplemented with synthetic cortisol plus electrolytes so they can cope with simple every day stimulus like the mailman. So stress is not as big a concern for our cush pups. ;)

In PDH, the pituitary-based form, the adrenal glands on the ultrasound typically appear larger than normal, both of them. In ADH, the adrenal-based form typically one gland is larger than the other, the other may even be atrophied (shriveled up). The US and LDDS do the best job of helping to determine which form the pup has. This can be very important to know as treating an adrenal tumor can be a bit more difficult and the pituitary tumor may start to grow causing neurological signs. So most vets want to know which form is in play.

The ultrasound is an expensive test and should be done only on a high resolution machine and read by the person who always reads that machine. Otherwise you run the very real risk of not being able to see everything that is needed and not getting accurate, detailed interpretation.

I'm glad you made it here and look forward to following yours and Zoe's journey.
Hugs,
Leslie and the gang

[labblab]

In terms of test results, I'd be most interested in the diagnostic tests for Cushing's (ACTH and abnormal values on blood/urine panels), all the subsequent monitoring ACTH results, and also abnormal values on any recent blood/urine panels. Has Zoe remained on the 10 mg. of trilostane since beginning treatment?

Marianne

[Crystal&Zoe]

Hi and welcome to you and Zoe! :)

The fluctuation in cortisol levels due to stress is a NORMAL function of the body, canine, human, feline, equine, etc. Cortisol is vital to our survival. It's only in Cushing's where the levels are so very high that this hormone turns on the system.

At this time, no one knows the cause of Cushing's. Studies have been done on feed, environments, genetics and no correlation has been proven. It seems to just be a fluke that some develop this disease. It presents differently in different species, too. In dogs, Cushing's is caused by tumors, either on the pituitary or the adrenal gland(s). What causes those tumors is unknown but stress is not the culprit or we would have proof of that from the scientific community by now.

Stress is MUCH more of a concern for pups with Addison's, a disease the opposite of Cushing's in which the body can no longer produce cortisol or not enough cortisol to deal with any stress. These pups must be supplemented with synthetic cortisol plus electrolytes so they can cope with simple every day stimulus like the mailman. So stress is not as big a concern for our cush pups. ;)

In PDH, the pituitary-based form, the adrenal glands on the ultrasound typically appear larger than normal, both of them. In ADH, the adrenal-based form typically one gland is larger than the other, the other may even be atrophied (shriveled up). The US and LDDS do the best job of helping to determine which form the pup has. This can be very important to know as treating an adrenal tumor can be a bit more difficult and the pituitary tumor may start to grow causing neurological signs. So most vets want to know which form is in play.

The ultrasound is an expensive test and should be done only on a high resolution machine and read by the person who always reads that machine. Otherwise you run the very real risk of not being able to see everything that is needed and not getting accurate, detailed interpretation.

I'm glad you made it here and look forward to following yours and Zoe's journey.
Hugs,
Leslie and the gang

Ok that makes sense about the stress level Leslie. Thank you. So I won't be letting her get away with things I don't my other two. Poor Zoe. I think she thought she had it made there for awhile. lol But we don't want to be asked to move from the community we live in because she may be small but she's got a mighty bark!

I have no idea what type of ultrasound machine my vet has but I do know it's brand new and she said state of the art. How the heck do I ask without causing offense? She is the one to do the ultrasound as well as read it. I believe the Low Dose Dex Suppression test indicated pituitary cushings and I simply cannot afford an MRI. I would have to travel several hours to get one for her. I'm ashamed to have to admit this because honestly, I would do anything for my babies that is within my reach. We've done quite a few ultrasounds. Thankfully my vet and are becoming friends and she seems to like me and has only charged me for the first one. She's wanting to track her progression as much as I do. I've gone through most vets in my area because I simply know more than the average pet owner in general health areas and can give them credible sources as to why I won't vaccinate every year, want titer testing done, and don't even get me started in the area of nutrition. So I want to keep my good relationship with the 2 vets I have for sure. They treat me as an equal when it comes to decision making and allow me to be a part of treatment plans. That didn't happen with any other of the vets I've tried. When treating with TCHVM's, it wasn't truly important what type of cushings she had. And when my integrative vet asked about the MRI and I said I could not swing it financially, she said that with Trilostane it works for both adrenal as well as pituitary cushings. So since her adrenal glands have been the same size all along until just this last time right before we started her on the Trilostane, could possibly the one becoming atrophied? I'm trying to remember but I think this was briefly discussed on the FB page and there is a possibility of adrenal glands doing this and then medication is no longer needed. Am I remembering that right? And am I being neglectful for not finding a way to get an MRI for her?


In terms of test results, I'd be most interested in the diagnostic tests for Cushing's (ACTH and abnormal values on blood/urine panels), all the subsequent monitoring ACTH results, and also abnormal values on any recent blood/urine panels. Has Zoe remained on the 10 mg. of trilostane since beginning treatment?

Marianne

She's only been on the Trilostane now for a little over 4 months. And she's remained on the 10 mg since the beginning. I'll get the results of her latest blood work and and stim test and get the numbers for you. Thank you!


I checked out Zoe's pictures and she is just beautiful! If you want to make one of these pretty pictures your avatar, just go to User CP, Edit Avatar.

I see Marianne has dropped in on you. You are in excellent hands. :) :D

Thank you! I was thinking the same thing about using one of the photos for my avatar. Thank you for suggesting it. She really does not look like she used to anymore which is hard for me. But I have to keep telling myself that just because she looks bad physically to people who don't know what's going on with her, she's physically feeling good and that's all that matters.

[Squirt's Mom]

Honestly, I think of the MRI and CT scans as measures when you know things have changed dramatically, as in the appearance of neurological signs that may indicate the pituitary tumor is growing or when considering an adrenelectomy or hypophysectomy. But not as part of the usual diagnostic process. The abdominal ultrasound can tell everything that is needed at this point. ;) So no, you are not being neglectful, just wanting to be as sure as possible that you have covered all the bases. :)


So since her adrenal glands have been the same size all along until just this last time right before we started her on the Trilostane, could possibly the one becoming atrophied? I'm trying to remember but I think this was briefly discussed on the FB page and there is a possibility of adrenal glands doing this and then medication is no longer needed. Am I remembering that right?

What happens in an overdose from Vetoryl or Lysodren that the pup cannot recover from, is the adrenals are necrosed, or killed off. As time passes, they will shrink and atrophy, as will any living thing that is no longer in use. This is Addison's and not what we are shooting for. ;) Interestingly enough, in some countries they do kill off the adrenal glands on purpose because they feel it is easier to treat Addison's than Cushing's. That is not the prevailing belief elsewhere.

With ADH, the adrenal form of Cushing's, one gland will be large and the other small or atrophied, but not both.

[labblab]

Due to the expense, very few people opt for an MRI of the head, especially in the absence of neurological symptoms that suggest a pituitary tumor is enlarging and placing problematic pressure elsewhere in the brain. So you are definitely not a bad mom for not pursuing an MRI at this time. You are in very good company. ;)

As for the recent ultrasound revealing an increase in size in one of the adrenals, as long as no mass or tumor is noted, my guess is just that both glands are not keeping the exact same pace in terms of enlargement.

Marianne

[addy]

Welcome,

There are many parts of your post that take me back to my Zoe. My Zoe died last February. We had been treating her for Cushings, eye issues, inflammatory bowel disease, allergies, etc. She started Vetoryl in June of 2010, a year after being diagnosed with Cushings.

Has anyone done a skin scraping on your Zoe? I found that my girl kept losing hair, paper thin skin, and the start of Calcinosis Cutis. She had topical yeast and bacteria on her skin. It was only after I started treating her skin and keeping her cortisol 5 ug/dl and under that her hair grew back thick and full. We used a medicated shampoo KetoChlor which is available by prescription. It flushed out the follicles and thing s got a lot worse before they got better.

My Zoe used to lick everything and chew her paws like crazy. Again, once her skin was treated and her cortisol was in a good place, that stopped.

My Zoe too need positive training and I reinforced everything with clicker training. If I had to muzzle her to protect her at the vets, I did. We made a game of the muzzle so she never cared she had to wear it.

I'm at lunch break so this is short., but I did want to stop by and welcome you and tell you dont give up on the skin and coat just yet.

[Crystal&Zoe]

Welcome,

There are many parts of your post that take me back to my Zoe. My Zoe died last February. We had been treating her for Cushings, eye issues, inflammatory bowel disease, allergies, etc. She started Vetoryl in June of 2010, a year after being diagnosed with Cushings.

Has anyone done a skin scraping on your Zoe? I found that my girl kept losing hair, paper thin skin, and the start of Calcinosis Cutis. She had topical yeast and bacteria on her skin. It was only after I started treating her skin and keeping her cortisol 5 ug/dl and under that her hair grew back thick and full. We used a medicated shampoo KetoChlor which is available by prescription. It flushed out the follicles and thing s got a lot worse before they got better.

My Zoe used to lick everything and chew her paws like crazy. Again, once her skin was treated and her cortisol was in a good place, that stopped.

My Zoe too need positive training and I reinforced everything with clicker training. If I had to muzzle her to protect her at the vets, I did. We made a game of the muzzle so she never cared she had to wear it.

I'm at lunch break so this is short., but I did want to stop by and welcome you and tell you dont give up on the skin and coat just yet.

Thank you for the welcome. And I'm very sorry for the loss of your Zoe.

No, we've never done a skin scraping but that's a very good thought. She's developing more and more warts which according to TCHM indicates her immune system keeps taking a hit. And she's developed blackheads in the past couple of months. Maybe what I'm seeing is the beginning of something like what you suggested? I thought the paper thin skin was just part of cushings. She doesn't really lick her paws or feet and has never had allergies. When she does lick it's usually due to not knowing what to do with pent up frustration or anxiety or excitement. The licking the floor thing I still don't know for sure what it is. Behavioral? Did it start with an upset tummy and turn into an OCD behavior? Did it start because she was hungry and it turned into an OCD behavior? I just don't know. I wish she could tell me. Something else that has changed in the past couple of years is that she's developed a foul odor at times. At first we thought it was coming from her belly indicating digestive upset. Then she needed a dental but we kept putting it off because we were wanting to keep her stress level down. But finally we could not put it off any longer and she had a dental recently. Her odor is much better now but it is still there time to time. And Maltese are not supposed to have a body odor. But in the past few months if we go more than a week in between baths she just smells bad. It's coming from her body, not her mouth. Although there are times I also smell a bad odor coming from her mouth. It's mostly her head, ear and neck areas that it's the strongest. It's not a yeasty smell. So I'm currently doing another herbal detox on her per my integrative vets recommendation and today it's been a week since her last bath. And so far she's not smelling. So I guess that's progress.

So paper thin skin and warts and blackheads and dry flaking skin are not typical 'cushings skin'?

[Squirt's Mom]

The thin skin, dark skin, and dry skin is typical of most cush pups. However Calcinosis cutis is not - it is one of the more rare complications and very difficult to get under control once it gets started. CC is calcium being deposited in the skin, often looking like blackhead or whiteheads, and those deposit work their way to the surface, causing open sores. A derm vet can tell you pretty fast if it is CC or not.

[Robert]

Hi just read your posts and this was only one dog but my little man tommy was the most placid laid back dog God ever put breath away into and he developed cushings. Cheets

[Crystal&Zoe]

The thin skin, dark skin, and dry skin is typical of most cush pups. However Calcinosis cutis is not - it is one of the more rare complications and very difficult to get under control once it gets started. CC is calcium being deposited in the skin, often looking like blackhead or whiteheads, and those deposit work their way to the surface, causing open sores. A derm vet can tell you pretty fast if it is CC or not.

Ok so I was looking it up on line. I took some pics with my cell phone but I don't have permission yet to post them. I would love some input from you all who have more experience with this and cushings skin in general. Should I post them on the FB group so you can see them? She does not have the large calcification spots as I've seen in other images on line but there were a couple that made me wonder.

[Crystal&Zoe]

Maybe this will work. I created a Skin and Hair Journal Album. Hoping all you have to do is click on the link which will take you to the Album.

After looking through some photos of other babies here, I'm realizing how much more hair Zoe has lost than others. No wonder both my vets jaws dropped when they saw her after a few weeks and every few weeks after. I could be wrong but I think she's started to maintain the amount of hair she has now and is no longer continuing to lose it. But it's probably a good idea to keep a photo journal.

This is the top of her back along her spine.

http://www.k9cushings.com/forum/picture.php?albumid=974&pictureid=7469



http://www.k9cushings.com/forum/picture.php?albumid=974&pictureid=7471

[Crystal&Zoe]

Hi just read your posts and this was only one dog but my little man tommy was the most placid laid back dog God ever put breath away into and he developed cushings. Cheets

Hi Robert. I'm so very sorry for your loss of your beloved Tommy. I can tell he was a very special little man and your love for him runs deep still.

[addy]

Hi Crystal,

The one photo I saw reminds me of my girl's skin issues. I sent you a friend request so you could see my Zoe's skin issues and hair loss.

I would bet money that is yeast and bacteria flakes I am seeing. Ask your vet for a bottle of Keto Chlor. Don't follow the directions on the bottle exactly. I can guide you along as how long to leave the shampoo on, when to cut back, etc.

I had to insist my girl's skin be treated.

[Crystal&Zoe]

Got the results of Zoe's last stim test after she had been on Trilostane. I'm not sure I truly understand what things mean but this is what her results say:

Cortisol Serial 2 (ACTH)
Time 1 /19
Time 2 Post 11:23
Cortisol Sample 1 1.5 (Reference Range 1.0-5.0)
Cortisol Sample 2 4.5 (LOW) (Reference Range 8.0-17.0)

So I get that Post-Trilostane: Pre & Post coristol levels between 1.5 - 9:1 ug/dL indicate optimal control. But what does Time 1 & Time 2 mean? And does this indicate Iatrogenic Hyperadrenocorticism? It says resting cortisol is usually between 1-5 ug/dL with little to no increase in the post-ACTH cortisol level. I'm assuming the resting cortisol level is Sample 1, right? And I'm not sure if going from 1.5 to 4.5 is considered little increase but since it's low, I'm guessing that it is. I've never really tried to discern the Stim tests before just looked at the reference range and was happy she was in that range.

Her last stim test before starting her on the Trilostane had these results:

Time 1 4
Time 2 5

Cortisol Sample 1 7.6 ug/dL 1.0-5.0 HIGH
Cortisol Sample 2 40.6 ug/dL 8.0-17.0 HIGH

Now to her blood panel, my vet was pleased with the results. I picked them up last night and haven't asked her about them yet. But I don't understand why she's pleased. Her last chem screen showed that only her AlkPhos was high. It was 483 IU/L with the reference range being 5-131. She also had an elevated MA showing:

Urine Microalbumin
(Canine Reflex)
Microalbuminuria 5.3 mg/dL <2.5 HIGH
The result is between 2.5 and 30 mg/dl, indicating microalbuminuria
(MA).
Microalbuminuria (MA) usually indicates compromise of the
glomerular barrier and is a significant finding when it is persistent
(3 or more positive results obtained 2 or more weeks apart).
Persistent MA, in the majority of pets, is due to primary renal
disease or renal injury secondary to other systemic disease. Systemic
diseases associated with persistent MA include inflammatory disease,
chronic infections, metabolic disease (e.g. hypertension, Cushing's
Syndrome, diabetes mellitus, hyperthyroidism) and neoplasia. False
positive results may occur with pyuria and gross hematuria.
Suggestions for evaluating patients with microalbuminuria:
1. Check for and treat underlying diseases indicated above
2. Recheck MA in 2-4 weeks
3. In the absence of underlying disease, monitor for progression of
MA and development of renal failure

We've been watching her MA for over a year now because it's been elevated. She also was not concentrating her urine and her Specific Gravity was 1.007 with the reference range of 1.015-1.050 which is low. We did not do another urinalysis to check her Specific Gravity or MA this time. Maybe we need to?


This time her Alk Phos is 309. Still high but lower than last time. But now these levels are also off:

GGT 23 (High) Reference Range 1-12
BUN 40 (High) Reference Range 6-31
Creatinine 0.4 (Low) Reference Range 0.5-1.6
BUN/Creatinine Ratio 100 (High) Reference Range 4-27
Tiglyceride 987 (High) Reference Range 29-91

I told her I was concerned about the odor coming from Zoe's mouth. She just had a dental so that's not it. And to just smell her mouth you don't smell anything. It's more if it's a breath coming from down deep, like when she yawns. If forced to describe it I would say it's a metallic smell but that's not exactly right either but closer than anything else I can compare it to. She told me her kidney levels look fine so she's not concerned about kidney failure. But why are they fine when they are not WNL's?

And she's continuing to lose even more hair. She's practically bald. We saw our holistic vet yesterday for acupuncture and he's thinking even though we have her cortisol levels managed, we don't have her hormones balanced and he's frustrated and stumped as is our integrative vet. He said he was going to go on VIN to see if an Endocrinologist may have any ideas or suggestions. For the most part Zoe's aggression is better but she just recently had a few days where she was pretty aggressive and even threatened to bite and put teeth on me. She's exhibiting good bite control so far and it happens when either one of the other 2 dogs gets too close to her or brushes up against her when she's sleeping or even a human. I do believe she thinks it's one of the other dogs when it happens and it takes her awhile to calm down when she realizes it's me or my mother. But I worry about her biting my mom especially since her reflexes are slower and she has thin skin and bleeds easily. It makes sense that if her hormones aren't balanced that could be why she's being aggressive at times. I asked my integrative vet if we needed to run another stim test and she really didn't think we did since her numbers were so good in her opinion. Those few days that she was more aggressive we also had to get up in the middle of the night to both pee and for a BM. The one time she again had mucous and diarrhea. So she's still struggling with digestive upset even though I did not give her any chews or anything out of the ordinary. I feel so bad for her and the other 2 because I can't give them the treats and treat toys and chews like they were used to and ask for. How can I give it to them and not to her? :(




Hi Crystal,

The one photo I saw reminds me of my girl's skin issues. I sent you a friend request so you could see my Zoe's skin issues and hair loss.

I would bet money that is yeast and bacteria flakes I am seeing. Ask your vet for a bottle of Keto Chlor. Don't follow the directions on the bottle exactly. I can guide you along as how long to leave the shampoo on, when to cut back, etc.

I had to insist my girl's skin be treated.

I had both my vets look at Zoe's skin and her latest area she's licking to the point she has an open sore. Both say they do not believe she has a yeast infection or candida. They say her hair loss is in a pattern and not in spots so they just don't think this is the reason for her continued hair loss. :( She does have an over production of wax in her ears that she never had prior to being sick and they do have a stinky, yeasty smell. I can't keep up on those ears. But she is on a double dose of probiotics and has been for almost 6 months now and has been on grain free diet and daily probiotics for over 7 years. I just can't imagine that would be an issue. But who knows? I'm getting frustrated that I get one hot spot cleared up and then another on rears it's ugly head. She's in her soft collar more than not and she hates it. And it's rubbing a wart on her neck that is getting bigger and sore looking.

[Harley PoMMom]

Got the results of Zoe's last stim test after she had been on Trilostane. I'm not sure I truly understand what things mean but this is what her results say:

Cortisol Serial 2 (ACTH)
Time 1 /19
Time 2 Post 11:23
Cortisol Sample 1 1.5 (Reference Range 1.0-5.0)
Cortisol Sample 2 4.5 (LOW) (Reference Range 8.0-17.0)

These stim results are from her 10-14 day of starting the Trilostane, right?

I believe that those "Time 1 and 2" represent when the blood draws were done. When using the stimulating agent Cortrosyn, which is generally used, a baseline/resting blood draw is taken than the Cortrosyn is injected and after an hour another blood draw is done which reflects the post number.

Her post number of 4.5 ug/dl is great, but her pre number is getting a bit low but can fluctuate throughout the day.


So I get that Post-Trilostane: Pre & Post coristol levels between 1.5 - 9:1 ug/dL indicate optimal control. But what does Time 1 & Time 2 mean? And does this indicate Iatrogenic Hyperadrenocorticism? It says resting cortisol is usually between 1-5 ug/dL with little to no increase in the post-ACTH cortisol level. I'm assuming the resting cortisol level is Sample 1, right? And I'm not sure if going from 1.5 to 4.5 is considered little increase but since it's low, I'm guessing that it is. I've never really tried to discern the Stim tests before just looked at the reference range and was happy she was in that range.

Yep, Sample 1 is the pre number, and her post (Sample 2) is 4.5 ug/dl which is not low when treating with Trilostane.



Her last stim test before starting her on the Trilostane had these results:

Time 1 4
Time 2 5

Cortisol Sample 1 7.6 ug/dL 1.0-5.0 HIGH
Cortisol Sample 2 40.6 ug/dL 8.0-17.0 HIGH

In a short period of time her post number (40.6 ug/dl) has decreased significantly, which is great, however that post number may still drift downward so just be on the lookout for signs of her cortisol going too low.



Now to her blood panel, my vet was pleased with the results. I picked them up last night and haven't asked her about them yet. But I don't understand why she's pleased. Her last chem screen showed that only her AlkPhos was high. It was 483 IU/L with the reference range being 5-131. She also had an elevated MA showing:

Urine Microalbumin
(Canine Reflex)
Microalbuminuria 5.3 mg/dL <2.5 HIGH
The result is between 2.5 and 30 mg/dl, indicating microalbuminuria
(MA).
Microalbuminuria (MA) usually indicates compromise of the
glomerular barrier and is a significant finding when it is persistent
(3 or more positive results obtained 2 or more weeks apart).
Persistent MA, in the majority of pets, is due to primary renal
disease or renal injury secondary to other systemic disease. Systemic
diseases associated with persistent MA include inflammatory disease,
chronic infections, metabolic disease (e.g. hypertension, Cushing's
Syndrome, diabetes mellitus, hyperthyroidism) and neoplasia. False
positive results may occur with pyuria and gross hematuria.
Suggestions for evaluating patients with microalbuminuria:
1. Check for and treat underlying diseases indicated above
2. Recheck MA in 2-4 weeks
3. In the absence of underlying disease, monitor for progression of
MA and development of renal failure

Once the Cushing's is controlled you may see these values normalize.


We've been watching her MA for over a year now because it's been elevated. She also was not concentrating her urine and her Specific Gravity was 1.007 with the reference range of 1.015-1.050 which is low. We did not do another urinalysis to check her Specific Gravity or MA this time. Maybe we need to?


This time her Alk Phos is 309. Still high but lower than last time. But now these levels are also off:

GGT 23 (High) Reference Range 1-12
BUN 40 (High) Reference Range 6-31
Creatinine 0.4 (Low) Reference Range 0.5-1.6
BUN/Creatinine Ratio 100 (High) Reference Range 4-27
Tiglyceride 987 (High) Reference Range 29-91

I told her I was concerned about the odor coming from Zoe's mouth. She just had a dental so that's not it. And to just smell her mouth you don't smell anything. It's more if it's a breath coming from down deep, like when she yawns. If forced to describe it I would say it's a metallic smell but that's not exactly right either but closer than anything else I can compare it to. She told me her kidney levels look fine so she's not concerned about kidney failure. But why are they fine when they are not WNL's?

All those abnormal values can be attributed to the Cushing's and improvements may take a while to see. That elevated BUN could be due to dehydration.


And she's continuing to lose even more hair. She's practically bald. We saw our holistic vet yesterday for acupuncture and he's thinking even though we have her cortisol levels managed, we don't have her hormones balanced and he's frustrated and stumped as is our integrative vet. He said he was going to go on VIN to see if an Endocrinologist may have any ideas or suggestions. For the most part Zoe's aggression is better but she just recently had a few days where she was pretty aggressive and even threatened to bite and put teeth on me. She's exhibiting good bite control so far and it happens when either one of the other 2 dogs gets too close to her or brushes up against her when she's sleeping or even a human. I do believe she thinks it's one of the other dogs when it happens and it takes her awhile to calm down when she realizes it's me or my mother. But I worry about her biting my mom especially since her reflexes are slower and she has thin skin and bleeds easily. It makes sense that if her hormones aren't balanced that could be why she's being aggressive at times. I asked my integrative vet if we needed to run another stim test and she really didn't think we did since her numbers were so good in her opinion. Those few days that she was more aggressive we also had to get up in the middle of the night to both pee and for a BM. The one time she again had mucous and diarrhea. So she's still struggling with digestive upset even though I did not give her any chews or anything out of the ordinary. I feel so bad for her and the other 2 because I can't give them the treats and treat toys and chews like they were used to and ask for. How can I give it to them and not to her? :(

Has her thyroid levels been checked recently? Low thyroid can cause aggressiveness in dogs. Maybe having a full thyroid panel may show something???

Hugs, Lori

[Crystal&Zoe]

Her post number of 4.5 ug/dl is great, but her pre number is getting a bit low but can fluctuate throughout the day.



Yep, Sample 1 is the pre number, and her post (Sample 2) is 4.5 ug/dl which is not low when treating with Trilostane.




In a short period of time her post number (40.6 ug/dl) has decreased significantly, which is great, however that post number may still drift downward so just be on the lookout for signs of her cortisol going too low.



Has her thyroid levels been checked recently? Low thyroid can cause aggressiveness in dogs. Maybe having a full thyroid panel may show something???

Hugs, Lori

Ok so what signs do I look for? This has never been brought up with either vet. And what do I do if this happens? The pre number that can fluctuste, can that be contributing to her grouchiness? And isn't her continued hair loss an indication her levels may randomly be too high? I'm getting confused.

And we've run 2-3 thyroid tests now over the past 3+ years. I'll have to look when the last one was but it was within the past 12 months. We sent it to Dr Dodds.

And thank you for explaining things to me. I'm still not sure I truly get it yet. :/

[Harley PoMMom]

Symptoms of cortisol dropping too low are: vomiting, diarrhea, lethargy, inappentance, or Zoe just not acting quite like herself. If any one of these symptoms are seen than stopping the Trilostane is needed. Since Trilostane has a short half life, usually just stopping the medication will perk a dog up, if not, prednisone is given. Prednisone mimics cortisol so the dog's system reacts to it like it would cortisol.

Improvements with the hair generally take months, say around 6 months.

Now, this last stim tests, was it done during that 10-14 day window after starting Zoe on Trilostane?

Hugs, Lori

[Crystal&Zoe]

Symptoms of cortisol dropping too low are: vomiting, diarrhea, lethargy, inappentance, or Zoe just not acting quite like herself. If any one of these symptoms are seen than stopping the Trilostane is needed. Since Trilostane has a short half life, usually just stopping the medication will perk a dog up, if not, prednisone is given. Prednisone mimics cortisol so the dog's system reacts to it like it would cortisol.

Improvements with the hair generally take months, say around 6 months.

Now, this last stim tests, was it done during that 10-14 day window after starting Zoe on Trilostane?

Hugs, Lori

No. This last stim test was done about 3 months after starting her on the Trilostane. I was told as long as we don't see anything truly concerning we could safely go about 6 months before doing another one. Is that not correct? This last stim test was done on Jan. 5, 2015

[Harley PoMMom]

According to Dechra, the makers of Vetoryl, once a optimal dose is achieved, an ACTH stimulation test should be conducted every 3 months.

Trilostane may continue to drop cortisol over a period of time even if the same dose has been given. So, even though Zoe's results are perfect and within the therapeutic range, I would still keep an good eye on her just to make sure those numbers don't continue to fall (the reason for having a stim test done every 3 months).

Now, lets see if I can explain how an ACTH stimulation test works :eek:

The ACTH stimulation test measures how well the adrenal glands respond to adrenocorticotropic hormone (ACTH). ACTH is a hormone produced in the pituitary gland that stimulates the adrenal glands to release a hormone called cortisol. The stimulating agent generally used is Cortrosyn which is a synthetic form of ACTH.

When those adrenal glands get "stimulated" they dump that cortisol into the dog's system, the ACTH stimulation test measures how much of that cortisol was dumped, which is known as the post number.

The pre number is done before the stimulating agent is injected, and is known as the resting/baseline number.

Cortisol is needed for the dog's system, and human, to work properly.

Hopefully I haven't confused you more, if you have any questions please do ask.

Hugs, Lori

[Crystal&Zoe]

According to Dechra, the makers of Vetoryl, once a optimal dose is achieved, an ACTH stimulation test should be conducted every 3 months.

Trilostane may continue to drop cortisol over a period of time even if the same dose has been given. So, even though Zoe's results are perfect and within the therapeutic range, I would still keep an good eye on her just to make sure those numbers don't continue to fall (the reason for having a stim test done every 3 months).

Now, lets see if I can explain how an ACTH stimulation test works :eek:

The ACTH stimulation test measures how well the adrenal glands respond to adrenocorticotropic hormone (ACTH). ACTH is a hormone produced in the pituitary gland that stimulates the adrenal glands to release a hormone called cortisol. The stimulating agent generally used is Cortrosyn which is a synthetic form of ACTH.

When those adrenal glands get "stimulated" they dump that cortisol into the dog's system, the ACTH stimulation test measures how much of that cortisol was dumped, which is known as the post number.

The pre number is done before the stimulating agent is injected, and is known as the resting/baseline number.

Cortisol is needed for the dog's system, and human, to work properly.

Hopefully I haven't confused you more, if you have any questions please do ask.

Hugs, Lori

Ok so in trying to discern the written test results, Time 1 and Time 2 are the times of blood draw, correct? So what time does /19 indicate and is 11:23 simply 11:23 am? And I was correct then in assuming the cortisol Sample 1 was prior to the Cortosyn injection, not right after the Corosyn injection. Correct? And Cortisol Sample was the 2nd blood draw after the correct period of time. And Cortisol Sample 1 is the 'resting' cortisol. Did I get that right?

So what is the time frame from taking the Trilostane to where it peaks? If I give it to her at breakfast and she eats at 7:00 am, when would be the greatest risk of her cortisol level dropping too low?

[Harley PoMMom]

Ok so in trying to discern the written test results, Time 1 and Time 2 are the times of blood draw, correct? So what time does /19 indicate and is 11:23 simply 11:23 am?

I have no idea what that /19 represents, and yes, I think that the 11:23 am is the time that the second draw was done.



And I was correct then in assuming the cortisol Sample 1 was prior to the Cortosyn injection, not right after the Corosyn injection. Correct?

Yes, you're are correct! ;)


And Cortisol Sample was the 2nd blood draw after the correct period of time. And Cortisol Sample 1 is the 'resting' cortisol. Did I get that right?

Yes, on both questions! See, you're getting this, it just takes time to wrap one's head around this dratted disease with all it's protocols! You are doing an excellent job!!


So what is the time frame from taking the Trilostane to where it peaks? If I give it to her at breakfast and she eats at 7:00 am, when would be the greatest risk of her cortisol level dropping too low?

Published literature from Dechra states that Trilostane peaks in the dog's body approx. 1.5 hours after administration and in 12 hours it has left a dog's system. So when giving Zoe's Trilostane at 7am the Trilostane would peak at around 8:30 - 9:00 am.

Here's an excerpt from Dechra's product insert:
In healthy dogs, maximal plasma levels of trilostane occur within 1.5 hours, returning to baseline levels within twelve hours, although large inter-dog variation occurs. There is no accumulation of trilostane or its metabolites over time.

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

Hugs, Lori

[labblab]

According to Dechra's published literature, trilostane typically reaches its maximal effect (lowest cortisol level) approx. 1.5 hours after dosing, and blood levels have returned to baseline after approx. 12 hours. They add the caution that, of course, individual variation can occur. But those are the general parameters for drug efficacy.

Marianne

Whoops, I see Lori and I were typing at the same time -- but she was able to give you a much more complete answer!! ;)

[Crystal&Zoe]

Ok so when Zoe typically has diarrhea, it's in the middle of the night and that would not be because her cortisol levels are dipping too low. But the fact that she tends to be more grouchy in the evenings could be that the Trilostane has completely left her system and her cortisol levels are too high? Or maybe it's just that in the evening is when we are all sitting down to snuggle in front of the tv and the other 2 just get too close. :confused: I'm hesitant to ask about going to twice a day dosing since she does seem to be doing well on most other points and from what you are all saying, it's just plain easier to do once a day dosing. But I do worry that her continuing to lose hair after being on the Trilostane this long (we're in our 4th month now) is indicating that something is not right, that her levels are fluctuation too much. I just worry I'm missing something and not relating everything to the my vets correctly so they can treat appropriately.

Has anyone else had one that continued to lose hair after being on Trilostane and is continually developing hot spots? Or an awful smell coming from deeper, forced breaths? If you all tell me this is just part of this horrid disease, I'll relax. But honestly, it's killing me because I just think how horrible is her existence at this point? To be super grouchy at your other house/dog mates. To continually have an itch you aren't allowed to scratch or lick and have to be in that blasted soft collar more often than not. To continually have digestive upsets where you are having mucousy diarrhea and not be able to have the treats and chews that you love so much and brings you joy. It doesn't sound like much of a life. Sorry. I'm just pretty down tonight for some reason. I can't wrap my head around the fact that even if I do everything right with this, she's always going to be struggling with these issues.

[addy]

My Zoe continued to lose hair and it had a pattern to it too and my IMS said she did not have yeast on her skin and she developed it in her ears despit using a probiotic. A second IMS agreed with me to be proactive and treat her skin. Her hair got worse before it got better and had I not insisted, I don't know where it would have all gone.

Every dog is different and certainly my Zozo had many other issues. But I can clearly say, the Ketoc Chlor flushed out her follicles, which by the way, have a cycle all their own of about three months.

And I faithfully cleaned her ears with an ear wash and wiped them with medicated pads.

Zoe chewed her paws for a very long time, once her cortisol was in the right place for her, she stopped licking and chewing.
We went through the whole allergy thing, the cone, all of it, Benadeyl, foot washes, antibiotic and cortisone spray.

I hope I don't sound like a broken record.

[Harley PoMMom]

I just reread your thread and have a few thoughts. :eek::) Dear Zoe has had to acclimate herself to her new surroundings, and I am betting she still misses your Father's attention. I'm thinking that this could attribute to some of her aggressive/grouchy behavior.

When a dog has untreated Cushing's that excessive cortisol running around in their system is kinda like a high, and when that cortisol is brought down, especially a significant drop, this may also add to a change in a dog's attitude.

Regarding Zoe's hair loss, I'd say wait a full 6 months to see any improvements because the hair follicles have to go through a cycle so they die off and then regrow and that can take a while. We have had some dogs on the forum that when their new hair grew in it was totally a different texture/color.



In terms of test results, I'd be most interested in the diagnostic tests for Cushing's (ACTH and abnormal values on blood/urine panels), all the subsequent monitoring ACTH results, and also abnormal values on any recent blood/urine panels. Has Zoe remained on the 10 mg. of trilostane since beginning treatment?

Marianne

I see that Marianne had posted this earlier in your thread, could you get those ACTH stimulation test results, both the diagnostic and monitoring, and post them here for us.

Zoe's Trilostane is being given with food, right? And the timeline of those ACTH stim tests, they are pretty much the same? What I mean is that each one of the ACTH stim tests were done within the same time-frame...e.g....4 hour post pill and performed at 11 am, something like that?

As for her that breath odor, did this come about when the Trilostane was started? I know when I get a sinus infection my mouth has that metallically taste, dogs can get sinus infections too. When she sneezes does any mucus come out her nose?

[Crystal&Zoe]

My Zoe continued to lose hair and it had a pattern to it too and my IMS said she did not have yeast on her skin and she developed it in her ears despit using a probiotic. A second IMS agreed with me to be proactive and treat her skin. Her hair got worse before it got better and had I not insisted, I don't know where it would have all gone.

Every dog is different and certainly my Zozo had many other issues. But I can clearly say, the Ketoc Chlor flushed out her follicles, which by the way, have a cycle all their own of about three months.

And I faithfully cleaned her ears with an ear wash and wiped them with medicated pads.

Zoe chewed her paws for a very long time, once her cortisol was in the right place for her, she stopped licking and chewing.
We went through the whole allergy thing, the cone, all of it, Benadeyl, foot washes, antibiotic and cortisone spray.

I hope I don't sound like a broken record.

No you don't. I'm just not sure how much to push in this area for more testing when I have 2 vets saying pretty much the same thing and they don't work at the same clinic or even really talk to each other. I've gone through a lot of vets to find ones that I feel comfortable with and will dialogue with me and I just don't want to rock the boat unless I truly feel it's necessary. And others here are saying give it a few more months. So maybe in a couple of months if there are no changes, then I'll push the issue a bit. :o


I just reread your thread and have a few thoughts. :eek::) Dear Zoe has had to acclimate herself to her new surroundings, and I am betting she still misses your Father's attention. I'm thinking that this could attribute to some of her aggressive/grouchy behavior.

When a dog has untreated Cushing's that excessive cortisol running around in their system is kinda like a high, and when that cortisol is brought down, especially a significant drop, this may also add to a change in a dog's attitude.

Regarding Zoe's hair loss, I'd say wait a full 6 months to see any improvements because the hair follicles have to go through a cycle so they die off and then regrow and that can take a while. We have had some dogs on the forum that when their new hair grew in it was totally a different texture/color.




I see that Marianne had posted this earlier in your thread, could you get those ACTH stimulation test results, both the diagnostic and monitoring, and post them here for us.

Zoe's Trilostane is being given with food, right? And the timeline of those ACTH stim tests, they are pretty much the same? What I mean is that each one of the ACTH stim tests were done within the same time-frame...e.g....4 hour post pill and performed at 11 am, something like that?

As for her that breath odor, did this come about when the Trilostane was started? I know when I get a sinus infection my mouth has that metallically taste, dogs can get sinus infections too. When she sneezes does any mucus come out her nose?


Yes her Trilostane is given in the morning at breakfast. The odor has been there now for over a year so it's not new with the Trilostane. I spoke with my integrative vet, Dr. Steph yesterday and a couple of thoughts are, since it's coming from a deep or forced breath and not just her mouth, are possibly GERD, acid reflux or still dealing with some type of digestive upset. She really doesn't sneeze and she doesn't have a runny nose.

Now for my shameful confession... I was seeing another vet back when I first noticed the changes in Zoe. We started with painful back issues that required her to be on Prednisone off and on a few times for just short periods of time. She was getting grouchier at this point and this started early in 2011. She had been diagnosed with IVDD at this time. I typically ask for a full CBC, chem screen and urinalysis once a year at their well exams. I'm looking at the test results in front of me and everything is WNL's with the exception of her Lipase which was just a hair low at 63 IU/L (reference range 77-695). Her AST was at 36 IU/L and her ALT was at 21 IU/L. Both on the low end of the normal range. Her Alk Phos was at 24 IU/L. She was exhibiting more than her normal grouchiness and getting a bit aggressive at that time and we also ran a thyroid test which was sent to the University of Michigan I believe. Her T4 result came back at 1.9 ug/dL (reference range 1.0-4.0). Her BUN was at 14 mg/dL, Creatinine at 1.1 mg/dL and BUN/Creatinine ratio at 13. This on 7/27/11. So we focused on back pain due to her IVDD as the cause of her behavioral changes. Then the very end of October 2011 we sold my house, my parents house and moved in to a place together where I could help them and Zoe's whole world changed. She again had another painful bout with her IVDD and we tried to manage pain with everything short of Prednisone and had to put her back on it again for a short time. It was around that time that she started to lick the kitchen floor and drink large volumes of water, but it was really only when she got over excited or agitated. It wasn't really effecting her potty habits at that time. It was also at that time that I noticed her having trouble getting up on furniture but thought it due to her painful back. Dad passed on 2/15/12 and I took her back to the vet on 2/20/12 and the record notes state I was concerned about her being puffy but no accidents although the vet didn't really see the puffiness I did and thought it due to the Prednisone and the excessive water drinking and licking the floor due to stress/anxiety due to the move and the death of my dad. I see now in the notes I mentioned I was also concerned with her thinning hair. I asked for a urinalysis on 4/23/12 and it showed specific gravity at 1.012 g/dL, ph at 5.5 negative on glucose, bilirubin, ketones, blood and protein. After no noticeable changes or improvement, I felt I needed to try something else to help with Zoe's pain since she wasn't improving so I sought out the help of a holistic veterinarian who only does complimentary therapy/medicine to go along with what the regular vet is doing. He (Dr. Dan) specializes in acupuncture, chiropractic, TCHVM and Western Holistic medicine. He noticed right away that Zoe's sacrum was out and that she had hair thinning when he was doing acupuncture. So he recommended she be tested for Cushings. Her grouchiness did improve some after he worked on her back and sacrum. So I went back to my regular vet and I guess by my going to see Dr. Dan put her nose out of joint because she was very different with me after this. She told me that she did not have cushings and so instead she ran another CBC and Chem Screen on 12/6/12 as well as another Thyroid test. Her thyroid test came back at 1.4 ug/dL. Her Platelet Count was slightly high at 500 10^3/uL, her ALk Phos was high at 303 IU/L (reference range 5-131), and her GGT was high at 18 IU/L (reference range 1-12). Everything else was WNL's. We first ran the Urine/Creatinine test and it came back positive. So next she ran the Low Dose Dex Suppression test and it came back indicating that she had pituitary cushings. Normally I ask for copies of all test results and blood work but I was really not myself for almost a full year after the move and death of my dad and I wasn't thinking clearly. I never asked for it and thought it had been sent to my holistic vet. I found out later that she would never send him copies even after multiple requests. She also never sent them to me when I requested them on several occasions later on. The relationship there became so strained it was uncomfortable and I felt she was not helping any of my dogs at this point. So for awhile Dr. Dan was our only vet as I tried several others until I finally found our current integrative vet, Dr. Steph. Once we found Dr. Steph, she somehow managed to get copies of the Low Dose Dex Test and Urine /Creatinine Test and sent copies to Dr. Dan as well. As I'm going through all my copies I see I still don't have copies of those 2 tests so I need to get them if you all need to see those numbers. We started to see Dr. Steph in Dec. of 2013 and love her! So for that year when we were only seeing Dr. Dan, he treated her with TCHVM and Western herbal medicine and acupuncture as if she had cushings but truly felt he was dealing more with a dog who was under extreme stress and due to her personality/temperament her body couldn't determine bad stress from good stress. So he was supporting her adrenal system. And her hair came back in nicely, she had a nice shape again and her grouchiness was better. Although she's always been a grouchy girl. What I found comforting is that both Dr. Steph and Dr. Dan kept saying the same thing about Zoe without ever talking to each other. They both found it hard to believe she truly had cushings given her body condition. The only thing was she still would lick the kitchen floor for a good 30 minutes before and after eating and would drink large volumes of water when excited about something or stressed about something. We talked about running the Stim test but neither seemed to indicate to me that it was something that had to be done since she was responding so well and doing so well. And....my business was not doing well and money is tight. I had spent so much already I guess I chose not to question. It wasn't until someone new on the FB group mentioned the Chinese Herbal supplements their holistic vet was using that was completely different than what Zoe had been on that I began to understand. I asked Dr. Dan about them and he told me that the TCHM's the other vet was using were not to actually treat cushings but to manage symptoms. So in his opinion, that dog was not truly being managed for cushings but only the symptoms. Now I see that we won't know if that was also the case for Zoe since I didn't pursue the Stim test. (I know that according to this group you can't manage cushings holistically. I really wish I had done the Stim tests now to find out.) So with Dr. Steph we did a CBC on 12/27/13 and the only values that were not WNL's were her Alk Phos at 320 and GGT at 16. No real change from the year prior. Her BUN/Creatinie ratio was at 30 and platelet count at 428. Her urinalysis was a bit different though with protein in her urine at 1+, Occult Blood said Trace (high) Negative, and MA was high at 8.2. I know we retested her MA a few weeks later but I see now that I don't have those results. On 2/7/14 we did another urinalysis and her PH was high at 8.5, Protein was high at 2+ Negative and MA at 7.3. The specific gravity was 1.038. She was again getting grouchier and we sent another thyroid panel to Dr. Dodds on 2/25/14 and it came back T4 at 1.41, Free T4 at 1.36, T4/FT4 at 1.04, T3 at 15.2, Free T3 at 1.6, TgAA at 2 Negative. I see a note from Dr. Richter that her thyroid levels are normal overall here although T3 could be higher. Recommend annual retesting. So it's time to retest. So the rest you already know from our introduction. All of a sudden Zoe started to lose hair again and get her pot belly again and her skin for the first time started to look like cushings skin, paper thin and dry and flakey. It was around this time we were struggling with her needing to pee more, having accidents and her drinking really increased. She was now drinking around 16 oz of water a day and she's a 9 lb dog eating a raw diet rich with moisture. We did a urinalysis on 6/14/14 and her Specific Gravity was 1.005 and her MA was 2.1 mg/dL. On 6/23/14 we did another urinalysis and is also when we did the first Stim Test as well as another CBC and chem panel. Her specific gravity was 1.007 and MA was at 5.3 mg/dL. Alk Phos was at 483 IU/L (a little higher than in the past couple of years). Her GGT came down to the normal range at 6 IU/L. For her first Stim Test Cortisol Sample 1 was 7.6 ug/dL and Cortisol Sample 2 was at 40.6 ug/dL. I had decided to put her on Trilostane at that point as encouraged by both Dr. Dan and Dr. Steph but got scared while reading some pretty scary and adverse effects by others in a different group. So we waited another couple of months while trying to tweak her holistic meds. But it became evident we were not managing anything anymore and we put her on the Trilostane. I closed my store the end of 2014 and Dr. Steph told me it was ok to not do the post Stim test. She has another Maltese the same size as Zoe she's been treating with Trilostane for a year now and she felt fairly comfortable not doing it. Had I been on the forum earlier, I would have told her not to worry about trying to help save me money and had it done. Thankfully nothing bad happened but I'm horribly ashamed and feel terrible that I did not do this correctly. I'm not laying blame on anyone. Both my vets were trying to be sensitive to my current circumstances and I didn't fully understand the risks. So now my shameful secret is out. Hopefully this will help any in the future going through something similar and for those with the experience and expertise to see if we are still missing something. Her second Stim test and Chem screen was done on 1/6/15. Her Alk Phos is at 309, lower than the previous one but still high. Her BUN is at 40, a huge jump but for some reason my vet does not seem concerned. Creatinine at 0.4 mg/dL (low). BUN/Creatinine Ratio at 100 (again a pretty big jump from the last one). And her Triglyceride is at 987 with the reference range of 29-291.

[labblab]

Oh Crystal, I am so sorry if you felt worried over telling us about Zoe's testing history. It is abundantly clear how much you love her and how hard you have been working to help her feel better. You have had so many things to deal with in your own life, on top of taking care of her. In a perfect world, we would all have the means and ability to pay for a whole host of tests and treatments and consultations. But our world is far from perfect, and we each do the best we can with what we are able to do at any given moment. There is no shame in that whatsoever. So we will just work on figuring out the best path forward that is possible and available -- recognizing that it won't be perfect, either. But we can try to maximize the value you get for the money spent, and it will be a plan we can work on together!

I will come back again later on this weekend to read back through Zoe's history and lab values, just to see if there's anything I can think of to add. But one thing I can confirm for you right now is what Lori said about hair/coat issues in the first months after starting trilostane. Dogs can end up virtually shedding their coats in chunks once the normal hair growth cycle resumes. That's what happened to my Lab -- I absolutely freaked when huge chunks of his fur started coming out after we started trilostane, because he didn't have much left to spare at that point! But the difference this time around is that when I looked closely, I saw that there was new little fuzz growing in where the chunks had pulled out. Prior to treatment, the skin is his bald areas was smooth and naked :o. He did end up growing back a lovely coat down the road. :)

Marianne

[Harley PoMMom]

Sweety, you have no reason to feel any shame, we completely understand the financial strain that this dratted disease puts on us. You are doing a wonderful job with Zoe, and your love for and devotion to Zoe is so very obvious.

Now, I do forget exactly what Zoe weighs but I am assuming she is a little girl, say around 15-20 lbs? Well, anyways, there is a cost saving method for those very pricey ACTH stimulation tests, and here is an excerpt from an article:
How to Extend Your Supply of Cortrosyn and Lower the Cost of ACTH Stimulation Testing

Cortrosyn is expensive. And once reconstituted, it has a limited shelf-life.

However, by following the protocol outlined below, you can easily dilute, aliquot and store Cortrosyn after reconstitution for up to 6 months. This makes each ACTH stimulation test much less expensive, because each vial of Cortrosyn can be used to perform as many as five ACTH stimulation tests.

Cortrosyn is supplied in vials each containing 0.25 mg (250 μg) of synthetic ACTH (cosyntropin) in powder form. Because the dose of Cortrosyn used to perform an ACTH stimulation test is only 5 μg/kg, small to medium sized dogs require only a fraction of the ACTH contained in each vial.



The full article can be found here:http://endocrinevet.blogspot.com/2011/03/how-to-extend-your-supply-of-cortrosyn.html

You can print that out and ask the vet about having this done.

[Crystal&Zoe]

Oh Crystal, I am so sorry if you felt worried over telling us about Zoe's testing history. It is abundantly clear how much you love her and how hard you have been working to help her feel better. You have had so many things to deal with in your own life, on top of taking care of her. In a perfect world, we would all have the means and ability to pay for a whole host of tests and treatments and consultations. But our world is far from perfect, and we each do the best we can with what we are able to do at any given moment. There is no shame in that whatsoever. So we will just work on figuring out the best path forward that is possible and available -- recognizing that it won't be perfect, either. But we can try to maximize the value you get for the money spent, and it will be a plan we can work on together!

I will come back again later on this weekend to read back through Zoe's history and lab values, just to see if there's anything I can think of to add. But one thing I can confirm for you right now is what Lori said about hair/coat issues in the first months after starting trilostane. Dogs can end up virtually shedding their coats in chunks once the normal hair growth cycle resumes. That's what happened to my Lab -- I absolutely freaked when huge chunks of his fur started coming out after we started trilostane, because he didn't have much left to spare at that point! But the difference this time around is that when I looked closely, I saw that there was new little fuzz growing in where the chunks had pulled out. Prior to treatment, the skin is his bald areas was smooth and naked :o. He did end up growing back a lovely coat down the road. :)

Marianne


Sweety, you have no reason to feel any shame, we completely understand the financial strain that this dratted disease puts on us. You are doing a wonderful job with Zoe, and your love for and devotion to Zoe is so very obvious.

Now, I do forget exactly what Zoe weighs but I am assuming she is a little girl, say around 15-20 lbs? Well, anyways, there is a cost saving method for those very pricey ACTH stimulation tests, and here is an excerpt from an article:


The full article can be found here:http://endocrinevet.blogspot.com/2011/03/how-to-extend-your-supply-of-cortrosyn.html

You can print that out and ask the vet about having this done.

Thank you both for being so very kind and tactful. It is much appreciated. I've held in those guilt and shameful feelings for a very long time now. If you only knew the history I've had with traditional vets over the past 16 years, you would know why I tend to lean towards integrative and holistic medicine. I'm not opposed to traditional medicine at all but it has failed me and my fluffs at every turn and even caused some health issues. I live in a small town and am traveling about 2 hours to see Dr. Dan and almost an hour to see Dr. Steph. I felt a huge weight was lifted off me when I finally found Dr. Dan because up until that point I felt like I had to be my own crews vet when it came to looking at test results and knowing what tests to ask for. Zoe was the first reported case of Lepto at the vet clinic we were at when she was 3 years old. I was told she was not a sick dog and I was just an overly worried mommy. I had to say, "Do I not have the right to ask for a full blood work up? If not, I'll go someplace else". They sure were sheepish when they had to tell me that her ALT and AST were of the chart scary high. And that's just the tip of the iceberg. So I'm grateful for any and all help and I'm overly cautious not to rock the boat with either vet I have now because I trust them both and really think highly of them. And because I've tried all the others in a 2 hour radius. :(

Oh, and Zoe is larger than the breed standard for a Maltese. She's right around 9 lbs. Jett is my middle on and he's 5 1/2 lbs and Callie, my youngest is a few ounces over 4 lbs. Not that you need to know that. :o

[addy]

Crystal, I am so sorry for everything you have gone through and you really have nothing to feel ashamed about. We all do the best we can with everything going on in our lives.

I don't mean to push you and certainly things may change and you can of course give Zoe more time. If I sound like a broken record it is because my dog's groomer finally pushed me to treat her skin after the thousands of dollars I spent on hearing bla, bla, bla from the so called specialists we saw.

That and another forum member who had a little shi tzsu with bad allergies guided me a bit as well.

Always do what your gut tells you to:)

Hugs

[apollo6]

Dear Crystal, I only know to well what you are going through. My Apollo was also on Trilostane . He was on such a low dosage, because he would get sick every time we would increase it. I did holistic also,
but my holistic vet finally said Apollo needed to be tested for Cushing's. He lived to be one month short of 14. Like you,no children,Apollo was my baby. I had bad experiences also with specialists,dermatologists. Like Addy said, listen to your gut. You know Zoe more than anyone else does. I always got copies of every test, every blood panel and asked questions, took notes, started a folder on Apollo ,noted each visit and what was said, compared each blood test with previous one. If she is still on Trilostane and still has not improved with hair growth, that is not normal. The skin infections are due to a weakened immune system. I also did supplements,herbs to help Apollo. But I always checked with the vet and forum for advice and input. We are here to help and guide you. I would check and research every drug Apollo was put on. I emailed Dechra (forgot spelling - company producing Vetroyl-Trilostane) these drugs are very strong and can be very potent. I fought putting Apollo on Trilostane.
It is a difficult disease to deal with. Remember you and Zoe are a team. Each case and each dog is unique, what works for one may not work for another.

Hugs Sonja and Angel Apollo

[Crystal&Zoe]

Thank you Sonja and Addy. I really need to get outside of myself a bit and see if perhaps I may be able to contribute to others as you all are for me and Zoe. I recognize that so far I've been really lucky with Zoe and technically she's doing very well as far as body condition.

So a couple of months ago Zoe developed a hot spot on her hip where a wart had developed. After having her in a soft collar for almost the entire time, it became apparent she was not going to leave it alone and we removed the wart hoping that she was simply picking on the wart. It didn't help and got worse. Finally I tried organic cold pressed coconut oil and that worked almost like a miracle. And blessedly she left it alone once it healed. Now last month she developed another hot spot on her vulva. Coconut oil helps but doesn't ever completely heal it. I'm guessing it's simply keeping it too moist in the area that it is to really heal. I'm going to try some diaper rash cream I think even though I hate the thought of her licking it. She'll be in the collar for the most part but I do give her a break a little bit at meal times. But now I'm wondering, does her vulva look maybe a bit swollen? Could this be a side effect of the Trilostane? I never thought about it being swollen or a side effect but now I'm wondering. Hope it's ok to post pics of my girls private parts.

This was taken last month.

http://www.k9cushings.com/forum/picture.php?albumid=974&pictureid=7487


I took this today.

http://www.k9cushings.com/forum/picture.php?albumid=974&pictureid=7488


btw...when will I be able to post pics directly into my posts?

[addy]

Hi Crystal-

Renee just went through some similar problems that were just discussed and linked to Triolstane. Here is the link to her thread:

http://www.k9cushings.com/forum/showthread.php?t=5908&page=52


Also,my girl had some problems as well with her vulva which ended up being a growth we had to have removed.

You are doing just fine!!!:):):)

[ShibaMom]

Regarding diaper rash type ointment, the other day at the vet's office, I saw a poster that was suggesting sunscreen for dogs in harsh sun, but cautioned against ones with zinc oxide.

Since I recently put some diaper rash ointment on Zanya's vulva for irritation from UTI, I was particularly curious.

Here's an excerpt from an article:

"Zinc oxide ointments are irritating to the GI mucosa, but absorption of zinc from the GI tract is poor. As a result, dogs and cats often vomit and self-decontaminate, decreasing the risk of systemic toxicosis. Prolonged or repeated exposure to zinc oxide ointments, such as when an owner applies zinc oxide topically and the animal repeatedly licks the ointment off its skin, may lead to systemic zinc toxicosis.
The other ingredients in zinc oxide ointments, such as cod liver oil, petrolatum, and mineral oil, result in a laxative effect but do not cause systemic toxicosis. Occasionally, some dogs will develop facial swelling and hives after ingesting zinc oxide ointments. The cause of this hypersensitivity reaction is not clear, but it is speculated to be from the parabens that are used as preservatives in these products."

From http://veterinarymedicine.dvm360.com/toxicology-case-how-help-dog-owners-manage-zinc-oxide-toxicosis?id=&sk=&date=&pageID=2

From vetstream:
"Zinc oxide ointment may be toxic if regularly applied to and licked off the skin or if a dog chews on a tube of ointment. Severe toxicity is unlikely from single acute exposures to such ointments."
https://www.vetstream.com/canis/Content/Disease/dis02959

At least that's good to know, for if applied once or twice. For me, I think I'll play it safe and not use it. To each their own call, of course!

Regards,
Samantha

[Crystal&Zoe]

Regarding diaper rash type ointment, the other day at the vet's office, I saw a poster that was suggesting sunscreen for dogs in harsh sun, but cautioned against ones with zinc oxide.

Since I recently put some diaper rash ointment on Zanya's vulva for irritation from UTI, I was particularly curious.

Here's an excerpt from an article:

"Zinc oxide ointments are irritating to the GI mucosa, but absorption of zinc from the GI tract is poor. As a result, dogs and cats often vomit and self-decontaminate, decreasing the risk of systemic toxicosis. Prolonged or repeated exposure to zinc oxide ointments, such as when an owner applies zinc oxide topically and the animal repeatedly licks the ointment off its skin, may lead to systemic zinc toxicosis.
The other ingredients in zinc oxide ointments, such as cod liver oil, petrolatum, and mineral oil, result in a laxative effect but do not cause systemic toxicosis. Occasionally, some dogs will develop facial swelling and hives after ingesting zinc oxide ointments. The cause of this hypersensitivity reaction is not clear, but it is speculated to be from the parabens that are used as preservatives in these products."

From http://veterinarymedicine.dvm360.com/toxicology-case-how-help-dog-owners-manage-zinc-oxide-toxicosis?id=&sk=&date=&pageID=2

From vetstream:
"Zinc oxide ointment may be toxic if regularly applied to and licked off the skin or if a dog chews on a tube of ointment. Severe toxicity is unlikely from single acute exposures to such ointments."
https://www.vetstream.com/canis/Content/Disease/dis02959

At least that's good to know, for if applied once or twice. For me, I think I'll play it safe and not use it. To each their own call, of course!

Regards,
Samantha

EEEEGADS! Thank you for sharing this! I was not comfortable with the diaper rash ointment but it was Dr. Steph's suggestion. Well I applied it for the first time tonight. She's not licked it because I did purchase some cute little diaper skirts when she was having potty accidents. But I won't be applying it again. Back to the drawing board. *sigh*

[kaibosmom]

Hi. I just read the last few posts but I've been reading all weekend about Cushing's. I did come across something about this. If I can find it I'll post the link. Sorry, I skipped over that part...my dog is a boy!

[ShibaMom]

I'm sure Zoe will be fine - as both articles said, unlikely from a single acute exposure. I know Zanya licked at it when I put it on her recently. I'm sure glad I saw that poster! Synchronicity!

Also, the issues really are through the GI tract, so being on her skin itself shouldn't have any negative effect. :)

Medicine, be it veterinary or human, really is an art. No one can know everything, and everyone makes mistakes. Good docs learn from the information others' have!

You're doing a fabulous job with Zoe, she's so lucky to have you as her mama. Keep up the great work :)

[Crystal&Zoe]

Early this morning I left all 3 of mine in bed while I got up to go to the bathroom. And all he$$ broke lose. Zoe gets very growly and snappy and aggressive at times when one of the other 2 get too close and I'm sure that's what happened. I know it's confusing to Jett and Callie because at times it's ok with Zoe if they are close or even touching her. But not at others. And I'm sure her body language is hard to read with her diminishing eye site and and back issues. But it's getting bad enough that I no longer feel it's safe to leave them home alone or even have all 3 in bed with me at night. So Zoe will have to go in an expen at night and when no one is home. I hate doing this but I really have no other option. Today could have been bad had I not been there. Looking over her records the other day I noticed I've been mentioning her progressing aggression now since 2010. I know she did not come from a reputable breeder and her temperament is not sound. Never has been. That's genetic. Makes me soooooo angry at people who don't know anything about genetic screening and temperament testing irresponsibly breeding. But it's getting worse. I've sent an email to Dr. Steph asking for another Thyroid check. I have a video I took of her laying next to me this morning and I'm just ever so lightly stroking her and she's growling and lip curling. Tried to load it to an album here but this forum won't load a video I guess. I sent a copy of the video to Dr. Dan and asked him what he would do if this were happening in his house and his response was, he really didn't know what he would do. I also sent a copy to my friend who is a positive reinforcement trainer through Karen Pryor Academy and studied behavior under Dr. Leuscher when he was at Purdue. She says this is serious and has been telling me it's serious for some time. I chose to think she's being overly cautious. I told my mother not to hold all 3 of them any longer when she's in her chair and she flat out refuses. It's no longer 'she might get bit'; it's only a matter of time. I don't think our state law requires a doctor to report a dog bite if it's the person's own dog but I'm looking into it. She is not utd on rabies due to her health conditions. I'm just feeling very frustrated at this point. I don't know what to do to help my girl and am afraid the responsible thing is something I don't want to or even can do. Has anyone else had a dog whose aggression continued to get worse even when the cortisol levels were being managed?

[Harley PoMMom]

One of members, Saskia, is a certified dog behavioral trainer, if you would like, I could PM her and ask if she would have any advice for Zoe?

Hugs, Lori

[Crystal&Zoe]

One of members, Saskia, is a certified dog behavioral trainer, if you would like, I could PM her and ask if she would have any advice for Zoe?

Hugs, Lori

I guess it doesn't hurt at all to get another perspective on this. Maybe my friend is too close to the situation. Is Saskia a certified positive reinforcement trainer through Karen Pryor too? I really won't take advice from someone who does not train according to what scientific data has shown from veterinary behaviorists. Sorry if that makes me seem snobbish but I've seen too many dogs develop something called conflict aggression when owners were using both positive and correctional forms of training. :(

But to be honest, I don't think it has anything to do with training at this point because she's reacting when neither dog has done anything to provoke it. No eye contact. Body language was non-threatening. Bodies are at an angle. Nothing to resource guard. She's done it to me when I just brush up against her. I can't help but think it has to do with pain or something medical and we are just missing it.

[judymaggie]

Just to throw this out there -- my last beagle, Maggie, had very severe sleep aggression. She shared a bed with me and, after incurring a bite when I accidentally bumped her during the night, her vet recommended a trial with prozac. I saw remarkable improvement and she seemed a lot more comfortable all around. I used generic prozac, not Reconcile.

Also, not sure where you live, but here in Florida, a dog bite must be reported to the authorities regardless of who gets bit. My Abbie chomped down on my finger when I was trying to get a large dead frog out of her mouth. I ended up with blood poisoning and Abbie got a rap sheet! :eek:

[Crystal&Zoe]

Just to throw this out there -- my last beagle, Maggie, had very severe sleep aggression. She shared a bed with me and, after incurring a bite when I accidentally bumped her during the night, her vet recommended a trial with prozac. I saw remarkable improvement and she seemed a lot more comfortable all around. I used generic prozac, not Reconcile.

Also, not sure where you live, but here in Florida, a dog bite must be reported to the authorities regardless of who gets bit. My Abbie chomped down on my finger when I was trying to get a large dead frog out of her mouth. I ended up with blood poisoning and Abbie got a rap sheet! :eek:

Not at all opposed to medication. Never once thought of something like prozac to help. I'll bring it up to Dr. Steph. Thank you!

Poor Abbie having a rap sheet. lol

[Squirt's Mom]

You can learn about our Sas all on your own ;) -

http://www.k9cushings.com/forum/showthread.php?t=6049

http://www.k9cushings.com/forum/showthread.php?t=3827&highlight=yunah

http://www.k9cushings.com/forum/showthread.php?t=570&highlight=yunah

[Crystal&Zoe]

You can learn about our Sas all on your own ;) -

http://www.k9cushings.com/forum/showthread.php?t=6049

http://www.k9cushings.com/forum/showthread.php?t=3827&highlight=yunah

http://www.k9cushings.com/forum/showthread.php?t=570&highlight=yunah

Thanks! I really apologize if I come across too guarded on behavioral and training issues. I've failed her the first couple of years I had her and am kind of sensitive I guess. :o

[Harley PoMMom]

Saskia is from the Netherlands, and she has a medical disorder known as Ehlers-Danlos. This requires the need for her to have a service dog which she trained to do many, many amazing tasks.

I see that Leslie was so kind to provide with links to Saskia's threads, Saskia has made videos of her dogs in training which she has posted in her threads.

[Crystal&Zoe]

Feels like I'm crash studying here. So I was wondering if perhaps twice dosing might keep her cortisol levels more consistent and that when she's super grouchy and aggressive is when her cortisol levels are too high. Although this morning when I videoed her growling at me it was approx. 2 hours after I gave her the Trilostane with breakfast. I was texting Dr. Dan and he told me attitude doesn't change based on the level of cortisol during the day. It's based on the overall balance of cortisol over a period of time. Have you all found that to be the case?

[addy]

It might be something else bothering her, something hurting. It could be if her cortisol is lower, some other pain that she was self medicating with higher cortisol is bothering her. Or if her cortisol is too high, she just feels crabby with all that cortisol.

It is sometime hard to tell. My own pup would turn into Zoe Kujo.:rolleyes:

Sometimes, multiple events push them past their bite threshold. Sometimes if only event 'a' happened and was not followed by event 'b' and 'c', they would be ok. Sometimes those events can be from the preceding day.

Not much help, I know:o

[apollo6]

Dear Cathy
Trilostane can increase sexhormones. It did for Apollo. It has been so long,I can not remember any aggression. What concerns is the dosage and how Zoe is feeling. I will try to get the website for Dechra and University of Tennessee on Cushing for you. But for now as Addy would often tell me when I was so frantic and frazzled, but Cushing in the drawer for a day and recope.
Hugs Sonja

[molly muffin]

Have you tried melatonin with Zoe? That might calm her down some too.

[Crystal&Zoe]

It might be something else bothering her, something hurting. It could be if her cortisol is lower, some other pain that she was self medicating with higher cortisol is bothering her. Or if her cortisol is too high, she just feels crabby with all that cortisol.

It is sometime hard to tell. My own pup would turn into Zoe Kujo.:rolleyes:

Sometimes, multiple events push them past their bite threshold. Sometimes if only event 'a' happened and was not followed by event 'b' and 'c', they would be ok. Sometimes those events can be from the preceding day.

Not much help, I know:o

I'm glad to know my Zoe is not the only one to be this way at times. And a good thought that perhaps now that her cortisol level is lower, perhaps her pain has increased with her back or some other area. I had been using a boswellia and curcumin blend for inflammation and a poppy/skull cap blend for nerve pain but stopped all meds after her week long digestive upset and never put her back on since she seemed ok. But that was right before we started her on Trilostane. Excellent thought! I so love help in trying to brainstorm figure things out. Thank you!


Dear Cathy
Trilostane can increase sexhormones. It did for Apollo. It has been so long,I can not remember any aggression. What concerns is the dosage and how Zoe is feeling. I will try to get the website for Dechra and University of Tennessee on Cushing for you. But for now as Addy would often tell me when I was so frantic and frazzled, but Cushing in the drawer for a day and recope.
Hugs Sonja

Interesting thought! Dr. Dan did say he felt we did not have her hormones balanced yet. And of course that could make her aggressive. I would really appreciate the link if you can find it. I'll look too. Thank you! I'm feeling a glimmer of hope. :)



Have you tried melatonin with Zoe? That might calm her down some too.

Yep. 3 mg twice a day. Can't imagine what she'd be like without it. Good thought though. Thank you'

[Crystal&Zoe]

Ok really stupid question but the more I'm reading the more questions I have. Is there a difference between sex hormones and adrenal hormones and cortisol which is a steroid hormone? When Dr. Dan was telling me he didn't think we had Zoe's hormones balanced yet I was thinking sex hormones. I guess I just think of cortisol as a steroid and not a hormone, even though it is. And now I just read in another post about adrenal hormones. My goodness are there a huge amount of different hormones?

[Harley PoMMom]

There are no stupid questions, so please do feel free to ask all you want, ok?

Oh those adrenal sex hormones, which are: 17-hydroxyprogesterone, estradiol, androstenedione, progesterone and aldosterone. If a dog's cortisol is high, than generally, the other steriod hormones are elevated also.

Now, estradiol can be produced outside the adrenals, like fat cells, hair follicles and the liver.

[Crystal&Zoe]

There are no stupid questions, so please do feel free to ask all you want, ok?

Oh those adrenal sex hormones, which are: 17-hydroxyprogesterone, estradiol, androstenedione, progesterone and aldosterone. If a dog's cortisol is high, than generally, the other steriod hormones are elevated also.

Now, estradiol can be produced outside the adrenals, like fat cells, hair follicles and the liver.

Thank you. I think I'm beginning to understand some things but the more I understand the more questions I have. I feel like I'm not smart enough to understand the various studies and articles I'm reading. Zoe was spayed at 6 months. So my understanding is there should be very little to no sex hormones, right? And I thought that adrenal hormones and sex hormones are different. At least that is what my vet just emailed me. But bless you, you are naming them! How you can do that is mind blowing as again, I'm not smart enough to understand this blasted disease. But in everything I'm reading, increased aggression is not mentioned once in connection to hormonal imbalance. I thought I was on to something when reading about hormone related skin disorders when it mentioned baldness, blackheads, and excessive wax along with inflammation of the outer ear (although Zoe does not have the inflammation), and abnormal skin or shape of nipples, mammary glands, vulva, prepuce (foreskin of the penis or clitoris), testicles, ovaries and prostate gland. But then the further I read I realized that this can't be Zoe since she's spayed. So back to my vet's email, she said testing the hormone levels would be moot since she's been spayed.

So now my questions are:

1. Can she have elevated or decreased sex hormones if she's spayed causing aggression?

2. Can she have elevated or decreased adrenal hormones if her cortisol level is in the normal range?

3. Can elevated or decreased hormones be the cause of her aggression and what tests should be run?

I'm not hearing anything from Dr. Dan and Dr. Steph really didn't answer these questions. Although she had patients to attend to and said she would reply later this evening with more info.

[labblab]

I am going to give you a link to a Dogaware article that gives you a good explanation as to the functioning of the adrenal glands and the hormones they produce. Here is a short answer to some of your questions, though. The ovaries and testicles are typicslly responsible for producing the majority of what we think of as sex hormones: estrogen and testosterone. However, the adrenal glands also contribute to the sex hormone "pool":


The third type of hormones originating from the adrenal cortex are the adrenal sex hormones. Secreted in relatively small amounts by the zona reticularis (inner zone of the adrenal cortex), these include progesterone, estrogens, and androgens. The effect of the adrenal sex hormones is usually masked by the hormones from the testes and ovaries, but may take on more significance in the spayed or neutered animal.

When the adrenal glands are prodded to overproduce cortisol (conventional Cushing's), they typically overproduce some/all of these other adrenal hormones, as well. In some dogs, cortisol levels may be normal at the same time the other adrenal hormones are elevated ("Atypical Cushing's"). Whether and how the elevations in these other hormones contribute to problems separately from the elevated cortisol is a question that is still under study.

Here's the link to the article:

http://www.whole-dog-journal.com/issues/9_7/features/Canine_Adrenal_Glands_15824-1.html

Marianne

[Spencersmom]

Being so inexperienced in all this....i don't want to over step anyone here, my thoughts are purely just that....thoughts!!

Regarding back pain....and please everyone help me out here! My one Chi had horrible back issues that we ended up maintaining with a handfull of meds every day. One of which was Gabepantin. Is this and option for cushpups with back problems?

Also, regarding MRI to diagnose brain lesions....when I took Spencer to the neurologist, that was an option given me. My question was this...if I have it done, then what? Answer was they could do radiation on the brain lesions....all at a tremendous cost with no guarantee! I was not able to do MRI or radiation. This is something you have to consider. Not everyone has an endless wallet or limitless resources for care!

Not all cushpups exibit classic symptoms! Spencer was never the norm!

Not sure if anything I have to offer is worthwhile compared to the more experienced ones here, but hope in some way to at least give thought!

[apollo6]

Dear Cathy below is the link to Dechra-manufacturer of Trilostane, on the top is a contact us link, you can email with questions.
http://www.dechra-us.com/Default.aspx?ID=38&pcatid=PRIMARY4&catid=PROPGRP14&fid=PROPFIELD107&ProductID=PROD123
also from the old forum
on this address, click on the article , gives info
http://www.caninecushings.net/forums/showthread.php?p=97135#post97135
The Universtaty of Tennesse no longer provides the info I was looking for. The site Marianne from Dogaware is a very good article.
I don't want to give you information overload.
Breath. It cam be pretty overwhelming.
Hugs Sonja and Angel Apollo

[Harley PoMMom]

Being so inexperienced in all this....i don't want to over step anyone here, my thoughts are purely just that....thoughts!!

Your thoughts/opinions are always welcomed here, that is one of the many wonderful things that the forum does, it provides us all with different opinions, experiences, knowledge, and thoughts.


Regarding back pain....and please everyone help me out here! My one Chi had horrible back issues that we ended up maintaining with a handfull of meds every day. One of which was Gabepantin. Is this and option for cushpups with back problems?


I just did a quick search, Gabapentin may cause hepatotoxicity, and in dogs with Cushing's their liver is already over worked, however, when a dog is in pain there has to be relief from that pain, and there are side effects with all drugs, and we have to do what is best for our furbaby.

[Crystal&Zoe]

I just got off the phone with our holistic vet, Dr Dan. He was shocked at how many cases on VIN there were of Cushing's dogs still showing symptoms even though their cortisol levels were being shown as managed. He said he spoke with an internist who recommended trilostane dosing bid and in some cases tid. Basically, in Zoe's case, her cortisol levels are not truly being managed throughout the course of the day is what he is thinking now. Far different then what he was telling me earlier. It was also recommended to retest her thyroid and for some reason they go hand in hand. We were already planning on doing that. She is currently on 10 mg once a day. He's recommending 10 mg bid. When I was discussing twice a day dosing with Dr. Steph, she was thinking 10 mg in the am and 5 mg in the pm. I haven't talked to Dr. Steph yet to tell her what Dr. Dan has found and she's the one to give the Rx. Any thoughts?

[Harley PoMMom]

The increased drinking/urinating, have these symptoms normalized?

[labblab]

Crystal, if you do opt to switch to twice daily dosing, you would not increase Zoe's daily total, you would instead split the total into two smaller doses. Since her January monitoring ACTH was right on target within the desired therapeutic range (1.5, 4.5), you would not increase the daily total at this point. Here's the official recommendation from Dechra:


Once daily administration is recommended. However, if clinical signs are not controlled for the full day, twice daily dosing may be needed. To switch from a once daily dose to a twice daily dose, the total daily dose should be divided into 2 portions given 12 hours apart. It is not necessary for the portions to be equal. If applicable, the larger dose should be administered in the morning.

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

This actually marks a departure for Dechra, since in earlier years they suggested that the daily total be increased a bit when making the change. However, we have been told by at least one noted endocrinologist that dogs dosed twice daily run a greater risk of having their cortisol drop too low. Coupled with some newer studies that have shown that dogs dosed twice daily actually often end up requiring a smaller daily total than dogs dosed once daily, it seems to me this is all further substantiation for Dechra's newer recommendation that the daily total not be increased if you decide to make the dosing switch. Your vets may not be aware of this change, so it may help if you print out that Product Insert to share with them if you do not already have a copy inside your Vetoryl box.

To expand on Lori's question, are you noticing an evening rebound in any issues other than the grouchiness? If not, I am still not convinced that cortisol is the problem there. You can certainly try a dosing shift to see if that helps, but it does make your life a bit more inconvenient since both doses of trilostane need to be given with a meal at 12-hour intervals. Plus, you will now need to shift to a compounded product since Vetoryl comes in capsules no smaller than 10 mg. Many of our members do use compounded trilo, so it is certainly do-able, but it will be a shift for you.

Marianne

[Crystal&Zoe]

The increased drinking/urinating, have these symptoms normalized?

She is drinking more normally but does drink more than my other two. Urinating frequency some days is back to normal but others she does ask to go out a couple extra times. She will need to go out in the middle of the night on occasion but usually it's for a BM as well as urinating. Nothing like it had been before we started on Trilostane.

[Crystal&Zoe]

:D
Crystal, if you do opt to switch to twice daily dosing, you would not increase Zoe's daily total, you would instead split the total into two smaller doses. Since her January monitoring ACTH was right on target within the desired therapeutic range (1.5, 4.5), you would not increase the daily total at this point. Here's the official recommendation from Dechra:



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

This actually marks a departure for Dechra, since in earlier years they suggested that the daily total be increased a bit when making the change. However, we have been told by at least one noted endocrinologist that dogs dosed twice daily run a greater risk of having their cortisol drop too low. Coupled with some newer studies that have shown that dogs dosed twice daily actually often end up requiring a smaller daily total than dogs dosed once daily, it seems to me this is all further substantiation for Dechra's newer recommendation that the daily total not be increased if you decide to make the dosing switch. Your vets may not be aware of this change, so it may help if you print out that Product Insert to share with them if you do not already have a copy inside your Vetoryl box.

To expand on Lori's question, are you noticing an evening rebound in any issues other than the grouchiness? If not, I am still not convinced that cortisol is the problem there. You can certainly try a dosing shift to see if that helps, but it does make your life a bit more inconvenient since both doses of trilostane need to be given with a meal at 12-hour intervals. Plus, you will now need to shift to a compounded product since Vetoryl comes in capsules no smaller than 10 mg. Many of our members do use compounded trilo, so it is certainly do-able, but it will be a shift for you.

Marianne

What I'm noticing is almost every morning, almost, she does ask to go out again within 2 hours of her first morning piddle. Some evenings she needs to go out an extra time. And occasionally she needs to go out in the middle of the night. But usually it's for a BM as well as piddling. Before this she never needed to go out in the middle of the night. And she still drinks more than the other 2. Less than 8 oz a day but she does not make yellow snow like the other 2. I just don't know what to do.

Do you have the name of the endocrinologist and studies you mentioned? I'd love to provide that info to Dr Steph. And with bid dosing, does it need to be precisely 12 hours apart like insulin or can there be an hour to 90 minute window?

[labblab]

Crystal, at the forefront of these studies has been Dr. Edward Feldman and the researchers at the UC Davis vet school. Here is a link to our resource section that lists an oft-quoted related study. Other research has also been done worldwide, but I believe the UC Davis research has especially triggered the recommendation for twice-daily dosing from many American clinicians.

http://www.k9cushings.com/forum/showthread.php?t=4442

The quote about lower dosing and a greater risk for lower cortisol with twice-daily dosing comes from Dr. David Bruyette, another noted California endocrinologist. Dr. Bruyette is the medical director at VCA's West Los Angeles clinic, and has been at the forefront of developing cutting-edge pituitary surgery and also possible new medication options for Cushing's. For a brief time, Dr. Bruyette actively posted on our forum here, and here is one of his replies related to twice daily dosing:


With regards to once vs twice a day dosing if we look at all the studies throughout the world you will see that about 80% of dogs do well with once daily dosing. One huge advantage of once daily dosing is owner compliance which goes up substantially when owners only have to dose once a day. While twice a day dosing may result in a lower amount of trilostane being used pre day it will require closer monitoring as the ACTH stimulation tests tend to be lower so we have to look for both hypocortisolemia and electrolyte abnormalities.

I am betting your vets will already be familiar with both Dr. Feldman and Dr. Bruyette, so they will undoubtedly be interested in their research and comments.

Marianne

[labblab]

Forgot to add that this is just my personal opinion, but I wouldn't think you'd have to be quite as precise about the 12-hour interval as you do with drugs like insulin or the phenobarb that I give my epileptic dog. After all, since you'd otherwise be giving the dose all at once, I don't see why it would be that big a deal to fudge a bit on the evening timing, although I would do it forward rather than backward (meaning give the second dose sooner than 12 hours rather than later). That way, the total effect will be contained within a single 24-hour time period rather than bleeding over into the next day.

Marianne

[Crystal&Zoe]

I'm a bit confused because part of the study includes owner observation of symptoms yet in the condensed summary it says,

"The study found that neither the UCCR or urine specific gravity was a reliable indicator of therapeutic response and could not be used to determine if dosing adjustments were required."

We haven't recently checked her specific gravity yet her urine has no color. So even though her drinking has greatly decreased, it's still enough to dilute her urine. Could that be indicative of an underlying kidney issue? I mean, her numbers on past labs don't look as high as you would typically see in a Cushings dog, right? So why is she still losing hair and licking herself to the point of causing open sores? Is this what I should expect when managing a Cushings dog?

Other possibilities of her growing aggression if not cortisol related would be pain, feeling ill or the pituatary tumor growing, correct? I put her back on the supplement for pain and inflammation yesterday and she did seem better last night. Still grouchy but only one mildly aggressive outburst. This morning before breakfast she went off on me when I picked her up. No meds given yet. And I'll do a thyroid test before changing her from once a day to twice a day dosing and give the info on dosing to Dr. Steph before we make any changes. Marianne, do you have any suspicions as to what is going on with Zoe?

[Harley PoMMom]

We haven't recently checked her specific gravity yet her urine has no color. So even though her drinking has greatly decreased, it's still enough to dilute her urine. Could that be indicative of an underlying kidney issue?

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.



Other possibilities of her growing aggression if not cortisol related would be pain, feeling ill or the pituatary tumor growing, correct? I put her back on the supplement for pain and inflammation yesterday and she did seem better last night. Still grouchy but only one mildly aggressive outburst. This morning before breakfast she went off on me when I picked her up. No meds given yet. And I'll do a thyroid test before changing her from once a day to twice a day dosing and give the info on dosing to Dr. Steph before we make any changes. Marianne, do you have any suspicions as to what is going on with Zoe?

My boy, Bear, had a bit of a grouchy temperament, when brushing him if the brush tugged his hair even slightly he would curl his lip and give a small growl.

And pain did make him very aggressive, he didn't like me picking him up, oh and he hated that kissing sound, when I would give the top of his head a smooch and make that lip smack sound he would growl at me. :p

[flynnandian]

maybe it is time for a real pain killer instead of a supplement only.
pain can certainly cause aggression in dogs.
i would ask my vet for a real painkiller and test if this would make a difference.
it certainly did for my dogs.

[Crystal&Zoe]

According to Dechra's published literature, trilostane typically reaches its maximal effect (lowest cortisol level) approx. 1.5 hours after dosing, and blood levels have returned to baseline after approx. 12 hours. They add the caution that, of course, individual variation can occur. But those are the general parameters for drug efficacy.

Marianne

Whoops, I see Lori and I were typing at the same time -- but she was able to give you a much more complete answer!! ;)

Yesterday we had out of town guests. Zoe was over-the-top excited to see someone she has not seen in a long time. But after about 10 to 15 minutes of being excited, she went to her bed and trembled for about 20 minutes. She was more sedate after that and had trouble going up the stairs. Today she has seemed just a bit off. And it has increased as the day has progressed. And the odor from her mouth is very bad today. When I was combing the hair on her front legs very lightly this morning she acted like it hurt. I don't know if that's due to the thin skin and making it more sensitive possibly? But then later in the day she stopped wanting to jump off of furniture. And this evening, when I picked her up, she no longer lifts herself up to help. She's just deadweight when I pick her up. If I lay her down, she's content to just lay there and not move or rearrange herself . Although she will adjust herself if not comfortable. She ate dinner with gusto. And licked the kitchen floor after for a good 15 minutes or so. So that part is normal. But I'm wondering if perhaps her cortisol level is too low? And maybe I should not give trilostane tomorrow morning? I will call her vet first thing in the morning. Although I am confused. If the dosage should be out of her system after 12 hours, and her levels going back to baseline, shouldn't she be perking up?

[addy]

Not necessarily, if her cortisol is truly too low, she may need a few days, a few weeks, to rebound, Did you speak to the vet today?

Sometimes once we lower their cortisol, they have a harder time with stress and tire out more easily as they can't pump out the cortisol to cope with the stress. Perhaps she just had a harder time handling the stress and excitement.

How is Zoe now?

[molly muffin]

It matters a great deal how much cortisol the adrenal glands can hold. If they don't hold very much, then as Addy was saying, it takes longer for them to rebound.
Saying that it is out of their system completely in 12 hours is a sort of false sense of security, in that as cortisol is lessened, not as much is stored and it keeps going down, unless they are at a stable, maintaining dosage. Which it can take some tweaking to get to.
If I have a dog who has issues with not feeling well with lower cortisol, then I would be fine, having a post ACTH number a bit higher.
If you hold off on the trilostane for a couple days, you can see if she rebounds of not. That might tell you how she is doing.

[Crystal&Zoe]

Thank you both for responding. Dr. Steph returned my email late last night and agreed it wise to not give the Trilostane this morning. She seemed more alert and not as sedate this morning but other wise everything else is still the same. She is definitely weaker in both her front legs and back legs. And she's still trembling when excited. She trembled when I was getting treats out and at dinner time. I left a message for Dr Steph that maybe it's not that her cortisol is too low but that maybe she's experiencing adverse reactions? Late this afternoon she was standing on the couch beside me as I was rearranging everyone's position to keep her on one side and the other two on the other to avoid conflict since her aggression has escalated and it appeared her legs gave out. But maybe she just kind of tripped on the blanket. Dr Steph just now emailed her reply to my call to not give her Trilostane again for another 48 hours and observe. She's leaving in the morning for a week long conference and it makes me nervous. She'll be available via email and her associate is at the clinic. But we have never seen him.

Edited to add: Her stomach is really gurgling today too and again the stomach odor coming from her mouth is really foul.

[molly muffin]

So don't give her any trilostane tomorrow either and see how she does. That is what I'd do.

Since she is available by email and her associate can see you and likely will be in contact with her too, it should be fine, but I do understand not wanting to go into anything while she is away.

[molly muffin]

How is Zoe doing? Did you skip a couple of days of the trilostane? Is she acting more herself?

[Crystal&Zoe]

I'm beyond confused at this point. One thing for certain is she's having pain in either her neck, shoulder or front leg area. Stopped the Trilostane Tuesday the 17th. By later in the day on the 18th she seemed to have more energy and I thought more muscle strength. Stairs were easier and she was even starting to jump off furniture again. And she seemed to have a bit more life in her eyes and seemed a bit more interactive when I talked to her. But she seemed more agitated and way more growly at Jett and Callie. Even if they just looked at her but were not too close. I guess that's better because before she was just going off on them without warning when they got too close. Then later that night I was combing out her leg hair very gently since I knew she had acted like it hurt last time, she cried out for an extended 3-4 seconds rather than just a yelp. She lip licked and trembled. After that she no longer wanted to jump off the furniture again and just wanted to be in her bed. She will walk without limping and later that evening came down the stairs on her own. Thursday she wanted to be with me and would follow me room to room, but really no interaction and her eyes were dull. Yesterday morning I gave her the Trilostane again. She's acting pretty much the same but her eyes seem to not be as dull and she seems to connect with me when I talk to her. But then yesterday when I was getting treats out for all 3 of them, she was on the chair and would not jump down but clearly wanted a treat and was shaking. I've not seen her shaking the past couple of days when she wasn't on Trilostane. It could just simply be she wanted the treat so badly and yet would not jump off the chair for it. Or it's an adverse reaction to the Trilostane. Today she's started to jump off furniture again but again had a trembling episode when someone stopped over.

These were my thoughts BEFORE the crying out while combing her episode:

1. She's on the correct dosage of Trilostane and experiencing some of the adverse reactions.

-OR-

2. Her dosage is too high making her cortisol level too low and not feel well.

-OR-

3. She's on the correct dosage of Trilostane and experiencing more pain due to worsening arthritis and degenerative disc disease from the Trilostane and now that her cortisol levels are being managed, they are no longer masking her pain and she's needing stronger pain meds.

Now I'm wondering if it's both 1 & 3 and when something hurts her it takes a couple of days to start to not have as much pain. Or could she simply just not feel good on Trilostane?

Was supposed to take her in Thursday for a blood draw to recheck her thyroid but we had blizzard conditions and felt it too dangerous to drive the hour drive to the vets. So we go on Tuesday and I'll have someone examine her to see if they can find a painful spot. I can't find an area that seems to cause her pain.


If it does boil down to her simply not feeling well on the Trilostane and it is truly the correct dosage, if her symptoms are managed by dosing every other day, would that be detrimental? I just want her to not feel lousy all the time.

[Harley PoMMom]

Is her dose of Trilostane still 10 mg once a day? I scanned Zoe's thread and saw that her last ACTH post stim results were 4.5 ug/dl, right?

Now, even though her post is great, it could very well be that for her she needs that post to run a bit higher, especially since she has IVDD.

[Crystal&Zoe]

Yes. She's still on the 10mg once a day. Started her back on that yesterday. Maybe skip a day and see how she acts?

[Harley PoMMom]

Well, I'm not sure if every-other dosing is the best solution, yet, is there any way some of those 10 mg capsules could be compounded down to 5 mg?

[Crystal&Zoe]

Yes. My vet has a compounding pharmacy she's very comfortable with. Too bad I have almost a full 30 day supply of the 10 mg.

Editing: You think they can compound the 10 mg down?

[Harley PoMMom]

Are the 10 mg capsules brand-name Vetoryl? If they are, I would think that they could, but not absolutely sure...

[Crystal&Zoe]

Yep. Red white and blue box that says Vetoryl on it.

I'll ask her about it this week.

[apollo6]

Dear Cathy
It has been a long time since I can remember all the issues Apollo had. Zoe should have grown back fur in less than a month on the vertroyl. Also it appears Zoe is having issues on the Trilostane/Vetroyl. When Apollo was on Trilostane he had jaw trembling and stomach gurgling. I think you said you had a holistic vet? If the funds allow,you should get a second option with an internal specialist specializing in Cushing. . Compounding can be tricky. Apollo weighed 10 pounds and less and was on less than 10 lb. I took him off the vertroyl occasionally. But I would check with the vet first. Also the stomach gurgling concerns me. If you can afford an ultrasound would reveal what is going on. Also There are three types of Cushings-pituitary,adrenaline, and think asyetic( can't remember the spelling) that determines the kind of treatment to pursue. We could give the site on internal specialists if you want. Once again we are not specialists,we can only share our own experiences. Also depending were you live,maybe someone on the site could recommend someone. I used Diamond ? from Arizonia, and you want to make sure the pharmacy is accredited.
Sonja and Angel Apollo