Suspected Cushings - What test to run?

[tlborman]

I have a 6 1/2 year old Weimaraner who is suspected to have Cushing's. She has exhibited excessive thirst, drooling, hair loss and sagging belly. The initial blood work shows elevated ALK PHOS, GGT, BUN/CREAT ratio, cholesterol, lipase, CK and RDW. Creatinin serum, WBC, NEU# and LYM# were all low.
My vet is recommending bypassing the Low Dex test and performing the University of Tennessee full panel. I was wondering if this was the normal route for determining if she has Cushing's?

Thanks for your help!

[addy]

Hi and Welcome.

Usually the UTK panel is done when there may be a possibility of atypical Cushings. Our internal medicine specialist ran that panel and also did an ultra sound. My dog had had a very high UC:CR urine test that indicated further testing was required. She did not display the usual Cushing symptoms.

Did your vet say why he preferred doing the UTK panel over a low dose dex test?

[tlborman]

That it would show a more compete analyse/result.

[addy]

Here is what the top endocrinologists say:


Diagnosis of Hyperadrenocorticism in Dogs
Mark E. Peterson, DVM

A presumptive diagnosis of hyperadrenocorticism in dogs can be made from clinical signs, physical examination, routine laboratory tests, and diagnostic imaging findings, but the diagnosis must be confirmed by use of pituitary-adrenal function tests. Screening tests designed to diagnose hyperadrenocorticism include the corticotropin (adrenocorticotropic hormone; ACTH) stimulation test, low-dose dexamethasone suppression test, and the urinary cortisol:creatinine ratio. None of these screening tests are perfect, and all are capable of giving false-negative and false-positive test results. Because of the limitation of these diagnostic tests, screening for hyperadrenocorticism must be reserved for dogs in which the disease is strongly suspected on the basis of historical and clinical findings. Once a diagnosis has been confirmed, the next step in the workup is to use one or more tests and procedures to distinguish pituitary-dependent from adrenal-dependent hyperadrenocorticism. Endocrine tests in this category include the high-dose dexamethasone suppression test and endogenous plasma ACTH measurements. Imaging techniques such as abdominal radiography, ultrasonography, computed tomography, and magnetic resonance imaging can also be extremely helpful in determining the cause.
Attached Files
File Type: pdf diagnosis_peterson[1].pdf (227.9 KB, 23 views)


Most dogs with high cortisol will have elevations in some of the other intermediate hormones that UTK will test for.

I checked their website and have found it to have changed from the 5 years ago when I used it.


General Information
The Clinical Endocrinology Service at the University of Tennessee, College of Veterinary Medicine provides adrenal, thyroid, and reproductive hormone testing for dogs and cats, as well as for several other species. Our Service has gained a national and international reputation for providing adrenal steroid profile testing. The adrenal steroid profiles (also known as adrenal panels) are determined in dogs, cats, ferrets, and rabbits that are suspected of having adrenal disease. These profiles provide a more complete evaluation of adrenocortical function by assessing hormone concentrations that arise from different parts of the hormone synthesis pathway. Classically, most adrenal function tests in animals involve the measurement of only cortisol however in some individuals these tests give normal cortisol results even though the animal has clinical signs suggestive of hyperadrenocorticism. Our Clinical Endocrinology Service is the only veterinary diagnostic laboratory in the United States to offer an adrenal steroid profile test in dogs, cats and rabbits and was the first to offer this test in ferrets.






It still seems to indicate the panel is useful when we might suspect normal cortisol.

The test cannot tell you if it is pituitary or adrenal Cushings.

I'm sure others will be along to weigh in on their opinion.

[Harley PoMMom]

Hi and welcome to you and your girl!

The UTK adrenal panel is expensive, if this were me, I would invest that money into other diagnostic tests for Cushing's, such as the low dose dexamethasone suppression (LDDS) or ACTH stimulation, and/or an ultrasound.

Could you edit your post and add the actual values with the reference ranges and the units of measurement...example: ALT 150 U/L (5-50)...Thanks! Does your girl have any other health issues? Is she taking any herbs/supplements/medications?

Please know we will help in any way we can, and don't hesitate to ask all the questions you want. ;)

Hugs, Lori

[tlborman]

Alk phos. 312 U/L (1-142)
GGT 10 U/L (0-8)
Bun/creat ratio 37.5 (4-27)
Cholesterol 453 mg/dL (138-332)
Lipase 216 U/L (17-152)
CK 335 U/L (101-328)
RDW 14.9 (10.6-14.3)
Creatinine serum .4 mg/dL (.5-1.5)
WBC 3.8 K/uL (6-17)
Neu# 2.9 K/uL (3-11.5)
Lym# .7 K/uL (1.1-4.5)

She is scheduled for 'a' blood test on Friday, but I haven't decided what test to tell him to run. As noted the UTK test is quite pricey. I am also to bring in a urine sample, but thought it was to check for UTI. He also thinks that she has vasculitus. She is taking Cosequin with MSM, ligaplex II, conquer liquid and was started on Hepato last Friday. She is on no medications. She is suspected to have IVDD.

[addy]

and if the test would come back showing elevated cortisol, I think, to be prudent, you would still want a second test done to confirm. My own opinion is I would not treat elevated cortisol based only on a UTK panel.

Have you started reading through our Helpful Resource section?

We like to give homework:):):):):)

[tlborman]

Haven't found the resource section yet - but will find it and do my homework :).

[Renee]

Generally, the 'gold standard' for diagnosing cushings these days is the LDDS, however, I would not rely on a single test to definitively diagnose. A second test to further confirm is always a good idea.

The LDDS has the ability to indicate whether you may be dealing with PDH or ADH.

I do not believe a UTK panel is 'superior' to an LDDS or better at providing a diagnosis, so I am a bit confused by your vet's reasoning. Certainly the panel provides very useful information, but it cannot diagnose cushings on it's own. It takes a combination of strong symptoms and multiple tests.

Has your vet ruled out diabetes and thyroid issues first?

[tlborman]

He has not mentioned diabetes, but she was tested for thyroid about six months ago when I noticed hair loss on her ear flaps. It was normal and confirmed normal by Dr. Dodds. Initial results of blood work from last Friday is also normal.

[Harley PoMMom]

Link to our Resource sub-forum:Helpful Resources for Owners of Cushing's Dogs (http://www.k9cushings.com/forum/forumdisplay.php?f=10)

Happy reading ;) and if you have any questions do not hesitate to ask them.

Hugs, Lori

[addy]

ALKP is not so high, we usually see much higher though my girl had lower numbers too.

Cholesterol is higher, that can be Cushing's, again very similar to my Zoe.

Bun creatinine ratio is elevated, that could be from a number of things.

Hopefully, Marianne will stop by as well.

[labblab]

Hello and welcome from me, too! In looking over the blood results, some are indeed consistent with Cushing's as has already been noted and a few not so much. For instance, you could expect to see elevations in WBCs and neutrophils, rather than decreases. But given your dog's overt symptoms in conjunction with several of the lab abnormalities, I can see why your vet is opting to test.

I'm going to step a bit outside of the box to say that, even though I don't typically encourage people to opt for a full UTK panel at initial testing, I can't say it's a bad idea to have it done. This would be my reasoning. The LDDS is favored by many clinicians as the diagnostic blood test of choice for dogs with classic symptoms and no other known illnesses. This is because it is less likely than the ACTH stim test to return a "false negative" and miss diagnosing Cushing's in a dog who truly has the disease. The trade-off is that the LDDS is more likely to return a "false positive" even if a dog does not have Cushing's, plus it does not give you a baseline cortisol level against which to measure treatment progress down the road.

For this reason, for a dog of my own, I actually would prefer to start with an ACTH. If it came back negative, I would then move on to an LDDS knowing that the ACTH falsely "clears" many dogs. But if it comes back positive for elevated cortisol, I probably would not bother with an LDDS since a positive ACTH is actually a more specific Cushing's test, and I now already have my baseline cortisol in place for starting treatment. Instead, I would move on to an ultrasound for the dual purpose of distinguishing between pituitary/adrenal Cushing's, and also to make sure there is nothing else going on that would account for that elevated cortisol, giving you a false positive on that ACTH.

As for the complete UTK panel...yes, it is more expensive than an ACTH testing cortisol alone, but I am not sure exactly how much more expensive. Whether you are testing only cortisol or all the adrenal hormones, a big portion of the expense comes from your own vet's charge for drawing the blood samples and the cost of the stimulating agent. I just checked, and UTK now charges $150 for the full panel analysis. For comparison purposes, I tried to find out what another lab, IDEXX for instance, charges to analyze cortisol alone -- but I could not find their price list. So you may want to ask your vet what the actual difference in cost would be. It may or may not be all that much, after all.

It may turn out that the UTK panel would not offer you much insight at all. Especially this would be the case if your dog exhibits elevated cortisol and you just move forward with conventional treatment. As Addy says, virtually all dogs with elevated cortisol will exhibit elevated intermediates, too. But if, by chance, your dog has normal cortisol on the ACTH and also tests negative on the LDDS -- but has elevated intermediates on the UTK panel -- that could lead you towards a different mode of treatment. And you would already have this info in hand; you would not need to go to the expense of repeating the costly ACTH stimulation solely for the benefit of the UTK panel down the road.

So I see I have written a book here, but just wanted to offer some thoughts as to why your vet may be making this recommendation. As to whether or not you want to proceed with the panel, as I say, I would pin him down as to the actual price differential to see whether or not you think the possible benefit would be worth it to you.

Marianne

[addy]

I wondered the same thing, after I read the blood work. I will say some of the results are consistent with my own dog's initial panel and Zoe did have elevated cortisol though her blood work and symptoms did not scream Cushings.

If you go ahead with the UTK panel, I still suggest a second test if the cortisol is elevated.

I do agree with Marianne's thoughts.

[Harley PoMMom]

Even though the UTK adrenal panel is $150, the vet's office will also charge a fee for taking the blood draws and this is usually where the major expense is.

[labblab]

Even though the UTK adrenal panel is $150, the vet's office will also charge a fee for taking the blood draws and this is usually where the major expense is.
That is true, but that major expense is the same (blood draws and stimulation agent) whether you are performing an ACTH analyzing only cortisol or whether you are analyzing all the adrenal hormones including cortisol. So the only differential expense is the cost of analysis: $150 for the full UTK panel including cortisol vs. the analysis for cortisol alone. I expect the cortisol-alone analysis charge depends upon whether it can be performed inhouse or whether it is sent to an outside lab like IDEXX. But for instance, if the cost of analysis of cortisol alone is $75, then you you might end up with a difference like this: $250 for ACTH analyzing cortisol alone; $325 for the full ACTH panel including cortisol. The difference will all depend on that cortisol-alone analysis charge, and you kinda need a crystal ball to know in advance whether it would be worth it. The answer will probably end up being "No" if your dog does have elevated cortisol, and that is why I don't typically recommend the full panel to people upfront. But if cortisol is normal and you end up wanting more info on the other adrenal hormones down the road, you'll have to pay the full $325 for the do-over.

So that is the cost comparison I would ask the vet about -- that is, assuming you want to have a diagnostic ACTH stimulation test performed at all.

Marianne

[tlborman]

I recently had a LDDT test performed on my 6 year old Weim due to some of the classic symptoms including weight gain, pot belly, increased water consumption and blood work showing increased alk phos, etc. LDDT test results were:

Cortisol (Pre) 8.0 High (ref range 1.0-6.5 ug/dL)
Cortisol (4 hr) 1.5 High (ref range 0-1.4 ug/dL)
Cortisol (8 hr) 1.0 Normal (ref range 0-1.4 ug/dL)

Based on these test results she was diagnosed as having Pituitary Dependent Cushings. She sees a holistic vet and he recommended treating her with a combination of melatonin, Chinese herbs and other vitamins. She has been on this treatment for ~5-6 weeks and I am not seeing any improvement. If anything her hair loss is more significant.

I know that this type of treatment can take longer than conventional methods, but I was wondering two things.

Are the test results indicative of Cushings and if so, has anyone had success with alternate treatment methods for Cushings?

Thanks in advance for any help!
Terrie

[labblab]

Welcome back, Terrie! You'll see that I've merged your new post into your original thread. I'm afraid I have only a moment to write, but most importantly, no, that LDDS test result is negative for Cushing's. Whomever told you it is positive is in error. In evaluating this test, the first value to look at is the 8-hour result. If it is within the normal reference range, it is inconsistent with Cushing's and the analysis stops there. Since your dog's 8-hour result was within the range expected for a normal dog (lower than 1.4), it is negative for Cushing's. It does not matter whether the baseline or 4-hour result were high. Stress alone can elevate a baseline cortisol. Here is a link that better explains the test interpretation:

http://veterinarymedicine.dvm360.com/clinquiz-interpreting-low-dose-dexamethasone-suppression-test-results

Can you fill us in on any other testing or new developments since you were last here? Did you ever have the ACTH testing done?

Marianne

[molly muffin]

Yes I'd be interested if you had an ACTH test done too.

What about a bile acid test to check liver? Several of the high levels on the blood work are liver related and further check on kidney's with a renal panel. (bun/creat ratio elevation on blood work)

Those are my next line of inquiry.

[tlborman]

Any other thoughts on what could be causing these symptoms?

[tlborman]

I have not had an ACTH test run.

She was put on Hepato following the blood test results.

[tlborman]

I have been trying to understand all of the information presented at this website including what is in the information section. I have additional questions about my gal that I hope you can clarify.

What is the benefit of running an ACTH test if an LDDT test has already been run, or put another way, what information do you get from the ACTH test that is different from the LDDT?

Is it possible that she has atypical Cushings since her LDDT test was normal?

Would it be more beneficial to run the hormone test panel from Tennessee and/or perform an ultrasound?

Thanks again for your help with this!

[molly muffin]

An LDDT or more commonly on here called an LDDS, Just so there is no confusion, is the same thing, tells you if they can suppress cortisol production. A blood draw is done, then they inject a simulating agent, saying there is enough cortisol, don't make any more, and then they draw at 4 hour and 8 hour, to see if the adrenal glands responded to that and did in fact suppress.

An ACTH test, they do a blood draw, then inject an agent that tells the adrenal glands to dump all the excess cortisol that they have stored in them. Depending on how much cortisol is both on the initial blood draw (circulating already in their bodies) and how much the adrenal glands dump out from storage, tells you if there is a normal amount of cortisol both circulating and being stored. If either are high, then there is something going on that is causing the adrenal glands to make and to store more than they should. This is cushings.

Cushings itself is caused by a couple possibilities, most often it is a very small micro tumor on the pituitary gland, sometimes these tumors grow and are then called macro tumors and can cause pressure, which is often see in different neurological symptoms. Sometimes there is a tumor on the adrenal gland itself that causes the cushings. Very seldom but we have seen, there are tumors on both pituitary and adrenal glands. The ultrasound can tell you if there is a tumor on one of the adrenal glands usually. An adrenal tumor will often have one gland (the one secreting the cortisol) larger than the other. With pituitary cushings, the glands are usually both enlarged to some degree. It can also tell you if there is something else causing the excess cortisol production, a tumor on a spleen or some other chronic illness. There is also cushings caused by steroid use, for instance when a dog is on prednisone for maybe allergies or some other reason. Predinson acts in the same way excess cortisol does and can have the same symptoms because of that. The other type is atypical, in which the cortisol is normal, but the sex hormone are elevated, this too can cause cushings symptoms. The University of Tenn tests for atypical cushings.

My dog was consistently negative on repeated LDDS test but positive on her ACTH. 5 % of dogs Will test negative on the LDDS always. I think it is due to the location of the tumor on the pituitary gland.

I hope that helps to clarify cushings and the tests a bit.

[tlborman]

Just to check back in with everyone on the latest on my gal. I started to go to an Internal Medicine Specialist a few weeks ago who wanted to do a Urine:Cortisal test. That test result was 72 and I was told anything under 13 was negative for Cushings. Anything over did not rule in nor rule out Cushings. The next test she wanted to do was an Ultrasound. The results of that test was both adrenals somewhat enlarged , but not hugely. No signs of tumors.

So the next test she wanted to run was either an ACTH test (as mentioned here) or the TN Adrenal panel test which would include the baseline ACTH test. Since the cost of that test panel was only a little more than the ACTH test, I opted for that test. We had the test run on Friday and I will let you know what those test results are when they come back in a week or so.

I sure wish there was a more definitive way to either rule in or rule out Cushings :o).

Thanks for all of your help in listening and answering questions!

[Harley PoMMom]

J
I sure wish there was a more definitive way to either rule in or rule out Cushings :o).



OMGoodness, ain't that the truth. It is such a challenging disease to diagnose. Can you refresh my memory and tell me what symptoms your girl is displaying?

Hugs, Lori

[tlborman]

She first developed loss of hair on her ear flaps and started drinking much larger quantities of water than normal. Over the last few months, she has progressed to significant hair loss on her belly and chest; and it is now progressing up her sides. She has developed a "pot belly" and her energy level is low, especially for a 6 1/2 year old weim.

[molly muffin]

It sure does seem she has some elevations somewhere, so the U of Tenn test will tell you if it is typical or atypical cushings. If the cortisol is raised at all, it is typical cushings and getting her started on meds, will be the next step.

I hate waiting. :) hope the results get here soon

[tlborman]

I just heard from the vet with my gals latest test results. Based on the ACTH test result she has been diagnosed with typical Cushings. Pre test cortisol level was 4 and post test it was 34.5 (she stated that 17.5 was the high end of normal). So she is to be started on vetoryl, once they call in the prescription for me tomorrow. What are the pros and cons with giving the drug once a day vs twice a day? I would prefer to give the drug once a day due to cost, but want to do what is best for her also.

They will e-mail me the complete test results tomorrow.

[Harley PoMMom]

When first starting treatment once a day dosing is the method I prefer. If the dog is diabetic than twice a day dosing is generally done to keep the cortisol on a more even flow. What is the Vetoryl dose she is starting out at? And how much does she weigh?

Hugs, Lori

[tlborman]

She is going to be started on 60 mg/day. She typically weighs ~63 pounds, but currently weighs ~70 even though she is not heavy. Believe it is due to water retention?

[Harley PoMMom]

Dechra, the makers of Vetoryl, now recommend a starting dose of 1mg per pound of a dog's weight, so that 60mg sounds reasonable for your girl's weight.

Just a couple reminders ;) Vetoryl has to be given with food, and those ACTH stimulation tests have to be performed 4-6 hours after the Vetoryl is given.

If you have any questions, just ask, ok?

Hugs, Lori

[tlborman]

It has been a while since I have checked in and I am looking for additional guidance. As noted previously, we started my gal (7 year old, 72 pound Weimaraner) on 60mg of trilostan once a day.

The first ACTH test came back with a post test result of 5.4 (reference range 8.0-17.0 ug/dL). It was recommended that we keep her on that dose for a while longer (even though her clinic signs showed only slight improvement).

Then we ended up in the emergency vet with a fever of 105° and she was diagnosed with an UTI (put on two weeks of Clavomax). Called my regular vet the next day and agreed to up the trilostan to 70 mg and ordered compounded medication from Wedgewood Pharmacy. We continued with the 60 mg pill and added 10 mg of compounded.

During this time her skin got much worse and I started giving her twice a week baths with a medicated shampoo. Approximately two weeks after starting the 70 mg dosage, we had another ACTH test with a post test result of 5.6 (clinic signs still showing only slight improvement).
We then bumped the meds up to 80 mg (60 mg pill + 20 mg compounded).

The latest ACTH test (~12 days after starting the new dose), came back with a post test result of 8.1! We have just started on 90mg a day. Please note that her skin condition has improved tremendously since started the medicated baths.

Just a note, the ACTH tests have been very consistently done. Medication given with breakfast at 4:30 AM, 1st blood draw at 9:30 and 2nd at 10:30. Taken home between blood draws. Also, pre-test values were all between 2.9-3.1 (reference range 1.0-5.0 ug/dL).

I am trying to understand why her levels are going up even though we are increasing her medication. Is this typical? Are we missing something else going on with her?

Thanks for any advice given!

[Harley PoMMom]

The first ACTH test came back with a post test result of 5.4 (reference range 8.0-17.0 ug/dL). It was recommended that we keep her on that dose for a while longer (even though her clinic signs showed only slight improvement).

The reference ranges for a dog on Trilostane therapy are: 1.5 ug/dl - 5.5 ug/dl, (not 8.0-17.0 ug/dL) and that post can go as high as 9.1 ug/dl as long as the symptoms are controlled.


Then we ended up in the emergency vet with a fever of 105° and she was diagnosed with an UTI (put on two weeks of Clavomax). Called my regular vet the next day and agreed to up the trilostan to 70 mg and ordered compounded medication from Wedgewood Pharmacy. We continued with the 60 mg pill and added 10 mg of compounded.

OMGoodness, is she over that darn UTI? They can be a bugger to get rid of sometimes. :(


During this time her skin got much worse and I started giving her twice a week baths with a medicated shampoo. Approximately two weeks after starting the 70 mg dosage, we had another ACTH test with a post test result of 5.6 (clinic signs still showing only slight improvement).
We then bumped the meds up to 80 mg (60 mg pill + 20 mg compounded).

The latest ACTH test (~12 days after starting the new dose), came back with a post test result of 8.1! We have just started on 90mg a day. Please note that her skin condition has improved tremendously since started the medicated baths.

Just a note, the ACTH tests have been very consistently done. Medication given with breakfast at 4:30 AM, 1st blood draw at 9:30 and 2nd at 10:30. Taken home between blood draws. Also, pre-test values were all between 2.9-3.1 (reference range 1.0-5.0 ug/dL).

I am trying to understand why her levels are going up even though we are increasing her medication. Is this typical? Are we missing something else going on with her?

Oh my, it could be that the compounding Trilostane isn't at the strength that it is supposed to be at. I've included this post from Marianne which explains this better than me.
... I don't think there is any question but that compounding is sometimes necessary. The issue that Dechra would raise is that the base for the compounded "reissue" needs to be Vetoryl so that the trilostane has been vetted and verified, and not raw trilostane that the compounder has bought on their own. We have already chewed that question over on multiple Mod forum threads in the past, and I know there are lots of issues involved. But I will just say that one of the huge stunners for me out of that FDA report on Wedgewood is that they were not testing or verifying the contents or purity of any of the raw ingredients they purchased on their own to make up their drugs. Just taking it on face value from the supplier as to what they were getting and using.

My understanding is that Diamondback will not compound from Vetoryl for reasons that we don't need to debate over again. But that means they are buying the trilostane from their own supplier. My hope is that they are more rigorous in their product control than Wedgewood. But regardless, my worry is that they might have gotten a batch that may have some problems, and they (Diamondback) would never know this unless they get feedback. From Audrey Cooke's study, we know for a fact that there are efficacy variabilities with some compounded products. Given their level of professionalism, I am guessing that Diamondback would want to hear about possible problems with any drugs they've sold.

Hugs, Lori

[tlborman]

Thanks for the clarification of reference ranges. I was aware that they are different for dogs on vetroyl and that she is trending toward the high end of the reference range. With that said, we do not feel that her symptoms are well controlled yet. We have seen slight improvement but based on my understanding I was expecting more once we got the dosage correct, especially in light of the fact that she has been on 60mg+ for 2 ½ months now. Maybe I am expecting too much too soon :).

With regards to the compounding, my vet shares your concern with using compounded drugs and recommended that we keep her on the 60 mg pill and just use the compounded drugs to supplement the dosage. That is why I don’t understand why the test results are getting worse. Even if the compounded drugs were not being given, I would have thought that her levels would stay the same since the 60 mg pill has consistently been given. Regardless, I have now received 30 mg pills to go along with the 60 mg pill as we continue on her new dose of 90mg.

Thanks again for any additional input!

[molly muffin]

If she was tested during a time that she had a UTI, it could be her body trying to respond to the infection by raising the cortisol. I don't know if that is possible when already on treatment or not, but rule of thumb I use it so not do the ACTH test during any kind of medical issue ongoing. So if an infection, I don't test, but wait for 2 weeks at least post treatment. I just never trust a result from a time period that has other things ongoing.

If your dog is having skin problems due to high cortisol, typically you want it to come down to at least under 5.0ug, we just see better skin responses on the forum when it is under 5.0ug, than normally if it is post between 5.0 - 9.0 ug.

Now having said that you are at 5.6ug post now or last test and increasing by 30mg. That might be a bit much and so please watch and make sure that she doesn't go too low.

[tlborman]

Hi Sharlene,

Thanks for the guidance on when to perform ACTH tests. I had not thought about interaction with the UTI meds. However the latest ACTH test was done following her treatment.

Her last dose of medication for the UTI was on 6/18/15. We started on 80 mg (60 mg pill + 20 mg compounded) on 6/21/15 and had an ACTH test on 7/3/15. That test result was at 8.1. Since that was just two weeks following the meds, perhaps the test results are still being impacted by the meds :confused:?

Also we are only bumping up the meds by 10 mg, just changing to all pills instead of pill + compounded meds. I will however be watching her closely since we have changed to all pills. We are just on day two of all pills.

I have a couple of weim friends whose dogs are well controlled (one is only on compounded meds from the same Pharmacy, Wedgewood). Their post test results have been between 1.5-3.5.