Puckie, new here, CC

[deannah]

Just wanted to thank everyone for such an informative thread! So, Thank You All.

I've just recently been treating my female, 8 year old Shih Tzu, Puckie, that was just diagnosed with Cushings. She also has a really bad case of CC and just started on her meds (Triilostane.)

Just wanted to 'bump' this post and thank you all.

Deanna

[molly muffin]

Remember to start at 1mg/1lb. I'm sorry that you are having the dreaded cc problems too. It can be a bugger to get rid of and take a bit longer than other symptoms as skin and hair have to go through their growth cycles and any calcium deposits already there have to break through and no more develop.

Welcome to the forum.

[Squirt's Mom]

Hi Deanna and welcome to you and Puckie!

I have moved your post and the comment to your post into a new thread that is allll for Puckie. Here you will talk to us about your baby and all that info will remain in one place. Some of us use our babies threads sort of like a talking diary - we can look back and see what was going on at a particular time. So this is Puckie's very own thread and I look forward to getting to know you both.

Hugs,
Leslie and the gang

[deannah]

Some more information on my Shih Tzu, Puckie, who has been diagnosed with Cushings and the tests and dosage that have been done to date.

I detected sores on her body sometime in March as well as the groomer had mentioned her hair was thinning. Originally was treated for mange, baths, etc. as I did not know what I was dealing with. When her tail started to bleed I contacted the Vet who did a complete blood test which showed the following highs and lows.

4/08/15
Results Reference Range
Total Protein - 7.0 mg/dL High (4.8 - 6.6)
AST (SGOT) - 41 U/L High (1 - 37 )
ALT (SGPT) - 110 U/L High (3 - 50 )
Alkaline Phosphate - 1276 U/L% High (20 - 155)
WBC
%Mon - 10.5 High (0.0 - 7.0)
%Eos - 1.0 Low (2.0 - 7.0)
RBC - 8.46 High (3.80 - 5.80)
HGB - 20.0 High (11.3 - 15.3)
MCV - 69.0 Low (60 - 72)
MCH - 23.7 Low (26.5 - 33.5)
MPV
#Neu - 8.2 High (1.4 - 6.5)
#Mon - 1.3 High (0.1 - 0.9
SA Free T4
Free T4 - 0.81 ng/dL Low (1.21 - 3.40

On 4/18/15 an 8 hour Dexamethasone Suppession Test was done. Results following:

Cortisol Sample 1 - 6.6
Cortisol Sample 2 - 8.9
Cortisol Sample 3 - 11.2

All results are for ug/dL

Name brand Vetoryl (10.mg) was prescribed at that time, but due to an illness I had, meds not started until 5/06/15 and conservatively prescribed for every OTHER day.

I made an appointment for a 2nd opinion as I was not happy with the prescribed doseage and not seeing many results, if any. This took place on 5/13/15, second opinion confirmed Cushings and doseage was upped to 10mg EVERY day and I did see positive results with this doseage. Maintenance BT was done on 5/27/15 and verbal results were not received until 6/03/15 as Vet was out of town on personal emerency. (don't have a printout of results yet):

Pre 4.0
Post 19.1

Second Vet prescribed an increase in doseage on 6/03 of twice daily using the 10mg morning and evening. This was done for 2 days when I saw a definite decrease in appetite. The morning pill was given on 6/05 and Vet was contacted regarding appetite. Decision was made to not give evening med for that day and to not give med for the weekend. Today is Sunday (2nd day of no med), but tomorrow will give her morning 10mg dose and then contact Vet.

Opinions are most welcome and thanks so much for this wonderful forum. This is a terrible disease and so lacking in information about it. Thank goodness I found this forum of knowledgeble people and links to more info. My brain feels fried!

Deanna and Puckie

[labblab]

Welcome, Deanna! I'm sorry I have only a moment to post right now, but can you elaborate more re: the decrease in appetite? Did Puckie exhibit elevated thirst and/or appetite prior to beginning treatment? If so, your hope is to see a definite decrease in either/both of these behaviors when taking trilostane. However, is Puckie's lack of appetite more worrisome than that? Any other unwanted symptoms such as diarrhea, vomiting, marked lethargy?

Regardless, Puckie would probably be better served to remain on only the 10 mg. daily for a full month before reassessment and upping the dose. Cortisol levels may continue to drift downward during the first month of treatment, even when the dose remains unchanged. For this reason, Dechra recommends holding off on increases until you know how much the cortisol will drop during that first month. After 30 days on the 10 mg., a dosing increase does make sense if the cortisol level still hangs high. But for now, I would stick with no more than the once daily 10 mg.

Marianne

[deannah]

Thanks Marianne for your response. Regarding your questions Puckie did have much elevated thirst and appetite prior to beginning treatment. Following her daily medication I did see a definite decrease in both of these. Her water consumption became much less than it was previously. Her lack/disinterest in food after doubling the Trilostane dose became alarming to me and the Vet as well. She did not want to eat her regular food at all .. breakfast, lunch and dinner. As I was concerned a bit about doubling her dose and lack of appetite I contacted the Vet. There has been no diarrhea or vomiting but her lethargy seemed to increase on the double dose.

Thanks again and hope that answers your questions.

Deanna

[deannah]

Am totally disillusioned today. I purchased the additional Trilostane needed for Puckie. Vet called back with no additional suggestions as to treatment. Had not had time to confer with his expert on this disease. I get the impression that nobody wants to treat this and guessing that it's left to me. Live in the boonies so no alternatives left here. Poor Puckie ..
Deanna

[labblab]

Hey there, Deanna, hang in there!! I apologize that I've just gotten back from a weekend trip and cannot write more tonight. But tomorrow I will review everything you've written so far and see if I can add any thoughts. So stay tiuned...;)

Marianne

[molly muffin]

The cortisol can continue to drop and usually does for 30 days with each dose increase. At least mine and most I've noticed tends to.
I think I would keep puckie on 10 mg once a day and not double it at this point. Then retest and see where you go from there. Since Puckie does have the dreaded cc most seem to respond best with the post cortisol below 5 ug. But you don't want to drop it too fast. It can make them feel pretty icky if it goes down fast.

If you don't have a lot of choice then you can learn the things you need to know about Cushing's to guide your vet. The area of sores you want to keep dry but clean so no infection can set in. There is a antibiotic spray some have used that you can order on amazon. Trichlor spray or shampoo. I like the spray option.

Hang I. There. We are right here with you. As long as your vet will work with you to help Puckie you can do this. :)

[deannah]

I've done all I know to do for now .. shampoo with chlorexidine, rinses, diet and cleaning the sores with sprays, chlorexidine, etc. Trying to guide the vet, but he seems to not have a clue. Doing the best I can for her at this point. Thank you for the help here. It's really appreciated!
Deanna

[labblab]

Hi again, Deanna. I'm back and I really want to "second" what Sharlene has written to you. Honestly, I think you are doing a great job with Puckie and with the passage of a bit more time, I am hoping you will see some improvement. It will probably be gradual in terms of the CC. But as Sharlene says, once the cortisol is within a therapeutic range, that should definitely help in addition to all the topical treatment.

I have to repeat that I think it is wisest to leave him at the 10 mg. until he has taken that dose for 30 days. At that point, you'll be better able to judge the true effect of that dose. Also, if an increase seems warranted, he may be better able to tolerate it at that time. Even when cortisol hasn't technically dropped too low, dogs can feel really yucky if the cortisol drops really significantly really rapidly: "corticosteroid withdrawal." When the cortisol decreases more gradually, the risk of unwanted side effects may be minimized.

But the bottom line is that you are doing a great job of advocating for him. We'll all be anxiously hoping that you start seeing some improvement very soon.

Marianne

[deannah]

Thanks for your response, Marianne. I am keeping Puckie on the 10 mg. dose for at least 30 days and possible a few more days before retesting. I really do not want her overdosed or underdosed. Sorry for my rant the other day .. just get so frustrated with vets who one comes to rely on for all the answers.

What is your opinion on the 30 days for a retest beings Puckie was totally off the Trilostane for 2 full days? Would that alter the results of a new test for her? That is why I was considering giving a bit more time for rechecking her cortisol level. I am also a bit concerned about her level of stress when taken to the Vet's office for testing. She starts panting as soon as we get in the car for trip and pants all the way there. Would this stress alter her test results in your opinion? The Vets say "no." Thanks again to all for all opinions!

Deanna

[deannah]

Good news today! Puckie was tested again yesterday with the ACTH Stim test and the Vet called today with her results and they were: Pre: 1.4 and Post: 6.7 both are ug/dl. She has been on 10 mg. once daily for almost 6 weeks.

Her symptoms have all improved, appetite, water consumption have decreased and her night times have all been consistently good. (no restlessness, peeing the bed, etc.)

The plan now is to continue the current dose, keep a close eye on her clinical symptoms and test her again in about 30/60 days. Any and all suggestions are most welcome. Now back to the research for our babies who cannot defend themselves!

Deanna and Puckie

[molly muffin]

That is very good. The post can go up to 9.0ug if the symptoms are controlled and you are happy with the way Puckie is doing.

I'd be very pleased with that result. Just keep an eye that her symptoms don't creep in again and that she is maintaining and I'd say you are doing just fine.

[deannah]

I have a question about the ACTH Stim test and the values:

5/28/15
Pre: 4.0
Post: 19.1

6/23/15
Pre: 1.4
Post: 6.7

All at ug/dl

Is such a huge drop from 19 to 6.7, on the post results normal? Puckie refused her breakfast this morning so I did not give her any Trilostane. Thanks for any info.

Deanna and Puckie

[labblab]

Yes, it is normal to see a drop of this magnitude when a dog has been treated with a therapeutic dose of trilostane for nearly a month. There is an interesting feature about Puckie's experience, though, that can serve as a lesson to us all. If I am re-reading her thread correctly, we do not know what her pre-treatment ACTH level was (her diagnosis was made via LDDS testing). However, her post-ACTH result after approximately two weeks of 10 mg. daily dosing was 19.1. Now, after 3-4 more weeks on the same dose, her post-ACTH cortisol has lowered to 6.7. So even with the dose unchanged, there was significant downward movement during that subsequent month.

Puckie's experience offers great support for the recommendation to leave an initial starting dose unchanged for at least 30 days even if the cortisol level at the 10-14 day mark is higher than desired. If cortisol is too low at that point, the dose definitely should be lowered. But early increases should be considered very carefully. If Puckie's dose had actually been doubled at that time, she very well may have crashed further down the line since her cortisol did continue to drop significantly during the subsequent month.

I wouldn't expect her cortisol to keep lowering significantly after six weeks at the 10 mg. dose. But it is always possible. So you are doing the right thing about remaining vigilant re: her behavior. I am hoping the lack of appetite is just a temporary glitch that is totally unrelated to the trilostane. But when in doubt, it is always safer to withhold the drug if a dog is acting unwell.

Keep us updated as to how she's doing, OK?
Marianne

[deannah]

Thanks for your response and suggestions, Marianne. Yes, Puckie was first diagnosed with Cushings via the LDDS test and began treatment from those results. I am hoping the lack of appetite is just a glitch, too, as her appetite (and lack thereof) is so related to her cortisol level.

She exhibited a lack of interest in food this morning as well, but I did change it a bit, no water or vitamins added, as it seemed such a waste of those expensive vitamins. I finally gave her the kibble in a toy which she then ate most all of it. So I did medicate her this morning with the 10mg of Trilostane. She ate her lunch and dinner yesterday with no problem, so felt fairly comfortable giving her the med this morning.

Since she also has the dreaded CC, I would hope to get her cortisol level under 5.0 in future tests and do realize it unfortunately will probably require an increase in the meds dosage. I will probably have her tested again in 30 days or so just to see how her levels are doing at that point, but will continue to observe her for any signs of overdose. I will update the forum with any changes. Thanks for all of you here. It so helps to have people to talk to and also read their experiences with this awful disease.

Deanna and Puckie

[molly muffin]

How is Puckie doing?

Just checking in on you. :)

[deannah]

Thank you Sharlene for your inquiry about Puckie. She is doing okay. Appetite has somewhat gone down, which is okay as she could lose a couple of pounds. However, she has gotten a new sore on her body (the old CC.) I'm wondering if this means her cortisol level needs to be increased or not. Anyone know?

I do know from here that it is best to get her level down to 5 or under. She was as 6.7 last test. I was going to wait for 30 days to have her tested again, but with the new sore I've given thought to have it done sooner. Any thoughts about that?

Other than the sore her symptoms seem okay. She seems to be scratching a bit more. I am using the chlorhexidine and did just get a new one made by Dechra. With the scratching I guess it's time for another bath.

Thanks again for this forum. It's invaluable as there is not a lot of info out there!

Deanna and Puckie

[molly muffin]

Calicum deposits under the skin that where already there can take months to break through, so No I wouldn't necessarily assume that her cortisol is up and needs to come down more.

Yes you really do want it under 5 ug, but cc is hard to clear up even then. It takes a lot of time for these to come through. You are looking at months. I know it's hard not to panic when you see a new one though.

Glad Puckie is doing well. Stay on the game plan, retest and then you'll know how the cortisol is doing.