New to the Cushing World! 7 year old dog

[Gwenny6]

Hello!

I am new to the Cushings world so I wanted to join here to make sure I am being advised the correct info by vet and to keep myself updated. My name is Jackie and my dogs name is Gwen. She will be 7 in August. I originally brought her to the vet due to hair loss and the Vet questioned her big belly as this could be a sign of Cushings. She was always hungry and thirsty also so the vet took a blood sample. Turns out she does have Cushings.

She began Lysodren, 500mg 2x/day on 7/15/2015. Today (7/26/2015) she wasn't inhaling her breakfast as she normally does. I did not give her am dose of Lysodren. I called the vet and he said not to give her the Lysodren today. He is not her normal vet - he is the on call vet for Sunday. He said that he will leave a note in her file and the Vet will get back to me tomorrow. I asked if I have to give the emergency prednisone that the vet previously gave me. He asked if she was lazier than normal. I said that it's hard to tell since she is always lazy! However, she is still peeing, pooping, eating treats when given, etc. so he said not to give the prednisone.
She is also on Simplicef 200mg tablets, 1 time per day (started 7/13/15. today is last day of this medication. Antibiotic due to a large scratch on her head that she kept scratching open).

If anyone can give any feedback, info, next steps it will be greatly appreciated. I already read the article on here for the Lysodren "loading" phase.

[Gwenny6]

As a follow up, Gwen definitely seem lethargic, took her a minute or so to get up outside, drooling more than usual so I called the vet back. He said to give her 20mg of the Prednisone. I just gave it to her. Any advice on what to look for or to expect would be much appreciated! I'm a nervous wreck over this!!

[My sweet Ginger]

Hi and I'd like to welcome you and Gwen to the forum.

Can you please tell us how much Gwen weighs?
Is she doing better after prednisone?
Song

[Gwenny6]

Thank you for your reply! I am a nervous wreck! It's painful to watch her be lethargic (slow to walk, etc). and I'm second guessing myself hoping that she wasn't on the Lysodren for too long since I'm reading a lot of dogs are loaded after 6 days. Gwen weighs 64lbs (overweight!!).

I gave her the prednisone almost an hour ago. She is still sleeping. As I said in my previous post it is hard to tell with her since she is always lazy and sleepy! Do you think she is in the Addisonian crisis or just loaded? Do I give more prednisone tonight or wait until I call the vet tomorrow at 8am? (The vet is on call all night tonight if I needed to contact him. However, the advice on this forum is amazing so I would prefer your advice!)

Thank you again!!!!!

[Squirt's Mom]

Hi and welcome to you and Gwen! :)

Ok at 64 lbs her dose should be ok at 1000mg a day (500mg AM and PM). The loading dose for Lyso is 50mg per kg per day. At 64lbs, Gwen weighs 29.09kg (64 / 2.2) so her dose would be calculated as 50mg x 29.09 = 1454.5 mg per day. So 1000mg a day should be fine however your vet is using the drug wrong. You need to STOP the med for now, call the vet in the morning for an ACTH asap.


She began Lysodren, 500mg 2x/day on 7/15/2015. Today (7/26/2015) she wasn't inhaling her breakfast as she normally does.

The correct way to use this drug is in two phases. The first is called the loading phase and stops when the dog shows signs you vet should have told you to watch for. The dog then has an ACTH to see where the cortisol level is after the load. If it is within range for a pup on Lyso, which is 1-5ug/dl, then the pup goes on to the second phase called maintenance in which the pup gets a dose 2-4 times a week NOT DAILY. So your baby should be taking 1000mg a WEEK not a day by now.

Have you seen any loose stools or diarrhea? nausea or vomiting? Has she lost her appetite? If you have seen ANY of these things along with the lethargy, get her to an ER now for an ACTH and to have her electrolytes checked.

Let us hear from you!
Hugs,
Leslie and the gang

[Gwenny6]

Thanks for your reply!! She has been on the loading stage since 7/15/2015 (500mg two times a day). This morning she ate all of her food but very slowly. I did not give today's dose of Lysodren and I am not going to. So she was loading from 7/15 to 7/25.

I know that the next stage will be maintance after they do the ACTH test.

Since she did seem sluggish today - slower walk, took longer than usual to stand up- I gave her 20mg. of Prednisone after speaking to the vet. I gave her the pred about an hour and a half ago and she is still sleeping. She just heard a noise and is her usual self with barking - just took her a little extra time to get up. Her walk is slower than usual.

No vomit or diarrhea. She is still eating treats. I am going to feed dinner now and see how much she eats.


I am going to call the vet in the am but just wanted some feedback regarding the process so far. Thanks!!

[Gwenny6]

Just fed her dinner. She ate about 3/4 of her food but very slowly. She seems to be drooling more than usual as well.

How long does the loading phase usually last for? I am assuming 11 days of it was too much?

[My sweet Ginger]

I was wondering about the length of loading because it seems longer than usual but her weight of 64lbs at a lower end of Lysodren loading dosage may explain why it took her longer than usual loading time. So maybe she will be ok even though she's slower and sleepy.
The signs of an overdose are poor appetite, increased sleep, diarrhea, vomiting, falling over while getting up or walking, swaying when walking (my pup did a lot of this).

I think the standard emergency rescue dose of prednisone is .25mg/kg so I think she got a hefty amount of prednisone so I wouldn't give her anymore tonight and talk to her vet early tomorrow morning.
Just watch her closely and she should get her ACTH stimulation test done after 48hrs although 48hrs is somewhat in question these days but it makes the most sense to me as Lysodren still works for another 48hrs from the last administration.
I think and hope she will be ok if she is still responsive.

[Gwenny6]

Yesterday evening about 3-4 hours after giving 20mg pred, Gwen seemed to have a little more pep in her step. Her eyes were still droopy, still drooling (seems like the back corners of her mouth - and when she ate the food would come out of these spots as well), and still overall slow and lethargic. She peed and pooped before bed. In the middle of the night she woke up and drank tons of water and peed. In the morning she usually pops out of bed, especially when she hears the other dogs barking. Today it took me prompting her to get up. She kind of fell off the bed so I know her footing is still off - seems like the back legs. She does still have an appetite, eating treats. I will be calling the vet at 8 to see what to do and if this is normal.

[Squirt's Mom]

Do Gwen a favor and don't ask the vet what to do - TELL him you want an ACTH and her electrolytes checked this morning, ASAP. ;) It is obvious from the way he is handling this very powerful drug that he is not familiar with it nor this disease. So often our well- and long-loved vets have put our precious baby's lives at risk because they simply did not have the experience needed to deal with this very complex disease. You must be Gwen's voice - she cannot speak for herself.

Let us know what you learn today after talking to the vet and hopefully they see Gwen very early.

Hugs,
Leslie and the gang

[My sweet Ginger]

I'm glad her poops are normal and she still eats ok. The drinking tons of water and peeing during the night probably has a lot to do with the hefty dose of pred from yesterday.
Hind leg weakness and lethargy are not normal.
My hope is that she gets better so that she can get her ACTH test done this afternoon by waiting a few more hrs. That will bring her very close to 48 hrs after Lysodren but more importantly will be at least 24 hrs after prednisone so she can get as close to her true cortisol values as possible when prednisone is out of her system. Also have them check her electrolytes. As I've said this is only my hope.
All bets are off tho if she gets worse and she should be seen by her vet immediately.
Please let us know what your vet's plans are.

[Gwenny6]

I just called and the vet tech said that the vet will be in at 9 and she will give her the message. Gwen is definitely alert but I can tell she doesn't feel well at all. If I don't hear from the Vet at 9:15 I am going to call her back. Thanks for the input. So stressful

[Gwenny6]

Has anyone heard of or used Adrenal harmony gold?

[Squirt's Mom]

Let us know what they vet says, sweetie, and keep a very close eye on your baby meantime. As for the Adrenal Harmony or Adrenal Gold or whatever they are calling themselves now, it is not going to help with the cortisol, the enemy in Cushing's. It might help with some of the signs but it may also make some worse. I wouldn't waste my money myself. Same goes for Cushex and all those other "cures" you find on the web. Honestly, if these things worked would this site be needed? No because everyone would be using those things with success. ;) But they don't work so here we are.

[Gwenny6]

Thank you so much for the support!! Which #s do you need? Electrolytes and ACTH? I want to make sure to request the correct info from vet. Thanks again!!

[My sweet Ginger]

Yes, both.

[Gwenny6]

Just spoke to vet. She said to give Gwen 20 more mg of Prednisone and bring her in at 1pm for the ATCH test. Thoughts?

[My sweet Ginger]

How is she doing compared to early this morning?

[Gwenny6]

Still sleepy and droopy eyes but eating and drinking. Just doesn't seem herself. Will the extra prednisone not give accurate results for the ACTH test?

[deannah]

Still sleepy and droopy eyes but eating and drinking. Just doesn't seem herself. Will the extra prednisone not give accurate results for the ACTH test?

I think that having prednisone in her system would make the results of the ACTH test inaccurate. Any experts thoughts? I'm a beginner in this disease, but following this thread.

[My sweet Ginger]

I think it will def skew the results of ACTH especially at that dose for her weight. With additional 20mg, we probably will be able to tell whether or not her adrenal glands are stimulating but will be hard to tell what her true cortisol values are.
If it were me I'd try to wait until 1pm without giving her another 20mg if she seems to be doing ok but I'm not with her nor a vet.
It probably will depend on how well or not well she's doing in the next few hrs.
I hope other more experienced members with more knowledge will stop by and give their thoughts on it.

[Squirt's Mom]

Since she is eating and drinking, I think I would withhold the pred. Have you seen any loose stools or diarrhea?

[Gwenny6]

No diahrrea or loose stools at all. I gave her the Prednisone after I spoke to the vet. My mom is home with Gwen and she said she has not gotten any worse. I'm feeling frustrated that the numbers will be skewed. I guess I will wait to see what she says and report back to you guys ASAP. If she recommends more pred ater is the 20 mg too high?

[Squirt's Mom]

The rescue dose for pred is 0.25mg/kg. At 64 lbs Gwen weighs 29.09kg so her rescue dose would be 29.09 x 0.25mg = 7.27mg. So 20 mg is more than enough, way too much for a rescue dose in fact but the vet may be thinking along another line that she thinks may require this higher dose. See what she says when you see her today.

[Gwenny6]

Just got back from the vet. They did the ACTH test so I will call tomorrow to see results. She said not to give anymore prednisone and obviously no Lysodren yet.

Gwen is definitely a lot better. Still drooling a lot and not herself though. Vet said drooling is probably from nausea.

The catalyst Dx test that they did today (is this the Electrolyte?):
BUN - 24mg/dL
Na - 153 mmol/L
K - 4.5 mmol/L
Na/K - 34
Cl - 113 mmol/L

This test was done at 1:15pm, 3.5 hours after the last 20mg dose of prednisone.

[My sweet Ginger]

What are the normal ranges for those values?

[Gwenny6]

What are the normal ranges for those values?

The catalyst Dx test that they did today:
BUN - 24mg/dL (normal range 7-27)
Na - 153 mmol/L (normal range 144-160)
K - 4.5 mmol/L (normal range 3.5 - 5.8)
Na/K - 34 (no range given....)
Cl - 113 mmol/L (normal range 109-122)


Vet also said that the Pred shouldn't effect the ACTH test.

[My sweet Ginger]

That's a relief. Everything looks good.
I do think pred affects the ACTH results as cortisol and pred are both steroid. Let's hope for the minimal effect and wait for the results.

[labblab]

Hello from me!


Vet also said that the Pred shouldn't effect the ACTH test.
l am afraid your vet is flat-out wrong about this. :(

If the ACTH stimulation test was performed less than four hours after receiving a 20 mg. dose of prednisone, it will most certainly skew the results upwards and render them inaccurate. The ACTH cannot distinguish between naturally-occurring cortisol and supplemental prednisone in the bloodstream. There is another type of steroid, dexamethasone, that can be given that will not affect an ACTH. But prednisone definitely will.

We can provide citations for this if you need them to present to your vet. But she needs to provide you with another test, for free, at a later time (at least 24 hours after any prednisone).

Marianne

[Gwenny6]

Hello from me!


l am afraid your vet is flat-out wrong about this. :(

If the ACTH stimulation test was performed less than four hours after receiving a 20 mg. dose of prednisone, it will most certainly skew the results upwards and render them inaccurate. The ACTH cannot distinguish between naturally-occurring cortisol and supplemental prednisone in the bloodstream. There is another type of steroid, dexamethasone, that can be given that will not affect an ACTH. But prednisone definitely will.



We can provide citations for this if you need them to present to your vet. But she needs to provide you with another test, for free, at a later time (at least 24 hours after any prednisone).

Marianne

Thank you for your reply!! I was definitely thinking the pred would effect!!! Gave her 20mg. pred at 9:30am. She had the first blood drawn at 1:15pm and the second one at 2:15pm.

So the ATCH will show the amount of cortisol and that will tell the vet what her weekly dosage of Lysodren will be? However, since the pred was given, sounds like that number will be inaccurate. :eek::(

[labblab]

Unfortunately, that is correct. Here is one quote from a veterinary testing laboratory in relation to using the ACTH to test for Addison's (you can find the same info from any lab :o). The info is true no matter what the ACTH is being used for. If only your vet had not told you to give more prednisone right before the test!


Prednisolone, prednisone and hydrocortisone will cross-react in the cortisol assay and give falsely elevated results. Such therapies should be avoided in the 24 to 36 hours prior to the test.

http://thehormonelab.com/handbook/adrenocortical-function/canine-hypoadrenocorticism-addisons-disease

[Gwenny6]

If this current test were to be valid, she would go on the Lysodren 1x per week (during loading it was 500mg 2 times per day) and then how often would she get the ACTH test done? Is the maintanace phase of Lysodren usually the dose during loading but just once per week (1000mg 1x week)?

[labblab]

When shifting to the maintenance phase, it is often the case that the same amount of Lysodren that was given daily is instead given weekly. Rather than giving the entire amount on one day, however, it is often recommended to split the total so that incremental doses are given two or three times during the course of the week (in other words, every two or three days). Sometimes the weekly maintenance total will vary a bit from the daily loading total, too, depending upon how quickly or slowly the dog loaded and whether or not there were ill effects from the drug. Since I used trilostane with my dog, I'm honestly not sure what the recommended ACTH testing regimen is for a dog on maintenance Lysodren -- I'll let other folks guide you who are more experienced with that part of things.

First things first, however, and I'm still really worried about your vet's apparent lack of familiarity with proper treatment and monitoring procedures, overall. I've read back through your entire thread, now, and I am wondering exactly what instructions you were originally given re: judging when the load was complete and/or when ACTH testing should be done. It kinda sounds as though you were just sent off with the medication and not much information at all as far as what to watch for and what you should be doing. Telling you today to give the prednisone right before the ACTH test does not make me feel any better about things. :( :( :(

I have to repeat that there is no way in which today's ACTH can give you valid results upon which to base Gwen's true adrenal function at this point in time. Here is another quote. This is from a blog authored by Dr. Mark Peterson who is a noted canine endocrinologist. His reply relates to trilostane treatment, but the point he makes would be identical even if the dog in question were being treated with Lysodren. If prednisone has been given too close to the timing of an ACTH stimulation test, dosing decisions can be totally compromised.


It is possible, however, that you are measuring some of the prednisone in the assay for cortisol, especially if you are giving the prednisone within 24 hours of the ACTH stimulation test. Prednisone and prednisolone will both cross-react in the cortisol assay to falsely increase the measured serum cortisol values. If this is true, basal and post-ACTH stimulated cortisol values in this dog could be very low, and the dose of the trilostane may need to be decreased even further or possibly discontinued.

I am worried that Gwen's ACTH will come back appearing to be either in the desired therapeutic range or even looking high, and that your vet will misinterpret these results. Based on Gwen's behavior prior to receiving the prednisone, she absolutely should not be given any more Lysodren at all -- either as a loading or maintenance dose -- until she's had a repeat ACTH that establishes the true level of her natural cortisol production. If it has fallen too low, she may actually need to continue with some daily supplemental prednisone (but at a lower dose than 20 mg.) for an indeterminate period of time. You simply cannot accept the results of today's ACTH as the basis for any dosing decision, other than NO MORE LYSODREN for now. I know this information makes things very awkward and inconvenient for you vis-a-vis the vet and also Gwen's treatment, but I don't know any way of sugar-coating the fact that improper Lysodren treatment and monitoring can kill a dog (and the same is true for trilostane). You've got to be working with a vet who knows what he/she is doing.

Marianne

[Gwenny6]

Thank you so much for your thorough response.

I have heard that in normal cases the ACTH should be run 48 hours after the last dose of Lysodren (which would have been today at 3:30 however since prednisone was given that is out the window!!). If I call my vet back regarding the skewed results of the ACTH test due to prednisone, when would you recommend another ACTH be ran? Would it give accurate results since she would have been off of the Lysodren for more than 3 days? If I stop today with the Prednisone (which I did) when will the ACTH give an accurate result? And you are saying that if I got an accurate ACTH test from today it may show that she needs more prednisone before starting maintenance Lysodren correct?

Regarding the Lysodren, I was given 40 pills 50mg and was told if notice not hungry, diarrhea or vomit to call the office immediately. I was also given Prednisone tablets as a backup.

And I completely agree with you. I feel TOTALLY uneasy about this vet. I go to a vet practice where they see any vet. When I went for her annual exam this is the vet that I got and she did tests and diagnosed Gwen so that's the only reason I continued seeing her. I asked her how often she deals with cushings and she said a lot. But after reading on here I feel really uneasy!

[Gwenny6]

What would be the long term effects if I didn't treat her for Cushings?

[labblab]

Probably retesting as soon as tomorrow afternoon would be fine, since that would be a bit longer than 24 hours since the last prednisone. Even if it is three days since the last Lysodren, that is fine, because what you are wanting to measure is her current cortisol production as of the time of the ACTH test. You will not be restarting Lysodren until you know her ACTH results are high enough. But testing again tomorrow is assuming that Gwen does OK between now and then and does not "crash" such that she actually needs some more steroid supplementation again before then. If that should happen, it would be much better if you could get some dexamethasone to give Gwen instead of prednisone. That way, the testing could still go forward, regardless.

But if she really crashes and acts like she needs more prednisone and that's what you've got on hand, that takes precedence over everything else. When a dog's adrenal function has been overly suppressed by medication, they sometimes have to continue on supplemental steroids for a period of time until their natural adrenal function rebounds again.

[labblab]

As far as long-term effects of not treating, all those symptoms will likely get worse. Plus, she can suffer internal damage, too. But let's not go there yet! Right now, I'm sure you are feeling totally frazzled and frustrated. But once you get this treatment protocol straightened out, there is every likelihood that Gwen will do just fine!

[Gwenny6]

Spoke to vet.

Her ACTH results - pre # was 1.8 (think it should be between 2-6) and post # was 3.6 (think it should be 6-18).

Vet told me to give her 10mg. Prednisone this am and tonight. I will call vet tomorrow with how Gwen's doing. She seems better today but still a little wobbly, eyes glassy and ears still back (normally ears stand straight up!).

[labblab]

Did you discuss with your vet the problems with the ACTH testing?

Just so you'll know, the range you have been given is the "normal" range for the test when it is used for diagnostic purposes, not for monitoring purposes. In other words, when the ACTH is being used to initially diagnose Cushing's (or Addison's), a normal dog will exhibit results in the range you've been given.

When the ACTH is used for monitoring Lysodren treatment, however, a different range is used. You are looking for a post-ACTH result between 1-5. So on the face of it, Gwen's result looks good, and right where you'd want things to be when you are ready to launch into maintenance dosing. The HUGE problem, however, is that she registered this result four hours after having been given 20 mg. of prednisone. This means her natural cortisol production was likely lower, and likely much lower. Perhaps even too low.

The pre-testing prednisone issue has got to be squared away with your vet before proceeding further with Gwen's treatment. It is not safe to move forward without knowing the status of her natural cortisol production. The longer you wait to find that out, the longer you risk either extreme: either you may prolong the supplemental prednisone too long before resuming Lysodren and lose the benefit of the initial load (i.e., have to start loading all over again) or you may stop the supplemental prednisone too soon and resume the Lysodren prematurely (risking Addison's).

Since Gwen had gotten more prednisone, she still cannot be retested accurately. If you and your vet think she still needs to be on a supplemental steroid, can you ask your vet for dexamethasone instead of prednisone so that the ACTH can go forward accurately?

Marianne

[labblab]

Also, for what it's worth, a daily total of 20 mg. is really high as a replacement steroid dose for a dog of Gwen's weight (29 kg. or 64 lb.). The typical physiologic rescue dose for a dog of Gwen's weight wouldn't exceed more than about 6-7 mg. per day. So if you keep on giving 20 mg. total for very long, she will probably start exhibiting a rebound of Cushing's symptoms based solely on the excessive supplemental steroid in her system. :o

[labblab]

Hi again! Just wondering how Gwen is doing? Hoping for an update soon, and to hear that she is feeling better.

Marianne

[Gwenny6]

Hi everyone!!!! Sorry for my lapse in posting. A lot has been going on.....the good thing is that I have an appointment tomorrow afternoon to see an Internal Specialist so we can get this figured out. What a whirlwind. However, I feel so excited and hopeful that I am see if someone who specializes in this!

[molly muffin]

Crossing fingers and hoping for some good guidance.

I have to say that I can't even imagine dealing with all the aspects of cushings possibilities without having my IMS handy.

Good luck!

[Gwenny6]

Went to IMS yesterday. She is more concerned about Gwens head tilt, wobbliness and stumbling. She has also been more sensitive to sound, smelling the grass a lot more outside, and randomly rubbing her ears. We are not treating for Cushings right now. Hoping it is just an inner ear infection and not a brain tumor causing these symptoms. She started 375mg of Clavamox 2x a day this am and we will go back to IMS in 2 weeks. MRI to see if tumor is thousands of dollars which I cannot afford. IMS was also concerned with Gwens vision since her eyes did not flinch when she did a few tests. She wiLl probably dialate them at our next visit. Praying she makes a recovery. :(:( I am distraught.

IMS does not think this has to do w/ the Lysodren.

Edit: Blood pressure was normal yesterday when IMS took it

[labblab]

Is Gwen still taking prednisone? Has anyone performed an ACTH test other than the one that was done right after she took the 20 mg. of prednisone? If not, I don't see how the IMS can rule out low cortisol as a contributing problem unless Gwen is still taking supplemental prednisone and yet is still experiencing these problems.

I just find it very coincidental that all these problems emerged right in the midst of Lysodren loading unless Gwen's adrenal function is also involved. Unless an accurate ACTH is performed, you cannot know for certain, and I hoped/assumed the IMS would make sure one was done. :(

Marianne

[Gwenny6]

Gwen hasn't taken pred since 8/2/15. I left the IMS a voicemail message about an hour ago bc I was also wondering if these side effects could be from low cortisol. She has not had another ACTH test done. The IMS didn't mention it yesterday but I will ask her. Could these symptoms be from low cortisol? Been doing research and haven't seen that

[labblab]

Aside from the visual issues, Gwen's problems are classic symptoms of low cortisol:


Lysodren is effective, yet it carries a great potential for serious side effects. If too much adrenal tissue is destroyed, a dog can be given permanent Addison's disease, hypoadrenocorticism (the opposite of Cushing's). This occurs inadvertently in approximately 5% of dogs given lysodren. A small minority of veterinary practitioners actually do this intentionally, and then they maintain the dog on daily medications for life. The risk of untreated Addison's is that a hypoadrenocorticoid dog can't manage stress the way a normal dog can, and can die from shock and heart failure. A normal body requires steroid hormones in order to survive.

More typically, a dog will experience a lysodren reaction in which cortisol levels are acutely too low. This occurs in approximately one third of canine patients and can be reflected in inappetence, vomiting, diarrhea, muscle weakness, wobbliness, lethargy, or even collapse and death. Less than 1% of dogs experience fatal complications. Owners must carefully monitor dogs taking lysodren and respond to such adverse reactions by stopping the lysodren and administering prednisone. Also, dogs on lysodren must receive periodic ACTH stimulation tests to monitor their blood cortisol levels. Thus, treating with lysodren requires a greater than average owner commitment to monitoring their dog.

I do not understand why the IMS would not have tested Gwen's cortisol. If her adrenal function is still oversuppressed and she is not receiving adequate replacement in the meantime, then most of her problems could be easily explained. Since she has not received any prednisone for several days, this would be the perfect time to test her natural cortisol production. Your original vet should have retested for free since it was bungled the first time around. But regardless, one needs to be done immediately by somebody.

[Gwenny6]

I completely agree with you. My emotions have been crazy I didn't even fully think about ACTH test. Just called IMS and left another message. Will the antibiotic effect the results?

[labblab]

No, the antibiotics should have no effect. Hey, don't beat yourself up -- the IMS should have pursued this on her own after learning about Gwen's history with the Lysodren loading and the prednisone! :o :o

[My sweet Ginger]

Since there's a possibility of Gwen's cortisol being too low I'd demand an ACTH asap to see where her cortisol levels are and go from there.
Although not all symptoms Gwen's experiencing are necessarily from low cortisol, definitely the wobbliness and stumbling are. Unfortunately I know all so well about them from my pup's during and after Lysodren treatment. We'd spent over thousand dollars just trying to figure out what was wrong with my baby with an IMS and after all the tests she still didn't have an answer for us. :eek::(:mad:
I took her to another IMS and after she read her records and my journal she didn't even want to run any tests because it was too obvious to her that my pup was suffering from low cortisol. So the first was very nice but clueless in that regard, hard to believe it but true.
So, in Gwen's case I'd like to know where Gwen's cortisol is right now before I do anything else.

[labblab]

Since there's a possibility of Gwen's cortisol being too low I'd demand an ACTH asap to see where her cortisol levels are and go from there.
Although not all symptoms Gwen's experiencing are necessarily from low cortisol, definitely the wobbliness and stumbling are. Unfortunately I know all so well about them from my pup's during and after Lysodren treatment. We'd spent over thousand dollars just trying to figure out what was wrong with my baby with an IMS and after all the tests she still didn't have an answer for us. :eek::(:mad:
I took her to another IMS and after she read her records and my journal she didn't even want to run any tests because it was too obvious to her that my pup was suffering from low cortisol. So the first was very nice but clueless in that regard, hard to believe it but true.
So, in Gwen's case I'd like to know where Gwen's cortisol is right now before I do anything else.
Yes, I think Song is exactly right about this. I should have qualified earlier that it may indeed be the case that something else is also going on with Gwen. But it seems to me that the possibility of low cortisol is the most obvious and immediate issue to be investigated first.

[Gwenny6]

Thanks so much guys. I 100% agree with you both. When I speak to IMS, if she says not necessary I'm going to say I want it anyway. I don't have the money but I would rather spend the $350 for the test to rule out the low cortisol. I have been wanting the ACTH test for a while now. Asked my previous vet but she said not necessary. I should have demanded it. I can be a bossy son of a gun in other aspects of my life so I don't know why when dealing with my best buddy Gwen and these vets I haven't been the same. I will keep you guys updated and I am def going to get ACTH test done.

[Gwenny6]

Going to vet this am for ACTH and electrolyte test. Will keep everyone updated!!!

[labblab]

Yay!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

[My sweet Ginger]

Gwen should be very proud of her mom. :)
How is she doing?

[Squirt's Mom]

OH good! Even if the results are normal you have info you didn't have before and can look elsewhere with a clear eye knowing the cortisol and electrolytes have been checked. Way to go, Mom! :cool::cool::cool:

[Gwenny6]

Thanks everyone!!!! Her electrolytes were all in normal range. Her ACTH results will be in this am so I will post as soon as I find out.

She started eating slow on Thursday morning. I gave her the Clavamox Thursday mid morning. Yesterday she was still eating slow. This morning she didn't even eat half of her food. I guess I will try to get her to eat more before I give her the Clav. this morning?

Hoping this is all just from low cortisol. We will soon find out....

[Gwenny6]

Test results still aren't a back yet. What should the pre and post numbers look like to show that she has enough cortisol?

[judymaggie]

Hi! Clavamox can be real rough on a dog's tummy. You might try giving Gwen pepcid (original) 15-20 minutes before her meal. You can ask your vet (or, if better for you, one of the vet techs that works with the IMS) for the appropriate dose for Gwen. I buy generic pepcid (famotidine) and it is really inexpensive -- just make certain that it is the original pepcid -- some of the other versions have other ingredients in them. My Abbie weighs 24 lbs. and gets 5 mg. before each meal (after which she gets Vetoryl).

[Gwenny6]

Her pre # is .2 and her post is .2.

On hold with IMS office right now bc she is the last one who treated her. However she is not in until tomorrow morning. Not sure if should give her pred.

I'm livid that I had to request this test and the vets didn't think this was a possibility of low cortisol!!!!! Could the antibiotic have effected the ACTH numbers #s?

[Squirt's Mom]

Gods, yes, give her the pred! My goodness...no wonder she hasn't been feeling good!

[labblab]

Her pre # is .2 and her post is .2.

On hold with IMS office right now bc she is the last one who treated her. However she is not in until tomorrow morning. Not sure if should give her pred.

I'm livid that I had to request this test and the vets didn't think this was a possibility of low cortisol!!!!! Could the antibiotic have effected the ACTH numbers #s?
OMG, well I guess we have our answer, or at least part of our answer!!! Gwen's cortisol is definitely too, too, too low with no adrenal reserves whatsoever. :( :( :( And no, the antibiotic ought not to have any effect on the test results.

With those results, I absolutely would not wait until Monday to give prednisone. So if the IMS office has nobody to cover appropriately, I would go ahead on my own and give her the medication. Do you only have 20 mg. tablets on hand? If so, given Gwen's weight, 1/2 a tablet or 10 mg. daily may be enough to replace the cortisol that Gwen is lacking. I believe that is where I would start, with 10 mg., and seeing how she responds to that.

Bear in mind I am not a vet, but I would forget about the Clavamox for the moment since Judy is right, it can definitely upset the GI system and that is the last thing Gwen needs right now if she does not feel like eating. And from what I can tell, the inner ear infection was just a shot in the dark, anyway, so there's not anything definitive to indicate that Gwen even needs to be taking the antibiotic anyway.

Marianne

[My sweet Ginger]

Yes, please. Please give Gwen prednisone like right now.
You know I'm crying reading the results of her ACTH because it brings me all the way back to the start of our long and winding maze.
Ginger's were 2.9 for both pre and post. We call them a blunted ACTH response and in some cases numbers by themselves don't really look bad enough. In fact I remember our GP vet telling me that her numbers were perfect.:eek: I only later found out that with those blunted numbers there wasn't any stimulation in her cortisol. The post number should be higher than the pre.

I'm so sorry this happened. I hope her adrenal glands will recover in time but she will need to go on prednisone therapy for as long as she needs.
What did your vet tell you to do? Please let us know.

Yes, if no instructions from from your IMS or vet, I'd go with 10mg once a day as Marianne suggested. That will be a tad more than the recommended rescue dose of 0.25 mg/kg but she may well need it right now.

[labblab]

Yes, as Song says, Gwen may need supplemental daily prednisone for an extended time period. It has now been almost two weeks since her last dose of Lysodren, so with numbers remaining this low and flat, we have to assume there has been minimal to no adrenal rejuvenation thus far.

The good news is that her electrolytes are OK. So that makes it seem as though Gwen's aldosterone production was not affected as severely as her cortisol. That makes the Addisonian treatment much simpler, and apparently limited only to the need to supplement cortisol alone.

I share your indignation over Gwen's vet care. Your first vet absolutely needs to know how severely she compromised Gwen's treatment by, excuse me for saying so, stupidly telling you to give Gwen 20 mg. of prednisone right before the ACTH. Now we know just how severely that skewed the results. It's apparent that Gwen has been Addisonian since that last dose of Lysodren, and her condition ought to have been identified and appropriately treated beginning clear back then. :mad:

Marianne

[My sweet Ginger]

Yes, that's exactly what happened to Ginger too. Her electrolytes were were not compromised, only her cortisol. As some of you may remember Ginger was on pred for over a year.
Also she never regained her appetite back fully and is still on appetite stimulant to this date.
Gwen will tell you with her clinical signs when her cortisol is rising but for now focus solely on her recovery as it may well be some time later.

[My sweet Ginger]

Oh my Lord, I've just realized the numbers are 0.2 for pre and post both. :eek: I read them as 2 and 2.:o:o
Poor Gwen, I don't even know how she's been managing herself the way she has without downright crashing all these days with these numbers.
I hope she's doing better after taking pred.

[Gwenny6]

I spoke to the emergency vet and she said that it looks like Addison's disease so she had me give her 10mg prednisone. She said to still continue to give antibiotic for ears. I will call the IMS tomorrow. Thoughts?

Thank you to everyone for recommending that we do the ACTH test. You guys are amazing!!!

[Gwenny6]

Just saw all the replies.....THANK YOU!!!!!! LIVID is an understatement for how I am feeling regarding the first vet and the IMS. Shouldn't the first recommendation be an ACTH test? If it weren't for you guys this would have gone in a terrible direction.

The emergency vet said to keep her on the antibiotic bc of the head tilt but I agree with you guys that I don't want it to mess with her GI anymore and she has been on so many meds I would prefer if she didn't have to be on it she shouldn't. Id also like to see if it all clears up just with the pred. Her head tilt doesn't seem as pronounced and it could have just been from her stumbling around.

Again, I truly cannot thank you guys enough!!!!!

[molly muffin]

OMG, just saw this! Definitely prednisone and yes, looks like Addisons.

I'm stunned that they didn't think an ACTH should be the first thing to check. Holy cow.

Well, find out how much they know about Addison from lysodren and if they have experience treating it.
(might also want to call around and find a different IMS/vet) Just a thought, it's up to you, but I'd be livid too and this is a biggee for them to miss and could have been deadly.

Big hugs,

[Gwenny6]

I completely agree!!! I live in NJ if anyone has someone to recommend I would gladly take recommendations. Gwen is now having some mucousy diahrrea. :confused::mad::confused:

[Squirt's Mom]

The bad diarrhea is to be expected with cortisol levels that low. You may notice some nausea and/or vomiting as well. She will not be up to par, but you already have seen that aspect. The pred should help with everything, the diarrhea, nausea, appetite - everything and do so quickly.

If the head tilt is due to some inflammation, the pred will also help with reducing the inflammation but it may NOT address the underlying cause. So keep in mind you may need to deal with whatever is causing the head tilt after she is stable again.

You did good to stand up to the vets and get the test that your baby needed even tho they said she didn't. When you are over being mad and can talk with civility again :D, take the information from the ER vet - tests, etc - along with information on Lysodren and how it is supposed to be used, the signs of an overdose, etc (can be found here in the Helpful Resource section) and the list of signs you were seeing and reported that DID indicate the cortisol had gone too low. Then sit and talk with them - you are in a position to teach them a thing or two about this disease and the drug they are using so they are less apt to harm the next cush baby that walks in their door. ;) The first thing they need to learn is no matter what, when a cush baby on treatment comes in with signs that could mean the cortisol has dropped too low the very FIRST thought should be to do an ACTH and check the electrolytes. Wellness checks and CBCs can be run all on the same blood draw as the one the ACTH is run on so there is no excuse NOT to check the cortisol while looking at organ function, etc.

But for now, Gwen needs your full attention to get her thru this crisis. So don't worry about educating your vets ;) right now; use this time to learn more while you take care of that precious baby girl. I am so so glad she is on the pred and hope you start to see improvement right away.

Hugs,
Leslie and the gang

[My sweet Ginger]

I'm praying Gwen is doing better this morning.

Very well said Les.

Later, when Gwen recovers and you can talk with civility :D;) although educating them of this disease is profoundly more important for their future innocent patients, don't just stop there. Request for a full reimbursement going back to that botched ACTH test and thereafter. She should do it with a full apology if she has any decency and dignity and shame. Also, I'd think she'd like to keep her total incompetence and ignorance very much under wraps if she can, wouldn't you think? :rolleyes: ;)
This is not only because I feel you should be compensated for what you've been going through emotionally and financially but also I want them to be accountable for their actions and learn to think twice when it comes to their patient's safety. In my opinion, both your vet and IMS let you and Gwen down immeasurably. After all they are the professionals and in Gwen's case not just one but both of them failed on many levels.

[labblab]

Just wanted to add that the Clavamox might have caused the diarrhea. It caused loose stools in my dog when we were treating for a UTI, and we had to switch her to a different antibiotic as a result.

Marianne

[Gwenny6]

Thanks for your responses. Gwen seems to be doing a little better today. Just had the little diahrrea last night but back to normal today.

I spoke to the IMS who said to give her 20mg pred for the next 3 days and then 10mg for the next 7 days. I will also continue with the antibiotic just in case there is something there for the ears.

[Gwenny6]

I just wanted to thank everyone again for your help and support throughout this crazy time. You guys saved Gwen's life!!!!! She is doing so much better today!!!!! Praying she keeps improving!!!

[Gwenny6]

When would you guys recommend getting a follow up ACTH test, electrolyte test, etc.?

Vet said she will be on 20mg pred 3 days then 10mg for a week and then possibly 5mg.

Are you guys aware of any previous posts regarding Lysodren induced Addison's? I'm not sure if she has full blown Addison's since her electrolytes are still normal? Is it rare that she will go back to Cushings or it depends?

Marianne - I saw that you mentioned in another post that a resting cortisol test can be done sometimes instead of the ACTH test (NOT to completely replace but just to see if Gwen's first number increases from the .2)?

I have a follow up apt. with the IMS on the 17th but I am not feeling too confident with her right now since she didn't think the ACTH was necessary. Can a regular vet monitor Addison's or do you guys prefer an IMS.

She is also still on the Clavamax.

[labblab]

Hi again! Just wanted to let you know that I have seen your questions but unfortunately do not have time right now to post anything in detail. Hopefully some other folks will also be by to add their thoughts, but I'll try to stop back by tomorrow to offer some comments of my own.

For the time being, it sounds as though you are on the right track in terms of maintaining, but tapering down on the size of, the prednisone dose. Out of curiosity, has the IMS made any comment about Gwen's low cortisol and the benefit of having gone forward with the ACTH????

Marianne

[molly muffin]

We have a member Tina, whose dog Jasper went Addison while on lysodren. This is her thread:

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

It depends on how much of the cortex was eroded and if it will be able to regenerate or not. Which is why a baseline, just to see if that .2 has gone up, wouldn't hurt periodically, but remember you are doing prednison therapy right now, so I I would wait until you have tapered off the prednison, then do a baseline at minimum, but a full ACTH would be better to see if the adrenal glands are able to produce any cortisol.

I prefer to have someone who has Dealt with Addison to monitor it. Tina's regular vet monitors her Jasper, but it really does depend on experience. I certainly understand why you would have some doubts about anyone who was involved in the lysodren/Addison causing scenerio.

As Marianne asked, have they said anything about missing this very crucial, almost no brainer, ACTH testing?

[My sweet Ginger]

Indeed we tapered off pred, decreasing ever so slowly until she was thought to have a macro and then the dosage was increased way up and stayed there for some time. That theory was thrown out after one year and we were finally able to taper her off pred a few months ago. Without MRI, it was by trial and error between IMS and neurologist.

I sure asked IMS when we should do ACTH and her answer was "She will tell you with her clinical signs." So far we only did 1 ACTH which was not to see where her cortisol was but just to see if her adrenals are stimulating at all.

I don't know how your IMS will treat Gwen but in her case I'd do a full ACTH after she's weaned off pred just to make sure her cortisol still not too low and if it still is to continue on with prednisone therapy as long as she needs it. Her adrenal glands may recover rather soon or they may not as my pup's. You just have to wait and see but I wouldn't be too anxious to go back to Lysodren treatment too soon.

[labblab]

Hi again, and how is Gwen doing now? Much better, I hope!

I see that Sharlene and Song have already given you much helpful info. For my part, I honestly don't know how soon another full ACTH should be done -- I would think maybe within 2-4 weeks? It may be that your vet will not want to entirely take her off the prednisone until she has confirmation that Gwen has rebounded with her own cortiol production. If Gwen has been lowered to around 5 mg., though, that seems like a reasonable plateau to remain at until you have those next ACTH results.

Once again, the really important thing to remember is that Gwen has to either be without prednisone for 1-2 days before the testing, or in the alternative, she needs to be dosed with dexamethasone instead of prednisone in advance of the test. Just to reconfirm the issue that was created when your original vet told you to give Gwen prednisone right before the ACTH, here is a set of printed lab interpretations that were included with a diagnostic ACTH that was just posted by another one of our members.


ACTH results should always be interpreted in light of clinical signs. False positive results may occur with stress or non-adrenal illness. In addition, exogenous steroids may be measured by the assay and result in falsely elevated cortisol levels.

As an interim test, yes, I would think you could probably just double-check her resting cortisol to see if it has risen at all. You need the full ACTH to get the complete picture, but under these circumstances, a resting cortisol may give you an indication as to how things are going.

Marianne

[Gwenny6]

Hi everyone!!

Just got back from the Vet. Gwen has been doing great and improving everyday!

She's been on the Clavamox for possible inner ear infection since 8/6/2015. IMS put her on this due to the previous head tilt. She has 3 more days of the Rx to finish up. Vet said today thT the head tilt looks normal so we don't have to continue the antibiotic for another 2 weeks unless I start to see head tilt increase (wondering if the head tilt was due to low cortisol since it effected her spatially).

8/8/15 - 10 mg prednisone after we received ACTH test - .2 pre and .2 post.
8/9/15 - 8/11/2015 - 20mg. Prednisone daily
8/12/15 - 8/16/15 - 10mg. Prednisone daily

IMS did electrolyte test today and everything looked great. So she is thinking it is Atypical Addisons since electrolytes are still normal.

Today we will start 5mg. Prednisone daily for the next 5 days and then do 2.5mg. Pred for some time while monitoring her behavior. If she continues to do well we will do 2.5mg pred every other day. IMS wants to see her back in a month for another electrolyte test. She said we will probably do another ACTH test in about 6 months or so, or depending on how she does with Pred.

Gwen is overweight at 64lbs. She has been at that weight for a couple years. Since the last time we were at the vet (on 8/5/2015) she has lost about 3 lbs. She was 28kg today. IMS said that this could be due to loss of muscle from Pred. Her face looks more like she did when she was a puppy. I also noticed more of her 3rd eyelid the past month or so.

In regards for either the Vet or IMS mentioning it was a good thing I demanded the ACTH - nope!!!! Infuriates me beyond belief. I'm trying to concentrate on the wellbeing of Gwen and not the fact that the vets screwed up. If it wasn't for you guys this would have ended very differently. I know at some point I will write a letter to the vets discussing the severity of this. I don't want this to happen to another dog in the future.

[My sweet Ginger]

That's wonderful, Jackie and what a good girl Gwen is!
I will pray that she will continue to improve.

It sounds like a good plan to me re tapering off prednisone. The important thing is that you have to watch her very closely for signs of low cortisol any time after dosage has been lowered or once she's done with pred.

I wouldn't put any time line yet for her next ACTH as it all depends on Gwen's behavior. Could be right after the tapering off or many, many months later. She will tell you with her clinical signs of Cushings.

Re their blunders, I don't think they will ever admit to it or even mention it first. I do hope you will bring it up to them at some point so some other pups will be saved by your courageous action. I cringe every time I think about all the pups that we haven't heard about on the forum who paid the price dearly, some even with their lives due to these careless and incompetent vets when dealing with this dangerous drug.
I'm very proud of you for standing up to your vets when it really mattered because I know it was NOT an easy thing to do.
Good job, mom. :);)

[mommyslittlegirl]

Hello,i so agree with My Sweet Ginger. I am so very glad you found this forum and stood up to your vets. I found this forum late and so many things are going on with my baby,no one can help her anymore. I should have demanded things which I did not. I thought I had the best vets for her but how wrong I was.

[labblab]

Overall, I feel comfortable with your IMS’s recommendation, too. The one piece that I strongly question is waiting that long for a repeat ACTH. There is no benefit to leaving a dog on prednisone indefinitely if the natural cortisol production has rebounded to a point where the supplemental steroid is not warranted. So if Gwen were mine, I would want to know the status of her own adrenal function sooner rather than so much later. I’m not putting a specific time frame on the testing, but I would think that when you take Gwen back in a month for the electrolytes, you’d at least perhaps want a baseline cortisol performed in order to see whether or not that has risen significantly. It always remains possible that her adrenal function will rebound and she will actually require additional Cushing’s treatment in the future. So either way -- continued low cortisol or high cortisol -- I wouldn't want to wait six months to find out. I don't know why your vets seem to be so resistant to ACTH testing!

I am not overly surprised that Gwen’s electrolytes are remaining normal. I am very glad, because it does simplify her treatment significantly. But when adrenal function has been altered due to Lysodren overdose, I don’t think it’s necessarily uncommon for cortisol to be the only casualty. We’ve had other dogs here, too, that only needed supplementation for low cortisol as opposed to replacement for low aldosterone, as well.

Marianne

[molly muffin]

I agree with Marianne, I wouldn't wait 6 months either, as I'd be going crazy not knowing what her adrenal glands are doing. Regenerating or not.

I am glad she is doing so well now though. That is a good sign.

[Gwenny6]

Hi everyone!

So Gwen was on 2.5 mg of pred every other day and then weaned off as of October 14 (noticed she started to get blackheads on her stomach). Vet told me to wait about a month and then bring her in for ACTH test. I am bringing her in tomorrow.

Just some strange things I am noticing.....patch of blackheads on her belly (she is a white pit bull mix so her belly is basically hairless), darker area on inside of back legs, and blackheads around her butt. Before she started the Lysodren a while ago she had a huge sore on the top of her head which kept scabbing and getting infected. It finally cleared with some antibiotics. I am now noticing a black scab on her back. Not sure if she scrapped it against something or if this is part of the cushings.

Thanks for any feedback!

[labblab]

Hi again, and welcome back! :)

I think the outcome of the ACTH testing will give us some clues regarding Gwen's new skin problems. It is possible that her natural cortisol level has rebounded to a higher level than is desirable, and if so, that may be triggering the skin issues. But we should know more after she is tested tomorrow. So definitely let us know just as soon as those results are back, OK?

How about her other behavior? Is she eating, drinking, peeing, behaving normally since being off the prednisone for this month?

Marianne

[molly muffin]

I totally am onboard with having taken her in for an ACTH test. I think it should be able to tell you more about what might be causing the other things. Blackheads, etc.

Let us know what the test show.

How is she doing otherwise as Marianne asked...eating drinking, etc

[Gwenny6]

Hi everyone!

Behavior is great and she is eating and drinking normally from what I can tell.

Her tests came back. Elctrolytes were good.

ACTH -
Pre was 2.5

Post was 3.5

Vet discussed starting maintenance phase of Lysodren but wanted to follow up with you guys. Those numbers don't seem high so does she need the Lysodren? She said since it took such a toll on her last time to give her 250mg every 3 days. Not starting anything yet.

Thoughts?

Thanks so much!!!