Any help appreciated

[jdroege@bigpond.com]

Hello, I'm new to the forum and hoping for some advise. My 9 years old poodle cross has been through so much over the last 8 weeks. It started with severe pain which turned out to be a mucocele, so after spending $10,000.00AUD we have had 3 abdominal ultrasounds, laparotomy and removal of gallbladder, diagnosis of Cushing's and Trilostane commenced at 20mgs compounded once per day ( 11 pound dog)...it goes on and on. Any way she is 2.5 weeks post op and her liver ALP have come down form 22,000 to 13,000(these figures are correct as they were copied from path results) ALT has also started to come down but I cant remember the figures. Her peeing and drinking have lessoned but she is still vomiting despite giving an anti-emetic and losec for her stomach irritation. Before her sudden onset overnight of abdominal pain she never vomited, now I don't know if its the Trilostane or whatever. The vomiting is about once per day and is undigested food. She has been on the Trilostane since the surgery, she is under a specialist vet but I'm tempted to ask for the dose to be reduced??? Any advise please as most on this forum I desperate to do what's right for her. Thanks Jude

[LauraA]

My girl uses Losec and I know that it causes her to vomit if she is on it too long. It is a common side effect of it, I think it is recommended that you don't use it any longer than 2 weeks at a time. How long has she been vomiting for? I would be feeding boiled chicken and mushy rice for now as it is easier for her tummy to digest. Has pancreatitis been ruled out?

[Squirt's Mom]

If this were my dog, no way in you know where they would be treating for Cushing's right now. With all she had going on I could not trust the test results that said she had Cushing's. Cortisol will rise in a natural response to any stressor so other illnesses can and do cause false positives on the cush tests. My own baby tested positive on five different tests but it turned out she had a tumor on her spleen causing the cortisol to be so elevated. Once the tumor was out, her cortisol returned to normal. Vomiting is also a side effect of Trilostane when it the dose is too high or the dog doesn't have Cushing's to start with. ;) I would stop the Trilo but I am only one voice - others may disagree.

[Harley PoMMom]

I agree with Leslie, I would definitely stop giving the Trilostane. Sometimes the pancreas can become inflamed if manipulated during a surgery, vomiting and abdomen pain are a sure sign of pancreatitis.

IDEXX has a test that is specific in diagnosing pancreatitis, it is called the spec cPL, here's a link about it: http://www.idexx.com.au/smallanimal/reference-laboratories/testmenu/innovative-tests/spec-cpl.html

Cushing's is one of the most difficult canine diseases to diagnose, and unfortunately it is often misdiagnosed. If any underlying illness is present when the tests for Cushing's are performed the chances of false positive results are more likely to happen.

Can you tell us more about your sweet girl so that we can provide you with the best feedback? Could you get copies of the results of all tests that were done on your girl and post those abnormal values here along with the reference ranges and reporting units..e.g...ALT 100 U/L (5-50)...thanks. Also what test was performed to diagnose her Cushing's, and could you post those results? Is she taking any other herbs/supplements/medications?

That starting dose of 20 mg for a 11 lb dog is too high, it is recommended that the initial dose should not exceed 1 mg per pound of a dog's weight, for your girl that would of been 11 mg, so she is taking almost twice the amount that is recommended.

We are here to help in any way we can, do not hesitate to ask all the questions you want. Hope your girl is feeling better real soon.

Hugs, Lori

[labblab]

Hi Jude, welcome from me, too! I'm sorry your poor girl (and you) have been through so much! No wonder you are worried about her.

I just wanted to add one note, and that is that even though we are expressing concerns about the trilostane, I don't think you should change anything without discussing/informing your specialist. I do agree with Leslie and Lori's concern, and especially with the worry that the newest dosing recommendations are to start dogs off at amounts no higher than 1 mg. per pound. Here's a link to a thread that talks about that in greater detail.

http://www.k9cushings.com/forum/showthread.php?t=185

However, we only have a few pieces of the puzzle to go on right now. For instance, we don't know the timing of the Cushing's diagnosis and what symptoms contributed to the determination (including symptom duration). Uncontrolled Cushing's can make dogs more vulnerable to both gallbladder mucoceles and also pancreatitis. And there may be a medical reason why your specialist thinks it is especially important to keep cortisol controlled during your dog's recovery. So even though I think it is important for you to discuss your worries about the vomiting in relation to the trilostane (and also the size of the dose -- I would want it reduced, too, to begin with), I think you need to first talk to the specialist before making any changes.

Marianne

[molly muffin]

Hello and welcome. I have the same concerns and agree, that this has to be discussed with your vet.

I'm going to throw something else into the mix, we have another dog on the forum who was diagnosed with cushings, and also had to have the gallbladder removed. She had a liver infection, only found during the gall bladder removal, but they treated that and didn't give her the trilostane, because they too thought cushings. Since the gall bladder removal and the anitibiotics, her liver number have come down pretty close to normal, everything else is normal now and no cushings.

Cortisol Will raise when something else is going on and can cause false positives on cushings tests.

This is a link to Icy's thread: http://www.k9cushings.com/forum/showthread.php?t=6980

[jdroege@bigpond.com]

Thank you for your responses, she became acutely unwell with severe abdominal pain 8 weeks ago, immediately able to diagnose UTI and ALP were at8,000 initially ( they were slightly raised when she had a her crucial element repaired last December). She was initially treated with antibiotics, denosyl and urodeoxychloric acid and has mucocele diagnosed by ultrasound. She seemed to be responding but them became more unwell with some vomiting, not eating etc, the pain had gone though. Vet got another ultrasound done that showed mucocele reduced, did the Cushings blood test( had to leave her at the vets for awhile) and found her ALP had risen to 13,000. Then 3 weeks ago another blood test showed ALP risen to 22,000 and vomiting/ poor eating continued and got referred to specialist vet hospital. Laparotomy done 19 days ago and gall bladder removed and liver biopsy, all other organs checked including a lymph node sent for biopsy. she has recovered well from surgery. The specialist vet started her on the Trilostane 20 mgs daily 2 days after surgery, I was told to dose her twice a day starting last Friday but I have kept it at the once per day. Her ALP last Friday when tested was back down to 13,000 and her other liver enzymes were also reducing. She will eat normally now but has some lethargy and vomits on an irregular basis, this morning I awoke to the sound of vomiting on our carpet at 5.30 am !!!. She was started on the Losec last Friday and I do have an anti emetic to give her but only give it in the morning before my elderly parents puppy sit her for me when I'm at work. Before all this she was drinking litres and going outside to pee during the night etc, this seems to have reduced considerably. My own vet was a vet in the UK when Trilostane was first used and he voiced concerns about the initial starting dose as well. The specialist vet has said he doesn't need to see us for another 2.5 weeks unless there are issues, im thinking that if she vomits again tonight I will call him and ask if I can stop the Trilostane until her liver enzymes have gone down and then retest for Cushings again. At present she is still on Denosyl, an antibiotic due to finish in 3 days, Losec, anti emetic as needed, Trilostane and Ursodeoxycholic acid. I'm not worried about having to spend more money ( my husband loves our dog and knows how much I love her). It's hard to know if vomiting is the liver or Cushings treatment. The specialist vet seemed to think that's it was vital to treat the Cushings. Thank you you all so much.

[Harley PoMMom]

Vomiting at any time while on Trilostane is not a good thing so it is highly recommended that the Trilostane be withheld until the dog has stopped vomiting and their appetite is completely normal again.

[Squirt's Mom]

Please please please stop the Trilostane for now.

[jdroege@bigpond.com]

You are all right, After another smelly vomit hours after she had eaten I have decided enough is enough. I couldn't get hold of the vet specialist vet so have emailed him to let him know what's happening. If the vomiting stops we will know it's the meds......if she keeps vomiting then we will need to look at what else. I know our regular vet was alarmed about the starting dose and asked me to double check there wasn't a mistake with the compounding pharmacy. The specialist vet had even expected me to increase her dose of 20mgs one per day to twice per day from last Friday and I couldn't bring myself to do it. She is such a wonderful dog. I will let you know what transpires over the next few weeks as it may be useful to others. Thank you . Cheers Jude

[Squirt's Mom]

Dear gods if your baby is still vomiting take her to an ER NOW! PLEASE! If this is an overdose it is life-threatening! Please don't wait if she is still sick! Please!

[jdroege@bigpond.com]

Just got back from specialist. Lily isn't in crisis but the vet believes her cortisol maybe a bit low. Her temp is up so its more antibiotics and a rest from the Trilostane . More blood tests to see if her liver enzymes are lowering. Not giving her the Trilostane this morning has helped as she hasn't vomited today at all ((fingers crossed). The plan is if her liver enzymes are still lowering to wait 3 weeks and retest everything. I had read everything I could on this forum, especially on the dosing protocol. The vet didn't agree with my demand that future dosing be 5mg morning, then increasing to twice per day after 2 weeks if tolerated and testing shows it needs to be increased, but agreed. I also have said I want a compounded suspension as I feel it will be easier to manage the change in dose requirements if needed as you can't halve a capsule. Anyway she is stable now and has had dinner and chased the cat so I'm happy. Now just waiting till tomorrow for blood results:).

[Squirt's Mom]

Good! Now keep withholding that Trilo for now, ok? And do let us know what the lab results are when you get them. I am SO GLAD you got her to an ER. But to be clear, if the cortisol is too low and that is the reason for the signs you have been seeing, then she is headed for a crisis if not in one now. A "crisis" is when the cortisol goes too low causing signs such as nausea/vomiting, loose stools/diarrhea, loss of appetite, lethargy. This causes a temporary Addisons' state where the adrenal glands are not producing enough cortisol to support the body's needs (cortisol is a vital part of our makeup and required for life). So for us cush parents. low cortisol with signs IS a crisis requiring action, even if that action is no more than stopping the drug for a bit. ;)

[jdroege@bigpond.com]

Just an update on Lily. The trilo has now been stopped for a week and Lily is just like my old dog from 10 weeks ago. Last week we had her liver tests again and her APL has now gone down to 5000, that's the lowest in 9 weeks of testing which means 3 weeks post gallbladder removal her ALP have gone from 22,000 to 5000...such good news. I have asked the specialist vet if her Cushings test could have been a false positive due to her being so unwell with her hepatic/gall bladder disease and he didn't think so. I am concerned as she only had 1 test where they do 2 blood test an hour apart, she didn't have the other longer test. I am going to request referral back to my original vet and request further testing before and Trilo is recommended....what do you think. Since the trilo has stopped her drinking has remained normal, it had previously been excessive but that could have due to the mucocele not necessarily Cushings. She is so well now that she keeps driving me crazy with her ball and the poor cat is getting a break. Thanks Jude

[labblab]

Such great news about Lily!! :)

Honestly, if it was me, I would enjoy this turn of events and not resume either the trilostane or more Cushing's testing unless you start seeing a return of Cushing's-consistent symptoms. And actually the longer, 8-hour test (LDDS) is even more likely than the ACTH to register a "false positive" in the face of other nonadrenal illness or injury. So in this situation, I don't know that I'd rush to have that test performed. Once again, I think you need to be truthful in your conversations with the vets about your intentions, but if Lily were mine, I'd be advocating for a vacation from Cushing's right at the moment. It is true that Cushing's can make dogs more vulnerable to two of Lily's previous problems: cruciate injuries and gallbladder mucoceles. So I am not saying you can discount the presence of Cushing's altogether as a possible underlying condition. But as well as she is doing right now, I believe I would want more concrete evidence of the presence of the disorder before resuming treatment, especially when it appears as though the trilostane was actually making her ill.

Marianne

[molly muffin]

I tend to agree, that if things are going well and you aren't seeing cushing symptoms then it might be better to not start any cushing medication yet.

It could be that all the high results where a false positive.

[Squirt's Mom]

Sounds wonderful, Jude! Like others, I would forget about Cushing's and enjoy my baby to the fullest. Should something come up in the future, your family here will be around. ;) Such good news! YAY! :cool::cool::cool:

[jdroege@bigpond.com]

Thanks so much for your replies. Our next specialist app is for this Thursday when she will have more liver enzymes testing done. Since I last posted on the forum Lily seems to have had a backward step, she isn't vomiting or anything but seems lack lustre , has decreased her interest in food and limited her playing. Not sure is after stopping the Trilo her cortisol levels came back to an optimist level and have now increased again hence the change in her behaviour. Will definitely ask specialist for a referral back to my local vet and not start Trilo again unless she is retested and my local vet thinks it is wise. My local vet was not the one to start her on Trilo and was worried about the specialist starting her on such a high dose when he wasn't even thinking of starting her. I'm now think her excessive drinking was the mucocele. Will update again soon. Thanks Jude