Is Trilostene working? Should we stop using -- allergic reaction? Advice on Cushings

[Wuchi]

Thank you ahead for any advice you have, been searching the site the last month – great resource for Cushings. I have a 12 year old, 3.7lb Chihuahua named Frito. She has been showing signs of Cushings since July 2015 (see test results below) and also the possibility of intermittent pancreatitis and IBS. I am at a loss of what to do next. She has 2 vets and a natural path looking after her and a very concerned family and friends.

Symptoms:
Currently has distended stomach, enlarged liver, low energy – not playing anymore or if so in small amounts, is bloated, has weight gain, is hungry (6 meals a day), gurgling stomach – has gotten better with Chinese herbs and home cooked diet of lamb and pork – she’s not getting enough vitamins though since she picks out the veggies and only eats the meat, has muscle loss – meat diet and acupuncture/cold laser/b12 aqua therapy has helped regain some coordination and strength, stuffed up nose (might be from extra skin gain around neck), a couple of the Cushings pimples, increased ALT, ALP, GGT, AST. As of 11/3 she is not 5.11lb.

Questions (see history below):
1) General advice: Anything we’ve missed? Next steps?
2) Red paws: Noticed about a month ago that paws were a little red, she’s never had that before. Has gotten significantly worse to the point where she doesn’t want to walk much or walks slowly. Nose looked a little red yesterday and snout/lip area may be slightly swollen. Should I stop all meds, including Trilostene for a couple days and slowly add back meds one at a time? What if it’s the Trilostene causing it?
3) Trilostene: Should I up the dose, lower it, try something else, go off of it…?
4) Diet: Any articles on a Cushings diet? Something without chicken and turkey? With the possibility of pancreatitis I need a low fat diet. Seems like protein helps with muscles, but don’t know about the liver – how bad it is. Some of the Cushings, liver, and pancreatitis diets I’ve found contradict each other.

History:
Took a while to diagnose – has been having major stomach stress --gurgles/pain since Nov 2014 (from overdose of flea meds and manufacturer no longer making her food), but blood work before dental in Dec 2014 was pretty normal, so that’s what threw us. Possibly aggravated by a Rabies shot in Spring, switching to eating chicken and people food for first time in her life (thought she was allergic to lamb), etc.. She also has food allergies (Dodds test: no chicken, turkey, beans, corn), and like many Chihuahuas is an extremely finicky eater (doesn’t like rabbit, venison, white fish, veggies, potatoes, so so on rice)– never a food motivated dog.

Stared Trilostene 5mg twice a day with food in July – started with pill (cannot pill her) had to break open and put in a blob of cheese. Vet found liquid suspension from Roadrunner labs in Phoenix, AZ so started her on that on July 19-24, 0.5ml twice a day. Started acupuncture/B12/cold laser/Chinese herbs at same time (Happy Wanderer Xia Yao San, milk thistle, and slippery elm sludge). Tried Denamarin with no success – got about 2 days of pills in her but wouldn’t touch, tried crushable tablet, wouldn’t take. Was on Ursodiol, kidney meds for a couple days but seemed to make her more wiggy so vet stopped them. She lost a bunch of the bloating at first, water intake and number 1’s slowed down, could almost sleep through the night, still breathing really fast at this time and not herself – she’s never been good on meds – when she took antibiotics everyone thought she was dying – turned gray and lethargic. Hunger the same, but a little less psychotic look on face when hungry. Test showed numbers went down, but not enough. Muscles kept getting worse, still starving. Never had skin/fur issues. Went to 0.6ml twice daily, changed out herbs to Harmonize the Qi for stomach and then moved to 0.8ml Trilostene.

Retested after 3 weeks at 0.8ml (had a bought of pancreatitus the morning before – due to treats/coconut oil – both had more fat in them than expected). Not much change, numbers went up just a tad. Started 0.9 this weekend along with suspended liquid of SAMe and Milk Thistle. Stopped SAMe after a couple days since Trilostene uppage was hard on the dog – some shortness of breath – ok now. She’s sleeping more, eating more, and muscles seem not as good, liver/stomach seems to be gassier and getting bigger-bloated, less herself but not as bad as when we 1st started the Trilostene. Red paws getting worse and swelling up some on pads. Checking with vet if should stop all meds for a couple of days and add back in one at a time to see what’s going on.

Test Results (Out of Range only)
• 12/17/2014 Pre-Cushing diagnosis (before dental surgery)
o RBC 8.68 (8-17) H
o HGB 19.7 (12-18) H
o Poly # 3150 (3600-11500) L
o Phosphorus 2.7 (3-7) L
o ALP 92 (10-84) H
o Cholesterol 131 (150-275) L

• 8/7 Dodds Alergy Test

• 9/13 Blood Test (pre-Cushing meds)
o PLT 656 (200-500) H
o Creatinine 0.4 (0.6-1.6) L
o ALP 789 (10-84) H
o GGT 173 (0-10) H
o ALT 751 (5-65) H
o AST 157 (16-60) H
o Cholesterol 530 (150-275) H
o Lipase 705 (0-425) H
o T4 RIA 0.6 (1-4) L
o Cortisol Pre 7 (0-10) In Range**
o Cortisol Post 56.6 (8-22) H

• 9/18 Bile Acid test (no before test): 359 umol/L (0-10) H

• 9/28 ACTH Test @ 2 weeks on 0.5ml twice daily (1.0ml), 1 hour in-between tests, 4-6 hrs after Trilostene dosage
o MCHC 37 percent (32-36) H
o PLT 822 K/uL (200-500) H
o Poly # 12240 /uL (3600-11500) H
o ALP 635 U/L (10-84) H
o GGT 111 (0-10) H
o ALT 421 (5-65) H
o AST 76 (16-60) H
o Cholesterol 374 mg/dL (150-275) H
o Lipase 829 U/L (0-425) H
o Cortisol Pre 7.4 ug/dL (0-10) In Range**
o Cortisol Post 17.7 ug/dL (8-22) In Range**
o T4 RIA 0.2 ug/dL (1-4) L
• 10/6 VetScan Test
o ALP 488 (20-150) H
o ALT 429 (10-18) H
o CRE 0.3 (0.3-1.4) lowest but in range
o GLU 128 (60-110) H
o HEM 2+
o LIP 1+

• 10/17 ACTH Test (1 hour in between) @ 3 weeks 0.? Twice daily (1.? ml)
o MCHC 39.4 percent (32-36) H
o PLT 857 K/uL (200-500) H
o Na/K ration 25 (27-40) L
o ALP 421 U/L (10-84) H
o GGT 89 (0-10) H
o ALT 460 (5-65) H
o AST 150 (16-60) H
o CK 634 (50-300) H
o Cholesterol 468 mg/Dl (150-275) H
o Lipase 974 U/L (0-425) H
o Cortisol Pre 10.5 ug/dL (0-10) H
o Cortisol Post 20.4 (8-22) **in range**
o T4 0.7 ug/dL (1-4) L

[mytil]

Hi and welcome to our site - I am sorry you and your girl are having these troubles.

I have just a sec but wanted to mention a few things. The red paws and nose could very well be signs of pododermatitis (basically an inflammation of the paws etc). This can be from her allergies, a topical infection (both can be made worse from Cushing's).

I am wondering if the combination of the Chinese herbs and the Trilostane are counteracting each other.

Her past history of pancreatitis and IBS can cause her stomach issues to be flare up and that along with the Trilo can make it more irritated. Are you giving her anything now for stomach issues?

Keep us posted.
Terry

[labblab]

Hello and welcome, although I'm very sorry that Frito is not doing well. Thanks so much for providing such detailed info! I have only had the chance to quickly skim through the data this morning, and will surely plan to go through it more carefully later. Bit here's some immediate first impressions.

First, I would be worried that the swollen lips/mouth (in conjunction with the red paws) may signal an acute allergic reaction to something Frito is ingesting, whether it be medication or food. This could turn serious, even life threatening, very quickly if she experiences swelling in her throat, as well, and blockage of her airways. So I would be monitoring her very closely and immediately taking her in for attention if the swelling worsens or persists.

In that vein, I personally discourage folks from making any other food or medication changes at the same time that trilostane treatment is begun. This is to try to prevent the very problem you are experiencing now -- you have no idea whether any ill effects are being caused by the trilo or by something else. Also, there may be unknown or unintended interactions between the trilo and the Chinese herbs/supplements. For instance, I see you started out giving slippery elm when the trilo was begun. We have been warned here that slippery elm may interfere with proper absorption of medications unless it is given either two hours before or after the Rx med. That is just one example of a possible problem, but there could be more since I am doubtful that any research has been done to see how any of the Chinese herbs specifically interact with trilostane. If you choose to continue trilo treatment, I personally would discontinue all the herbs until Frito is stabilized on a specific dose of trilo and you are seeing symptom improvement on that drug.

Most important of all, though, I am very worried about Frito's liver! She is exhibiting elevations in liver-specific markers that far exceed what is typical of Cushing's alone. Plus, I see she had a highly elevated bile acid test which I presume is indicating that her liver is not functioning properly. I'm also not exactly sure what to make of the new elevation in her CK (creatine kinase). I know it can be associated with muscle wasting, and muscle wasting results from Cushing's. But in conjunction with the highly elevated liver values, I worry that it may be associated with something even more sinister. Has Frito had an abdominal ultrasound performed? I believe I'd want to start there ASAP, and also perhaps in conjunction with a liver biopsy. I am really worried about that liver! If it was me, I believe I'd suspend all the meds for the moment while I pursued liver-specific diagnostics.

But once again, welcome, and I'll try to look through Frito's info in greater detail later today.

Marianne

[Wuchi]

I soaked her paws in epson salt for 10 min last night -- she didn't seem to lick them as much, will try again tonight to see if it temporarily help still I figure out what's bugging her. The lamb looks to not be the culprite since she stopped eating that last Fri. Thinking it's either the Trilostine or the Harmonize the Qi and might be agrivated by the cold damp weather that's started up here in the northwest.

The herbs have been for her stomach and liver and muscle strength. Stomach has calmed down considerably since before starting them -- she used to yelp and jump across couch from stomach pain/gurgling. For a while right before the herbs and trilostene started she couldn't pass gas which was painful for her, so that's a win for her and a loss for us ;)

She has tried about every stomach med out there throughout her life -- she will be on food for a couple of years and then the manufacturer stops making it or changes the formula. Then it takes 6months to get her on another food and for her stomach to calm down. She's probably tried every premise food out there that's why we are doing home cooked. The over counter meds (Pepcid, etc) either make her sick or do nothing at all.

She was transitioning foods (thought originally everything was related to the IBS) all thru Mar-Aug this year which added to her stress.

Will stop herbals in case causing an allergy -- think its the Trilostine or Xiao Chai HuTang -- timing wise

[Wuchi]

Good note on watching the throat for swelling -- she will be with people all day today and has acupuncture this afternoon (want to keep body swelling down too). Before Trilostene she had a lot of congestion in nasal area but that's much better now. Lungs have been fine the whole time.

I forgot to note she was only on the slippery elm the 1st two weeks so shouldn't have impacted the second test since given about 5 weeks after first. So won't continue that one.

Yep good note on the food changes but that's Frito's plight -- she's been healthy her whole life except for the sensitive tummy. Just trying to keep food in her. She's been on lamb/ pork for about 1 1/2 months now.

Definitely worried about liver and that the IBS is making her eat more in addition to the Cushings. Plan of attack by vets has been to calm Cushings down then get liver calmed down. Have been doing milk thistle since about 2nd or 3rd week on trilo. Will definitely take your comments in to consideration.

With a liver biopsy do they have to put her under -- that would worry me some.

[Wuchi]

She had an ultrasound and X-rays on aug 19th.

FYI on bile acid test -- vets said that it could be falsely high due to the Trilostine meds (if I remember correctly). And that they needed a test prior to taking Triilo to accurately read the bile.

Abdominal Ultrasound 1 Image Submitted 8/19/2015
Findings
Multiple still images of intra-abdominal soft tissue structures and a video of the intestines are available for interpretation. Mild generalized stomach and small bowel wall thickening is noted. The gastrointestinal mural thickening is predominantly arising from the mucosal layer. Segmental small bowel corrigation is noted. A few segments of small bowel are mildly gas distended. Reduction and small intestinal peristalsis is suspected. The stomach is empty and contracted. The included pancreas is echogenic and heteroechoic. The pancreatic changes are most severe within the right limb. Mild hepatic enlargement with rounding of the caudal margins is noted. The hepatic parenchyma is mildly echogenic and coarse. The gallbladder is within normal limits. There is no evidence of intra-abdominal lymph node enlargement. The adrenal volume is high normal. The adrenal glands are bulbous and hypoechoic. Mild to moderate loss of renal cortical medullary distinction is apparent. Multiple, pinpoint foci of mineralization are associated with the corticomedullary junction and at medullary regions of both kidneys. The remaining intra-abdominal soft tissue structures are unremarkable.
Conclusions
1. Evidence of mild inflammatory bowel disease or an equivalent inflammatory process with segmental small bowel ileus.
2. Coarse to heterogeneous pancreas suggesting hyperplasia and fibrosis associated with prior or chronic low-grade pancreatitis.
3. Suspicion for a mild vacuolar hepatopathy or equivalent benign pathology. Concurrent infiltration with inflammatory disease cannot be ruled out.
4. Borderline bilateral adrenomegaly, likely representing mild hypertrophy associated with chronic illness and/or stress. Early-onset of pituitary dependent hyperadrenocorticism cannot be definitively ruled out.
5. Mild degenerative renal changes.
6. Small nephroliths and/or pinpoint dystrophic mineralization, which is considered incidental.
Comments
Chronic inflammatory bowel disease, possibly with intermit exacerbation of low-grade pancreatitis, could be accountable for the clinical history.

[Wuchi]

She had 2 X-rays with same results -- one at same time as ultrasound and another on Sep 14.

Abdomen: The liver is generally enlarged with rounded margins. The liver extends beyond the costal border. The spleen, kidneys and urinary bladder appear unremarkable. The pylorus is displaced caudally by the enlarged liver. There is mild distention however there is not evidence of intestinal structure. Moderate hepatic enlargement. Rule out Cushiing’s disease or diabetes. Hepatic inflammation, infection or neoplastic infiltrate are also considerations.

[Wuchi]

Vet wanted to see her today was concerned about paws -- sometimes a sign of heart failure. She got a thumbs up that her heart is working fine. Only red on paws at moment -- so thinks drugs or something she is walking on. We're stopping all herbals and leaving on Triostine for a couple days to see if herbals or Trilo are causing problem. If trilo is not the problem then will test in 10 days.

I asked on approach to liver and thought is that if can get Cushings under control the liver count will come down and if still high then issue is with liver too -- possible tumor then and not much can do since she is so small that chemo would probably not be an option.

But still open to advice -- this stuff is so hard to figure out and each dog is so different.

Is the liquid Trilo the same strength as the powder pill? Didn't know if that has an impact on results?

[Wuchi]

Popcorning a couple of questions -- would like any info, 2 cents, links, etc

Dosing/meds: if my chihuahua's right ear started twitching this weekend (when resting and waking up -- a little eye twitching when waking up too) and we just upped her dose from .8ml twice a day to .9ml twice a day is that from the extra Trilostine or from the Cushings (eg Trilo not working)? Note: I accidentally missed her Trilo dose last night so she was off meds for 12 hours and was still twitching. The ear is on the same side of mouth I give her meds on.

[Wuchi]

Do you know of any good links or examples for what to not feed your dog if they have Cushings, pancreatitus, IBS and liver problems? I've read to not feed them liver or gravy or potatoes (if fed only in small amounts). And somewhere read no probiotics if having a pancreatitus flare up and low fat.

[Wuchi]

Do you have any recommendations for a Cushings and/or liver specialist for dogs in the puget sound USA area (WA, OR, Vancouver BC, Idaho)? Frito has some great doctors but would be great to get another consult. If none in puget sound, are there any that do virtual consults?

[labblab]

Hi, I'm sorry it took me so long to get back here again! I see you've asked several questions, and I'll try to cover at least a few of them. As far as liquid vs. powder trilostane: the active chemical ingredient ought to be the same in both preparations. The drug company or the pharmacist who prepares the medication will be the one in control of the dosage concentration. So the only way to know exactly what dose is contained in any given capsule or liquid is by checking the label on the specific box or bottle.

I really have no idea what might be causing the twitching of Frito's eye. That is not a symptom that has been described here before, so all I can tell you is that it is not commonly associated with trilostane.

I have found helpful information re: dietary suggestions for dogs with specific health problems in articles authored by Mary Strauss on her http://dogaware.com/ website. I am neither a vet nor a nutritionist, so I cannot professionally evaluate her suggestions. But I have personally felt as though her advice has been helpful to me and my own dogs. If you check her website, you can find specific dietary suggestions related to to different problems: pancreatitis, kidney issues, liver issues, etc. So you might want to check that out.

In closing, I remain quite worried about Frito's liver. I am not very knowledgeable about bile acid tests, but I am unaware of any way in which trilostane would mess up the results. So I'm truly not sure why your vet is dismissing the significance or importance of that highly elevated test result. I agree with you that if it were me, I believe I'd welcome a specialist's opinion re: all of Frito's abnormalities. Here's a link that may help you find a specialist in your area. You will be searching for an internal medicine specialist that works in the area of "small animals" (as opposed to "large animals" like horses, cows, etc.). University vet schools can be great places to seek specialized attention, but I think Washington State University and its vet school is off in a different part of the state from you? Anyway, take a look at this link and see if you can find anybody nearby:

http://find.vetspecialists.com/

And please do keep us updated, OK?
Marianne

[Wuchi]

Many, many thanks for the reply -- might be a time for a trip to eastern Washington ;)

[molly muffin]

Hello and welcome from me too.

Like Marianne I have never heard of a problem with trilostane and the bile acid test.
The test results all indicate that pancreatis is still a factor and that the liver function continues to be a problem area.

Just for reference, the normal range for a dog on medication(trilostane) post ACTH is 1.5 - 5ug and can go up to 9.0ug if symptoms are controlled. The ranges you are posting are the normal range for a dog that isn't under treatment for cushings.

The pancreatis can affect the liver as all of this is interconnected to each other. Add on IBS and it is going to be harder to figure out which came first and what is causing the others to be worse and that is what you need to concentrate on. Because the liver and the pancrease are both a problem area, this can also cause the cortisol to be high. The cortisol rising is a natural reaction to any chronic problem. So is cushings really the underlying problem or is the liver and pancrease the problem. That is what the vets need to be trying to determine in my opinion.

Frito has an awful lot going on and all of it is very serious, so I want a specialist involved and working with the vet. Do a search for Internal Medicine specialist in your area and see if there might be any available to start with and then get a referral to them or make an appointment which ever way their system works. (some require a referral) and take all the test results to the specialist. That is what I would do.

[Wuchi]

Thank you for taking the time to look at Frito's records -- it means a lot :)

I've made some calls and am trying to get in to see an internal medicine specialist as soon as possible. Would be great to know more about what's going on with the liver (it worries me too). I tried the JustAnswer.com vet and they had similar concerns and didn't know for sure if it was Cushings but thought the liver/kidney issue was more prominent.

Yes, Cushings is not fully under control -- better than before, but not close enough to her regular behavior/eating habits yet.

FYI - I started Frito on the Milk Thistle and Qi herbals again since both are supposed to help the liver (and it doesn't seem like she's allergic to them).

[molly muffin]

milk thistle is definitely good for the liver and I think we've had another member use the Qi herbs too.

Justanswer vets are usually pretty good from what I've read online.

I think we are all concerned about that liver. Any luck with the specialist yet?

[Wuchi]

Thanks for the reassurance on the milk thistle. Have an apt this Wed morning with an internal medicine specialist and we're going to look at doing a liver aspiration if recommended. Will keep you guys posted.

[Wuchi]

Good news! Got Frito's test results back from this weekend's test. The numbers finally dropped. She is at 0.9 twice daily liquid Trilostine. I think she was doing good at 0.8 (a lot but not all Cushings issues had calmed down) but numbers were high.

I checked the date for when she had pancreatitus and it was the same weekend she had the ACTH test (the one before this one where the numbers started going up) -- thinking it was because of the stress of the pancreatitus -- wishing we had held off on test till she was better.

Took her in to an internal medicine specialist at Blue Pearl -- he had experience with Cushings and 2 of my vets recommended him. He had the same treatment plan that my regular vet was recommending, get the Cushings calmed down first, then after 4-6months (after liver has had time to repair) retest to see how the liver is doing. He said that he has seen numbers as high as 10,000 for some of the liver counts in Cushings dogs and once they got the Cushings in control the numbers returned to the normal range. He stressed, as you guys already know, that every dog with Cushings reacts differently. And to get the Cushings in range but not to get to worried/obsessed about getting it down to the smallest number -- might not be right for that dog. Frito's main vet recommended we hold at the .9 x 2 amount.

Keeping fingers crossed that her energy will start returning -- ordered some liquid vitamins for her so hopefully that will help.

Cortisol pre 3.2 (1-10)
Cortisol post 10.1 (8-22)
PLT 755 (200-500)
BUN 35 (6-29)
ALP 298 (10-84)
GGT 36 (0-10)
ALT 321 (5-65)
Cholesterol 294 (150-275)
Lipase 528 (0-425)

[molly muffin]

Just checking in to see how Frito is doing.

Yes, that pancreatis could definitely have affected the ACTH.

Hope to hear everything is going well.

[Wuchi]

Thank you so much for asking -- it's been a journey for sure. She's getting more like herself -- the sunshine has helped a ton. Trying to get her out walkies more and she's started playing some to. Still not a 100 percent but think time will help her. And she's not a groggy as before.

Her red paws have calmed down some since the rain stopped. I have 2 other friends with dogs that are going thru same thing with red, itchy paws my natural path thinks it's the moisture -- seems worst when she comes in from outside so might be miss/molds in grass and maybe she's a little more alergic with the cortisone calming down.

She definately doesn't like the SAMe w/milk thistle mix and she has a bigger dose of 0.7ml -- she was ok with the milk thistle by itself but that was 0.25 twice daily. If it tastes like it smells I can't blame her.

[molly muffin]

Molly isn't a particular fan of the sam-e either. I did find some breakable chewable ones that she will take, but it's not with a happy face. :)

Glad to hear that she is being more like herself. Allergys can be real buggers.

[Wuchi]

Hi looking for some additional advice -- Frito has been doing pretty well on the Trilo 0.9 ml twice daily -- she's using a liquid compound from Roadrunner Pharmacy. This Saturday she was doing really well, walkies, alert, etc. I picked up a refill from the vet of the Trilo and right after her dinner tried to give her her 0.9 dosage.

She flinched and pulled back right away and acted almost as if it was burning her or something (I administer the Trilo with a syringe). This was a new reaction not playful or fussy, more something was wrong. And stupid me I gave her the full dosage. She went on the couch to lie down for her nap and couldn't get comfortable, seemed like it knocked her out almost, then she started flynching (eyes and ears). After about 20 min called vet and ended up giving her a 1/2 pill of prednisone after about 20 min of heavy breathing she seemed to calm down and get back to semi normal. She was sorta ok (still a little lethargic) thru lunchtime on Sun. Then seemed to want to sleep/was wiggy (honey didn't perk her up) and that lasted thru most of today (Mon) -- on Sun only gave her 0.5 of old Trilo not new refill and she took it normally no flinching, skipped morning dose since wouldn't take any food this morning and gave her old Trilo 0.9 dose at noon. Got her walking to help the inflammation and get things moving again. Ate a couple kibbles but only high value treats and not as much or as eager to eat as normal. Stopped Trilo and gave her 1/4 pill of Prednisone at 9pm tonight she perked up for about 15 min ate some snacks seemed herself and then went back to not much energy, uncomfortable, not much appetite. Tummy has been gurgling the whole time thru this but she hasn't gone 2 in a while so was thinking at first that was what was going on. But I'm pretty sure it's an overdose -- she's looking at me with concern like she did before Cushings diagnosis and I had a bad feeling before i received this batch of meds too.

How long do I keep her off Trilo? Are there any tests I should run tomorrow (electrolytes, etc)? Will the prednisone throw tests since its cortisone? Was due for 4 month Cushings test next month. How often should I give her prednisone -- currently prescription says 1/2 pill twice daily? When do I start Trilo again and in what dosage? Taking her to vet tomorrow.

Oh, her breathing is a little shallow too. Just a complete bummer since she was finally feeling better.

FYI -- called roadrunner pharmacy and told them Frito's story they're contacting the vet.

Many thanks for any advice :)

[labblab]

Hi again, and gosh I am so sorry that Frito is feeling poorly. Given the time difference between your end of the country and mine ;), I am assuming that you are taking Frito in to see the vet today and I think that is a good thing. As you already guessed, however, prednisone will skew tests of cortisol level for at least 24 hours after dosing. Frito's blood chemistries can still be checked accurately, however.

Right now, since we don't actually know what's wrong, I truly don't know how you will end up proceeding with the trilo/pred dosing. It certainly does seem suspicious that the ill effects started right after being given the new liquid. But if the liquid indeed caused the problem, we don't yet know whether it was due to trilostane overdose or whether there was instead some other contaminant or erroneous drug involved. And that will all have a bearing on the path forward.

So let's see what your vet has to say after having spoken to Roadrunner and also examining Frito. Please do let us know how things go today.

Marianne

[Wuchi]

Thanks for the quick response. Yes taking her in today so will check blood and electrolytes. Good input on cortisone and how long prednisone stays in system. Will keep you posted on the results.

[molly muffin]

Oh dear. Yes it does sound suspicious based on the timing. Like there was something off about that bottle of trilostane but unless the bottle is checked no way to know for sure I guess? What did the vet say?

[Wuchi]

Will know in about an hour or so the vet did a blood and electrolyte test but decided to send it out to have it tested. She's still not 100 percent kinda out of it but played a little so that was good.

[Wuchi]

Just got back from vet and he said it didn't look like Adisons so that's good news. I had him give Frito a B12 shot to perk her up some. Said she might be battling an infection (took an antibiotic last thurs and white blood cells are elevated.

He recommended skipping Trilo tonight and starting back up
Tomorrow morning at 0.9
Twice daily.

Here's the numbers

January 19, 2016 blood work (out of range)

WBC 18.5 K/ul was 12.3 on 11/15
PLT 777 K/ul was 755 on 11/15
Polys 16,398 /ul was 8920 on 11/15
Lymphs 926 /ul was 8920 in range on 11/15
BUN is in range now from 36 to 29
Creatinine 0.5 was 0.6
ALP 170 U/L was 298 on 11/15
GGT 20 U/L was 36
ALT 157 U/L was 321
AST 70 U/L was 58
Cholesterol 333 mg/dL was 294
Lipase 672 U/L was 528

Notes: Leukogram indicates a stress/steroid response. The thrombocytisis is likely related to Cushings.

[Wuchi]

Another question need to figure this one out pretty fast will also surf the Internet: the roadrunner pharmacy mix looks water base and all of the meds are suspended (white color) just got the pet health pharmacy mix and its suspended with oil (miniral oil?) it's aweful, separated easily and is all over everything (can't get off of hands easily). Same prescription was used at both places. Does anyone know what roadrunner could have used so I can reorder the right suspension liquid? This is getting expensive and im just about out of Trilo -- even did a rush order.

[Harley PoMMom]

Sorry I don't have a clue as to what Roadrunner could have used. With the capsules, I do believe we had a member whose dog have a side effect from a new prescription of Trilo, I'm thinking it was a filler that the pharmacy used.

How is Frito doing?

[Wuchi]

Thanks for the info -- Frito's doing better still a little off. Took her to her cold laser therapy and acupuncture and that helped some (gets her lymph nodes flowing better to help with inflammation). She's eating more regular food instead of treats now (was off of Trilo for a couple days) so instead of 0.9 two times a day trying 0.8 two times a day (watching to see if water drinkage or muscle weakness increases). Getting a cortisone test in about 4 weeks. Blood work showed liver dropping down more so that's good.

Looks like the pharmacies use a sesamie oil or Tragacanth (plant) to suspend the liquid. Tragacanth Suspension is what I needed so am trying Diamondback pharmacy in AZ -- they offer overnight shipping so that's a plus too. Turns out not all pharmacies are certified to use Tragacanth so there's more restrictions on length of storage.

Pethealthpharmacy.com has the oil based suspension (really nice people and quick phone response) and said a lot of pets like that. Since Frito is so petite and has stomach issues didn't think the oil would be a good way to go.

[Harley PoMMom]

Many of our members use Diamondback as their compounding pharmacy and are happy with their service. Keep us updated ;)

Another thought, since Frito has stomach issues Pepcid AC may help, ask your vet what they think.

Hugs, Lori

[molly muffin]

We've even been told that when it is needed, University of Davis has been known to send prescriptions to Diamondback for trilostane. So, another good recommendation there.

Maybe try introducing a probiotic for the gastro too? I use florafora with my dog, she loves it.

[Wuchi]

Thanks for the reassurance -- Diamondback overnighted the meds and their price was the cheapest of the three pharmacies so that was an added bonus.

It's been a rough couple of weeks for the pup -- think you guys are correct on the probiotic -- she was in a time release antibiotic and think it did her stomach in. Trying freeze dried Tripe (vet said as long as it wasn't cooked it had probiotics in it) and small amounts of Greek yoghurt with honey. Unfortunately the Pepcid hasn't worked in the past but will give it a try if the other stuff doesn't work. She loved the flora probiotic but I finally figured out why -- has chicken flavoring in it which she is allergic too. Sigh.

Had to stop Trilo for a couple of days (she was off meds a couple days the week before) since was agrivating her stomach but that led to increased eating and non-coordination (muscles in legs started to go down quickly -- very upsetting). Started her up again at 0.5 twice a day this evening and will work back to 0.9 over the next month. Feels like we're starting over again. Just hoping her stomach calms down quickly so she's not so uncomfortable.

[molly muffin]

Oh no hope the tummy calms down too.

[Wuchi]

Looking for any other thoughts on how to get a small dogs stomach calmed down. Frito is still gurgling away -- some days worse than others -- on the really bad days have stopped the Trilostine she's back on Trilo about half her normal dosage -- fur is getting more corse so trying to balance the bad Cushings effects with the belly stuff.

Adding even more pumpkin to her pork and lamb to see if that helps. Also adding small amounts of tripe (non cooked -- about 1 week) and Greek yoghurt to get probiotics back in her after the antibiotic. Have tried over the counter meds with no luck in the past. She also cannot do the chicken/rice diet due to allergies and hamburger is a little strong for her (don't really want to change food diet since took months to get her stable on that).

[Joan2517]

Poor little girl...my Lee's stomach gurgles all the time now, some days worse than others. I hope she feels better soon.

Joan

[Wuchi]

Thank you -- hope your puppy gets better soon too.

[Harley PoMMom]

Have you tried slippery elm bark (SEB)? Here's a link about it: http://www.littlebigcat.com/health/slippery-elm/ One word of caution with SEB, you need to give it a couple of hours away from other medications as it may interfere with absorption.

Hugs, Lori

[LeoLove]

I would suggest to do without the honey -- it's technically sugar and isn't helpful. My dog loves plain yogurt...make SURE it's not sweetened. Must be plain.

I also HIGHLY recommend IAMS prostora chewable probiotics.

It's a little pricey... but works better than anything I've tried for GI issues.

http://www.amazon.com/IVF-PROSTORA-MAX-15CT-BOX/dp/B002E0E4YM

[molly muffin]

Just be careful not to overdo the pumpkin, too much and you can swing the other way since it also helps with constipation.

Oat bran I've read is another alternative but I don't know anything about it or how you make it and introduce it.

[Wuchi]

Great ideas -- many thanks :) yep I heard the pumpkin can go either way so watching it close. I'll check out the slippery elm, probiotics and oats something eventually has to work.

Once the weather gets better that will help a lot. Then can get her walking more -- that helps some.

[judymaggie]

Hi! I was curious about the Forti-flora having chicken flavoring. I sent an e-mail to Nestle Purina PetCare and here is their reply:


The animal digest in FortiFlora consists of protein from poultry and pork. To produce this powdered protein, the clean and undecomposed meat tissue has been enzymatically hydrolyzed.

Hydrolyzation of the protein molecules is the same process used to make hypoallergenic proteins (such as the modified isolated soy protein in our HA Hypoallergenic Canine Formula), in which the molecular weight of the molecules is reduced to a level unrecognized by the pet’s immune system. Therefore, FortiFlora typically does not cause an allergic response in dogs and cats with food allergies to pork and/or poultry.

Interesting explanation, especially the "typically does not cause an allergic response" -- very carefully written!

[Renee]

I also HIGHLY recommend IAMS prostora chewable probiotics.

It's a little pricey... but works better than anything I've tried for GI issues.

http://www.amazon.com/IVF-PROSTORA-MAX-15CT-BOX/dp/B002E0E4YM

Second this recommendation. I'm not a fan of Iams in general, but when I need a good probiotic to help with digestive upset, I have always found Prostora to be good. Much better than forti-flora in my experience as well.

[Wuchi]

Thanks for the input on the probiotics. Frito really liked the taste of the fortiflora (she loves chicken) but since she is so alergic to chicken didn't want to risk it -- her Cushings escalated when she switched her diet from lamb to chicken -- then the Dodds test confirmed she was alergic to it.

Well good news Frito is starting to feel better (after antibiotic/med scare). Seems like the tripe and adding a little pumpkin to each meal is helping along with trying to coat her tummy with slippery elm sludge (my natural paths recipe) before non-Trilo meals. Still some gurgles and some days better than others but not the constant pain she was in before. Also have reduced her liver treats a lot so that helps some too because they were pretty rich.

Bumping her up on her dose of Trilo to .7 x 2 aiming for .9. Crossing fingers. Usually takes her 3-4 days to adjust to any dosage changes.

[Squirt's Mom]

A word of caution with Slippery Elm, Marshmallow and other demulcent herbs like that. They must be given 2 hours either side of medications - 2 hours before or 2 hours after. Otherwise they will interfere with the absorption of the drug. Their "band aid" action will prevent the Trilo from being absorbed. ;)

[Wuchi]

Thanks for the tip on Trilo and slippery elm. Good information to have -- definitely don't want to mess up the Trilo absorption. Giving between 4-6 hours before/after Trilo.

[Wuchi]

Hi need some quick advice on hotspots. My dog has been up and down since Jan but she's finally in range and on a lower dose of Tirlo and has been for a month now. Her energy is back and she'sore playful. See numbers below

Unfortunately she got her first hot spot now March on her belly then one on her tail -- both have kind of healed - belly one is black under the skin. Does anyone know why? Then she got her 1st yeast infection. Now she has a hot spot below her #2 area and just petted her back by the tail and a huge white crusty scan pealed up about the size of a nickle -- she's tiny -- most activity around the #1 and #2 area.

She has seen her vets a lot. We've tried
Coconut oil. Topical antibiotic in small portions cannot take orally, chlodial silver, apple cider vinegar and are now on a shampoo with antibacterial properties. Also giving her tripe for probiotics.

Was hoping once we got the Cushings under control she'd have a little more comfort. Doc says to shampoo area daily for a week then if still bad send skin sample into the lab.

Thoughts?


4/18/2016 blood test
HGB 18.4 H (12-18)
PLT 576 H (200-500)
Poly 12810 H (3600-11500)
Creatine 0.4 L 0.6-1.6 mg/DL
ALP 289 H (10-84) U/L
ALT 409 H (5-65) U/L
AST 89 H (6-60)
Cholesterol 333 H (150-275) Mg/DL

Yeast infection -- shampoo every 3 days 2 weeks then once a week
Fri 4/29 Mon 5/2

Cushings ACTH STIM test
4/28/2016 -- 3 hours
1.8 pre
4.4 post

5/16/2016 -- 4 hours
1.2 pre
3.9 post

[Harley PoMMom]

Is there any oozing or pus coming from these spots?

[Wuchi]

No. One of the origin ones on the belly was that way. All of the newer ones are a white dry skin circlet hat falls off and then a small bald spot with some crusty stuff at the base of the remaining hair on the edges of the circle. Then it either stops or keeps spreading.

The shampoo is Keto Hex by Vet One -- if somebody knows of an alternate one please let me know -- it smells like flowers and gives me a headache and the dog doesn't like the smell either.

Using Quadritop topical antibiotic on the skin sparingly.

She's still a little loosey goosey in the #2s but better than a couple months back when a different batch of trilo went straight thru her.
Some is from the liver treats but need those to encourage taking the trilo.

[molly muffin]

I don't really have a shampoo maybe the Dechra TrizChlor 4 Shampoo.
http://www.amazon.com/Dechra-TrizChlor-4-Shampoo-8-Ounce/dp/B00K4X8TF6

mainly with any spot, i like to keep the hair around clipped and keep as dry as possible. Too much moisture can lead to bacterial/yeast infections.

[Wuchi]

Thanks for the link just ordered some it had pretty good reviews too. Seems like they should make a dry shampoo if hot spots get agrivated by moisture.

Has anyone stopped giving their dog milk thistle and then had skin problems? (Another theory)

Also read an article where they linked hot spots to back/spine problems. Has anyone had any experience with that?
My dogs back by her tail has had some problems (this is where a lot of the hot spots are). Natural path worked on her back hips and said the left one wasn't moving as much as it should. Could this aggravate the skin?

[molly muffin]

Keeping dry is my assumption, in that we know moisture in and around a sore can be a breading ground for bacteria. It is the same in humans.

I haven't heard of hot spots being linked to back/spine problems but I'm not really up on hot spots either. Maybe one of the others know more about it.