Behavior/personality change

[Gaissa]

Hello, I'm a new member here with a 12-year-old German Pointer that was diagnosed with Cushings 1,5 years ago. She is treated with Vetoryl (currently 30 mg) and is actually doing physically quite well with the medication.

However, during the last year or so her behavior/"personality" has changed for the worse. She has always been rather easily stressed out and wound up, but since the diagnosis she has also started to develop fears and (fear) aggression. For example, there was a period of approximately one month last spring when she would wake me up several times every night without any obvious reason. She was somewhat anxious and fearful, but when I got up, she would calm down and go back to sleep on her bed - only to wake me up again only a couple of hours later. She was, of course, thoroughly checked by a vet, but no reason for her behavior was found.

Last summer was better, although her fear of thunderstorms increased dramatically. Then at the end of last year she developed yet another fearful behavior pattern: when I leave the house in the morning to go to work, she seems to get a kind of panick attack, even though the rest of the family is still at home sleeping. She will not let my husband sleep, but keeps jumping on the bed until he gets up - and after that she calms down and goes to sleep on her bed again. She did suffer from mild separation anxiety even before the Cushings diagnosis, but this behavior is different and new to her.

Those were a couple of examples of my dog's behavior during last year. Such behavior could, of course, be related to age and lots of things. However, yesterday I happened to read about a dog that was diagnosed with atypical Cushings, and the description of his behavior changes sounded very familiar to me. Now my dog was officially diagnosed with adrenal Cushings, but I have now started to wonder whether her Cushings could be atypical. I don't have access to her lab tests now, but I rememeber that there has always been some trouble with interpreting her ACTH test results.

My question and plea for help is whether anybody here has recognised behavior/personality changes (especially fear and aggression) in their dog before or after the (atypical) Cushings diagnosis?

Hanna

[molly muffin]

Hello and welcome to the forum.

If you could get the ACTH results that would be very helpful and any other abnormalities to blood work. When was her last test? If it hasn't been done in awhile, you might want to consider redoing it.

Some dogs also do better on a split does, am and pm. Instead of 30mg once a day, you give 15mg morning and 15 mg evenings. So that is a thought too.

In Atypical cushings, the cortisol is not risen, but the other sex hormones, at least 2 are abnormal. The treatment for this is normally, melatonin and lignans.

Also, has her thyroid been tested lately? As thyroid can cause behavioral changes too.

When you do your next ACTH test, they can send it to University of Tennessee which is where they do the testing for Atypical if you want to pursue that option.

[Gaissa]

Thank you for responding so quickly. I am aware of University of Tennessee being able to test for atypical Cushings, but I'm afraid that is not an option for me, because we live in Finland, Europe. Our veterinary clinic/vet should be experienced in treating Cushings, but they never mentioned atypical Cushings, and I guess it is not possible to test for it here in Finland.

I'm not sure if Gaissa's sex hormones and thyroid have been tested. She had blood tests done in June 2014 because she had once again lots of skin bumps and lumps and tags (all of which turned out to be benign). In June 2014 Gaissa also started to have Cushings symptoms, and the vet suggested to test for Cushings in July - and that was when the disease was diagnosed.

Gaissa's last ACTH test was done as long as five months ago, because she has been doing well physically. The veterinary clinic is closed today, so I only have access to the emails I have received form the vet earlier regarding Gaissa's test results. I'm not sure if that is enough information, but I tried to translate the test results anyway:

1. First ACTH test in July 2014 (no test results available at the moment). Medication was started in August 2014 with 120 mg Vetoryl.

2. Second ACTH test in August 2014 (only some blood test results available at the moment)

Blood test:
Liver: in June 2014 AFOS 320, ALAT 122; in August 2014 AFOS 249, ALAT 87. Reference ranges AFOS (19-106), ALAT (24-136).
Electrolytes: in June 2014 Sodium (Na) 151, in August 2014 Sodium (Na) 146. Reference ranges 144-158.
Potassium in June 2014 4,2 and in September 2014 5,5. Reference ranges 4-5,4.

At that time (August 2014) Gaissa was treated with 120 mg Vetoryl, and based on the second ACTH test results the dose was dropped to 90 mg Vetoryl

3. Third ACTH test in September 2014

Test results within reference ranges.

CORT - Cortisol (ECLIA) "32.6". Reference range: 24.8-124.2.
CORT2 - Cortisol, 2nd sample "91.1". Reference range: nmol/l.

COMMENT - . Treatment monitoring - Hyperadrenocorticism: Regarding the clinical symptoms the following stimulation values should be reached: - Therapy with trilostane (Vetoryl): Cortisol post ACTH < 200 nmol/l and > 50 nmol/l 4-6 hours after administration of the tablet.

4. Fourth ACTH test in October 2014

CORT - Cortisol (ECLIA) "15,8". Reference range: 24.8-124.2.*
CORT2 - Cortisol, 2nd sample "17,3". Reference range: nmol/l.*

COMMENT - . Treatment monitoring - Hyperadrenocorticism: Regarding the clinical symptoms the following stimulation values should be reached: - Therapy with trilostane (Vetoryl): Cortisol post ACTH < 200 nmol/l and > 50 nmol/l 4-6 hours after administration of the tablet.

Based on this ACTH test, the dose was still 90 mg Vetoryl.

5. Fifth ACTH test in February 2015 (no test results available at the moment)

Based on this ACTH test, the dose was further dropped to 30 mg Vetoryl.

6. Sixth ACTH test in July 2015 (no test results available at the moment).

If this is not informative enough, I'll contact the clinic and ask for more detailed test results.

Hanna

PS. We were told to fast for 12 hours before the ACTH test - and I've read on this forum that fasting invalidates the test results. If this is true, are the test results actually useful at all?

[molly muffin]

Vetroyl/trilostane is absorbed best with food. Fasting doesn't allow the meds to be properly absorbed into the body to give you a good idea of what it is doing.
Proper protocol for ACTH testing is to give the med in the morning with food and test 4 hours later First the initial draw and then an hour later the post draw.

Between sept and oct 2014 there was a marked decrease in the ACTH result and she is very low. I would like to see the February and july results. At those levels in out the dosage should have certainly been dropped if not stopped.
However since they have had you fasting. I don't know how accurate these results are.

[labblab]

Yes, the big danger about relying on fasted monitoring ACTH tesults is that the numbers would likely have been even lower had food been given along with the trilostane dose so that the drug was metabolized most efficiently. I agree 100% with Sharlene -- the October 2014 test results were worrying as they were. With a non-fasting test, they would probably have been lower. I think it is really important that you have an ACTH repeated now, following the protocol has Sharlene has described. If your vets need confirmation that the test should be done on a nonfasted blood sample, please urge them to contact Dechra directly (the makers of brandname Vetoryl).

I realize that I am more focused on your dog's cortisol level right now than I am on the problem that brought you here -- the anxiety issues. But from the standpoint of safety, the cortisol level is really the top priority. Plus, it is possible that an inappropriate cortisol level might have a bearing on the changes in behavior. So that's where I would start.

I also would have her thyroid level retested since I believe hypothyroidism can be associated with behavior changes similar to the ones you are describing. Hypothyroidism is not uncommon in conjunction with Cushing's. For many dogs, the thyroid levels normalize once cortisol is therapeutically lowered. But other dogs may suffer from low thyroid as a persisting and independent problem. Treatment is simple -- an oral supplement. So it may be worthwhile to request that your vets perform a comprehensive thyroid panel in addition to the ACTH.

Marianne

[Gaissa]

Thank you for your replies again. I went to the veterinary clinic today and asked for more detailed information about Gaissa's test results, so here they are now (or rather part of them, as they gave me 20 sheets of paper). I also made an appointment with Gaissa's vet Friday next week for an ACTH (and thyroid?) test – I am very grateful if anybody here is so kind as to take a look at the test results and to comment on them before that.


1st ACTH test June 2014, before medication was started (I was sure that the first test was in July, but test results obtained in June were reported)

CORT – Cortisol (ECLIA) 127.5 nmol/l (Reference range 24.8 – 124.2)
CORT – Cortisol, 2nd sample 171.4 nmol/l


2nd ACTH test July 2014, before medication was started:

CORT – Cortisol before administration 99.1. nmol/l
CORT – Cortisol, 2nd sample 96.1 nmol/l (Reference range 24.8 – 124.2)
CORT – Cortisol, 3rd sample 102.4 nmol/l

The 2nd ACTH test results were followed by the following text (which was in English – I don't know whether the samples were actually sent abroad)

COMMENT – Note

The 8-hour suppression value is > 40 nmol/l which indicates hyperadrenocorticism. The specifity of this test is considered 70-80%, therefore a positive test result should always be interpreted in connection with the clinical symptoms and further laboratory parameters.
If certain criteria are met, this test can be used to differentiate between adrenal and pituitary hyperadrenocorticism: pituitary hyperadrenocorticism is likely if one of the two suppression values is < 50% of the basal cortisol value or if the 4-hour suppression value is < 39 nmol/l.
If none of these criteria are met, a differentiation with the Low dose dexamethasone test is not possible. In this case, the suitable examinations for the differentiation between adrenal and pituitary hyperadrenocorticism include High dose dexamethasone test, ACTH value and abdominal ultrasound.

After the 2nd ACTH test, medication with 120 mg Vetoryl was started in August 2014.


3rd ACTH test September 2014:

CORT – Cortisol (ECLIA) 32.6 nmol/l (Reference range 24.8 – 124.2)
CORT – Cortisol, 2nd sample 91.1 nmol/l

Medication with 120 mg Vetoryl was continued.


4th ACTH test October 2014:

CORT – Cortisol (ECLIA) 15.8 nmol/l (Reference range 24.8 – 124.2)
CORT – Cortisol, 2nd sample 17.3 nmol/l

After this ACTH test, if I remember correctly, medication was stopped for a while and the dose was dropped from 120 mg to 90 mg Vetoryl.


5th ACTH test February 2015:

CORT – Cortisol (ECLIA) 16.5 nmol/l (Reference range 24.8 – 124.2)
CORT – Cortisol, 2nd sample 34.0 nmol/l

After the 5th ACTH test, the dose was dropped to 30 mg Vetoryl.


6th ACTH test July 2015:

CORT – Cortisol (ECLIA) 26.4nmol/l (Reference range 24.8 – 124.2)
CORT – Cortisol, 2nd sample 30.6 nmol/l

The 1st, 3rd, 4th, 5th and 6th ACTH test results were followed by the following text (which was in English – I don't know whether the samples were actually sent abroad)

COMMENT – Note
Diagnostic evaluation – Hyperadrenocorticism
The value after stimulation is < 440 nmol/l, which is not suspicious for hyperadrenocorticism.
Only 50-85% of the dogs with hyperadrenocorticism show an increased cortisol level after stimulation with ACTH. Therefore it is recommended to perform an additional low-dose dexamethasone test in clinically suspicious cases.
Diagnostic evaluation – Hypoadrenocorticismus/iatrogenic
A low base cortisol level and a low or no stimulation after admission of ACTH indicates Hypoadrenocorticism (Morbus Addison) or an iatrogenic Hyperadrenocorticism.
Treatment monitoring – Hyperadrenocorticism:
regarding the clinical symptoms the following stimulation values should be reached:
- Therapy with trilostane (Vetoryl):
Cortisol post ACTH < 200 nmol/l and > 50 nmol/l 4-6 hours after administration of the tablet
- Therapy with mitotane o,p – DDD (Lysodren):
Cortisol after ACTH 27 – 138 nmol/l (Feldman/Nelson, Canine and feline Endocrinology and Reproduction, 3. edition 2004)
Please note that the reference values presented herein are only valid for the ACTH test performed 4-6 hours aftre medication. Another protocol performing this test 2-3 hours after medication is being occasionally recommended. However, other reference values are to beconsidered for the latter. For any further information please feel free to contact our Medical Consulting team.(I have no idea where that team might be).


Blood test June 2014 (before diagnosis, done because of skin problems):

WBC 8.43
RBC 7.29
HGB 16.2 g/dl
HCT 46.97 %
MCV 64 fl
MCHC + 34.4 g/dl
PLT 343
PCT 0.31 %
MPV 9.0 fl
PDWs 13.1 fl
PDWc 40.0 %
RWDs 44.5 fl
RDWc 14.8 %
LYM 1.18
MON 0.50
NEU 6.57
LY% 14.0 %
MO% + 6.0 %
NE% 77.9 %
EOS 0.13
EO% 1.5 %
BAS 0.05
BA% 0.6 %

Further (blood) tests:
Liver: in June 2014 AFOS 320, ALAT 122; in August 2014 AFOS 249, ALAT 87. Reference ranges AFOS (19-106), ALAT (24-136).
Electrolytes: in June 2014 Sodium (Na) 151, in August 2014 Sodium (Na) 146. Reference ranges 144-158.
Potassium: in June 2014 4,2 and in September 2014 5,5. Reference ranges 4-5,4.


Urine sample February 2015:

GLU 5.22 mmol/L
UREA 8.2 mmol/L
CREA 103 mol/L
PHOS 1.11. mol/L
CA 2.65 mmol/L
TP 63 g/L
ALB 30 g/L
GLOB 33g/L
ALT 48 U/L
ALKP 87 U/L
TBIL < 2 mol/L
CHOL 4.91 mmol/L
AMYL 527 U/L

OMP: 1.045

STIX:
blood +2
pH 7.5
prot: +1

SEDI:
a couple of epit. / 40x
some erythrocytes/red blood cells /40x

URIC:
no growth

Once again, I am very grateful for any replies.

Hanna

[molly muffin]

Okay when it comes to the blood and urine test, only things that are high or low need to be posted with the ranges.

It looks like elctrolytes where in range, during the 2014 time period when her cortisol was very low, so good they checked that. It also looks like it is coming back up slowly but you do want it to come up a bit more.

The last test shows
Pre - 26.4nmol/l (.95 ug) (Reference range 24.8 – 124.2)
Post – Cortisol, 2nd sample 30.6 nmol/l (1.10 ug)

you really want the post to be around 70nmol, which is 2.53 ug a good stable place. If symptoms are controlled post can be up to 250nmol (9.ug)

So you can see why I am happy to see it coming back up and I think that is what you want to keep an eye on.

Where any of the blood test you gave our of reference range (high/low)?

I think it is fairly safe to make the assumption that the increased fear/panic behavior could easily be tied to the low cortisol levels. A dog when they get excited, or fearful, produce cortisol (adrenalin) to help them deal with it. This requires that there be enough in reserve in the adrenal gland for it to dump into their body at times of stress. When the reserve (post ACTH) is very low, they don't have that available to them and everything is an exaggerated fear response.

[labblab]

Thanks so much for this additional info. As Sharlene says, it will help us a lot if you can sort through and highlight any of the regular lab values that are either too high or low. Without knowing the "normal" range, it is hard for us to really judge those values.

I also want to reconfirm what Sharlene has said about the ACTH testing. First of all, the second test with the three values in July 2014 was actually a diagnostic LDDS test, and not an ACTH. The results of that test were consistent with Cushing's, but they did not distinguish between the pituitary and adrenal form of the disease. Further testing would have needed to be done to do that.

My big worry, though, is that all three of the most recent monitoring ACTH tests were too low. And if your dog was fasted for all of these tests, the results would likely have been even lower. The October 2014 test was WAY too low, so it's good that the Vetoryl dose was lowered. However, February 2015 was still too low (34.0 nmol/l) and so the Vetoryl dose was lowered again. However, the July 2014 was even lower at 30.6 nmol/l (and again, too low) but the dose was left unchanged. There is no telling how low your dog's cortisol may be now.

Here is a quote from the lab interpretation which tells you what your dog's therapeutic cortisol leve ought to be while being treated with Vetoryl (trilostane):


- Therapy with trilostane (Vetoryl):
Cortisol post ACTH < 200 nmol/l and > 50 nmol/l 4-6 hours after administration of the tablet


So at no time since September 2014 has your dog's cortisol actually been high enough to be considered safe!! And again, if her tests were all done on a fasting basis, her results might have been even lower.

I am honestly quite surprised that she has not exhibited more symptoms consistent with low cortisol throughout this time period. But as Sharlene says, the anxiety, etc. may be a result of her body's inability to cope with stress due to the low cortisol. Again, I am very relieved that she will be tested again next week. And this time, she truly needs to eat a meal along with her morning dose of Vetoryl, and the vet needs to perform the test 4-6 hours after dosing.

Marianne

[Gaissa]

Thank you again. I'm sorry I forgot to add the reference values for the blood and urine tests. Not all of the values are of interest/necessary, but I included them anyway because I don't actually know what some of the abbreviations stand for. I guess there are no test results for sex hormones though.

Blood test June 2014:

As far as I can tell, almost all values are within reference ranges, excpet for

high MCHC+ (Mean Corpuscular Hemoglobin Concentration) 34.4 g/dl (31.0 – 34.0)
high PCT (platelet hematocrit?) 0.31 % (0.00 – 0.00)
high PDWs (platelet distribution width ?) 13.1 fl (0.0 – 0.0)
high PDWc (platelet distribution width ?) 40.0 % (0.0 – 0.0)
high RWDs (red cell distribution width ?) 44.5 fl (0.0 – 0.0)
high RDWc (red cell distribution width ?)14.8 % (0.0 – 0.0)

Or does 0.0 – 0.0 mean that there is no reference range?

WBC 8.43 (6-17)
RBC 7.29 (5.5 – 8.5)
HGB 16.2 g/dl (12.0 – 18.0)
HCT 46.97 % (37.00 – 55.00)
MCV 64 fl (60 – 77)
MCH 22.2 pg (19.5 – 24.5)
MCHC + 34.4 g/dl (31.0 – 34.0)
PLT 343 (200 - 500)
PCT 0.31 % (0.00 – 0.00)
MPV 9.0 fl (3.9, - 11.1)
PDWs 13.1 fl (0.0 – 0.0)
PDWc 40.0 % (0.0 – 0.0)
RWDs 44.5 fl (0.0 – 0.0)
RDWc 14.8 % (0.0 – 0.0)
LYM 1.18 (1.00 – 4.80)
MON 0.50 (0.20 – 1.50)
NEU 6.57 (3.00 – 12.00)
LY% 14.0 % (12.0 – 30.0)
MO% + 6.0 % (2.0 – 14.0)
NE% 77.9 % (62.0 – 87.0)
EOS 0.13 (0.00 – 0.80)
EO% 1.5 % (0.0 – 8.0)
BAS 0.05 (0.00 – 0.40)
BA% 0.6 % (0.0 – 2.0)

Urine test February 2015:

All values were within reference ranges.

I now feel bad for not having found this forum a lot earlier and for not taking Gaissa to the vet after last summer – but I'm glad we have the appointment next week. As for the appointment, this time Gaissa won't fast before the test. Is there anything else I/the vet should know? Will the regular ACTH test be enough, or should something else ”extra” (eg. thyroid, sex hormones) be checked? And based on the lab test results, do you think that it is obvious that Gaissa has typical (adrenal) Cushings (instead of atypical Cushings)? And what if her cortisol still is low? Is there any alternative medication available? I remember the vet saying that 30 mg is the lowest Vetoryl dose possible (although I've read here about 15 mg doses).

Hanna

[molly muffin]

Vetroyl comes in 10 mg and 5 mg also. 30 mg use to be the lowest dechra made but not any longer. They have been making 10 mg for quite awhile and they added 5 mg last year. Your vet needs to keep up on the latest info.

I would want due to the low cortisol an ACTH done properly and electrolytes checked via blood. Sodium, potassium etc.

The abnormalities currently seen could be due to low cortisol long term. I'm not sure. But I'd just watch those to see if they come back up once you get appropriate levels.

[Harley PoMMom]

I agree with Sharlene, Gaissa's cortisol needs to be checked, and as Sharlene suggested those electrolytes too.

Another important thing, as Marianne pointed out, is that the Vetoryl has to be given with food to be properly absorbed and those monitoring ACTH stimulation tests need to be performed 4-6 hours post pill.

How is Gaissa's appetite? Any vomiting or diarrhea? Is her drinking/urinating normal?

Hugs, Lori

[Gaissa]

It is good to have a plan for the appointment and lab tests tomorrow: ACTH (no fasting) and electrolytes. Gaissa also has a couple of new skin bumps that need to be checked. Gaissa has always had slightly atopic skin in her head, and she started to have skin bumps and lumps when she was approximately eight years old; some of them were so big or worrisome that they had to be operated twice. I keep wondering whether Gaissa's skin problems were actually an early sign of Cushings.

Gaissa didn't have increased appetite before Vetoryl medication, and she now eats fairly well. She has always had a rather sensitive stomach and tends to have loose stools and occasionally diarrhea. Ever since Gaissa was young, she has had a specific digestive diet that helps with these problems. Gaissa vomits seldom, less than once a month, usually only after eating something unsuitable to her. Excessive drinking was the first and most prominent Cushings symptom. Medication helped with this, but Gaissa still drinks often and more than before the diagnosis. Before medication it must have been hard for her not to pee indoors, but she has never had a peeing accident.

Hanna

[molly muffin]

If the skin bumps are calcium deposits then yes they could have been an early sign of cushings.

Let us know how things go tomorrow.

[Gaissa]

We went to the vet a week ago, and I just received the following lab test results:

Cortisol before medication (I guess this means before the synthetic form of ACTH was injected - I gave Gaissa her normal 30mg dose of Vetoryl with food 5,5 hours before the test): 68,2. According to the vet, this is a good value, not too low.

The second cortisol sample (after medication ie. the injection): 113,2. According to the vet, this value is not too high and the Vetoryl dose of 30 mg is ok.

Urine sample: urine concentration (I'm not sure if the translation is correct) 1,045. According to the vet, this is a normal value and indicates that Gaissa's drinking is normal as well (however, the day before the test my husband and I joked about our living room turning into a swimming pool because of Gaissa's drinking and dropping water on the floor). pH normal (6,5), and no blood, sugar, inflammatory cells or bacteria.

Gaissa's general health was good for her age; her heart and lungs were ok. However, she has lost 3 kg weight since the last appointment half a year ago.

According to the vet, we should continue with the 30 mg dose of Vetoryl. Does this sound ok to you?

As for the behavior abnormalities, I asked the vet whether they might be due to Cushings and whether melatonin might help with Gaissa's restlessness/panic in the mornig when I leave for work. The vet said that the behavior changes probably have nothing to do with Cushings and that melatonin would probably not help if given in the evening; it might merely help Gaissa fall asleep. Instead, she recommended giving Gaissa Clomicalm and a vitamin B complex. Do you have any advice on this? I've read success stories about melatonin on this forum, and I would prefer trying that before Clomicalm. I guess melatonin is not commonly used for dogs here in Europe/Finland, and the vet was not familiar with melatonin as an alternative treatment for (atypical) Cushings. In fact, I think that she was not familiar with atypical Cushings at all.

If the lab test values aren't detailed enough, I'll ask for more detailed information - this is what the vet sent me via email today.

Once again, I'm very grateful for any replies.

[Harley PoMMom]

Her ACTH numbers are perfect!!! YAAA!!! Converting from nmol/L to ug/dl which is what we are used to seeing in the States...they are pre - 2.47 ug/dl and the post - 4.10 ug/dl....Great job Mom!!!! Continuing with the 30 mg dose sounds right to me. How are her symptoms? The only other thing I would of probably gotten done was a check on the electrolytes. When does the vet want to do another recheck of her cortisol? And a USG of 1045 is just fabulous, you are seeing yellow pee now, right? Yellow pee is something we celebrate around here :eek::D

Yep, melatonin is something that my Harley took, he was diagnosed first with Atypical Cushing's, and it calming him during thunderstorms and other loud noises was most definitely a wonderful side effect, he took 3 mg twice a day. Now, you want the plain melatonin not the fast acting or rapid releasing kind. Here's what Harley took: http://www.vitaminshoppe.com/p/melatonin-3-mg-120-capsules/vs-1336#.VqKdxeF4GXw

Hugs, Lori

[molly muffin]

Yes, definitely hurrah for the perfect ACTH test results. Just what you want to see and a good place to stay.

Good that everything else is good too.

So, the anxiety is the main thing here and melatonine Might help. It does some dogs. I tend to give mine melatonine before a thunder storm for instance. I give 3 mg to a 8.2kg dog.

[Gaissa]

Thank you for your quick replies again. Until today I was so happy that everything was ok, and I was going to ask for more detailed lab test results when I would be able to visit the clinic again.

However, last night there was a major setback, and the situation seems very bad and sad now. Gaissa woke me up at night, wanting to go out (which is what she does approximately once a week at night). I took her out, but she was barely able to walk: she was tilting to the left, almost lost her balance a couple of times and actually fell down once. We managed to get back in, and there she lay down and fell asleep after a while, and didn't seem to be in pain.

I called the clinic in the morning and managed to get an appointment in the afternoon, although with a new vet. In the morning, Gaissa still moved in a wobbly way and lost control of her back feet a couple of times. However, this didn't seem to bother her much, and she was happy to eat (although she spat out the Vetoryl capsule - she has learned to hide it in her mouth and spit it out after a while). We had a two-hour ride to the clinic, during which she presumably slept at the back of the car.

The vet was very young and consulted an older vet several times during the appointment. She said there is a small chance that the symptoms might be due to Vetoryl/Addison's disease and that in order to find that out, all she could do is to take a blood sample and check the electrolytes. However, it turned out that the electrolytes were ok, and considering the fact that everything else (cortisol, blood test, urine test, heart, lungs) was ok just ten days ago, the symptoms must be neurological. The vet said there might be one veterinary neurologist in the town, but considering Gaissa's age and Cushing's disease there's not much anybody could do. She gave Gaissa an injection of pain medicine and sent us home.

On our way home I took Gaissa to a dog park, and to my surprise she seemed to have no or little problem moving there - she even wanted to play with a young dog and they even kept chasing each other.
After the dog park, I've taken Gaissa out a couple of times, and she is a bit wobbly again, but has not lost her balance. She has eaten pretty much, which I don't think she would do if she was in pain.

So here I am very sad and confused, not sure about what to do. If the symptoms are neurological, there's probably not much that can be done. In fact, the vet implied that the best thing to do might be to let Gaissa go - which, of course, must be done if she is in pain. However, there are two things that keep bothering me now: when we got to our flat in the town, our daughter found a Vetoryl capsule on the carpet. Gaissa must have spat it out the last time we were here - which was before and after the ACTH test ten days ago. What if Gaissa spat the capsule out in the morning before going to the ACTH test? In that case, the test results would be far from accurate. Or do you think that the test results would have revealed that Gaissa hadn't swallowed the capsule in the morning?

The second thing that confuses me is what I've found on the internet after googling Gaissa's symptoms in English. Could this be canine vestibular disease - in which case it might heal? I hadn't heard about CVD before, and the vet didn't mention that either.

Is it ok to wait, or should I have Gaissa euthanised as soon as possible? I'm not sure, and I decided to take Gaissa to our regular vet again tomorrow to hear her opinion. Right now, it is midnight here in Finland, and Gaissa is sleeping peacefully next to me. I had forgotten how nice it is to have her sleep next to me - she was allowed to do that on one bed when she was younger, but not any more when our daughter was born five years ago. It breaks our hearts if it is time for her to go, but we try to be prepared for that.

[labblab]

I am so sorry about these new developments, but I definitely think a decision to euthanize is premature. Throughout the years, we have actually had a number of dogs on the forum who have suffered from vestibular disease with subsequent recovery. What you are describing sounds very similar to other stories we have read, so I do think it is a genuine possibility. Another possibility might be a small stroke, but again, Gaissa may recover relatively normal function even if that is the case.

A neurologist ought to be able to help diagnose either condition, so it may be well worth the effort to arrange a consultation. With either vestibular disease or a stroke, as I understand it, there may not be any specific treatment. But spontaneous resolution or improvement are genuine possibilities. So I would not be hasty in making any immediate decisions!! And I hope your regular vet will agree about this tomorrow.

Marianne

[molly muffin]

Okay, first, electrolytes don't always have to be off for there to be an Addisions crisis. A crisis not being exactly the same thing as all out into Addisions.
It is unknown if she had her trilostane before the last ACTH test.

So, a couple questions...
How has her appetite been leading up to last night?
Have you seen any sign of tilting or wobblyness prior to last night?
Did she actually take her trilsotane pill this morning?

If she was mine, for right now I'd stop the trilostane completely and see how she does. If it is due to the trilostane and electrolytes are fine, she should perk back up.
If this is vestibular disease, yes they can recover, it takes awhile.
I think that would be My plan for now. Then I would retest the acth later if she improves off it.

She was low for a long time and now the ACTH is questionable as far as complete accuracy.

So, I'd wait and see how this progresses or if it clears up.

Having a quiet snuggle is the Best!

[Gaissa]

Thank you, this was a valuable piece of advice again. I managed to get an appointment with the veterinary neurologist today and cancelled the appointment with our regular vet.

What a pity if there is no way of knowing whether Gaissa had her Vetoryl capsule in the morning before the test. I did keep an eye on her after giving the capsule, but she might have spat it out later on her bed - or she could have spat it out some other morning, as well. I didn't notice the capsule earlier; it must have fallen out of the bed ten days ago when we were leaving the flat and I moved the blanket on the bed.

So the vet said the electrolytes were ok yesterday. Here are the test results ten days ago and yesterday, just in case they are useful:

Blood sample 15.1.:

Na 148 mmol/l (144-160)
K (Potassium?) 4.9 mmol/l (3.5 - 5.8)
Na/K 30 (-)

The only value outside the reference range was

UREA 9.6 mmol/l (2.5 - 9.6)

Blood sample 29.1.:

Na 154 mmol/l (144-160)
K 4.5 mmol/l (3.5 - 5.8)
Na/K 34 (-)

Gaissa has been eating fairly well. However, the day before the neurological symptoms began she didn't want to eat until in the evening. I paid attention to that, because I stayed home taking care of our daughter who was ill. Yesterday she ate a lot, but this morning I haven't given her any food yet.

I didn't give Gaissa the Vetoryl capsule this morning. Is there any danger in not giving her the medicine? How long can/should the Vetoryl medication be stopped?

Gaissa has lost muscles and been a bit weak especially in her hind legs approximately for half a year. She has occasionally had trouble jumping to the car, but she has not had wobblyness and tilting until now. My husband said that he has occasionally seen Gaissa bump into furniture or something else, as if she wasn't able to see well. Then again, she has somewhat "cloudy" eyes (nuclear sclerosis?), which the vet said is not dangerous.

If anybody happens to be online, I'd be grateful for quick replies again, as we'll go to the vet in an hour and a half.

[Gaissa]

Gaissa is back from the veterinary neurologist now. The vet did a quick but thorough neurological examination, and concluded that Gaissa's neurological status is perfectly normal for her age now. What a relief!

The vet said that Gaissa's neurological symptoms most likely were not due to Vetoryl/Addison's disease; in that case the symptoms would probably have been somewhat different. Instead, the symptoms were probably caused by vestibular disease, the cause of which is unknown. One symptom implies that the disease was/is central (yesterday Gaissa probably had a slightly deteriorated vestibular sense in one of her hind legs, but this was not the case today). Then again some other symptoms imply that the disease is peripheral and thus less worrisome.

The vet sent us home and said that if the symptoms reappear, it is possible to do a MRI scan. However, I don't think I'll be able to finance that, and considering Gaissa's age and condition it would not be sensible either, if there is nothing to be done anyway. As for now, we are happy and hope that the symptoms won't come back.

As for the ACTH test, there indeed is no way of knowing whether Gaissa swallowed the Vetoryl capsule before the ACTH test, which is worrisome. All I can do is to comapre the two latest test results and see how big the changes are:

6th ACTH test in July 2015, Vetoryl medication before the test 30 mg:

CORT – Cortisol (ECLIA) 26.4nmol/l (Reference range 24.8 – 124.2)
CORT – Cortisol, 2nd sample 30.6 nmol/l

7th and the latest ACTH test in January 2016, Vetoryl medication before the test 30 mg:

CORT – Cortisol (ECLIA) 68.3 nmol/l (Reference range 24.8 – 124.2)
CORT – Cortisol, 2nd sample 113.2 nmol/l

As you can see, the medication was the same (30 mg) in July 2015 and in January 2016. In July, the vales were much lower than now. The question is which do you think is more probable:

a) Gaissa swallowed the capsule before the test, and the values can be that much higher now than in July?

b) Gaissa didn't swallow the capsule before the test, and that is why the values are better now than in July?

I know the only way to know for sure is to do the ACTH test again, but I'd rather not if it is not necessary. I have to take a day off from work to drive to the clinic, and our insurance won't cover any more expenses until in July. Then again, Gaissa is worth the money though.

I'm so glad that I wrote here last night and got the advice. Without that, I/the vet might have ended up hurrying and euthanising Gaissa. I do realize it may have to be done any day if the symptoms come back, but right now everything seems to be fine.

[Harley PoMMom]

If this were me I would rather err on the safe side and presume that Gaissa's January 2016 ACTH post result is higher than in July 2015 because she didn't swallow her Vetoryl capsule.

How is her appetite and has her drinking/urinating increased?

[molly muffin]

Great news about the neuro report!! That really is good.

It doesn't hurt to miss vetroyl doses. When molly is having a gastro upset, I don't giver the trilostane/vetroyl. When she feels better, then we start again.
Starting and stopping vetroyl is fine.

[Gaissa]

I keep blaming myself for not being careful enough with giving Gaissa the Vetoryl capsules. I don't want to force feed the capsules, because Gaissa dislikes it so much, and normally she does swallow them rather well when given wrapped inside a piece of cheese. However, sometimes we do find capsules on the floor. As we stayed in the flat three days, there is a 1/3 chance that Gaissa spat the capsule out on the day when she had the ACTH test. It is frustrating not to know, and I'm thinking about having the ACTH test redone. However, I can't arrange it to be done until next Friday; I hope that's not too late.

It is good to know that pausing Vetoryl is ok. I have not given Gaissa Vetoryl yesterday and today – how long do you think it is safe to continue pausing? What if Gaissa did swallow the capsule before the ACTH test and the values are reliable – how long a pause is safe in that case? And what are the symptoms if the pause is too long? Will Gaissa be drinking excessively? Anything else? I'm sorry I keep asking so many and silly questions, but our vet would probably not be able to answer any of them.

I keep monitoring Gaissa as much as possible, which is easy now that I'm not at work during the weekend. I think that Gaissa does drink a bit more than usually, and her appetite is also a bit better than usually. It is hard to say whether she urinates more than usually, because I take her out so often that she doesn't need to wait and ask for it. Gaissa hasn't vomited and doesn't appear to be nauseous. She doesn't seem to have any neurological symptoms any more, although her hind legs are somewhat weaker than before (a bit wobbly, but more due to muscle weakness and nothing like two days ago). Gaissa's behavior is otherwise normal, but she doesn't sleep as much/peacefully as usually. For example, it is late evening here now, and normally she would be sleeping at this time. She has been lying on her bed for an hour or so, but she keeps popping her head up every now and then and occasionally has a staring look in her eyes. I keep wondering why – what if she is in pain/discomfort.

I'll try to get some sleep now – after all, it won't help Gaissa if I stay awake and end up way too tired. What would you suggest doing in the morning – should or should I not give Gaissa the 30 mg Vetoryl? We don't have 10 mg capsules, so titrating the dosage is not an option.

[Gaissa]

If anybody happens to read this, I am still wondering how long it is safe to pause giving Gaissa Vetoryl. This is her third day without medication, - is it safe to continue pausing, or should I give her the capsule tomorrow morning? I'll leave for work in the morning and won't be at home monitoring Gaissa until in the evening (although my husband will be able to take her with him to work and keep an eye on her every now and then).

[labblab]

Hi again from me! There really is no danger from continuing to withhold the Vetoryl aside from the possibility that you will see increasing Cushing's symptoms. If you would feel more comfortable holding off for another couple of days in order to see how Gaissa is feeling, I don't think that should be any problem. You can always resume the medication at any time, especially if you start seeing an increase in Cushing's symptoms.

Please try not to be too hard on yourself about the capsules being spit out. Our doggies can be very sly about these things :o. In the future, one thing you might try is to immediately give her a series of 1-2 little treats to eat right after her capsule. Hopefully, she will be eager to eat the treats, and that will force her to either swallow the capsule or visibly try to spit it out right in front of you. She can't easily harbor the capsule in her mouth and swallow the series of treats at the same time. ;)

Marianne

[molly muffin]

I have stopped for a few days.

If you have any concerns, some people have stopped when concerned about an overdose and waited for symptoms to reappear then start again.

It depends on how she is doing. Is she walking, drinking, eating alright? If so then I would prob restart and see how she does.

I see Marianne and I where typing same time. If concerns then just don't give it for a while longer.

[Joan2517]

Good morning! What I do with Lena's pill is, I give her her breakfast, then put the Vetoryl in a spoon with the wet dogfood with another spoonful waiting and she swallows the first one fast, to get the other. Then I watch to make sure she hasn't cheeked it! Only once did I find the outside of the capsule on the side of her mouth. This works for us! I used to do it with cheese, cream cheese and yogurt, but then she wouldn't eat her regular food, she just wanted the treat food...had to come up with a different plan!

[molly muffin]

Checking in to see how Gaissa is today while you where at work? Did she go hang out with your hubby for the day?

[Gaissa]

Thank you for your quick and kind replies again. Gaissa is still doing well; there is no sign of neurological symptoms.

Today was the 5th day without Vetoryl. I was a bit worried about pausing the medication, but I can't actually see any change/more Cushings symptoms in Gaissa so far. She does probably drink a bit more tahn before, but her appetite is not very good. She will not touch her regular dry food until in the evening, but she does eat meat and other treats.

Do you think it is still ok/useful to continue pausing the medication?
And if I can arrange the ACTH test to be redone on Friday, should I start giving Vetoryl tomorrow morning (ie. Wednesday)? And if Gaissa's symptoms had to do with too much Vetoryl, will they come back as soon as we start medicating again? Lots of questions again.

When we were at the neurologist, I asked her if it might help Gaissa to give her B vitamins for neurological support. The vet said it is ok to try that, so I have been giving Gaissa a liquid B complex for animals, as well as small doses of human grade B12, B1 and B2 vitamins. There seems to be a lot of research done and availabe about B vitamins for human use, but how about dogs? Do you have any experience with those vitamins?

The vet also said it would be ok to try melatonin for Gaissa's restlessness/panic in the morning - she said that melatonin would probably be better than Clomicalm considering Gaissa's liver. (I guess Vetoryl is pretty hard on the liver?) I haven't tried melatonin yet, but I did give Gaissa a Zylkene capsule this morning before leaving to work. That, however, didn't help at all - Gaissa didn't let my poor husband sleep. This really is starting to be a big problem - obviously, Gaissa is mentally and possibly also physically in pain, and my husband is getting increasingly tired. He doesn't complain though, even though Gaissa is more my dog than his.

[Joan2517]

Hello,

My Lena has had the wobbles a few times and also tilts slightly sometimes, but it comes and goes. At first we thought it was the bricks on the walkway, the wood floors, old age, etc.

Her back legs are very weak and she does have trouble walking, but then there are times that she goes down the few steps into our backyard with no problem at all, while I stand there with my mouth open. The past few days she has been taking longer walks in the backyard and I've even caught her running up to the house a few times.

Gaissa may just be having a bad spell. She may surprise you and get better.

Joan

[molly muffin]

Molly has a luxating patella pretty bad on one leg, and about a grade 2 on the other leg, but the other leg she has a misformed hip joint, so all in all she has some days that it is harder to get around if her cortisol is lower.
On those days when I notice her having problems I skip the dose for a couple days, till she seems to be doing better. (will be discussing this with IMS)

If you are going to redo the ACTH test, then I would not give her any vetroyl prior to that test, as long as she isn't exhibiting symptoms and see what her cortisol is like without it. That is just what I would do. Then if it is increased, you could start back, but maybe at a lower dose even.

I don't know about the vitamin B dosages in dogs and what to give them or how much. I haven't tried it, although if memory serves we have had others try it.

hmm. I can't remember if Judy gives Abby vitamin B or not.

[judymaggie]

I don't know about the vitamin B dosages in dogs and what to give them or how much. I haven't tried it, although if memory serves we have had others try it.

hmm. I can't remember if Judy gives Abby vitamin B or not.

Nope, not me :) and I honestly have never heard of giving dogs vitamin b supplements. We head to the vet on Thursday. If I can remember, I'll ask my vet about this.

[Harley PoMMom]

Today was the 5th day without Vetoryl. I was a bit worried about pausing the medication, but I can't actually see any change/more Cushings symptoms in Gaissa so far.

Do you think it is still ok/useful to continue pausing the medication?

In some dogs where there cortisol dropped too low the Vetoryl was stopped indefinitely. The time it takes for the adrenal cortex to rejuvenate is different for every dog. Discontinuing the Vetroyl when a dog is not acting them-self is the right thing to do.


And if I can arrange the ACTH test to be redone on Friday, should I start giving Vetoryl tomorrow morning (ie. Wednesday)?

No, you don't want to give her the Vetoryl if you are getting an ACTH test done, her dose of Vetoryl will be dependent on those ACTH stim results AND how she is acting.


And if Gaissa's symptoms had to do with too much Vetoryl, will they come back as soon as we start medicating again? Lots of questions again.

If it comes back that her cortisol has dropped too low than the Vetoryl needs to be withheld until Cushing's symptoms rebound and an ACTH stimulation test shows that her adrenal glands are producing enough cortisol.


When we were at the neurologist, I asked her if it might help Gaissa to give her B vitamins for neurological support. The vet said it is ok to try that, so I have been giving Gaissa a liquid B complex for animals, as well as small doses of human grade B12, B1 and B2 vitamins. There seems to be a lot of research done and availabe about B vitamins for human use, but how about dogs? Do you have any experience with those vitamins?

Sorry, I can't help you there.


The vet also said it would be ok to try melatonin for Gaissa's restlessness/panic in the morning - she said that melatonin would probably be better than Clomicalm considering Gaissa's liver. (I guess Vetoryl is pretty hard on the liver?) I haven't tried melatonin yet, but I did give Gaissa a Zylkene capsule this morning before leaving to work. That, however, didn't help at all - Gaissa didn't let my poor husband sleep. This really is starting to be a big problem - obviously, Gaissa is mentally and possibly also physically in pain, and my husband is getting increasingly tired. He doesn't complain though, even though Gaissa is more my dog than his.

I know melatonin helped my Harley's anxiety with loud noises and thunderstorms. He took 3 mg twice a day and it had a calming effect. Now, you want the plain melatonin, not the rapid, extending release or fast acting kind.

Hugs, Lori

[Gaissa]

Once again, I'm not sure what to do. Our vet called me this morning and said I could bring Gaissa for a new ACTH test later today. However, she said that she doesn't think it would make sense: according to her, electrolytes in the blood test a week ago (when Gaissa had the vestibular symptoms) were ok and thus the symptoms were not caused by too much Vetoryl/Addison's disease. Can I trust this, ie. are "ok electrolytes" enough to confirm this? The vet also said that I can/should start Vetoryl again now or after the weekend. Any thoughts/suggestions?

[labblab]

Unfortunately, it seems as though many vets are not aware that Addisonian changes that are drug-induced in Cushpups do not always produce the same symptom profile that is more common with naturally-occuring Addison's Disease. While it is true that classic Addison's Disease most often results in both low cortisol and electrolyte abnormalities, Vetoryl overdosing may end up adversely affecting only cortisol production alone, and not necessarily also dropping aldosterone too low (aldosterone is the adrenal hormone that controls the electrolytes). Per the U.S. Product Insert for Vetoryl:


4. Long term monitoring:

Once an optimum dose of VETORYL Capsules has been reached, re-examine the dog at 30 days, 90 days and every 3 months thereafter. At a minimum, this monitoring should include:

• A thorough history and physical examination.
• An ACTH stimulation test (conducted 4-6 hours after VETORYL Capsule administration) - a post-ACTH stimulation test resulting in a cortisol of < 1.45 μg/dL (< 40 nmol/L), with or without electrolyte abnormalities, may precede the development of clinical signs of hypoadrenocorticism.
• Serum biochemical tests (with particular attention to electrolytes, and renal and hepatic function).

Good control is indicated by favorable clinical signs as well as post-ACTH serum cortisol of 1.45-9.1 μg/dL (40-250 nmol/L).

If the ACTH stimulation test is < 1.45 μg/dL (< 40 nmol/L) and/or if electrolyte imbalances characteristic of hypoadrenocorticism (hyperkalemia and hyponatremia) are found, VETORYL Capsules should be temporarily discontinued until recurrence of clinical signs consistent with hyperadrenocorticism and ACTH stimulation test results return to normal (1.45-9.1 μg/dL or 40-250 nmol/L).

VETORYL Capsules may then be re-introduced at a lower dose.


http://www.dechra.us/Admin/Public/Download.aspx?file=Files%2FFiles%2FSupportMaterial Downloads%2Fus%2FUS-046-TEC.pdf

Since Gaissa is not yet exhibiting outward signs of elevated cortisol, to be on the safe side, it probably would be better to have that ACTH test performed prior to restarting the Vetoryl. Even though her electrolytes are OK, her cortisol may still remain at a level that is lower than is needed or is safe for the medication to resume. If your vet has questions or doubts about the testing, she can contact Dechra directly and I am certain they will be happy to discuss Gaissa's situation with her.

Marianne

[Gaissa]

Thank you for the advice again. I ended up not taking Gaissa to the vet today - the vet insisted that if electrolytes are ok, there is no need to worry about Addison's. However, now that I've read the latest reply I realize that is not the case.

I'll call the clinic and ask if some other vet might still be available today - or would it be ok to do the ACTH test on Monday? Now that Gaissa has been off medication (today is the 7th day and Monday would be the 10th day) before the ACTH test, will we have to start all over again, ie. have the ACTH test done again 10-14 days, 30 days and 90 days after restarting Vetoryl? Or would it be possible to determine the correct Vetoryl dosage after just one ACTH test? I'd rather not have many test done if it is not absolutely necessary - going to the clinic is pretty stressful for Gaissa, and, of course, expensive as well.

[labblab]

Since you are asking for opinions, here's mine -- but bear in mind, I am not a vet and I am just telling you what I would do if Gaissa was my own dog.

I've looked back through your entire thread and I am reminded of both her age and also the fact that her ACTH results had really been too low ever since the fall of 2014. If she were mine, I honestly don't believe I would ever start back on the Vetoryl again unless you see a resumption of Cushing's symptoms. She is a senior girl for her breed, and so at this point I would be most focused on everyday quality of life as opposed to slow chronic changes that the disease might bring. If she is not being bothered by uncomfortable symptoms of the disease, I would not subject her to all the monitoring testing and possible side effects that accompanies the medication.

As long as she is behaving normally right now, I would not rush in for another ACTH. I know you are watching her very closely, and if you see more abnormal symptoms that could be associated with cortisol that is either too high or too low, then I would want another ACTH. But if she seems stable right now, I think I would just enjoy this break. :o

But as I say, that is just my opinion and others may certainly disagree.

Marianne

[Squirt's Mom]

I have taken the liberty to change the title of Gaissa's thread. Since her cortisol has been elevated, she does not have the form referred to as "Atypical" and I didn't want members who's dogs actually do have Atypical to read her thread and become confused as the treatments for the two forms are altogether different. ;)

[molly muffin]

Marianne makes a good point. What do you think about just seeing how she does and if symptoms come back then do the ACTH and see if you want to pursue treatment or not based on how she is actually doing?

[Gaissa]

Thank you again. It took me time to write here again, because our daughter had her 5th birthday yesterday. She loves Gaissa so much (she even calls Gaissa her sister), and we were so glad that Gaissa was still with us yesterday.

Today is Gaissa's 10th day without Vetoryl. Gaissa started to drink a lot the day before yesterday, and yesterday she also wanted to eat more than usually. We are still in town, so I called the clinic and got an appointment for the ACTH test in the afternoon. Even though the vet said earlier that I could just start giving Gaissa the 30 mg Vetoryl again, I rather trust the advice given on this forum and take Gaissa to the test. I'll let you know about the results later.

[Gaissa]

Gaissa is back from the vet again; this was not our regular clinic and vet. If I remember correctly, our regular vet said just like you did that I could bring Gaissa to the ACTH test when she is off medication (today is her 11th day off medication). This vet, however, insisted that if the ACTH test is done now off medication, it will not be of any help at all, ie. that the test results will not help in determining the correct Vetoryl dosage. She suggested not doing the test now and doing it later instead, after restarting the 30 mg dosage. I told the vet about this forum and even suggested calling Dechra, but she remained skeptical. She agreed to do the test though, probably thinking I was just another neurotic pet owner.

I'll get to hear the test results at the end of the week. But what should I do now? Should I wait and not give Gaissa Vetoryl until I hear about the test results, even though she has started to have more Cushings symptoms now? Or should I start giving her the 30 mg dosage anyway- this is actually what the vet told me to do? Will you be able to help me interpret the test results in terms of how to continue with the medication/dosage?

[judymaggie]

Hi! Good for you for sticking to your guns in getting the vet to administer the ACTH!! Others will respond, I'm sure, but, in my opinion, you should wait until you get the results of the ACTH to decide whether it is time to restart the Vetoryl even though you have started to see symptoms again. One of the reasons the ACTH was necessary was to determine if Gaissa's cortisol levels were too low. Waiting a few days is not going to make a difference in Gaissa's overall care but starting the Vetoryl if her levels are already too low would be a problem.

Folks here will definitely help you interpret the test results. Make sure that you get two numbers from the vet -- a "pre" and a "post" number.

Hang in there -- you are being a great Cush mom!

[Harley PoMMom]

I agree 100% with Judy, those ACTH stimulation results may show that Gaissa needs to start at a lower dose of Vetoryl than the 30 mg, so it is crucial that no Vetoryl is given until those ACTH stim results are known, and we will help you understand them. ;)

Hugs, Lori

[Gaissa]

Thank you for the encouragement. I felt bad at the vet's, not "obeying" her and telling her what I wanted her to do, when she clearly had a professional opinion of her own. I don't want to appear disrespectful, and I do understand that vets can't possibly know everything about every disease. In fact, I think it would be very distressing to be a vet, expected to know so much about various animals. I mentioned this forum to the vet, and she googled "k9 Cushings", so hopefully she'll have a look here some day.

Gaissa is sleeping peacefully now. I'm afraid I won't be sleeping that well, as I'll probably need to take her out to pee due to increased drinking at least once during the night. So far Gaissa has never had an accident since she was a puppy, and if she did, it would probably be very embarrassing for her. Gaissa's pee is still yellow, but that is due to the vitamin B2/riboflavin that I have been giving her for neurological support (just a moderate amount, as there indeed seems to be little research on B vitamins for dogs).

Our daughter just gave Gaissa a good night hug. Lately our bedtime story has been a story about canine heaven (by Emma Clark; I think the title in English is "Up In Heaven") - just in case.

[molly muffin]

You aren't looking for a diagnosis on how much to administer, you are looking to find out what her adrenal glands are producing now after having been off vetroyl for a period of time.

I think this is a matter of the vet, who is not the regular vet, not fully understand the whole scenerio, which is of course complicated.

Hang in there and see what the ACTH results show and then you can make a better decision.

[Gaissa]

Hi again! Gaissa's ACTH test was done a week ago (when Gaissa had been off Vetoryl for 11 days), and I got the results today:

cortisol pre stimulation 156
cortisol post stimulation 110

Shouldn't the values actually be vice versa? However, this is what the assistant told me on the phone

I didn't have a chance to talk to the vet, so I don't know what she might have suggested - what do you think I should do with the Vetoryl medication/dosage now? Today is Gaissa's 18th day off Vetory, and she drinks loads of water now.

[molly muffin]

So th cortisol is going back up a bit.
Normally yes the post is larger than the pre but we have seen it be the opposite. You said she is drinking more. But is it too much like she is going potty all the time again. Drinking more than an ounce per pound of body weight? Any other symptoms? How is she over all?
If you do want to restart medication I wouldn't give the 30 mg again but a lower dose. Even 10 would be better as the 30 had her much too low in my opinion.