14 year old with Adrenal mass

[Lpearce]

Hi everyone, I am new here. I have a 14 year old, 50#shepherd mix named Pepper. She has probably had Cushings for at least 18 months now but it wasn't diagnosed till this past November. She has had every Cushings test including CT scan and MRI. Ct showed mass on her left adrenal gland with a smaller right gland. Had MRI a week later, MRI radiologist said he thought right gland was slightly swollen too. However Internal medicine specialist disagreed.ugh! So with her age and uncertainty I decided to try Veteroyl. After a three weeks in December on 30mg in am and 30mg in pm, we were carrying her outside to potty. She lost all muscle use in rear end. ACTH test still showed high cortisol levels. After two days off Veteroyl she's back to her old self. So I'm back to square one. Just had blood panel done which showed normal levels except for a higher ALP due to Cushings. Thinking about doing another CT scan just to double check glands. Surgeon said she could do surgery back in November. So I'm rethinking surgery? It's torture watching Cushings steal her health. Her symptoms are excessive thirst, hunger, muscle wasting and UTI's. Any help???
Lisa

[judymaggie]

Hi, Lisa and Pepper! It sounds like you are in a tough spot, trying to decide how to proceed with Pepper's treatment. Differing expert opinions certainly aren't helping you. Did the surgeon you met with in November address both the pros and cons of surgery in a senior dog? Our admin folks will be along to speak to specifics but it would help if you could post the numbers (pre and post) from her latest ACTH.

[molly muffin]

Hello and welcome.
I'd like to know what the ACTH numbers where too after the incident where Pepper couldn't walk and was on the 30/30 dose. That Pepper is now walking fine, makes it sound like he had a strong reaction and cortisol drop on the medication. It's always I think, a bit tricky getting dosages right with adrenal tumors.

Has a surgeon evaluated Pepper yet for surgery?

We do have a list of questions that you can use as a guide when speaking to the surgeon that one of our members whose dog had and adrenalectomy made for us.


Part I - Questions to ask when considering if surgery is an option for your dog’s adrenal tumour:
1. What type of tumour do you suspect, ?functional, ?non-functional, pheochromocytoma, benign, metastatic
2. Expected life span for my dog in a normal situation. If your dog is close to, at or past his expected lifespan for his breed is surgery going to be of any benefit?
3. Prognosis for my dog if we treated medically i.e. with Cushings medications. AND if we do not proceed with surgery how long do you think it would be before the tumour started adversely affecting his quality of life?
4. If he is miserable now, does the benefit of potentially risky surgery outweigh his current quality of life?
5. Are there any other health problems that could impact on a positive surgical outcome, for example: if your dog is overweight or has heart, BP, liver, kidney or lung conditions
6. Is there any sign of tumour spread – imaging should be done, including ultrasound and on advice of specialists either CT or MRI to check whether there is local invasion around the tumour, into blood vessels including vena cava or spread further away in the body to lungs etc
7. Surgeon recommendations – would he/she do it for their own dog?
8. Psychological impact for the owner: It is important to understand this is risky surgery, sadly current guidelines indicate 1:5 dogs do not make it, and some recommendations are not even that high. Can you accept it if your dogs dies during or in the postoperative recovery period surgery? This is where it is important to weigh up whether the benefit of your dog being fully cured is worth the risk of possibly losing him.
9. Financially – can you afford it? Find out estimate of costs.
10. Hopefully this will not happen, but if your dog collapses, e.g his heart stops either during his surgery or afterwards what emergency measures should be undertaken, do you want your dog to have CPR, how far are you (the owner) willing to go for your dog to be saved in such circumstances

Part II - Surgery has been recommended as treatment for your dogs adrenal tumour, here are a few suggestions on what questions you should ask your surgeon:
1. Are you board certified? How many operations of this type have you done? What complications have you experienced? What were the outcomes?
2. Please explain to me how you will do the surgery, which part would likely give you the most trouble? Will you be doing the actual surgery or a resident in a teaching situation? If so, is their close supervision?
3. Will there be a specialist anaesthetist available for the surgery?
4. If it hasn’t been done, do we need a CT/MRI scan to look at the tumour more closely to check for vena cava involvement or any other tumour spread?
5. What are the risks associated with this surgery, including
• Bleeding (including trauma to blood vessels or other organs during surgery)
• clots
• Blood pressure or heart problems such as arrhythmias
• pancreatitis
• pneumonia
• kidney failure
• infection
• wound problems
• bowel problems
• anaesthetic risks
• adrenal insufficiency or electrolyte abnormalities
• death (sorry but you have to ask that risk too)
6. If we proceed with surgery does my dog need preoperative treatment with Cushing’s meds, antihypertensive if high blood pressure is a problem – phenoxybenzamine recommended preoperatively for dogs with pheochromocytoma, anticoagulants or anything else?
7. How will you treat to prevent clots postoperatively?
8. What would you do if you found anything else during the surgery i.e. nodules in other organs e.g. spleen, opposite adrenal, liver, kidney. Would you remove them and what are the risks associated when doing additional abdominal surgery together with adrenalectomy
9. How long will it take and when will you contact me so I know all is OK, when can I visit after surgery?
10. How will the postoperative period go, how long would you anticipate he would need to stay in hospital? How will we manage pain?
11. What monitoring would be needed, e.g. heart monitoring, oxygen levels in the postoperative period
12. If your dog has an adrenocortical tumour affecting cortisol production will he need to be on steroids following surgery and for how long?
13. If there are problems when I take him home, who do I contact? Hopefully the surgical team until all is stable.

I'm so glad you found us as it can be really scary out there when going through this and it really helps to know there are others doing the same thing.

Welcome

[Lpearce]

Thank you both for the reply. I don't have results of last ACTH test after Veteroyl, I certainly can get them. My vet Dr Turenne just said they were high, and the Veteroyl was not lowering her cortisol. That was when they raised the dose by 10mg. Making it 40mg morning and night. Within a week, Pepper couldn't walk. The surgeon has went over all the pros and cons of the surgery and I certainly know all the risks. But at this point, I'd almost rather Pepper die on the table than do nothing at all for her. It's torture. She's not bad enough to say ok that's it, but her quality is not great right now. Just waiting for the next major health problem Cushings brings on is horrible for her and myself. :(

[labblab]

Welcome from me, too, and I'm really sorry about the tough choice you're facing. Just to clarify things for us, Pepper was outwardly doing better on the 30 mg. twice daily, but her cortisol level was high so her dose was bumped up to 40 mg. twice daily? It was at that point, after a week, that she pretty much collapsed? I am wondering whether another ACTH test was done at that point, and if so, the results.

With a dog her age, it really is a tough call knowing which way to go. I think pretty much across the board, specialists say that removing an adrenal tumor is the best treatment option if a dog is a good surgical candidate. But even then, the surgery still carries strong and definite risks.

I guess if she were mine, given her age and depending on whether or not she had seemed a lot better on the 30 mg. twice daily, I might want to backtrack and retry that dosage again. I wouldn't care so much about the actual cortisol level, but more about how she's feeling. That is with the understanding that I would not be altering the longer term risks/damage potentially caused by the tumor's presence or growth, but I would be trying to make her more comfortable in the here-and-now. I think that would be the option I would be considering vs. the surgery. But that's just based on my own thinking, and the vets may have strong reasons for recommending otherwise.

Please do keep us in the loop, and let us know those actual test results if you can.

Marianne

[Lpearce]

Hi, thanks for your help. These are the results i gathered today.

After two weeks of 30mg Veteroyl in morning/30mg in evening
Fro DCPAH lab at MSU
Cortisol baseline. 65 (nmol)
Cortisol 1 hrs post ACTH 210 (nmol)

After three weeks of Veteroyl and weird trembling episodes
Baseline 157
1 hr. 317

????????

[judymaggie]

Lisa -- if my conversions are correct, at 30 mg. twice daily Pepper's ACTH numbers were:

Pre 2.5
Post 7.6.

If I am understanding correctly, after two weeks her dose was then increased to 40 mg. twice daily with the following ACTH numbers after three weeks on the higher dose:

Pre 5.7
Post 11.5.

Since Pepper's cortisol levels were definitely in a good range when taking the 30 mg. twice a day, I'm not quite sure why the vet would think her levels were high. Dechra recommends no changes in dose for at least a month.

I would agree with Marianne that back-tracking on Pepper's dose could be a good next step. You also might try starting back on an even lower dose, say 20 mg. twice a day or 20 mg. in the a.m. and 10 mg. in the p.m., and work gradually back up, giving Pepper time to adjust to each increase.

[Lpearce]

Well no actually, she didn't raise Peppers Veteroyl after that first test. She raised to 40 after the second test. Then less then a week later Pepper couldn't walk. I don't know how to do the conversion, and I'm a little unclear on what's normal range? I keep seeing different reference ranges?
Lisa

[My sweet Ginger]

Hi, welcome from me too.
Just to be sure how long was Pepper on 30mg x2 Vetoryl that resulted in the ACTH numbers of pre 65 and post 210 nmol? Thank you.

[judymaggie]

Lisa: Here is a link that might help you with guidelines from the Vetoryl manufacturer: http://www.dechra.us/Admin/Public/Do...US-046-TEC.pdf

The flow chart on page 2 is very helpful with regard to understanding ranges.

This is a link to the conversion chart that I use:

http://www.endmemo.com/medical/unitconvert/Cortisol.php

Just type number in "nmol/L" box and click on "calculate" and equivalent in ug/dL will appear.

[Lpearce]

Hi, thank you, Pepper was on the 30mg twice a day for two weeks when she had that first ACTH test. And thank you Judy for the added info, big help!!!
Lisa

[My sweet Ginger]

I agree with Judy in that after 2wks on 30mg x2, pre 65nmol (2.4 ug/dl) and post 210 nmol (7.6ug/dl) didn't really require any increase at all as Vetoryl works for 30 days. If anything I'd have been concerned that Pepper's cortisol may go too low at that rate in another two wks.
With that said I'm scratching my head here about the numbers, pre 157 (5.7) and post 317 (11.5) after 3wks on the same 30mg Vetoryl.
I don't know what to think about these numbers.
Do you know what made your vet to perform another ACTH only one wk after the first one that was done two wks after on 30 mg that resulted in 157 and 317?

[labblab]

Well no actually, she didn't raise Peppers Veteroyl after that first test. She raised to 40 after the second test. Then less then a week later Pepper couldn't walk. I don't know how to do the conversion, and I'm a little unclear on what's normal range? I keep seeing different reference ranges?
Lisa
Well, I am definitely scratching my head, too. There are a couple of oddities here. It looks as though Pepper's post-ACTH result increased from 7.6 to 11.5 between two and three weeks on the same dose of 30 mg. twice daily. Based on that sharp increase in ACTH result, your vet increased to 40 mg. twice daily, which I now understand and it does make sense. But unfortunately, behaviorally, Pepper did not respond well to the increase.

I honestly don't know exactly what to make of all this, other than the recognition that adrenal tumors can be highly variable in terms of hormone production and spikes. Generally, it can be harder to regulate adrenal Cushing's via medication management, and that is one reason why surgical removal is the favored treatment if a dog is a good surgical candidate.

Just to double check one thing. Were both ACTH tests performed under the same circumstances: hopefully, 4-6 hours after the trilostane dose was given along with food?

Marianne

[Lpearce]

I know my vet and the Internal medicine specialist are just as confused.
Yes both test where done following that protocol.
The reason why she did another test at three weeks, just one week after the first one was because Pepper was acting weird. She was doing this weird tremor thing. So Dr Turenne was thinking she was too low. So when it came back higher than the first one, she thought maybe symptoms were Cushings related, tumor growth, spike in production of cortisol???? Not real sure, so that was when raised her 10mg to the 40mg. That's what scares me about trying Veteroyl again, those tremors. I don't know, I have an appt next Wednesday with the specialist for another ultrasound. I will see what she has to say?ugh!!
Lisa

[Mari]

I am not very knowlegeable about test ranges and such, (and am new to the forum) just wanted to say that we also have a 14 year-old female German Shepherd mix with adrenal-dependent Cushing's disease and understand your concerns. Tests pretty much have ruled out pheochromocytoma for our dog. She's on Trilostane 20mg once a day, symptoms much better, labs show cortisol levels are in normal range, but she is experiencing occasional rear leg weakness too. It is scary. I hope Pepper improves and you get some answers and will keep her in my prayers.

[Mari]

p.s. Daisy has tremors sometimes, too.

[Lpearce]

Hi Mari, how much does your dog weigh? How long has she been on 20mg of trilostane? Is it twice a day?

[Lpearce]

Just found out Peppers Endogenous ACTH test came back at 21.6. Consistent now with PDH. PDH with adrenal tumor now???

[Trish]

Hi, my dog had an adrenalectomy over 3 years ago now, he did. It have cushings but a different type of adrenal tumour. If you decide to go down that pathway I can give you some advice! All the best

[Mari]

Hi Lisa,
Daisy weighs about 33 pounds and takes 20 mg of Trilostane once a day (in the morning). But the vet may add another 20mg 12 hours after the first, as she often wakes up at 4 a.m. hungry and needing to go outside. She started it in November.

[molly muffin]

Mari just so you are aware if you go to twice a day dosing you don't double the dose to 20mg morning and 20 mg evening. You split the dose so that instead of giving it all in the morning you give 10mg am and 10 mg pm. This keeps the cortisol levels more steady throughout the day. Doubling can cause overdose. So check ACTH and if the range I'd good then split the dose. If the range is off increase slightly depending on how off it is but not usually large increases. My specialist never increases by more than a few percentage points.

[Lpearce]

I'm wondering if Pepper being on 30mg twice a day was too high?? It's weird because her ACTH test was in pretty good range after two weeks then a week later high, after no increase??? I'm having ultrasound tomorrow and will talk to IMS about returning to a smaller dose of Vetetoyl IF I don't do surgery.

[molly muffin]

It can still change even after 30 days on the same dose too.

Adrenal Cushing's can be real buggers to get control of. Let us know what the vet thinks of the increase after medication.

My dog too will be okay for awhile and then lose control and well do a small increase and start all over again.

[Lpearce]

So after a stressful 1 hour plus car ride to IMS and hardly having strength to walk in appointment because Pepper insisted on standing the whole time there. And her rear weakness is bad right now. She struggled in and pooped all over the lobby and just collapsed right in front of reception desk. She was shaking, so I just laid right down on the floor with her. We laid there for about 15 minutes so she could recover then Pepper had her ultrasound. Now it shows a swollen right adrenal gland. So now both are swollen but left is still as big as four months ago. Dr Rice did not think surgery would be a good option. I guess are best options are a lower Veteroyl try, or Lysodren???Never making that drive again, if I do Lysodren I need to find someone near who knows how to monitor it.. Ugh. Poor girl

Lisa

[Kincsem]

So after a stressful 1 hour plus car ride to IMS and hardly having strength to walk in appointment because Pepper insisted on standing the whole time there. And her rear weakness is bad right now. She struggled in and pooped all over the lobby and just collapsed right in front of reception desk. She was shaking, so I just laid right down on the floor with her. We laid there for about 15 minutes so she could recover then Pepper had her ultrasound. Now it shows a swollen right adrenal gland. So now both are swollen but left is still as big as four months ago. Dr Rice did not think surgery would be a good option. I guess are best options are a lower Veteroyl try, or Lysodren???Never making that drive again, if I do Lysodren I need to find someone near who knows how to monitor it.. Ugh. Poor girl

Lisa

Aw, hugs! You sound like a wonderful and caring owner. What area are you in?

[Lpearce]

Hi, we are in Ann Arobr, mi

Lisa

[marinaliz]

Hi Lisa! I am following your threat since you have first posted. I am new to the forum and also new with Cushing’s disease. My dog has been diagnosed -initially- with the adrenal-based form almost three months ago. Let me tell you that I do really understand your fears for your sweet dog. I have talked to many specialists since she first diagnosed and fortunately things are not as bad as I initially thought.

Unfortunately, I cannot give you any advice but you are in the right place to get plenty! However, I would like to share some of my thoughts for the findings of the first and the last ultrasound you have performed. Specifically, you have mentioned in your first post that a mass was found on your dog’s left adrenal gland during the first ultrasound. What was the size of this mass? Was it compared with the findings of the last ultrasound? Has the mass been increased? The time interval between the two ultrasounds was 4 months? Has a LDDT or HDDT been performed for Cushing’s diagnosis? There are cases that tests such as LDDT can distinguish between the adrenal and the pituitary form. In our case, although that two masses had been found in my dog’s left adrenal gland, the results of the LDDT were consistent with the pituitary form of the disease. Also, I would like to mention some more points, in case that you are not already aware of them:

- In the adrenal-based form of the disease, 50% of the tumours found on the adrenal glands can be cancerous. However, the size of the tumor could be an indicator (along with other findings of the ultrasound), >2cm tend to be malignant, >4cm are almost always carcinomas.

- In the adrenal-based form, the affected adrenal gland has a mass on it and the contralateral gland is usually atrophied (it is rare the normal adrenal gland to be seen with normal dimensions). In your case, you mention that both adrenal glands are enlarged. None appeared atrophied or normal.

- In the pituitary hyperadrenocorticism adrenal glands can either appear normal or hypertrophic (with or without symmetry). Hypertrophy can be simple or nodular. Nodular hyperplasia can be confused with adrenal neoplasia, an error that has led to unnecessary unilateral adrenal surgery.

I hope my post doesn't confuse you more than it helps you.

[Lpearce]

Hi there, I copied this from her first ultrasound almost four months ago:
The right adrenal gland was normal to perhaps somewhat modest in size (5.2mm by 16.7mm). There was a mass effect identified in the left adrenal gland; it measured 13.0mm (cranial pole) by 14.3mm (caudal pole), extending 38.4 mm in length with a poorly circumscribed hyperechoic nodule of 15.2mm by 9.6 mm in the caudal pole. The left adrenal gland was situated in close proximity to the renal vasculature however did not appear to be invading the vessels based on ultrasound appearance. There was no free fluid in the abdominal cavity.

I don't have the new ultrasound results yet, however, Dr Rice said left adrenal hasn't changed much but right adrenal was now larger.
And I'm almost positive Pepper had the low dose Dex test performed. Those were the numbers a posted before.
What is modular hyperplasia and adrenal neoplasia??

Thanks for the help
Lisa

[molly muffin]

Well hyperplasia means enlargement and neoplasia means a growth of new tissue, which could be a nodule or other growth on an organ.

[Lpearce]

So Pepper and I saw a new IMS close to our house. He looked over all of Peppers test results and took a long time going over everything and discussing options. Surgery is definitely off table so my options are:
No treatment and just try to manage symptoms the best we can?
Or try a lower dose of trilostane (20mg) twice a day and see how she reacts? At 14 1/2 I'm torn but thinking I should try the compounded trilostane ( which he recommended over Veteroyl)
I can always discontinue if I see the weird trembling or rear collapse again? Peppers symptoms right now are excessive thirst and hunger but some days are worse then others. She just had a urine culture and nothing grew, yay!!! The real problem is her muscle wasting. She has lost so much muscle mass, especially in rear end. That's why I want to try the trilostane again. Thoughts please??

Lisa Pearce

[Harley PoMMom]

I certainly do understand the quandary you are in with trying to find the right solution for your dear girl. I believe if Pepper's symptoms seem bothersome to her than I would opt to restart the Trilostane but at even a lower dose, say 20 mg once a day and see how she reacts to that dose.

Improvement with the rear leg weakness does take a long period of time. Hydrotherapy may help with the muscle loss.

Glad to hear that she doesn't have an UTI!!

Hugs, Lori

[Lpearce]

Well I have compounded trilostane left over and they are 15 mg. so IMS thinks start at 15mg now twice a day? What do people think about going right to Lysodren? The muscle wasting is really my biggest concern. trilostane can cause weakness because it can block other hormones too?? That's what my first IMS said... Ugh I'm so confused....



Lisa

[Harley PoMMom]

When switching from Trilostane to Lysodren it is recommended to wait at least 30 days. As far as the muscle wasting I believe the elevated cortisol is more likely the culprit than the Trilostane. Now, if a dog's cortisol drops too low this can cause a dog to be very lethargic and have difficulty in standing up.

Did Pepper have a CBC/chemistry blood panel performed recently? If not, I would probably have one done just to make sure that those levels are within normal units.

The 15 mg of Trilostane twice a day does sounds reasonable. How does Pepper seem to be feeling/acting and how is her appetite?

Hugs, Lori

[Lpearce]

She just had a full blood panel couple of weeks ago. It looked good, BUN, little high and the ALP still but Vet said everything was good? She has been off trilostane for 4 weeks now. Now would be the time to try Lysodren but I'm so afraid...thinking I'm more comfortable doing the trilostane at a much lower dose this time.

[Lpearce]

Her appetite is good, loves her walks... Only real problems right now are the rear end weakness and panting.

[judymaggie]

Lisa -- having first tried Lysodren with my Abbie who is now on Vetoryl/trilostane, I think, if I were in your shoes, I would try the lower dose of trilostane rather than start with Lysodren. The Lysodren loading can be very stressful for the owner and, from personal experience, finding the right Lysodren dose is often more difficult. Since the only symptoms you are now seeing are rear end weakness and panting, I think it would be difficult to determine if Pepper was loaded. During loading one primarily looks for changes in eating and/or drinking and the changes can often be very subtle.

[Harley PoMMom]

Hi Lisa,

I agree with Judy, it can get nerve-racking while trying to load a dog with Lysodren, and in order to get that load a dog has to be started at a specific dose (50 mg/kg/day, divided and given BID, which for Pepper's weight of 50 lbs that comes out at a Lysodren dose of 1136 mg., Lysodren is known to cause gastric upset so this may cause Pepper to have more tummy issues.

Hugs, Lori

[molly muffin]

I'd try lower if the ACTH bears out that he needs to be restarted.

High cortisol causes a weakening of tendons and ligaments, this is usually what causes the rear leg weakness.

This is different from the wobbly, can't stand of having a lower cortisol crisis, when they are literally too sick to stand up.

[Lpearce]

Thank you everyone, we started the 15mg of trilostane twice daily this morning. Hoping she responds ok. Appreciate all the support in deciding this... Ugh. Lots of pressure... She relies 100% on me and i hope I am doing her right. Love this girl with all my heart.

Lisa Pearce
Pepper

[molly muffin]

It is a lot of pressure when you are trying to do the best you can and they can't just tell us what is wrong, how they feel at any given moment. We just do the best we can to give them the best life possible.
I hope this dose works for Pepper.

[Lpearce]

Hi everyone, so far Pepper seems ok on her trilostane. She's on 15mg twice a day. she seems more relaxed, not panting as much. I will schedule the ACTH test soon. Only real problem right now is loose stools. She's been on it for a week, will this get better??

Lisa

[judymaggie]

Lisa -- there are several things to try and resolve the loose stools. I actually do all three of the following with my Abbie who is very prone to loose stools:


add pure pumpkin (not pumpkin pie mix) to food
add forti-flora (or other probiotic) to food once a day
get metronidazole from vet


The easiest to start with is the pumpkin -- I started with a very small amount added to Abbie's food and gradually increased. Too much can have the reverse effect. Abbie loves the taste.

I am assuming that Pepper doesn't have diarrhea, just loose stools. If diarrhea, I would be more concerned. Just curious -- does your vet know you started Pepper back on the trilostane?

[Lpearce]

Hi Judy, yes my IMS knows I started trilostane last week. No it's not diarrhea, just loose. I have some Tylosin left over from a bout before, think I should give that?
Lisa

[judymaggie]

Lisa -- I would be hesitant to start an antibiotic without my vet's knowledge/concurrence. Maybe hold off on that until tomorrow when, hopefully, you could make contact with your IMS.

[molly muffin]

I would try the pumpkin too and see if that makes a difference.

[Lpearce]

Thank you everyone. ACTH test is Thursday, hope it shows some control. She is definitely not panting as much. And her appetite is bit more normal. We will see...

Lisa

[budindian]

My vet started my baby to high on the vetoryl and he was experiencing the same symptoms you are having with your baby. That vetoryl is some tricky stuff to get regulated. I had to start him at the lowest dose possible and work our way up. Wish you well with your baby.
You are in a very good place for advice on cushings. It was on this site I found out the dosing guidelines for the Vetoryl and printed it off and took it to my vet.

[Lpearce]

Ugh. Pepper has had a rough day. She's having that same weird weakness episodes she had before on a much higher dose of trilostane. This morning she fell over a few times. She will be standing there then start to collapse and usually catches herself. I really don't think this is a result of her cortisol being too low. But she does goes in to IMS tonight at 7. This IMS likes to run his tests an hour before pill dose??? Idk he says he's been doing it this way for a long time?
She is panting a lot today and she does still have a great appetite. I think this is the same thing that happened before, a negative reaction to trilostane. Or her levels are coming down and she is suffering from arthritis now? But before her levels were still high with this kind of weakness.. Idk any thoughts??

[labblab]

When you say the IMS wants to run the test one hour before pill dosing, do you mean the ACTH? If so, the only info he would be gaining is what the Vetoryl's effect is on the body during the time that the drug is least active (i.e., "trough" value right before redosing). This approach might have value if your main goal is to evaluate the advisability of switching to twice daily dosing due to symptom rebound if the effects of the drug seem to be wearing off prematurely. But Pepper is already being dosed twice daily, and testing in this manner does nothing to address safety concerns associated with possible overdosing and the appropriateness/size of dosing increases. For that, you have to know what the cortisol level is when the drug is maximally active: 4-6 hours after dosing ("peak" value).

Given Pepper's worrisome behavior, it seems to me that your greatest concern is to make sure she is not being overdosed. Testing right before dosing will not tell you that with accuracy, nor can it safely guide you in terms of dosing increases. I would strongly question your vet before spending money on an expensive test that is not providing the info that seems most important for Pepper right now.

Marianne

[Lpearce]

Yes ACTH, I questioned it too??? Now what should I do? Suppose to be there in an hour. I don't even know if I want to give Pepper any trilostane tonight.

[labblab]

Have all of Pepper's previous tests been done this way? (Forgive me for not taking the time to look back in your thread to review her test history).

[Lpearce]

No they were done at the 4 hour mark. This is her new IMS testing this way 😣

[labblab]

I can't argue with taking Pepper in to be seen this evening for general evaluation, but I would really balk at the ACTH testing. There will be no meaningful way to compare these results to the previous ones. I would really want this test to conform to the previous ones. Remind us as to why you're shifting to the new vet?

[Lpearce]

Ok, I totally agree. I changed IMS because my first one was an hour plus drive and it was too much for Pepper. Wanted to find one near my house so Dr Rice recommended this new one.

[labblab]

Well, this will be an opportunity to see whether this new IMS is a "keeper" in terms of willingness to take your concerns into account, and making reasonable accommodation. ;)

[molly muffin]

Print out the brochure from Dechra the manufacture and especially the flow chart for monitoring and take it to the new vet.

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

[Lpearce]

Rough week for Pepper. I had to discontinue the trilostane Thursday. She was getting worse to the point of falling over. For some reason trilostane messes with her stability. I got the worst reasons ever for doing the ACTH an hour prior to dosing. I won't be going back there. Yes the test was expensive but I decided to just do it to see where her levels were. I wasn't continuing trilostane but wanted to make sure it wasn't because her levels were too low. Last time this happened they were still high. Haven't got those numbers back or even a call asking how she is doing :(.
This Cushings road is long and heartbreaking :(
Don't really know what to do next, I just know Pepper sure can function better today after two days off melds.

Lisa

[Harley PoMMom]

Oh Lisa, I am sorry to hear that Pepper is having a rough time. :( For reasons that aren't fully understood some dogs are really sensitive to Trilostane and Reese may be one of them.

Since she is not acting like herself taking her off the Trilostane was the right thing to do. One option is to start her at a really low dose, however this would probably be rather expensive.

Hoping she is feeling better soon.

Hugs, Lori

[Lpearce]

Thanks Lori, I think we are done with the trilostane route. At this stage I think I will try to manage her symptoms the best I can and let her live the rest of her life. She will be 15 in June. Not comfortable trying the Lysodren now. So hard...:(