Diarrhea..no parasites, no other symptoms what to do

[kristenv]

I am sort of perplexed about next steps for Leia. A quick recap:
A friend of ours found her as a stray last October, and we elected to keep her. Got her vetted and given her skin appearance and spotty hair growth I suspected Cushings which was confirmed (we also found that she had a tapeworm which we treated, and she had a negative Giardia antigen test at that time)
Here are her LDDS
RANGE 11/23/2015
PRE DEX 1.0-6.0 1.8
POST 4HR DEX LESS THAN 1.5 0.6
POST 8 HR DEX LESS THAN 1.5 7
She eats like a horse, actually more than a few of our pups that weigh more than her, but we found if I decreased her intake she loses weight. It is concerning because she has several masses and lumps on her, Once we get the Cushings a little better controlled we will be removing these.

So long and short we started her on Trilostane...optimal dose is 3mg twice daily..but here is where it gets weird. I started her on a lower dose to sort of work her up to the 3mg dose, and she keeps getting diarrhea the next day after the 3 mg dosing. it has happened now 5-6 times, the last 2 times she had a little blood in her stool which was very worrisome. She shows no other symptoms of her levels being too low, she is not lethargic, is eating a ton....I am not certain what my best next steps are. We had her retested at a dose of 2mg (results are below) and her post stim was 15.9, so she definitely needs a higher dose.
has anyone seen anything similar? she had NO diarrhea in the month we had her prior to starting the Trilostane, so it seems to me to be the causative factor. my vet Dr P suggested placing her on some metronidazole to see if she responds well to that, to differentiate intestinal inflammation from Trilostane reaction.
Anyway..if anyone has any suggestions I would sure appreciate them She is our 3rd Cushings dog and the other 2 never had any problems with tolerating the Trilostane..so this is new territory for me.

thanks!
Kristen
Jenner, Alex, Samy, Dottie, Ari, Leia
At the bridge Mr B, Riley, Nabisco, Washington and Rory

Leia
10ish years old
8 lb chi-rat terrier mix
3mg Trilostane twice daily
3mg Melatonin daily at bedtime


DATE 12/29/2016
RANGE
ACTH STIM PRE 2-6 6.3
ACTH POST 6-18 15.9
****POST ON TRILOSTANE 1-5


REF IDEXX 10/16/2015 12/29/2015
ALP 5-160 433 211
ALT 18-121 127 117
AST 16-55 51 50
GGT 0-13 8
Albumin 2.7-3.9 3.4 3.9
total protein 5.5-7.5 6.8 7.4
globulin 2.4-4 3.4 3.5
Total Bilirubin 0-0.3 0.1 0
bilirubin conj 0-0.1 0 0
BUN 9-31 19 23
creatinine 0.5-1.5 0.4 0.6
cholesterol 131-345 333 263
glucose 63-114 100 72
calcium 8.8-11.2 10.5 10
phosphorous 2.5-6.1 6.4 5.5
chloride 108-119 109 105
potassium 4.0-5.4 4.9 5.2
sodium 142-152 144 144
alb/glob ratio 0.7-1.5 1 1.1
bun/creat ratio 47.5 38.3
bilirubin unconj 0.7-1.5 0.1 0
NA/K ratio 28-37 29 28
WBC 4.9-17.6 12.3 10.7
RBC 5.39-8.7 5.41 7.3
HGB 13.4-20.7 12.3 18.1
HCT 38.3-56.5 36.9 46.9
MCV 59-76 68 64
MCH 21.9-26.1 22.7 24.8
MCHC 32.6-39.2 33.3 38.6
%RETIC 2.2 1.7
RETIC 10-110 119 124
%NEUT 82.6 76.5
NEUTROPHIL 2940-12670 10160 8186
%LYMPH 10.8 16.1
LYMPH 1060-4950 1328 1723
%MONO 5.3 5.3
MONO 130-1150 652 567
%BASO 0.1 0.1
BASO 0-100 12 11
%EOS 1.2 2
EOSINIPHIL 70-1490 148 214
AUTO PLATELET 143-448 622 708
T4 1.0-4.0 1.8
SpecCPL
SDMA 0-14 10
Heartworm Neg

[judymaggie]

Welcome, Kristin & Leia! Kudos to you for taking in a senior pup -- I thought my having two Cushing's pups was a coincidence but you are on your third! We really appreciate all the information you have provided. Our admin staff will be along soon and they may think of additional info which would be helpful but I did want to address the diarrhea. It does seem odd that Leia's diarrhea only occurs after the trilostane dose is increased. It might be that there is an inflammation process going on and that extra amount tips her over. My situation is different in that my current Cushing's pup, Abbie (a beagle), has had chronic diarrhea since I adopted her at 7 years old (she is now almost 13). Knock on wood, for the last several months she has been diarrhea free! Even though different than Leia's pattern I wanted to share how I have been treating Abbie's diarrhea. I now give her a low maintenance dose of metronidazole, forti-flora once a day and canned pumpkin mixed in with each of her meals. I added each of these one at a time with about a month in between to make certain she had no negative responses. I also give her pepcid before each of her meals that she gets Vetoryl (Abbie is also on twice daily dosing). You might start with the most innocuous one which I think is the pumpkin. I started with a very small amount and gradually added more until I saw improvement. If you do decide to try the pumpkin, be sure to get pure pumpkin, not pumpkin pie mix.

[labblab]

Welcome back, Kristen! I know it's been a few years, and I see that sweet Washington is now at the Bridge :o. Thank you so much from our entire group for continuing to take in these babies with all their special needs. And if it would please you, it would be our privilege to add Washington to our special memorial thread on our "In Loving Memory" forum. You can just let us know about that.

Turning to Leia, Judy has gotten you off to a great start. Only one question comes immediately to my mind, and that is to ask about the trilostane itself. Given the dosage, I am wondering whether Leia is taking the med in liquid form? If so, we have just learned this week that there are two very different types of suspensions that are typically used. Surprising to me, one is sesame oil, for instance. If it is in liquid form, I wonder whether Leia's sensitivity may be to the suspension rather than the drug. If so, you'd think that any dose would affect her. But it is just a thought I wanted to throw out there...

Marianne

[kristenv]

Thanks so much for the ideas Judy!
I added the pumpkin today and will transition in the probiotics in as few weeks :). Sounds like you have had a long battle Abbie's tummy..I hope your approach stays successful!

Hi Marianne, thank you for remembering and for the kind words! Yes we sadly only had Washington for a short time, but it was incredibly precious time. He was an amazing boy..... I truly feel he left me with a mission in my heart to help these poor seniors.
Shortly after we adopted Riley and Nabisco after he passed, and were blessed with them both for 2-2 1/2 years..Riley had Cushings, Nabisco pancreatitis/IBD.


Which of course brings me to Leia. She is such an exuberant little bundle of joy! I get her medication through Roadrunner Pharmacy. It is refrigerated so I am not entirely sure that it has oil in it, I sort of assumed it was water based. I can call and ask tomorrow...is there a better formulation or pharmacy that people have less issue with? I will be honest I hadn't even considered that the formulation itself could be a problem.

She is on day 2 of the metronidazole..so far so good on that, which also makes me think it is not the trilostane itself

Kristen

[labblab]

I agree, it sounds as though the trilostane formulation itself isn't the issue. But just for your consideration, here's a conversation that we had just last week on another member's thread about liquid suspensions. I think this member was using Roadrunner, too, but ended up picking up a refill from her vet and then was not happy with the subsequent product from the vet, and is now ordering from Diamondback Drugs (also in Arizona). Here's where the conversation picks up, and if you wish, I'm sure you could ask this member more specifics as to what exactly prompted the move in the first place, and why she wasn't reordering from Roadrunner. I do think both Roadrunner and Diamondback are very reputable and service a lot of veterinary clients.

http://www.k9cushings.com/forum/showthread.php?p=183999&highlight=Roadrunner#post183999

I surely hope Leia continues to improve.
Marianne

[molly muffin]

I totally agree with the fora flora probiotic. Trying a bit if pumpkin and maybe the antibiotic as we have had to use all 3 at various times with my Molly too. Although I don't think Molly's is related to the trilostane so much as being prone to gastro upset which might be the case with Leia too.

I think I like diamondback better for liquid suspension. Seems someone else's dog too had a reaction to a liquid although I can't remember if it was roadrunner they used. But now we know about the suspension agent that might make a difference for some dogs.

[kristenv]

A quick update..so far so good using the Metronidazole and pumpkin! Her poops have been perfect and she is on the full recommended dose of Trilostane.
My plan is to stay on the Metro for 2 weeks, than see if we can transition her to tylan. If that goes well I will then add in the probiotics.
One change at a time.
Thanks again for the suggestions....they were really helpful!
Kristen

[molly muffin]

Yay, great to hear that things are getting better.

It really is all about baby steps isn't it. :)