Haleth, 14 yo SCWT - brave Haleth has passed

[Haleth]

Hello Collective Wisdom,

Haleth, my 14yo Soft-Coated Wheaten Terrier was officially diagnosed with Pituitary-dependent Cushing's just under two weeks ago, but looking back the signs appeared possibly as early as July or Sept 2014, a couple months after she survived a burst liver tumor (malignant: hepatocellular carcinoma) that was surgically removed. At the same time it was noticed that for the first time she had a high UPC (4.25) and elevated cholesterol, which the specialist thought might point to either PLN (H is a Wheatie after all) or damage because of the cancer. However, her UPC began to fall gradually and at last check in the fall of 2015 it was around 1, which made our internal medicine specialist and a second one that specialized in PLN and related problems take PLN off the table.

In September 2014 came the first of an ongoing series of skin infections that we treated with antibiotics and medicated shampoo. One of the vets finally thought to test for MRSP in October 2015 and she was positive for it. It was, after a 12-week battle, taken care of (we thought, but more on that later). The next signs were lethargy starting in mid-late winter 2015 and then the original IM specialist, who had been doing ultrasound re-checks regularly since he diagnosed the cancer, spotted that the adrenal glands were enlarged. He ordered an LDDS test, but she didn't fall into the "definitely has it category" so no medication but monitoring was ordered. Another one followed in the fall but she was still in limbo.

In December, however, she began to drink and have accidents almost every day, so we ordered a third LDDS test in the new year, with the change mentioned above. The IM fellow said he was fine with any of the medication options Hallie's regular vet chose. She chose Trilostane 50mg. Hallie's weight had been seesawing since December 2015. Before she was @22.5 kilos, but after a minor surgery to remove a benign perianal tumor and Christmas travel her weight fell to 19kg in late Dec., then up to over 20kg. She had 4 doses of Trilostane, but her appetite, which had been powerful in Dec., began to fall after early Jan, but we thought she was tired of her food (prescription diet, Z/D dry and canned). After 3 doses her appetite fell suddenly from maybe eating 2/3 to at most 1/4 of her expected food intake. She also threw up or regurgitated a little and she became even more lethargic (this did start a few days before Trilostane) and on this Monday morning Hallie was so weak she had problems coming down the stairs. Called the IM specialist who felt it wasn't the Trilostane and suggested the regular vet check her ASAP. Regular vet took her on as an emergency case and asked to keep her, as she felt it was a UTI. Took her off Trilostane, sent her home with Baytril (for now while they cultured the urine) and a different hypoallergenic canned food (RC) to try and jump start her appetite. H ate a normal dinner enthusiastically and took the Baytril, but was underwhelmed this morning (ate a small portion and threw it up). I was out of town from Mon. afternoon until this evening (my partner was here).

When I came home this evening she was very quiet but would look at me and relax into pats. Unfortunately, it was during the initial patting session that I found an area on her lower back crusted over with a fair amount of green-grey muck, maybe an inch or so long. Since she also had an abcess (MRSP at work again) in December higher up on her back, I was on alert and called the vet. She wasn't in but another member of the practice suggested warm compresses and to speak with my vet in the morning about the Baytril (was it that or the UTI causing the vomiting) and the spot on her lower back. Washing the area with water revealed 2-3 separate spots, with one much larger and covered with lots of crusted stuff, kind of grey-green-dark in color. Touching close to the area caused Haleth's back to twitch and she didn't like it, but didn't aggressively fight the application of water. We were able to get more food into her by a) just using a mix of old and new canned (no kibble) plus her regular pumpkin and supplements, b) giving her only about 2/3-3/4 can of food, and c) giving it to her by hand. She did regurgitate some liquid after at first enthusiastically eating most of the food, so we took a break. I then gave her tiny amounts of low-fat yogurt and then the rest of the food w/o incident about an hour later. From that we learned that even smaller meals may be necessary. I should add that she begged for treats during dinner and brightened up considerably after getting the food in her.

So, that's the gist of our experience to date. I just wanted to introduce Haleth, but also ask if this experience is unusual, including the vomiting/regurgitating. I know you'll want lab results, so I'll try to get them on the next visit (tomorrow?). H had 4 doses (Wed-Sat) of 50mg Trilostane; her weight was @19-20kg range. It was 19 and a bit yesterday. She also takes Benazepril, Metacam, and Ursodiol (for gall bladder problem). Fish oil, joint supplement, and probiotics are the supplements.

Best, Kirsten

[labblab]

Hello Kirsten, and welcome to you and Haleth although I am sorry for the problems that have brought you to us. It sounds as though Haleth has had a lot going on, and unfortunately it may be a little tricky trying to separate out the true causes for the separate issues. As you already know, allowing us to see the actual test results will be helpful. In the meantime, I admit that her combo of symptoms are a bit of a puzzle.

Starting her off on the 50 mg. was probably an acceptable dose, although it is a tiny bit higher than the currently recommended formula of approx. 2 mg/kg (or 1 mg/lb). It would be easy to blame the trilo for the loss of appetite and regurgitation, but you note that these issues arose even before the trilo was started. So it would seem as though there was something else that was already amiss. One wild card to throw out there is the possibility of pancreatitis. It always occurs to me when a Cushpup starts vomiting for no other obvious reason, because there does seem to be increased vulnerability in the face of elevated steroids.

One other culprit might be the metacam, since the combo of NSAIDS and elevated steroids (either naturally-occurring or through supplemental dosing) can be dangerous in terms of GI damage. So until cortisol levels are brought under better control, it might be safer to shift to a different class of pain relief such as tramadol. Tramadol does not have an anti-inflammatory benefit, but it does have a safer profile when given in combo with steroids.

Turning briefly to the skin infections, I can truly relate to that dilemma, having just weathered a nine-month saga battling MSSA on my non-Cushpup Lab. In her case, it was actually a combo of aggressive bathing and both topical and oral lipids that seemed to turn the corner for us, as the infection always returned after completing oral antibiotic courses. I did discover that not all medicated shampoos are created equal, and it was finally through use of a specific chlorhexadine shampoo and spray that we (hopefully!) have gained the upper hand.

Anyway, these are just a few random thoughts to throw out to you. As we have said, it will be good to see the actual test results and then we can go from there.

Marianne

[molly muffin]

Wow, that is a lot going on. I just want to say hello and welcome to the forum.

I'm wondering if maybe it is the skin infection that is making her feel awful, in combination with the lower of cortisol by the trilostane, she might not feel great at all.

If the cortisol went higher due to the skin infection, a natural response, and with everything she has had for as long as she has had it, could it be the cortisol rose in response to that and not cushings. (yes this kind of prolonged increase in cortisol could cause the glands to enlarge I'd think)
but over all, the skin infection is probably the most important thing to get treated and under control right now. Maybe you could also try a lower dose of trilostane to, while this is going on if you are going to treat both.

I'd definitely stay away from metacam if at all possible.

[Haleth]

Hello Marianne and thank you for your reply!

That's a good thought re: pancreatitis. Our previous Wheatie, Jeff, had the acute version and it was terrifying, though he survived and was with us for a couple more years (he passed at age 16). Today Haleth was better although she refused to get up in the morning or eat then. She did get up @3 pm and ended up eating more food then she did yesterday by day's end (though she spat out the kibble and only went for the new Hypoallergenic canned and the old Hypoallergenic, but only if it was smeared with the new stuff). No vomiting/regurgitating. She didn't seem to be in distress like Jeff was when got pancreatitis and had no problems with the stairs. She's drinking more water again, to be expected since she's been off Trilostane for days.

We visited the vet again and they shaved part of her lower back/hips, finding evidence of two shallow abscesses, one the size of a looney, the other a dime. They also gave us antibiotic ointment and changed her back to the oral antibiotic Clavaseptin, which she has been fine with in the past (it was used to kill the MRSP strain). We won't get the urine culture until Friday. I will keep an eye on her to make sure she has truly stabilized/no more vomiting. So I'm more hopeful that the lethargy was more the dual(?) infection and maybe the Trilostane working together?

Tramadol has been used, but then Hallie had a problem with it. In June she had a reaction for the first time ever to the liquid flea/tick med Advantix. She was up and pacing herself to exhaustion, falling and then getting back up again. It was horrible, lasted over 24 hours. Tramadol was used @the same time for unrelated matter and she had a more minor episode and they took her off it. However, she had it in post-op conditions before then and in her recent surgery they gave her a tiny dose and told us to stop immediately if she reacted, but she thankfully was fine. So they and we are wary of Tramadol.

Yes, chlorhexadrine is wonderful! We were spoiled for a bit with clear skin, but now I'm understanding Cushing's better I think we'll have to go back to the one bath a week maintenance plan once her abcesses look less raw.


Again, thank you for your comments!

[Haleth]

Hello Molly and Sharlene,

Thank you for the warm welcome!

We've taken her off Trilostane at least until the urine culture comes back and probably until the infection's gone. Hopefully, MRSP isn't involved, but it's stubborn. I think I'd rather not try to figure out if the infection, Clavaseptin (though it's been fine in the past), or the Trilostane is causing a problem if side effects happen, so your advice makes sense. We'll also revisit the dosage.

Happily the abscesses seem shallower than the first one, but it's amazing how fast they come up. :(

One question I have is if we should ask the dog walker to wash her hands before walking Haleth. It's a solo walk, but of course not the only pup she walks. I guess I'm worrying about exposure to infections. In fact, now that I think on it, one of her pups has cancer and if Hallie has MRSP she'll need to know because it won't be safe for her.

As for the Metacam, see my previous reply re: Tramadol. I am not happy about needing the Metacam, just at this moment I don't want to take her off because "too many changes all at once", unless it was a matter of life or death. I did head of someone who used Adequan injections on their pup who had Cushing's but I know nothing about it yet.


All the best,

K. and Haleth

[molly muffin]

I would ask her to wash her hands before walking or handling Haleth, and afterwards so she doesn't take anything back to another dog. Especially till you know exactly what it is.

Yes many do use Adequan injections and they have been helpful for many pups with arthritis and severe inflammation.

[Haleth]

I would ask her to wash her hands before walking or handling Haleth, and afterwards so she doesn't take anything back to another dog. Especially till you know exactly what it is.

Yes many do use Adequan injections and they have been helpful for many pups with arthritis and severe inflammation.

Thank you for the suggestions! We ended up giving the walker a couple weeks off; better safe than sorry.

Mini-update: Haleth's urine culture came back clear so no uti. So she only had the abscesses. We kept her off Trilostane until last Wednesday and re-started again. So far it's been going better. No vomiting and she seems less week if a bit quieter. She's still picky about her old food but will inhale anything new so I'm guessing she's fallen out of love with z/d. Once she's stable we're thinking of changing her to a conventional low-fat diet with moderate protein and low phosphorus to protect her kidneys. But for now we will see what her ATCH test on Friday (day 10) will bring. I plan to get her test results then for the LDDS tests. Wondering if we should do a general blood test and urinalysis since she hasn't had those since last May. Sh s had multiple liver panels and tests to check the protein creatinine ratio because of her problems over the summer. And several abdominal ultrasounds (checkups).

[Haleth]

Another update on Haleth. After her first ATCH test it was confirmed she was in fact "overdosing" on Trilostane. She's been rested for 10 days and tomorrow she will start 30mg Trilostane 1x daily (her weight has been hovering @20kg). We're supposed to watch her appetite, as that was the main sign of the OD, as well as increased lethargy and occasional shaking. Everything crossed that this will be an effective yet not too powerful dosage!

[judymaggie]

Wondering if we should do a general blood test and urinalysis since she hasn't had those since last May. Sh s had multiple liver panels and tests to check the protein creatinine ratio because of her problems over the summer. And several abdominal ultrasounds (checkups).

Hi! Whenever I have an ACTH run, I also ask that at least electrolytes be checked and usually get a super chem panel if it has been a while. With Haleth having low cortisol issues, I would recommend a super chem panel if it has been approximately six months since the last one. This will include the electrolytes which are definitely needed.

[Harley PoMMom]

Could you please get a copy of that ACTH stimulation test and post the results here. If Haleth's cortisol has dropped too low her adrenal glands may need more than a 10 day rest, with some dogs it can take months for their adrenal glands to function properly which is why it is recommended that an ACTH stimulation test be performed before the Trilostane is restarted.

[Haleth]

Hi! Whenever I have an ACTH run, I also ask that at least electrolytes be checked and usually get a super chem panel if it has been a while. With Haleth having low cortisol issues, I would recommend a super chem panel if it has been approximately six months since the last one. This will include the electrolytes which are definitely needed.

Hello!

I forgot to mention they did test Hallie's electrolytes twice; potassium was high when they did the ATCH test, but all values were in normal range as of this past Saturday. She's had lots of bloodwork in the past year because of her medical problems (some of which were likely early signs of Cushing's); they did a full workup before her surgery in December, so she's due for a full chem in May. She also had several liver panels done in 2015. I should get those when I turn in her compounded Trilostane for a refund...

[Haleth]

Could you please get a copy of that ACTH stimulation test and post the results here. If Haleth's cortisol has dropped too low her adrenal glands may need more than a 10 day rest, with some dogs it can take months for their adrenal glands to function properly which is why it is recommended that an ACTH stimulation test be performed before the Trilostane is restarted.

Hello,

I was able to obtain some results; let me know if you can see these links to the screenshots. First is the first and only ATCH with accompanying electrolytes: https://www.evernote.com/l/AApaAr2F46dGWaRHdLiwyPB10-zKlnd9Dgk

Here is Saturday's electrolytes test: https://www.evernote.com/l/AApQwDMrofRKv55caiZmWKTQVKO1t1xCY8M

Jan. 13 LDDS test:
https://www.evernote.com/l/AAoEvnevEkRJbZiaOcRCyEtAofBSLZjp8Yc


ETA: Pre-op Bloodwork Dec. 17, 2015
https://www.evernote.com/l/AAp1U5F5VYpHAJKCCmTaGYNMlpar5kWCJsI




����

[Harley PoMMom]

I can see those test results and thanks for sharing them. Looks like her pre = 72 nmol/L and her post = 62 nmol/L, and when converted to U.S. units pre = 2.61 ug/dl; post = 2.25 ug/dl, which is within the therapeutic ranges when using Trilostane. Sometimes dogs get cortisol withdrawal syndrome within 10 days of starting treatment, so it could be that Haleth is feeling yucky because of the rapid decline in her cortisol but since an ACTH stimulation test wasn't performed before treatment with Trilostane began there's no way to compare it, so decreasing her Trilostane dose may be warranted.

This Cushing's journey can be a roller coaster ride but hang in there cause we are here to help ;)

Hugs, Lori

[Haleth]

I can see those test results and thanks for sharing them. Looks like her pre = 72 nmol/L and her post = 62 nmol/L, and when converted to U.S. units pre = 2.61 ug/dl; post = 2.25 ug/dl, which is within the therapeutic ranges when using Trilostane. Sometimes dogs get cortisol withdrawal syndrome within 10 days of starting treatment, so it could be that Haleth is feeling yucky because of the rapid decline in her cortisol but since an ACTH stimulation test wasn't performed before treatment with Trilostane began there's no way to compare it, so decreasing her Trilostane dose may be warranted.

This Cushing's journey can be a roller coaster ride but hang in there cause we are here to help ;)

Hugs, Lori


Thank you so much, Lori!

I think the vet was feeling bad since we have been there so often since H's liver cancer diagnosis, so lots of money on surgeries, lab work, and meds. Still, from what you said it sounds like an initial ATCH would have provided a baseline?

Hallie had her first dose today, so hopefully this time 'round the crash will be minimized, yet it will still be effective. Crossing fingers, toes, and paws here!

[molly muffin]

We're crossing toes and paws here too. I hope she feels better soon.

Did the skin condition clear up?

[Haleth]

We're crossing toes and paws here too. I hope she feels better soon.

Did the skin condition clear up?

Thank you for your kind wishes!

The abscesses are gone, but now I am seeing the crusty patches that look like the start of a staph infection. We have medicated shampoo (chlohexadene) and spray and will see if that helps. I'm hoping the Trilostane will lead to an improvement in her immune system. Do people find that skin infections/abcesses etc. decline once the dog has stabilized?

Haleth's had 2 doses of 30mg Trilostane and I'm noticing the random shaking happening briefly in the late afternoon/early evening. This happened before at the 50mg level, so I hope that doesn't mean that she'll still be crashing hard. However, her thirst and appetite remain ravenous. IIRC it took at least 3 doses before we noticed a change in the past. I'm almost hoping that the lower dosage will slow her loss of appetite down somewhat, that it will appear more slowly and be somewhat less dramatic. Going down to eating maybe 1/4 of her current intake was too much.

[Haleth]

New question:

For the past three days I've noticed Haleth shivering at some point @4-6 p.m. She's had three doses of Trilostane (one each day). I also noticed this occasional short-term shivering in the earlier rounds of Trilostane as well (50mg vs. 30mg). I think many of these happened in later afternoon-night maybe once of so a day. However, we could be missing things in the morning or after bedtime.

We may have seen similar behaviour also before she was on Trilostane this late fall/winter, though at the time we put it down to her hearing we were taking her to the vet, as iirc it happened at the top of the stairs sometimes when I was trying to coax her to go down. These later incidents start in the TV room, so I'm not sure what's setting them off.

I've seen that it can be a side effect or the meds or a possible neurological thing. Has anyone noticed shivering at the same time of day?

[molly muffin]

Many of us have noticed shivering and tremors. Molly has. Sometimes. Sometimes in the morning and sometimes in Afternoon or evening.
It is listed as a possible side affect of trilostane. I know that Mollys cortisol is not to low. She is tested regularly and we are still trying to get her I to the right range.
Molly has kidney problems too so I wondered if thT contributed to the shivering. She has protei loss via urine.

Yes I would hope after she is st le that the skin issues would lessen although that is one are that can tKe longest to clear up because skin and hair have to go through cycles.

[Haleth]

Many of us have noticed shivering and tremors. Molly has. Sometimes. Sometimes in the morning and sometimes in Afternoon or evening.
It is listed as a possible side affect of trilostane. I know that Mollys cortisol is not to low. She is tested regularly and we are still trying to get her I to the right range.
Molly has kidney problems too so I wondered if thT contributed to the shivering. She has protei loss via urine.

Yes I would hope after she is st le that the skin issues would lessen although that is one are that can tKe longest to clear up because skin and hair have to go through cycles.

Thank you for sharing that information. I haven't noticed shaking the past couple days, but our weekend schedule is different, so I'll have to see if it's still happening this week.

One concern: she's now becoming even more lethargic. Normally my partner only has to say "breakfast" to get her up in the morning, but since Friday she's been extremely hard to get moving. We use a treat as a lure and she will be enthused about eating it, but then will need to take a break at the top of each stairway (2). I remember this being a problem in round one of 50mg especially. I think you said she might be feeling yucky as the cortisol is lowered? Part of it is she's also more restless part of the night trying to get comfortable (moving back and forth between her crate and cool mat - she IGNORES the nice orthopaedic bed we bought to cushion her joints) or needing to go out (usually once). So she's been feeling lethargy for about a year, but it's intensified under Trilostane. I assume we grin and bear it because it should right itself @weeks 3-5? How lethargic would your pup have to be before you'd take her in or stop the Trilostane? I guess I'm nervous, as one morning during round one she had problems with our steep stairs and I wonder if she'll lose control again. She does have back end weakness from the Cushing's, but also some arthritis, and I've heard she might be feeling that more? I'd talk about changing her arthritis med, but I feel it's safer to figure out the Trilostane before introducing something new...

Even though it's expensive, I will be glad to have another ATCH test this Friday (day 10) to see if 30mg is OK for her or not.

[molly muffin]

Lethargy as in wobbly can't stand walk, is usually a sign of too much trilostane.

Stairs can be very tricky with any dog with rear leg weakness. We don't let Molly do stairs any more do to, legs, back and eyesight. She is small enough to be able to carry though.

Higher cortisol levels definitely mask arthritis and make them feel a bit better.

I think what you are looking for here is a balance for the various issues and the cortisol. So it might be that she will need to have her cortisol in the 5 - 9 range to maintain an appetite and better mobility.

You know her best, so if you get the feeling that she is too low then definitely test on Friday (day 10) but if you feel that it is maybe joints, rather than too low cortisol, then you could wait till Monday (day 13) If you are worried though, get it done.

Does she get the split does or just once a day? I don't remember off the top of my head. Maybe if she is restless at night, then a split does would work better?

[Haleth]

Lethargy as in wobbly can't stand walk, is usually a sign of too much trilostane.

Stairs can be very tricky with any dog with rear leg weakness. We don't let Molly do stairs any more do to, legs, back and eyesight. She is small enough to be able to carry though.

Higher cortisol levels definitely mask arthritis and make them feel a bit better.

I think what you are looking for here is a balance for the various issues and the cortisol. So it might be that she will need to have her cortisol in the 5 - 9 range to maintain an appetite and better mobility.

You know her best, so if you get the feeling that she is too low then definitely test on Friday (day 10) but if you feel that it is maybe joints, rather than too low cortisol, then you could wait till Monday (day 13) If you are worried though, get it done.

Does she get the split does or just once a day? I don't remember off the top of my head. Maybe if she is restless at night, then a split does would work better?

Thank you so much for your advice! Unfortunately Day 10 is most ideal day, as I won't be around on Day 13-14 and the vet is closed on Day 12. She was tested on day 10 last time, so I was thinking it would be consistent?

[molly muffin]

It sounds like day 10 would be best then. Just remember cortisol usually drops for 30 days or sometimes more on the same dose. So expect wherever she is now will go down more.

[Haleth]

Posting a quick update: Just got a call from the vet regarding Haleth's Day 10 ATCH test and apparently she's at an acceptable level on the higher end, so she would like to continue the 30mg dose of Trilostane for the rest of the 30-day period (around Mar. 24-25). I should be getting the e-mailed results later today and I will post those.

Hallie has become more lethargic while on the med, though my partner said she wasn't bad the last couple days (she's been veeeery hard to wake up in the morning and after breakfast and a walk she heads right back into a nap, for ex). She was having accidents still as of this weekend, but again my partner said she did manage to hold it for 5-6 hours last night, which might be a first sign of a positive change (previously it was safest to take her out every 1.5-2 hours between mid-afternoon and midnight). I'll be heading home soon and will see if the heavy drinking and accidents will continue or not this week. I take it most people see a change in the drinking/urination patterns within a couple weeks?

Appetite wise she's definitely better on the 30mg. Her appetite hasn't crashed. At most maybe she's a shade less hungry than before. Again, I will be watching her for general trends.

[Haleth]

Posting a quick update: Just got a call from the vet regarding Haleth's Day 10 ATCH test and apparently she's at an acceptable level on the higher end, so she would like to continue the 30mg dose of Trilostane for the rest of the 30-day period (around Mar. 24-25). I should be getting the e-mailed results later today and I will post those.

Hallie has become more lethargic while on the med, though my partner said she wasn't bad the last couple days (she's been veeeery hard to wake up in the morning and after breakfast and a walk she heads right back into a nap, for ex). She was having accidents still as of this weekend, but again my partner said she did manage to hold it for 5-6 hours last night, which might be a first sign of a positive change (previously it was safest to take her out every 1.5-2 hours between mid-afternoon and midnight). I'll be heading home soon and will see if the heavy drinking and accidents will continue or not this week. I take it most people see a change in the drinking/urination patterns within a couple weeks?

Appetite wise she's definitely better on the 30mg. Her appetite hasn't crashed. At most maybe she's a shade less hungry than before. Again, I will be watching her for general trends.

Adding Haleth's latest ATCH results (context above): https://www.evernote.com/l/AArQMYjJEPpLrJmqE2jb0rcwZC6LUS8_6pMhttps://www.evernote.com/l/AArQMYjJEPpLrJmqE2jb0rcwZC6LUS8_6pM

[labblab]

Thanks so much for this update, but unfortunately I can't get your link to open. Can you maybe just post the actual ACTH test numbers in a reply so that we can see them? Then once we know the numbers, we can comment further.

Marianne

[Haleth]

Thanks so much for this update, but unfortunately I can't get your link to open. Can you maybe just post the actual ACTH test numbers in a reply so that we can see them? Then once we know the numbers, we can comment further.

Marianne

Ack, I'm sorry. It worked last time, but this time it's not working for me either. I'll look into it, but in the meantime:


ATCH Test:

Cortisol (pre): <27.6 ref. 28-120 nmol/L

Cortisol (post) 190 ref. 220-550 nmol/L

[labblab]

Thanks so much for the results. For our U.S. readers, they convert to:

Pre: <1.0 ug/dL
Post: approx. 7.0 ug/dL (The reference range that the lab provided is for a dog without Cushing's)

The "post" result does indeed seem fine at this stage, since it's up from the 2.25 ug/dL that resulted from the 50 mg. And normally, it's the "post" result that warrants the most evaluative interest. However, the fact that her "pre" result is so low is a bit of a puzzle to me, and also could certainly explain why she's been acting a lot more lethargic. If her baseline level stays abnormally low through much of the morning, no wonder the poor girl isn't feeling too perky. :o

I would definitely still keep a close eye on her, which of course you already are. As Sharlene mentioned above, at her age, she may just need to have her cortisol run a bit higher than might be optimal for a younger dog. So it may end up being a bit of a trade-off in terms of less than perfect symptom resolution but greater mobility. But on a positive note, as time goes on, you still may likely see additional symptom improvement since right now, you are only at the 10-day mark.

For sure, I agree with the vet that I would not be increasing the dose at this stage. In fact, you may find that the dose needs to be lowered again if her cortisol continues to move downward throughout the rest of the thirty days. Please keep updating us as to how she's doing, OK?

Marianne

[molly muffin]

I agree with everything that Marianne just said. I'd really like the pre to be a bit higher, but I know in my own dog that the pre fluctuates quite a bit and if that is the case then it will be alright. The post is actually good, but running a bit higher, might make her feel better.

It really is a monitoring sort of disease, in that finding that optimal dosage can be tricky, especially with our older furbabies.

[Haleth]

Update:

We're coming into Haleth's 4th week on 30mg Trilostane; next Thursday is the 30day ATCH test.

So far, no real effect on her eating and drinking; I'm glad she's not crashing appetite-wise like she did on 50mg, but she's still having accidents.

Scabs are appearing on her skin again; I'm wondering if the MRSP is returning. Does anyone know if treatment will eventually lead to a somewhat stronger immune system?

At any rate I will call the vet tomorrow because the scabs are definitely spreading and she's very itchy. :(

If she has to go on Clavaseptin again, I wonder if she'll have to stop the Trilostane?

[Harley PoMMom]

Getting that elevated cortisol within the therapeutic ranges should give the immune system the boost it needs.

Wishing you good luck with Haleth's ACTH stim test and please post those results when you get them ;)

Hugs, Lori

[labblab]

I'm so sorry you're having more problems with the skin infection. I definitely agree with Lori that a therapeutic cortisol level should help in the long run. In the short run, though, you're right -- you may need another antibiotic course and/or more intensive topicals. Normally, you can continue to give trilostane alongside antibiotics, so that shouldn't be a problem.

With my nonCushing's Lab, though, we ended up thinking that aggressive shampooing, antiseptic spray on the lesions in between the baths, and both oral and topical lipids may have helped resolve her recurrent staph infection as much as the oral antibiotic. Are you still using the chlorhexadine shampoo with Haleth? We were bathing our girl 2-3 times a week when she was at her worst. I know that can be a challenge with a big dog, though.

As Lori says, definitely let us know how the next ACTH turns out.

Marianne

[Haleth]

I'm so sorry you're having more problems with the skin infection. I definitely agree with Lori that a therapeutic cortisol level should help in the long run. In the short run, though, you're right -- you may need another antibiotic course and/or more intensive topicals. Normally, you can continue to give trilostane alongside antibiotics, so that shouldn't be a problem.

With my nonCushing's Lab, though, we ended up thinking that aggressive shampooing, antiseptic spray on the lesions in between the baths, and both oral and topical lipids may have helped resolve her recurrent staph infection as much as the oral antibiotic. Are you still using the chlorhexadine shampoo with Haleth? We were bathing our girl 2-3 times a week when she was at her worst. I know that can be a challenge with a big dog, though.

As Lori says, definitely let us know how the next ACTH turns out.

Marianne

Thank you for sharing your experiences! Yes, we have the shampoo you mentioned, plus Duoxo's Calm mousse. The tough thing is bathing her more than once a week with my partner's schedule, as I don't feel safe carrying her down to the laundry sink myself. Incentive to work out. The vet put her on Chloraseptin, but she's had a bit more trouble (one vomiting incident, one minor regurgitation and tummy noises) with it this time. She's on a powdered probiotic for dogs, but maybe I should switch her to kefir.

We learned today that Hallie's results are still "high normal". The vet was fine with keeping her at 30mg, but as H is still drinking like a fish and having 1-2 accidents nearly every day, I asked if we should wait or up her dose a bit. So the vet suggested trying her at 40mg and testing how she does at that level. 50mg was too much, but 40mg iirc should be closer to the recommended dosage? She's 20.6kg. I'll ask for the latest ATCH numbers tomorrow.

Cross your fingers that 40mg is "just right"!

[molly muffin]

Fingers crossed!!! Hoping for good results, in the "perfect" range :)

[Haleth]

Fingers crossed!!! Hoping for good results, in the "perfect" range :)

Thank you!

One question: should we schedule another ATCH test after 10 days at 40mg? I heard the medication is in, but I'm thinking of not starting her until next Wednesday, so that I will be home most of the time and so track better how the upped dose affects her.

[Harley PoMMom]

Yes, it is recommended that after a dosage increase that an ACTH stimulation test should be performed within 10-14 days.

[Haleth]

Yes, it is recommended that after a dosage increase that an ACTH stimulation test should be performed within 10-14 days.

Thank you!

I will have another ATCH done on day 10, since the other dosages had a test on that date. I'll then post the results of that and the previous ATCH tests. We're on day 4 here; no sign of change in appetite or drinking and Haleth is still having accidents. Her walker let me know that her back legs seemed very unsteady today. Indeed she was quite stiff this evening and stood like she was bracing herself as she wolfed down her dinner. She did wag her tail at me and attempted to steal my food wrapper twice, so that is pretty normal for my BBQ loving girl.

Have people found anything particularly helpful with hind end weakness? Gentle exercise? And how long did it take for that symptom to improve after medication started. I assume it takes rather longer than symptoms like incontinence...

[Harley PoMMom]

Improvement in the rear leg weakness does take a considerable amount of time. Hydrotherapy is one that I read that may help.

[Haleth]

Latest update for Haleth:

She was changed to 40mg of Trilostane daily since the ATCH in late March was a "high normal" and her eating and drinking habits and therefore her near-daily accidents had not changed. On Monday she had her 10-day ATCH to see how that worked. The vet said she was still high normal. Hallie's appetite had gone down a bit, but her bathroom routine had not changed. The vet felt it was still best to stay at 40 mg and test her again at 30 days because the cortisol levels should still continue to fall. If there was no substantial change, then we could discuss the option of going back to 50mg, but splitting the dose into 25mg 2x daily. Just giving her 50mg 1x was too much (see upthread). Oh and Haleth's weight is back up to 20.7kg as of Monday.

FYI, here are Hallie's last two ATCH tests (late March 30mg; April 40mg):

https://www.dropbox.com/s/res5h0k8u2a1quo/Haleth%20Robinson.pdf?dl=0

ETA: later test is listed first

[molly muffin]

I'll put the results of your last two ACTH tests in here:

03/24/2016

ACTH
Pre 34 nmol
Post 183 nmol


04/11/2016

ACTH
Pre 50 nmol
Post 197nmol

So it actually went up a bit instead of down with the increase from 30mg to 40mg. She is within the acceptable paramenters at the 7.1ug post, but with the accidents, I think you are going to be needing her to go below 5.0ug. Which isn't much but we'll have to see if 30 days gets her there.
You could add in 5mg to make it 45mg rather than 50mg.
My other thought is that 50mg now might not be as big of a hit to her as it was previously as she has gone up gradually now.

[Harley PoMMom]

Since a positive change was seen in her appetite but no improvement in her drinking/urinating you may want to have an urine culture and sensitivity test done to see if there is any bacteria in her urine (UTI).

HUgs, Lori

[Haleth]

Hello all,

We just received the results of Haleth's latest ATCH, plus the bloodwork results for her annual senior wellness assessment, which includes CBC and kidney and liver panels. Let me preface this with the news that Haleth became increasingly lethargic around last Thursday. By the weekend to took real work to wake her for a morning brief walk and breakfast (which some days she ate and others maybe 1/4 to 1/2) and then she would sleep for 7+ hours then dinner and walk (usually finished that) and back to sleep. Her appetite and drinking lessened and at most we took her out 3-4 times a day rather than 5-6. On her visits to the vet on Monday and Tuesday she didn't shake (normally she does) and on Tuesday she was moving even more slowly.

When we saw the vet today she said that Haleth was heading towards an Addisonian crisis and had suddenly become anemic and was to spend 7 days off of Trilostane. She wants to see H on Thursday to re-check her electrolytes and to see if she's well enough for more of a true annual physical and maybe a vaccine. The following Wednesday we are supposed to see the IM specialist for her usual abdominal ultrasound re-check. I will be talking with both about what our next step should be with Trilostane. Haleth now weighs 20.3 kg: 50mg caused the same crisis, 30mg wasn't enough to change her most visible symptoms (over-drinking and urinating), but did put her in the high end of normal. 40mg seemed fine; in fact I thought it might prove too weak to change the outcome much given the results at the 10-day test. But here we are just after day 30 and again it's too much. The vet thought backing down again might work, though she didn't say if that meant 35mg, but her partner (we saw her at the day 10 test) also suggested splitting the dose might be an option if 40 didn't work. Note I don't know if she'd still make that assessment now, given the different results. Oh, and below are the results from the last two ATCH tests for comparison's sake.

May 2 ATCH
Pre 27.6 nmol
Post 115 nmol

Link to all blood work here: https://www.dropbox.com/s/5xwl4a0m10496es/haleth%20lab%20work%20may2.pdf?dl=0

Finally, Haleth has another skin infection and scratching up a storm for the past week, so the vet gave us a short course of Venectyl-P to help with the itching. She noted it had cortisol, but given her low levels it certainly wouldn't hurt to give her some short term. She also mentioned Apoquel, but didn't want to commit to it until Haleth's labwork is better.

Feeling discouraged and sorry for our sweet girl. :(



I'll put the results of your last two ACTH tests in here:

03/24/2016

ACTH
Pre 34 nmol
Post 183 nmol


04/11/2016

ACTH
Pre 50 nmol
Post 197nmol

So it actually went up a bit instead of down with the increase from 30mg to 40mg. She is within the acceptable paramenters at the 7.1ug post, but with the accidents, I think you are going to be needing her to go below 5.0ug. Which isn't much but we'll have to see if 30 days gets her there.
You could add in 5mg to make it 45mg rather than 50mg.
My other thought is that 50mg now might not be as big of a hit to her as it was previously as she has gone up gradually now.

[labblab]

Hello again, but I'm so sorry that Haleth is doing so poorly right now. Thank you for the newest ACTH results, and I've also been to see your Dropbox summary of her lab results. What I am seeing there is that she exhibited elevated CR, BUN, and SDMA (all kidney markers), as well as high potassium and therefore an abnormal potassium/sodium ratio.

Seeing those values makes me now understand why your vet is warning that she was heading towards an Addisonian crisis. Otherwise, I was puzzling because I know you've also mentioned concerns about her "crashing" before, but in honesty, her post-ACTH cortisol levels have really never been anywhere too low for a dog being treated with trilostane (although it is true that her "pre" levels have never been robust). Back in February, however, when she was taking the 50 mg. of trilo, you also mentioned high potassium. So my best guess now is that the vet's worry is really related to whether the trilo is consistently driving Haleth's aldosterone too low, as opposed to her cortisol. Aldosterone is another adrenal hormone, and it controls the levels of potassium and sodium in the body. However, just for information's sake, here's a complete listing of Haleth's "pre" and "post" ACTH cortisol levels (given in U.S. units of ug/dL), at least as best I've been able to compile.


February (after 50 mg. dosing): 2.61; 2.25

early March (after 30 mg. dosing): <1.0; 7.0

3/24 (still taking 30 mg.) 1.2; 6.6

4/11 (after switch to 40 mg.) 1.8; 7.1

5/2 (still taking 40 mg.) <1.0; 4.2



In quickly scanning your entire thread, I am struck by the fact that Haleth has been lethargic and unwell for quite a long time, both before and after starting the trilostane treatment. Unbalanced electrolytes now can certainly account for problems, but I do have to puzzle whether there has been something else smoldering all this time that is yet to have been identified. The elevated kidney markers may be related to dehydration and the unbalanced electrolytes, but I don't know whether those issues would also cause the elevated SDMA. So the kidney elevations may only be secondary, but I'm guessing it's possible that there may be a primary kidney issue going on in it's own right. Time will tell as to whether or not those values normalize again quickly.

The anemia certainly would be an immediate worry, I would think, especially if the cause is unknown. I do believe that chronic Addison's can result in mild anemia, but I dunno whether you'd expect a sudden decline like you're seeing here. Is Haleth still getting the Metacam? With the anemia, I would be worried that she may have developed a GI bleed as a result of taking that medication.

To me, the bottom line is that enough worrisome stuff is going on that I would be very eager to talk with the IMS. I am a proponent of reasonable vaccination protocols, but I certainly would not consider a vaccination of any sort at this time, especially given Haleth's anemia. Vaccinations should not be given at a time that a dog is unwell, and Haleth's blood profile and behavior certainly constitutes "unwell," even if her electrolytes have bounced back by tomorrow. I'd want to discuss any current vaccination decision with the IMS before proceeding.

I understand why you're worried about Haleth, because I'm worried about her, too :o. The poor girl has been unwell for quite a while now, and I surely hope the IMS may be able to take this new info into account in order to figure out exactly what all is going on with her. Please keep us updated!

Marianne

[labblab]

You know, upon rescanning your entire thread, I'm back to puzzling again about the original Cushing's diagnosis. Haleth has had so much going on for her within the past six months, including the liver surgery. But her initial presentation back in Dec/Jan prompted some question marks in my mind, and now that I've revisited your thread, I'm still really wondering.

If I'm correct, she first had two "negative" LDDS test, finally followed by a "positive" alongside enlarged adrenals on ultrasound. But both of those results could be caused by physiological stress resulting from conditions other than Cushing's. Upon looking at this week's lab tests, I was struck that her liver enzymes are all totally within normal limits, and I see that her pre-op labwork last December (prior to liver surgery) only showed a very mild elevation in ALKP. Most Cushpups exhibit at least moderate elevation in ALKP that may not necessarily completely resolve with treatment. I'm also puzzled by the high level of proteinuria which mysteriously resolved prior to the trilo. Also, her behavior at the first of the year did not really jive with Cushing's: vomiting and extreme lethargy almost to the point of collapse which again began even before starting the trilostane. Truly, I have to wonder whether there is something else going on for her in addition to, or in place of, Cushing's.

I apologize for writing so much this morning for you to have to plow through, but I'm just really worried about your girl and I hope you can find some answers quickly.

Marianne

[Haleth]

You know, upon rescanning your entire thread, I'm back to puzzling again about the original Cushing's diagnosis. Haleth has had so much going on for her within the past six months, including the liver surgery. But her initial presentation back in Dec/Jan prompted some question marks in my mind, and now that I've revisited your thread, I'm still really wondering.

If I'm correct, she first had two "negative" LDDS test, finally followed by a "positive" alongside enlarged adrenals on ultrasound. But both of those results could be caused by physiological stress resulting from conditions other than Cushing's. Upon looking at this week's lab tests, I was struck that her liver enzymes are all totally within normal limits, and I see that her pre-op labwork last December (prior to liver surgery) only showed a very mild elevation in ALKP. Most Cushpups exhibit at least moderate elevation in ALKP that may not necessarily completely resolve with treatment. I'm also puzzled by the high level of proteinuria which mysteriously resolved prior to the trilo. Also, her behavior at the first of the year did not really jive with Cushing's: vomiting and extreme lethargy almost to the point of collapse which again began even before starting the trilostane. Truly, I have to wonder whether there is something else going on for her in addition to, or in place of, Cushing's.

I apologize for writing so much this morning for you to have to plow through, but I'm just really worried about your girl and I hope you can find some answers quickly.

Marianne

Wow. Thank you for all of this! I should add that Haleth has a gall bladder mucocele (maybe mentioned briefly in my intro post), which was diagnosed iirc several months before the adrenal glands enlarged. That can cause lethargy, in fact when she began to slow down noticeably in the winter of 2015 we thought that was a likely culprit. The IMS has treated it with ursodiol rather than surgery. I will have some questions for the IMS, so I appreciate your concern! The IMS has tended to be conservative in treatment, apart from OK'ing Haleth's surgery for liver cancer (July 2014). He left the choice of Cushing's meds up to the regular vet, as he had no problem with either, for example. Would the constant skin infections make her feel crummy as well? I will ask about the Metacam with both vets. I think someone here mentioned Adequan?

Finally, I'm wondering if I should get a second opinion from another IMS, especially considering we are blessed with so many IMSs here in Toronto...

[Haleth]

Additional info:

July 2014
liver tumor ruptures and elevated cholesterol and UPC of over 4 discovered
liver lobectomy perfomed on one lobe, Haleth started on Benazepril and Hill's K/D begun after recovery period from surgery as IMS suspects either kidney damage from cancer or PLN

September 2014
acne appears on H's neck and remains there to this day, first of many, near-constant skin infections to the present -- most involve seborrhoea but in late 2015/early 2016 has accesses -- MRSP spotted in fall of 2015

in 2014-2015 UPC falls to around 1

Winter to early Spring 2015
in Feb or March notice Haleth is becoming less energetic -- a bit of arthritis seen, then gall bladder issue discovered -- both could be slowing her down -- laser treatment series not seem to do much

June 2015
severe neurological reaction to AdvantixII (switch to Nexguard), adrenal glands are enlarged, first LDDS test, later in summer try hydrotherapy and Metacam

Fall 2015
consult with IMS specialist in US who researches PLN in fall 2015, she is suspicious of the PLN and finally declares that the additional labwork suggests she doesn't have it, she has Haleth put on a hydrolized diet as a precaution

Late Fall 2015 - early winter 2016
MRSP caught in fall requires weeks of Clavaseptin iirc 10 weeks before it seems to be gone, abscesses, by early December Haleth is drinking and eating heavily and has daily accidents, in early January LDDS test comes back positive instead of borderline for first time and 50mg Trilostane tried for 3-4 days but has another abcess and is very woozy so take a week or longer break before trying 50mg again, sends Cortisol too low and hurts electrolytes, change to 30mg

Winter-Spring 2016
30mg leaves unrinary accidents unchanged and results high normal after 30 days, so up to 40mg, after 10 days numbers around the same as for 30mg, about a week or so later H begins to get very lethargic and appetite drops and accidents lessen dramatically, between day 10 and 30 H becomes anemic and electrolytes become unbalanced

[molly muffin]

hmm, you know what Marianne is making some very good points.

I think I would see a different IMS to get another opinion. One that is especially knowledgeable (check out their bios online) in the endocrine system.

The gall bladder itself, the infections, all can lead to increase production of cortisol which would cause the adrenal glands to be bilaterally enlarged.

[Haleth]

hmm, you know what Marianne is making some very good points.

I think I would see a different IMS to get another opinion. One that is especially knowledgeable (check out their bios online) in the endocrine system.

The gall bladder itself, the infections, all can lead to increase production of cortisol which would cause the adrenal glands to be bilaterally enlarged.

Ack, my most recent post was eaten! What I said was whether you or anyone else in the GTA (greater Toronto area) could recommend an IMS outside of the VEC. There are several IMSs each at the TVEH and CTVRC, which are the next closest clinics to us; have you any experience with them?

Apart from that Haleth seems more like herself today. She came down of her own accord around 3 and then walked around the block. She ate dinner enthusiastically and played with her treat toys several hours later. She's had a couple doses of Vanectyl-P and I gave her a half a banana at dinner in case it might help with potassium. Tomorrow morning we are back at the vet's for a re-chack of the electrolytes and her wellness exam. From what you told me I should hold off on her vaccine (and considering how thoughtful our vet has been she may again herself call for another delay) and ask for a referral. I should perhaps also ask about Adequan though I'm a bit wary of changing too much too soon.

[molly muffin]

My IMS is at the Mississauga/Oakville ER Clinic, Bristol Circle, off of Winston Churchill, so pretty far out of your way if you are downtown area.
My IMS just is back from maternity leave (thank god, I love her) and is available 2 days a week. If you do want to go that far out, then PM me and I'll give you her details.

[labblab]

Quick warning: Haleth's problem has been that her potassium is too high, not too low -- so you don't want to be giving her foods that are high in potassium like bananas!

[Haleth]

Quick warning: Haleth's problem has been that her potassium is too high, not too low -- so you don't want to be giving her foods that are high in potassium like bananas!

Oh, thank you so much! How very stupid of me not to double-check the labwork before giving her banana! :mad: Well, at least both I and my partner know not to give her any.

I'll definitely let the vet know that H had half a banana.

[Haleth]

My IMS is at the Mississauga/Oakville ER Clinic, Bristol Circle, off of Winston Churchill, so pretty far out of your way if you are downtown area.
My IMS just is back from maternity leave (thank god, I love her) and is available 2 days a week. If you do want to go that far out, then PM me and I'll give you her details.

Your generous offer is tempting, but I worry that it would be hard to find a date when both she's available and our one vehicle would be free, given that it's needed by my partner for work and then gigs and rehearsals. I think to get in sooner I will need something I can get to via cab. I think I'll try to google the names to see if any of the Toronto IMSs specialize in Cushing's but then there's a worry it might not be Cushing's or only Cushing's so maybe it matters less if they are a Cushing's expert.

[labblab]

I am just now noticing that Haleth is also taking benazepril, I presume due to her previous episode of proteinuria. I very much wish I had noticed this earlier. We do have other dogs here who are taking ACE inhibitors like benazepril alongside trilostane, but they must be monitored carefully since Dechra issues a specific cautionary note about that drug combo. Since Haleth has been troubled by high potassium levels and abnormal renal values, I do hope your vets are aware of this issue.


Angiotensin converting enzyme (ACE) inhibitors should be used with caution with VETORYL Capsules, as both drugs have aldosterone-lowering effects which may be additive, impairing the patient's ability to maintain normal electrolytes, blood volume and renal perfusion. Potassium sparing diuretics (e.g. spironolactone) should not be used with VETORYL Capsules as both drugs have the potential to inhibit aldosterone, increasing the likelihood of hyperkalmia [high potassium].

If Haleth is especially sensitive to the effects of benazepril, perhaps a different drug could be tried (if, in fact, she is still needing to continue to take a drug of that class at all).

Marianne

[Haleth]

A quick update:

Haleth's potassium level was much better today. No mention of vaccinating her with anything, which was great. She's also off of Metacam since she's on Vanectyl-P for the short-term (as stated above she's off of Trilostane for at least a week, perhaps longer). We will see how she does this weekend and discuss things more about future treatment. The vet was wondering about whether Trilostane was ideal in Hallie's situation but doesn't want to jump, apart from at least taking a break. On Wednesday I'll see our regular IMS for H's regular re-check (liver, gall bladder, adrenals) and ultrasound. I'll see what he says re: medication and whether it really is Cushing's. But I suspect I will still want to see another IMS before making a final decision re: medications.

I'm very inclined to ask about adequan, even if we have to wait a bit to make sure it's safe. Also is anyone's cushpup on Apoquel? What was your experience like? It's just been made available in Canada and the vet mentioned it as a possibility on Monday, but again wants to make sure H is well enough before considering it more seriously.

Thank you again to all who are making suggestions! Such a valuable and helpful community! <3

[labblab]

I'm so glad your appointment went well, and that Haleth's potassium level was lower. Out of curiosity, were her kidney markers included today and were they any lower (CR for creatinine, and BUN)?

I have never used either Adequan (for arthritic pain) or Apoquel (for allergy relief), although I've considered both for my elderly nonCushpup girl. If you are interested, here are a couple of links I've bookmarked that discuss Apoquel and Atopica for allergy relief.

http://veterinarynews.dvm360.com/apoquel-qa-will-oclacitinib-revolutionize-treatment-allergic-dermatitis?pageID=1

https://skinvetblog.com/2014/10/07/apoquel-vs-atopica-a-comparison-of-two-medications-to-control-atopic-dermatitis-in-dogs/

Marianne

[molly muffin]

We have members who have used both adequan and Apoquel with no ill effects. Lovely to hear that Apoquel is finally available here. For extreme allergy relief I'd try it.

Yes I do see what you mean, if you have one vehicle available, then you need an IMS who is closer.

[Haleth]

No, only the electrolytes were covered. I'm tempted to re-test for anemia and the kidney-related markers as well as have a urinalysis done (UPC). I'll ask the vet and IMS about when would be a sensible time (after the week is up? later?).

I suspect we'll be needing a skin culture done as well, as Haleth's back is covered in scabs as well as some "orphans" elsewhere. I do have antibiotic ointment and we have chlohexadrine shampoo and spray. I just wish we could bathe H as often as recommended. We can do once per week, but as I can't lift her and my partner is often away. He has a regular job, and now a rise in rehearsals and gigs, so we haven't been able to do the 2x a week in 2016. :(


I'm so glad your appointment went well, and that Haleth's potassium level was lower. Out of curiosity, were her kidney markers included today and were they any lower (CR for creatinine, and BUN)?

I have never used either Adequan (for arthritic pain) or Apoquel (for allergy relief), although I've considered both for my elderly nonCushpup girl. If you are interested, here are a couple of links I've bookmarked that discuss Apoquel and Atopica for allergy relief.

http://veterinarynews.dvm360.com/apoquel-qa-will-oclacitinib-revolutionize-treatment-allergic-dermatitis?pageID=1

https://skinvetblog.com/2014/10/07/apoquel-vs-atopica-a-comparison-of-two-medications-to-control-atopic-dermatitis-in-dogs/

Marianne

[Haleth]

We have members who have used both adequan and Apoquel with no ill effects. Lovely to hear that Apoquel is finally available here. For extreme allergy relief I'd try it.

Yes I do see what you mean, if you have one vehicle available, then you need an IMS who is closer.

Thank you both for the Apoquel/Adequan info and feedback!

Wishing you a wonderful weekend,

Kirsten and Haleth

[Haleth]

We had some distressing news yesterday. At the re-check abdominal ultrasound by the IMS, he spotted a new 4cm mass at the original surgical site on the liver. There were no other signs of masses elsewhere, although he noted the adrenals were larger than they were back in January. At the time of the surgery, we were told that there weren't clean margins because of the blood vessel and so that has come back to haunt us.

At this time the IMS feels we cannot treat it until the Cushing's is under control, so he proposed that we try splitting H's dose for a week and then do another ATCH as well as have me record when Hallie is urinating to see if that balances control of the Cushing's clinically and also addresses the excessive thirst/urinating. He also wants the see the tumor again in a month to see if it has changed or not. At present it is not an immediate emergency, but if it gets too big it could burst and I do not want to put my sweetie through that pain again. Once the Cushing's is treated satisfactorily, the IMS stated there would be three main options: 1) a second surgery that removes half of the liver to more fully ensure clean margins (the original surgery removed only one lobe); 2) try Palladia to see if it will keep the tumor from growing; or 3) watch and wait. A very hard choice.

[labblab]

I'm so very sorry to read about the new mass, especially since the first tumor was cancerous. But I have to say, this discovery makes me wonder even more about the actual validity of the Cushing's diagnosis, as opposed to the adrenals being enlarged and the cortisol bring elevated as a result of other underlying physiological stress. Apparently the IMS is convinced that Haleth does have the disease, but how are you feeling about perhaps still pursuing that second opinion about all this? It sounds as though you have some difficult decisions ahead of you, that's for sure! :o :o

Marianne

[Joan2517]

I'm so sorry for this news...you are in my thoughts and prayers.

[Whiskey's Mom]

So sorry about your sad news. Sending you strength, courage and hugs.
Annie and Whiskey

[molly muffin]

Oh dang. I too wonder if Cushing's is occurring or if the liver is causing the cortisol increase. I think the IMS is thinking they need to get the cortisol down before they do surgery right? Whatever is causing it.
I remember that one of our members dogs also had two liver surgeries. Luckily the liver is a regenerating organ. So they can recover from it.
Also wanted to mention that they need to do blood pressure checks and make sure that is stable also.

We are right here with you.

[Trish]

Hi, my dog Flynn had a third of his liver removed way back in 2011 for a massive hepatocellular carcinoma. A year later he had an adrenalectomy for a pheo which is how we ended up on the forum :) on his checkup scan the following year, we up to 2013 now he had liver recurrence like your Haleth. So back he went to theatre and had another 25% of his liver removed.

Livers have such a remarkable ability to rejuvenate,when his surgeon did the adrenalectomy he said he would have never known he had 1/3 of his liver removed the year earlier. I guess what I am trying to say is that if they have to get liver cancer this appears to be the one to get! I hated putting him through surgery again but it is now 2 1/2 years since his last surgery and he is 15 so I thank my lucky stars for his surgeons for all this extra time we have had.

He also has benign hyperplastic nodules and on his last scan about 9 months back they were struggling to see any normal liver tissue, so now at the age he is I have stopped the scans, because the surgery wouldn't be an option again. But blow me down, he keeps on trundling on :) :) Flynn doesn't have cushings though, so we did not have to fight that battle. Wishing you all the best

[Haleth]

Thank you everyone for your kind thoughts and support! It has been an upsetting week and sometimes I feel I should be buying a cot and setting it up at the vet's. Haleth's slowly getting the Vanectyl-P out of her system and the split dose of Trilostane may be taking affect. Today her drinking slowed for the first time and although her appetite was hearty (licked her bowl clean), she didn't finish her "bone" (not really a bone but a softer edible chewing stick) and hang out wanting to play with her Nina Ottoson treat toys. Granted she got plenty of treats during her bath and to lure her up and downstairs. She still is in sleep 80-90% of the day mode, so I hope things begin to balance out over the next few days and we see more energy.

Last night I tried to treat the guck from 1-2 probable abscesses (they came up after the one we spotted on Wednesday and had cleaned at the vet). I used a mix of epsom salts and warm water and left it on her skin 10-15 min to soften the hardened guck so I could get it off her skin and hair. Had to do that twice to get most of it off. Then I used chlorhexadrine wash from the vet to clean the likely sites (I can't really see) and then rinsed it off and put antibiotic ointment on the one spot I could see. I fear either that wash or the epsom paste may have caused a reaction, because H promptly started being obsessive over her back leg and belly. Note that the abscesses are along her spine and side, so she was fussing on a different spot than the ones I washed, but maybe water dripped down. I assume it was related because it happened within minutes of me finishing with the abscesses. Happily she then left the area alone until we gave her a medicated bath and conditioner today. She's still somewhat itchy though, and I wish she was well enough to try Apoquel yet.

You won't like this, but we are going to return to using Metacam, with the vet's and specialist's permission, for at least a short while, starting tomorrow night (last Vanectyl-P was on Wed. morning). Hallie has been noticeably stiffer and less able to go up our two sets stairs (10+ each) strongly in the last week or so. Her hips have also looked a bit off, but the one piece of good news was that the rehab specialist felt she was in good condition considering: she had decent muscle tone and extension, etc. A bit more guarded in one shoulder when being massaged, but not terribly compromised. So I assume the difficulty is maybe a combo of the electrolyte "crash" and the loss of Metacam. IDK. But H has been far more restless at night and is back to digging at her bedding (a habit she picked up at the emergency clinic when she was hospitalized in 2014) to try and make herself comfortable. So until we have the Cushing's controlled, I don't want to change to something different. I want to know that the Trilostane dose is "safe". But I also want her to sleep and be able to enjoy walking: she's back to pretty much going across the street and going a few doors up and back. I do intend to talk with our vet about changing it, but I think I need to get past the next week and see how the first ATCH test on Thursday goes.

The rehab vet kindly lent us an orthopaedic harness, which made getting in and out of taxis a breeze, but H seems to be spooked about using them going up the long stairs. I am probably doing something wrong, so I hope we find some stairs the next time I'm at the rehab place. Most of the time she doesn't need it, but I would like to take the rehab vet's suggestion to use it to exercise her gently on the stairs.

[Haleth]

Trish, thank you for your kind and optimistic words. I'm sorry Flynn has been through so much!!

Was Flynn 14 when he had his 2nd liver surgery? That is Haleth's age. I worry that this time it might be too much, though we have access to a good place with a veterinary surgeon, anesthesiologist, other in-house specialists, and a dedicated ICU. If she begins to perk up after the Cushing's is controlled, then I might feel more certain, though I would certainly ask a 2nd opinion. The other matter is money, I'm afraid. Our finances have taken a beating from the first surgery, the year+ of chronic skin infections, reactions to AdvantixII, arthritis treatments, two benign tumor removals (eyelid and anal gland), and numerous LDDS and ATCH tests. That's not counting the medications: Ursodiol, Metacam, Benazepril, and Trilostane). I've reached out to one charity, but I don't know if or how much they'd be able to help. I doubt any relatives would help, as they would be the type to have put Haleth down rather than have the first major surgery, let alone a second. To them she's an old dog; sweet, but one doesn't lavish this much care on a dog in their opinion. :(


Hi, my dog Flynn had a third of his liver removed way back in 2011 for a massive hepatocellular carcinoma. A year later he had an adrenalectomy for a pheo which is how we ended up on the forum :) on his checkup scan the following year, we up to 2013 now he had liver recurrence like your Haleth. So back he went to theatre and had another 25% of his liver removed.

Livers have such a remarkable ability to rejuvenate,when his surgeon did the adrenalectomy he said he would have never known he had 1/3 of his liver removed the year earlier. I guess what I am trying to say is that if they have to get liver cancer this appears to be the one to get! I hated putting him through surgery again but it is now 2 1/2 years since his last surgery and he is 15 so I thank my lucky stars for his surgeons for all this extra time we have had.

He also has benign hyperplastic nodules and on his last scan about 9 months back they were struggling to see any normal liver tissue, so now at the age he is I have stopped the scans, because the surgery wouldn't be an option again. But blow me down, he keeps on trundling on :) :) Flynn doesn't have cushings though, so we did not have to fight that battle. Wishing you all the best

[Haleth]

Question: if your cushpup's appetite crashes suddenly do you try boiled hamburger/ground chicken and rice? Haleth's appetite was slightly reduced yesterday (didn't finish a chew stick - not rawhide) but ate meals just fine. Today she ate maybe half of breakfast at most, will eat treats, just "drank" her dinner (we add warm water and kefir), the pill pocket containing the Trilostane, and a couple small pieces of freeze-dried tripe and then regurgitated some or most of the liquid (couldn't feel pills) and then went back to bed. New and old kibble spat out so none of that was ingested. I did hear a couple sounds from her stomach at that time, but that was it. She also had loose, pudding-like stool yesterday and maybe the day before that but then this afternoon it was back to having form, if soft.

I'm calling the IMS tomorrow and the regular vet, but I'm wondering if it would be good to see if she'll put more on her stomach.

[Haleth]

Her tummy is definitely making noises! Is Pepcid safe for Cushpups on Benazepril and TRilostane?

[Haleth]

Phew! I offered Haleth a 2-to-1 mixture of white sushi rice and boiled ground chicken with fear that she'd turn her nose up at it. Just 3/4 cup total because I didn't want to give her too much to start.

Wow! She ate like a plowhorse who hadn't had breakfast! I know what she'll be having for breakfast then, barring problems overnight. And in fact, I won't give her more, because I want to see how she handles it. It was a joy to see her enthused about her food, and frankly a relief.

[Whiskey's Mom]

Whiskey eats poached skinless chicken breast every day mixed with wet dog food. Some days he just picks all the chicken out. He had a tummy Infection last year and chicken and rice was all he ate for a week and he gobbled it down like crazy. I'm still on the hunt for a dog food that he'll consistently eat, but I know he'll lick his bowl clean if I feed him chicken and rice. It's very frustrating and I agree-literally jump for joy and feel such relief when he eats everything! I poach a big package of chicken breasts and freeze some so I'm never without it for my boy. I should add that he eats LOTS of healthy treats. His meals have become my obsession. :p

[DoxieMama]

I'm glad that you plan on calling the vet and IMS today. Not eating is not a good sign, especially when giving Trilostane. Also ask them about Pepcid, though I have read that it is okay, don't take my word for it. :)

Please keep us updated on what they tell you.

[judymaggie]

So glad that Haleth enjoyed the chicken & rice! My Abbie had spinal surgery in February and the only thing she would eat when she came home was chicken. Fast forward two months and Abbie is still eating a mix of canned food, dry food and .... yup, chicken!

Abbie gets generic pepcid original and is on trilostane and two blood pressure meds. In spite of all her issues, she has never had an upset stomach. I give her the pepcid 15-20 minutes before breakfast and dinner (the meals that are followed by trilostane). I definitely agree that you should ask your vets about adding pepcid. I am not aware of any contraindications but I am not a vet!

[Whiskey's Mom]

Whiskey was on Pepcid when he had the tummy troubles last year. Antibiotics & Trilostane too, but I'm sure you'll ask your vet if its ok first with all the other stuff going on. And during that time his stomach was gurgling so loudly it woke us up, which was a good thing because we made it outside in time.

[Haleth]

Thank you everyone for your comments and support about Haleth and eating! She continued to eat the chicken and rice mixture with enthusiasm today and we added a spoonful of low fat cottage cheese as well and her normal meds. No gurgles today and her stool is better.

On the other hand she is back to sleeping more like the last time her electrolytes went out of whack. She's also stiff and sore, though I think that's tied to the week without Metacam. She only had one dose before last night and I doubt she got all or perhaps any of it into her system last night, since we lace her food with it. However, she just got her evening dose and I hope we see an improvement over the next few days. She does need the HelpEmUp harness the rehab folks lent us now to navigate our steep stairs, but we try to minimize the time she wears it because she dislikes the feel of the hip attachment and because we need to keep the air on her skin because of all the seborrhoea and abscesses.

We'll be seeing the vet on Thursday for the ATCH and electrolytes test, and maybe a further discussion of her skin and soreness. Not sure if we can decide on any changes until we get the results back from the tests. Then on Friday we see the rehab folks for a massage and pointers on the harness.

Thank you again, everyone!

[molly muffin]

We will all be anxiously awaiting those results. I do hope her electrolytes are okay this time. I think those stairs are going to be one of the biggest hurdles for you and her.

[Haleth]

I had been wondering why my last post hadn't garnered any replies, only to learn that the post was eaten or somehow lost. *sigh*

Here's the update:

Her electrolytes were better on Thursday (sodium was normal, potassium was high but not as high. This was after trying a 30 + 30mg split per the IMS's directive. His reasoning: Hallie is metabolizing the Trilostane too fast and/or the pituitary gland is damaged to the point where the aldosterone level is affected more. So if 30mg 1x was fine clinically (numbers were fine) but H was still having accidents because drinking a lot still, plus H is more active in the afternoon/evening, that may point to fast metabolizing, so doing 30mg 2x would mean she'd have that 30mg affect all day. Plus, he distrusts compounding, so he feels it's better to deal with the capsules as presented by Dechra if at all possible. At the time I was blindsided by the announcement that Hallie's liver cancer had returned, but the idea of 60mg per day made me very anxious. I called both the regular vet and the IMS and he stood by his treatment plan of 30mg 2x and then electrolytes and ATCH after 7 days. I spoke with my partner and he too felt we should try it for the week.

Well, it certainly did affect her drinking and eating, as you can see from my frantic posts above. She only was eating a bland diet after 5 days. She was sleeping or dazed about 95+% of the day. During walks (usually short) most of the time was devoted to stopping and staring, an intensification of some earlier behaviour at the end of her walks for the past year (may or may not be tied to knowing that cookies would be employed to get her up the steps). She seemed weaker in the hind end as well, with her balance not as good. So on Thursday when the electrolyte results came back (sodium normal, potassium high), the IMS was called by my vet and he told her to stop the 2nd 30mg dose and then they'd chat after the ATCH results came in. On Friday I took Hallie to the rehab for a very short bit of water treadmill exercise and massage. The rehab person noticed she was definitely stiffer than last week. Then I got a voicemail from my vet (actually a sub for the regular vets who were away) that stated that the ATCH was "clinically satisfactory" acc to the IMS and that we should continue the 30mg 2x and add in florinef to control the potassium and then do another ATCH in 3 months. Well with Hallie acting like a zombie I was not happy, but when I called the IMS was gone for the holiday weekend. I told the sub that I was going to not do the 2nd 30mg until I spoke with the IMS about H's demeanour. Nor would I add the Florinef. My partner feels we should ask for a 30+10 or a 10+10 ( or even 10+10 2x) regimen, or some combo using the Dechra capsules to see if that was better. We had 2 10mg left over when we gave H (30+10 1x), but H has still been very lethargic, so I said maybe only on Sunday and Monday. Yesterday it was more effort to get her to eat dinner (took a break and then finished the chicken) and this morning she ate only 1/2 of breakfast (mostly just the chicken rather than rice) and none of her meds. This pm she was back to pudding stool.

I've tbh been crying, fearing that her continued lethargy (for ex, today we got her up after 9am but she didn't go out until 6pm), especially her staring into space during walks, occasional stumbles, or laying down with her head up when not sleeping mean she was having neuro problems. Or maybe it's taking time for the cortisol depletion to get better? I don't know. But I'm very worried. Our regular vet didn't feel we need a 2nd opinion, but that was before the visit to the IMS with the bad news re: liver cancer and the reaction to 30mg 2x.

ETA:

We bathed her and she was normal for that, apart from it looking like more of an effort to keep her hindquarters up; it was like she was semi-crouching. She was active afterwards, rubbing herself on the carpet as usual. Then she looked at my partner as if to say she wanted on the couch and he lifted her up for a cuddle. She stayed there through our dinner, watching but not going after the food, as she might have done a couple weeks ago. I then brought up her dinner (leftover breakfast) and added some poached chicken (all she ate of breakfast) and then some of her canned lamb dinner and added in fish oil and metacam liquid. Also the pill pocket with her ursodiol. She ate none of it. I tried hand feeding her and once or twice it looked like she might go for it, but no. I then went upstairs and @15 min later she followed and drank a bit of water having from her crate and then went in. Asked my partner if she had eaten (because she usually drinks after eating), but no.

So no trilostane ingested today, or any of her other meds. I'm wondering if I should try another protein (beef? bison? Lamb?) or break out canned tripe, or try feeding her in a couple hours. Or if it's best to wait until morning, considering she committed a little this morning (forgot to mention that earlier) and her stool has returned to a pudding state.

[DoxieMama]

Hopefully one of the admins or other more knowledgeable members will be by to respond to your post soon. What I've read about splitting doses is that if you're using 30mg once per day and the results are good, other than a recurrence of symptoms at night, then you would split the total daily total... so 15am/15pm or 20am/10pm or the like. I'm not sure why the IMS would suggest doubling the dose when the numbers are "fine". (Can you find out the exact results?) And since she isn't eating, I'm glad she didn't get any trilostane today. Don't give her trilostane unless she eats ... and even then, I agree with you guys and wouldn't increase given her reaction.

I sure hope she is feeling better in the morning.

[Haleth]

Hopefully one of the admins or other more knowledgeable members will be by to respond to your post soon. What I've read about splitting doses is that if you're using 30mg once per day and the results are good, other than a recurrence of symptoms at night, then you would split the total daily total... so 15am/15pm or 20am/10pm or the like. I'm not sure why the IMS would suggest doubling the dose when the numbers are "fine". (Can you find out the exact results?) And since she isn't eating, I'm glad she didn't get any trilostane today. Don't give her trilostane unless she eats ... and even then, I agree with you guys and wouldn't increase given her reaction.

I sure hope she is feeling better in the morning.

Thank you Doxie Mama for your kind words of support! I agree; I've only heard of splitting a dose into 2 half doses, rather than doubling it. I have sent a Dr. Goldstein at another Toronto referral clinic a request to recommend himself or one of his IMSs for a second opinion. I doubt he'll see it before Tuesday, however. I'm also tempted to call the third referral clinic I know of in town that has multiple IMSs. Both are less than a half hour away, so I hope someone can help.

I'm happy to sat that Haleth did eat roughly half her breakfast and, after I wrote that post, I tried feeding Hallie a couple spoonfuls of Merrick's Working Dog Stew, which has beef tripe plus fruits and veggies (a new canned food for her). Oh and I heated it too. She was lying down but then her nose started to work and she tried to eat it lying down but then sat up. Since she seemed enthused I then gave her a mix of more of that plus some of her leftover chicken and rice. Again I microwaved it and mixed it, with more of the Merrick on top after adding in about half of her metacam (there may have been some left on the rice and chicken so I thought it best to be safe). She ate nearly all of that. So I hope between them she got a full single meal (half of her normal intake) and the metacam, but I haven't tried to push any of the other meds. I wanted her to have the metacam to address any joint pain. So no Trilostane today and I'm not sure if I should give her more tomorrow morning or not.

I'll also add that she shook for a short period this afternoon. This seemed to be separate from her bath time shaking (she hates baths), since it happened after she dried herself on the carpet and went to lie down. She then came to me and shivered for 30-60 sec. but then it stopped. I do recall this happening earlier on different Trilostane doses in the afternoon/early evening.

[Whiskey's Mom]

Hi! Can't give you dosing advice, just hoping your pup feels better soon. Hallie is so lucky to have you for an owner! I have no knowledge compared to the others on here, but Whiskey had an intestinal infection last year and his symptoms were similar. Lethargy. No appetite. Pudding stool. Staring. A bit of Trembling. His Trilostane was stopped and he was on antibiotics and Pepcid and he did get some IV fluids. We gave him chicken broth to keep him hydrated. I know Haleth has a lot going on so I could be totally wrong. Also I'm familiar with the drug florinef, as used in humans :), and I know you need to increase fluid intake for it to work properly. Don't know if it's the same in pups but thought I'd mention it. All the best to you and Haleth.

[Haleth]

Hi! Can't give you dosing advice, just hoping your pup feels better soon. Hallie is so lucky to have you for an owner! I have no knowledge compared to the others on here, but Whiskey had an intestinal infection last year and his symptoms were similar. Lethargy. No appetite. Pudding stool. Staring. A bit of Trembling. His Trilostane was stopped and he was on antibiotics and Pepcid and he did get some IV fluids. We gave him chicken broth to keep him hydrated. I know Haleth has a lot going on so I could be totally wrong. Also I'm familiar with the drug florinef, as used in humans :), and I know you need to increase fluid intake for it to work properly. Don't know if it's the same in pups but thought I'd mention it. All the best to you and Haleth.

Ah! Thank you! Haleth's tummy has been making noises on occasion the last week or so. Now I wonder if I should take her into the emergency vet, or wait until Tuesday. She did eat about one meal's worth and she is drinking, but the lethargy, weakness (esp hind legs) and staring especially worries me. It's like her personality is being leeched away, with it appearing in flashes or certain times of day. Do you recall how long it took you to figure out the problem with your sweetie? Did he vomit on occasion and/or an orange liquid? Did any labwork point to the infection in particular?

[Whiskey's Mom]

Poor Haleth and poor you. I understand the stress and worry. We didn't have any lab work done to pinpoint a specific infection, but his liver values were not good previous to that and he also had a uti at the same time. We kind of knew right away what was wrong because he never had these issues before. Vomited a few times and making kind of a dry heave sound. He had more pudding/liquid stool and a lot of squatting on wobbly legs-especially the leg that he had injured-which he couldn't put much weight on to begin with. Very rumbly tummy, lots of stinky gas and a pasty mouth. He had several rounds of metrodiazonol(?) and amoxicillin til he was himself again. He just reminded us of a human that has a stomach virus, not himself at all. Tough decision about the vet but if she's not drinking I'd be concerned about dehydration. Our saga dragged out over the Thanksgiving holiday, very nerve wracking-Our vet closed & the E vet An hour away. Hope she feels better. Hugs from us. :)

[molly muffin]

EEEK no, if you give 30 mg once a day, to maintain the same effect on twice a day dosing, you give 15mg am and 15mg pm.

This is how we get into trouble with over dosing, vets who do things like that and is a very probable reason for the staring, excessive weakness and lethargy.

I would try stopping the trilostane and see if she doesn't improve. This is serious stuff as you know.

Edit to add: We just had a test that showed my dog was low on 24mg trilostane. Shaking was prominent, not eating. Stopped the medication for 4 days and then started a lower dose. Will retest in 2 weeks. Just so you know what I am doing.

[Haleth]

Poor Haleth and poor you. I understand the stress and worry. We didn't have any lab work done to pinpoint a specific infection, but his liver values were not good previous to that and he also had a uti at the same time. We kind of knew right away what was wrong because he never had these issues before. Vomited a few times and making kind of a dry heave sound. He had more pudding/liquid stool and a lot of squatting on wobbly legs-especially the leg that he had injured-which he couldn't put much weight on to begin with. Very rumbly tummy, lots of stinky gas and a pasty mouth. He had several rounds of metrodiazonol(?) and amoxicillin til he was himself again. He just reminded us of a human that has a stomach virus, not himself at all. Tough decision about the vet but if she's not drinking I'd be concerned about dehydration. Our saga dragged out over the Thanksgiving holiday, very nerve wracking-Our vet closed & the E vet An hour away. Hope she feels better. Hugs from us. :)

I'm sorry Whiskey had to go through that. Haleth has been drinking and her stool had form today, but she is gassy (though not with awful smells). Wouldn't eat anything but the Merrick heated up, so no meds. She just lay down after her morning walk by the front door and has remained there.

Because she has refused the bland chicken and rice, I wonder if she'd go for hamburger and rice, or if it's better to stick with the canned, although I bought several different proteins plus canned tripe. I don't know if the switch from bland to Merrick in a day is causing this, but then she had a bout of not eating her regular food last Monday but then happily ate the mix of ground chicken and rice. Seemed OK but then we began struggling again and of course we only tried the Merrick when the bland was refused. I'm wondering if I should fast her tonight and tomorrow morning and call the vet, or even take her to the emergency clinic (where her IMS also is). Or if it's best to get calories in her regardless tonight and tomorrow. I don't like the fact that she's not even tried to leave the first floor today; even yesterday she came upstairs with my partner, or on days when he's not home she will go up to the 2nd floor or (more often) to the 3rd, when I am sleeping there. You'd think after 3 days of just 30mg Trilostane and then none yesterday or today she'd be perking up even a bit. And yet when you give her a massage while she's lying down she acts like all's normal: "rub my chest if you rub my tum I will make it clear you must rub my chest" and no complaints or a stretch when a rub a back leg.

[Haleth]

EEEK no, if you give 30 mg once a day, to maintain the same effect on twice a day dosing, you give 15mg am and 15mg pm.

This is how we get into trouble with over dosing, vets who do things like that and is a very probable reason for the staring, excessive weakness and lethargy.

I would try stopping the trilostane and see if she doesn't improve. This is serious stuff as you know.

Edit to add: We just had a test that showed my dog was low on 24mg trilostane. Shaking was prominent, not eating. Stopped the medication for 4 days and then started a lower dose. Will retest in 2 weeks. Just so you know what I am doing.

Hi Molly. Just to clarify: Haleth only has had 1 30mg dose only on Thursday-Saturday. Yesterday and today none. She stopped wanting the bland diet yesterday and that continued today; ditto to pill pockets. I just tried again to see if she'd take a pill pocket (tried both flavours) and no dice. Today she seems relaxed (see my reply to Whiskey's Mom) but not interested in anything but lying down, but didn't even leave the first floor today, when normally she will go up 1 or 2 floors to be with me or my partner. She is drinking a bit more. Should her appetite be perking up, or do you think it will take a couple more days. Right now my plan is to call my vet in the morning and get an appointment or a phone referral to another IMS. The only reason for coming in would be to get bloodwork or a urinalysis (though she's not showing signs of pain or strain when urinating). But if the referral centre has a lab then I'd prefer to take her in just once. Does this sound sensible? Or should I be calling an emergency/referral centre today?

[Harley PoMMom]

With being off the Trilostane for 2 days her appetite should of picked up by now.


Ah! Thank you! Haleth's tummy has been making noises on occasion the last week or so. Now I wonder if I should take her into the emergency vet, or wait until Tuesday. She did eat about one meal's worth and she is drinking, but the lethargy, weakness (esp hind legs) and staring especially worries me. It's like her personality is being leeched away, with it appearing in flashes or certain times of day. Do you recall how long it took you to figure out the problem with your sweetie? Did he vomit on occasion and/or an orange liquid? Did any labwork point to the infection in particular?

Is Haleth vomiting and is the color orange sometimes? If so this can be a symptom of pancreatitis and would explain her lack of appetite.

Hugs, Lori

[Haleth]

Hello Lori, only twice once on Saturday and once this pm. In fact because of that and the refusal the come upstairs we reluctantly took her to the VEC this evening. We just left her there overnight as she is dehydrated and there is pain upon palpitating. I say reluctant because of our disagreements with the male IMS. But the only other 24hr places are in Mississauga and Scarborough.

ETA: she also regurgitated/vomited before Saturday, but again only once a day and not every day and it wasn't orange.

[labblab]

I am so sorry that Haleth continues to do so poorly. I would have to fear, though, that the primary issue right now might be the return of the liver cancer as opposed to Cushing's or Cushing's alone. Poor Haleth does sound quite ill to me, and unfortunately possibly more like pancreatitis as Lori has suggested, or a cancer patient...:o. Also, has her anemia ever been rechecked or reevaluated? Obviously, low cortisol could also play a part, though, due to having her trilostane dose doubled, so I would give no more until or unless she appears to have normalized. I hope the vet hospital has been better able to get a handle on what is going on.

Marianne

[Haleth]

I am so sorry that Haleth continues to do so poorly. I would have to fear, though, that the primary issue right now might be the return of the liver cancer as opposed to Cushing's or Cushing's alone. Poor Haleth does sound quite ill to me, and unfortunately possibly more like pancreatitis as Lori has suggested, or a cancer patient...:o. Also, has her anemia ever been rechecked or reevaluated? Obviously, low cortisol could also play a part, though, due to having her trilostane dose doubled, so I would give no more until or unless she appears to have normalized. I hope the vet hospital has been better able to get a handle on what is going on.

Marianne

Hello Marianne,

To update: we got a call from the emergency doctor this morning staying she had a good night except for a bit of diarrhea. The electrolytes test showed she still had high potassium, but a second test this morning showed that it has descended to high normal, probably from the IV fluids they gave her. They also gave her something for the diarrhea and pain and her heart rate went lower overnight (she was on an EKG in case the potassium caused spikes in the heart rate. Later this morning they gave her benazepril and ursodiol, but we made it quite clear to her last night that no Trilostane should be administered without our permission. Still later (after 9:00?) she called back to say the rest of the bloodwork had come back and that the renal values were higher than they had been in early May; that might be because of the dehydration or because of a progression of renal disease. I called Blue Cross and asked them to forward the UPC and UCC results (which I hadn't received) to the VEC. The emergency vet (night shift) then said that she was about to hand control to Dr. Mason (the IMS who we have been working with), who should be giving us a call at some point before he leaves for the day with an update. It's after 1:00 p.m. here, and I am worrying that Haleth might be stuck in there a second day if nothing is resolved, as I haven't heard from Dr. Mason. To be fair, he is fully booked today, but he is also on consult, so I hope he's seen her by now and has done something concrete like an ultrasound or ordered a urinalysis and is awaiting results.

I'm trying to decide if I should be scheduling a second opinion in here, but I feel like I don't have enough info yet. Or do you think I should begin the process regardless? I did get a recommendation for one of the IMS's over in Scarborough at the local emergency hospital. Theoretically we could transfer her there; however, I know my partner nixed going there yesterday and he is afraid of hurting Haleth too much.

Re: liver cancer
It's hepatocellular carcinoma, which is typically indolent rather than aggressive. It was 4cm on May 11, and the IMS felt it wasn't an immediate emergency (wasn't large enough to be in danger of bursting) and wanted to get the Cushing's under control before deciding on a course of treatment. Haleth wasn't a candidate for either surgery or chemo unless that happened first. So, I do hope there is an ultrasound to see if it has grown suddenly, or appeared elsewhere (there were no signs of this on the 11th). Also, iirc the kidneys looked ok and the gall bladder was holding steady, though still sludgy.

[Whiskey's Mom]

Wow. Poor Haleth she has so much to deal with all at once. :( hope she's doing better and home with you soon.

[molly muffin]

Oh my gosh. Judy checked in and saw this. You must both be so worried.
I think for now the main thing is to get her stabilized for a bit. Eating, drinking, normal poops. No trilostane until this is stable. You never give trilostane to a sick dog, so you want this stable, good call telling them this. Ask about the pancreatis possibility and maybe a repeat ultrasound.

I sure do hopes he is doing better now.

[Haleth]

Oh my gosh. Judy checked in and saw this. You must both be so worried.
I think for now the main thing is to get her stabilized for a bit. Eating, drinking, normal poops. No trilostane until this is stable. You never give trilostane to a sick dog, so you want this stable, good call telling them this. Ask about the pancreatis possibility and maybe a repeat ultrasound.

I sure do hopes he is doing better now.

The positive news: her potassium is down, her heart rate is lower, which they think indicates she isn't in pain. She is drinking a lot and was cleared for solid food this afternoon and when I came to visit it looked like she had eaten some of the food in her bowl, though she never returned to it when I was there, even when I offered it at an elevated level and my partner and I tried to hand feed her. She was warm, which caused some panting, but before we left apparently the landlord finally relented after many complaints from the staff and turned the air on in the building tonight. With vet tech assistance, I took Haleth out and she waited until we left the building before urinating (no stool, but that was no surprise given her @24-hour fast). Although weak and not entirely stable we went further than I expected with many breaks to stare at the scenery and sniff the air.

The sad news:
When I spoke to the IMS this afternoon, he indicated that her BUN, Urea, and Creatinine were much higher than they were in her May 2nd bloodwork. So if there were hints of early kidney disease on the 2nd, she may be in a more advanced stage now, which given that her kidneys looked fine on the 11th in the ultrasound, was a shock. He said he wanted to see her bloodwork tomorrow, to see if treatment (fluids, antibiotics in case there was an infection not otherwise spotted in bloodwork or ultrasound) was bring those values down significantly, to get a sense of how advanced it is.

I am grieving for my dear Haleth, because I remember how quickly kidney failure took our late boy Jefferson (roughly two weeks from diagnosis to when we decided to end his suffering). And even then we now both think we should have considered euthanasia sooner. Depending on what the vet tells us, we may bring her home for palliative care (he stated that there was little they could do for her apart from fluids and keeping her comfortable), or decide to ask a mobile vet to help us set her free from her pain tomorrow or the next day. What do you all think? Should I still get a second opinion?

[molly muffin]

What are her actual creatinine, bun, urea numbers?
Are they saying that this issue here, the reason she is I. Emergency is due to her kidneys?

I think much depends on how bad things are with kidneys, liver. Etc.

I am so sorry that this seems to all just be piling up at the same time.

Dependent on what they tell you, get copies of the lab work, then have a chat with your partner but I'd she is okay enough to be with you for awhile and Not in pain, then enjoying some time with her could be an option.

So much just depends on how she is doing. :(

[Haleth]

What are her actual creatinine, bun, urea numbers?
Are they saying that this issue here, the reason she is I. Emergency is due to her kidneys?

I think much depends on how bad things are with kidneys, liver. Etc.

I am so sorry that this seems to all just be piling up at the same time.

Dependent on what they tell you, get copies of the lab work, then have a chat with your partner but I'd she is okay enough to be with you for awhile and Not in pain, then enjoying some time with her could be an option.

So much just depends on how she is doing. :(

Hi Molly, I can get the labwork tomorrow (or so I hope as I've never requested it from the VEC before), but I believe the Creatinine went from 173 (May 2nd labwork I have) to over 400. I'm afraid I was too upset to recall the rest of the numbers.

As for Haleth's behaviour the last few days before we hospitalized her: she lost interest in first her regular food and then her bland diet and all her treats and pill pockets (which she had always loved), though she still was interested in canned heated Merrick food on Monday. She's much more interested in water now and was over drinking today in the hospital. She ate a bit of approved veterinary food but refused the pill pocket from the vet tech and had to be manually pilled. She can walk, but much of her walk even tonight involved staring off into the distance (though sometimes sniffing so maybe this is partly a vision thing?), and she still seemed weak, especially the hind end. For the last week or so during most of the day she was dazed (lying down but with her head sort of hanging) or sleeping for much of the last two weeks and on the day we hospitalized her she didn't want to come upstairs to be with us like she normally does. I guess I fear if she still isn't interested in food and is dazed most of the time indoors and out, she will not be enjoying her life any more. She's been like a zombie for the past couple weeks, with only bits of her personality coming out here and there. Am I being too negative? I hope so, but I also don't want to be selfish and make her suffer.

Should we give her a chance to recuperate? I go 'round and 'round, and was recently arguing about giving her a chance to my partner. But then I remember how swiftly our late Jefferson deteriorated with kidney failure. On the day we set him free he could not get up. And I fear my desire to keep him made me delay too long.

[molly muffin]

Quality of life is everything. With hind end weakness she might know she can't do the stairs.
Yes that is a big increase in the creatinine.
It is likely that the kidney disease has made her lose any appetite she had.
Sometimes it isn't being negative it just is being realistic. Maybe the best thing to do is have a talk with your vet about prognosis and options.

[labblab]

I'm so sorry to awaken this morning and read this news. I agree 100% with Sharlene, though. Please know that we are standing alongside you and sweet Haleth, no matter what.

Marianne

[DoxieMama]

Oh, I am so sorry! I don't know what I would do, either, though Sharlene has a great suggestion to talk to the vet.

Many hugs sent your way today.

Shana

[Harley PoMMom]

I am so sorry that sweet Haleth is not feeling well. Dog's with kidney disease usually have an elevated phosphorus level, which can make them feel nauseated, and a phosphorus binder is needed.

[Haleth]

Quality of life is everything. With hind end weakness she might know she can't do the stairs.
Yes that is a big increase in the creatinine.
It is likely that the kidney disease has made her lose any appetite she had.
Sometimes it isn't being negative it just is being realistic. Maybe the best thing to do is have a talk with your vet about prognosis and options.

Hello All,

I wanted to update you. Last night we stayed with her for three hours. The staff at the VEC were wonderful and compassionate, moving her to a sheltered area outside her crate so we could lie down and talk with and pat her. Haleth ate some of her hospital food and drank lots. She was able to go out side with only occasional assistance and waited until we were out before going. We brought her old cooling mat (the staff had warned us that things can get lost so we didn't bring the new one), because she prefers to be cool. Haleth chewed through her IV before we came so she had to wear a cone unless we were watching her. The staff felt that was a positive sign, as active resistance suggests more energy.

This morning the IMS called to say that her kidney values had dropped by half what they were yesterday. He felt that was encouraging news (an attitude seconded by the mobile vet I spoke with later on) and said he wanted to keep her in another day to further stabilize her and hopefully see lower numbers tomorrow. This was encouraging, because yesterday he was talking about letting her go home today on compassionate grounds if her numbers were about the same or worse. The mobile vet speculated that Hallie may have eaten something toxic and I wondered if it was an infection because I heard that can sometime cause acute kidney failure? But even though H's walks are much shorter it is true she ate some of her beloved sweetgrass a night or two before she was hospitalized. She's eaten sweetgrass for years without an incident, but maybe this patch had something on it, or maybe she snatched something on a walk that we didn't see. And yet again, she was lethargic before then, so it's hard to tell when the kidney crisis started.

What all this will mean beyond the fact that she is banned from Metacam for life, I can't say yet. I am more hopeful than I was yesterday, but I am afraid to be too optimistic. But it's true that Haleth has shown us often enough that she is a tough little warrior chieftess, like her namesake.

[Joan2517]

Some good news. I am praying that she continues to improve...we know how hard this is.

[DoxieMama]

That is some good news, indeed. We are all cheering and praying from the sidelines here.

[judymaggie]

Good update! As much as I'm certain you want Haleth to be home with you, it sounds like the veterinary staff is being reasonable keeping her another night and wanting to make certain that everything is stable.

[Whiskey's Mom]

Sending healing thoughts and love!

[molly muffin]

I couldn't be more pleased to read that she is doing better and her numbers have dropped, which makes me think that this is a toxin perhaps and not end stage kidney disease.
I think I would not use metacam any more, ever. Something easier on the system would be better I think. There are options out there so discuss those options with the vet. The IV can flush her system and since she is responding to that flush, it is a positive sign.
I definitely feel more optimistic reading this update. How is she doing today? I'm crossing fingers for some more good news.

[Haleth]

I couldn't be more pleased to read that she is doing better and her numbers have dropped, which makes me think that this is a toxin perhaps and not end stage kidney disease.
I think I would not use metacam any more, ever. Something easier on the system would be better I think. There are options out there so discuss those options with the vet. The IV can flush her system and since she is responding to that flush, it is a positive sign.
I definitely feel more optimistic reading this update. How is she doing today? I'm crossing fingers for some more good news.

I'm glad that you feel it's positive news as well! I hope the trend downwards continues for her tomorrow. And no, I will make sure Haleth is never given it again. If she is released tomorrow, I will ask the IMS about safer options.

We heard during our visit tonight that Haleth ate most of her two recent meals. A mobile vet we spoke with suggested we bring warm Swiss Chalet roast chicken and take off the skin; said she ordered it for her dogs who needed to eat but are reluctant. She specifically said it had to be Swiss Chalet chicken, as the ready-made roast chickens in grocery stores don't have the same effect. Haley loved it! My partner and I fed her with permission a fair portion of skinless white and dark meat, saving the rest for her midnight and/or morning meal. She had her "I am focused on your food" face on. She also continued to drink and had one accident before we came back to see her, because they are keeping her well-hydrated and the Cushing's is untreated for now as she has been so ill.

After eating and drinking, she felt relaxed enough to lie down and had a snuggle with my partner and I on the floor, something she can be reluctant to do when stressed. She also whacked my partner with her paw to let him know he was misbehaving (food not fast enough?) and later tried to gnaw off her IV port twice, but we stopped her quickly. She has to wear a cone when we're not there, but we're allowed to take it off. Because of that cone I felt so happy that they have left her in one of the somewhat larger partitioned spaces on the floor right by the nurses' desk (they can and do lean over to talk to them and give them love) they put her in last night. In the kennel she was in earlier she had less space and so kept banging her head into the bars and walls.

We do not know what tomorrow may bring, but today we have had more hope than we have in days.

Thank you so much to everyone who has been supporting our dear girl. Your knowledge and kindness is what makes this community so wonderful!

[Haleth]

This morning's update:

Haleth's urea is down to 15 and her creatinine is down to 220 from 221 yesterday and 397 the day before. The IMS wants to release her this afternoon. He also mentioned that she would need subcutaneous fluids. Any thoughts on this? We will be seeing him on release so will ask him more questions then.

[Joan2517]

She'll be so happy to be home with you! The fluids are not hard to do...you'll do fine.

[DoxieMama]

Home today! Woo hoo!!

[Harley PoMMom]

This morning's update:

Haleth's urea is down to 15 and her creatinine is down to 220 from 221 yesterday and 397 the day before. The IMS wants to release her this afternoon. He also mentioned that she would need subcutaneous fluids. Any thoughts on this? We will be seeing him on release so will ask him more questions then.

I've had to do the subQ fluids for my boy, Sampson. It is really easy to do, you pinch up their skin making a tent-like and inject the fluids, has the vet told you how much to give..and those fluids that remain in the bag have to be refrigerated so when you get the bag out of the frig it will need to be warmed up, I used the microwave for that.

Here's a YOUtube video showing how to give a dog subQ: https://www.youtube.com/watch?v=mxAAyISHRk8

Hugs, Lori

[Whiskey's Mom]

So happy that your sweetie will be home with you. Hope you all have a restful night's sleep!

[Haleth]

Haleth is home with us now.

The positive: Hallie knew Leigh and I and went to us in the room for our subQ lesson. She smacked two people with her paw (a good sign) and loved being massaged. Once she got outside she mostly reverted to staring and not being comfortable with moving (Something that has been happening more and more outdoors day or night, though she was natural in the largish exam room). She jumped up onto her seat and eventually lay down. Once at home she wandered the first floor and then snuck upstairs while I was distracted with a contractor who rang the doorbell. We found her in one of her favourite spots, right in the music room by my partner's drumset. She sacked out for awhile, like she was relieved to be where she wanted to be. She ate maybe half of her dinner (a mix of her Fromm's Senior and hypoallergenic food and with boiled and rinsed hamburger) and took one pill via pill pocket, but refused the other. My partner is going to keep on trying with the other pill, but I suspect we'll have to learn how to pill, unless we can find a reliable alternative (maybe the duck flavor? or an actual meatball? peanut butter?). She's on Pepcid, so I hope that helps her appetite.

The sad: the IMS feels that Haleth most likely is dealing with renal disease, saying that they can sometimes suddenly progress. That happened with my 16yo boy Jefferson, who lived for maybe a couple weeks after his diagnosis. In Haleth's case, the IMS believes, between the cancer and the kidneys, she may have six months to a year. There was no talk of surgery or chemo and tbh I don't think I'd want to put her through that after this past week. Part of me actually is happy that we may have her for more than a day or a week (if all goes well), because that is much longer. Another part wonders if I did the right thing to press for her treatment instead of letting her go, but then we did not know what was behind her lethargy. For now, we will see how the coming week goes and see what her bloodwork looks like in two weeks. The IMS feels if the bloodwork's still the same as today, she may be stable for a time. If not, and we don't see her enjoying life, we may decide that she should be allowed to rest.

I'm also thinking of changing to a mobile vet to allow Hallie to be treated at home, although I'm not sure if she can also do ATCH tests. The staff at her regular vet love her, but despite that I know that until recently she shook when she went there (she started shaking post-liver cancer surgery). So a mobile vet would be kinder. The vet I'm thinking of is integrative, so she might have some thoughts re: diet that may help. If anything I think we will need help in keeping things super palatable now, instead of expecting Miss Chowhound and Cookie Lover. I've joined the K9Kidney group now as well, and for both groups I hope to have the labwork fielded to my regular vet and then to me tomorrow. Finally, I've been thinking about a bucket list for Hallie, maybe getting a wagon or pet stroller so we can visit local haunts we used to visit when she had more stamina. Visits by human friends, massages, delicious food?

Again, thank you all for your loving assistance! <3

[Joan2517]

The bucket list is a lovely idea! Take pictures...I'm sure Hallie will enjoy it. Happy that she is home with you.

[DoxieMama]

I love the idea of a bucket list for Hallie. If the mobile vet can provide most of the care she needs, that also sounds like a good idea. Even if she can't do everything, it might prevent some stressful visits to the regular vet. (I had a similar agreement with a mobile, holistic vet with our first dog Jupiter when he was ailing from lymphoma. He worked with our regular vet to provide the best care possible.)

Lots of hugs for you, and massages for Hallie.

Shana

[molly muffin]

I've been away for a few days, but do want to find out how your baby is doing?

[judymaggie]

Hi! We haven't heard from you in several days. Please let us know how Haleth is doing.

[Haleth]

I've been away for a few days, but do want to find out how your baby is doing?

I'm afraid I stopped posting without planning to.

I'm afraid Hallie was not at all keen on sub-Q fluids and as her kidney numbers fell back into normal range. A few weeks after my last post Haleth was also diagnosed with an aggressive mast cell tumor under her left leg. We tried chemo briefly but then she was back in hospital again in late July while I was out of the country. We were trying to juggle the return of her liver cancer, Cushing's, the kidney crisis, and then this new cancer. Our lives narrowed down to caring for Hallie. On the morning of Sept 7, 2016 we released her from her suffering after a crisis of unknown origin starting the night before. Terrier-true she still managed to enjoy a cup of frozen vanilla yogurt that night.

Thank you for following up. I am sorry I didn't reply. It's been a year and the memories still are painful. I came back here when someone asked about Cushing's and their pup on another site and I went to look through my mail so I could send them a link. Thank you to the many wonderful people on this site that supported my courageous girl.

[Haleth]

Hi! We haven't heard from you in several days. Please let us know how Haleth is doing.

Thank you for your concern for my dear girl, who has passed on. We had a rough time but she was a trooper to the end. I just replied upthread in case you would like to know details.

[Joan2517]

I'm so sorry for the loss of your sweet girl.

[labblab]

I am also so very sorry about your loss of Haleth, but also very grateful that you've returned to let us know what happened. This way, we can always join you in honoring her life and her courage -- and we can always continue to offer our support to you. If it would be a comfort to you, it would be our privilege to add Hallie to our special memorial thread of honor for 2016:

http://www.k9cushings.com/forum/showthread.php?t=7676

You can let us know the date of her passing and also whether you'd like us to add a photo link, and then we'll take care of everything from there. Once again, my heart goes out to you in your loss, and I send warm wishes to you and your family, always.

Marianne

[Squirt's Mom]

Dear Kirsten,

I am so sorry you return to us only to share such painful news but I thank you for doing so. Now we can place her name among the rest of her family here who are in the Rainbow Fields and we can join you in celebrating her life.

You both fought a long and hard battle with courage and determination, fueled by a deep love. That love abides thru all time and binds you and your precious Hallie always. One day you will hold your sweet girl again. Til then she will watch over you just as you watched over her.

My deepest sympathies,
Leslie




The Rainbow Bridge
inspired by a Norse legend

By the edge of a woods, at the foot of a hill,
Is a lush, green meadow where time stands still.
Where the friends of man and woman do run,
When their time on earth is over and done.

For here, between this world and the next,
Is a place where each beloved creature finds rest.
On this golden land, they wait and they play,
Till the Rainbow Bridge they cross over one day.

No more do they suffer, in pain or in sadness,
For here they are whole, their lives filled with gladness.
Their limbs are restored, their health renewed,
Their bodies have healed, with strength imbued.

They romp through the grass, without even a care,
Until one day they start, and sniff at the air.
All ears prick forward, eyes dart front and back,
Then all of a sudden, one breaks from the pack.

For just at that instant, their eyes have met;
Together again, both person and pet.
So they run to each other, these friends from long past,
The time of their parting is over at last.

The sadness they felt while they were apart,
Has turned into joy once more in each heart.
They embrace with a love that will last forever,
And then, side-by-side, they cross over… together.

[molly muffin]

Oh no, I'm very sorry to hear that. We do understand how hard it is when they pass. It's been just over a year for me too and yea, it's still hard.

My sincerest condolences

[DoxieMama]

I am so sorry to hear of your loss. Thank you for returning and letting us know, allowing us to share your grief and remember dear Hallie in our ways.

Shana