My 14 year old doxie - probable Cushings - Visuddha has passed

[DoxieMama]

Hi everyone,

As the title says, my 13 year old miniature dachshund appears to have the classic symptoms of Cushings. Visuddha has gone through a couple bouts of pancreatitis over the years, has very bad teeth (only 7 left after the latest dental) and his vet suspected a heart murmur in 2014 though hasn't mentioned that again. At his last check-up in September, he said he was in great health, other than his teeth. He gave us antibiotics for that infection and to hopefully help decrease the drooling that was crusting on his chin, which could be repeated monthly as needed. We repeated it once after 6 weeks but hasn't had those since November.

He has been drinking a boatload of water for the past few months. We usually go to bed between 8 and 9pm, and for the last month (or maybe longer) he wakes me at 2 or 2:30am for a drink and to go outside. Then he sleeps for another hour when he wants breakfast, drinks more and goes out again. He doesn't go out much more often than normal during the day but he certainly pees buckets when he does. He has had a few "accidents" in the house, though my husband thinks he's just being ornery. I tend to think that because he doesn't bark to go out, we don't always notice in time to prevent the accidents. My husband cleans the carpets regularly because of it, and is increasingly irritated by the need to do so. I had a couple friends mention the possibility of diabetes but I kept putting off calling the vet to have that checked.

Then, last weekend, my husband and I went out of town for Saturday night. When we returned on Sunday afternoon, Visuddha's abdomen was severely swollen. Our son had fed both dogs kibble and apparently our other dog (Jackson, 5-year old Australian cattle dog mix) turned up his nose. But there was still kibble in the dish, which NEVER happens in our house, so I should have known what happened. When Visuddha started retching unsuccessfully, I was worried about bloat and took him to the pet ER. The tech there agreed with my suspicions, the vet was not as concerned and when they did an X-Ray it showed his stomach was full of food. Oh such an expensive meal for the little guy. :p He had the expected diarrhea but otherwise recovered within a couple days. (By the way, Visuddha is normally fed mostly or all canned food, while Jackson gets mostly kibble with a couple spoonfuls of canned mixed into it.)

My regular vet's office called to check on him Monday morning, at which time I mentioned his increased drinking. I made an appointment for Tuesday afternoon. At the appointment, the vet suggested kidney disease, liver disease or endocrine disease as possibilities and I was surprised because I was expecting diabetes. I agreed to a full blood panel and urine test to determine just what was going on. The next day, the vet called and said "you weren't kidding when you said he was drinking a lot - his urine is VERY dilute" and that from the results, it appears he has Cushings. He suggested a UCC test next, using the urine sample they already had, which confirmed that Cushings is very, very likely.

I stopped by to pick up the actual results on Thursday and chatted with the vet for a while. He also stated that Visuddha has the classic symptoms; in addition to the PU/PD, he has thin skin and hair on the sides, potbelly appearance with no weight gain, and I think he mentioned a large liver on palpating the abdomen but I'm not positive about that now. I've also seen him stumble a couple times, usually in the early morning at the bottom of the stairs like he slips a bit on the tile or is perhaps weak or sleepy; and he's been more inclined to ask me to pick him up to get in my lap on the couch rather than try to jump. I attributed these things to his age, of course, and was actually pleased that he wasn't jumping as much since I know that's not good for his back. Now I'm not sure if it could be due to deterioration from Cushings, instead. :(

Here are the test results of note:

2/23/2016
CBC - this is all within reference range, though I will mention the note "Cannot get accurate platelet count due to clumping. Platelet estimate is adequate." PLT 334 (200-500)

Differential
Mono # 1620 (H) (150-1340 /uL)

Total Body Chem Screen
ALP 1051 (H) (10-84 U/L)
GGT 32 (H) (0-10 U/L)
ALT 106 (H) (5-65 U/L)

Urinalysis
Yellow, Clear, pH 7
Blood Small (A)
Urine Sp. Gravity 1.009 (1.005-1.055)
Bacteria: Few Rods
RBC's 0-4
Epithelials Few
All other results negative/none seen

Urine, Creatinine 24.0 mg/dL (in range)
Cortisol, Urine 14.00 ng/dl (in range)
Cortisol/Creatinine Ratio 182.13 (H) (0-20)
Interpretation: An elevated (>20) is consistent with a variety of illnesses, including hyperadrenocorticism. Further testing (LDDS test and/or ACTH Stimulation test) is advised to establish a diagnosis of hyperadrenocorticism.

My vet said the Cortisol/Creatinine Ratio of 182 is a clinic record! :eek: He has been a vet since 1987, and started this clinic in 1992. Since then, he has seen three cases of Cushings due to an adrenal tumor, none of which chose to pursue surgery (the surgeon in each case did not believe they would be successful). All other cases he has seen have been pituitary. I don't know how many cases he's seen but I got the impression he's been down this road a number of times. One in particular was a former staff member's dog who did not initially treat, until the dog was urinating so much that she had to put him outside and felt guilty about it. So they started him on trilostane and was able to get that symptom under control and bring him back inside. I know there's no way I could leave my little guy outside. He follows me everywhere and hates when I leave, even crying outside the door when I am in the bathroom sometimes. Vet visits aren't too bad, though if there are other dogs in the waiting room sometimes he's quite vocal and strains to reach them (I did not train him well when he was younger so he doesn't play well with others, to put it mildly).

As I see it, I have two hurdles to overcome regarding treatment: one, his age and two, the expense. As for the expense, I'm sure I don't need to explain that to anyone here. Tests are costly and required if treating, and the medication itself isn't cheap. This is a sticking point between my husband and I. Of course it's impossible to know how much longer he would live if completely healthy, if the increased cortisol is masking other symptoms, or if treatment would even be successful. Or helpful. I mean, we may not be able to get the symptoms under control before his aging body fails anyway. I'm just confused and uncertain what to do. My husband doesn't trust doctors, etc and that makes this so much more difficult.

The next step for us according to our vet, if we treat, is an abdominal ultrasound. He doesn't use the ACTH test for diagnosis, only to monitor the drug effectiveness/etc. He said the LDDS test was the only way to maybe determine which type of Cushings an animal had, before ultrasound. But now an ultrasound is his preferred approach. That is more expensive, though. And from what I've read, neither one is foolproof. So do I follow my vet's preference with the ultrasound and possibly not have anything confirmed? Or go with the less expensive LDDS test and still need an ultrasound after that?? :confused: Or simply spoil and keep him as comfortable as possible, for as long as I can?

I know that I am the only one that can make the decisions, here. I'm just venting a bit in what appears to be a safe place, with others who feel the way I do about their pets. Co-workers and friends are no help. They say "do what you can to help", or "he's 13? oh...", or "nope, that's way too expensive". lol :p I'm hoping this is a safe enough place that I can share my thoughts and concerns, and eventual decision to treat or not, with others who have struggled with this disease.

Thanks to anyone who took the time to read my novel. :o I wanted to include as much information as possible, and document what I can remember while it's all fresh in my mind.

Shana... with Visuddha, Jackson and kitty Leeloo

[labblab]

Hello Shana, and welcome to you and Visuddha. I am so glad you've found us, and yes, we certainly do understand your worry and doubts! We really hope this will feel like a safe place for you to talk, because that is absolutely our intention.

From what you've written, it sounds to me as though you've already done a lot of thinking about the pros and cons of treatment for a senior dog, and you're absolutely right -- there are trade-offs either way. For a geriatric dog, my usual focus is upon the dog's quality of life and comfort. If Cushing's symptoms are not making the dog particularly uncomfortable, then I'd probably worry less about slow chronic damage and forego the expense/monitoring of treatment for the time being. However, if my dog's quality of life was being significantly compromised by the thirst/urination/hunger/muscle wasting, then I'd want to pursue treatment and at least give it a chance.

So if Visuddha was mine, my first step would be to assess the quality of his current daily life, and go from there. One wild card for you, however, is your husband and HIS quality of life :o. It does not sound as though he is being very understanding or compassionate re: Visuddha's needs. A dog who has been previously housebroken but starts having accidents is not being "ornery," and probably feels nervous and upset, himself. Soiling his den is contrary to his natural instinct, and it is not something that he is purposely or willfully doing. So for multiple reasons, the excessive thirst/urination may end up being a major stressor in your household if it continues or worsens.

The double bind, however, is that Cushing's diagnosis, treatment, and monitoring does indeed involve expense. So you'll need to find a way to get your husband onboard re: the benefit of treatment if that is the route you choose to go.

As far as diagnostics, here's one cautionary note re: that UCCR. A urine sample that is taken under stress while at the vet's office cannot be trusted to be accurate for a UCCR. All lab protocols for conducting that test state that the urine sample should be the first pee of the morning, obtained at home, under as less stressful a situation as possible. Some experts even recommend pooling 2-3 samples gathered on successive mornings, since testing performed on a single sample may reflect natural inconsistency that occurs from day-to-day.

However, given Visuddha's symptom profile, do I think he has Cushing's? Yup, I think it is highly likely. But I would want to perform one of the two diagnostic blood tests prior to advancing to an ultrasound. And in this situation, I can't argue with picking the LDDS since it does offer the possibility of distinguishing whether it's the pituitary form of the disease that is present.

So, bottom line, I'm afraid you are the one who is stuck in the middle on this. To the best of your ability, I believe I'd try to evaluate which scenario will jointly keep Visuddha and your entire household the most comfortable right now. But we are definitely here to continue to discuss your options with you.

Marianne

[Harley PoMMom]

Hi Shana,

Welcome to you and Visuddha! What an unique and cool name for your sweet girl! Thanks so much for all those details as it does help us in providing you with more meaningful feedback. ;)

I certainly do understand the dilemma in treating an elder dog, I strongly believe that quality of life is more important than quantity. Treatment can unmask arthritis in an arthritic dog and those vet visit are numerous and can hurt the pocketbook. There are some cost saving tips that may help with the expenses. The reason those ACTH stimulation tests are so expensive is because of the stimulating agent which is usually Cortrosyn. Cortrosyn comes in a .25 mg vial and the instruction on the label says to inject the dog with the entire vial. What most vets don't know is that only a fraction of that is needed for smaller dogs. Any remaining Cortrosyn can be stored in the freezer for up to six months. If Visuddha weighs 20 pounds, your vet should be able to get five ACTH stimulation tests out of one vial. That is a huge savings to you so it is well worth discussing this with your vet. I have included a link below to Dr. Mark Peterson's veterinary blog where he provides information on the amount to use as well as how to reconstitute and store the remaining Cortrosyn. You can either provide the link to your vet or print the blog. Dr. Peterson is a renown endocrine specialist and I suspect s/he knows who he is.

http://endocrinevet.blogspot.com/2011/03/how-to-extend-your-supply-of-cortrosyn.html

If the treatment plan is using Trilostane another way to save some money is to have the medication compounded or to buy from an reputable online pharmacy.

Just to clarify one thing, diabetes has been ruled out right? Because diabetes and Cushing's do share many of the same symptoms. Was the urine for the UC:CR test collected at home? If not the stress at being at the vets can yield a high UC:CR result. And yes, Visuddha's UC:CR results are high however any non-adrenal illness will cause those results, and the other tests for Cushing's, to be elevated so that is why other health issues need to be ruled out. Cushing's is an expensive disease to get a confirmed diagnosis for, there just isn't one test that can accurately identify it so multiple tests have to be performed to validate a diagnosis.

Regarding the ultrasound, it can be a very useful diagnostic tool, other abnormalities may be found with the internal organs, and as we like to say around here, you get a lot of bang for your buck with an ultrasound. However not all ultrasounds are created equal. A good quality ultrasound/interpretation depends on a few things; the tool used, the technician performing it, and the physician interpreting it. Usually a Board Certified Veterinary Specialist is the best choice to perform an ultrasound.

There are pros and cons in treating Cushing's in an elder pet. Cushing's is typically a slowly progressive disease but it does have the potential to cause systemic damage over time such as high blood pressure, vulnerability to pancreatitis or reoccurring pancreatitis, infections, high cholesterol, kidney damage, etc. So for a younger dog, I'd certainly recommend treatment to eliminate some of these risks, improve long-term quality of life, and allow the dog to live out his/her normal lifespan. However, for a dog nearing their life span, immediate quality of life issues are more important to me.

I don't know if what I wrote was helpful in the decision to treat or not but I do want to reassure you that we will not judge you whether you decide to treat or not, we are here to help in any way we can so I hope that you will feel comfortable posting here. ;)

Hugs, Lori

[DoxieMama]

Thank you both for your welcomes, and your thoughtful and informative responses. Marianne, I have most definitely done a lot of thinking about this potential diagnosis all week. I've read numerous articles (the reference section here is fantastic!), as well as posts by others and their experiences. I am so grateful for all the information everyone has shared, as it provides much comfort and allows me to remain calm in the situation.

You both mention one of the concerns I had regarding Visuddha's testing so far: the UC:CR sample was collected at the vet's office. I have since read about the preference to obtain this sample at home in the morning and therefore wonder about the validity of the result. However, his other physical symptoms are strong indicators in both my and my vet's opinion. Of course, we would not begin treatment without a confirmation using another method (ultrasound and/or LDDS).

Now, I just did a bit more research regarding the ultrasound and found a website for the place where Visuddha would have this done. In their FAQ, they request withholding food for 12 hours prior to the ultrasound which is estimated to take 2-4 hours. I hadn't considered it would take so long, though it certainly makes sense. I don't want to do that unless it's necessary... I feed him at 3:30 in the morning and would hate to make him wait SO much longer for food. If you have never had a dachshund, perhaps you don't know just how horribly they are starved. :p At least, my little guy certainly acts that way. He always has, which makes that as a potential symptom of Cushing's something I can't really compare. By the way, both of the staff members who would potentially perform the ultrasound are Board Certified in Radiology.

Lori, thank you for the information regarding Cortrosyn. As Visuddha only weighs about 11 pounds, splitting the vial into multiple doses would certainly be a way to keep expenses down! I'll see if my vet has heard about that. He did mention using a compound, in regards to selecting a company and sticking with them rather than switching around as each could be a little different. So that's a money-saving measure already in place.

His glucose result was in range at 103 (ref 65-130) so my understanding is that diabetes has been ruled out. I have the test results here so if there are any other values you're curious about, just ask. Everything else is within range, though.

I should also mention that Visuddha doesn't seem to me to be all that different than normal. Normal for him - a good day for him - is to lay in my lap as much as possible. That's always been the case. He's never been one to do much running around. But I wonder if he wouldn't be more active, if he was well.

As for my husband, he's tough to nail down. I think I mentioned his aversion to doctors, medications, etc. I was always the one who went to the doctor myself, and took the kids and animals. He basically says, "Do what you have to do" when it comes to that. I can and have done exactly that. When it involves me or the kids, I tell him we're going and that's it. He might give me a hard time, mostly teasing, but if I think it's necessary then I do it. I would absolutely prefer if he would agree with me so I always discuss things with him, though sometimes it is after we've got the diagnosis and medication. In this case? If I decide to pursue treatment, I'm going to need him to participate by knowing and recognizing new/increased symptoms. He is GOOD at that, if he knows what to look for, sometimes better than I am. And honestly, treatment would be as much for him as for Visuddha, if it would eliminate accidents inside. They're not regular, at least not yet, but from what I understand will likely only become so if not treated.

Boy am I wordy. I feel like I'm all over the place with this post. Sorry! I'm trying to respond to your comments and provide more information as it comes to me. I've edited and re-wrote it enough times now. :o Do let me know if you have any other questions or suggestions. Thanks!

Shana and her little zoo

[judymaggie]

Hi, Shana and Visuddha! Lori and Marianne have certainly given you plenty to think about as you try to determine the best treatment plan for Visuddha. Marianne had posted some excellent information to another member who was deciding whether or not to treat her senior pup so I wanted to give you the link to that post:

http://www.k9cushings.com/forum/showpost.php?p=93044&postcount=3

Whatever you decide to do, we will all be here for you!

[labblab]

If it turns out that treatment is not a good option for you and the excessive urination is the primary issue, is there any area of the house that you could designate as an indoor toilet area where you could put down pee pads such as a tiled bathroom or laundry room? If Visuddha learns there is an acceptable/preferred area to urinate when he can't get outdoors, maybe that would ease some of the stress in the household.

Also, I notice that you feed him breakfast at 3:30 a.m. Is this his only formal meal of the day, or does he also eat during regular dayrime hours? I am putting the cart far ahead of the horse here, but I just want to alert you that trilostane should be given along with a full meal for maximal absorption, and monitoring ACTH tests are performed 4-6 hours after mealtime dosing. So if you think you will opt for treatment, you may want to start delaying his breakfast until a bit later time if that coincides better with your ability to get him in to the vet's office.

As far as fasting for the ultrasound, I think the rationale is twofold: to eliminate the risk of aspiration of regurgitated food if sedation is required, and to avoid obscuring the imaging of organs near or behind the stomach. I always hate to make my dogs fast for testing, too, but sometimes it just can't be avoided. You don't want to go through the expense and stress of the procedure only to be told that important abdominal areas couldn't be viewed due to a full stomach.

Marianne

[DoxieMama]

Thanks, Judy. I appreciate your message.

Marianne, I could put pads down in our master bath at night and maybe that would help. I could also put them in our laundry area for during the day, though that's not tiled. He sometimes goes in there already so it wouldn't be a bad idea to see if he'd use the pad. I tried them once years ago without much success, though. What about doggy diapers? A friend of mine suggested that, though I haven't looked into it as I'm not sure Visuddha would be amenable to the idea. I'm not sure that *I* am.

Breakfast is at 3:30am because we've been getting up for potty at 2am and I haven't been getting back to sleep. My husband gets home from work around 3 so it's been relatively convenient. Dinner is typically 4:30 or 5pm. If treatment would help him sleep in a little more, I wouldn't mind that at all. ;) Then breakfast could be later. It used to be closer to 5am.

If we do an ultrasound and they want him fasted, he'll be fasted. It's no fun for either of us, but I do understand it's for the best. He'll just have to deal with it.

Shana

[Harley PoMMom]

I would definitely look into diapers since he isn't a big boy, and if you are going to use pee pads I use the bed pads for humans as they are a lot cheaper.

I've had to fast my boys for ultrasounds and since it was such a long period of time when they had eaten I took food along with me in that way I could feed them as soon as the procedures were done.

Hugs, Lori

[Renee]

Hi there Shana,

You've gotten excellent advice from everyone so far, so I will just weigh in with my thoughts too.

Assuming you decide to go ahead and treat, if expense is a concern, I would suggest to go ahead with the LDDS and skip the ultrasound for now. The reason I say this is that 1. the US is more expensive, and 2. even though the US provides a lot of 'bang for your buck', it is not a definitive diagnostic tool for cushings. You vet does sound quite knowledgeable, but I must admit to some trepidation that he would diagnose cushings based on a UC:CR and ultrasound alone. Your baby most certainly does present with most, if not all, symptoms of cushings, but we are real sticklers on following protocols here, for your pup's safety. The LDDS is considered the gold standard in diagnosing cushings, along with strong symptoms and ruling out other disorders.

When I was going through the diagnostic phase with my girl, I opted to run an ACTH and LDDS and hold off on the US. I later did a CT scan, but that was because the US in my area is expensive, so I figured for a bit more, I would get a better imaging done. I was looking for an adrenal tumor so I could consider surgery. Incidentally, we have referred back to that CT numerous times!

I have a non-cushings pug that is a terrible marker and we use belly bands. You can find them in many different places, but the best ones that I have found are custom made by snowbound hounds. You line the band with an incontinence pad (not a feminine hygiene pad), and then just change out the pads as they are soiled. Here is the online website: http://snowboundhounds.com/belly-bands.html Whether you treat or not, I highly recommend getting a few of these for your baby. They are life savers at my house! Also, we installed a dog door. A lot of people are against dog doors, but my girl was going outside every few hours, especially at night. That dog door has been such a help for her.

[molly muffin]

Hello and welcome from me too.

I am a big advocate of the ultrasound as Renee said bang for buck, however, if you don't think surgery is an option if it is adrenal cushings and I don't think it really is with age a factor, then an LDDS would be more productive way to go in my mind.

It really is a balancing act with older dogs.

[DoxieMama]

Lori, good idea to bring food for after a long procedure! Luckily our main vet is only a mile from our home, so that's not been a problem there. But if we have to go further (for ER, for example), I will keep that in mind.

Reneé and Sharlene, I appreciate your both taking the time to share your thoughts. I am leaning toward having the LDDS test done. Aside from your mention of it as the gold standard for diagnosis (which is a great point), the lower expense is appealing. But the real crux of the decision is that we would not opt for surgery if that were indicated.

Reneé those belly bands are intriguing! I had not heard of those before. Do you have a recommendation on material (they have flannel lined cotton both with and without elastic, as well as fleece lined cotton)? I think the fleece sounds like the best option but would be interested in your experience with them if you wouldn't mind sharing. Unfortunately, a dog door is not an option for us. We have definitely considered it numerous times over the years, but unless we decide to remove built-in seating in our tiny kitchen, it is just not feasible.

Can anyone speak to the option, when having the LDDS test done, of leaving your dog at the vet for the duration vs bringing them home in between draws? I am not sure which would be less stressful (and therefore, provide a more accurate result). Or does it matter?

[Renee]

I don't get the belly bands with elastic, as I don't think the pads fit nicely in them and I think they are uncomfortable for the dog. I have a mix of the fleece vs cotton lining. Either one is fine. I prefer the fleece, because I think it makes the band a bit stretchier, but it's not a big difference. Belly bands are far and above better than diapers for male dogs. Most important is making sure to line with an incontinence pad. I use the moderate absorbancy generic brand target pads.

I left my girl at the vet for the entire day of the LDDS. But, she does not get overly scared at the vets office. She just sleeps in the kennel. I have trouble believing that a dog would 'fail' an LDDS based on nervousness / fear alone, but I could be wrong.

[Harley PoMMom]

Unfortunately the LDDS test can yield a false positive result if the dog is really stressed.

Does Visuddha act nervous or anxious when you are not around? If so, than bringing him home in between blood draws could be beneficial.

[DoxieMama]

Thanks, Renee. I'll get a measurement of him and order a couple of those belly bands.

You know, now that I think about it, it would probably be better for Visuddha to leave him at the vets for the duration. I would be more concerned about dogs in the waiting room or outside that would cause him stress. As for his behavior when I'm not around, I think he's actually more anxious when I'm in sight but not reachable; the staff has always said he was well behaved during previous stays.

[Renee]

Unfortunately the LDDS test can yield a false positive result if the dog is really stressed.


Thanks Lori for the correction. :) I wasn't sure. How sad that a poor pup could pull a false positive just based on fear of the vet.

[molly muffin]

I always left molly for the duration at the vets. She stresses more if she sees me than she does if I am not there.

[DoxieMama]

OK. I just scheduled his LDDS test for next Wednesday. In the meantime, I need to continue to work toward delaying his breakfast to a more reasonable hour. This morning, I fed him at about 4:30, though he was not too happy with me for an hour... I'm hoping that if I can move mealtimes (especially breakfast) to as late as possible, then next week it won't be quite so hard for him (or me) to skip breakfast that day.

[Renee]

I'm glad you are moving the breakfast time up. It's hard work, but he will adjust! And, if he starts treatment, you'll want to control the feeding time to coordinate your monitoring testing.

Make sure you get copies of the results from your LDDS when it's done.

[molly muffin]

Oh dogs are funny about their meal times, they have an internal alarm clock I'm sure that goes Ding! time for food! :) :) :)

[DoxieMama]

Mine most definitely have an internal alarm clock which is very accurate when it comes to mealtimes. :)

It has been a few days since I started pushing breakfast time later. Last night, I added green beans to dinner, as I've read others have done to help with their dogs increased appetites. We also went to bed much later than usual. Visuddha woke at about 3:30 for his mid-night potty and drink (which is an hour later than usual). I brought him back to bed with me and woke around 6am to find him sleeping peacefully near my feet. I woke him for breakfast! It has been ages since that happened.

So a larger dinner, later bedtime and my insistence that I will not get up until the time I've set for breakfast seems to be working. I'm planning to feed him as late as possible for the next couple days, so hopefully Wednesday morning he won't be too hungry before he goes in for his test.

I will post the results when I get them.

[molly muffin]

Crossing fingers that Visuddha does will at the vets with the later breakfast!

[DoxieMama]

Thanks Sharlene.

This morning, he expected breakfast at 4:30 again, as he has all week. I distracted him for an hour or so, got myself ready to go then he napped in my lap until it was time to leave for the vet. I could tell he was confused when I didn't feed him, instead picking him up and taking him to the truck. He was shivering, obviously nervous about what was going on. He relaxed quickly and we drove to the vet. Once there, I let him walk around a bit though that wasn't very relaxing as it was sprinkling and he's not fond of walking in the rain. He was shivering again while I waited for them to be ready and when I handed him to the vet tech. I also brought along his bed and blanket, which I was (am) hoping helped calm him.

I called about an hour later and he was doing well, did not appear stressed - no more shivering.

Luckily, my workday looks like it's going to keep me very busy, so I can also not be stressed.

Fingers crossed!

[molly muffin]

Molly went to the vets today too. She is always shaky when I first put her in the car and about half way there she calms down. We do the walk around outside first too and then go inside. She usually calms down after I leave.
I know she does so much better once she can't see me when I leave her and she gets all the attention from the staff in the back.

I bet it is like that for Visuddha too.

I'll never forget how happy I was the first time the specialist told me that molly had come running up to her and was like, hi, remember me, pet me, pet me. That's when I knew that molly would be fine with this specialist and group of vets. I think it's important that the dogs and the vets treating them form that bond. Better for both.

[DoxieMama]

That's awesome.

Visuddha was just fine. In fact, they took a picture of him relaxing in his bed. Said he was completely calm and well behaved. Kind of reminds me of when my kids were young and people told me what good and helpful boys I had. I thought, "Helpful? Since when?" Lol

I'll get the results today.

[DoxieMama]

Vet just called with the LDDS test results. He said Visuddha definitely has Cushing's. I asked if he could tell if it is pituitary or adrenal, and he said "That's a good question" and gave me the numbers.

Before: 4.1
Mid-point (4 hours): 5.1
After (8 hours): 5.7

He is going to call a specialist and get back to me.

Looks like adrenal to me. Or cannot be determined based on this test. So now I wonder if we do more testing, and if so, what? Or ... I don't know. I was really hoping for different results from this test.

[Harley PoMMom]

Unfortunately those LDDS test results do not show if the Cushing's is adrenal or the pituitary type. I recommend having an ultrasound done, if both adrenal glands are visualized there is a strong chance that a differential diagnosis can be made, another really good asset to having an ultrasound done is that potential abnormalities may be observed with the other internal organs.

Hugs, Lori

[labblab]

I totally agree with Lori that an ultrasound would be my next step, too. But there is an "if," here. If you would not opt for surgery even if an adrenal tumor is visualized, then trilostane will probably be recommended as the treatment of choice, either way, should you decide to proceed with giving Cushing's medication. So in that event, knowledge as to whether or not it's pituitary or adrenal may be of less interest or value to you.

Marianne

[DoxieMama]

Lori and Marianne, thanks for your responses. I'm still waiting to hear back from the vet and what the internist tells him. But we went into this test initially knowing that if it came back as positive for Cushing's, we do not intend to put him through the surgery if it is an adrenal tumor. Given that, we are inclined to *not* do an ultrasound at this time.

Shana

[DoxieMama]

The internist's comments to my male vet (as relayed to me) were in line with what I've read here, though he said that she said the older med (I think he said OPP?) can be effective on adrenal tumors. He would not be comfortable using OPP without absolute confirmation that it is an adrenal tumor, and I agree. However, we are both willing to start Trilostane to see if it has any effect.

The vet tech just called to give me price quotes on both Vetoryl and compounded Trilostane. The quotes were for a 30 day supply of 22mg Trilostane vs. 30mg Vetoryl. I told her I would much prefer to start him off at 1mg per pound (THANK YOU to members of this site for informing me of the new recommendations), as I've seen that as the starting recommended dose.

She then told me that 2mg is the recommended starting effective dose, and by beginning at half that, we will not know if this is helpful or not. I said that my research shows the new recommended starting dose is 1mg and, especially given the toxicity of this drug, I would be much more comfortable with the lower dose initially. I requested a quote for a 30-day supply of 11mg Trilostane, which could be given ONCE per day to make sure that Visuddha doesn't have any adverse reactions to it. After we know that he tolerates the meds, then we can discuss raising it.

Of course, I know not to raise it until after the second test (first one at 10-14 days, second after a month), as his levels may continue to decrease until then.

Thank you! Thank you! THANK YOU!

I'm hopeful. I still have this pit in my stomach... but I'm hopeful.

Shana

[labblab]

Dear Shana,

Good for you for sticking to your guns about the dosing!!! We have several current publications on our "Trilostane/Vetoryl Information" thread (on the Resources forum) that reference the 1 mg. per pound recommendation. So you may want to print some of those out to take in to give to your vet. ;)

Regarding the use of trilostane vs. mitotane for treatment of adrenal tumors, here's a 2013 article by noted endocrinologist, Dr. David Bruyette. He lays out the rationale that I've seen cited by other clinicians. In some cases, mitotane can have a physiologically destructive effect on the actual tissue of an adrenal tumor. However, for the reasons cited in the article, it seems to me as though the majority of adrenal tumors are now being treated with trilostane if surgery is not an option.

http://veterinarymedicine.dvm360.com/just-ask-expert-adrenal-dependent-canine-cushings-disease-mitotane-or-trilostane

Also, just for your knowledge going forward, you may be able to obtain better pricing for both compounded trilostane and also brandname Vetoryl if you order directly from internet veterinary pharmacies. Of course, you will want to make sure you have selected a reliable, credentialed provider. But we can give you some suggestions in that regard if you want to explore that as an option in the future. However, if your vet has a compounder in whom they have confidence, then that may be the simpler way to start out.

Marianne

[Harley PoMMom]

Kudos to you for standing your ground on the starting dose!!!

Mitotane and O,p'-DDD are other names for Lysodren. There was a time when Lysodren was considered the best treatment for adrenal tumors because it was thought that it’s mode of action could shrink the tumor. However, dogs with adrenal tumors tend to be more resistant to Lysodren. This than requires a much higher loading dose which in turn makes the dog prone to Addison's.

Hugs, Lori

[Help4Bailey]

I'm so glad you went with the lower dose Trilostane. I originally went with my vets recommendation of 30mg for a 24 lb dog and it was way too much and she collapsed. I removed the meds for 1 1/2days and I requested 10mg tablets and Bailey has been on the new dose for 5 days and has been able to go through the night without peeing or getting up until last night which she has a little diarrhea. I have a call into the vet about this issue. Again I am so glad you went with the lower dose. Lynette

[DoxieMama]

Thanks for the link to the article, Marianne. Good info! I've printed it out to add to my growing file. I also printed out the insert for Vetoryl which includes the newer recommendations for starting dose. I wonder if perhaps they misread them, seeing the 2.2mg per kg and reading it as per pound. :confused: I'll be sure to discuss it with them.

As soon as I got off the phone with the vet, I requested a quote from Diamondback Pharmacy, having seen that recommended in a few threads here. They came back with the same price! I hadn't asked my vet who they go through but will do so when I pick up the prescription from them. Maybe that's who they use! :)


Mitotane and O,p'-DDD are other names for Lysodren. There was a time when Lysodren was considered the best treatment for adrenal tumors because it was thought that it’s mode of action could shrink the tumor. However, dogs with adrenal tumors tend to be more resistant to Lysodren. This than requires a much higher loading dose which in turn makes the dog prone to Addison's.

Lori, thank you for the other names of mitotane. My vet mentioned two of them in our conversation so far, but I hadn't connected them as the same one. I remember him saying that this might shrink an adrenal tumor in an earlier conversation, but I don't recall anything about dogs being more resistant to it. What I DO remember is that there is a higher potential for Addison's, whether that be because the dosage is higher due to resistance or just because of how the drug works. It's just scary no matter how I look at it.


I'm so glad you went with the lower dose Trilostane. I originally went with my vets recommendation of 30mg for a 24 lb dog and it was way too much and she collapsed. I removed the meds for 1 1/2days and I requested 10mg tablets and Bailey has been on the new dose for 5 days and has been able to go through the night without peeing or getting up until last night which she has a little diarrhea. I have a call into the vet about this issue. Again I am so glad you went with the lower dose. Lynette

Lynette, I'm sorry to hear about Bailey's response to the higher initial dose! I'm glad she is doing better with the lower dose now. I hope the diarrhea is resolved soon and she continues to improve!

All of this information helps solidify my decision.

Thank you all... SO much.

Shana

[molly muffin]

Did you ask Diamondback about vetroyl pricing or compounded trilostane pricing?

How is Visuddha doing?

[DoxieMama]

Did you ask Diamondback about vetroyl pricing or compounded trilostane pricing?

How is Visuddha doing?

I requested a quote for both 22mg and 11mg trilostane. Their price matched the quote I received from the vet for the 22mg.

He's about the same. Still drinking loads of water, and has had a few accidents. The time change is GREAT for us, though. We sleep in until 4:30, then breakfast is about an hour later. (Most of my friends/co-workers think I'm crazy saying I "sleep in" until 4:30... they think that's early! lol :p)

Thank you for asking. :)

Shana

[molly muffin]

Shana dear, I'm pretty sure that 4:30am IS early. I checked, the birds weren't even peeping.

hmm, so he must get it from a compound pharmacy that has about the same prices.

Well I can relate to the drinking loads and having a few accidents. :) My little green bissel is my friend. :)

[DoxieMama]

LOL! Okay, you got me there.

Yes, very grateful for the carpet cleaner.

I must admit, as we have a fenced yard, I don't take the dogs out for a regular walk. The last few times I've tried, it's been cold and/or wet, and Visuddha doesn't like either. It took great cajoling to continue just around the block the last time we went out. But tonight confirmed that was likely due to the weather. The little guy was FULL of energy this time. We didn't go far, only a mile and a half or so, but I didn't want to push him too much. It was fun to be out there with them again.

[DoxieMama]

I hadn't heard back from the vet regarding the lower dosage, so I called them today to inquire. The vet tech came on the phone and apologized, as she has a note in the chart that she DID call me back and left a message. She either called the wrong number or my phone is being difficult. Either way, they are good with starting at the 1mg per pound, so 11mg per day. She said the compounding pharmacy will be calling me to place the order (I asked the name and she said Diamondback gave them the lowest quote so that's who I'll be getting it from). She wants me to call them before we start giving it to him.

Progress!

[Renee]

Good progress!! You are doing great. Keep it up.

[DoxieMama]

Thanks.

I just came back to edit my post, but since you replied, I'll put this separately.

The vet tech had mentioned a couple times during our conversation that we were starting on "the half dose". But when she said, "We'll try him at the half dose for a week and if there are no problems, then we can go to the full dose by giving him two", to which I really wasn't sure how to respond. I think I said "right", but I didn't want to argue with her, again, about the starting dose recommended at 1mg per pound.

I will not be increasing the dose from 11mg until we've had an ACTH test, at which time I will post the results and ask for opinions here before increasing anyway. Unless we need to DEcrease the dose or stop it entirely, I plan to stick with 11mg for one month and an ACTH test at that time that shows it is necessary to increase.

(I'm pretty sure I said all this earlier, too, but saying it again strengthens my resolve and reminds me of my plan.)

What I really came back to post though is to ask when you all would recommend starting treatment? The vet tech said to call them before I start, which is fine. I will probably get the pills some time next week. I was thinking to start dosing on a Saturday morning so I can be with him all that day and the next. OR on Friday morning, when my husband could stay with him for a couple hours. I guess the question really is, if he's going to have a bad reaction, when might that occur? On the first day, within a few hours, or after a couple days....?

[Harley PoMMom]

Kudos,again, for standing your ground with the starting dose! You are such a fabulous advocate for your boy!! A adverse reaction is generally seen with in an hour or two after giving the Trilostane. With Visuddha starting out at the recommended dose for his weight, 11 mg, I believe he will do just fine. We always iterate; If in any doubt, withhold the Trilostane, Trilostane has a short half-life, it leaves the dog's system rather quickly, so if any ill effects are noted, stop the Trilostane and see if this perks the dog back up.

Many of our members use Diamondback and are happy with their service.

Hugs, Lori

[DoxieMama]

Lori,

Thanks for the reply. If it only takes an hour or two for an adverse reaction, then I can start during the week! Whenever I get the meds, chat with the vet and start the next day. Breakfast is now around 5:30, I leave for work around 6:45 and I can ask my husband to stay up for an hour or so afterward if we plan ahead. Then if anything is amiss, there is someone at the vet's office as early as 7am so I could call them and avoid an ER visit. That might just work out better than starting on the weekend!

Shana

[Harley PoMMom]

I see no problem starting him as soon as you get the Trilostane and I also think that it's a great idea that the hubby is willing to stick around an hour or two for Visuddha's first Trilostane dose.

Just a reminder ;) Trilostane has to be given with a meal to be properly absorbed and those ACTH stimulation monitoring tests have to be done 4-6 hours post pill. :)

Hugs, Lori

[DoxieMama]

Trilostane with the meal, with ACTH stim tests 4-6 hours post pill. Got it. That's one of the reasons we've pushed breakfast a little later (aside from me preferring to SLEEP at night - go figure!).

This weekend was good. Wouldn't you know it, I forgot my cell phone at home on Friday. Luckily I got home before the pharmacy closed and I was able to complete the order for his Trilostane that evening. So we should be getting those some time this week.

There's nothing quite like sitting at your computer desk and finding your lap covered in pee..... :p

I love my boy. :o

[Harley PoMMom]

Awww, you're such a wonderful mom! Remember we are here for ya, any questions just ask them, you, hubby, and Visuddha will get through this and we are here to help with that, ok? ;)

[molly muffin]

Yep, we are right here with you, every step of the way!!

What a great guy your hubby is to adjust his schedule like that. Kudos to him and you!

[DoxieMama]

Visuddha received his package of meds in the mail yesterday. I found it a little amusing it was addressed to him... his first mail! The vet wanted me to call them before we started dosing, so I'll do that today.

My husband and I are going out of town for a few days soon, and our eldest will be taking care of the dogs. He is not known for getting up early, nor being the most attentive pet sitter. :p Therefore, we'll wait to start the medication until after our return.

[molly muffin]

I would probably start after you got home too. I just think you'll feel better being there when you start.

Isn't that funny, molly's was addressed to her also. Her first mail!

[DoxieMama]

We are home and will start Trilostane in the morning with breakfast.

Has anyone seen enlarged lymph nodes with Cushings? Visuddha's seem quite large now. I asked the vet about them at his yearly checkup in October and he wasn't concerned then. But they seem bigger now... Just wondering if this is another possible symptom of Cushings or might be something else.

Shana

[Harley PoMMom]

The over production of cortisol can suppress the immune system which leaves a dog susceptible to infections. If Visuddhaha's has an infection somewhere this could possibly cause the lymph nodes to be enlarged, although this is not something we typically see in dogs with Cushing's.

Hugs, Lori

[molly muffin]

Hmm, molly had an enlarged lymph node that later went away.
Was the white blood count up on the last cbc?

[DoxieMama]

Hopefully there's a simple, and fixable, explanation for his enlarged lymph nodes.

WBC on 2/24 was 13.1 K/uL (reference range 6.0-17.0).

He does have recurring issues with his mouth. They gave me antibiotics at his regular checkup and said if it helps, then we can repeat those monthly. We did two rounds of that about 6 weeks apart, but it has been a few months since the last. The visible symptoms (mostly drooling) subsided after that, though that has started up a bit again lately. I think I'll call them tomorrow and see about getting another refill.

[DoxieMama]

I thought I'd pop in and keep this updated with how things are going. We started Trilostane on Monday (11mg dose, once per day after breakfast) which I am hiding in a piece of cheese. No adverse reactions noted. Visuddha is still eating and drinking like a horse. Monday night, he slept 6 hours before waking me. Last night he woke me after 5 hours, then 3 more... total of 8 hours both nights. This is typical lately. So far, so good!

Shana

[labblab]

Shana, thanks so much for the update and we'll keep our fingers crossed that things keep on improving for you two!

Marianne

[molly muffin]

Great to hear from you and a big whooo hooooo for getting some more sleep lately. :)

[DoxieMama]

Haven't been getting more sleep yet, Sharlene, but I am looking forward to it!

I stopped by the vet's office after work to pick up the antibiotic for Visuddha's mouth, and made the appointment for his first ACTH test to be 14 days after starting - on the 18th. The receptionist told me that it needed to be fasted, but I know from resources here (article 1 (http://www.endocrinevet.info/2011/03/whats-best-protocol-for-acth.html), article 2 (http://www.endocrinevet.info/2013/11/protocol-for-acth-stimulation-testing.html)) that is simply not true, and I told her as much. Of course, having stopped by on my way home from work, I didn't have any of the articles with me to hand over. Anyway, she said that we didn't want his blood to be lipemic and that's why it must be fasted (I had to ask her to explain what lipemic meant, so I'm sure that didn't help), then looked through another patient's chart to try to find evidence that their ACTH test was done fasted (which of course doesn't prove anything to me) but found no notes to that effect.

I told her the test protocol per the manufacturer says it needs to be performed 4-6 hours after dosing, and since trilostane is fat soluble, it it contradictory to suggest that the test should be performed fasted. After suggesting she contact Dechra to see their recommendations herself, she said she is following the vet's instructions ... at which I said then have HIM contact the manufacturer himself. Her response was that he "follows the protocol per WSU and the manufacturer information that they have". Finally, she asked me if I could stay a few minutes longer so I could talk to the vet directly. Absolutely, I could.

She went to the back, then returned and agreed that the test needs to be performed after dosing but "to give him just the teensiest tiniest amount of food you can". I told her I give it to him in cheese and she said that's perfect. We made the appointment for 8:30am (breakfast is normally at 4:30am) and she said "that way he can have his full breakfast at 9:30". Right.

I'm inclined to give Visuddha his normal breakfast, then the trilostane, at 4:30am that morning. Then I can go in and have the test done at 8:30 as planned. I am also willing to ... withhold the information regarding his breakfast that day, because I worry they wouldn't be willing to perform the test if I didn't fast him as they ask.

The last time I spoke with the vet in person, I found that he isn't too keen on people getting information on the intranet. The bottom line for that, I think, is that too many will research symptoms online, attempt to treat the dog themselves or not treat them because they believe it to be something that will go away on its own, and then end up bringing in a patient that is far more advanced in disease than if they had brought them in initially. Which, to be fair, is a valid concern. And I told him that I do my research online AND discuss with him and what I've found has always supported what he says. Until now. :(

I would like to share the articles with him. What does everyone think would be the best approach? Print them off and take them over as soon as I can or just bring them with me when we go in for the appointment? I don't know if they would refuse to test him if I didn't fast him, but I believe Dr. Peterson's article to be the correct course of action. Also, I don't want ME to be stressed that day since I know that Visuddha could pick up on that. Not a good plan.

Sigh. I was really hoping I wouldn't encounter this issue.

Any experiences you can share to bolster my confidence on this one would be appreciated.

Shana

[molly muffin]

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

Print this off and give him. On the monitoring chart it clearly says with meal. Also this is the information to contact Dechra the manufacturer himself if he wants. http://www.dechra-us.com/contact/technical-support

No need to mention Internet. Online. Forum. If those are negative buzz words for your vet. Just. Hello manufacturer says....

Keep it simple but do this before test day. No need to go in there stressed out on test day. A stop on the way home from work should do it.

a vet can have an opinion but he cannot should not argue with testing protocols from the manufacturer of the drug.

[labblab]

I'm inclined to give Visuddha his normal breakfast, then the trilostane, at 4:30am that morning. Then I can go in and have the test done at 8:30 as planned. I am also willing to ... withhold the information regarding his breakfast that day, because I worry they wouldn't be willing to perform the test if I didn't fast him as they ask.

Since you still have plenty of time before the 18th rolls around, my own thought is that it would be better to discuss this issue with your vet up-front, beforehand, so that everybody is on the same page re: the testing and the test interpretation. I'm really glad Sharlene gave you that actual publication by Dechra, because as she says, the monitoring flowchart explicitly states that it is important to give the Vetoryl along with breakfast on the day of testing. Also, as I discovered when I called Dechra personally a few weeks ago, their technical reps will verbally confirm how important it is for a full meal to be given on the day of the test.

So I do think it is important to get this issue cleared with your vet beforehand. Another big reason to discuss this in advance is because it is true that some other blood tests need to be run after a dog has fasted in order to be accurate. And as your vet has noted, if Visuddha's blood sample has a high level of fat ("lipemic") in it, they will know that you've fed him a meal whether or not you tell them, and those sample results may be skewed.

As big a pain as it might be, the better option may be to schedule the other blood tests for a different day if your vet feels that fasting for longer than the 4-6 hours post-breakfast/Vetoryl is important for the accuracy of that other testing.

But the bottom line is that I do think you need to talk this over with the vet beforehand. If you print off Dechra's own monitoring flowchart, I don't see how he can refute the recommendation. But as Sharlene has said, he can call Dechra directly in order to have this info confirmed.

Marianne

[DoxieMama]

Well this is weird. I was sure I'd posted a reply to Sharlene this morning before I left for work, but there's nothing here. Oh well. Technical glitch (which is probably just personal glitch pre-coffee, lol)

Marianne, the ACTH is the only test we discussed doing on the 18th. So the staff's argument regarding the blood being lipemic was not about any other test being skewed. All discussion was regarding the ACTH itself. And I never actually talked to the vet - just his front office staff. (I'm not even sure if she has any veterinary training or is just knowledgeable after working there for years.) However, if any other tests are needed, I'll be sure to schedule those on a separate day. That is a good point to note, for future reference.

I have printed off the chart and plan to drop by the vet's office with it. Hopefully I can actually talk to him, rather than just his front office staff. If he's too busy, I'll leave it along with a request that he call me when he has time to discuss.

This may simply be a case of either "the staff doesn't know as well as the vet" or "the vet doesn't know but will respond positively to being provided the info". Before we started the dose, another staff member had called me with the vet's recommendation of 2mg per pound. I insisted on starting with the lower dose recommended by Dechra and did not feel as if she really heard what I was saying. It actually felt as if she was "talking down" to me in the sense that they're the professionals and I should follow their recommendations. I said the starting recommended dose by the mfgr is 1mg per pound and that's what I wanted to do. She said the starting effective dose is 2mg per pound, and starting lower wouldn't do anything. Agree to disagree, but I'm not going to give him more than the 1mg dose. When I talked to the vet himself later, he agreed that the 1mg is the lowest end of the range recommended and we would start there. (I'm not entirely sure if he didn't still think we should start higher, but we agreed to start at the 1mg regardless.)

I was thinking about this more this morning, and in retrospect, I think the staff simply follows the vet's recommendations and expects everyone else to do the same. He's there boss, so that makes sense. Many times, I have done so, too. But I also do my own research, because while internet sources may not be the most reliable, if they back up his statements then I feel a lot more comfortable with the course of action chosen. Not to mention, I'm better able to process the detailed scientific information provided (either by the vet or the online sources) when given time to do so. I always read the medication inserts (or at least the warnings and side effects), and with Trilostane, they're scary! I'm willing to spend a little more time and money treating Visuddha conservatively, testing him frequently, and doing my own research, to hopefully get the best possible outcome for my little guy.

Anyway. I feel like I'm blabbering.

I am Visuddha's advocate and I'm going to do my best to make sure that the vet and I are on the same page. Right now, his staff are not my favorite folks. :mad:

[Joan2517]

You stick to your guns...I wish I had known better. If I had, I never would have let my vet put my 6lb 4oz baby on 30mgs. They work for you and you have every right to start out at the recommended dose, or even lower if that's what you want to do and if the recommendation is with food, then do it.

[lulusmom]

A lipemic (high fatty) blood specimen will not effect the accuracy of the acth stimulation test so unless your vet is planning on collecting the same specimen for other labs, in which case a separate fasted sample on another day should be taken, I would give Visuddha the same amount of food she gets everyday with her Vetoryl. You do not want to deviate from the normal dosing routine in any way so as to insure that the results of all acth stimulation tests are reflective of levels achieved under the same optimum conditions as dictated by established protocol. T his also applies to the timing of every stim test that is done. To give a tiny amount of food, as instructed by your vet, is a definite deviation which can effect absorption rate which can be expected to skew the results of an acth stim test upward.

I completely agree with Marianne about being up front with the vet. You should be working as a team and being on the same page is always going to be in Visuddha's best interest. If your vet refuses to acknowledge the existence of proper protocol, even when credible references are presented to him, you have this group to fall back on to provide you with what you need to be an excellent advocate for Visuddha....but I am always thinking about those dogs under a vet's care whose owner doesn't have the support of a group like us. If you can get through to your vet and help him learn, I think you can be a hero to not only Visuddha but to your vet's other patients who may be at risk because he is not following proper protocol. Believe me, you would not be the first one to provide a general practitioner vet with free continuing education on a very common endocrine disorder and the drugs that are prescribed to treat it. :D

Glynda

P.S. It took forever to type this in between interruptions at work and I see that you posted while I was typing so I apologize if any of my comments are irrelevant.

[DoxieMama]

Joan, we've started the treatment at the recommendation of Dechra - 1mg per pound, or 11mg for my 11 pound boy. The issue now is that they are telling me to fast him before his first ACTH test.

Glynda, all your comments are relevant, even if work interrupts them. :) I always planned to share the information with the vet, just wasn't sure whether to approach him now, or wait until the day of the test. I definitely want to make sure that he (and his staff) are as fully informed as I am! ;)

Thanks to everyone for their comments and support. I'll let you all know what he says when I talk to him...

Shana

[Joan2517]

Yes, I saw that after I posted...

[DoxieMama]

No worries, Joan! :)

Quick post to note that, while I do believe what you're all telling me (and the chart that Sharlene shared), I thought "Why not call Dechra myself?" So I did. They told me the same thing: their recommendation is to give the Vetoryl with a MEAL the morning of the ACTH Stim test. However, they also said that if there would be other blood tests that day, that may be a reason the vet would recommend a smaller amount of food (as Marianne suggested). She seemed somewhat hesitant to contradict my vet's instructions, though I assured her I intend to provide this information to him.

Now I can not only provide him with the sheet but also what they told me personally. I've written their phone number on the printout so he'll have that handy, in larger type than provided within the document itself.

I am relentless sometimes. lol

[lulusmom]

Relentless is good!!!!

[DoxieMama]

You guys are not going to believe this, but when I went into the office, they still say the recommendation is to fast him for the test (giving the Trilostane with as small an amount of food as possible). I didn't talk to the vet, but his tech (the same one that I argued with over the dosage to begin with). I gave her the information from Dechra, including my conversation with them. She said, "Let me check the book on our lab protocols because that's more accurate than the manufacturer" at which I responded, "What?!?!". :eek:

She also called the lab, and talked to the vet. Let me try to summarize for you. I apologize if the terminology or phrasing is inaccurate; I tried to make notes as best I could.

The lab's concern is that if he eats a full meal, the sample will be too lipemic for the machine. If that's the case, the fat refractiles off the reading and they would be unable to get a result at all. They recommend a low lipemic sample/fasted is best. There was also mention of the possibility of giving him just a small amount of very high fatty food (like a piece of cheese) with his meds. The vet tech said that they use an antibiotic that is fat soluble, and a piece of cheese is perfect to provide sufficient fat to process the medication, but is small enough that it is digested quickly so the sample would not be lipemic. This is what the she said she would do if it were her dog.

The lab/vet tech asked if I give him the meds at the same time every day, which I do, and said that since that's true then there wouldn't be a significant change in the levels the next day even if fasted. After she was off the phone, I mentioned to her that Trilostane stays in the system for 12-18 hours. She agreed that the effective dose remains in the system, but there are still "trace amounts" (can't remember her exact phrasing) that remain which is why they are off the meds for a certain amount of time before switching to another medication if necessary. [Alarms go off for me on this now, but didn't at the time. It's not about the dose in the system, it's the effect thereof, right? So giving him the meds without any food just makes no sense.]

That said, the vet does not want me to worry. If this concerns me so much, then I can give Visuddha his normal meal and meds the morning of the test. Of course, the risk is that the lab will be unable to get a reading and the test would need to be repeated - fasted (or with the small piece of cheese) - and since I would be going against their recommended protocol, it would be on my dime.

ALSO, just to make things more interesting, they DO plan to run more tests for "kidney and liver values" which of course have the same issue. Can be done fasted or not, recommended fasted.

So now I am completely confused as to why Dechra would recommend giving with food, other vets (yours!!) do the same, but mine - and their lab - say that it could cause a problem and make the sample unreadable. Why does this one lab have an issue and no one else does?? What the what??

I'll talk to my husband this weekend about this. We've got a decision to make.

What do you guys think?

[molly muffin]

I'd be interest d to know what lab they use. IDEXX is international and one of the best labs out there. They use the same protocols that Dechra recommends. Just for the record my IMS does ACTH and kidney liver all the same too and after meds given with a meal.

Yes there is a wash out period between switching Cushing drugs. And I believe I've read or heard there is a cumulative effect of trilostane over time. However trilostane not being fully absorbed would effect the test.
I'd say not feed an overly fatty meal. Never feed a Cushing dog high fat meals as they Re prone to pancreatis. Cheese with pills is fine. But in general I mean. Moderate higher good quality protein lower fat works best.

Perhaps the lab they use has problems with lipemic in their machine. Which is not a good for a lab but maybe is less expensive than other labs or something.

My IMS at one point told me to make sure that any labs done by my vet is sent to IDEXX labs as that is what they use and want the results to be consistent. She just didn't want different labs giving different results as we couldn't tell necessarily what was going on if we did that.

So. There is nothing wrong with using a different lab. My concern is that the lab is not having the test done correctly not because they legitimately think their way gives the best accurate results but because their equipment isn't up to the standards to Do the test correctly. So they make excuses up to account for it.

Does that make sense?

[DoxieMama]

Thanks, Sharlene. That does make sense. If the lab has issues with their equipment, that's a big concern and one I hadn't even considered.

[labblab]

Good for you for going to so much effort to try to straighten things out. You are such a good mom!!!!!

One totally aggravating fact is that you always seem stuck talking to this vet tech instead of directly to the vet himself. The vet tech has already established the fact that she is not knowledgeable about trilostane treatment, so in honesty, anything that she says seems suspect to me. Is she even truly consulting with the vet, or just telling you that she is??? Regardless, anytime info is relayed through a third person there is a far greater chance of confusion or error or misunderstanding. Can you possibly insist on talking directly to the vet from now on, even if it means waiting a while for a phone call to be returned or making a specific appointment? If not -- if everything has to always go solely through the tech -- you might want to even investigate a vet change. I realize this arrangement is easier for the vet's practice, but it is proving to be a very unsatisfactory arrangement for you! How nice of them that they are telling you beforehand that you may be penalized for asking that the ACTH stimulation test be performed properly...! :mad:

This is my own speculation about things. First of all, the ACTH is used as a diagnostic test as well as a monitoring test. When used as a Cushing's diagnostic, it is fine for the dog to be fasted, and that is probably even preferable especially if other blood panels are going to be performed at the same time. Values for things like blood glucose and cholesterol will indeed be skewed if the dog has not been fasted. Plus, a high lipemic level can affect other types of readings, too, and even render certain blood samples unreadable for those other panels. So as a matter of course, the lab's preference may certainly be for a fasted sample whenever that is doable. However, did the tech specifically explain to the lab that this was to be a monitoring ACTH test instead of a diagnostic test? Did the lab rep understand what that meant even if she said it?? Who knows.

In terms of the kidney and liver testing, if your vet prefers a fasted sample, maybe it would be best to hold off and do that blood draw at another time. But in terms of the accuracy of the ACTH results, I would abide by Dechra's recommendation on this one. As you already know, we have lots of members here and lots of monitoring ACTH tests performed after dogs have been fed their breakfast. And I honestly cannot remember a single member reporting here that their ACTH had to be repeated because there was too much fat in the blood sample. So if you have to go even one step further, I agree with Sharlene that I'd find out what lab your vet uses, and then perhaps try calling them directly, too, in order to see whether there is truly a problem -- and leave that awful vet tech out of the loop!

And yes, I agree with you that even though trilostane may have residual effect on adrenal function, it's not because there is still a "trace" of medication hanging around in the blood as the vet tech erroneously stated. Here's Dechra's explicit comment in that regard:


CLINICAL PHARMACOLOGY:
Trilostane absorption is enhanced by administration with food. In healthy dogs, maximal plasma levels of trilostane occur within 1.5 hours, returning to baseline levels within twelve hours, although large inter-dog variation occurs. There is no accumulation of trilostane or its metabolites over time.


Marianne

[DoxieMama]

However, did the tech specifically explain to the lab that this was to be a monitoring ACTH test instead of a diagnostic test? Did the lab rep understand what that meant even if she said it?? Who knows.

Marianne, this is a great point and I do not know what was said to the lab. The tech went to the back to consult their book and called them from there. The receptionist shuffled between us to ask questions of me while the tech was on the phone. I know I mentioned to the tech afterward that a fasted test makes sense BEFORE treatment ensued, but not after.

I do want to clarify that the tech said "I can ask him if you can do the test without fasting, maybe if you're willing to pay for a re-test" or something to that effect. This was said before consulting with the vet, but after the call to the lab. She called me later that evening to tell me my vet doesn't want me to worry and if I want to feed him the morning of the test, then to do so.

As for what lab they use, I have copies of the blood tests and UCC done previously. I assume they'd be using the same lab for the ACTH but don't know for sure. I did not ask.

The struggle for me is that the lab told the tech that if the sample is too lipemic, they wouldn't be able to get a reading. But then, as you said, so many others have done this test after feeding a full meal without issue. Also, I sent a message to Dr. Peterson who confirmed previous statements; bottom line: do not do the test fasted, or it will be invalid.

Hmmm. You know, I think everyone may be correct in what they're saying. If the sample is too lipemic, the lab wouldn't be able to get a reading. But feeding doesn't cause the sample to be too lipemic (based on the results of all those who have done the test non-fasted).

Whoa - I've got to run or I'll be late for work. I'll ponder this some more.

Thanks.

[DoxieMama]

Good morning! I am a little concerned this morning because Visuddha seems to be a bit lethargic. Today is the first day that I've been home with him since starting Trilostane on Monday. I think this is normal... but I'm hoping someone can confirm that.

This is day 6 of 11mg Trilostane (he weighs approx. 11#), which I give to him in a little cheese after he eats his breakfast at 4:30am. So far this week, he has been sleeping in my lap after breakfast for an hour or so while I work on my computer. Then he follows me upstairs while I get ready for work, back downstairs to go outside, gets a biscuit and I leave for the day. I am only home for two hours after he gets his meds, but I haven't noticed anything out of the ordinary for him. My husband and/or son are home all afternoon and while they're not nearly as watchful as I am, they have not noticed any odd behavior, either. Evenings have been completely normal - he's alert and active when I get home, has dinner then follows me around/sleeps near me until bedtime.

Today, as is normal for me, I was on the computer for a few hours. Visuddha slept in my lap the whole time. Previous to starting Trilostane, he did the same. However, when I get up for coffee, laundry, etc, he would wake up and while a little sleepy, was still alert. This morning, he seems a lot more sleepy than usual. Honestly, he looks drugged. He still followed me up and down the stairs just fine, but as I sit here now, he is half asleep again. My husband is working/playing with our other dog in the back yard so I'm going to take Visuddha out there and see how he does.

Does this sound like a normal response to starting Trilostane?

Shana

[Harley PoMMom]

Lethargy is listed as an adverse effect from Trilostane. How is he eating and is there anything that looks unusual with his stool (loose or an odd color)? If everything else is normal than Visuddha may be going through a bit of cortisol withdrawal syndrome, this happens when that elevated cortisol is lowered rapidly.

I'd keep a watchful eye on him, which I know you already are, and if he doesn't seem to perk up you can always just withhold the Trilostane to see if the lethargy goes away.

Keep us posted.

Hugs, Lori

[DoxieMama]

Thanks, Lori. I am absolutely watching him like a hawk today. I think he's self conscious when he goes outside - never seemed to like me watching him go potty. lol He's still eating with gusto and finishes his entire meal, though wasn't begging for food before mealtime which isn't really like him. He has always been very aware of when mealtime should be, and lets me know if I'm late with dinner. ;) Today, he seemed quite content to lay in my lap. He was awake and I could tell he was waiting for any sign that I was going to get up to feed him, but he wasn't bugging me like normal.

His drinking seems to be lessening, and he doesn't pee as often or for as long each time. I have not seen him poo yet though. We have a fenced yard and though we don't have a real "doggy door" we do have a screen that our first dog Jupiter ran through years ago. After fixing it twice, we decided to just leave it. Now Jackson and Visuddha can come and go as they please when the weather is nice, which it has been. Until today, I haven't been going out with him. Bad mommy. :( I went out and picked up what I could find this morning, though.. maybe a little soft but still well formed and the color is normal. I'll keep an eye on this.

He's always been a sleepy bug so lethargy is a difficult symptom to identify for him. But he definitely appeared drugged this morning, as if he was stoned. I noticed this about 3 hours after dosing (so 7:30) and that lasted oh, a couple of hours? He's been sleepy all day but more normal sleepy, if that makes sense. We took a nap together this afternoon, and now he's half asleep in my lap again.

Assuming this is cortisol withdrawal syndrome, which it seems to be to me, should I give him his normal Trilostane tomorrow? And maybe see if we can do the ACTH test earlier than the 18th, like on Wednesday (which would be day 10 of treatment)?

OH! I almost forgot, he seems to be losing a little weight. He's been fluctuating right around 11 pounds and was exactly that on March 30th. We went out of town and when we started treatment on Monday, he weighed 10.8. Today he's 10.6 which is really low for him. I always weigh him at about the same time every day, an hour or so after eating (when I weigh myself - :)) He got a little extra dinner tonight.

ALSO. He is now taking ZydaClin due to his mouth issues. (He's only got 6 or 7 teeth and bad gums. When his drooling is excessive, we give him a round of the abx. This was started on Wednesday evening.)

Shana

[molly muffin]

yes how is he doing this evening?

They also can have cortisol drop lethargy, in which their cortisol does a drop from the medication and they just feel awful for a bit. If it is that, then it usually passes. If it doesn't pass and you without the vetroyl and he perks back up in the morning, then perhaps the dose needs to be adjusted and the follow up test will tell you where his cortisol is at.

[molly muffin]

I think we were typing at the same time. If he is eating fine and drinking fine and no diarrhea or vomiting and just the sleepyness then might just be the cortisol drop. I usually try to do that very first test at around day 12 - 14 just for my own peace of mind.

You are doing once a day dosing right? He might do better on a split dose. Half in the morning and half in the evening. Since you can't split them yourself, you would start that after this set of meds runs out.

[DoxieMama]

Hi Sharlene, yep we were typing at the same time. I also edited my post after yours to mention his weight loss and to record the abx he's on, in case that makes a difference (and for the record).

Definitely no vomiting and is eating and drinking fine. I'll let you all know if there is diarrhea but I don't think so, from what I've seen so far.

I've got the test scheduled for day 14 but am considering moving that up to middle of the week (day 10 on Wednesday) so I can get the results sooner.

Once a day dosing, right. 11mg in the AM and that's it.

[Harley PoMMom]

Since he is eating/drinking normally and no diarrhea, I see no issue in giving his Trilostane dose, however, you know your boy best and if you think the Trilostane should be withheld, by all means, trust your instinct.

[DoxieMama]

His stool tonight is rather soft and a little lighter in color than normal. He does have some weakness in his back legs: after standing in the yard for a moment, it looked like he wanted to start walking but his left leg kind of gave out and he sat. He immediately stood up and walked around, went potty, walked up the 2 steps to come inside. My husband and I agree that he was showing some weakness before starting Trilostane though, too, so don't think that's due to the meds.

I think I will continue to give him the meds for now, see how he does tomorrow. I will call the vet Monday to move up the appointment for his stim test either way.

This is really stressful!! I suspected as much, but I guess I didn't really think it would be so difficult. I can't help but wonder if I'm doing the right thing, or making things worse, by giving meds that are supposed to make things better. Sure hope he perks up soon.

[molly muffin]

It is very difficult, especially at the beginning.

If he continues to be drugged sleepy in the mornings you could do 6 mg am and 5 mg pm if this dose is working but really you don't want to change doses upwards for 30 days. As cortisol will continue to drop during that time.

[DoxieMama]

Last night was very restless for both of us. We went to bed a little late, yet Visuddha woke every hour except between midnight and 2am. He went outside every time except at 3am... no idea why he whined to get up that time because he didn't drink water OR go out. His drinking is definitely lessening. I filled his water bowl last night and it still had water in it after breakfast, whereas before he would have drank two full bowls from bedtime until breakfast.

This morning he is more normal, more alert. He ate breakfast and I gave him his Trilostane dose after. He's still sleepy but just his typical sleepiness - easy to wake and doesn't appear drugged like before. Maybe my extra long hours at the desk yesterday gave him enough time to fall into a deeper sleep? Who knows. He hasn't pooed yet this morning but I'll keep watch for that. He also seems more steady on his feet so far today.

[molly muffin]

How is Visuddha doing today?

[DoxieMama]

Thanks for asking, Sharlene. He is doing well.

Sunday he behaved as he has been, following me around while I did household chores. I wish I would have been able to get a picture of him napping in the sunshine from the window, but I was shoulder deep in the fish tank. Hard to take a picture from that position! ;) And I can't leave the room without him noticing and following me.

Yesterday morning and today I've continued to give him the 11mg dose in a bit of cheese when he is finishing his breakfast. He naps in my lap for a bit while I work, which is what he's doing now. All appeared well before I left for work, but I still asked my husband to keep an eye on him when he got up (he works nights). He sent me a text around noon saying he looked fine to him. Fine to me last night, too.

We went to bed around 9, and I woke to him whining a little after 4am. I swear this is like having an infant. I cheered for him sleeping through the night! lol

So far, so good! :) :) :)

Shana

[DoxieMama]

I was away most of the day yesterday but Visuddha appeared well when I was home. He ate his dinner last night and looked good, then I went out for a few hours. When I came home, he seemed a little wobbly/weak. We went to bed late.

He slept about 6 hours. When we get up, I typically turn on the light in our closet rather than the room light or a lamp. This morning, he walked toward the bedroom door, then turned around and walked into the closet and just stood there for a minute. I think he was looking for me and confused, and he didn't respond when I called him until I got close enough to either hear me or feel my footsteps. I'm not sure I've mentioned it before but we think he may be losing his hearing or already lost it. He turned around and came out but was really walking slowly, so I carried him down the stairs rather than forcing him to navigate them. I set him down so I could open the sliding door to the backyard and he stopped for a drink. His hind legs still look wobbly.

He ate breakfast this morning and went outside. Later, he seemed out of it again. Not as much as Saturday but it's a bit worrisome.

The vet's office called yesterday to check on him. I had planned to call them anyway due to his lethargy Saturday, as well as the softer stools. I told the receptionist of my concerns and said I wanted to know the vet's opinion about maybe testing him sooner than Monday. She said "I don't know, I'd have to ask the doctor". :rolleyes: He was in surgery at the time so she said I probably wouldn't hear anything until later in the afternoon.

Because of the lethargy, weakness and (not quite) diarrhea, I called them bright and early this morning to see if I could get him in today for the ACTH test. They weren't answering the phone yet and now it's creeping up on 5 hours since I gave him his meds. I guess I'll schedule the test for tomorrow if they have an available appointment.

Edited to add: the receptionist called me back right after I posted this. Appointment is tomorrow morning at 8am.

Shana

[Harley PoMMom]

I wonder if some of Visuddha's confusion could be from canine cognitive dysfunction (CCD). If so, we have had several members use Novifit with some success.

Let us know those ACTH stim results when you get them. ;)

Hugs, Lori

[molly muffin]

Oh dear, yes I'd want a test too. Did the vet call you back?

I don't let molly do the stairs any more. She took a tumble on like the last 2 steps one day. Even though she didn't hurt herself she could have and I said that is it little miss, no more.
Oh she tried to escape more than a few times but you can never underestimate the diva in my molly. Now she will bark for someone to come get her if we don't hear her huffing and puffing at us. (course she is behind a baby gate because she is not to be trusted) I think it is a good call carrying him down the stairs especially.

I do hope they can do the test tomorrow.

[DoxieMama]

Hmm. CCD is a possibility, I guess. He has a couple symptoms, though not many that I've noticed.

The vet asked if he could hear at his last regular appointment (in October), and I hadn't noticed anything before that. But since then? Definitely. I remember now about a month ago, we were on a walk. Visuddha is not the friendliest or quietest dog around if he hears or sees another dog. He still barks like crazy when he sees one. But there was one in particular that was behind a fence so he couldn't see him, who was barking like crazy. Jackson was excited, he wants to play with everyone he sees... but Visuddha walked by as if nothing was going on. So there's definitely some hearing loss. How much is unknown.

Sharlene, no the vet has not called me back. :/ I'm really not very happy with how they've handled things lately. I called this morning shortly after 7am, when I know someone is there (and they screen the calls - they've picked up before). The receptionist knows I give him the meds at 4:30 in the morning, and the test needs to be started ~4 hours later. But she didn't call me back until 8:40. Perhaps they really did have so many other messages that she needed to respond to that it took so long, but ... ugh. I was really irritated this morning, because I stayed home from work just in case and now I have to be late again tomorrow.

Oh well. I made the appointment for the test tomorrow morning. I want it now, regardless of what the vet thinks. I will be giving him his meal, and then the pill in a small piece of cheese, just like every other day. Please cross your fingers that everyone does this test like they're supposed to and they don't have any issues processing it. The receptionist said they typically get the results back the next day, so that's what I'm counting on happening. I don't want to wait through the weekend.

Shana

[DoxieMama]

We are home waiting the hour to return to complete the ACTH test. Visuddha is resting in his favorite place - my lap. When we got inside the vet's office this morning, he started shaking. I did my best to calm him and he had almost stop shaking when they took him to the back. Poor little guy. He wasn't shaking when they brought him back to me a few minutes later. He gave me a quick lick to the nose and was ready to head out the door! :)

The vet tech popped out for a quick second just before we left to confirm if he was fasted or not. Nope, not fasted. She said "OK!" and off we went.

Test results should be available tomorrow afternoon. I'll be sure to get the numbers and post them.

Thanks for holding my hand as we go through this for the first time.
Shana

[DoxieMama]

When we went back, Visuddha was a little shaky but not as much as the first time.

The vet tech came to get him and said they were having some difficulty doing something with the first sample (spinning it?) because it was too lipemic. So they're going to send it to the lab and see if they can do it. :confused:

Please cross your fingers and say a prayer that they will get the results without issue...

[labblab]

I apologize for being cynical, but I find it fascinating that the tech specifically decided to ask you beforehand whether Visuddha had been fasted, and now (of course) is having trouble spinning the blood. I wonder if she would have had as much trouble if you had told her he had been fasted.

Again, we have never encountered this much of a problem with other ACTH testing here, and I can't figure out what the issue is for your vet unless you are feeding Visuddha really fatty food -- which I assume you are not.

I have to wonder whether the tech is trying to punish you for "disobeying" her. Can you tell I don't much care for her???

[labblab]

I am so irked about this myself that I've taken a few minutes to Google lab protocols, and the only caution that I can find about lipemia is that excessively fatty blood samples can render the analysis of certain test values inaccurate, such as certain blood chemistries. We already know that, but we also have been reassured by the experts that cortisol assays don't fall in the category of tests that are skewed by lipemia.

Nowhere do I find anything that says that lipemic blood cannot be submitted after having been centrifuged -- just that the sample may look abnormally "milky."

I am no expert on either hematology or lab procedures, as I've said before. So I may be totally missing the boat here and making huge mistakes in my assumptions. But I truly don't understand what your vet's problem is with submitting the blood samples to the lab. Over the years, my own dogs have had blood samples taken both fasted and nonfasted. None of the samples had to be discarded, whether they were fasted or not. On samples that were noted to be more highly lipemic, there were specific warnings on the sheets as to how the results might have been skewed, but the lab was able to process the blood either way. So I just do not understand why your vet is so unusually taxed by drawing and submitting Visuddha's blood!

Edited to add: Here's a link to a very technical paper that discusses the issues associated with lipemic blood samples. I've only started to wade through it myself, but if you scroll down to the flowchart at the bottom, you'll see that if lipemia doesn't affect the analysis of the test that's been requested (such as the ACTH stimulation test), then you don't have to involve yourself in complicated efforts to try to clear the lipemia from the blood sample.

http://www.biochemia-medica.com/2014/24/57

[DoxieMama]

Marianne,

I completely understand, and truly appreciate your research. While neither of us is an expert, what you've found makes sense and helps alleviate my concerns about the result. If you recall, I had considered *not* telling them that he had eaten. And if they didn't ask, I was fully willing to walk out of there without mentioning it. But I couldn't be dishonest about it, and they asked, so that's that. I believe they would have been able to tell even if I hadn't said anything, from what I've read (and a comparison picture I saw somewhere online showing a lipemic vs non-lipemic sample - looks pretty obvious to me).

I really don't think it is the vet that has the problem. He has not mentioned anything to me about it specifically, and the only quote that I can attribute to him from the tech was to say that we could do the test non-fasted if I wished.

It's the tech that infuriates me. And the receptionist, who really has no business arguing the topic with a client at all, in my opinion.

One other point that I want to make is that when we returned for the post draw, I took Visuddha into one of the exam rooms, as there were other dogs in the waiting room and I didn't want to take any chances he would be stressed. When they took him to the back, they did not initially close the door all the way, so I overheard some of the conversations. I heard the vet say "that won't affect the result at all" .... "no, the ACTH". Then the door was closed. So, I want to give him the benefit of the doubt here.

His staff, on the other hand, can shove off. :)

[DoxieMama]

Oh, and since you mention it, I feed Visuddha Taste of the Wild Pacific Stream (salmon) canned. The DM basis of the fat content is 16.6%, if I remember correctly. I have a spreadsheet comparing the values of various foods at home.

He gets his Trilostane inside a little bit of colby jack cheese. I either shred it or shave off a few small pieces and then wrap it in a ball around the capsule, squeezing it in my hand.

I normally also give him a biscuit or two before I leave for work, as well as a fish oil capsule (when I remember, maybe every other day or so). He did not get these this morning until after the test was complete.

[labblab]

Do you ever get to speak to the vet directly? Assuming the blood can be analyzed, I can already guess that the next hurdle will be that the tech will be the one to call and deliver the results as well as instructions as to where to go from here. And at this point, if it was me, that would be totally unacceptable. You are paying for the knowledge and expertise of a licensed veterinary physician. I do understand that techs are often intermediaries, especially in large specialty practices. But after the grief and misinformation this tech has put you through, I don't see how you can trust a single word that comes out of the tech's mouth.

No matter how busy a practice may be, a competent and professional vet ought to make time to talk personally with any patient who requests it. Given the fact that this is Visuddha's very first monitoring ACTH and you've been worried about his behavior, frankly, I'm very disappointed that the vet didn't come out to speak with you today out of his own volition. But even if you have to ask to talk to him directly about the results, it ought to happen. The call or conversation may have to come at the beginning or end of a day, but time ought to be made. If not, really, where are you placing your trust? In the ignorance of a rude and poorly informed vet tech? If so, I believe I'd start looking for another vet.

[DoxieMama]

Oh, yes! He was in the front office this morning when I walked in, taking care of paperwork. I came in briefly and grabbed some tissue to pick up after Visuddha's deposit on their lawn :o and he asked how Visuddha was doing today. I told him he's doing better today, walking fine and more alert than before. Ok, good. I went outside and he was gone when I came back in. I was actually surprised there wasn't more of an "office visit", but then I didn't have to pay for one unnecessarily... ;)

The vet has always called to deliver the test results himself, takes the time to answer any questions, explain the options, and offers his advice. Before the LDDS test, when I stopped by for copies of the bloodwork and had questions, he came out and spoke with me for 10 or 15 minutes, explaining everything that I asked at the time. He called while I was on vacation, before we started the Trilostane. We spoke for a few minutes about the plan, and he made sure I was aware of the side effects to watch out for when we began dosing. He's really quite thorough in his explanations, and I've never had reason to doubt what he tells me directly.

Other than the higher starting dose, I have never outright disagreed with his advice.

I really do not have issue with the vet. We have been taking our pets to him for 15 years, and while he appears a little rough around the edges, I believe he knows what he's doing. Most of the time. ;) My husband shares your opinion, though, after these issues with the vet tech and receptionist. I guess I'm giving the vet the benefit of the doubt, but I'm also keeping my eyes and ears open. If there is any doubt that Visuddha's care is being compromised, I will request a referral for the IMS here in town immediately, and then consider changing to another practice. While I realize I am walking a fine line at the moment, I don't believe we've crossed the line yet....

[lulusmom]

Hi Shana. I couldn't have stated my dismay with your vet's office any better than Marianne. She is spot on, as usual. Marianne may not be a veterinary professional but I suspect there are few, if any general practitioner vets who possess anywhere near the level of understanding Marianne has on all things concerning canine cushing's. She knows diagnostic and treatment protocol and she knows Vetoryl (trilostane) like the back of her hand. I don't believe anyone, vet or layperson, has been as communicative with Dechra and veterinary endocrine experts as Marianne. There are few questions that she can't answer and when she can't she goes to the horses' mouths. :) She is absolutely considered an expert here and your vet, and most certainly his ignorant staff, could learn a lot from her. Actually they could learn much from a lot of members here.

I realize you like your vet and appreciate the time he takes with you but I personally don't give him a pass on this. It is his responsibility to educate his staff on proper testing protocol so as to insure that they conduct themselves in a manner that is always in the best interest of his patients and their owners. Giving clients bad information is not acting in the best interest of his patients. The implications of not following protocol far exceeds wasting your hard earned money and putting your pup through needless stress for a test that would be of no use. Had you followed those bad instructions, the results of the acth stimulation test would most likely have yielded a post stimulated cortisol much higher due to malabsorption of the drug. At that point, your vet could have very well decided that the current dose is ineffective and prescribed an increase, putting your pup at serious risk of an overdose. It really is an inexcusable blunder that should never have happened. I do hope you take the time to mention this to your vet so that he gets it and trains his staff accordingly. Believe me, you wouldn't be the first person to educate their vet and their staff. No matter what, I'm glad that you followed your gut and had Visuddha's back. Good job!

Glynda

[DoxieMama]

Glynda,

I surely hope I didn't come across as if I disagree with anything Marianne has posted. I absolutely did not mean to, if so, because I DO agree with what she has shared with me regarding treatment protocol as well as her suggestions on approaching the vet. I also agree with her regarding the deplorable actions of the vet tech. Her latest post stated that if I did not receive communication from the vet himself and rather, all communication were through the tech, then it would be time to look for a new vet.... but I do talk to him directly. The vet tech communicated the initial starting dose and when I insisted on following Dechra's recommendations (and those posted here), the vet was the one who called me back to confirm.

I feel like I'm repeating myself, and probably coming across as if I think my vet is the greatest thing ever and his staff sucks. While the latter is obviously true, the former is not my opinion at all. I was only sharing my experience with the vet directly, as most of my previous posts have not been about him or his personal care.

That said, you're absolutely right. He needs to be sure his staff is educated and sharing the proper information with clients. Had I followed their advice, Visuddha would have been started on either 22mg or 30mg per day which is not only two or even three times the current recommendation of the manufacturer, but given some of the symptoms I've been seeing would very, very likely have been too much. If that wasn't bad enough, the ACTH test would have been done fasted (and I very possibly would have given him the med with no food whatsoever), yielding inaccurate results and as you say, likely to have been interpreted as an even higher dose would be needed. Visuddha's care would absolutely have been compromised, if it were not for the information I've found myself, mostly here - from you, Marianne and Sharlene.

I printed off the chart that Sharlene provided earlier in the thread, from Dechra, regarding treatment protocol and gave that to the vet tech. I also mentioned to her the likelihood of an inaccurate result of the ACTH if given fasted. Obviously that did not get through to her. I will talk to the vet and make sure he has the same information. If he and I are on the same page, then I'll also tell him that he needs to make sure his staff follows the proper protocols as well. If not, well, then I'll get the referral for the IMS to take care of Visuddha's Cushing's and I'll start looking for another vet. The potential outcomes otherwise are simply not acceptable.

Thank you. So much.

[labblab]

Shana, I am left humbled and :o <blushing> :o from Glynda's praise, because coming from someone as knowledgeable as she is herself, her comments mean such a great deal to me. However, I am definitely not an expert, I have no formal vet training, and nobody here should ever feel hesitant to disagree with anything they think I've said in error. I don't interpret anything you've said as being "disagreement," anyway -- just clarification, and that is always, always helpful.

Those of us here on the forum can never know exactly what is transpiring between a pet parent and a vet, so we are left making assumptions and drawing conclusions that may or may not be accurate. That's a huge reason why I always encourage folks to talk openly with their vets about any of our own suggestions. There may be very important puzzle pieces of which we are unaware, or about which we happen to be flat-out wrong. I feel as though I am still learning something new every day.

So I'm really glad to hear that you've had more of a dialogue with your vet than I had realized previously. But I'm also glad to know that you will seek additional consultation if you think that is in your boy's best interest. I'm really hoping you can have a fruitful conversation with your vet, and some of these question marks about procedure can be clarified, as well.

In the meantime, I hope you all have a quiet and uneventful evening after all the excitement of the day, and that you get some good news about those ACTH test results tomorrow. We'll be here, awaiting your postings!

(And by the way, thank you so much for all the helpful and supportive replies you've been posting to other members here. They are very much noticed and appreciated! ;)).

Marianne

[molly muffin]

Well, sounds like what you overheard was the vet tech, arguing the fasting with the vet? Who corrected the tech that it wouldn't make a difference on the ACTH test.

So, okay, not a vet tech, don't work in a hospital currently, however, having said that I did work in pathology at a hospital in a previous life/career, and one of the things I did was process specimens for testing, including centrifuging and I have to say, that tech in my personal opinion needs to find a new career, or head back to school, because you can totally spin a blood specimen that is fatty and while it will be on the more cloudy side than a fasted test, in any good lab machine it will not be of consequence and certainly is doable for testing. What you will get in most cases is higher than normal levels of things like cholesterol, etc results due to the no matter how small, amount of fat in a diet. But it is what you are testing For that makes the difference. Cortisol is not reliant upon the fat in the blood to differentiate. So, poop on that tech, fooey the receptionist, and sounds like your vet is having the same problems with the tech that you are. goodness, gracious.

I think I already expressed my dismay at a lab that doesn't have the equipment to run a nonfasted blood test of any sort.

[DoxieMama]

You are all incredible, incredible people, who have the innate ability to say just the right things.

I will absolutely post the results of the ACTH test, as well as the results of further conversations with the vet and his staff.

I updated our oldest son on all that has transpired lately with the vet staff, as well as one of my co-workers and friends. I wish I could bring you all with me when I talk to the vet next. You'll be there in spirit, I am certain.

Luckily, I haven't given up wine this week. ;)

Hugs all around....
Shana

[molly muffin]

Luckily, I haven't given up wine this week. ;)


hahahha, Never give up the wine!! With cushings you tend to need it at the most Unexpected and some expected times.

You are going to do just fine with the vet. Try not to harm the receptionist and tech, even though I know the urge to throttle is pretty strong.

We have to look at this as, even while incredibly frustrating, as a teaching opportunity to treat, test, dose cushings disease appropriately. Every conversation while challenging, and while sticking to what you Know is correct, will help both your furbaby and those who come after you and are treated by this staff for cushings.

It is the only way to get through those most difficult experiences while maintaining some sort of sanity. :) and if nothing else, pour another glass of wine and BREATH! :) :)

[DoxieMama]

Absolutely. I couldn't agree more. Both about the conversation, teaching moment (because I want my vet to take care of my pup and all others he may be presented with)... And the wine. ;)

[DoxieMama]

I called the vet this afternoon to get the results. Spoke to him directly. He said according to the protocol, Visuddha's levels are good and we should keep him on the same dose. However, his sodium potassium ratio is a touch low. Sodium is on the low side of normal (I did not get the actual number for that), and potassium is a bit on the high side of normal.

ACTH Results:
Pre: 1.1
Post: 5.2
Potassium: 5.5 (range 4.0-5.7)
Sodium: 144 (range 140-158)
Sodium/Potassium Ratio: 26 (range 27-40)
Chloride: 107 (range 100-118)

He said if I see any signs of weakness to bring him in IMMEDIATELY and they will test enzyme level again. If no issues for the next week, bring him in next Friday to test that anyway.

He suggested I could put a little salt on his food. One quick google search and I don't believe I will.

I told him that I'm sure he probably heard about the discussions regarding the ACTH protocol being fasted or not, which he confirmed. I asked him about that and he basically said 6 in one hand, half a dozen in the other. He said, and I'll be paraphrasing from memory here, the lab has million dollar equipment so they can centrifuge the samples even when they're lipemic. Some Cushing's dogs are lipemic anyway, other could be due to diet or they don't process as well. Certain breeds (can't recall what breed he mentioned) are almost always lipemic regardless and that's why they're at greater risk for pancreatitis.

I've got to go. I'll write more later.

Waiting for my car in the shop now. Hopefully they finish in time for me to get got the vets for the paperwork. Apologies for typos since I am on my phone now.

The final thing the vet told me on the phone was that the protocol says to test again in 90 days. He previously told me test at 14, 30 and 90, which is the recommended protocol. I asked him about that and he said this is the protocol that comes with the drug. So he doesn't plan to test ACTH again for 90 days. :(

Because of the symptoms I have seen already and the low sodium potassium ratio, I am concerned that Visuddha is at risk for addisons. Knowing the cortisol levels will likely continue to go down, as we have only been using trilostane for 12 days, I need to be even more vigilant for signs of overdose. I am going to talk to my husband this weekend but I want to either get the necessary referral from this vet to take him to the IMS (which I'm leaning toward) and/or make an appointment with another GP for a second opinion...and a new practice altogether. Poo.

I'm still going to drop off the printout of dr petersons blog, because I want him to read that. And I want to know what his reaction will be in doing so. But I don't trust him anymore. And that sucks. But it's about Visuddha and my other pets. I want them to have the best care and we aren't getting that here.

[molly muffin]

Okay so the lab is well able to centrifuge the specimens, fasted or not and the tech is full of crap and no way did the lab say their equipment couldn't do it your vet spoke the truth and I'm inclined to believe him. Some dogs are more lipemic, schnauzers is one breed that is usually more lipemic and they are inclined to high cholesterol levels and their fat contents have to watched, cushings or not.

The protocol for testing is 14, 30, 90. This is true, with some vets opting to not want to test as much at 14 as they do at 30 due to levels continuing to drop for usually 30 days.

I agree, you do have to keep an eye on him so he doesn't go down too much and especially with the sodium/potassium ratio already being a bit off . This might go back into a more normal range, but yes I would agree, anything off, take him in for a electrolyte check. I would definitely do a 30 day check on ACTH. His levels right now are perfect.

I think your vet is doable for treating, but still think the tech and receptionist are off base.

[DoxieMama]

Yep, the lab was fully capable. Schnauzers is the breed the vet mentioned.

I definitely will have another ACTH test done at 30 days.

I checked his previous lab reports and wanted to note the changes:

2/24 (pre diagnosis) to 4/14 (11 days on Trilostane):
Sodium: 147 to 144 (range 140-158)
Potassium: 4.3 to 5.5 (range 4.0-5.7)
Na/K Ratio: 34 to 26 (range 27-40)
Chloride: 102 to 107 (range 100-118)

Excessive drinking and urination have mostly ceased. He still occasionally drinks a lot, usually first thing in the morning. He has slept through the night for the past few days, 7 or 8 hours at a time. It's weird! lol

[DoxieMama]

I picked up the lab results and updated the sodium level in my previous posts.

Other numbers which the vet did not mention (including range and previous result from 2/24/2016):

BUN 36 (was normal at 18, range 6-29)
ALP 731 (was 1051, range 10-84)
GGT 21 (was 32, range 0-10)
ALT 37 (was high at 106, now normal, range 5-65)

Some of the notes included: Interpretation of the ACTH stimulation test depends on patient history, physical exam, laboratory testing, and ultimately the reason for running the test. Also consider the effect of concurrent medications, such as steroids, when interpreting results..... Patient is being treated with Trilostane for Cushing's disease: pre and post cortisol values should be between 2.0 ug/dL and 7.0 ug/dL when the test is started 4-6 hours after the Trilostane is administered with food (emphasis mine). This recommendation is for daily dosing of Trilostane. The timing interval should be kept the same for each individual patient.

So ALP, GGT and ALT have all decreased, but BUN increased. Glucose is normal (96, range 65-130) as is creatinine (0.8, range 0.6-1.6).

Should I be concerned about the high BUN?

[Harley PoMMom]

I wouldn't be concerned with the BUN level, dehydration can cause an increase in the BUN.

That's awesome that those liver enzyme levels have come down!!!

[molly muffin]

I agree with Lori. I don't worry about the BUN unless I see the creatinine going up too.
Excellent that you are seeing a decrease in the liver numbers!

Funny about the emphasis there, :) :) :) Think the vet tech should read the results a bit more thoroughly. LOL

[DoxieMama]

Ok, thanks. Glad to know that BUN isn't a concern. (At least now I know the lab has the proper info. :rolleyes:)

Visuddha is still doing well, now two weeks on the meds. The first couple of hours after getting his meds he still seems a little lethargic, but always responsive when I wake him. I'm keeping a close eye on him still, ready to run him in for testing if anything is concerning.

Good news! He is sleeping through the night, drinking and eating normally now. He is going down the stairs on his own, though I still carry him up most of the time. He RAN outside when Jackson went out to chase a squirrel, no way he can keep up but it's the first time I've seen him run in so very long. Then last night, he actually tried to jump up on the couch to sit with me. He hasn't tried to do that in months!

[molly muffin]

That is so awesome that he is doing so good. Yay!!!

Isn't it great to see them feel well again. :)

[DoxieMama]

Good morning. Not much new to report. He sleeps a lot, but I can't really say that's not normal for him. He hasn't shown to be unresponsive as he was on that first Saturday, though I often wake him in the morning to be sure. He's probably getting irritated at me for that, but turnabout is fair play, right? ;)

A few nights this week he has been waking every few hours. Last night he was up after one hour, got a drink and out to pee. Then 3 hours later, he whined to be let out of his crate. He looked in the food dish but ignored the water dish, walked out onto the deck, then came back in and then slept in my bed for another 3 hours. I told my husband it was as if he forgot why he got up. :confused:

Otherwise, he's doing well.

[DoxieMama]

I may be getting ahead of things here, but May 1st will mark 28 days on Trilostane. I plan to set up an appointment for another ACTH test near then. I'm curious though, since we have to order the Trilostane and it takes a few business days to arrive, what would you suggest regarding the timing of the test?

Thank you.
Shana

[labblab]

When will you run out of your current supply of 11 mg. capsules? If it is around the same time, I'd schedule the test for a few days before you'll run out so that you'll have enough time to order a new supply at whatever dose becomes appropriate. If you still have plenty of the 11 mg. capsules left, though, then you can schedule the test whenever it is most convenient for you. Even if an increase seems warranted, there is no great urgency in getting the new capsules delivered. And if a decrease is warranted, you'd probably stop the med altogether for at least a couple of days, anyway.

Marianne

[DoxieMama]

I only have a 30 day supply, so it will last until May 3. I think to allow time for the test results, order processing and shipping, I would need to schedule the test for a week before that. If the test result shows a change is necessary, then of course we "start the timer" again. But if all is well, then we don't need another test for 60 days, right? Even though this test will be more like day 23 or 24...

[DoxieMama]

The vet's office called on Friday to check in. When I spoke with them, I scheduled the ACTH test for Wednesday morning. That will be day 24.

Right now, Visuddha is in my lap, shivering a little bit. It's not constant, or extreme. It's been 8 hours since his dose of Trilostane.

[molly muffin]

I usually try to schedule about a week before I would run out a medication unless a test is needed prior to that.

How is the shivering, shaking doing?

Molly seems to shiver more in the morning right now than any other time.

[DoxieMama]

Thanks Sharlene. I noticed a little more shivering last night but only for a brief moment. He's been fine so far this morning.

[DoxieMama]

I took Visuddha in for his second ACTH test this morning. I spoke with the vet briefly on both visits; during the second visit he said that Visuddha's potassium level is high which may indicate that his current dose is too much. He requested that I withhold the dose tomorrow morning due to the high potassium. We will determine our next action based on the results of the ACTH which we should have by end of day tomorrow.

[Harley PoMMom]

Is Visuddha on any blood pressure medications? And is his potassium elevated or low?

[DoxieMama]

Whoops. I have edited my previous post. Potassium level is elevated. He is not on any medications other than the Trilostane at this time.

[molly muffin]

hmm, have they done a Blood pressure check on him? What about any protein in the urine?

Yes you do want that potassium and sodium to always be balanced as closely within range as it is possible to get.

Lets see what the ACTH comes back with.

[DoxieMama]

They have never done a blood pressure check on him, and his latest urine showed negative for protein.

Here is the 24-day ACTH and in-house bloodwork results (which interestingly states IDEXX Laboratories):

Pre: 0.6
Post: 3.4
Potassium: 6.0 (range 3.5 - 5.8)
Sodium: 154 (range 144-160)
Na/K ratio: 25.67
BUN: 32 (range 7-27)
ALKP: 454 (range 23-212) - still high but lower than it was :)
ALT 36 (range 10-100)

--------------------
For reference, 11 day ACTH results and lab bloodwork were:

Pre: 1.1
Post: 5.2
Potassium: 5.5 (range 4.0-5.7)
Sodium: 144 (range 140-158)
Na/K Ratio: 26 (range 27-40)
BUN: 36 (range 6-29)
ALP: 731 (range 10-84)
GGT: 21 (range 0-10)
ALT: 37 (range 5-65)

So, cortisol is down more and in a good range... but Potassium is now high and the Sodium/Potassium Ratio is lower. Vet said that the internist he consulted with suggested a decrease of approx 25%, so from 11mg we are going to 8mg. In the meantime, he said to give him the 11mg every other day. I asked about just not giving him anything until we get the 8mg; he said he doesn't want "his Cushing's to return" (by which he means the symptoms) and this way we could keep his cortisol from rising too high. Though Trilostane is only in the system for up to 24 hours, this would keep things "semi-regulated".

Vet just called to confirm that he was able to place the order with the pharmacy tonight, so I should be hearing from them soon. I expect we'll probably get the 8mg by the middle of next week, based on the shipment time of the original order. He also requested I let him know what I decide to do regarding the 11mg. If I don't give it to him at all, then will it be more difficult (aka take longer) to get his cortisol down again than if I were to give it to him semi-regularly? I know Dechra's recommendation is to stop the dose for 7 days if ACTH test results are low, or if Visuddha is showing symptoms of Addison's.... but he's not. He is eating, drinking, pooing normally. It's his enzymes that are off.

What to do, what to do....

[Harley PoMMom]

Since the potassium is continuing to climb I would stop giving the Trilostane completely and wait for those 8 mg capsules. Symptoms may rebound quickly but once on the lower dose of Trilostane it shouldn't take long to get them under control....just my 2 cents!

Hugs, Lori

[Renee]

I guess there are enough variables that you could go either way, but with his baseline so low, and the potassium being out of range, I would probably stop all together for a bit and then start back up at the lower dose. You won't 'undo' all your progress by holding off for a few days. I've withheld Tobey's dose for multiple reasons, days and weeks at a time. I've never regretted it, nor did I feel it harmed her.

[DoxieMama]

Not giving him the 11mg is what I'm leaning toward. I find it ironic how hesitant I was to give it to him in the first place and now, I know it helps and I want him to feel better! But too much is a bad thing... and this is just a touch too much, it seems.

Would there be any harm in giving it to him a couple times in the next week?
Would it be 'pointless' to do so?

I'm just thinking, if his symptoms do rebound quickly... would a couple doses help to keep that at bay, or maybe do more harm than good?

[DoxieMama]

Re-reading the product insert, it says
If the ACTH stimulation test is < 1.45 μg/dL (< 40 nmol/L) and/or if electrolyte imbalances characteristic of hypoadrenocorticism (hyperkalemia and hyponatremia) are found, VETORYL Capsules should be temporarily discontinued until recurrence of clinical signs consistent with hyperadrenocorticism and ACTH stimulation test results return to normal (1.45-9.1 μg/dL or 40-250 nmol/L). VETORYL Capsules may then be re-introduced at a lower dose.

I did not give it to him yesterday per the vet's instructions, pending lab results. So today is day 2 without. Do we need to do another stim test before starting on the 8mg?

He woke last night at 2am to drink and go outside. I'm glad I got a good night's rest on Wednesday night! ;)

I did more research this morning, before I re-read the insert. Found this link which has a lot of info. Saving it here along with some snippets from the page http://www.laboklin.com/pages/html/en/VetInfo/aktuell/lab_akt_1401_en.htm


Trilostane selectively and reversibly inhibits the enzyme system 3-β-hydroxisteroiddisomerase, which stops the synthesis of cortisol, corticosterone, and aldosterone. The side effects of an excessive level of medication can therefore be as diverse as the functions of the secreted hormones.

The most critical side effect is a low aldosterone level, since this can be fatal. Aldosterone is generally synthesized and secreted independently of the ACTH/corticosterone cycle. Synthesis and secretion are regulated via the renin-angiotensin system. Aldosterone synthesis is inhibited by Trilostane independent of the renin-angiotensin system. The resulting aldosterone deficit leads to hyperkalemia, which leads to bradycardia, hyponatremia, hypotonia, and reduced kidney perfusion with pre-renal azotemia.

Clinically, these patients become apathetic and lose weight. These signs are easily noticed by owners, but can be difficult to interpret, particularly at the beginning of treatment with Vetoryl®, especially since weight loss is often desired and apathy is observed in many patients with Cushing’s disease.

Changes in the sodium (Na), potassium (K), and chloride (Cl) concentration in serum indicate changes in aldosterone secretion and should therefore be checked regularly in order to be able to make a timely therapy adjustment.

The clinical signs are often unspecific and can be acute or occur intermittently over weeks and months.

[Harley PoMMom]

When a dog's pre and post cortisol numbers have dropped too low, <1.5 ug/dl, it is critical that before treatment resumes that an ACTH stim test be performed to make absolutely sure that the adrenal glands are producing enough cortisol.

I'm a bit concerned that Visuddha's post number has continued to decrease while being on the same dose of Trilostane which is why I think that stopping the Trilostane is a good move. However since the post value hasn't gone too low and along with the decrease of his Trilostane dose to 8 mg I would feel comfortable not having an ACTH stim test performed before starting the 8 mg dose but within 10-14 days an ACTH stim test should be done to make sure that this new dosage change is not having a negative effect on his cortisol.

Hugs, Lori

[molly muffin]

I agree, that there is likely no need to test prior to starting the 8mg, but definitely afterwards. This is day 24 when he was tested, and we can expect to see cortisol levels drop for around 30 days.

Based on that expectation and the electrolytes which in your case is the most important, I would stop completely till the 8mg comes in and then restart.

[DoxieMama]

Since it is an electrolyte imbalance rather than the cortisol level that is prompting the discontinuation and lower dose, should I request another in-house test to verify that they are back in normal range before we start again?

[molly muffin]

If they can do an inhouse and let you know what they are right away then by all means you can do that. Be aware that there is sometimes a bit of descripancy between a lab test from like IDEXX and an in house, so you can't do a one - one comparison normally but you will have an idea of how they are doing for instance if they are in range.

[DoxieMama]

Yep. I see there are different ranges on the last two, as the first one was by the lab and this latest was in-house. It will be interesting to see the difference after not being on Trilostane for a few days.

[lulusmom]

Be aware that there is sometimes a bit of descripancy between a lab test from like IDEXX and an in house, so you can't do a one - one comparison normally but you will have an idea of how they are doing for instance if they are in range.

Sharlene, that is very disconcerting. Can you tell me how you learned of this information? I was at a veterinary conference about five or six years ago and IDEXX had a booth there. IDEXX actually manufactures the Snap Cortisol test and it was relatively new on the market back then so I had lots of questions for them. They were super nice folks and were happy to answer all my questions. I was holding Willa, a dog who was born without front legs, so she was a great ice breaker. Key answers I got were the machine is very, very expensive so not a lot of gp vets can afford them. I specifically asked them about the accuracy and I was told that if proper protocol is followed, results are as accurate as their in house labs. I'm therefore wondering if a discrepancy would be an infrequent occurrence that could be attributed to operator error?

[molly muffin]

I am talking about in house chemistry tests. The ranges of in house vs IDEXX results is usually different so it doesn't match up exactly the same. My IMS told me that as they use IDEXX but also use in house if they need to get a fast answer. It is comparable but a 5.5 might be the same as say a 6.5 in house. The ranges will of course reflect the difference but if a person is expecting the same number that might not happen although the interpretation is the same.
Maybe I am not explaining that well. It's basically just a matter of difference of equipment I think. The ACTH is probably the same exactly because the protocol for measurment is the same and not machine dependent

[labblab]

Sharlene, I think your explanation of the differences is accurate, and I think ACTH results are also lab-dependent. For instance, the UTK "normal" range for cortisol post-ACTH is noticeably lower than for most other labs. So it is definitely true that people always need to pay attention to the printed normal ranges in order to assess and compare results from different labs.

[DoxieMama]

I noticed the difference between the bloodwork done on the 14th by the lab, and that done at my vet's on the 27th. A snippet of the electrolyte levels:


In-house bloodwork results (which interestingly states IDEXX Laboratories):

Potassium: 6.0 (range 3.5 - 5.8)
Sodium: 154 (range 144-160)
Na/K ratio: 25.67

--------------------
Lab bloodwork were:

Potassium: 5.5 (range 4.0-5.7)
Sodium: 144 (range 140-158)
Na/K Ratio: 26 (range 27-40)

The lab range for potassium is tighter than in-house, whereas for sodium both the top and bottom of the range are a little lower. The bottom end of the Na/K is the same, though it wasn't listed on the in-house lab the vet mentioned it to me.

It's something to keep in mind when comparing results.

[DoxieMama]

We have been 5 days without giving the Trilostane dose, and Visuddha hasn't shown any symptoms yet. We continue to sleep through the night with no need for drink/potty breaks, and he hasn't shown an increase in drinking that I've noticed. I need to call and make an appointment to have his electrolytes tested; I'm thinking maybe Wednesday afternoon.

Dechra's insert says "Capsules should be temporarily discontinued until recurrence of clinical signs consistent with hyperadrenocorticism ...". Since his ACTH results aren't too low, does that mean I should wait until he shows signs of PU/PD again before starting the 8mg dose? Regardless of his potassium or Na/K ratio?

[Whiskey's Mom]

They have never done a blood pressure check on him, and his latest urine showed negative for protein.

Here is the 24-day ACTH and in-house bloodwork results (which interestingly states IDEXX Laboratories):

Pre: 0.6
Post: 3.4
Potassium: 6.0 (range 3.5 - 5.8)
Sodium: 154 (range 144-160)
Na/K ratio: 25.67
BUN: 32 (range 7-27)
ALKP: 454 (range 23-212) - still high but lower than it was :)
ALT 36 (range 10-100)

--------------------
For reference, 11 day ACTH results and lab bloodwork were:

Pre: 1.1
Post: 5.2
Potassium: 5.5 (range 4.0-5.7)
Sodium: 144 (range 140-158)
Na/K Ratio: 26 (range 27-40)
BUN: 36 (range 6-29)
ALP: 731 (range 10-84)
GGT: 21 (range 0-10)
ALT: 37 (range 5-65)

So, cortisol is down more and in a good range... but Potassium is now high and the Sodium/Potassium Ratio is lower. Vet said that the internist he consulted with suggested a decrease of approx 25%, so from 11mg we are going to 8mg. In the meantime, he said to give him the 11mg every other day. I asked about just not giving him anything until we get the 8mg; he said he doesn't want "his Cushing's to return" (by which he means the symptoms) and this way we could keep his cortisol from rising too high. Though Trilostane is only in the system for up to 24 hours, this would keep things "semi-regulated".

Vet just called to confirm that he was able to place the order with the pharmacy tonight, so I should be hearing from them soon. I expect we'll probably get the 8mg by the middle of next week, based on the shipment time of the original order. He also requested I let him know what I decide to do regarding the 11mg. If I don't give it to him at all, then will it be more difficult (aka take longer) to get his cortisol down again than if I were to give it to him semi-regularly? I know Dechra's recommendation is to stop the dose for 7 days if ACTH test results are low, or if Visuddha is showing symptoms of Addison's.... but he's not. He is eating, drinking, pooing normally. It's his enzymes that are off.

What to do, what to do....

I see above that your vet suggested giving Vetoryl every other day, which is what I do. When I questioned my vet, she stood by that dosing schedule as of now, and the people at Dechra said that yes, some vets do that depending on the dog and it's symptoms. Just wondered if you did that and how your little cutie is doing? Based on the advice given here and by my vet I'm constantly obsessing over it all. Whiskey is fine but I'm still so stressed. Thanks!

[DoxieMama]

Hi, thanks for asking about Visuddha. He's doing well at the moment, no medication and no symptoms returning yet. I chose not to give him any of the Trilostane while waiting for the lower dose to arrive. It came in the mail yesterday, and I plan to have his electrolytes tested before we start again. My decision was based on the suggestions of those here and the recommendations of Dechra which I posted above - essentially, because the electrolytes are off, stop dosing completely.

My vet's suggestion was only for "in the meantime" while waiting for the lower dose, as Visuddha's cortisol is not (yet) too low on the 11mg dose. I suspect that if his post-ATCH cortisol was lower, he would have also recommended stopping completely as Dechra suggests. Either way, he knows that I will make the decision that I am most comfortable with and will help to support that as best he can.

I understand your obsession, really I do. I research and research, post here and on the Facebook group, and then research more. I've asked questions, made decisions and then second-guessed myself and everyone else more than once. But I am already noticing a decrease in my obsession, as time goes on and my dog does well. No need to stress and worry when he's fine! Of course, I'm still keeping an eye out to make sure that he truly IS fine... lol ;)

Hugs,
Shana

[Harley PoMMom]

Dechra's insert says "Capsules should be temporarily discontinued until recurrence of clinical signs consistent with hyperadrenocorticism ...". Since his ACTH results aren't too low, does that mean I should wait until he shows signs of PU/PD again before starting the 8mg dose? Regardless of his potassium or Na/K ratio?

I'm not sure what I would do here, especially since Visuddha's symptoms have not rebounded by now which I would believe they should have.

I think the path I would take is to have an ACTH stimulation test done and have his electrolytes rechecked. If the ACTH stim results still show good control I would be inclined in not restarting the Trilostane even at the lower 8 mg dose...just my 2 cents worth!

Hugs, Lori

[Renee]

Agree with Lori! I generally wait for symptoms to recur before starting at a lower dose.

So many things to consider and weigh. I sure can sympathize. I've been up and down, back and forth numerous times with my girl.

[DoxieMama]

Thanks ladies. We have an appointment to have his electrolytes tested on Thursday afternoon. Hopefully those will show improvement.

I think I'd like to wait to do another ACTH test. They're so expensive! If he isn't drinking/peeing more, then I am not sure I want to medicate or test until either he starts to do that, or some other symptom pops up. Symptoms are one of the big reasons for medicating in the first place, right? Then again, I know there's other potentially unseen repercussions for not medicating, which an ACTH test would indicate. Back and forth, as you said, Renee. Sigh.

[molly muffin]

Well depending on what the electrolyte shows, you can wait and as long as symptoms haven't come back, not medicate yet and then do another ACTH test if symptoms do show up.

[DoxieMama]

That sounds like a good plan.

[DoxieMama]

Electrolytes were tested today. Previous results quoted below for easy reference.

Potassium: 4.1 (range 3.5-5.8)
Sodium: 154 (range 144-160)
Cl: 108 L (range 109-122, value on 4/27 was 116 and on 4/15 was 107)
Na/K Ratio: 37.5 (normal) Yay! :)

Vet is not concerned about chloride level at this time.

Visuddha has started begging quite a bit more the past couple of days, and for the past few nights he has been waking up to go outside. Otherwise, he's doing well. We're planning to restart at the lower 8mg dose on Saturday.


In-house bloodwork results (which interestingly states IDEXX Laboratories):

Potassium: 6.0 (range 3.5 - 5.8)
Sodium: 154 (range 144-160)
Na/K ratio: 25.67

--------------------
Lab bloodwork were:

Potassium: 5.5 (range 4.0-5.7)
Sodium: 144 (range 140-158)
Na/K Ratio: 26 (range 27-40)

[Harley PoMMom]

So glad to see that Visuddha's potassium has sorted itself out!!! Restarting at that 8 mg sounds like a good plan especially since his symptoms are returning.

Hugs, Lori

[molly muffin]

Whoo hoooo glad to see those electrolytes looking good!

I'd go with the lower dose too and see how he does.

[DoxieMama]

It has been one week at the new, lower dose of 8mg. Visuddha is doing well. He's sleeping better, though still not quite all the way through the night. The past few days his drinking has lessened so when he wakes up, he is not frantic to drink water or go outside so that's better. We even went for a walk yesterday! Not far, but I didn't have a lot of time before work. He's napping now but we'll go for another walk today and see how much stamina the little guy has. :)

One of the vet assistants called yesterday to check on him. I appreciate their doing so. The next test is not yet scheduled but we're planning on going at about 3 weeks this time unless he shows worrisome symptoms earlier.

[judymaggie]

Definitely sounds like you are moving in the right direction--good work, Mom!

[Harley PoMMom]

So glad to hear that Visuddha is tolerating the new Trilostane dose so well!!!!

[Tinkerbellsmom]

I've read this entire thread and have to say that you inspire me! You've done an amazing job advocating for Visuddha. I'm glad to hear that things are leveling out and he is doing better.

[DoxieMama]

Thank you.

I am so grateful for this site. I wouldn't understand half of what I've learned without the guidance and support of the people here. It's just such a comfort to be able to post questions and get feedback from others who have been/are in the same boat (unfortunately). I feel like Visuddha and I have got the best support team ever.

<3
Shana

[DoxieMama]

Today is day 14 on the new dose. Visuddha seems to be doing really well, sleeping (mostly) through the night, drinking and peeing less. As others here have recently commented in their threads, he is also showing signs of hind end weakness.

He had stumbled a bit here and there before and initially when we started Trilostane in April, to the point where I was carrying him up and down the stairs. He had difficulty going up the one or two steps to the deck at the time as well. That isn't a problem at this point, but he wobbled and fell a couple times this morning after coming down the stairs. (He might have slid down a few of the steps - not sure as he was behind me. :o I'll be keeping a better eye on him and carrying him as needed.)

Otherwise, as I said, he seems good. No lethargy, still eating etc. I am going to call the vet and see when I can take him in for an electrolyte check soon, because I'm curious how those look on this dose.

Shana

[judymaggie]

Shana--So glad that you are seeing a reduction in symptoms. As cortisol drops, any arthritis that had been present, can come to the forefront. My Abbie has arthritis as well as IVDD so we keep her cortisol level at the higher end of the acceptable range. Were you aware of any arthritis before starting treatment? You might consider adding a glucosamine/chondroitin supplement to Visuddha's regimen.

[Tinkerbellsmom]

Glad he is doing well!

[labblab]

Shana, I'm so glad to hear that your little boy is generally doing so well! Good job!! I'm sorry about the stumbling because I know that presents worries for you. But overall, this sounds like a very good report and I'm very happy for you both!

Marianne

[DoxieMama]

Judy, thank you for the suggestion. I don't know about arthritis, but Visuddha has had back issues in the past and is now permanently arched. :(

I was giving him a glucosamine/chondroitin supplement some time ago but he didn't like the flavor so it was more of a struggle than it seemed to be worth at the time. He does occasionally like a fish oil supplement but I don't give him that daily.

Does anyone have any recommendations as to a particular brand of glucosamine/chondroitin?

[molly muffin]

I usually try to give treat type, as that is the easiest to get molly to use. Have you tried Dasuquin? Molly liked those but it is so expensive to get that here in Canada. You can order it on Amazon.

[DoxieMama]

Visuddha had rather soft stool this weekend, but that was fine this morning. I suspect maybe a few too many veggies (carrots, apples, cucumber snacks in the AM when I juice them for myself). Otherwise he's still doing great. No lethargy, in fact has a good amount of energy... even able to go for a bit of run with me this weekend. :)

I took him in for an ACTH and electrolyte test this morning. The vet called about half an hour after the first visit to provide the results of the electrolytes, at which time we realized there had been a bit of a mix-up; they didn't start the ACTH test. So we ran back in and got that started (still within the recommended time frame since his dose this morning).

Today's test results:
Potassium: 5.6 (range 3.5-5.8)
Sodium: 156 (range 144-160)
Cl: 115 (range 109-122)
Na/K Ratio: 27.9 (just inside normal, 27-40)
BUN: 31 (range 7-27)
ALP: 623 (range 23-212)

Vet mentioned BUN is a bit high still, and while electrolytes are normal, potassium and the ratio is just within range. He said to keep a close eye on him for now.

We'll have ACTH results tomorrow.

[Harley PoMMom]

BUN can be elevated from being a bit dehydrated so I wouldn't worry too much about that ;) Trilostane is known to cause imbalances in the electrolytes, what was his ALP before treatment? Glad that the loose stool stopped as that is always worrisome, also happy that he is doing well!!!

[DoxieMama]

Right, we lowered the dose because of the Na/K ratio being low. That was at 25.7 after 24 days of 11mg, so now having 27.9 after 24 days of 8mg is better. :) The vet mentioned that we might need to lower the dose again, depending on ACTH results and how he does.

ALP was 1051 before treatment in Feb, 731 after 11 days of 11mg, 454 after 24 days (April 27th). He was without Trilostane from April 28 until May 7th when we restarted on 8mg. Now they're high(er) than on the previous dose but not as high as untreated.

Oh, if anyone is interested, I created a view-only version of my Google Doc that I started for him, with symptoms, dosages, and test results. That should be available here (https://docs.google.com/spreadsheets/d/1dxl-JS6GyJ7R8FcGgzgaSShznfx18Dm3PdV1LGn6cMc/). :)

[lulusmom]

Shana, thank you so much for posting your chart. It really makes it easy to see just how much progress you have made with Visuddha. Congratulations. I'll be looking forward to seeing the results of the acth stimulation test which should tell you if higher cortisol is the reason for the increase in Alkp. Liver enzymes can change on a dime so you never know if the most current results are going to persist or be better tomorrow. The good news is that they are still much better than when you first started the journey.

Glynda

[DoxieMama]

Thanks Glynda. I'm very happy with how Visuddha is doing right now. His liquid input/output seem normal, he's more active and LOOKS better than he has in a long time (the vet said so this afternoon also... it's not just mama that thinks so :)). We both think we're getting closer to the right dose.

ACTH Results:
Pre: 0.8
Post: 4.3

This is after 24 days on 8mg. After 24 days on 11mg, they were Pre: 0.6 and Post 3.4.

Electrolytes (already posted but relative now), Potassium was 6.0 (high) on 11mg and is 5.6 (high-but in range) now. Sodium was 154 now 156. Na/K ratio was 25.7 (low) and is now 27.9 (low-but in range).

The notes on the lab report for a patient on Trilostane state: "pre and post cortisol values should be between 2.0 ug/dL and 7.0 ug/dL when the test is started 4 hours after the Trilostane is administered with food."

I spoke with the vet about these results, and he mentioned that the manufacturer isn't concerned about the pre number but the lab mentions the lower limit. Since Visuddha is most definitely below 2.0, he is waiting to talk to their Internist to see what they recommend at this point. He and I seem to be on the same page (finally! :D :p) and aren't sure... we could keep him on the 8mg or possibly decrease it more. I'm leaning towards a slight decrease, myself. I'll talk to him again tomorrow after he has a chance to discuss things with the Internist.

Shana

[molly muffin]

It is wonderful when they look so much better and are doing well isn't it :)
So glad to hear this.
My specialist also has always said that they don't worry about the pre number so much, as long as the post number is within a good range.
With Visuddha it isn't the cortisol range so much that was worrying as it was the electrolytes. He just isn't a dog who is going to do well on the lower range I think.
Let us know what the internist thinks.

[DoxieMama]

So.... we have fleas. :( We have NEVER had to deal with this before. I got bit, while sleeping, and then found one of the buggers on me while going to work. I called the vet's office and they have two options: Vectra 3D (topical which must be applied once per month, for three months) or Bravecto (ingestable which lasts for three months). She said we need to start treatment ASAP of both dogs and the cat.... vacuum and sweep the whole house and all furniture daily for at least two weeks... Ugh!!

Does anyone have any experience or recommendations on either of these products? Or anything else they have used successfully?

[Harley PoMMom]

Fleas are the worst!! I had an infestation a few years back and my animals were on Frontline, vet said that in time fleas can get a resistance to the flea medicines so I changed to Advantage II and it has worked, I have never used Vectra 3D or Bravecto, sorry.

Hugs, Lori

[judymaggie]

Shana -- I use Nexgard with Abbie. Similar to Lori's experience, I had been using Advantage but the time frame it would work kept getting shorter. My vet's experience had been the same. I like the Nexgard because it is a chewable. I found that the topicals made Abbie's fur/skin very greasy.

Unfortunately, even after your home is flea-free, there can still be fleas in the yard so it is really important to find a treatment that works.

[Joan2517]

Ugh!...Vacuuming, washing, vacuuming, washing! It seems like it will never end. But it does...we used to use Frontline topical and now we use NexGard pills. Both worked great and we had 4 dogs and 2 cats...now just 4 dogs. We never used it on the little dogs though, just checked them constantly. I used Zodiac on Lena once about 6 or 7 years ago and she had such a bad reaction, she was hyper and jumping out of her skin for 2 days before it finally subsided, so we never used anything on her again.

Good luck!

[labblab]

Hi Shana, you may want to check with Molly's Mom, because she was considering using Bravecto, as well. Good luck getting rid of those darn little pests!!

http://www.k9cushings.com/forum/showthread.php?p=189084#post189084

Marianne

[DoxieMama]

Oh thanks Marianne! I knew I had seen it mentioned somewhere. I've sent her a message.

Joan, that's my concern. I've never used any of this stuff and all the meds just sound awful. I suppose it's no different than any other, side effects are possible and if you research things then you can drive yourself crazy with worry.

According to my favorite vet tech (:p), I have to use the topical Vectra 3D on the cat, because the Bravecto isn't available for her. I guess that makes that decision easy enough.

Unless you can use something "natural" ... ACV, DE, lemon, etc etc .... who knows if any of that is truly effective or not? I just don't know what to do right now. I'll have to see what my husband thinks when I can chat with him tomorrow.

In the meantime, I plan to stop and pick up a flea comb and go over all 3 animals tonight, and then I suppose I'll be spending hours vacuuming. Makes me wish I had a much, much smaller home.... and less carpet.

What's weird to me though is that I haven't seen any evidence of fleas on the animals. Just bites on ME and the one critter. Maybe it's not even fleas.... maybe I just have bugs. LOL :o

And now... all day long, even though I'm at work, every little twitch, itch or anything is making me psychotic. AAGGGHHH!! :rolleyes:

[Renee]

I have severe bug anxiety, so I can only imagine you must be making yourself crazy sitting at work.

Are you sure it's a flea that was on you? Is it possible it's a different bug?

A few years back I had a foster that had dog lice. Oh man, that was a mess. I had to treat my three pugs with Revolution and do the insane amount of cleaning. It was horrible. Our house is fully carpeted and big. I felt terrible about the chemicals though. Just the smell of the pesticide on their skin and seeing how it irritated them. It was very difficult. I am so glad we don't have fleas in Alaska to deal with. Tobey was badly broken out with CC at that time and I was terrified those lice were going to burrow into her lesions.

[DoxieMama]

Nope, not sure it was a flea. I got a picture of it... after I kind of squished it.

Can you see this?
https://drive.google.com/open?id=0ByWPc_gCaKGUOW4ydE1tcVcyZExGZFp0cHVMeTNTd ldsZUNj

[Renee]

That appears much too big to be a flea. Fleas are very small and black and they hop / jump.

Sorry for this - that looks like it might be a bed bug. The brown coloring and the shape of the body.

You might take that picture, or the bug if you kept it, to a pest control place in your area for identification.

[DoxieMama]

Oh noooooooo. I guess since I found one, I'll be able to find another. That's weird, though. And disconcerting.

[Renee]

I am praying I'm wrong, that's for sure! I'd take fleas any day over bed bugs.

Best course of action is to get it identified by a professional. It's entirely possible I am wrong and that is a flea. I'm sorry. You are probably furiously googling now.

[mommyslittlegirl]

I live in southeast Texas and probably the flea capital of the world. I don`t have fleas at my place but my mom gets them every spring and summer. She has a dog and several cats. You can usually see the fleas in the fur and you will also see flea dust. That is small black spots or clumps on the animal. It looks a lot like small black pepper. The flea dust is actually the feces of fleas.

[DoxieMama]

I used the new flea comb I got on both dogs and the cat (who was NOT happy about it, ha). Jackson had a couple bugs that I saw on his rump but that was all I noticed. Got nothing from Visuddha or the cat, although their wriggling butts got me wet. :rolleyes: I checked Visuddha's bed. In one of the seams there was what I can only guess is larvae... both the bugs on Jackson and this larvae look like what is in this picture (http://www.doyourownpestcontrol.com/fleaCycle.jpg). (Bed bug larvae look more like little bed bugs... like this (https://www.epa.gov/sites/production/files/styles/large/public/2014-02/bed-bug-ctual-size.jpg).) I am linking the pictures rather than embedding them here because... eww. ;)

Guess I know how I'll be spending my weekend. And we need to make a decision on how we're going to treat the animals and get that started soon.

In Cushing's related news.... the vet called. He spoke with the internist who said Visuddha's response is borderline and she would like it to be higher. However, "here is where art and science meet". We could choose to continue on the current dose, and just check his resting cortisol along with electrolytes in another few weeks. OR. Reduce the dose by another 20%. He said it was up to me, and I asked him what he would do. He would reduce... which is what I was thinking too so... that's what we're doing. I will use up the rest of the 8mg, then start him on the new dose of 6.5mg when that comes in (he'll likely be without for a couple days, but he said that will be okay).

What do you guys think about just testing resting cortisol and electrolytes next month?

[Renee]

Well, pain in the butt that it is, I'm glad it's fleas and not the dreaded bed bugs! What a fun weekend you have ahead of you. :rolleyes:

[Whiskey's Mom]

Whiskey had fleas for the first time last year, right between his Cushings diagnosis and his torn ACL! :( I had always used K9 advantix-I hated it but it worked. It seemed so strong plus it made his fur all oily. Yuck. I didn't treat him last year-I figured he had enough going on. Then I saw the fleas on his tummy and if you walk around with white socks on youll see them jump on your feet. So I reluctantly treated him with half the vial. Then I vacuumed like crazy and tried using the Mule Team Borax method. You can google it I can't seem to get the link in here-sorry! It was a bit of a pain(I didn't go crazy & move every piece of furniture) But it worked-no more fleas! I'm not treating him now but I check him every day for those hateful ticks. They're bad here. Good luck & good riddance to your fleas!

[Harley PoMMom]

Since his dose is being decreased I think that having his pre and electrolytes checked are a good option.

When I had that flea infestation instead of using the shampoo for fleas I bathed my animals with dawn dish soap (the blue one), it's the suds that drown those pesky things so really any sudsy soap/shampoo will do.

Hugs, Lori

[DoxieMama]

Thanks Lori.


Well, pain in the butt that it is, I'm glad it's fleas and not the dreaded bed bugs! What a fun weekend you have ahead of you. :rolleyes:

Right! Since I've shared this wonderful tale with you all, I figure I'll let you share in the fun. Last night, I started the process. I got to empty the vacuum numerous times, clean it of a clog once... used it a couple more times and then it wouldn't turn back on. I suspected that it had overheated (has a feature to protect itself in that case) so gave it half an hour as the manual suggests. Nope. An hour later it still wouldn't turn on. My husband took it apart this morning and informed me that we need to get a new one. :rolleyes:

And I had a really fun panic attack "of the heebie jeebies" as my friend put it, in the shower this morning. I need to chill out. LOL

Lori, I have the blue Dawn dish soap, as well as some "pet shampoo". I'll probably use both on the dogs this weekend. As for treatment, I'm really really hesitant to try the two that the vet tech recommended, due to so many horrible reactions reported. I'm leaning more towards "natural" treatments like DE...

[labblab]

Hi Shana, I just wanted to add a thought in relation to your question about performing a resting cortisol alone next month. I am thinking you might prefer to save the money to put towards a full ACTH at that point or later on. This is the reason why. Anytime a Cushpup's resting cortisol comes in at a level below 1.5-2.0, the recommendation is to proceed to a full ACTH to make sure that the stimulated value shows an acceptably high response. If it does, then the lower "pre" level is not viewed with much concern. Visuddha's most recent ACTH is a perfect example of that. If you had tested the resting cortisol alone, the .7 would have forced a repeat test with the full ACTH anyway. Since his post-ACTH value was fine, though, you could breathe easier.

I am just worried that, even with the dosage decrease, his resting cortisol may not be high enough to waylay the need for a full stim, and you will have ended up paying the additional cost of the baseline reading all for naught. I do agree with testing his electrolytes, but I think I'd revisit the notion of the baseline with your vet in order to decide how helpful it would really be.

Marianne

[molly muffin]

Omg. Ugh fleas. I use to fight them something awful when I lived in the states. Not as much up here in Canada. I do feel for you and got some hibbiejeebies myself after seeing the pics.
How is the routing of the fleas going. Bet your weekend has been super busy!

[DoxieMama]

Marianne, thanks for the info. Sounds like a full ACTH is probably best. My vet had mentioned just testing the resting cortisol if we kept the dose the same, as a way to save me a bit of money.

With all the back and forth with the vet and the IMS, the prescription wasn't sent until Saturday. I'm hoping we get it tomorrow. I did not give Visuddha his meds yesterday morning (oops) so he had his last 8mg pill today. We'll start the new 6.5mg dose the day after it arrives.

As for the fleas........ my husband doesn't think we have them after all. The two I 'found' on Jackson....... could have been anything, who knows. I can't be certain, as I've never seen them before, and they might not have even been bugs for all I know. :o I went over him really carefully the next night and found absolutely nothing. No flea dust, no live bugs, nothing. I still washed and vacuumed everything this weekend; the house hasn't been this clean in months! :rolleyes: For now, I'll just do regular checks on the beasties (reminds me of head checks for ticks after being in the woods when I lived in Wisconsin), and cross my fingers that I just overreacted.

[DoxieMama]

Today is day 2 (+Sunday) without Trilostane. Hope Visuddha gets mail today!

[molly muffin]

Did the meds come? How is he acting without them?

[DoxieMama]

Yay! They came today. He has been about the same, I think... only waking in the middle of the night because he wants me to bring him into my bed. :p

[molly muffin]

Yay, meds came.

Well that makes sense to want to get into the bed. Molly will wake me when she wants up on the bed too. Usually by huffing and puffing at me. What does Visuddha do to wake you?

[DoxieMama]

He generally sleeps in his crate, which I close (so he can't wander out at night and pee wherever he wants). And since I sleep with a fan on, he has to be a little loud. Whining usually does the trick. :)

[DoxieMama]

We started on the new dose on the 9th and that night, of course, he woke 3 times to drink and go potty. :rolleyes: I'm wondering if that was just due to the heat or if it was symptoms returning. He's slept through the night (6-7 hours) since.

I am planning to schedule an ACTH for the 29th, which will be 20 days after starting. That way maybe we'll have results and can determine the next month's dosage before the 4th of July holiday interferes with ordering and shipping.

[DoxieMama]

Visuddha had his breakfast at about 5:15 today, meds right after. At about 2:30 this afternoon he vomited up half his breakfast. After vomiting he went outside for a minute. When he came back in, I picked him up and he was shivering. I wrapped him in a blanket hoping it's just from cold and he stopped shivering and is now sleeping on my chest as I lay on the couch. My husband said he has seemed off today. :(

Dinner is usually at 4:30pm. We will see how that goes.

[Budsters Mom]

On no! Sounds like an overdose of Trilo. Withold it until Vis is feeling better and acting more normally. Trilo leaves the system in about 12 hours. Never give Trilo to a dog who has been vomiting or otherwise appears ill.

Kathy

[judymaggie]

Shana -- please listen to Kathy. Also, it would be best to withhold all food until tomorrow and, if no more vomiting, then introduce wet, white rice with a little chicken broth in it. Hope Visuddha feels better quickly!

[DoxieMama]

That's what I thought, as well - not to give him the trilostane. I also wondered about the food. He's acting like he usually does at dinnertime now and is not going to be happy if I don't feed him something! He also just went outside and pooped - that's a bit soft.

It's so weird. This is Day 10 of 6.5mg, the lowest dose yet. It seems that 10-14 days in, his stool is always a little soft, but that resolves after a couple more days. Vomit is a new one for him though.

Why do they always seem to present issues on the weekend, or otherwise when the vet is not available? :p

[Budsters Mom]

This happened to many of us here and it SUCKS!!!!:mad::o


Why do they always seem to present issues on the weekend, or otherwise when the vet is not available? :p

[Budsters Mom]

It would be safe to withhold food, but please make sure fresh water remains available. It should not be withheld from a Cush dog. You can give small amounts every hour or so, but guzzling large amounts is not recommended. They had me do this when Buddy was vomiting.

[DoxieMama]

He has had fresh water and kept that down. I did give him a small amount of food last night but that came up about an hour later. :( Rice is just about ready and we'll try a small amount of that with chicken broth this morning. NO Meds.

He is acting like he's hungry, but it's two hours later than normal. (My in-laws came over for dinner and card games last night so we didn't get to bed until after midnight!)

[DoxieMama]

I gave Visuddha 2T of rice with a little chicken broth (and an ice cube because it was still quite hot) at about 7AM this morning. No vomiting. I was in the kitchen doing some other chores at 9:30 and he looked hungry, so I gave him another tablespoon. So far, so good.

Should I give him trilostane tomorrow or not? I'm planning on calling the vet to get him in for an electrolyte test I think, though it won't be until the afternoon unless he's doing poorly beforehand.

[judymaggie]

Shana -- hopefully, Visuddha kept the rice down. If he did, you can give him small amounts every few hours. I would do the rice for the rest of today and then tomorrow add small amounts of plain poached chicken to the rice. Do that for at least three days and then start adding in a little bit of his dog food with each portion of rice and chicken. Gradually give more dog food and less rice/chicken over the next three days.

If Visuddha didn't keep down the rice, then back off and no food until you speak with the vet tomorrow.

Any other changes that you have seen? I am wondering if Visuddha may have eaten something he shouldn't have -- maybe outside? My Abbie's first emergency hospitalization was for "dietary indiscretion" ... I think the culprit was cat poop. Another thing that comes to mind is pancreatitis.

The rice diet is so hard with our hounds -- as I'm sure you know, they do not have any inner signal to tell them that they have eaten enough, etc. They will act like they are starving even when you know they aren't!

P.S. I was typing as you were entering your post. Glad that he kept the rice down! As I said above, continue to do that every couple of hours and I think you should then gradually add chicken. I would recommend not giving him trilostane tomorrow as he will not be eating a "full" meal by then and will have a pretty empty stomach.
Hang in there -- the "hungry" looks can be tough to ignore!

[DoxieMama]

Judy, thank you.

My first thought was pancreatitis, as he's had that a couple times in the past and I know it's a concern. But when that happened before, it was pretty quick - nothing, including water, stayed down. Since he's kept the rice down this morning, you may be right about a possible dietary indiscretion. He did have access to the front room yesterday where the cat litter box is, though I'd cleaned it out right before he was allowed in there... sometimes he'll find stray poop that I missed that was outside the box. Of course, something from the backyard is possible too.

After vomiting yesterday he was shivering, which he's been doing the last few days here and there. I do think that's mostly due to cold, as that stops if I wrap him up in a blanket. It's worth mentioning, in case it's not the cold.

He's also been a little wobbly, especially upon first waking. I liken it to my stumbly self in the morning before I've had some coffee but again, it's worth mentioning. He does seem to walk normally after being awake for a while.

Finally, I noted soft stool yesterday shortly after he vomited.

I won't give him the trilostane tomorrow then. I will mention this episode when I call the vet, so they'll have record of it, too. Hopefully he just got into something and giving his tummy a few days of bland diet will allow it to heal.

[judymaggie]

Shana -- a "good" case of gastroenteritis can cause the symptoms you are mentioning but definitely mention everything to the vet.

Your pampering and a bland diet should go a long way to make Visuddha feeling better!

[Harley PoMMom]

Oh Shana, I'm just now seeing this issue with Visuddha and I don't know how I missed it. :(:o

I hope that Visuddha is back to feeling like his ole self, it is so worrisome when they aren't acting their normal self.

My Harley had pancreatitis, it was chronic so we were never able to get that fickle pancreas happy. If Visuddha's previous pancreatic episode was sudden than it was probably the acute kind of pancreatitis and unfortunately it can turn chronic. Is Visuddha's tummy sensitive to the touch?

Hugs, Lori

[DoxieMama]

Lori, his stomach is not sensitive to the touch. I fed him another couple tablespoons mid-afternoon, then we went out to visit with my husband's family for a few hours. We just got home and I gave him 3T more rice and broth. He's still doing well. I may feed him one more time before we go to bed. I'm going to boil some chicken now so I have it ready for tomorrow.

[DoxieMama]

Visuddha slept 9 hours straight. My husband says he smells like pee, though neither he nor his bed are wet. (My sense of smell is horrible.) He ate his little bit of breakfast just fine, and now in my lap is shivering occasionally and is somewhat lethargic. :( Will be calling the vet today.

Any suggestions on tests we want to have done? Electrolytes are at the top of my list. Resting cortisol? Other bloodwork?

Edit: I gave him a quick bath and then more chicken at about 6 am. His ears are up, tail is wagging, looks like a happy normal pup now.

[judymaggie]

Shana-- glad to read your edit that Visuddha perked up. It may be that his glucose level was low first thing which might account for the lethargy and shivering. That is the only other marker that I would suggest the vet check. Try to feed Visuddha every couple of hours to keep his energy up. Did you add the chicken this morning?

[DoxieMama]

Judy, thanks for the reply. His first meal was about 3T of rice with broth. The later one was a few small pieces of boiled chicken. I'm going to call the vet after they open (in an hour) and make an appointment to bring him in some time today. I am hoping they have an appointment around 9 or 10... then I can feed him afterward. My husband sleeps during the day; depending on what time he gets up I'll ask him to give him some food then.

Should I just ask for electrolytes and glucose testing?

[judymaggie]

Shana--Those are the only things I can think of but, if your vet does a chem panel to check those levels, you would also see his white blood cell count and more. Will be interested to learn what your vet's thoughts are.

I would mix the chicken into the rice to increase the calorie count.

[DoxieMama]

Vet appointment is at 2pm. I am taking the afternoon off so I can feed him around noon, with the mixture (didn't do the mixture this morning because I didn't actually have the chicken ready :o).

[DoxieMama]

I just came home. He was sleeping and I woke him up. He walked down the stairs and outside. I had to use the restroom myself; when I went outside to look for him he was headed back in. Very lethargic.

I brought him in and offered him the food I had made up (chicken w/rice and broth). He ate about half of it and then turned away. NOT like him at all. His back end just stumbled around.

He's shivering. Tummy appears to tighten, then release (like he is going to vomit or poop?).

Called the vet and they close from noon to 1:15 for lunch. Soonest I can bring him in is 1:30. Two hours from now. :( :( :( So worried about my baby....

[Harley PoMMom]

How is he doing? I know you must be so worried. Just as Judy mentioned I would have a CBC/chemistry panel done. I wouldn't think it is the Trilostane but you just never know.

[Renee]

Oh dear. I am so sorry this is happening. That tightening tummy is likely pain. I know you had said you didn't think it was pancreatitis, but it can present a little differently each time. I know you are scared and anxious. With just two hours until the vet, I am sure you are okay to wait. I would be prepared though to have bloodwork done and possibly leave him for supportive care for at least a few hours.

[judymaggie]

Thinking good thoughts for Visuddha, Shana -- hang in there!

[DoxieMama]

The vet's office called at noon to let me know the vet would be back in the office at 1:15 and I could bring him in then. I told her he is having a severe issue right now, she asked me to describe:

After posting the above, I took him outside and sat with him on the deck. He wanted to get down, stumbled a few steps away and then strained to defecate. After maybe 20 seconds of this, he "relaxed" into his normal posture and just stood there with his tummy tightening repeatedly. He did not respond to me when I called him. (I have a video of this that I showed the vet.) I picked him up and he was completely lethargic, tongue hanging out and mostly non responsive.

She put me on hold and the vet came on. I described this to him, he asked me to check his gums (light pink and very dry). He told me to bring him in right away, which I did.

His weight is normally 11 pounds. He's 10.1. VERY Dehydrated. His potassium is very low (didn't give me the number but I'll get it later). His pupils do not respond the same to light, which the vet says indicates a neurologic issue. Perhaps a stroke.

They have him now, to rehydrate him and bring his potassium up while we wait for the rest of the blood test results.

They'll call me if anything exciting happens. (My vet's words... he's such a comedian. :p)

[judymaggie]

Poor baby and how scary for you! I am so glad that the vet considered this a priority and you were able to bring him right in. Keeping both of you in my prayers -- hopefully, the fluids will put things back on an even keel.

[Renee]

Oh, I am so very sorry he has taken such a turn. I know exactly how terrified you must be. Sending many prayers that this is just a temporary set back and that V can get better quickly.

[DoxieMama]

Vet called back. He said they weren't able to get results from liver numbers, which is because they are so high. Diluted it and redid the test.

alt normal range 10-100, his is 2158
ggt normal range 0-7, his is 377

His liver is not working. They did an Xray and there is an abnormal shape mass on the liver. He also has gravel or something in his tummy. (Cat litter? Something from outside?)

He said we could take him for an abdominal ultrasound; if it is a tumor they can biopsy it. I talked to my husband and have a message in for him to call me back to answer questions: if we do the ultrasound, what are the possible outcomes of that? Surgery? We likely will not do that... Any other options? What if we don't do the ultrasound? What do we have to expect?

I'm so completely devastated and struggling so hard to not melt into a puddle of tears right now.

[judymaggie]

Shana -- I wish I was closer and could give you a hug -- cyber hugs will have to do. I am sure you are shocked by this turn of events. I think I would have the ultrasound done along with a consult with an internist. At least you could know exactly what is going on and then make a decision where to go from there.

Is Visuddha still at the vet?

[molly muffin]

Omg Shana. Just got off work and saw this. So scary. Okay if surgery isn't an option then what sort of alternatives are there and what is the prognosis. I'd stop all Cushing meds for now. That is low priority compared to this.

If you do see an internist we have a list of questions that we use for surgery possible dogs which might give you some ideas to use.

[DoxieMama]

I have a message in to the vet asking for possible prognosis of an ultrasound or not. Exactly what you said Sharlene, what sort of alternatives are there and what is the prognosis.

My husband said I should go get him. I want to. But if he's on IV for hydration then I'm not sure I want to take that off yet.

I am waiting anxiously for his return call.

[Harley PoMMom]

A bile duct obstruction or inflamed gallbladder will cause high elevations in the liver enzymes.

Keeping you all in my thoughts and prayers and sending huge loving hugs.

Lori

Edited to add: I see other symptoms of a bile duct obstruction are weakness, lethargy, fatigue, vomiting, abdominal pain...Just wonder if something is going on with that bile duct??

[DoxieMama]

Lori, that is one of the possibilities my vet mentioned. Just got off the phone with him again. He said by doing an ultrasound, we could determine if it is a bile duct obstruction, if the tumor is just in one lobe, etc. They would also look at the rest of the abdomen to see what's going on in there.

In the meantime, they will continue to push fluids for the next hour and a half. I will go pick him up and bring him home. If he makes a turn for the worse, we can take him to the pet emergency clinic where they can continue the care my vet is providing him now.

I expect we won't be giving him anything to eat tonight.

He said the Xray shows something like gravel. It's not food, because it's... and I couldn't understand what he said. I asked him to repeat it twice but I still didn't get it. Radiation something or other?

An ultrasound will show exactly what we're dealing with; otherwise we would be guessing. Depending on what it is, it may or may not be treatable with meds. No way to know unless we do that ultrasound.

Going to chat w/hubby now...
Thanks for the continued support!
Shana

Edited to add: I called and requested they set up the appointment for the ultrasound. Bringing him home in an hour, and going to cuddle him all night. Send prayers and good thoughts that he does well until that appointment - and that they can get him in ASAP!

[labblab]

Shana, I'm so sorry hear what's going on! Just want you to know that I'm keeping your sweet boy in my thoughts, and surely hoping there may be a nonsurgical solution at hand.

Sending tons of hugs your way,
Marianne

[molly muffin]

We are all here with you.

I'd do the ultrasound so you k ow better what options you have.

[DoxieMama]

He is home now. He has a catheter in so I can give him fluids every few hours, and in case he needs to go to pet ER tonight. HOPE NOT!!

We will find out when we can do the U/S in the AM. The vet has a message in requesting they call as soon as they get in, hoping they call before they open so I can get down there quickly. Crossing my fingers and saying prayers they can do it tomorrow AM. My boss replied to my text allowing me to take a vacation day tomorrow.

No food tonight, as he had sufficient calories this morning/noon. It's a balancing act between ammonia levels and hypoglycemia.

Abnormal test results from today (ranges in parens):

Na 153 (normal 144-160)
K 3.3 (3.5-5.8)
Ratio: 46.4
RBC 11.17 M/uL (5.5-8.5)
HCT 75.1% (37-55)
MCH 14.2 pg (18.5-30)
NEU 13.39 K/uL (2-12)
TBIL 1.5 mg/dL (0-0.9)
CHOL >520 mg/dL (110-320)
AMYL 384 U/L (500-1500)
ALT 2158 U/L (10-100)*
GGT 377 (0-7)*

* Chemistry results for the latest analyzer run have been multiplied by the dilution factor for a dilution of 1 in 4 total.
(My vet explained that the first test 12:24pm did not provide a reading for ALT or ALKP. The second diluted test gave the ALT and GGT results noted above. There is still no reading on ALKP.)

Vet tech just called. I'm headed back down there for subcutaneous fluids to help us get through the night and hopefully not have to go to the ER. Back in a jif!

Edit: We're back. But it looks like I covered everything already. So, off to relax on the couch and spend some quality time with my baby dog. Thanks for hanging in here with me today.

[Joan2517]

Shana, just saw all that has happened today...keeping you and your sweet boy in my thoughts and prayers.

[judymaggie]

Shana--I surely hope that you and Visuddha can get some rest tonight. Please give him a gentle hug from us! Hoping that ultrasound can be done as quickly as possible so you know exactly what is going on. "See" you in the morning!

[Harley PoMMom]

Saying special prayers for you and your sweet boy, sending loving and huge hugs.

[molly muffin]

Checking in this morning to see how he is doing and send good wishes your way.

[labblab]

Me too!!! Hoping so much for some improvement today and some helpful info from the ultrasound.

Marianne

[Tina]

Shana, I am so sorry to read about everything that happened with Visuddha yesterday, how scary. I am hoping you both were able to get some rest and that he is doing better this morning. Hopefully you will be able to get the ultrasound asap. Sending prayers and hugs. xo

[DoxieMama]

Thank you all for your loving thoughts and cyber hugs. I appreciate them so very much.

I was unable to flush Visuddha's IV from the very beginning, so they'll have to put a new one in. He's been restless all night, sleeping anywhere from half an hour to two hours at a time, then getting up sometimes for a drink and/or potty trip, sometimes for no apparent reason. I've not gotten much sleep at all.

He is very wobbly, but has successfully navigated the short steps on our deck throughout the night mostly without help. Whenever he shakes himself off, he falls over. When awake, he has licked my arm multiple times while we are lying down, and wagged his tail when on the ground and I pet him. Otherwise, he's just a sleepy pup who doesn't feel well.

The vet and imaging offices both open at 8am, 3 hours from now, so I'm hoping for a call by then about the ultrasound. I'm hoping they call and tell me to head in immediately.

[judymaggie]

I am hoping that you have heard scheduling info re the ultrasound. I would think that Visuddha would be a high priority! Hang in there--answers will come soon.

[DoxieMama]

I just got home after dropping him off for the ultrasound. They will call me to pick him up in 2-3 hours, and will contact my vet with the results (including any biopsy or fine needle aspirates they do - same day results yay!).

Before we left, I asked them about giving him a little rice which they said was fine. So he had maybe 1T of rice at about 9am. No visible issues from that, so I'm more hopeful than I was.

I haven't eaten anything yet today, so I'm going to go do that now. I'll post results when I have them.

[Harley PoMMom]

Sending positive energy your way. I know how worried you must be and hopefully by now you have gotten something to eat, you need to take of yourself too.

Keeping you both in my thoughts and prayers.

((((HUGS))))

[Trish]

Hi Shana
Gosh what a day or two you have had. Have my fingers crossed for the very best outcome from the ultrasound.
Big hugs
Trish xx

[Renee]

We're all here with you and little V. You are not alone!

[judymaggie]

Sending good vibes your way! I'm so glad that you can get results today -- I second Lori's encouragement to take care of yourself.

[molly muffin]

I am checking in too. Hoping for positive results!!!
You DO Have to remember to take care of yourself, even though I know that isn't a priority when so worried, but you need to be strong to help him.

HUGS

[DoxieMama]

How comforting to come back and find all of your messages. Group hug for all of you!

I did get myself something to eat after my last post. I knew I needed sustenance to have a clear head. A bit of a nap would be nice, but that was interrupted by a call that Visuddha was done with his ultrasound and ready to go home. I picked him up and stopped by the vet's office to have them remove the catheter. While we were waiting to be seen, the vet got the report on the ultrasound. The good news is, there is no tumor. He did see some inflammation. The gravel in his tummy was confirmed but of course we don't know what else he might have eaten. So we don't know the root cause at this point. But the vet wanted to keep him for the next few hours and get him rehydrated again, start IV antibiotics and see if he will keep some food down. So I left him there and will return to pick him up around 5pm. I'll ask for copies of the report when I pick him up.

I don't know what to expect next, but I'll update as I know more.

[molly muffin]

Well yay no tumor!! So it rather sounds like his electrolytes where off again(potassium). And the gravel might be making him throw up and upsetting his gastro system.

So this is all better news than we all worrying about. Any gallbladder
Blockage? Now doe all the other organs look. Nothing on liver t lol? Did they give you a copy of ultrasound report?
What do,they suggest now for going forward?
I know a million questions right :)

[judymaggie]

HOORAY -- :D:D:D:D, NO TUMOR!! Gravel or ... kitty litter? Might look the same on an ultrasound. Am with Sharlene in wanting to know what other organs look like -- I am not familiar enough with the bile duct to know exactly where it is located and how it might look on an ultrasound. I know you want to get Visuddha back home but good idea for vet to get him restabilized -- I bet he is absolutely exhausted from today's events.

[Harley PoMMom]

I'm joining in, too, celebrating that there is NO tumor!!!!! Whew~~Get better Visuddha, we're all rooting for ya ;)

(((HUGS)))

[DoxieMama]

Visuddha is home again, though the vet did ask how I felt about taking him down to the Pet Emergency to spend the night so they can continue to monitor him and give him fluids. I chose to bring him home, feed and provide antibiotics and watch him through the night. If he has a seizure, collapses or another major issue, I am to take him to Pet ER immediately. If he does not, but is not doing well in the AM, I am to bring him back to the vet so they can check his levels again. Low glucose is of particular concern now.

Vet told me to bring him home and feed him immediately, then get those meds in him. I did. I fed him 3oz of rice/cottage cheese mixture, then with my husband's help, got his liquid abx down him. He ate the pill hidden in a bit more rice/cottage cheese from my hand. (I'm hoping I can hide his liquids in food and he'll still eat them. He does NOT take meds well, and I'm horrible at administering them.)

Vet comments:
1) His ultrasound did not detect any obvious tumors of his liver, or anywhere else in his abdomen. No evidence of a bile duct obstruction was seen.
2) His fine needle aspirate of the liver showed mild inflammation, but the pathologist noted that a complete biopsy would be more informative.
At this point we are thinking some type of liver insult from something he ate. The gravel in his intestines shows he has been eating dirt, so who knows what else he may have picked up in the yard.
We should not give the trilostane until he is eating and acting normal. I think you should feed him a combination of cooked white rice mixed 50:50 with some low fat cottage cheese 2-3 ounces three times a day. If he continues to appear weak, does not eat or drink, we should recheck him immediately.
We are treating him with two antibiotics (Clavamox, metronidazole) and lactulose (laxactive). We are treating a potential cholangiohepatitis and trying to reduct any excessive blood ammonia.

Notes on the pathology report (skipping history): An abdominal ultrasound reveals bilateral adrenomegaly, a normal appearing liver, and lots of gallbladder sludge. The liver was aspirated for cytologic review.

Description: Three slides are available for review. The slides contain low numbers of nucleated cells and moderate numbers of erythrocytes. There is a predominance of oval to polygonal cells situated in both cohesive clusters and singly with generally distinct cell borders. Their cytoplasm is abundant, lightly basophilic, slightly granular, and contains a small amount of distinct vacuolation. Many cells contain blue-green pigment granules consistent with bile or lipofuscin. Their nuclei are round to oval, with a finely stippled chromatin pattern and a single central nucleolus. Occasional bi-nucleated cells are seen. This population exhibits mild anisocytosis and anisokaryosis, and these cells are consistent with hepatocytes. Neutrophils appear mildly increased relative to the degree of Hemodilution, while monocytes, small lymphocytes, eosinophils and platelets are present in proportions compatible with peripheral blood. The background is lightly basophilic, stippled, and contains low numbers of bare hepatocyte nuclei. No infectious agents are observed.

Interpretation: Mild hepatocyte vacuolar (lipid) degeneration - see comments.

Comments: Many of this patient's hepatocytes contain small, abnormal accumulations of lipid (image 1). This nonspecific indicator of hepatocellular injury can occur seconary to hypoxia, hepatotoxic exposure, or inflammatory disease. Hepatocytes can also accumulate lipid in cases of systemic hyperlipidemia or lipid dysregulation (e.g., pancreatitis, protein losing nephropathy). While cytology is a good screening test for diffuse (e.g., lymphoma) and focal neoplasia, it has limited sensitivity for the detection of hepatic inflammation, necrosis or fibrosis. So, while hepatic neoplasia is unlikely based on these samples, biopsy and histopathology would be necessary to exclude inflammatory, necrotic, or fibrotic disease and should be pursued if this patient's liver enzymes remain elevated despite good regulation of his endocrine disease.

(There are additional comments regarding the enzyme AST due to a miscommunication - I must have written AST on the paperwork rather than ALT causing confusion. The vet intends to call the pathologist in the morning to clarify and see if this changes her report at all.)

Blood test results from today:

GLU 53 mg/dL (70-143)
CREA 0 mg/dL (0.5-1.8)
TP 4.0 g/dL (5.2-8.2)
ALT 1124 U/L (10-100) (this has gone down from yesterday's 2158)
GGT 320 U/L (0-7) (also down from 377 yesterday)
K 2.7 mmol/L (3.5-5.8) (also down from 3.3... not good)
Na/K Ratio: 58.5 !!!


He was resting in my lap while I typed most of this post. Then he needed to go outside - little BM that appears pretty soft. He then "jogged" across the yard to go back into the house. :D We are not out of the woods yet but I'm pretty darn happy with how he is acting right now.

Keep those prayers and good thoughts coming, please!!

[Harley PoMMom]

Tons and tons of prayers being said and sent for our dear Visuddha. I am so glad to hear that he is doing better and is home in his loving environment.

I would think that the hypoglycemia would have an impact on the liver and cause elevations in those liver enzymes???

Keeping fingers crossed that Visuddha will show more improvement tomorrow.

Sending huge and loving hugs, Lori

[DoxieMama]

Thanks Lori. I'm also wondering if his not having hardly eaten is cause for those low numbers. Maybe having some food will help all of them. Plus the abx, and being home without poking and prodding.

I fed him a little more before we went to bed, as he was still very hungry. We have been up every hour to hour and a half throughout the night. Water every waking, potty afterward most of the time. The first few trips my baby dog looked strong, walking through the kitchen and in/out to potty with nary a wobble. At about 2am he was a little unsteady so I gave him 2.5 ounces food along with one of the meds (laxative one I think... Dose every 8 hours). He ate that with relish and is sleeping again.

Me, not so much. All the what ifs... Second guessing etc has me up. So I figured I'd post a little update. :)

Oh it sounds like he is awake. Time for snuggles I think.

[labblab]

Hi Shana, just now awake myself and anxiously reading your report. Surely hoping that today y'all will turn the corner for the better. Sending prayers and well wishes your way!

Marianne

[DoxieMama]

Thanks Marianne.

The vet's office called to check on him this morning. After updating the vet, they called back and said that he would like to check his electrolytes and glucose levels again. If they are not normal, he recommends their keeping him today and trying to remedy that. The sooner I can bring him in, the better their chances of doing so.

I was so hoping to just spend the day with him. It's my choice. Of course I want to do the best for him, I just hate leaving him alone. :(:(:( Not to mention the expense.

I asked her to give me a couple hours, so they're expecting us around 9:30 this morning. I will take him for the tests, but I don't know if I will leave him there... I took another vacation day today so I could be with him, not be home while he's at the vet's office all day. Again.

[DoxieMama]

We just got home from the vet. Yes, we. :) I didn't get a copy of the results (will do later) but was told that his potassium increased 0.1 (so 2.8 now, still low) and glucose is normal. They donated an expired bottle of RenaPlus potassium supplement for me to start giving him and want to test him again tomorrow morning. Continuing all other supplements, and feeding every 4-6 hours or more frequently if I notice weakening/wobbliness.

[DoxieMama]

Just got a copy of the ultrasound report:

Imaging Findings:
Ultrasound evaluation of the abdomen shows no evidence of peritoneal effusion. The liver is mildly hyperechoic, but appears normal in size. There is a large quantity of sludge within the gallbladder. The distal aspect of the biliary bile duct is within normal limits and measures 3.8 mm. There is no evidence of inflammation surrounding the gallbladder. The kidneys are normal in shape and size with good corticomedullary distinction and no evidence of renal pelvis dilation. The urinary bladder is moderately distended with no abnormalities. The adrenals are large and normal in shape. The left measures 9.3 mm while the right measures 8.9 mm. The pancreas is normal in size and echogenicity. No gastrointestinal tract abnormalities are identified. The spleen is normal in size and echogenicity. The medial iliac and mesenteric lymph nodes are within normal limits and measure less than 4 mm. The prostate is small and hypoechoic.

Impression:
1) Unremarkable liver. 2) Gallbladder sludge. 3) Large adrenals.

Comments:
A fine needle aspirate of the liver was acquired. This should be helpful to rule out neoplasia such as lymphoma. This may also rule out underlying inflammation. I do not see evidence of inflammation surrounding the gallbladder. Therefore, I do not feel that the elevated liver enzymes are attributed to gallbladder disease. Also, the distal aspect of the bile duct is within normal limits and measures 3.8 mm. Symptomatic therapy for cholangiohepatitis may be considered. The adrenals are large and normal in shape. This is attributed to hyperplasia. However, benign neoplasia such as adenomas cannot be completely ruled out. Following the ultrasound examination, a lateral view of the abdomen is acquired and showed the liver to be within normal limits for size. There is a large quantity of radiopaque debris within the descending colon. This may be attributed to small rocks or bones. The vomiting may be attributed to dietary indiscretion.

[judymaggie]

Shana -- so glad that you and Visuddha can spend the rest of the day together. All in all, in spite of how sick Visuddha got, the ultrasound report is really good. Not only does he not have a liver tumor, his liver is "unremarkable" which is great for a Cush pup! My Maggie had a lot of gallbladder sludge in her later years and she was on Ursodiol for several years. Interesting reference to "dietary indiscretion" -- don't you wish our pups could talk!!

More hugs headed your way -- try to get some rest!

[molly muffin]

Yay, glad you could spend the day together. Food can definitely affect sugar levels and other levels, and he hasn't been eating much lately due to the throwing up.

I agree, the ultrasound is pretty darn good, so I have high hopes for our boy. :)

[DoxieMama]

My vet called this evening to check on my baby dog, who I reported to him has plateaued, though may be slightly improved. It's hard to say. He has been eating his 3 ounces of rice/cottage cheese mixture every 4 hours, drinking a little water every 2 hours and going out for potty every 2-4 hours. He has not had a BM today, which of course we need to watch for. I've been going out with him every time, keeping him in my sights to be able to document how he's doing (and note that he has eaten very small amounts of grass twice today). Otherwise, he rests in/near my lap.

The plan to test tomorrow morning remains, as well as allowing the covering vet to "get a look at him" (which I hadn't planned time for but it makes sense). Oh yes, our vet is going on vacation for two weeks, starting today. Great timing, right? Heh. The covering vet (Dr C) is a resident of the Pet Emergency which is open nights and weekends, and is "very good" according to my vet. I'm sure she will be fine.

I asked him how frequently he thinks we need to test him. He said that we want to at least get a weight on him daily if possible, which I can do at home with my digital scale. I've been doing that anyway, but now I'll start to document it. That will help monitor dehydration (as well as checking his gums and skin elasticity). Otherwise, testing after tomorrow he deferred to Dr. C.

I also asked him, given best case scenario and V recovers from this, how long will we continue on the rice/cottage cheese diet. We will do this until his liver enzymes return to normal. I questioned if that would ever be possible given his Cushing's and he said we want to see GGT and ALT a whole lot closer to normal than they are now. (GGT was 377 Monday, down to 320 yesterday then up a little today. ALT was 2158, 1124 and 880. ALP has been so high we don't have a number on that yet.) We also want to see his potassium come back up into the normal range.

We do what we can, wait and see.

I never thought I would be here, with a senior dog having various health issues, and struggling with caring for him... knowing what is the next right thing to do. Taking vacation time, rearranging my schedule, giving up sleep... feeding a special diet, forcing meds down him, taking him to the vet/specialist day after day after day for blood draws and IV's.

I'm sorry. I know I've posted quite a lot here these past few days. But I haven't shared this in any depth with anyone other than my husband. I've been only as specific as necessary with my boss, told a couple co-workers only that we're having tests done and trying to figure out what's wrong. The one co-worker I gave a bit more detail to today, one of her questions was "how old is he?" which.... just irritates me so :mad::rolleyes::mad::eek::p

Even still, I wonder if I'm doing right by him. I know I am. Yet, I question.

I've got to work tomorrow, which only exacerbates things for me. I'll come home at lunchtime to feed and provide meds, but the rest of the day he'll be "on his own".

Enough whining. I'll check in tomorrow.