Diabetes and "normal" cortisol levels

[Gizmo'sMom3]

Hi all, Gizmo has a new vet in our new city and I am not confident in him. He has been treated with 20mg Vetoryl for the past year and a half for Cushings. He has been drinking and peeing excessively and they tested his urine today and I was told there was glucose in it. They gave him a diabetes diagnosis which requires twice a day insulin injections! I am looking for a new vet for a second opinion before I proceed with that. Do you know of any reason why glucose would be high in the urine of a dog with Cushings?

Also, a different vet examined Gizmo today and she said that she likes to keep his cortisol levels lower than what his last test showed in December (which my vet said is normal). Turns out they didn't take a baseline but the post injection level was 6.7 She said she suggests changing the dose of his Vetoryl (or splitting his dose up to 10mg 2x/day). I can't find a chart of what "normal" Cortisol levels are. Can anyone provide me that information? Thank you!

[mytil]

Hi and welcome to our site.

It can certainly be very confusing when vets approach Cushing's in very different ways but let me us try to sort this out for you. First of all, read through this link on Vetoryl (specifically the chart on page 11) - http://www.dechrace.com/pdfs/vetoryl/VETORYLTechnicalBrochure.pdf.

There are some vets that do not record the resting cortisol levels when taking an ACTH for monitoring purposes.

Twice a day (BID) dosing is used a lot if the symptoms creep back so that is not unusual. What numbers is this new vet looking to see?

Please post the glucose numbers here as well. Cushpups do get diabetes (may not necessarily be caused by Cushing's but in some cases I have seen there is a connection) and that makes it a bit harder to keep the cortisol levels in check and so the symptoms return. I would certainly get another testing to check the glucose levels if it were me and if it turns out he is diabetic please make sure the glucose levels are stabilized first and foremost as this could be skewing the ACTH testing results. Then IMO I would then make any Vetoryl dosing changes.

What breed is your boy?

Keep us posted
Terry

[labblab]

Hello and welcome from me, too! Terry has given you the link to a very helpful publication. As you'll see, when Cushing's symptoms such as excessive thirst/urination persist or rebound in a dog taking trilostane, it is recommended that the post-ACTH cortisol level be lowered to a level between 1.54 - 5.4 ug/dL. So I am guessing that is the basis for the vet's suggestion for a dosing change.

The complicating piece, of course, is whether Gizmo really has diabetes and is that instead what is causing the thirst/urination. Is the vet basing the diabetes solely on glucose in the urine, or was his glucose level high on his blood work, too? I would assume that before starting insulin, a panel of blood chemistries would also have been done. Can you check on that and let us know about any abnormalities?

Dogs with Cushing's can also be vulnerable to developing diabetes, so we have had many other dogs with both illnesses through the years. Sometimes it can be hard to untangle the two diagnoses and the symptoms since there is a lot of overlap between the two. But if Gizmo does now truly have elevated glucose levels after this length of time of Cushing's treatment, I would have to assume the diabetes is truly present.

If so, and if Gizmo does start on insulin, then it is preferred that trilostane be given twice daily rather than only once in the morning. So the new vet's recommendation to shift to 10 mg. both morning and evening may be a good one all the way around. It may lead to somewhat lower cortisol levels and also will be the best regimen if insulin is started.

I'm going to encourage you to also join our sister forum that deals with diabetic dogs. The folks there can help you clarify the diabetes diagnosis, and will be very supportive if you start insulin. We have other folks who belong to both forums, so we will hope that you will continue to post in both places. ;)

http://www.k9diabetes.com/forum/

Thanks in advance for any additional info you can share, and again, I'm really glad you found us.

Marianne

[Gizmo'sMom3]

Terry and Marianne, thank you so much for this input. My sweet Gizmo is an 11 lb Maltese. The diagnosis was made solely based on dip stick in his urine. They then took blood to test his glucose and are also sending the urine out to a lab to "confirm" the diagnosis. They did not run a full blood chemistry because it was $250 and they didn't feel it was necessary. I never paid $250 for a routine blood panel!! Insane. It seems to me that they should be looking at everything and ruling other things out too (eg, UTI). However, it does sound like this may be a valid diagnosis. I hate that I walked out of there with a $400 bill and will now have to get a second opinion before I proceed with anything.

Thank you so much for the referral to the diabetes forum. That looks like a great resource for me. The vet was so casual in mentioning I would have to give insulin shots twice a day for the rest of his life. That's a bigger commitment than Vetoryl!

Michelle

[Gizmo'sMom3]

Gizmo's glucose level in his blood was 517. I'm making an appointment to see a specialist :(

[labblab]

I think that's an excellent idea! With a blood glucose level that high, it will be inportant to see somebody knowledgeable just as quickly as possible. When you make the appointment, be sure to let them know how high that glucose reading was so that they'll recognize the urgency of getting in. And do keep us updated!

[mytil]

Hi Michelle,
Glad to hear this.
Keep us posted
Terry

[molly muffin]

Hello I just want to welcome you to the forum. Marianne and Terry have gotten you off to a good start.

It is not uncommon for cushings dogs to develop diabetes, and it can come on very sudden.

A specialist is definitely the best option Hopefully they can give you a quick appointment.

[Gizmo'sMom3]

Thank you all for your advice and support. I wanted to post an update for others in case they have a similar issue in the future.

molly muffin, the specialist said exactly what you said (and thank you for the welcome to the forum, it's a great resource!):

- It is common among dogs with Cushings and it can come on suddenly (we had bloodwork done in Jan and his glucose was normal). It can be tricky to see if it's the Cushings or Diabetes causing the symptoms because many of them are the same.

- Interestingly, uncontrolled/poorly-controlled Cushing's can CAUSE diabetes. Gizmo's cortisol level after his stim test in Jan was 6.7 which I have now learned is too high and this vet confirmed that.

Also interestingly, some dogs (cushinoid or not) clear up diabetes on their own within 3 months of diagnosis. In Cushinoid dogs, controlling the Cushings may cause the diabetes to go away. I am PRAYING that is the case with sweet Gizmo. At the moment I'm chasing him around my apartment with a needle trying to get him to take insulin :(, followed by 3 different eye drops and a glob of cream cheese with vetoryl. It's not fun. I had to put a checklist on my fridge because he's now taking so much stuff I can't keep track of it or remember what I had already given him!

[molly muffin]

It's always so much harder when you are trying to tackle not one disease but two.
I am sure that you will get into a routine eventually but a list on the refrigerator isn't a bad idea at all.
My dog has more medicine and stuff on the counter top than we humans do. :)

[Gizmo'sMom3]

It's always so much harder when you are trying to tackle not one disease but two.
I am sure that you will get into a routine eventually but a list on the refrigerator isn't a bad idea at all.
My dog has more medicine and stuff on the counter top than we humans do. :)

Me too :( Poor guy. I wish we could explain it to them. It's also hard finding someone comfortable treating them. I can't afford to see this specialist regularly, so I have to find a different regular vet that I trust to treat more routine issues like ear infections or whatever. My vet has made it clear that he's not comfortable treating Gizmo.

[Sissy's Mom]

Hi Gizmo,
I have a diabetic that also takes thyroid,and we are getting ready to test for cushings.
I keep a notebook by her meds and mark them off on notebook!!! Also write down notes about behavior,problems,etc! It helps with multiple issues...
Best of luck, i also have a regular vet for reg stuff and do recheck bloodwork cause she is cheaper ( and good) then an IMS for the more technical stuff.works good for us.both vets send reports to each other:)

[Gizmo'sMom3]

Hi Gizmo,
Also write down notes about behavior,problems,etc! It helps with multiple issues...
Best of luck, i also have a regular vet for reg stuff and do recheck bloodwork cause she is cheaper ( and good) then an IMS for the more technical stuff.works good for us.both vets send reports to each other:)

Sorry to hear about Sissy. I hope everything works out. Cushings is much easier to deal with than diabetes, I think. Gizmo refuses to stop moving the minute I go for his neck and then he pulls away the minute I stab him, if/when I can :(. Thanks for the tip on how you handle the vets. I think that's what I'm going to do (with a new vet because I don't like my current one) and keep the specialist for the more serious/technical stuff.

[Sissy's Mom]

Thanks,hope your vet situation works.
Lol,i dont know.i have gotten familar with diabetes,cushings scares me.i think mostly because of its effects on thyroid and diabetes!!!!

[Gizmo'sMom3]

Thank you. I'll figure it out. I'll trade with you...a second Cushing's diagnosis for the diabetes! There is no insulin shock to worry about or anything. Once you get the dose right, it's easy. And then just monitoring. Surprised the diabetes came first though. My vet said that uncontrolled Cushing's can cause the diabetes, but sounds like yours happened the other way around. Best of luck.

[Sissy's Mom]

Ya,sissy has been diabetic almost 4 yrs,but her vets have always said she has cushings,but tests never have been conclusive...she doesn't drink and pee a lot,no panting,just her belly and hair loss.at least visible signs anyway...its so hard to know if you should treat...i think her thyroid and diabetes not being well controlled would be the benefit.havent figured out my feelings on all that yet...see what the first test shows i guess, when i can do that:eek:

[Gizmo'sMom3]

Hi all, you have all been so helpful for me in the past that I am reaching out for advice again. My sweet Gizmo has been very difficult to treat over the past year or so. He was diagnosed with diabetes which was difficult to get under control, but we finally did so. His Cushing's has been treated for about 4 years now. However, over the past 2 months, he has started to urinate ALL over the house, including in his bed (and also drink excessively). We have treated for a UTI, did an ultrasound, did multiple diabetes curve tests and also multiple stim tests. My vet is thinking that possibly Gizmo belongs to a small sub-set of dogs that show that they are being controlled by their Cushing's med (in this case, Vetoryl), but in fact, are not controlled. So he is suggesting we try switching him to Mitotane (which he has acknowledged is not a popular choice for treating Cushing's but has still suggested we try to make the change). Has anyone heard of this before or had experience with this? Where the tests show it is under control but they are still highly symptomatic? Here are the results from his latest stim. I am already giving him 10mg in the morning and at night and I cannot increase to 3x a day.

3/27/17:
1) < 1.0 ug/dL
2) 3.7 ug/dL

Thank you so much.

Michelle

[Harley PoMMom]

Those are good numbers, he is getting his Vetoryl with a meal and those ACTH stimulation tests are performed 4-6 hours post pill, right?

Dogs with Cushing's generally have diluted urine which a regular urinalysis may not pick up so it is recommended to have the urine cultured, so if this wasn't done, I believe that is the next step I would take.

If the decision is made to start the Lysodren a 30 day washout period is required before switching from Vetoryl to Lysodren and vice versa.

Did the urine accidents and increased drinking just start? Does it seem like those symptoms rebound more at night?

Hugs, Lori

[Gizmo'sMom3]

Hi Lori,

I did culture his urine in early November. What would be the numbers of the culture that would be helpful for you to see? And yes, the stim test was done in that time frame and they are the same numbers that showed up 3 months ago. The urination is all times of the day, definitely not only at night. And it seems to have started to be noticeable in the past few months.

Thanks,
Michelle

[molly muffin]

How are his BUN and Creatinine? That is a perfect number for control of cortisol. Usually they switch to miotane when control cannot be achieved with vetroyl.

We have seen dogs with that are resistant and the UTI comes back full force and they end up needing to be on antibiotics for the UTI for around 30 days, sometimes even more to get it to fully clear up and not come right back within a week or so.

[westcoastflea1]

read this article tests on humans with cushings http://www.eje-online.org Cabergoline was described as having potential positive metabolic effects. Similar to other dopamine receptor agonists, it could lower blood pressure and improve glucose tolerance independent of its cortisol lowering effect. Dopamine agonists lower peripheral resistance, relaxing vascular wall smooth muscles, with consequent improvement of blood pressure (32). Also, bromocriptine improved glucose homeostasis in type 2 diabetes patients by stimulating splanchnic glucose reuptake and by helping insulin-mediated suppression of hepatic glucose production (35).

[Gizmo'sMom3]

I am switching my sweet Gizmo to lysodren. I have read conflicting information about the washout period. My vet planned on 14 days because he said it is short-acting, but some people seem to say 30 days. Is there any official documentation or information on how to make the switch or what the washout period is? Thank you!

[Harley PoMMom]

I've taken the liberty and moved your post inquiring about the 30 washout period when switching from Vetoryl to Lysodren, in this way all information regarding your precious boy is in one place,

This excerpt is from a Q&D with Dr Feldman:
DVM: ...Is there a particular protocol you use if you switch between the two medications to avoid possible complications, in light of a couple of reported cases of acute adrenocortical necrosis following a switch?

Feldman: Any dog switched from one to the other should receive no medication for at least six weeks.

Editor's Note: Edward C. Feldman, DVM, Dipl. ACVIM, is the chair of the Department of Medicine and Epidemiology at the University of California-Davis School of Veterinary Medicine. He is a co-founder and former president of the Society of Comparative Endocrinology, a special interest group open to all veterinarians, and is a co-author of the Textbook of Veterinary Internal Medicine with Dr. Stephen Ettinger and Canine and Feline Endocrinology and Reproduction with Dr. Richard Nelson.



This article can be found in our Helpful Resource Forum: http://www.k9cushings.com/forum/showthread.php?t=2231

There are more articles that convey that same message, I'm at work and this is the first article I thought of.

Hugs, Lori

[lulusmom]

Hi Michelle.

Lori has provided you with some very good information on switching from Vetoryl to Lysodren and vice versa so I won't repeat her. What I wanted to mention is that it is not beyond the realm of possibility that Gizmo could have an enlarging pituitary macroadenoma that has compressed enough to inhibit the release of vassopressin also known as antidiuretic hormone. This hormone regulates water retention and tells the kidneys how much water to conserve so if there isn't enough or no vassopressin being secreted, the kidneys no longer concentrate the urine and a dog develops central diabetes insipidus. Switching to Lysodren would not remedy this situation as neither that drug or trilostane has any effect on the pituitary gland. These dogs usually respond to Desmopressin Acetate eye drops which is a synthetic form of vassopressin. If I were in your shoes, I'd seriously consider a trial of Desmopressin (DDVAP) eye or nose drops before discontinuing trilostane, which will almost surely cause spikes in Gizmo blood sugar as cortisol rises. If both cortisol and bg are well controlled and the cause of Gizmo's excessive drinking and peeing is lack of vasopressin, then he should respond rather quickly to the DDVAP. I personally think it's worth a try. I would hate for you to go through a wash out and loading with lysodren only to see no improvement. My second cushdog was ultimately diagnosed with diabetes insipidus. Neither trilostane or mitotane resolved his PU/PD and unfortunately, he did not respond to DDVAP drops. I hope this helps.

Glynda

[Gizmo'sMom3]

Hi Michelle.

Lori has provided you with some very good information on switching from Vetoryl to Lysodren and vice versa so I won't repeat her. What I wanted to mention is that it is not beyond the realm of possibility that Gizmo could have an enlarging pituitary macroadenoma that has compressed enough to inhibit the release of vassopressin also known as antidiuretic hormone. This hormone regulates water retention and tells the kidneys how much water to conserve so if there isn't enough or no vassopressin being secreted, the kidneys no longer concentrate the urine and a dog develops central diabetes insipidus. Switching to Lysodren would not remedy this situation as neither that drug or trilostane has any effect on the pituitary gland. These dogs usually respond to Desmopressin Acetate eye drops which is a synthetic form of vassopressin. If I were in your shoes, I'd seriously consider a trial of Desmopressin (DDVAP) eye or nose drops before discontinuing trilostane, which will almost surely cause spikes in Gizmo blood sugar as cortisol rises. If both cortisol and bg are well controlled and the cause of Gizmo's excessive drinking and peeing is lack of vasopressin, then he should respond rather quickly to the DDVAP. I personally think it's worth a try. I would hate for you to go through a wash out and loading with lysodren only to see no improvement. My second cushdog was ultimately diagnosed with diabetes insipidus. Neither trilostane or mitotane resolved his PU/PD and unfortunately, he did not respond to DDVAP drops. I hope this helps.

Glynda

Hi Glynda, thanks SO much for this detailed information. It actually makes me feel better because I did try that. Although it was in pill form (called Desmopressin). Are eye or nose drops different? I was praying that it would work, but it didn't :(

[Gizmo'sMom3]

I've taken the liberty and moved your post inquiring about the 30 washout period when switching from Vetoryl to Lysodren, in this way all information regarding your precious boy is in one place,

This excerpt is from a Q&D with Dr Feldman:

This article can be found in our Helpful Resource Forum: http://www.k9cushings.com/forum/showthread.php?t=2231

There are more articles that convey that same message, I'm at work and this is the first article I thought of.

Hugs, Lori

Hi Lori, thanks for sending through this article. There seems to be conflicting information. My vet is at a large vet hospital here in LA and I trust his experience. And there don't seem to be other resources online that say it should be that long. I wonder how my vet decided on 2 weeks. Maybe I will call back tomorrow and ask.

[labblab]

Hello again from me! For what it's worth, here's another reference to a 30-day washout taken from the U.S. Product Insert for Vetoryl. However, as you'll see, it is referencing a switch from Lysodren to trilostane, rather than vice versa:


Mitotane (o,p’-DDD) treatment will reduce adrenal function. Experience in foreign markets suggests that when mitotane therapy is stopped, an interval of at least one month should elapse before the introduction of VETORYL Capsules. It is important to wait for both the recurrence of clinical signs consistent with hyperadrenocorticism, and a post-ACTH cortisol level of > 9.1 μg/dL (> 250 nmol/L) before treatment with VETORYL Capsules is initiated. Close monitoring of adrenal function is advised, as dogs previously treated with mitotane may be more responsive to the effects of VETORYL Capsules.

Some years ago, I contacted the vet who was the chief technical rep for Dechra U.S. at the time, and asked his opinion about a switch from trilo to Lysodren. His response then was that, in his opinion, the timing might best be dependent upon a dog's specific lab and symptom profile as opposed to an arbitrary time period, but that he would not recommend reinstituting treatment until symptoms had recurred and post-ACTH cortisol had rebounded to a level back up to 9-12 ug/dL. I have no idea what Dechra's official current recommendation would be, and I do think there remains some variability among clinicians as to timing. Dr. Feldman is for sure one of the more conservative in this regard.

Personally (and I am certainly not a researcher or clinician myself), I would not feel comfortable instituting Lysodren treatment, even for a symptomatic dog, until a post-ACTH test demonstrated a rebounded cortisol level. Until that occurs, you would have no objective indicator that any lingering physiological effect of the trilo on the adrenal function had ended, and I think this time period might be quite variable from dog to dog. I realize this is a bit more of a complicated path to negotiate for a dog like Gizmo, who is diabetic and still symptomatic even though his cortisol is within therapeutic range. I also realize that the longer he goes without Cushing's treatment, the more erratic his glucose level may become.

But these are just a few more pieces to fit into the puzzle, and I think it's a good idea to talk with your vet further as to his specific reasoning for picking the two-week time period.

Marianne

[Carole Alexander]

Regarding the washout if you switch from Vetoryl to Lysodren, my local vet said two weeks as cortisol was already lowered. Absolutely not said my IMS. She said to wait at least a month, six weeks ideally. Instead my dog had an MRI revealing a macro tumor. But, the IMS also said that many dogs with micro pituitary tumors cannot tolerate Vetoryl.

[lulusmom]

Hi, Michelle, and thank you for responding.

It seems as though you've left no stones unturned in trying to figure out why Gizmo has persistent PU/PD. When was the last urinalysis done and can you share the results. I would be most interested in the USG. Just in case there may be another stone or two you may want to turn, I've attached a Q & A page from Dr. Mark Peterson's Insights in Veterinary Endocrinology entitled "Diagnostic Approach to PU/PD: Urine Specific Gravity". You will notice that depending on USG, atypical leptospirosis could be a differential diagnosis. Did your vet rule this out?

You will also note that atypical hyperadrenocorticism is listed as the number one suspect and though Gizmo has "typical" cushing's, it is known that while Vetoryl (trilostane) does a remarkable job of lowering cortisol, it can increase the intermediate adrenal steroids. I switched my cushdogs from trilostane to mitotane and after six weeks, my Lulu's intermediate steroids/hormones were much, much higher on a UTK adrenal panel than the adrenal panel done pre treatment. Oddly enough, those huge elevations caused no clinical symptoms and it was not until her post stimulated cortisol was 25 ug/dL that she became symptomatic again. She started treatment with mitotane and after studies came out indicating that trilostane could grow hair, I switched her to trilostane after an extended wash out period. After she lost her coat completely after two years on trilostane and noticing the escalalating controversy regarding the legitimacy of atypical cushing's, I made the decision to switch her back to mitotane. She remained bald for the rest of her life which was nothing more than a cosmetic issue. Aside from her coat which was probably more a genetic issue that is common in Pomeranians, she did beautifully on both drugs and was a happy, happy girl for several years after diagnosis.

Is it possible that Vetoryl has caused elevations in the other adrenal steroids that could be causing Gizmo's unexplained PU/PD? It's possible but after monitoring thousands of threads throughout the years, I personally don't recall any dog stabilized on Vetoryl (trilostane) that despite excellent control of cortisol throughout the day experience a return of clinical PU/PD that could not be attributed to a secondary problem. If Gizmo's other adrenal steroids were to be the cause of PU/PD, Lysodren's mode of action would most likely address that problem as the drug does reduce over-secretion of other adrenal steroids. That brings me to the reason why many specialists insist on a four to six week washout period when switching from one drug to the other. Lysodren is a toxic drug that targets the adrenal cortex and when given in large loading doses, the goal is to kill off enough of the adrenal tissue to stim the over-production of cortisol. Vetoryl is an enzyme inhibitor that interferes with the synthesis of cortisol. Theoretically an enzyme inhibitor should not necrose/kill adrenal tissue but there are more than a few published cases of varying degrees of adrenal necrosis in dogs being treated with Vetoryl. We've seen some dogs treated with Vetoryl go into total remission after a serious overdose crisis and I personally suspect that remission was brought about by serious adrenal necrosis. It is also well know that Vetoryl causes marked adrenal gland enlargement so between those two issues, I do believe starting Lysodren loading too soon could be a big mistake. As I mentioned before, you are between a rock and hard spot because diabetes complicates things. The controlled regulation of diabetes you have achieved could be completely lost during the washout period. There is also the danger of a hypoglycemic crisis during loading so monitoring for both low cortisol and low blood sugar is absolutely mandatory. I don't have time to provide all of the information I want you to have right now but will be back later. In the meantime, I have included a link below to Lysodren Loading Instructions and Related Tips which can be found in our Helpful Resources subforum. If you go through with the switch, I highly recommend that you print out these instructions and keep them handy through the loading phase.

http://www.k9cushings.com/forum/showthread.php?t=181

952

[Gizmo'sMom3]

lulusmom, wow, this is incredibly helpful. We did a urinalysis in early November:

specific gravity: 1.027
ph: 7.0
protein: 2+
glucose strip: 3+
occult blood: trace
rbc: 4 - 10 hpf (high)

Everything else is listed as normal/negative. So it seems like atypical leptospirosis wouldn't be the cause?

[lulusmom]

It looks like back in November, Gizmo's USG was normal. Since you are switching treatments because Gizmo is now peeing and drinking in excess, if it were me, I would want to do a urinalysis now to make sure that his urine is not concentrated. If the USG is still normal, I personally wouldn't assume that Vetoryl is failing to do the job. I would also want to do a sediment and culture to make sure a urinary tract infection is ruled out. I would really hate to see you go through a wash out period and see no changes with Lysodren, which is why I am racking my brain to make certain that all the bases are covered.

[Gizmo'sMom3]

It looks like back in November, Gizmo's USG was normal. Since you are switching treatments because Gizmo is now peeing and drinking in excess, if it were me, I would want to do a urinalysis now to make sure that his urine is not concentrated. If the USG is still normal, I personally wouldn't assume that Vetoryl is failing to do the job. I would also want to do a sediment and culture to make sure a urinary tract infection is ruled out. I would really hate to see you go through a wash out period and see no changes with Lysodren, which is why I am racking my brain to make certain that all the bases are covered.

Thanks so much for this. I am running out of money to treat my pup and I was trying to avoid having to do another culture which costs over $250 for some ridiculous reason. I tried treating with antibiotics just to see if he improved, but there was no change. My vet told me he read an article about dogs that show that their cushings is controlled via their test, when in fact it isn't. He said it is a small percentage, but he said he thought of Gizmo when he read it.

[lulusmom]

What your vet said would only apply if the symptom you are seeing is a confirmed clinical symptom of cushing's. Perhaps you can have a standard urinalysis done which will tell you whether Gizmo is concentrating his urine. If his urine is concentrated then I don't believe switching to Lysodren will remedy the problem. I know this has got to be frustrating for you and I wish I could be of more help.

[Gizmo'sMom3]

Glynda, you have been a huge help! To clarify, I would do another urinalysis like the one I did in November?

[lulusmom]

Michelle, yes, it's like the one your vet did in November.

[Gizmo'sMom3]

Michelle, yes, it's like the one your vet did in November.

Cool, thank you!