Our Pug Peggy Sue may have Cushing's/ Peggy Sue has passed

[rolfecms]

Hello everyone,

We think our 12 year old pug Peggy Sue may have Cushing’s Syndrome. We were researching online last night and came across information that led us to believe that’s indeed what she has - and then we found this web site so I thought I’d post. We have scheduled an appointment with an internist on Thursday Aug 15 - wish it could be sooner because we don’t want Peggy Sue to suffer any more than she already has due to one misdiagnosis after another.

She exhibits most of the clinical signs of this disorder -

Very thirsty; drinks lots of water
Lots of urination (she uses her litter pan frequently)
Ravenous all the time - she stands by her dish and barks endlessly or scratches at the door where her food is kept
Pants very easily and often
Has developed an abnormal pot belly
Has gained weight which has made it somewhat difficult for her to walk very far
Is somewhat lethargic

Peggy Sue’s health issues started back in October of 2015. She was having some trouble with her hind legs so the doctor prescribed Meloxicam for arthritis.

Then she began panting without apparent reason. One evening she became very restless when her panting would not stop, so my wife rushed her to the emergency room.

With simple observation she was diagnosed with arthritis of the spine and was given a steroid shot and prescribed Gabapentin. Soon after we took her to her regular doctor who advised us of possible courses of action and to continue the existing treatments until we returned from vacation in mid May.

In late May her regular doctor performed some tests and took x rays. He diagnosed tracheal collapse and eliminated the Meloxicam because 1) he didn’t feel she needed it and 2) her liver numbers were higher than normal. He advised us to feed her less and to begin a daily SAMe supplement for her liver toxins.

In June we had an appointment with a surgeon to discuss her issues and the course of action. Upon observing Peggy Sue the doctor ruled out trachea collapse. To resolve her panting he recommended a bronchoscopy with possible laryngeal sacculectomy, procedures that could cost $5K+.

Peggy Sue seemed to be doing better so we thought we’d take a wait and see approach while continuing the Gabapentin. Then we decided to slowly wean her off that medication - which we did without adverse effects, but of course we are still faced with her symptoms.

This past weekend we discussed getting another opinion with a friend who had experience with her pets’ health issues. Her comments caused us to do our own research which quickly led us to Cushing’s. We wish we’d done this work months ago, but better late than never.

We’ll update you once we’ve met with the internist. Thanks for this forum and any advice you’d like to share with us.

[DoxieMama]

Hi, welcome to you and Peggy Sue! I'm so glad you've found us. Cushing's is difficult to diagnose, one in which all the other possibilities must be ruled out first, but what a runaround you've had!

Do you happen to have copies of any of the tests done on Peggy Sue? If you do and could list those values which are abnormal, along with their reference ranges, that will be helpful.

I'm glad you'll be seeing an IMS, and hope they will be able to provide an accurate diagnosis for what's going on with her!

Shana

[Squirt's Mom]

Hi and welcome to you and Peggy Sue! :)

I love the name! I, too, have a Pug and her is named Sophie. They are such sweet and funny little dogs, aren't they? Sophie is the nurse and comic relief in our house. Any time someone is not feeling well, Soph is there to give kisses and keep a close eye on things. And out of the blue she does the goofiest things! :D When a stranger approaches, she takes that bully dog stance and acts like a big ole baddy but the second it looks like they might pet her, she starts wiggling so hard her skin can't keep up. :p She's never met a stranger!

You have done a great job of trying to find out what is going on with your sweet girl and just may be on the right track finally. As Shana said, Cushing's is hard to diagnose, a process of ruling out as much as anything...and you already have a bit of that done! ;) And you have made a wise move in choosing to see an IMS. The tests that are most often used to diagnose this condition are the LDDS, ACTH, and abdominal ultrasound. There are few others but these are the ones most vets choose...not all three are always done but you now have the names of the tests they may want to do so they won't sound like more Greek. If an abdominal ultrasound is chosen, make sure they use a high resolution machine if at all possible.

Now is the time to start making a habit of asking for copies of the actual test results - not invoice but test result numbers. It is a good idea to start a file to keep at home. For one it can come in very handy should Peggy Sue ever need to see a different vet and for another it will help you answer our many, many questions. ;):D For folks who don't know us, we can seem like a nosy bunch! :p

I'm glad you found us and look forward to learning more as time passes. I want you to know a couple of things right now - Cushing's is not a death sentence. With the correct diagnosis and proper treatment our babies can, and often do, live out their normal lifespan...and beyond. And you, your wife, and your precious girl now have a new family here at K9C - we will be with you every step of the way; you are never alone.

Hugs,
Leslie and the gang

[rolfecms]

Hi, welcome to you and Peggy Sue! I'm so glad you've found us. Cushing's is difficult to diagnose, one in which all the other possibilities must be ruled out first, but what a runaround you've had!

Do you happen to have copies of any of the tests done on Peggy Sue? If you do and could list those values which are abnormal, along with their reference ranges, that will be helpful.

I'm glad you'll be seeing an IMS, and hope they will be able to provide an accurate diagnosis for what's going on with her!

Shana

Hi Shana, thank you for the welcome! We will request her test results; thank you for suggesting that. We already made sure that her records are provided to the internist before our appointment. And I will request that any test results be provided (via email if possible).

I'll share the info as we receive it.

Clarence

[rolfecms]

Leslie,

Thank you for your very warm welcome - it's so comforting to know there are others who've been down this path with their dogs and care about those who follow! :)

Peggy Sue is a sweet, intelligent pug and one of two female pugs in our family (Maggie Mae is her younger cousin). Peggy Sue is very aware of her surroundings so it has made us very sad to see her overtaken by this health issue - she is so preoccupied with eating/drinking and seemingly continuous panting that there is so little time left for her to enjoy life or to be the sweet companion she once was. And her pot belly contributes both to her unsteady gait and eponymous pig appearance.

We're also frustrated that it's taken so long to get to this point - and that she's lost nearly a year of her precious life to this chronic but apparently treatable condition.

It's such a verity that you are own best advocate and no one can know or care about your pet friends better than you yourself. Asking questions of your vet are simply not enough - people need to do their own research so they'll be able to obtain the optimal course of treatment for their sick companions. Having the resources of this forum are invaluable.

Thank you for identifying the tests normally used to diagnose Cushing's (LDDS, ACTH and abdominal ultrasound) and obtaining the test results afterward. We'll share all our findings with this forum. We also appreciate that your concerns about knowing and sharing transcend any semblance of nosiness.

We'll see what the internist recommends, but given all her symptoms listed above (it seems she could be a poster child), would one of these standard tests be better than the others? We want to do all we can to positively diagnose and treat this malady but we also don't want redundant tests performed that will simply add unnecessarily to the cost.

Clarence

[Renee]

Welcome to another pug family. I have three pugs myself (and run a pug rescue). My girl, Tobey, has had cushings since 2013. We started treatment in December 2013. It's been a bit up and down, since she battles CC, but she carries on like the fighter she is!

Don't beat yourself up too much about how long it's taken to get to this point. Cushings is a very slow moving disease and most pets have it for months, even years, before diagnosis. I believe my Tobey had it going on a solid year + before we figured it all out. And even then, it took 6 weeks before we began treatment.

An IMS is an excellent start to this process, but even so, make sure you read as much (reliable) information about cushings as you can, so you are prepared at the first visit.

The 'gold standard' test for cushings is the LDDS. There are instances where it is not the correct diagnostic tool (such as when your dog has concurrent diabetes), but for the most part, you should plan on running the LDDS. When I was going through diagnostics, we chose to run the ACTH, LDDS, and eventually a CT scan. Also, plan on a comprehensive blood panel. You'll want to rule out diabetes and thyroid issues, as those can mimic cushings symptoms quite a bit.

I think you are on the right track!

[Squirt's Mom]

I wanted to be absolutely sure of what we were dealing with so I had every test available run - LDDS, HDDS, ACTH, abdominal ultrasound, and UTK panel (this test checks for intermediate hormones that can cause the same signs as elevated cortisol). I've been called a bit anal. :D My Squirt was a bit of an oddball - like her mom! :p The US showed a tumor on her spleen and once that tumor and half her spleen were removed, her cortisol returned to normal. The tumor had caused false-positives on all the testing for cortisol. However, her intermediates remained elevated meaning she had a form referred to as Atypical - normal cortisol, elevated intermediate, or sex, hormones. In time she became true Cushingoid with elevated cortisol - most Atypical pups do follow that path.

The HDDS is rarely used any more - it was used to help differentiate between the pituitary form (PDH) and the adrenal form (ADH) but the LDDS can now make that distinction. The US can also help with that determination. In PDH we typically see both adrenal glands enlarged and in ADH we usually see one very large while the other is much smaller or even atrophied.

Today, if I had to choose, I would use the ACTH and the ultrasound if funds were limited. While the LDDS *is* the gold standard for Cushing's testing, it is also notorious for false-positives if there is a non-adrenal condition present, like our spleen tumor. Because of our experience with the tumor, I always recommend the ultrasound. Others will have different recommendations based on their experiences. ;)

[rolfecms]

Thanks for sharing Squirt’s medical history. From the size of Peggy Sue’s belly it makes eminent sense for an ultrasound together with the ACTH test. We of course want to avoid any false positives that an LDDS test alone might give. With this important knowledge in mind we’ll see what the internist recommends.

[rolfecms]

Welcome to another pug family. I have three pugs myself (and run a pug rescue). My girl, Tobey, has had cushings since 2013. We started treatment in December 2013. It's been a bit up and down, since she battles CC, but she carries on like the fighter she is!

Don't beat yourself up too much about how long it's taken to get to this point. Cushings is a very slow moving disease and most pets have it for months, even years, before diagnosis. I believe my Tobey had it going on a solid year + before we figured it all out. And even then, it took 6 weeks before we began treatment.

An IMS is an excellent start to this process, but even so, make sure you read as much (reliable) information about cushings as you can, so you are prepared at the first visit.

The 'gold standard' test for cushings is the LDDS. There are instances where it is not the correct diagnostic tool (such as when your dog has concurrent diabetes), but for the most part, you should plan on running the LDDS. When I was going through diagnostics, we chose to run the ACTH, LDDS, and eventually a CT scan. Also, plan on a comprehensive blood panel. You'll want to rule out diabetes and thyroid issues, as those can mimic cushings symptoms quite a bit.

I think you are on the right track!

Thanks for your comments, Renee. They give consolation for us to know that we've been able to get to this point as soon as we have - and before we put Peggy Sue through unnecessary and expensive treatments.

We'll make sure we read as much as we can before Peggy Sue's Thursday appointment.

[rolfecms]

Peggy Sue had her appointment today; the link to the exam summary is below.

The doctor performed the ACTH and took blood. Depending on the results (due Monday), we will return for an LDDS and ultrasound. Liver disease is also a possibility because her blood test from 5/31/16 showed the ALT liver enzymes (659) greater than the ALP's (367). The doctor said he would expect these numbers to be reversed for Cushing's.

Let's hope and pray for the best.

Peggy Sue Exam Summary with Historical Blood Test Results (https://drive.google.com/file/d/0B5BK-JzLUuM2c2dSYU5nLUpDRGM/view?usp=sharing)

[Renee]

Hey, thanks for checking back in with an update on miss Peggy Sue! I think your plan is excellent. I'm anxious, as I am sure you are, to get those ACTH results and move forward.

It really sounds like the vet you saw is well informed and thinking about everything. I agree, it is odd to have the ALT exceed the ALP. Not unheard of, but primary liver may be an issue.

Too bad the test results take so long! My ACTH results come the next morning.

[tank&kat]

Your Peg certainly is an odd case. If the ACTH results are positive for Cushing's, she will go on record as having the highest ALT I have ever seen in a cushingoid dog. Don't worry, I don't know if that number is high for primary liver disease, only that it is high compared to other cush dogs and most likely related to something else.

Everything that you have told us about her symptoms leads me to believe there is a good chance the ACTH results will be >20 ug/dL. A cortisol concentration of >21 can be used as a positive diagnosis for Cushing's. It's not so much as her presenting symptoms as it is the timing it took to get to this point. Nothing to feel bad about at all...this disease closely mimics the normal aging process in dogs and it is completely normal for symptoms to appear gradually over a period of time. The ACTH test is less effected by concurrent illnesses/stress than the LDDS so I agree 100% that it was the initial choice for diagnostics in this case. Just my opinion but I think an abdominal ultrasound would be superior to the LDDS if the ACTH is inconclusive or normal.

Did the vet run a urine analysis? Those results would be very helpful to confirm PU/PD and to also rule out the possibility of a UTI? This also lets us know if there was any protein found in the urine which is common for dog's with Cushing's (proteinuria). Does she drink more than an ounce of water per pound of body weight each day?

~Kat

[rolfecms]

Kat, thanks for the info.

I don't believe a urine test was performed. Peggy Sue drinks a lot of water (we refill her bowl more than once per day) but she shares her water dish with Maggie Mae. We can begin monitoring more closely if there is doubt in the diagnosis. Depending on the results we can also request a urine test.

[rolfecms]

We received Peggy Sue's ACTH and blood test results today - see the link below.

She was positively diagnosed with Cushing's as we had expected. We're relieved to know that and anxious to begin treatment as soon as possible!

Her post-ACTH cortisol number was 43.0 so there was no question of the diagnosis. Her liver numbers were reversed from the May test: ALP was 745 and ALT was 485.

She will have an ultrasound tomorrow after which we'll discuss treatment options.

A couple of questions -

Is Trilostane or Lysodren a better option?
Would a urine test be beneficial?


Thanks for your help!

Peggy Sue ACTH & Blood Test Results (https://drive.google.com/file/d/0B5BK-JzLUuM2SEV6ZldLdXAwSTg/view?usp=sharing)

[lulusmom]

He and a belated welcome to you and Ms Peggy Sue.

Thank you for posting the test results and I agree with Kat that Peggy Sue's ALT is a lot higher than we are used to seeing. From the internal medicine specialist's note, it appears that was noted as well and that the abdominal ultrasound will help him assess the liver for abnormalities other than those usually observed with cushing's.

As far as treatment goes, both Vetoryl and Lysodren are very effective. I've treated dogs with both drugs and always extended the same level of respect as they are serious drugs. Since you are treating with an internal medicine specialist, I believe you should go with the treatment he recommends. Before Vetoryl was FDA approved, Lysodren was the only effective treatment and it has taken a backseat to Vetoryl as side effects are more common with Lysodren. The key to mitigating and even eliminating side effects with either drug is an experienced vet and an educated pet owner. Whatever treatment you decide, I heartily recommend that you familiarize yourself with it. We have some very good reference material on both drugs in our Helpful Resources section. We have staff and members who can share a lot of experience and knowledge with you.

I'm sorry for the reasons that brought you here but I'm glad you found us. We'll be looking forward to your update on the abdominal ultrasound findings.

Glynda

[tank&kat]

I would still do the urine analysis. It is fairly inexpensive (my vet charges $35-40). Proteinuria, UTIs, PU/PD <1.019 are all common findings in dogs with Cushing's. My dog had 2 UTIs in less than a year before he was officially diagnosed. If anything, do the test to rule out a UTI as they can sometimes be painful but easy to treat.

Both trilostane and mitotane are equally effective at controlling symptoms and maintaining normal cortisol levels. Generally, it is best to go with whatever drug the vet is more familiar with but if an abdominal ultrasound shows an adrenal tumor, I would treat with trilostane. Adrenal tumors are extremely resistant to Lysodren and typically require doses greater than what is normally used to load a dog (50mg/kg/day). Dogs receiving those kind of massive doses of Lysodren can get very sick.

It is good to see the ALT come down a little. I am curious to hear the results of the ultrasound and what meds will be using. This disease is very treatable and most dogs will live out their normal life span once controlled with medication. A few months before my dog was diagnosed (he was dx in June 2015), I was convinced he wouldn't make it through that summer. After treatment began, his symptoms improved slowly but I will never forget the day I knew, without a doubt, that he would be with me much longer than I thought. He suddenly had 10xs more energy. I also noticed something so small as him wagging his tail for the first time in almost a year. Considering his age, he is doing exceptionally well.

Stay positive! We are all here to help answer any of your questions.

~Kat

[rolfecms]

Reviewed abdominal ultrasound results with doctor today - see the link below.

Diagnosis: pituitary dependent hyperadrenocorticism. Adrenal glands were very enlarged - normal size is 0.8 cm but Peggy Sue’s are 2.0 cm. A 1.3 cm nodule in the left dorsal liver likely represents steroid hepatopathy (ie, a result of Cushing’s) and nodular hyperplasia.

Course of treatment: Lysodren 500 mg tabs in loading phase of 125 mg (0.25 tab) twice per day after meals. Doctor chose this medication over Trilostane because of the extent of the symptoms and the desire to begin addressing them sooner. He said that with Lysodren her symptoms should begin to ease in 2-4 weeks whereas Trilostane, though safer, would take 12-16 weeks.

He cautioned that monitoring is very important with Lysodren because of its potency. We should notify him immediately of any changes so that steps could be taken to mitigate any side effects of the drug. It is possible that Peggy Sue could be given a shot of synthetic cortisol if the drug causes her cortisol levels to drop too quickly too soon.

Loading phase is expected to last 10-14 days but could end as soon as 3 days. Vet should be contacted immediately whenever changes in her appetite or behavior (such as lethargy) occurs or in case of sickness/vomiting.

Given the possible outcomes we are very happy with this diagnosis and relieved that we are beginning to treat Peggy Sue!

Peggy Sue's abdominal ultrasound results (https://drive.google.com/file/d/0B5BK-JzLUuM2X0E3a205S2J2czg/view?usp=sharing)

[Renee]

I have not used lysodren, so I cannot tell you if your vet is following the proper protocols. I do hope you have prednisone on hand though, just in case.

Both Leslie and Glynda (and Lori?) are familiar with lysodren and the loading phase, so hopefully they stop by very soon.

[rolfecms]

I have not used lysodren, so I cannot tell you if your vet is following the proper protocols. I do hope you have prednisone on hand though, just in case.

Both Leslie and Glynda (and Lori?) are familiar with lysodren and the loading phase, so hopefully they stop by very soon.

Thanks Renee. What symptoms would/should prompt prednisone and how is it administered? Our vet has a 24 hour facility that is close to us.

[Squirt's Mom]

Hi Clarence,

Here is a link from our Helpful Resource section on Lysodren. Since you have a 24/7 clinic available to you, the pred isn't quite a critical but knowing the signs of trouble are. They are - loss of appetite, loose stools/diarrhea, nausea/vomiting, lethargy - if you see any of these things stop the Lyso and get Peggy Sue in for an ACTH asap.

Lysodren is given in 2 phases - the loading and the maintenance phases. The goal of the loading phase is to erode a minuscule layer of the outer cortex of the adrenal glands so they can't "hear" the signals to produce and release more and more cortisol. The maintenance phase is designed to maintain that level of erosion.

In loading, the drug is given twice a day at the rate of 50mg/kg/day so at 19.4 lbs, Peggy Sue weighs 8.82kg (19.4 / 2.2). 8.82 x 50 = 441mg per day divided into two doses of 220.5 AM and PM. Since the pill only comes in 500mg, using 125mg 2X a day is doable - it is better to have the dose a bit too low than to have it a bit too high. ;-) It may take a bit longer to load but that is ok - and it may not. ;)

The signs of loading are sometimes very subtle - something as simple as looking up from the feed bowl when her name is called where she would not have done so before starting the Lyso. It is a good idea to measure the amount of water she is taking in now and compare as the loading phase goes along. A decrease in the amount of water she drinks would also be a sign. You do not want to let the load go on long enough that you see those signs mentioned above - nausea, diarrhea, etc. That would mean she was overdosed and the pred required. The load can take as short a time as a few days to as long as a few months but the average is around 7-10 days. Once you see that subtle sign she may be loaded, stop the Lyso and call her vet for an ACTH.

If the post number of the ACTH is at optimal - between 1-5 ug/dl - then she will go to the maintenance phase in which she will be given the Lyso 2-4 times a week, NOT daily, at the same daily dose as she loaded on. In her case that would be 250mg/week. Lyso does need to be given with food so it is properly absorbed.

Hope this helps!
Hugs,
Leslie and the gang

[lulusmom]

Hi and welcome to you and Peggy Sue.

Leslie has given you some great information but I would like to share a concern about the loading dose your vet has prescribed. Your vet has prescribed a dose equal to 28 mg/kg and while this this is acceptable, it can protract the loading phase. Most specialists prescribe the full 50 mg/kg. With this dose, average loading is 5 to 8 days but we've seen dogs load in as little as two days. The low dose your vet prescribed explains why he feels the average loading phase is 10 to 14 days. I have loaded my own cushdogs more than few times and both their specialists and gp vet prescribed a full 50 mg/kg loading dose..... and they were tiny, weighing only 5 lbs and 7 lbs. If it were my dog, I would definitely talk to the vet about increasing the loading dose from 1/4 pill am and pm to 1/2 pill am and 1/4 pill pm. That equates to a total daily dose of 43 mg/kg which is a much more effective loading dose that will definitely shorten the loading period and resolve symptoms much quicker. Regardless of dose, you will be playing the most important role during this phase and must monitor Peggy Sue for any change whatsoever in her eating habits or water intake. As Leslie said, the change can be as subtle as her looking up at you or someone else instead of her usual head down, lick bowl clean until it looks like its fresh out of the dishwasher. :) I didn't go back to refresh my memory as to whether or not Peggy Sue has a voracious appetite so I'll mention here that if her appetite has not been affected by cushing's, I heartily recommend that you reconsider Trilostane. The reason for this is that if the most common symptoms in a cushdog is polyuria/polydipsia (excessive drinking & peeing), that symptom does not always resolve right away so overdosing is much more likely in these dogs. It is for this reason that world renowned expert endocrinologist, Dr. Edward Feldman, instructs his audience to use the appetite as the gauge for determining at which point a dog is telling the owner that loading has been achieved. My dogs were like Hoover vacuums so when they looked up or took longer than 10 seconds to inhale their food, I knew something was up.

I am a bit concerned about your vet's opinion that if you choose Lysodren for Peggy Sue her symptoms should begin to ease in 2-4 weeks whereas if treating with trilostane, though safer, would take 12-16 weeks. This is absolutely not true. If administered properly both drugs can see the symptoms more commonly associated with cushing's, like voracious appetites, excessive drinking and peeing and panting, resolve within days to a week. Other symptoms like muscle wasting and skin and coat issues can take months to resolve on both drugs. If the ranges your vet provided are what he sees in his practice, then I would have to believe that his extremely conservative approach to dosing may well be dragging things out for his patients. This is another reason why you may want to reconsider trilostane (name brand is Vetoryl).

Bottom line, both drugs deserve your respect as both can cause serious side effects and the onus will be on you to prevent that from happening by monitoring Peggy Sue very closely so that you don't miss a sign during loading. Monitoring for signs of low cortisol is something you will need to do for the rest of Peggy Sue's life if she is under treatment with Lyosdren or trilostane.

I've included a link to our Lysodren Loading Instructions and Related Tips that can found in our Helpful Resources subforum. I highly recommend that you read it carefully, print it out and keep it handy while you are loading. We have a wealth of information on trilostane as well. We will all be here to help in any way we can. FYI, we always like to see our Lysodren parents update us every day while loading. We worry right along with you and want to help you ace this phase of treatment.

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

Glynda

[Squirt's Mom]

:p Thanks for adding the link since my feeble mind forgot to on my post! :D

[rolfecms]

Hi Leslie and Glynda; Thanks for your replies with the important info, link and especially your concerns.

I believe the internist chose the loading dose of 125 mg twice daily so that Peggy Sue's cortisol levels would be reduced more gradually given her high post-ACTH level of 43 together with her other symptoms. The concern is not to jolt her system too quickly with a higher dose even though the loading phase might take more time. Is this a valid concern?

Peggy Sue wakes us up every morning (about 06:45) when she stands by her dish and barks for breakfast until she is fed. This behavior occurs multiple times per day as she's always ravenous and has been doing this for several months now. We will notice immediately when this behavior changes.

My wife is home most days so she can keep her eyes on her. Additionally we have an internet camera so we can monitor her from our cellphones at all times.

I'll keep everyone updated with daily posts during the loading phase.

[rolfecms]

See the link below for a log that I created for Peggy Sue. I'll update it on a daily basis.

Peggy Sue's Cushing's Log (https://docs.google.com/spreadsheets/d/1Mo434cpdkKv1fQrCZpcW8kZGkJaiNwq67QxqRDYFHmY/edit?usp=sharing)

[Squirt's Mom]

Very good! One of our members set up a water intake log a few years back that is handy, too. Here is the link to that - http://www.k9cushings.com/forum/showthread.php?t=3583

[rolfecms]

Very good! One of our members set up a water intake log a few years back that is handy, too. Here is the link to that - http://www.k9cushings.com/forum/showthread.php?t=3583

Thanks for the water intake log, Leslie - we'll keep that updated. We have two pugs and they both use the same water bowl. We'll try and get Maggie Mae to use another bowl. Any suggestions on this?

I have added the link to Peggy Sue's log in my signature area below for easier access.

[Squirt's Mom]

Basically we assume the non cush pup is drinking a normal amount of water. So you would figure what would be normal for 2 pups the size of your babies - normal is about 1/2-1 oz per lb. Any amount over that you can assume is from Peggy Sue. ;) BUT if your pugs are like mine, they drink a whole lot of water for no good reason....Sophie drinks like she's just come in from the desert yet has nothing wrong per repeated blood work!

[labblab]

Yes, I agree with Leslie, it'll probably be way too tough to try to segregate the water bowls. But if you've not already started the Lysodren loading, you can measure the total water that is drunk by both girls each day for a couple of days. Using that daily total as a baseline, you can figure that any amount drunk more or less will be a result of changes in Peggy Sue. Maggie Mae's intake ought to remain more constant.

Marianne

[rolfecms]

I just filled out Peggy Sue's water intake spreadsheet for day 1 and the link is below.

I modified the spreadsheet to adjust for our 2nd 19 lb pug Maggie Mae who shares the water bowl. She's not a heavy drinker so I used 0.5 oz per lb for her. I then deducted 9.5 oz from the total water consumed.

According to the spreadsheet the optimal water intake for Peggy Sue is 17.49 oz. The total water intake yesterday was about 26 oz which after deducting Maggie Mae's share of 9.5 leaves 16.5 which is less than the optimal amount.

Not sure how to interpret this, because we know Peggy Sue drinks a lot of water and her chin and underside (below chin) is always wet to prove it!

Peggy Sue's Water Intake Log (https://docs.google.com/spreadsheets/d/1Mo434cpdkKv1fQrCZpcW8kZGkJaiNwq67QxqRDYFHmY/edit#gid=783174734)

[rolfecms]

Just updated the water intake for yesterday - for both pugs it was 42 oz and after deducting 9.5 oz for her sister, Peggy Sue drank 32.5 oz. This is considerably more than the day before; but it could be we made an incorrect measure on that day.

I have included the water intake spreadsheet as another tab in the main spreadsheet; the link to both is below in my signature.

We have noticed no change in behavior thus far after 4.5 days of Lysodren loading. I know we need to be patient but we're so anxious to start seeing some change soon.

[judymaggie]

Hang in there! My Abbie loaded after eight days on the "traditional" loading dose -- with Peggy Sue's low dose, you may well have to wait longer. You are doing a great job with documenting everything and am sure you won't miss it when Peggy Sue is loaded.

[rolfecms]

Hang in there! My Abbie loaded after eight days on the "traditional" loading dose -- with Peggy Sue's low dose, you may well have to wait longer. You are doing a great job with documenting everything and am sure you won't miss it when Peggy Sue is loaded.

Thanks for the kind words of encouragement. It's like watching water boil - nothing happens until you quit thinking about it but in this case it's easier said than done!

[rolfecms]

I wanted to update you on Peggy Sue since last week's post.

Peggy Sue completed the full 14 day regimen of 125 mg Lysodren given twice-daily. We observed no change in her behavior; in fact the symptoms appeared to have worsened. She was just as hungry and thirsty, she gained weight and her pot belly got bigger. We started giving her Gabapentin again to calm her panting.

We were very disheartened to say the least and felt helpless that we weren't doing more to make her feel better.

We had a appointment with the internist yesterday when they did the second ACTH test. The doctor continued the Lysodren regimen but increased the AM dosage to 250 mg while keeping the PM the same at 125 mg.

We received the encouraging results today: Her post-ACTH coritsol number dropped from 43 ug/dL to 23. While this number is still far too high and remains over the Cushing's cutoff number, it's nearly half of what it was. It also explains why her symptoms have not improved yet. Here are the latest results, also posted in the log below: 9/9/16 Test Results (https://drive.google.com/file/d/0B5BK-JzLUuM2WnZEMkRxb3dKYzQ/view?usp=sharing)

So we continue to watch, wait and hope/pray for the best.

[Joan2517]

Hoping and praying right long with you...

[Squirt's Mom]

This isn't really a surprise. In my earlier post I said -


In loading, the drug is given twice a day at the rate of 50mg/kg/day so at 19.4 lbs, Peggy Sue weighs 8.82kg (19.4 / 2.2). 8.82 x 50 = 441mg per day divided into two doses of 220.5 AM and PM. Since the pill only comes in 500mg, using 125mg 2X a day is doable - it is better to have the dose a bit too low than to have it a bit too high. ;-) It may take a bit longer to load but that is ok - and it may not.

And Glynda, lulusmom, had this to say -


Leslie has given you some great information but I would like to share a concern about the loading dose your vet has prescribed. Your vet has prescribed a dose equal to 28 mg/kg and while this this is acceptable, it can protract the loading phase. Most specialists prescribe the full 50 mg/kg. With this dose, average loading is 5 to 8 days but we've seen dogs load in as little as two days. The low dose your vet prescribed explains why he feels the average loading phase is 10 to 14 days. I have loaded my own cushdogs more than few times and both their specialists and gp vet prescribed a full 50 mg/kg loading dose..... and they were tiny, weighing only 5 lbs and 7 lbs. If it were my dog, I would definitely talk to the vet about increasing the loading dose from 1/4 pill am and pm to 1/2 pill am and 1/4 pill pm. That equates to a total daily dose of 43 mg/kg which is a much more effective loading dose that will definitely shorten the loading period and resolve symptoms much quicker.

So that the cortisol didn't respond as desired isn't shocking....disappointing to you I know, but not a surprise for me. ;) Now that she is on a better dose you should see those signs of the load achieved soon so keep a very close eye for those and stop immediately when you do see them. To refresh your memory -


...must monitor Peggy Sue for any change whatsoever in her eating habits or water intake. As Leslie said, the change can be as subtle as her looking up at you or someone else instead of her usual head down, lick bowl clean until it looks like its fresh out of the dishwasher. (via lulusmom)

Keep in touch and let us know how things are going for the next few days. If you have any question in your mind that the load MAY have been achieved, stop and ask for an ACTH. It is much better to do an extra test than it is to let the load go too long. And the load may happen very quickly now. ;)

Hugs,
Leslie and the gang

[rolfecms]

Joan and Leslie,

Thanks for your support. We're of course very concerned for Peggy Sue but her issues seem to pale in comparison to Molly's at this point.

You were right about the lower dosage of Lysodren taking longer. The internist said so but we were so anxious to see improvement - and when her symptoms worsened you can understand how our hearts dropped.

Impatient as we were, we trusted the doctor's opinion that we not bring the numbers down too fast, given how high they were initially (43) and the possible negative consequences. But now that they're down significantly (23) it appears to be a safe and good time to increase the dosage.

Seeing the test results calmed our fears that she was suffering from something as yet undiagnosed. We all want the best for our furry little friends and I believe we're on the right path for Peggy Sue.

We'll keep you updated.

[Squirt's Mom]

You don't increase the dose with Lysodren. Peggy Sue will remain on this dose until she is loaded then she will go to the maintenance phase in which she takes the drug 2-4x a week. Lysodren does NOT follow the same protocol as Vetoryl where dose changes are frequent. Pups on Lyso typically stay on the same dose once they get to the maintenance phase. I'm going to quote myself from that earlier post again -


Lysodren is given in 2 phases - the loading and the maintenance phases. The goal of the loading phase is to erode a minuscule layer of the outer cortex of the adrenal glands so they can't "hear" the signals to produce and release more and more cortisol. The maintenance phase is designed to maintain that level of erosion.[/quote[

[quote]The signs of loading are sometimes very subtle - something as simple as looking up from the feed bowl when her name is called where she would not have done so before starting the Lyso. It is a good idea to measure the amount of water she is taking in now and compare as the loading phase goes along. A decrease in the amount of water she drinks would also be a sign. You do not want to let the load go on long enough that you see those signs mentioned above - nausea, diarrhea, etc. That would mean she was overdosed and the pred required. The load can take as short a time as a few days to as long as a few months but the average is around 7-10 days. Once you see that subtle sign she may be loaded, stop the Lyso and call her vet for an ACTH.

If the post number of the ACTH is at optimal - between 1-5 ug/dl - then she will go to the maintenance phase in which she will be given the Lyso 2-4 times a week, NOT daily, at the same daily dose as she loaded on. In her case that would be 250mg/week. Lyso does need to be given with food so it is properly absorbed.

And share this link about Lysodren from our Helpful Resource section again -

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

Have you see any changes in Peggy Sue? How is she doing? Let us know how things are going over the next few days and remember if you have any thoughts that the load may be achieved, stop the med immediately and call for an ACTH.

Hang in there! This part will be over soon then the easy part comes....just remembering when to give the med. ;)

Hugs,
Leslie and the gang

[labblab]

As Leslie says, it's true that normally the dose isn't increased during the load, but this is assuming that a therapeutic dose was used to begin with. I am assuming that what you are talking about here is increasing Peggy Sue's loading dose now in order to actually achieve a successful load, since the dose was too low to begin with in. In this case, I believe it does make sense to increase the dose. ;)

Marianne

[Squirt's Mom]

Marianne - the loading dose was just increased a few days ago. So another increase at this point wouldn't make much sense - we need to give this increase a chance to achieve the load. ;)

[labblab]

Hmmmmm...has there actually been a second increase? I was assuming we were still talking about the initial increase on 9/9. It'll definitely be good if we can get some clarification about that.

Marianne

[Squirt's Mom]

Marianne, from the post #33 -


We had a appointment with the internist yesterday when they did the second ACTH test. The doctor continued the Lysodren regimen but increased the AM dosage to 250 mg while keeping the PM the same at 125 mg.

So I take that to mean the dose was increased by 125mg a day. ;)

[labblab]

Yup, I think so, too. That's the increase I'm talking about -- as a result of the initial dose being too low. But you think the dose is being increased yet again since 9/9? That's the part that needs to be clarified.

Marianne

[Squirt's Mom]

No I didn't take it that way at all but I may be wrong. I took this statement as a misunderstanding of how to use Lyso VS Vetoryl -


But now that they're down significantly (23) it appears to be a safe and good time to increase the dosage.

To me that says they think since the numbers have come down since the 125mg/day increase on the 9th, it's time to increase it again BUT I could be mistaken. ;)

[Squirt's Mom]

Hopefully Clarence will clarify soon. :)

[rolfecms]

Hi again,

Thanks for your posts and concerns.

To clarify, there has been one dosage increase that happened last Thursday, Sept 9 when Peggy Sue had her appointment with the internist and had her second ACTH test.

Peggy Sue is still in the loading phase but her internist felt that with the current ACTH number of 23 it was safe to increase the dosage until she is loaded.

My wife is at home with her every day and keeps an eagle eye on her for any changes in her behavior.

Current observation is Peggy Sue still barks for her food, is ravenous and pants alot. Hopefully we'll see a change in the next few days.

[molly muffin]

How is loading going? Are you through the phase yet?

[rolfecms]

Hi Sharlene and thanks for your concern.

Still loading, she barked for her food again tonight.

Hopefully soon.

[Squirt's Mom]

No decrease in water intake? No changes at all in appetite or manner of eating?

[rolfecms]

No decrease in water intake? No changes at all in appetite or manner of eating?

I think she's reached the loading point -

This morning she is very tired - she normally stands in her stroller but she was lying down today. Her hind legs seem weaker too - she fell twice in the park.

She's also not acting as frantic as she was and she did not bark for her breakfast.

She's still eating and drinking a lot though.

I will phone the doctor today.

[labblab]

Based on what you've reported, I would not give her any more Lysodren until her cortisol level has been tested. I surely hope your vet agrees. As we say, you can always start the med back up again if you need to. But you can't take back a dose (or overdose) that's already been given.

Marianne

[rolfecms]

Thanks Marianne.

The internist is off today. I was able to speak with an assistant in internal medicine.

Since it is Friday, if we have the ACTH test done today we won't get the results until at least Monday.

It makes sense to hold off on any more Lysodren until we do the test as you suggested.

Not sure if we should hold off on the ACTH until I can speak with the internist on Monday?

[DoxieMama]

If you can do the ACTH test today, I would. Then do not give any more Lysodren until after you've gotten the results and confirmed what dose/procedure to follow (as you may need to resume loading, or move into maintenance phase).

Shana

[labblab]

Bear in mind I am not a vet, but I think it will be OK to wait until Monday to test. For a long time, we had been advising people here to wait 48 hours to test, anyway, because there was some thought that the cortisol could continue to drop lower for a time period after the last dose was given. As it turns out, there really is not any research that we can find to support that belief. Still, I'm sorry there's a full weekend intervening now before you can even talk to the internist. But the flip side is that you may have more clues via Peggy Sue's behavior as to how things stand.

What did the assistant advise you to do?

Marianne

[labblab]

I see Shana and I were typing at the same time, and I truly cannot argue with her suggestion to go ahead and test today, either. If you test today, you say you'll get the results on Monday. If you test on Monday, how quickly can they turn around the results? Because that is an issue -- if you don't get those results until Tuesday, you've lost several days of loading in between if it turns out you need to continue on.

[rolfecms]

The assistant took the default response (I believe) and told me to bring her in or to take her to her vet. I can't say I have loads of confidence in that opinion.

Our local vet (across the street from us) is open on Saturday and the office where we took Peggy for her ACTH tests is open 24/7 and is a short drive away.

Perhaps taking a wait and see approach until Monday while withholding Lysodren for now is the wisest approach.

[labblab]

I wouldn't so much call the assistant's recommendation a "default" response, but actually the more conservative response. That way, you'll be able to have a game plan in place just as soon as the test results can be reviewed on Monday. If it is indeed easy for you to test today, then I probably would go ahead and do so, too.

The biggest risk to waiting until Monday is that you'll lose even more time in resuming the load if you need to do so. Since it's already been such a long time loading, another setback would be unfortunate. Unfortunately, without a crystal ball, it's just impossible to know how things stand right now without the test. So that is your dilemma.

[rolfecms]

Peggy Sue's post-ACTH coritsol number was 23 last Thursday (9/9). On that day we increased the Lysodren dosage by 125 mg per day.

What would we expect the number to be now if she has loaded?

[Squirt's Mom]

You are looking for a post, or second, number around 2.5-3ug/dl to be ideal. The range is 1-5ug/dl - anything below 1 means the load has gone too long and the drug must be stopped for a while and perhaps prednisone given; anything above 5 and the load has not been achieved and the 2x a day dosing will continue.

How are her stools? Any changes there?

[rolfecms]

You are looking for a post, or second, number around 2.5-3ug/dl to be ideal. The range is 1-5ug/dl - anything below 1 means the load has gone too long and the drug must be stopped for a while and perhaps prednisone given; anything above 5 and the load has not been achieved and the 2x a day dosing will continue.

How are her stools? Any changes there?

Thanks for the numbers. No change in stools.

[rolfecms]

Peggy Sue had an appointment with her vet this morning (Saturday). Doctor performed an ACTH and blood work. She was given a steroid shot to avoid Addison's. An ulcer was discovered on the right side of her tongue, so Amoxicillin was prescribed (100 mg twice per day for seven days)

Blood was normal except for elevated liver numbers. ACTH results will be ready tomorrow. Lysodren withheld until results are known.

[Harley PoMMom]

Was the steroid shot given after the ACTH stimulation test was performed? If not it will interfere with the results of that test because it will be measured as cortisol which will make the results useless.

Hugs, Lori

[Squirt's Mom]

Would you please post the actual results of the ACTH when you get thm? All too often we have seen vets who don't know how to interpret the lab numbers, relying on what the lab posts instead of what the goal is for a dog on treatment. Most labs post ranges for a dog NOT on treatment or a dog that does NOT have Cushing's and quite a few vets don't know the difference so we really like to see those results.

Why was the pred given? Was Peggy Sue displaying signs of the cortisol being too low? It is not protocol to give pred unless that is the case since the pred will simply raise the cortisol back up so I hope your vet did that because she was exhibiting signs of an overdose. What did you/the vet see that prompted the steroid (pred) shot?

[rolfecms]

Peggy Sue was given the steroid shot after the ACTH test. The vet said it was their standard operating procedure at this point (end of loading phase) to guard against Addison's. I was not aware that steroids would be given until we took her in on Saturday, so I had no way of verifying whether it made sense to do so. It appears that it is not normally done.

We did not receive the results today - not sure why because they said they would be ready.

I'll post the results once I receive them.

[labblab]

Hmmm...yes, unless Peggy Sue was appearing to be unwell (e.g., vomiting, diarrhea, significantly lethargic), there would be no need for supplemental steroids. The unfortunate piece is that if Peggy Sue's cortisol was not abnormally low, the steroid shot may exaggerate pre-existing Cushing's symptoms. So bear in mind that she may again temporarily exhibit worsened excessive thirst, urination and hunger. These effects will wear off over time. How long they last will depend upon the duration of effect of the steroid shot. But if it turns out that Peggy Sue is not actually loaded yet and she needs to resume the Lysodren, you will want to make sure that no more steroid is given because that will mask the loading signs.

Marianne

[rolfecms]

Thanks for the advice Marianne.

Until yesterday we had been dealing with the internist for her treatment, but we went to her normal vet yesterday for this ACTH. So now I know better.

Peggy Sue was hungrier and thirstier today than she had been, so it must have been that steroid shot.

[rolfecms]

Vet just phoned with the ACTH results.

Peggy Sue's pre-test number was 3.1 and her post-test number was 8.5.

Vet will send the results to the internist and phone him tomorrow to discuss the next steps. Until then Peggy Sue is to receive 125 mg Lysodren tonight and 250 mg tomorrow morning.

Vet said the reason they gave the steroid is they were concerned that her numbers would be much lower than they turned out to be.

When the ACTH results are emailed to me I will post them.

[Squirt's Mom]

That is such a shame and absolutely wrong in my mind that the shot is given just as a matter of course. Here is a patient KNOWN to have excess cortisol flooding their little body, on a course of treatment to lower that corticosteroid, and yet a supposedly trained professional adds MORE steroids to that little body. Sad and angering to me. Especially in light of that post # - so now sweet Peggy Sue has been subjected to a "neat" little roller coaster ride on steroids for absolutely nothing. :(:mad:

What prompted stopping the Lyso and having the ACTH in the first place?

I'm really sorry this happened and hope your sweet girl is ok and soon loaded.
Hugs,
Leslie and the gang

[labblab]

Hey Les, I can answer one of your questions. A couple of us here recommended that the vet be contacted re: possible testing on Friday based on Peggy Sue's behavior that morning.


This morning she is very tired - she normally stands in her stroller but she was lying down today. Her hind legs seem weaker too - she fell twice in the park.

She's also not acting as frantic as she was and she did not bark for her breakfast.

[Squirt's Mom]

ahhh thanks! I looked back in the thread before asking but obviously not far enough! :)

[rolfecms]

We received the results from tests given on 9/17/16:


ACTH Test (https://drive.google.com/file/d/0B5BK-JzLUuM2QTFuZUV4V2JnUFE/view?usp=sharing)
Blood Test (https://drive.google.com/file/d/0B5BK-JzLUuM2cGZCN1BzQ0pSS00/view?usp=sharing)

The ulcer on the right side of her tongue is just under 1 cm. She is on a 7 day regimen of Amoxicillin.

Has anyone experienced this with their cushpups? To our knowledge Peggy Sue has never had one of these and not sure what would have caused it.

[Harley PoMMom]

We received the results from tests given on 9/17/16:


ACTH Test (https://drive.google.com/file/d/0B5BK-JzLUuM2QTFuZUV4V2JnUFE/view?usp=sharing)
Blood Test (https://drive.google.com/file/d/0B5BK-JzLUuM2cGZCN1BzQ0pSS00/view?usp=sharing)

Can you post the actual numbers for us...thanks! ;)




The ulcer on the right side of her tongue is just under 1 cm. She is on a 7 day regimen of Amoxicillin.

Has anyone experienced this with their cushpups? To our knowledge Peggy Sue has never had one of these and not sure what would have caused it.

Ulcers are not a common ill effect of Cushing's but high cortisol does weaken the immune system so it could be that the ulcer was caused by the Cushing's.

Lori

[rolfecms]

Can you post the actual numbers for us...thanks! ;)Lori

Peggy Sue's pre-test ACTH number was 3.1 and her post-test number was 8.5.

[Renee]

I find it very frustrating that your vet wanted to start Peggy Sue on lysodren because she felt it would be faster than vetoryl in resolving her symptoms and gaining control, and yet, you've been loading since 8/24 and still have not achieved a proper load. :mad: Poor Peggy Sue, and poor you guys. What a long roller coaster to be on!

I have not experienced any mouth ulcers in my pug. Just the dreaded CC. Are the abx helping her? Any chance of doing a culture on the ulcer?

[judymaggie]

Hi! Here are the highs and lows on the attached lab print-out:

MCH 37.9 H (range, 21.9-26.1)(up from 25.7 on 5/31/16)
Reticulocyte 118H (range, 10-110)(up from 93 on 5/31/16)
Neutrophil 12.877 H (range, 2.94-12.67)(up from 9.243 on 5/31/16)
Lymphocyte 1.043 L (range, 1.06-4.95)(down from 0.97 on 5/31)
Monocyte 1.548 H (range, 0.13-1.15)(up from 0.654 on 5/31/16)
Platelet 571 H (range, 143-448)(up from 414 on 5/31/16)

There are comments about the reticulocyte level as well as the neutrophils (appear slightly toxic) and the platelets (clumped on the blood film, appear increased on the blood film).

I think it is unfortunate that your vet did not run a chem panel which would have evaluated Peggy Sue's electrolytes. In light of his rush to give her steroids, you would think he would have tested those.

[rolfecms]

I find it very frustrating that your vet wanted to start Peggy Sue on lysodren because she felt it would be faster than vetoryl in resolving her symptoms and gaining control, and yet, you've been loading since 8/24 and still have not achieved a proper load. :mad: Poor Peggy Sue, and poor you guys. What a long roller coaster to be on!

Thanks Renee for your concern. Peggy Sue had her initial ACTH test on 8/19. It feels like forever tho and we're so ready for Peggy Sue to have some relief from her symptoms. Hopefully it won't be too much longer for the loading phase to be in the rear view mirror. It's great that my wife can be home during the day so we can monitor her condition around the clock.

Peggy Sue is a real trooper and she's always been very aware of her surroundings. She used to hate going to the vet. Now she takes it in stride because she knows there's something wrong and understands the need to do this so she can get better.


I have not experienced any mouth ulcers in my pug. Just the dreaded CC. Are the abx helping her? Any chance of doing a culture on the ulcer?

We started the Amoxicillin on Saturday evening so it's a little early to tell. I will discuss this with her internist to see what he thinks.

[rolfecms]

I just spoke with the vet who reviewed Peggy Sue's latest test results with the internist.

Lysodren dosage is now 1/4 tab (125 mg) twice per day for the next five days or unless we see differences in her behavior. An ACTH retest will be scheduled for next Monday.

On concern is Peggy Sue's hind legs were very weak this morning. Is this typical with cushpups at this point? I'm not sure when this symptom would normally lessen or if there's anything we can do.

[DoxieMama]

So the dose was decreased? I know next to nothing about Lysodren, but I've been following along and that doesn't make any sense to me.

[rolfecms]

So the dose was decreased? I know next to nothing about Lysodren, but I've been following along and that doesn't make any sense to me.

She had been on 250 mg AM and 125 mg PM. ACTH test this past Saturday was 8.5. Internist lowered this to 125 mg twice a day until Monday.

[labblab]

Well, I must admit that I'm totally confused :confused:. So you've backed off again to the lower Lysodren dose that came nowhere near achieving a complete load the first time around??? I really do not understand your IMS's reasoning at all. I fear that when you retest on Monday you'll have gained no ground and perhaps even lost some again. But I'll let others here who have personally used Lysodren add their thoughts since I may be off base here with my concern.

However, I must confess that at this point I am wary of your vet's actual experience with using either Lysodren or trilostane. I just now noticed this comment that you made earlier in your thread.


Doctor chose this medication over Trilostane because of the extent of the symptoms and the desire to begin addressing them sooner. He said that with Lysodren her symptoms should begin to ease in 2-4 weeks whereas Trilostane, though safer, would take 12-16 weeks.
I take no issue whatsoever with Lysodren being recommended as a treatment option, but the reasoning given by your vet makes no sense to me. If trilostane dosing follows the recommended treatment and monitoring protocol, research suggests that 70-90% of dogs exhibit improvement in overt symtoms such as increased activity level and lessened panting, hunger/thirst/urination within 4-6 weeks, and some much sooner. My own dog stopped drinking and peeing as much after only three days on the medication. It is true that some symptoms such as pot belly and skin/coat abnormalities typically take longer to resolve (3-4 months), but that is also the case for Lysodren. So it makes no sense to me to pick Lysodren over trilostane because of the speed of symptom resolution. And unfortunately, given the loading protocol that your IMS has been using, Peggy Sue's Lysodren load feels as though it is taking forever to achieve.

As far as the hind leg weakness, it may be the case that she has some underlying arthritic issues that the lowered cortisol is unmasking. This is not uncommon among older dogs after Cushing's treatment has begun. If the weakness does not resolve, then it may be the case that you may want to pursue some additional orthopedic diagnostics and/or pain relief medication.

Anyway, I'll surely keep my fingers crossed that Peggy Sue's loading phase will finally come to an end within a few more days. But as you can see, I am apprehensive about your vet's strategy. :o

Marianne

[rolfecms]

I think the sequences of events and their circumstances led to the change in Lysodren dosage.

We noticed that Peggy Sue's behavior changed on Friday - so we phoned our local vet (rather than her internist) to discuss another ACTH. Based on what we told the vet the dosage was withheld out of an abundance of caution (and the concern that her numbers could be dangerously low) and we scheduled an ACTH for the next day (Saturday).

The vet found the big tongue ulcer and when the ACTCH results became known (8.5) it was thought that the ulcer had caused the change in Peggy Sue's behavior. The Lysodren was restarted until the test results could be reviewed with the internist, who was out of the office from Friday thru Monday.

On Wed the internist instructed the vet to reduce the Lysodren dosage to 125 mg twice per day, to allow the Lysodren regimen to continue until Monday when the internist will see her again for another ACTH.

[rolfecms]

Update on Peggy Sue - had an ACTH test on Monday and received the results today.

Pre-ACTH cortisol = 3.7 ug/dl
Post ACTH cortisol = 5.4 ug/dl

The maintenance phase has begun. Dosage is 125 mg 3x weekly on Monday, Wednesday and Friday.

If she does well she will have her next ACTH in one month.

Latest test results (https://drive.google.com/file/d/0B5BK-JzLUuM2XzNzMWdKSHo0UEU/view?usp=sharing)

We're very happy with Peggy Sue's progress thus far - less frantic, much less ravenous, less panting, and both my wife and I noticed her body shape has improved slightly. She asked to sleep in our bed last night and slept thru the whole night. She hasn't done that in a long time.

[Squirt's Mom]

That post # is still too high to start maintenance but it's close so hopefully she won't lose what load she did achieve. Ideally you want the post # closer to 2-3....the optimal range proving the load has been achieved is 1-5ug/dl. So 5.4ug/dl is a bit too high but hopefully it will work. Keep an eye out for her signs returning, tho. If that happens, she will have to be loaded again. ;)

Sounds like she is feeling better that's what matters most of all!
Hugs,
Leslie and the gang

[rainiebo]

I haven't used lysodren - but from what I have experienced with Vetoryl, I can only say that it takes tweaking to get the meds and levels within acceptable range. It sounds like you are staying on top of achieving the right outcome for peggy sue, but it can be frustrating. Follow your "gut" and hang in there - progress will come.

[molly muffin]

How is she doing on the maintenance dose?

[rolfecms]

Hello everyone, it's been a while since I last posted. Peggy Sue seems to be doing OK now, although we had a scare at Christmastime when she had an infection, high liver enzymes and bile acids. She was treated by her internist with antibiotics and the meds described below.

Peggy Sue had another ACTH test this week; here's her ug/dL numbers:

03/02/17: 11.5
12/24/17: 10.5
10/28/16: 5.2
09/09/16: 23.0
08/22/16: 43.0

She has been on Lysodren 125 mg 3 times per week since the maintenance phase began on 9/28/16.

Vet has temporarily increased dosage to every other day until she consults with Peggy Sue's internist next week.

Peggy Sue is also on these additional meds:

Denamarin, 125 mg 1x day for liver function
Ursodiol, 60 mg 1x day for gall bladder

Vet said that the Lysodren may be replaced with Trilostane.

Has anyone had experience switching these meds?

Thanks

[Squirt's Mom]

Hi and welcome back!

To me, it looks like Peggy Sue needed a mini-load back in Dec. Since that didn't happen, her cortisol has continued to rise. So instead of switching just yet, I would talk to the vet about doing a mini-load to get her back on track. Can you tell us again how much she weighs?

Is she taking the Lysodren with food? It is typically given after the meal. It is a fat soluble drug so it must be given with food.

Were any of the ACTH's given during some of her recent health problems?

To switch to Vetoryl (Trilostane) Peggy Sue MUST be off of the Lysodren for at least 30 days before starting the Vetoryl (Trilostane). Lysodren stays in the body for a long time so this helps prevent any overlap between the two drugs, which could be very, very bad. ;)

[Harley PoMMom]

She has been on Lysodren 125 mg 3 times per week since the maintenance phase began on 9/28/16.

Vet has temporarily increased dosage to every other day until she consults with Peggy Sue's internist next week.

If I'm understanding this correctly, she is now taking the 125 mg every other day?


Vet said that the Lysodren may be replaced with Trilostane.

Has anyone had experience switching these meds?


Leslie is spot on that a dog must have a washout period of 30 days before switching to Trilostane. Dechra, manufacturer of Vetoryl/Trilostane, states that a 30 day wash-out period is needed before switching from Lysodren to Trilostane.

Thirty days is the appropriate washout period unless a dog's post acth stim number is clearly above normal and is overtly symptomatic.

Hugs, Lori

[molly muffin]

Hi. Typically a load is achieved when the post number is under 5.0ug but I agree it was pretty close to that. However, it isn't unheard of for a dog to lose a load when they go to maintenance and then prescribed protocol is to reload and then go to maintenance again.

If you move to vetroyl, then there does need to be a 30 day washout before introudcint vetroyl. Has you discussed reloading with your vet?

[rolfecms]

Thanks for all your feedback.

Peggy Sue's weight history in pounds:

03/02/17: 16.5
12/24/16: 16.0
10/27/16: 17.3
10/22/16: 17.2
09/08/16: 20.4
08/22/16: 19.0

We are administering Lysodren with food every other day. This increased last Friday based on her latest ACTH number from 3x per week.

Her ACTH of 10.5 was taken on her 12/24/16 emergency visit.

It seems to me that a reload would be desirable to waiting 30 days to begin Trilostane. I will discuss this possibility when vet calls me back after discussing with Peggy Sue's internist.

[judymaggie]

Hi! I can totally relate to the ups and down you are experiencing with Peggy Sue while on Lysodren. My Abbie started out on Lysodren because our vet had little experience with Vetoryl. I was reluctant but decided to give it a try. Abbie loaded without incident and then couldn't keep the level during maintenance. As I recall, I think we did at least three medication adjustments and one mini-load after which her numbers plummeted below 1. At that point my vet finally agreed that we needed to switch Abbie to Vetoryl. Thankfully, he was willing to dose and test per the guidelines that I have learned here on the forum.

As others have said, we did wait 30 days to start the Vetoryl. The first ACTH at 14 days showed a good drop in cortisol and she reached even better levels at 30 days. Since then cortisol levels have been maintained. I purchase Vetoryl from California Pet Pharmacy and trilostane from Diamondback Pharmacy in order to get the dosage combination that has worked. This has allowed me to save a great deal of money on the medication.

[rolfecms]

judymaggie, thanks for the info and words of support.

Peggy Sue's internist will continue the new every-other-day Lysodren regimen for 3 months and then do another ACTH test.

The other meds (Denamarin and Ursodiol) will continue unchanged.

Gall bladder ultrasound this Saturday.

The vet said that the 30-day wait time for switching from Lysodren to Trilostane does not apply if the cushing's is uncontrolled. Has anyone else heard this?

[Squirt's Mom]

Your vet is 1010% wrong. Do NOT allow them to start your baby on Vetoryl without a 30 day wash out. It puts her life in danger, period. ;)

[rolfecms]

Your vet is 1010% wrong. Do NOT allow them to start your baby on Vetoryl without a 30 day wash out. It puts her life in danger, period. ;)

Thank you. Is Addison's disease the danger here?

[Squirt's Mom]

Yes, Addison's and worse - death.

[rolfecms]

Yes, Addison's and worse - death.

Ok, if a switch to Trilostane is recommended in three months time, I will insist on a 30 day wash out.

I don't believe her current ACTH number of 11.5 represents a wildly out of control Cushpup - especially since she is not showing symptoms. If the number does not change much it would make more sense to me to reload with Lysodren rather than switch after a wash-out.

Do you agree with this approach?

[Squirt's Mom]

Yes, if Peggy Sue were mine, that is what I would do....my own Trinket is on a very odd dosing with Lysodren. It's not doing much for her signs but she has a cyst on her adrenal gland that IS shrinking, which seems to be her vet's main goal right now. So while the "correct" step would be to do a mini-load with Peggy Sue now then do an ACTH to check the level and retest 2 weeks after the maintenance dose was started, there is more leeway with Lysodren than with Vetoryl. So seeing how she does on the every-other-day dosing is reasonable, tho odd. :D Trink and I are on an odd path, too! LOL Continue keeping a close eye on her signs over the next few months just as you have been. ;)

[rolfecms]

Hi everyone,

It's been awhile since I posted, primarily because Peggy Sue (our 13 year old pug) has been doing well in general.

First the good news: she had a reading of 2.9 on her two most recent ACTH tests, with the last one being August 31. So we're very glad that the Cushings is under control after we moved her from Lysodren to Trilostane in May of this year.

The not so good news is she has been having episodes that we think are seizures. They seem to always happen soon after she wakes up, and especially after she wakes up quickly.

The symptoms and resulting episode occur in the span of about 3-5 minutes. She begins panting, then loses her balance, rolls over and her body goes limp. She has a distant look in her eyes and sometimes she howls for a brief period. After a short while she is back to normal. Note: She never howls at any other time.

The first episode was in December 2016 when she was not on any medication except for Lysodren. These episodes have increased in frequency to the point where we need to do something if we can. I've spoken with the vet who wants us to capture the episode on video so she can see it. I haven't been able to do that yet.

She has a good appetite, weights about 16.5 pounds and gets outdoor exercise every day which she enjoys.

Peggy Sue's daily meds consist of the following:

Trilostane, 10 mg (for Cushing's)
Ursodiol, 62.5 mg (for gall stone prevention)
Sam-e, 200 mg (antioxidant for liver)
Milk thistle, 88 mg (antioxidant for liver)
Dasuquin, 300 mg (for joints)
Fish oil, 500 mg

Questions I hope you can answer about her episodes:

Are they seizures?
Are they related to Cushing's?
What causes them?
Is there anything we can do to mitigate them?

Thanks so much for any information you can provide.

[Squirt's Mom]

Good to hear from you again tho I am worried about the signs you are describing with your sweet girl. Vetoryl has been proven to cause the pituitary tumors associated with Cushing's to grow if they are prone do do so. No studies have been done looking at the same with Lyso but it stands to reason it would have the same effect on these micro tumors that want to be macros. The elevated cortisol acts as a sort of treatment keeping those tumors smaller then when treatment starts and the cortisol is lowered, the tumor is allowed to start growing. For some reason I cannot find the link to this info right now but hopefully someone else has it at their fingertips and will post it here for you. I will keep looking too. ;) BUT the first thing I would do is talk to the vet about this possibility...and maybe even stop the Vetoryl to see if that helps at all.

Hugs,
Leslie

[molly muffin]

It is definitely a possibility that a pituitary tumor has grown to become a macro tumor and this is causing the seizures and possible pain (the howling) Does she ever exhibit any other neurological symptoms like getting stuck in corners, not wanting to lower her head to eat, stumbling (when not in a seizure)?

It is also possible that something else, such as thyroid could be causing the episodes. It certainly sounds like a seizure of some kind though. So I would want a full panel to rule out any other possibilities.

There is also possible seizure meds that can used, but stopping the vetroyl could be a way to test and see if related to medication.

[rolfecms]

Hello friends,

Our angel baby Peggy Sue passed away this morning at home, apparently of a heart attack following a collapse (syncope) that awoke me with a howl. She was 13.5 years old.

She had been diagnosed a week ago with pulmonary hypertension at 10 times the normal pressure.

Her collapsing episodes were caused from insufficient blood to the brain, so the cardiologist had prescribed Sildenafil and Vetmedin. It had significantly brought down her pulmonary blood pressure. There was no sign of heart disease.

All the tests showed absolutely no signs of Cushing's, so I'm grateful for the medications now available to treat it. These drugs allowed Peggy Sue to be with us that much longer.

Please accept my heartfelt thanks to you all for the support you provided us and our little girl.

Now comes the hard part: learning to live without our Peggy Sue.

I will keep all of you with Cush pups in my thoughts and prayers.

[Harley PoMMom]

Oh Clarence,

I am so sorry for the loss of your precious girl, Peggy Sue, and my heart goes out to you and your family. Losing them is so painful and the
poignant void they leave in our life is unimaginable. Please know we are here for you and always will be.

With Heartfelt Sympathy, Lori

[Joan2517]

I am so sorry for your loss of Peggy Sue. Living without them takes time...however much time you need.

[Squirt's Mom]

Dear Clarence,

I am sorry to hear about your sweet girl. I know your heart is broken and know that pain only too well. Time will help but not heal the wounds these losses leave behind but we can learn in time to rely on our memories we so cherish to get us thru those hard moments. You worked hard to give Peggy Sue the best life possible in spite of her illnesses and I know she is grateful. Know we are here with you any time you need to talk.

My deepest sympathies,
Leslie

[molly muffin]

My sincerest condolences on the loss of your precious Peggy Sue. :(

[TysonsHuman]

So sorry for your loss of Peggy Sue. My big boy Tyson passed away a couple of weeks ago after a long 3 year battle. This site was extremely helpful in my quest to deal with the illness over the last few months. And you are correct, the hard part is trying to come to terms with the feeling of loss and emptiness. May you be comforted in knowing that there are many here who feel your pain of loss and send you our prayers as you move forward dealing with the loss of your loved one. Your memories will sustain you in the coming days. RIP PEGGY SUE.

[DoxieMama]

I am sorry for your loss. Run free, sweet Peggy Sue.