10 days on lysodren and need your guidance

[jzkeegan]

My little maltese, Cali, is 6 lbs, and 14 years old. She was diagnosed with cushings several weeks ago and we determined to treat with lysodren. I had it specially formulated because she is so small, and we started with 40mg 2x a day. We tested on day 5 and her pre-test was 6 and post was 21. So...dr advised we continue with the loading phase. It has been 10 days and the numbers are nearly identical (pre 6.6 and post 21.5).

She is still drinking a TON and peeing a ton so I knew she was not "loaded."

I am waiting for the vet to call me back with instructions. But I wanted to ask you all in your experience what you've done if the 10 day loading phase did not work. Do you raise dose immediately and if so do you go super slow? Do you start the loading phase all over again with an increased dose? Is this common for the dog not to respond after 10 days? I know my vet started on the smaller dosing, but since Cali is so small, she didn't want to risk putting her in Addisons.

Any advice would be greatly appreciated! Thank you!

[DoxieMama]

Welcome to you and Cali, though I'm sorry she's not responding to treatment yet. I do not have experience with lysodren so will not be able to answer your questions on that. I'm sure others will be by who do.

In the meantime, would you mind sharing the symptoms that led you and/or your vet to test for Cushing's in the first place, as well as the test results which resulted in her diagnosis? Not because I doubt it but we like to have the full picture so to speak. :)

Once again, welcome! I look forward to learning more about your precious little girl.

Shana

[molly muffin]

Hello and welcome to the forum.

I'm giving you a link to our lysodren loading instructions: http://www.k9cushings.com/forum/showthread.php?t=181

you should load at 50mg per 1kg. 6lbs is 2.72 kg so load dose should be 68mg twice per day. (138mg daily) so 80mg daily might not be enough to get a load going for her.

did they do an ultrasound or ldds test during the diagnostic phase? an ultrasound would show if there was an adrenal tumor, which can be harder to get control of. An LDDS test results might show that too though.

I'm thinking the load is probably not strong enough and that is why it is taking longer.

[Harley PoMMom]

Hi and welcome to you and Cal from me as well!

I agree with Sharlene, Cal loading dose is lower than what is recommended, and because of this it will take a lot longer to achieve a load. Also, Lysodren is a fat soluble drug and needs to be given with some fat, is this being done?

The link that Sharlene posted is full of information regarding Lysodren so I do urge you to read it and feel free to print it out so you have it as a quick reference.

Please do not hesitate to ask all the questions that you want and know we will help in any way we can.

Hugs, Lori

[Squirt's Mom]

Welcome from me as well! I am a Lyso fan personally. :)

Are you giving the drug with food? It must have fats to be absorbed and used by the body so Lysodren must be given with a meal. Is she on any other meds? Do you use steroid creams for any reason?

Glad to have you join us and look forward to hearing from you again soon!

Hugs,
Leslie and the gang

[labblab]

Hello and welcome from me, too. I just want to reinforce Shana's request for some background info on Cali. It will help us a lot if you'll tell us more about her overall health history, the symptoms that led your vet to suspect Cushing's, and the results of her diagnostic tests.

As the others have said, your lack of improvement on the Lysodren thus far is most likely the result of using too low a dose for the load. However, even though it doesn't make logical sense, the adrenal glands of dogs who don't have Cushing's do not seem to be as responsive to the effects of Lysodren as are the adrenals of Cushpups. So when we have members who tell us their dogs are not responding to the medication, I always like to double-check the diagnostic history, as well.

Thanks in advance for any additional info!
Marianne

[jzkeegan]

Hi and thank you to all for your replies!!

Here is calis story.

About 1 year ago she began losing some hair. I thought this was due to age and didn't think any more of it.

A few months ago she started drinking a ton of water and peeing large less concentrated volumes of urine. After three days of this I took her to the vet and they ran blood work and informed me she was in early kidney failure and to switch her diet to a kidney diet. The vet did not seem terribly concerned.

She also was developing crusty scabby sores in her skin tags (skin tags which has been there for about two years and are benign)

Then one month later I took her for her wellness exam and dental and they ran blood work and her liver values were up significantly from the last blood draw one month prior.

We ran a bile acid test and that came back at 53.

Both vets in the practice guessed that it was likely we were looking at liver cancer. We had the option to ultrasound to confirm and we chose to do such.

In the meantime it was me who read all I could about Cali and her symptoms and cushings disease kept popping up.

We had the ultrasound done and it was confirmed that she has two tumors in both adrenal glands and NO cancer. I was thrilled and chose to test right away.

We ran an acht (?) test and her pre number was 7 and post was 21.

The vet gave me an option to use lysodren or trilostate (?). She explained the latter was a bit more safe because of the mechanism of treatment, but it's significantly costlier and the blood test needs to be done way more frequently in he first year of treatment. In contrast the lysodren works on melting the adrenal glands which does run a higher risk of addisons, however it is more affordable, given 2x a week (after loading phase) and blood tests are run every 6 months.

We chose lysodren and the reason the loading dose was so low is the vet wanted to inch slowly up as to avoid putting her in addisons. We just moved from 40 mg 2 x a day to 68mg 2x a day. (Her acht test still was at 6 pre and 21 post before we upped her dose)

It has been three days of higher dose and I see no change. She is drinking and peeing more than ever.

Thanks for hearing my story and any and all input or advice is welcome and appreciated!!

[Harley PoMMom]

Adrenal gland tumors are very resistant to Lysodren and it usually takes larger than normal doses of Lysodren to achieve a load which in turn increases the chance of an Addison's crisis.

My layperson"s opinion would be to switch to Trilostane after a washout period from the Lysodren.

Lori

[labblab]

Yes, like Lori, I'm really noticing your comments about the presence of adrenal tumors. Can you tell us any more specifics? You mention two tumors -- do you mean that each adrenal gland seems to have a tumor, or are there two tumors in one gland?

I'm wondering whether the ultrasound instead just showed that both of the adrenal glands were enlarged as opposed to containing tumors. If so, that finding would instead be consistent with Cushing's caused by a pituitary tumor.

Why this is meaningful is because, as Lori notes, adrenal tumors may be more resistant to Lysodren's effects. Additionally, the presence of two adrenal tumors may be a bit more sinister in terms of long-term prognosis, since adrenal tumors may be either benign or cancerous, and they have the potential of invading important blood vessels. So the size, exact location, and growth patterns of adrenal tumors can be important factors in weighing treatment decisions.

I'll be anxious to hear more about those ultrasound results.
Marianne

[jzkeegan]

Hi! Ok...so I went to the vet and physically picked up the report from her ultrasound. Here is what it said:

Adrenal glands: Left-cranial pole 7.1mm, hyperechoic nodule, rounded margins. Right Maximum 6.6 mm in thickness normal echogenicity.

liver: mildly enlarged, diffusely hyperechoic with a single hyperechoic nodule (1.5cm) on the right. Gallbladder wasll is normal, with mild debris, some of which is adherent. no organization. Biliary tree is normal.

kidneys: left 2.6 cm, right 3 cm, decreased cmd with multiple cortical cysts (4.6mm maxiumum) pelvis is normal.

conclusions:
1. mild nodular hepatopathy.
-This may be vacuolar change or hyperplasia, but given high bile acids an inflammatory or infectious hepatopathy is also possible. Neoplasia is unlikely.
2. Bilateral chronic renal degenerative changes with cortical cysts.
3. mild adrenomcgaly. Cushing's disease is a reasonable differential diagnosis.


Thoughts?

[molly muffin]

hmm, I see the hyperechoic nodule on the left adrenal gland, it doesn't mention one on the right. I'm really bad at making sense of these sometimes, but the adrenal glands are surrounding by hyperechoic fat, so I wonder if it means it's a fatty nodule and that is why they said noncancerous.

Did they say if they thought the drinking and peeing could part of the kidney disease? Rather than a direct result of cushings?

When do they want to test again for cortisol? or are they waiting on symptoms to show a load?

[labblab]

Hi! Ok...so I went to the vet and physically picked up the report from her ultrasound. Here is what it said:

Adrenal glands: Left-cranial pole 7.1mm, hyperechoic nodule, rounded margins. Right Maximum 6.6 mm in thickness normal echogenicity.

liver: mildly enlarged, diffusely hyperechoic with a single hyperechoic nodule (1.5cm) on the right. Gallbladder wasll is normal, with mild debris, some of which is adherent. no organization. Biliary tree is normal.

kidneys: left 2.6 cm, right 3 cm, decreased cmd with multiple cortical cysts (4.6mm maxiumum) pelvis is normal.

conclusions:
1. mild nodular hepatopathy.
-This may be vacuolar change or hyperplasia, but given high bile acids an inflammatory or infectious hepatopathy is also possible. Neoplasia is unlikely.
2. Bilateral chronic renal degenerative changes with cortical cysts.
3. mild adrenomcgaly. Cushing's disease is a reasonable differential diagnosis.


Thoughts?
I'm so glad Sharlene has brought our attention back to the ultrasound report today, and I'm going to quote the report again here so we don't have to scroll back to the previous page to see it. ;)

Like Sharlene, I don't know exactly what to make of the "hyperechoic nodule" in the right adrenal gland. However, the written "conclusions" don't mention that nodule, so apparently is not thought to be particularly significant nor sinister.

"Mild adrenal adrenomegaly" is noted, however, which I'm assuming is referring to mild enlargement of both adrenal glands. If so, this would be consistent with Cushing's caused by a pituitary gland tumor, and I'm guessing that's what the third conclusion is pointing towards.

Bottom line: when you have a chance, I'd confirm with your vet that he/she thinks the Cushing's is caused by a pituitary tumor (as opposed to an adrenal mass) because that info can affect the overall treatment plan.

Marianne

[jzkeegan]

For all that are following Cali, and being SO SO SO helpful...I wanted to update you. I did check with the vet, and yes, this is a pituitary cushings (not adrenal). It has been 7 days since we upped the lysodren dose. Cali is 6 lbs. We started her on 40mg 2x day and after a acth confirmed no change we upped her dose to 65 mg 2x a day.

I see NO change in her drinking (still spending a LOT of time at the water bowl). Therefor, I do not expect that her next ACTH draw will show any change.

Where to go from here if this is the case? Do I continue to raise the Lysodren dose and continue loading until we see an ACTH level within normal range? Do I stop Lysodren and wait a month and move to Trilostane? Or do I stop treatment all together because she is a 14 year old maltese?

From a quality of life standpoint, she is very thirsty and drinks a lot, her hair has lost a lot of volume but does not bother her, she has many skin tags on her body which have become crusty and a little bloody that don't seem to resolve. She seems a little weak when she walks...sometimes takes a small stumble for no reason. She seems to lack energy but nothing worrysome.

I'd love to be prepared when/if the vet calls tomorrow to tell me the ACTH has no change.

The cost of these ACTH tests every time we run one is $155...so it is not cheap.

Thank you in advance for yoru thoughts and guidance. It is MUCH appreciated!

[labblab]

I surely understand your frustration, and I'm so sorry you guys are having a tough time. It sounds as though you've just now had another ACTH performed after the week on the higher dose, and you're awaiting results. Is that true?

I know you're hoping to arrive at a gameplan in advance, but I think we need to wait to hear the test results before making more decisions. This is because it really does seem to me that it "all depends"... First and foremost, we'll be wanting to know whether there's been any downward movement at all on the cortisol level.

May I ask the source and form of the Lysodren? Is it a compounded version, and is it in a liquid or a tablet form?

Marianne

[molly muffin]

Unfortunately it is hard to make a game plan until you see the ACTH results. Seeing movement downwards in the post number would be a good sign.

Strange that we have 2 dogs, both on the smaller side, having problems with lysdoren loading. You are definitely not alone on this journey.

The vet will be calling you tomorrow with results?

[jzkeegan]

Hi! I thought I would start a new thread since I am not sure if my older thread will get lost.

Just to fill you all in...my smaller 6 lb maltese has been diagnosed with cushings (confirmed pituitary), and we have been on a lysodrin journey trying to load her for over 2 weeks.

Started her on 40mg 2x a day. For those that are wondering...this was purchased through a pharmacy in Arizona, and it was nearly the ONLY one I could find that would compound such a small dose and it is in LIQUID form.

After seeing no change, we moved her dose to 56 mg 2x a day.

I have seen no change in the amount of water intake (maybe...just maybe...less in the last day...but as a busy mom of three children, I am admittedly not there every moment and I have another dog who shares the water bowl.)

Anyhoo...test results are in from the new ACTH. pre was 3.5 and post was 5.5! (7 days ago pre was 6.1 and post 21.5)

I thought this was amazing and wonderful! The vet, however suggested we move to 60 mg 2x a day becasue she said that the goal is post number of 5 (not 5.5).

Cali went from post numbers at 21 and 21.5 (during loading at 40mg) to now 5.5 on 56 mg lysodrin. Doesn't it seem dangerous or overkill to move up even a little just to get that last .5? Or is the vet correct?

If I move up the lysodren by 4mg...I have to test again at 3 to 5 days (another $155). I don't mind the money if necessary and will make a difference in how she feels...but I am starting to question whether this is really necessary (or will put Cali at risk for addisons)

sorry for long post.

THANKS FOR ALL YOUR SUPPORT!
J.Z.

[labblab]

Hi again! You'll see I went ahead and merged your new post into your original thread. It's important for us to be able to review a dog's complete history when we talk things over, and I think especially so in Cali's case. Whenever you post a new reply to your original thread, it will always bump it back up to the top of the index page, so you don't have to worry about your thread being buried. ;)

The reason why Cali's history seems especially important to me is because it seems as though your vet is stabbing at extremes in terms of the Lysodren loading protocol. She first started out with a dose that was too low, and now I would personally feel worried about her instructions not only to continue the load, but to even increase the dose. I agree with you -- I think the post-ACTH level of 5.5 is probably a satisfactory ending point for the load, given the fact that Cali is 14 years old and extreme lowering of cortisol might unmask some other problems for her (like arthritis, for instance). I would really worry that continuing the load for several days (especially at an increased dose!) is risking Addison's.

If it was me, I'd want to halt the load now and shift to maintenance dosing. One thing I might feel comfortable about would be to increase the maintenance dose a bit (moving up to 120 mg. from 112 mg. for the weekly total). That ought to keep the cortisol from increasing any higher and might lower it a tiny bit.

Please bear in mind that I am not a vet, and I hope that others with Lysodren experience will weigh in. But these are my worries and thoughts.

Marianne

[Harley PoMMom]

Those treatment ranges for the Cushing's medication are guidelines and are not set in stone. I believe one can not treat by numbers only and have to take in account how the dog is feeling, acting, and how the symptoms are.

Has is Cali feeling, acting, and how are her symptoms?

[lulusmom]

Hi and a belated welcome from a fellow Maltese lover.

For someone who has no first hand experience with Lysodren, Marianne is very astute and spot on in her opinion. I think she must know my dogs' internal medicine specialist because her suggestion to start maintenance at an increased dose is exactly what our specialist instructed me to do. One of my dog's post stimulated cortisol after loading was a bit higher than Cali's and we definitely got the post stimulated cortisol below 5 ug/dl with an increased maintenance dose. My other dog's stimulated cortisol post loading was 8 or 9 so we did a mini load for two days and that did the trick.

If you go with a 120 mg maintenance dose, which I think is a reasonable choice, you should split the weekly dose into three or four doses per week. Never give it once a week as a dog is much more likely to relapse. It's been awhile but as I recall, I gave my dogs their maintenance doses on Monday, Wednesday and Friday. You can choose whatever days work for you as long as Cali gets the entire 120 mg in any given week. When my dog switched to maintenance on an increased dose, I think we did an acth stimulation test after two weeks to make sure cortisol was within range.

You may still be seeing less than desirable improvement in the drinking and peeing because the post stimulated cortisol is not within range or it could be that Cali's kidneys are taking a bit more time to concentrate her urine. This is not uncommon.

Liquid mitotane makes it a lot easier to do dosing adjustments and dogs usually love the taste. One of my cushdogs would almost suck on the syringe to get every drop. :) The only down side is that the longer it takes to use it, the more likely the liquid is to get gooey.
Hopefully they've made strides in preventing that in the last decade.

I really think you are seeing a very bright light at the end of the tunnel. Just a wee bit longer.

Glynda

[jzkeegan]

I have so much to fill you all in on...and I DESPERATELY need your help.

So...we ultimately over supressed my little girl. at .7 ml of 80 mg lysodren. She was on this for 2x a day for 7 days and after a ACTH test, she came in at pre 3.7 and post at .9 (I hope that I remember these nubmer correctly) but baseically the vet said that while she is not full blown in addisonin crisis, she is near it. She presented with waking in a pool of her own urine and not moving from it. When I took her to bath her, she did not fight me (not normal) she had no appetitie. She was lethargic and disoriented. We stopped lysodren right away and put her on 5 mg of prednisone once daily for 3 days, then took it to 1/4 pred for three days.

The vet then suggested we resume lysodren today at .5 ml of 80 mg 2x a week. HOWEVER, my little girl has miraculously become a different dog. She is eating. Dringking normal. Playing. Climbing stairs. She is a new dog! I am so thrilled I don't want to change a thing.

However my vet said that we can't continue the prednisone becasue THIS could also put her into addisons. What? How can this be? The VERY drug that saved her from an addisons event while on Lysodren could now put her in addisons? I am so confused? I shared this with my vet but her explanations continued to confuse me.

She suggested we wean her off the prednisode for four days, then test her to see if her adrenal glands are working. Then from there, we watch her to be sure she isn't addisonian, and test again one week later, then decide if we need lysodren, pred, or nothing.

I am losing faith in my vet. She is SUPER responsive to me...I have her cell...she loves my dog...she texts me day and night...but I am confused and scared.

Thoughts? Please? any and every. Thank you!

[labblab]

I am hoping you can give us more details about exactly what has been happening with Cali. When you wrote last, your vet was recommending that you increase Cali's Lysodren dose and continue loading even though her post-ACTH cortisol had already dropped to around 6 or so. Did you go ahead and continue loading for a full week after that point in time before testing again? If so, and if Cali is truly oversuppressed, I am going to be perfectly blunt and tell you this is 100% your vet's fault. She may be very caring, but she does not understand the proper use of the medication and has jeopardized Cali's health and safety. But perhaps --hopefully-- I am misunderstanding things.

Also, you need to find out exactly what these most recent ACTH results are. I do not believe that a pre-ACTH of 3.7 and a post-ACTH of .9 can possibly be correct. Do you have the numbers reversed by any chance? If so, a post of 3.7 is actually OK, and that would relieve our worry considerably. However, if the post is truly .9, then your vet is actually finally giving you a reasonable gameplan with this recommendation:


She suggested we wean her off the prednisode for four days, then test her to see if her adrenal glands are working. Then from there, we watch her to be sure she isn't addisonian, and test again one week later, then decide if we need lysodren, pred, or nothing.
If Cali's adrenal function is only temporarily oversuppressed and it starts rejuvenating over time, you will ultimately want to begin maintenance Lysodren dosing. If you continue giving prednisone when it's not really needed any more, you risk artificially shutting down the body's natural cortisol production (thus perpetuating an Addison's condition). However, a third alternative is that Cali may remain permanently Addisonian due to a Lysodren overdose -- her adrenal glands may never properly recover and naturally produce cortisol again. In that event, she will need to remain on prednisone for the rest of her life. The only way you can determine which of these three options is true is by testing again as your vet has suggested above.

But once again, we need to know exactly what Cali's most recent ACTH results were. Knowing those numbers will make a big difference as far as how things stand and the path forward.

Marianne

[jzkeegan]

Hi! I am sorry about the confusion. Yes, I had the numbers backwards. I believe her last blood draw had her at pre of .9 and post of 3.6. The vet said the pre number was a little too low (they want around 1.6) but the post number was good.

So just backing up for a bit. Once we upped her dose of lysodren to .7 from .5 (because .5 was not doing the job), we kept her on the loading dose of .7 for 7 days. We tested her then, and the results were somewhere in the 3's for pre, and post was 5.5. The vet then moved us to maintenence dosing. I gave her last loading dose on a tuesday, and was to give her first maintenence dose the following saturday. However, by that thursday (two days of receiving no lysodren), I noticed her lethargic and acting off. By Saturday, I found her in the morning (on my bed) laying in a pool of her own urine. I got her up to bathe her and she did not fight me on this (she normally hates her bath). She would not eat. I gave her the first maintenence dose thinking that she was acting this way becasue she needed more lysodren since she hadn't had it since tuesday. But once I did this, I took her to the vet to have her weigh in on whats going on. They put her on pred right away and tested her acth. Her numbers came back at pre of .9 and post of 3.6. I was advised to continue the pred at .5 for three days then move down to 1/4 tab of .5. It has now been a week and Cali is doing better than I have seen her in over a year! Like amazing. So the vet is suggesting weaning her off the pred, by every other day for this week and testing her on Sunday, then testing her again with nothing one week later than determining if we start up the pred again or start the lysodren. I am just terrified to start lysodren again because she is doing SOOOO well now, and she started doing so badly on it. So, I hope this made my story easier to understand. Any thoughts?

[labblab]

Hmmm....I am very relieved that Cali's post-ACTH was 3.7, because that would tend to take her out of a genuine danger zone in terms of being Addisonian. But I'm still a bit confused.

First off, what was the size of the maintenance dose of Lysodren that you gave on Saturday? Also, you say that the vet proceeded to give Cali prednisone that same day? To the extent you can remember, what was the exact timing of all these events on Saturday -- the maintenance Lysodren, the supplemental prednisone, and the ACTH testing? The timing of all this is important because the two medications would have had an "oppositional" effect on Cali's cortisol level. The Lysodren would perhaps have lowered it while the prednisone would have increased it. So it may be hard to know exactly what her natural adrenal function was on that day, and this is why it is important to retest once the prednisone is out of her system and before you begin dosing with Lysodren again.

Just to clarify, until that Saturday, Cali had received no additional Lysodren subsequent to the post-ACTH result of 5.5? If not, it seems very surprising to me that her cortisol level would have dipped to 3.7 after only one single maintenance dose, and that she would already have been behaving as though her cortisol was too low by Thursday -- before any maintenance dose was given at all. :confused:

Anyway, once we have the answers to these questions, hopefully we can make some better sense as to what is going on. Also, just to offer a general explanation as to why maintenance dosing is important, the adrenal tissue will begin to rebound in most dogs once the loading phase has ended. If no more Lysodren is ever given, the dog will end up returning to a Cushinoid state. So the solution is to continue to dose the Lysodren on the maintenance schedule in order to keep the adrenal function under control. Assuming that Cali's adrenal glands have not been permanently overdosed by the Lysodren load, you will need to resume the maintenance Lysodren dosing at some point in order to keep her cortisol production from shifting into overdrive again. However, as your vet says, you will need to perform some more monitoring testing before you know whether you are yet at that stage.

Marianne

[molly muffin]

You do want to be able to get her off the pred and then see where her levels stay at. If they start to go up, you go back to a maintenance dose, but at a lower dosage than the one you where on when she went low.

The goal is to be able to keep her feeling good at the least medication possible.
If she is ever lethargic like that or not eating, don't give the lysodren as it is a sign of low cortisol and ask to be able to keep emergency dosages of prednisone on hand to give her if needed.

[jzkeegan]

Hi. Ok...so here are the exact course of events and her testing. We started her on a higher lysodren loading dose on May 14 of .7 ml of 80. 6 days later, on May 21 she had her blood draw for ACTH. This was on a Sunday. I was advised to continue lysodren at the loading dose until we got results. So I gave a dose on Monday and Tuesday, and on Tuesday night I got the results of the pre (I think 3.6 or something like that) and post at 5.5. I was told to stop and go to maintenence. It was that Thursday that she began to fail. she stopped eating and was lethargic. She was due for her first maintenece dose on Saturday (.7 ml of 80 mg lysodren) and I gave it to her in the morning. About 2 hours later I took her to the vet out of concern for how she was acting. They did a electrolyte test which came back normal, then ran the ACTH. Because it was memorial weekend. The vet sent her home with Prednisone. We gave her 5 mg that Saturday night and Sunday night. We got the results of her ACTH Monday afternoon and that was when the pre was .9 or there abouts, and post was around 3.6ish. We were advised to continue pred at 1/4 tab of 5 mg until further notice. She was doing MUCH MUCH better...in fact the best I have seen her in over a year!! We continued pred at 1/4 tab of 5 mg until this past Monday where we are weaning her off at 1/8 tab of 5 mg every other day. Today is last day (friday june 9) and my vet thinks I should run another ACTH on Sunday and then go from there (possibly restart lysodren maintenence at .5 ml of 80 mg). I am not so sure...thoughts?

[labblab]

Thanks for this additional info, and now we have a better understanding as to what happened. The fact that you continued loading Cali for two days subsequent to the first ACTH explains why she was feeling poorly and registered still lower results upon retesting. Under these circumstances, I agree with your vet as far as checking her ACTH one more time now that she'll have been "off" the prednisone for 48 hours (testing while actively giving prednisone will skew the results).

If Cali remains perky and healthy after the prednisone is finished and her pre-ACTH value has risen above 1.0 and her post-ACTH has gone no lower than that 3-4 ug/dL range, then I agree with the prospect of moving forward with maintenance after another week or so.

However, here are some questions I have about the specifics of your vet's plan. To recap, you had ended up giving Cali a loading dose of .7 ml twice daily, correct? That would be a daily total of 112 mg (56 mg x 2). In shifting to maintenance, were you planning to break that 112 mg total into 2-3 doses spread throughout the week? A few vets do give the full maintenance total in one single dose, but it is far more common to break the weekly total into two or three smaller doses given 2-3 days apart. This provides a more consistent pattern of adrenal control.

If Cali is indeed now ready to proceed with maintenance, I'm concerned that your vet is advising you to back off from the .7 x 2 dose (112 mg total) to the .5 x2 (80 mg.) as a weekly maintenance dose. It seems as though she would be running the risk of being overly cautious again, just as she was in the beginning when Cali did not load properly on the .5 x2 daily dose. It seems to me that the problem was not that .7 x 2 was too high -- she finally loaded effectively on that dose during a week of treatment. The problem is that your vet told you to continue the loading dose for a full two days subsequent to the test. So you were continuing the load, and then even immediately beginning maintenance without knowing the effect of those two additional loading days. By the way, you will now know that Lysodren should never be given to a dog who is acting lethargic, inappetant, or has vomiting/diarrhea since these can all be signs of low cortisol.

So it seems to me that it was your vet's protocol and not the size of the daily dose that created the problem for Cali. Since she did not initially load properly on 80 mg. daily, my worry is that she will not remain well-controlled using that as a weekly maintenance dose, either -- over time, her adrenal cortex may rebound to the extent that you'll have to revert to reloading all over again. Cali actually loaded properly on the 112 mg. daily dose. If you had just stopped the loading until the test results were back, I think she would have felt OK and been able to begin maintenance dosing the subsequent week.

I think we've given you this link before, but please please PLEASE read over the recommended treatment and monitoring protocol for Lysodren use so you'll be better able to discuss your vet's recommendations with her. Also, you'll know what signs to watch out for in terms of under or overdosing.

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

Marianne

[jzkeegan]

Just wanted to give you an update. Cali's last dose of prednisone was on Friday at 1/8 5mg. tiny dose. We tested on Sunday (yesterday) and her numbers came back at pre 1.2 and post 3.5

While the vet was VERY happy with these numbers, Cali is acting lethargic and does not have a great appetite. The vet suggested we go back on a teeny tiny dose of prednisone for a couple months since we know that she is not in addisons and we also know that her adrenal glands are well supressed but still functioning.

She is not recommending any lysodren. She feels like this supression may last a while and when we see symptoms again we can treat with maintence dosing.

What do you guys think of this plan?

[Harley PoMMom]

Some dogs feel better when their cortisol runs a bit higher that what is recommended so this may be true for Cali.

The problem with not giving the Lysodren and waiting until symptoms rebound is that you may have to reload her so my opinion is to lower her maintenance dose a tad to allow those adrenal glands to produce just a little more cortisol.

Lori

[labblab]

If Cali is acting lethargic again now that the prednisone has been discontinued, I can see continuing with a tiny dose for a very short time period -- like for another week or so. As Lori says, some dogs may feel more comfortable when their cortisol runs a bit higher, so giving a bit of prednisone short term may act as a bridge to tide her over until her natural production begins to rebound again (assuming that it will), and you begin maintenance dosing.

However, your vet's recommendation to continue the prednisone for months while awaiting a return of symptoms totally cancels out the point of loading with the Lysodren in the first place :eek:. Unless Cali is truly Addisonian without an expectation that her adrenals will naturally produce cortisol again, there is absolutely no reason for dosing her with prednisone on a long term basis. Giving prednisone to an actively Cushinoid dog is like pouring gasoline on a fire. It makes absolutely no sense to me, and can open Cali up to a host of other problems. If she remains on prednisone long term, you may actually interfere with the ability of her adrenal glands to ever resume natural cortisol production. Or, in the reverse, you may create a situation where her Cushing's symptoms rapidly flare out of control and you'll be long past managing it with only a maintenance dose of Lysodren.

A huge red flag for me is that you say your vet feels as though Cali's adrenal suppression will be long term. It may be true. The extended loading period may indeed have permanently damaged Cali's natural adrenal function. But there is absolutely no way to know whether this is true without ongoing blood testing, and really no basis for your vet to make that assumption right now. I know the ACTH testing is very expensive, but in combination with Cali's behavior while prednisone-free, it is the only way to know what is truly going on with her natural cortisol production.

If Cali were my own dog, I'd perhaps go ahead and resume the prednisone for a bit longer, but for no more than another week. I would then discontinue it again, see how she behaves, and then reconsider my options once again based upon her behavior.

Marianne

[molly muffin]

Prednisone is one of those drugs that seem like a miracle at the time, but the longer it is used, the worse the side effects from using it can be. It can cause the adrenal glands to not produce enough cortisol on their own and too much of a build up can cause cushing type symptoms.
So it is something you want to be careful with, even in small doses for prolonged use. I'd probably try what Marianne suggested. Another week on small dose (very small) and then a retest and try to have it off pred completely.

There is also a kind of withdrawal from having higher cortisol that dogs feel, which is like being lethargic, not interested in anything, feeling their aches and pains more. It's usually will pass as natural cortisol levels are maintained, if it is a withdrawal.