Yogi has crossed the Bridge - questions about Trilostane

[AngieB]

Hello. I am so glad to have found this forum. :)

My 10 y.o. flat coat has just been diagnosed with Cushing's and is having his ultrasound today to determine if pituitary or adrenal related. The initial advice was to start him on 60 mg/day Veterol, and that has not yet been started.

My initial question is whether folks on this forum recommend for future treatment going forward:

a) continuing treatment through my regular vet practice who is consulting an internist or
b) seeking a specialist directly or
c) seeking a general vet who has lots of experience treating Cushing's patients.

I like my vet, and also I have experienced some delays in communication already and need to find out how many Cushing's patients she has treated. I know that specialists are more expensive - so am interested in the importance of either specialty or experience.

I will provide more stats once received. Thank you for any information you can provide or direct me to on the forum.

Angie

[DoxieMama]

Hi Angie, and welcome to you and Yogi! I believe your vet's experience treating Cushing's is important, but if she is consulting an internist (and you're consulting us), you're in the same position I was in when treating my pup. And you have us, too! The experts around here have 'seen' more dogs with the possibility of Cushing's than any vet/internist around.

Of course, all decisions on Yogi's treatment will be up to you, including this one. If I were to do it over again, I'd stick with my regular vet... because I know him, trust him, and he is willing to consider my thoughts and what I've learned in my own research. His office is also really close to my home. I make a point to get copies of all test results though, so if I do have to go somewhere else for any reason, I have those available immediately.

I'm sure others will be along to welcome you also. In the meantime, please let us know if you have any questions.

Shana

[labblab]

Hello Angie, and welcome to you and Yogi — we’re so glad you’ve found us, as well! In terms of vet partners, we’ve seen success (and also issues...) with all the options you’ve cited. I think the extent to which an internist needs to be involved really depends upon the experience and communication skills of the regular vet. It’s true that specialty practices tend to be more expensive, but sometimes less money is involved in the long run because they may be more efficient in terms of diagnostics and also more knowledgeable about cutting-edge treatment protocols. Since Cushing’s can be difficult to conclusively diagnose, it is not uncommon for folks to initially consult with an internist for testing and treatment recommendations, and then return to the regular vet for ongoing care and maintenance. However, we’ve also had members who have stuck with their regular vets throughout, especially when symptoms/testing seem pretty clear cut. So I think your decision may depend upon how things unfold.

Turning to diagnostics, can you tell us more about Yogi’s overall health history, as well as the symptoms and testing that have led to the general Cushing’s diagnosis? An ultrasound can provide a lot of helpful info about the status of other internal organs in addition to the adrenal glands, so that’s an excellent diagnostic step.

As far as Vetoryl dosing, current generally accepted recommendations are to begin at a dose no greater than 1mg. per pound. From the standpoint of weight, I’m guessing that 60 mg. would fit into that formula given the size of most flat coats. However, just as a cautionary note, it has been our experience here that “bigger” dogs often require less dosing per pound than do smaller dogs. Paradoxical, but true. So if you do proceed with Vetoryl, you may want to purchase capsules in a smaller dosing size (like 30 mg.) to begin with. It’s more expensive to buy two boxes of 30 mg. as opposed to one box of 60 mg., but it gives you greater dosing flexibility when you begin treatment — you can always combine smaller capsules, but you cannot open and divide larger ones. If 60 mg. turned out to be too much for Yogi, the larger capsules would be wasted.

OK, that’s enough for now! Once again, we’re so glad you’re here. And even though I’ve always had Labs, I love flat coats, as well! One of my very best friends has had a number of flat coats over the years, and their dispositions and their antics never fail to bring a smile to my face. It’s a great breed!

Marianne

[Squirt's Mom]

Hi Angie,

Welcome to you and Yogi! :)

Since you have started the testing process it is time to develop a new habit - that of getting the actual test results from every test from here on. That way you have all Yogi's info in hand should he ever need to see a different vet - like on vacation, etc. - plus you will be better able to answer alllll our questions. :D

And to start our game of 20+ questions ;) - what prompted the testing for Cushing's in the first place? What signs did you see or what gave the vet the idea to look for Cushing's? How old is Yogi? Is he on any other meds, herbs, supplements...and if so, what for? Does he have any other health issues that you are aware of? How much does he weigh?

Speaking of weight - the recommended starting dose of Vetoryl is 1mg per lb. So a dose of 60mg would be appropriate for a dog weighing 60 lbs.

Ok...that's enough for now. I'm sure others will be along shortly to chat with you. I'm glad you found us and look forward to more info soon!
Hugs,
Leslie

[Carole Alexander]

Hi Angie and Yogi,

Lots of folks are giving you great information and questions. On the question of regular vet or IMS, you may want to wait until you have more information to decide. But there are definite differences. My regular vet has an old ultra sound machine and blood pressure machine; the teaching hospital/specialists often have shiny new equipment that provides better images and information. That was important to me in them discerning adrenal versus pituitary Cushing's and then when my dog developed high blood pressure. My local vet had far less experience in treating Cushing's, but specialists can err as well and will in general charge top dollar. Also, I don't know where you live but if you live in a large or larger city, many local vets are quite sophisticated. Costs of teaching hospitals/speciality vets are less in the middle of the country than on either coast. If Yogi's Cushing's is straightforward, you begin treatment at the proper dosage, do the testing and all goes well in controlling his Cortisol, your regular vet may be fine. I would urge you to get more information and consult with the experts here and then decide.

[molly muffin]

Hello I just want to say hello and welcome to you and Yogi. What a fun name and a handsome lad.

The others have gotten you off to a great start.

I personally had 2 vets and an IMS, as my dog had other issues. It really does depend on your vet and how experienced and communicative they are. Some are better than others. My IMS because my go to for the cushings and kidney disease and was very responsive, so I didn't have to go as often, then I used my regular vets for normal things like shot, tummy upset, BP checking.

[AngieB]

Hi, Thank you all SO MUCH for your responses and questions. I have been referred to the NC State Vet School Internal Medicine department for Yogi's care for his first visit next week. I am starting the Vetoryl today 60 mg 1/day per the IMS' instruction until the appt next week. (Thanks for the info about dosage - I had already purchased the 60 mg, so will inquire about lower dosage at his next visit).

Below are his test results and symptoms. I appreciate any suggestions on information that I should ask on my first visit beyond if dosage can be reduced. Also, could someone advise on whether I should put this info on a separate post - or just add it to my initial one? I'm new at this!

Symptoms: hair loss around 1 eye (for 6 months), frequent urination & thirst (for 1 month), weakening in hind quarters (for 1 month), voracious appetite (his whole life!!! )

10/27/17 UA_Analyzer
SC 1.007
pH 7.0
BLD 50
BIL negative
All other normal

10/27/17 SediVue_DX
RBC 1-5/HPF
All others “none to rare” including WBC, BACr, BACc, sqEPI, nsEPI, HYA, nhCST, CRY, CaOxDi, STR

10/27/17 Catalyst_One blood test
TT4 0.8 (Low)
TP 8.1(Low end of High range)
ALB 3.9 (Low end of High range)
GLOB 4.2 (High end of Normal range)
ALB/GLOB .9 (High end of Normal range)
ALT 103 (High end of Normal range)
TBIL 1.1 (High)
AMYL 561 (Low end of Normal range)
K (Low end of Normal range)
All else in normal range


11/7/17 Dexamethason Suppression
PRE DEXAMETHASONE 3.3
POST 4 HR DEX 4.8
POST 8 HR DEX 3.9

*This is when the internal specialist at the lab advised my general vet that Yogi has Cushing's

11/13/17 Abdominal Ultrasound
Interpretation Summary
1. Bilateral adrenomegaly, rule out hyperplasia due to PDH.
2. Non-specific hepatic parenchymal changes, rule out diffuse hepatopathy (vacuolar), cholestasis, or dehydration.
3. Small bilateral non-obstructive nephroliths.
4. Small amount of mucinous hyperplasia of the gall bladder wall, likely incidental.

Comments
Liver: The liver is normal to mildly enlarged with normal margins and a homogenous echotexture. Overall the echogenicity of the liver is decreased resutling in increased conspicuity of the portal vessel walls.
Gall Bladder/Biliary Tract: The gall bladder is small with a hyperechoic mucosal lining that is mildly thickened and irregular. No cystic or bile duct distension is present.
Pancreas: Normal.
GI Tract: The stomach is distended with a large volume of echogenic ingesta. No mural abnormalities are present. The small intestines and colon are normal. .
Spleen: Normal.
Kidneys: Both kidneys have small 1-2 mm, hyperechoic peripelvic and peridiverticular concretions. No pelvic or ureteral dilation is present. Renal size and margination are normal. .
Adrenal Glands: The caudal poles of both adrenal glands are thickened (LT=12.4 mm; RT=11.2 mm) with normal shape and echogenicity.
Urinary Bladder: Normal.
Reproductive Tract: Normal prostate.
Lymph Nodes: Normal.

[Harley PoMMom]

Here in Yogi's thread is where all information about him should be posted, so you handled that perfectly.

Looking at his urinalysis I see that blood was found in the urine (10/27/17 SediVue_DX
RBC 1-5/HPF) which could mean he has an urinary tract infection (UTI) and from the ultrasound stones were seen (Small bilateral non-obstructive nephroliths) both of these issues can make a dog drink and pee more so since Yogi's increased thirst/urination started just a month ago I'm a bit concerned. One recommendation I have is to ask the vet if Yogi's urine should be cultured to rule out an UTI.

Another thing that bothers me, looking at his chemistry blood panel (10/27/17 Catalyst_One blood test), it is really unusual for a dog with Cushing's to not have an elevated serum alkaline phosphatase (ALP). In fact, 80% to 90% of dogs have a steroid induced isoenzyme of alkaline phosphatase (ALP) so if one of those dogs has Cushing's, you are gonna see anywhere from a mild to severe increase in ALP.

Now, there is that 10%-20% of dogs with Cushing's and their ALP does not elevate that drastically, I have seen this situation a couple times on the forum, so it could be that your boy falls in that 10% - 20% group.

Has the vet mentioned that the Vetoryl has to be given with a meal to be properly absorbed, and that it is recommended that an ACTH stimulation test should be performed 10-14 days after treatment was started? Regarding the protocol of an ACTH stimulation test, which is how the cortisol level is checked, the Vetoryl needs to be given with a meal and then the test has to done 4-6 hours after the Vetoryl dose was given.

You're doing a great job! Oh, welcome to you and Yogi!! So glad you joined our family but sorry for the reasons that brought you here.

Lori

[AngieB]

Lori, Thank you for looking at his information. Those are great questions and make me glad I am going to the ICM next Thursday.

(below the "first vet" is the regular vet and the "ICM" is the specialist)

- UTI - I forgot to add that his urine was cultured then he was put on antibiotics first to see if it was a UTI. The first vet tried two different antibiotics. After antibiotics, he continued symptoms. Both tests I have results for (10/7 and 10/27) showed RBC 1-5/HPF

- Stones - The first vet did not mention she saw stones. In fact, she said all results other than the Cushings were awesome?!

- Vetoryl - The first vet told me about giving with food and having the ACTH stimulation test afterwards.

- ALP levels - That is concerning/puzzling. I will need to discuss with the ICM.

At this point, I've only given him one Vetoryl and am wondering if I should hold off on more for a week because of the questions! I reached out to the ICM and they said that if he continues to take Veterol, it will skew any test results if they retest next week. The ICM cannot advise one way or the other until they see him next week.

Angie

[Harley PoMMom]

I reached out to the ICM and they said that if he continues to take Veterol, it will skew any test results if they retest next week.

Angie

Can you tell us what test he is having done next week that the results will be skewed if he continues with the Vetoryl or did you mean if Yogi stops taking Vetoryl the test results would be invalid? If my assumption is correct the retest that the ICM is referring to is the ACTH stimulation test which is how cortisol levels are checked, and to accurately gauge how the Vetoryl is working it should be taken every day using the protocol I mentioned in my prior post. :)

Lori

[AngieB]

Sorry for any confusion. The testing would be to confirm diagnosis, not to do the ACTH stimulation test. I talked with the ICM. They do not automatically go with the first vet's diagnosis, and will evaluate the test results to date and then determine if they want to test anything independently before giving their own diagnosis.

If the ICM wants to do additional testing to confirm diagnosis, Yogi taking Vetoryl a week before could impact bloodwork. So, I decided to hold off on giving additional Vetoryl until the ICM confirms diagnosis this week (Yogi has had only 1 pill to date). If the ICM agrees it's Cushing's, I can start Vetoryl this week at the ICM's recommended dosage level, then schedule the ACTH test.

Angie

[Harley PoMMom]

Thanks so much for the clarification. When you get the results of the tests that the ICM wants to perform could you share those with us, please? And good luck!

[AngieB]

Thank you. I will! It's such a comfort to be on this forum.

[AngieB]

Yogi was seen at NC State Vet School Internal Medicine (NCSU ICM). Based on the prior bloodwork and ultrasound, they suspect he is Cushinoid (Cushing's). However, they have concerns about some of the test results that are atypical, so performed additional bloodwork and also a vector borne panel. Two test results are pending and should arrive next week.

Problems & Diagnoses: suspected pituitary dependent hyperadrenocorticism & decreased platelets

Meanwhile, I am tracking his food & water intake and urine/stool. NCSU ICM started him on 30 mg every 12 hours of Vetoryl, and other than appearing sleepy & tired, seems to be tolerating it. He will have an ACTH test scheduled on day 11 of the Vetoryl at my regular vet (NCSU ICM is booked). NCSU ICM will adjust meds pending test results and he will be seen on day 20 of the meds for a follow up exam. ACTH test is also scheduled for day 32 of the Vetoryl (holidays).

Results are below. I have it in excel, but the table format didn't copy so have bolded anything LOW or HIGH.

GLUCOSE 87 MG/DL 70-131
UREA NITROGEN 10 MG/DL 6-26
CREATININE 0.5 LOW MG/DL .7-1.5
PHOSPHORUS 5.5 MG/DL 2.5-5.6
CALCIUM 10.6 MG/DL 9.4-11.4
MAGNESIUM 2.2 MG/DL 1.8-2.5
PROTEIN-TOTAL 6.5 G/DL 5.2-7.3
ALBUMIN 4.4 HIGH G/DL 3-3.9
GLOBULIN 2.1 G/DL 1.7-3.8
ALB/GLB RATIO 2.10 HIGH .9-1.8
CHOLESTEROL 249 MG/DL 124-344
BILIRUBIN-TOTAL <.2 MG/DL 0-.2
ALKALINE PHOSPHATASE 88 IU/L 16-140
ALT 49 IU/L 12-54
AST 21 IU/L 16-140
GGT 3 IU/L 0-6
CK 108 IU/L 43-234
SODIUM 150 MMOL/L 140-156
POTASSIUM 4.3 MMOL/L 4-5.3
CHOLORIDE 108 MMOL/L 108-122
BICORBANATE 20 MMOL/L 18-26
ANION GAP 26.3 HIGH 11.2-19.9
NA / K RATIO 34.9 27.7-35.9
OSMOLAITY-CALC. 295.4 MOSM/KG 278.7-311.6
AMYLASE 480 IU/L 236-1337
LIPASE 246 HIGH IU/L 12-147
ICTERIC INDEX 0
HEMOLYSIS INDEX 55
LIPEMIA INDEX 6

11/30/17
URINALYSIS CYCTOCENTESIS 12:12 PM REF RANGE
PHYSICAL PROPERTIES
COLOR LIGHT YELLOW
TURBIDITY CLEAR
SPECIFIC GRAVITY 1.003 LOW 1.015-1.045
CHEMICAL CHARACTERISTICS
PH 7 4.5-8.5
PROTEIN, BUMIN NEG
PROTEIN, DIPSTICK NEGATIVE
GLOCOSE NORMAL
KETONES NEGATIVE
BILIRUBIN, DIPSTICK NEGATIVE
BLOOD NEGATIVE
MICROSCOPIC EXAM
WBCS RARE /HPF
EPITHELIAL CELLS RARE /HPF
CRYSTALS-AMORPHOUS RARE /HPF
FAT DROPLETS FEW /HPF

HEMATOLOGY
WBC 5.67 X10^3/UL 4.39-11.61
RBC 8.12 HIGH X10^3/UL 5.7-8.01
HEMOGLOBIN 19.4 G/DL 13.8-20.3
HEMATOCRIT 55.7 % 39.2-55.9
MCV 68.5 FL 61.8-75.1
MCH 23.9 PG 20.2-25.3
MCHC 34.9 G/DL 30.8-35.4
RDW 12.2 % 11.3-13.5
PLATELETS 176 LOW X10^3/UL 190-468
MPV 10.7 FL 7.9-13.8
PCT 0.19 LOW % .2-.58
RETICULOCYTE % 0.62 % .11-1.26
RETICULOCYTE # 0.051 X10^3/UL
RETICULOCYTE ABSOLUTE 51000 /UL 8040-93730
PACKED CELL VOLUME 52 % 39-58
PLASMA PROTEIN 7.5 HIGH G/DL 5.9-7.3
SEGMENTED NEUTROPHILS 4.423 X10^3/UL 2.841-9.112
BAND NEUTROPHILS 0.113 X10^3/UL
LYMPHOCYTES 0.51 LOW X10^3/UL .594-3.305
ABNORMAL LYMPHS 0.284 X10^3/UL
MONOCYTES 0.34 X10^3/UL .075-.85
PLATELET CLUMPING FEW
PLT. NUMBER APPEARS DECREASED
LARGE PLATELETS FEW
SUMDGED WBCS OCCASIONAL
ANISOCYTOSIS MILD
POIKOLOCYTOSIS SLIGHT

[Harley PoMMom]

Those blood panel results are not what we usually see in dogs with Cushing's but all dogs are different so their reactions to Cushing's can be just as different as well. Is the vector borne panel one of the tests that the results are pending?

How much does Yogi weigh? I believe it was mentioned that the recommended starting dose for Trilostane, which is the active ingredient in Vetoryl, is 1 mg per pound of a dog's weight. If the dose is too high symptoms that can be seen are; vomiting, loss of appetite, diarrhea, or Yogi just not acting his normal self. If any one of these are observed an ACTH stimulation test should be performed to make sure the cortisol hasn't dropped too low.

Also, most clinicians recommend leaving the starting dose unchanged for around the first month of treatment, this is because cortisol levels tend to continue to drift downward during the first month, even when the dose is left unchanged. Please keep us updated.

Lori

[AngieB]

Yes, the vector borne panel is one of the results that are pending.

Yogi weighs close to 58 pounds, so I think the dosage of 60 mg (30 mg every 12 hours) seems in line. I will keep an eye to see if any symptoms appear. Thanks for that info on keeping the dosage unchanged!

Angie

[AngieB]

Yogi had his ACTH Test after 11 days on Veteroyl (30 mg every 12 hours for a 60 pound dog. Here are the results:

Cortisol - Pre ACTH 4.1 ug/dL
Cortisol - Post ACTH 12.5 ug/dL

These were at my regular vet and she is going to forward these to NC State Internal Medicine (ICM) for response. She noted that he may need to go up in dosage, and NCSU would need to respond. NCSU (the ICM) has not yet responded re: the other testing that they did re: the low platelets and bloodwork not entirely consistent with Cushings.

He appears to now be able to go 3.5 hours without urinating - most times, but not all. Otherwise, he seems like he has not changed symptom-wise.

Are there any questions I should ask?

Angie

[Harley PoMMom]

Although his post result isn't within the therapeutic ranges I still wouldn't increase the dose as cortisol can continue to drift downward during the first month of treatment. I would also want to wait until the vector borne panel results are known. Are they planning to do another urine culture to make sure that the UTI is completely gone?

Lori

[AngieB]

The vector borne panel results came back negative, and the ICM does not know why his platelets are low and other unusual bloodwork. The ICM has no action plan re: that and only reached out through the receptionist after 3 tries to follow up. The information I got from her was reading the communications log from NCSU to my regular vet.

The ICM did respond to the ACHT test and reached out to my regular vet, who later emailed me. The ICM advised my regular vet to increase Yogi's dosage to 40 mg Vetoryl every 12 hours instead of 30 mg very 12 hours. It took me four calls to confirm the correct Rx to pick up, which was concerning.

At this point, I am getting my new Rx from my regular vet and have a follow up with the ICM on Nov 20th. Neither addressed the UTI, so per your recommendation, I requested the regular vet do another urine culture to make sure the UTI is completely gone. I will take this in today and pick up the new Rx.

Bottom line - I'm not confident I have the right care team at this point. It feels like ping pong between the two and I my goal was to transition to one point of care with the ICM. If they do not have availability, I may need a new provider.

Is this craziness with multiple providers what other people experience?

Angie

[Squirt's Mom]

With the ITU in play PLUS having started Vetoryl less than 30 days ago, no way I would increase his dose now.

[Harley PoMMom]

I fortunate that my vet and the IMS had a good communication line between themselves and they both didn't have a issue with keeping me in the loop, which I demanded they do. :eek::)

Since Yogi's dosage is being increased, is an ACTH stimulation test already scheduled for a recheck? This should be performed within 10-14 days.

Lori

[AngieB]

Hi Lori,

Yes, his recheck has been scheduled 13 days after his dosage change, along with another test to see if his platelets remain low. Then he will see the ICM after those test results come back. Yogi appears to be going longer in between bathroom breaks, and actually brought a ball to me to play fetch yesterday. That is the first time since all of this started. I'm hoping the increased dosage is starting to have a positive effect.

Angie

[AngieB]

Yogi's Rx for Vetoryl has been increased several times followed by ACTH Stim tests. The latest Vetoryl dosage has been: 50 mg AM and 50 mg PM. Yogi is 60 lbs. This is the ACTH test result from last week:

Pre ACTH Cortisol 5.6
Post ACTH Cortisol 9.7

The note on the IDXX report says Per the manufacturer, pre-and post-ACTH cortisol levels of 6-9 ug/dL may be sufficient for some animals if clinical signs are well controlled.

I have sent the results to NCSU Internal Medicine for their advice on whether to increase the dosage or stay as is. Except for 2 urination accidents this month, his symptoms are very well controlled and he seems good.

Please feel free to share any thoughts. I will update when I get their response.

[Harley PoMMom]

In your December 13th post I see that you were having Yogi's urine cultured, did it show that the UTI was completely gone? Are those most recent ACTH stimulation test results (Pre ACTH Cortisol 5.6 ~ Post ACTH Cortisol 9.7) from the 50 mg dosage increase or the 40mg?

[molly muffin]

So Yogi seems to be doing well? Symptom wise, other than a couple accidents, he seems more himself?

And what of his platelets and other test results that were off? Have those resolved?

He's such a lovely boy. I like his avatar picture.

[AngieB]

Hi, yes Yogi is doing much better and seems more like himself! The vet specialist recommended we stay at the current Vetoryl Rx for the next month and assess if he continues to do well before increasing the dosage. The platelets and other test results that were off have resolved based on the last full blood screen. So fingers crossed that the next month is good.

I am curious how to search on this forum to see what to expect if he does well on Vetoryl for a while - and what the path or progression when things start to deteriorate. I am hoping he does well for a long time - and also want to educate myself on what happens when it no longer works. Is there a way to search for that without reading all the individual stories?

Thank you!

[Squirt's Mom]

I'm glad Yogi is doing better and pray the trend continues! You can learn a great deal about Cushing's, the drugs used to treat, and many other things in this section of our forum, the Helpful Resource section - http://www.k9cushings.com/forum/forumdisplay.php?10-Helpful-Resources-for-Owners-of-Cushing-s-Dogs

For something specific you want to read about, use the Search feature at the top right of the page. You can use the box or go to the Advanced Search for more options.

[molly muffin]

Yay glad he is himself again and his platelets are back where they should be.

It will always be necessary to stay on top of what his adrenal glands are doing using the ACTH test. It isn't uncommon that after a dog has been on a dose for awhile for them to need an adjustment, often downwards and not needing as much. This can happen at any time, but especially I have noticed after being on the same dose for a year. Thats just a personal observation on my part and we are talking long time going forward on a stabilized dose.

I would also say that you want to do cbc's regularly. I did them every 6 months even when things were going well, as you have to watch things like kidneys and pancrease and other organs, as they are often the ones that end up causing problems later on. (this is true of any animal as it gets older though)

So just some thoughts I had when reading your post.

[AngieB]

Hello,

My dog, Yogi (11 y.o. 60 lb flat-coated retriever) presented symptoms last year and was initially treated by my vet. In Jan 2018, he moved to NCSU Vet Internal Medicine and was diagnosed with pituatary dependent Cushing's. He presented some data that is a bit out of line with Cushing's diagnosis (ALP not elevated), but they decided to treat using Trilostane (Vetoryl). Since January, the vet has adjusted the dosage of Trilostane several times in response to symptoms (see below). Blood work and ACTH tests were completed throughout this period. Recently, because the ACTH tests were so low, the vet requested I stop Trilostane dosage for 1 time, then restart, and finally requested I stop dosage to reevaluate. The vet has indicated they are not sure how to proceed given his response and proposed four potential options at this point, including restarting Trilostane.

I would greatly appreciate any input on what questions to ask the vet, and also steps to take.


12/12/17 ACTH Pre 4.1 Post 12.5 - vet increased dosage from 30 mg twice a day to 40 mg twice a day
12/27/18 ACTH Pre 3.6 Post 8.0 - dosage remained at 40 mg twice a day
1/12/18 - no ACTH test - dosage increased from 40 mg twice a day to 50 mg twice a day
1/16/18 ACTH Pre 5.6 Post 9.7 - dosage remained at 50 mg twice a day
2/15/18 ACTH Pre 2.4 Post 3.0 - dosage remained at 50 mg twice a day
3/15/18 ACTH Pre 2.0 Post 4.8 - dosage remained at 50 mg twice a day
5/3/18 ACTH Pre <1 Post 2.3 - dosage reduced from 50 mg twice a day to 40 mg twice a day
5/21/18 ACTH Pre 1.1 Post 2.5 - dosage remained at 40 mg twice a day
6/11/18 ACTH Pre 1.9 Post 4.1 - dosage remained at 40 mg twice a day
7/26/18 ACTH Pre <1 Post 1.6 - Yogi was EXTREMELY lethargic, dosage stopped for 1 dose, restarted at 35 mg twice a day to reset
8/8/18 ACTH Pre 1.3 Post 1.4 - revised to 35 mg twice a day
8/9/18 dosage stopped to reassess

8/8/18 Bloodwork, electrolytes tested, all normal except: Anion Gap (High 26.2 - range 11.2 - 19.9) and HA / K Ratio (Slightly high 37.1 - range 27.7 - 35.9)

Yogi has been off Trilostane since 8/9/18. He is alert, however, his symptoms of frequent drinking and urination have resumes (he has to go out ever 3 hours). Bloodwork has been done, and appears normal (I'm requesting the latest).

The vet at NCSU states they are perplexed. They have done a lab and determined that the enzymes have not been negatively impacted. They do believe Trilostane is having a positive impact to his symptoms. The vet provided the following 4 options with #1 as recommended:

1) try 40 mg one time per day and move to testing via the cortisol test instead of the ACTH test (i.e.,cortisol test at 8 AM, dose at 9 or 10 AM w/food). This Rx to start now, then first cortisol lab in 2 weeks
2) Try Mitodane/Lysodane. The vet states they have never seen a dog come off this b/c of bad effects, requires >intensive monitoring
3) MRI to look for micro adenoma tumor not visible
4) do not medicate - Vet has a concern over quality of life, potential UTI, pancreatitis

I have mapped the tests, bloodwork, results and dosage. To me, the dosage increase to 50 mg was ok at first, but I suspect it was too high. I am concerned about continuing to medicate him with Trilostane when his ACTH tests show cortisol so low. I am concerned that there is a continual disclaimer about his diagnosis as Cushing's - as if there may be something else going on. Do I need to seek an endocrinologist?

Any help or suggestions would be greatly appreciated. Note that I posted earlier when I was trying to find a specialist.

Angie

[Squirt's Mom]

I have merged your latest post concerning the 4 options the vets have offered for Yogi into his original thread. We like to keep all info about each dog in one thread. That way it is easier to look back thru the history.

[AngieB]

Thanks. I was wondering how to change the title so people could see and respond to the "trilostane" instead of the original question.

[Squirt's Mom]

I have edited the title to read - " Yogi - questions about Trilostane". Hope this helps! :)

ps. only moderators and admins can change titles but anytime you need something changed let one of us know and we will see what we can do! ;)

[AngieB]

Thank you!

[labblab]

Hello Angie, and welcome back to you and sweet Yogi although I’m sorry that you’re facing some puzzling challenges right now. I’ve read through your very complete update (thank you for that!), but want to think things over a bit more before writing a more involved reply. My initial knee-jerk reaction is that, even with the rebounding thirst/urination, I’d be hesitant to resume the trilostane at any dose until a repeat ACTH reflects a rebounding cortisol level, as well. You’ve both had to endure so many ACTH tests thus far that I hate to recommend yet another one. But especially with some lingering questions about the accuracy of the original diagnosis, it may be the case that the thirst/urination don’t honestly reflect the underlying cortisol level.

We do know what the NCSU vet is referring to in regards to the pre-pill resting cortisol test, and we can talk about that some more. In the long run, that may turn out to be a good option. But in the short run, I want to think things over a bit more. As far as endocrinologists, I would have assumed that Yogi would be seeing an internist with specialty interest in endocrinology at NCSU. Are you thinking that is/was not actually the case?

Marianne

[AngieB]

Marianne,

Thank you for your response, and consideration to think things over.

At NCSU, they assign an internal medicine resident to clients. This resident consults with a more experienced person. Since I have been there, both the resident and who they consult with has changed once or more. I do not speak with the more experienced person, though the resident refers to what they say re: consultation.

I so appreciate all the team at NCSU, they have been great with this and other emergencies (Yogi has previously ingested a purse and part of a plastic boot, requiring endoscopy). And yet, I would move heaven on earth for this pup - and want to seek counsel from someone who will look at the data beyond the Cushing's almost likely-diagnosis. Seriously, could debris remaining from the ingestion have an impact? Or could it be undiagnosed issues from the liver, etc.? I want to treat the problem, not the symptoms.

Angie

[labblab]

Hi again, Angie. I’ve continued to mull over Yogi’s situation, and I have a suggestion that you may or may not be interested in pursuing. But it involves contacting a noted endocrinologist to see whether he might be willing to offer you some additional guidance re: Yogi’s situation. Rather than reinvent the wheel, I’m going to reprint a reply that I recently posted to another member. If you do decide to contact Dr. Bruyette, definitely tell him that you’re a member of this forum and that we’re all perplexed by Yogi’s situation, including the folks at NCSU. Do tell him that there are remaining questions about the original diagnosis, as well as his response to trilostane. I would relay all the info contained in your latest reply to us, as well as telling him you can supply ultrasound results as well as original lab testing info (including the lack of an elevated ALKP reading). In the meantime, I’ll continue to mull things over, too (although I’m hoping Dr. Bruyette will respond to you cuz his feedback will be a lot more valuable than mine!). By the way, he did directly respond to the member below with helpful info.


Hi Eve,

Normally, we try to keep all posts related to a dog consolidated within one single thread. With that in mind, in a few days we’ll probably merge this thread into your original thread about Zimmy. However, I’m temporarily leaving it “be” in order to see whether it garners you help in finding an endocrinology referral.

In that vein, here’s one suggestion for you that may or may not prove to be helpful. But I’m going to direct you to the website of a veterinary consultation service headed by Dr. David Bruyette. Dr. Bruyette is a noted internist/endocrinologist who formerly directed services at the VCA hospital in West Los Angeles, is an expert on canine Cushing’s, has been a consultant with Dechra re: clinical use of Vetoryl, and helped pioneer surgical intervention on enlarging pituitary tumors here in the U.S. Last but not least, at one time he was a contributor to this forum. While serving as medical director at VCA, he was surprisingly receptive to directly fielding email questions from our members. Now that he is immersed in developing his new service, I don’t know whether he has as much time available. But you’d have nothing to lose by contacting him in order to see whether or not he could help guide you in terms of Zimmy’s care.

His new service is designed to be utilized by vets. But in a situation like this, he might allow you to personally contract for some assistance. Or at the very least, I feel certain that he could recommend an endocrinologist in your area. So take a look at the website, and see what you think. If you do decide to contact him, be sure to tell him you’re a member of our forum. Here’s the homepage for his service:

https://www.veterinarydiagnosticinvestigation.com/

And here’s Dr. Bruyette’s email address: DaveBruyette@veterinarydiagnosticinvestigation.com

Good luck!
Marianne

[AngieB]

Thank you, Marianne. I appreciate it!

Angie

[Harley PoMMom]

In your December 13th post I see that you were having Yogi's urine cultured, did it show that the UTI was completely gone?

An UTI will cause increased drinking/urination, and if Yogi's urine is still dilute than I would recommend having his urine cultured again just to make sure that an UTI isn't lingering.

[AngieB]

Thank you. His UA on 8/8 showed pretty wel so I may have that checked again. It was:

Yellow, slightly cloudy, specific gravity 1.015

CHEMICAL CHARACTERISTICS
PH 8

And all the remaining results look to be negative or normal

[Harley PoMMom]

The specific gravity is low and with dilute urine a regular urinalysis may not pick up bacteria so when urine is dilute an urine culture is recommended.

[AngieB]

Hi, It's been a bit since I posted. Since then, several different doses of Trilostane have been tried and have not brought him in range (40 mg 1x/day, 45 mg 1x/day). He developed two large open sores on his back and after testing it appears that it was caused by blood clots under the skin. So he started taking blood thinners.

At some point in here, I indicated to the vet at NCSU several times that I wanted to reach out to Dr. Bruyette for a consultation. The NCSU at NCSU said she reached out to Dr. Bruyette for a consultation and they discussed that Yogi was not presenting as a typical Cushing's case. I believe she said they discussed there was the possibility of a macro tumor. The idea of an MRI was raised, and she shared some info about potential radiation and/or surgery available in WA state as potential paths if something were to be revealed on an MRI. Somewhere in there the idea of trying Mitodone was decided not to be a good option, because Yogi could not be stabilized long enough to transition.

Early October, after the two wounds, Yogi was moved off the 1x per day Trilostane (with Cortisol test) and placed on a new Trilostane dose of 40 mg 2x/day with the ACTH test regime. After two weeks at that dosage, he was doing better (more alert) but his ACTH was not in range and his appetite and weight decreased a few pounds. The Trilostane dosage was then reduced to 30 mg 2x/day. On this dosage, he seems more alert and has wanted to play with his toys twice. His appetite is still not 100% but he seems more "Yogi." However, since the ACTH levels are still out of whack, an MRI has been scheduled to see if we are dealing with a macro tumor.

Yesterday 10/20, he had what I would describe as a seizure/tremor episode where his upper body esp. his paws contracted into a praying mantis position and he had tremors for upper body only. This was 1 hour after his breakfast & Trilostane does. The episode occurred after 30 minutes of panting, lasted approx. 10 minutes but I was not timing it with a watch. I took him to the ER, and his bloodwork was fine, so they were reluctant to give him anything for the episode as it was his first. The advised me to video tape the next one. After the episode was over, he appeared back to usual but tired.

Episode #2 occurred tonight 10/21, about 1 hour after his dinner & Trilostane dose (I'm not sure if there is a correlation), after he was playing with a toy. (He has not been interested in toys much for a while). Soon thereafter, he had another seizure/tremor episode. I videotaped 4 minutes of it during which his front paws did the praying mantis contraction, his upper body was shaking, and his eyes closed at times as if it was painful. The episode lasted end to end 40 minutes in total. About 10 minutes in, I was able to get him up for a short walk and he seemed normal, then the shaking resumed when he laid back down. Following the episode, he seemed really tired and went to sleep.

I hope this is it for the evening. I'm trying really hard to keep it together so I can be helpful to Yogi - when really I want to cry seeing him so uncomfortable.

Since he is scheduled for an MRI in the AM when his regular vet is in, I will take him in then - unless another episode occurs. After that, I'll know more whether he has a macroadenoma. I have read the threads on the website on that, and am waiting to see what the MRI reveals.

Regardless, I would like to be able to post the 4 min video for folks on the forum to look at, but am not sure how to do that. Can someone advise how to do that or send me to where the instructions are? Thank you.

[labblab]

Hello again, Angie. You already may be heading off for Yogi’s MRI this morning, and if so, I surely hope things will go smoothly for you. At this stage of things, I do think the MRI may offer some important information. We’ll anxiously await your news in this regard.

As far as the video, you can try emailing it to our administrative gmail address. Members cannot directly upload attachments to the forum, but hopefully one of our technologically savvy staffers can retrieve the email and then post the video here on your behalf. Here’s our address: k9cushings@gmail.com.

Please do report back to us when you’re able. And please give Yogi a big hug from his family here!

Marianne

[AngieB]

Thanks, I will keep you all posted. I showed the video to the vet, and she mentioned they would look at whether it's time to put him on anti-convulsant meds. I read that phenobarbitol is sometimes used, and tried to do a search on some of the newer meds. Is there a quicker way than reading threads for anti-convulsant as the search word to find out from the forum what others have used?

[AngieB]

The MRI radiologist report is not out yet. However, the vet indicated Yogi's MRI revealed a significant tumor (pituitary macroadenoma). She indicated it was visible to see on the MRI that the tumor is compressing the tissue and creating swelling and could likely be the reason for seizures. I will get more info once the radiology report is final and the team there interprets and potential next steps for care. This may include a radiation option. From what I understand, surgical options, if even viable, would likely be in WA.

In addition to his 30mg Trilostane 2x/day, he has been put on anti-seizure meds (Levetiracetam (Keppra) 500 mg delayed release capsules - 2 by mouth every 12 hours. In addition, he is to continue on Clopidogrel 75 mg tables 1 per 24 hours to thin blood. His cutaneous necrosis (2 wounds from blood clots) are considered resolved.

I am very concerned about his pain level and quality of life. I really would appreciate any perspectives on this from folks who have been at this stage. Also, what questions should I be asking when I speak with the vet next? I don't know how large it is, or how much pain he could be in either on a day to day basis or when in a seizure.

Angie

[Harley PoMMom]

Oh Angie,

I am so sorry to hear that Yogi has a pituitary macroadenoma. :( On the forum I have seen where prednisone is generally prescribed as it can help reduce the inflammation that the tumor is causing. You and Yogi are in my thoughts and prayers.

Lori

[labblab]

I am not surprised to hear this news about the tumor, but also very sorry that yet another major challenge — and major decision — may now be facing you. Through the years, we’ve had members who have undergone a variety of treatments for enlarging macrotumors. Initially the only option here in the U.S. was the prospect of over a dozen traditional radiation treatments over the span of a month, with general anesthesia required for each procedure. Over time, more specialized options have been introduced in some centers, including cyberknife-type treatment that only requires a very few sessions, and also actual surgery. Returning to Dr. Bruyette, he helped pioneer successful canine surgery as a joint effort between UCLA and Cedars-Sinai Hospital in L.A. One of our very own members, Lucy, was his first patient in that pilot program, and I believe surgeries are still bring done there on select patients. Here are some write-ups:

http://dogaware.com/articles/newscushingssurgery.html

https://www.cedars-sinai.edu/Research/Research-Areas/Endocrinology/Mans-Best-Friend.aspx

We’ve also had members who have received advanced treatment at UC Davis and Washington, among other centers. I think Florida may also offer advanced options, as well. As you might expect, results have been variable. Some dogs have had very good responses and remained neurologically improved for an extended period of time. Some have not. Some have had an extended respite from Cushing’s treatment. Others have had to continue with Cushing’s treatment even though the tumor size was reduced enough to relieve neurological symptoms. I think a lot will depend on the actual location and dimension of the encroachment, as well as the vets’ assessment of Yogi’s overall viability as a treatment candidate.

Age may be a factor in his candidacy and also your decision. I’m guessing he may now be eleven. I’ve not had either of my two retrievers (Labs) reach twelve, with or without Cushing’s. So one consideration may be the length of his expected lifespan, even with successful treatment. In other words, would he really have enough quality time left to gain from an invasive intervention. However, on the flip side, if he could benefit substantially from 2-3 cyberknife sessions and affordability was not an issue for you, then maybe that would be a worthwhile option.

I’d say, let’s see how the actual MRI report reads, and then see what your vet recommends. And then we’ll be here to talk over all your options.

Marianne

[AngieB]

Thank you both for responding so quickly. This forum has been such a resource for information and source of support.

Angie

[AngieB]

I have an appointment today with the radiology oncologist to explore options with that path. The report isn't final, but I have a verbal that the tumor is 1.5 cm.

Angie

[AngieB]

Here is the update from Yogi's MRI results (radiology report pending) and discussion with the radiation oncology vet. I would appreciate any feedback or thoughts to consider.

Selected stats from Physical Exam 10/22/18
Wt 23.5 kg BCS: 4/9 MMI 3/3
Hydration: euhydrated
Temp 101/7 pulse: 130 bpm (anxious in hospital setting)

10/22/18 MRI - MRI revealed a 1.5 cm pituitary mass with mild to moderate peri-lesional edema and no additional changes to explain his clinical signs (lethargy, hyporexia and recent onset of seizures). A finalized radiology report is still pending and is subject to change. Due to acute onset and subsequent progression of neurologic disease and mild to moderate edema seen around the lesion on MRI, prednisone .5mg/kg/day was also recommended either for palliative care of the lesion or in the period preceding additional therapies (RT, surgery). The owner was instructed to continue Triolostane and clopidogrel at the current doses. Typically fractionated RT is considered the recommended option for radiation of pituitary macroadenomas, however, in Yogi's case stereoactic RT may need to be considered due to current clopidogrel therapy and propensity thromboembolic disease (in conjunction with LT IV access). Although RT may not improve he endocrine portion of his disease, the hope is that the compression of surrounding tissues would improve and prevent the signs noted...Yogi's case is complicated by the fact that he is likely hypercoagulable with a historyof possible cutaneous thromboembolic disease, and monitoring for signs f bleeding during multiple anesthetic events is recommended.

My notes: location is in mid brain directly on the pituitary in between the optic nerve and spinal column

10/23/18 Radiation Oncology Visit

Diagnosis:
1. Hyperadrenocorticism (PDH) with pituitary macroadenoma and regional edema on MRI 10/22/18 = on 30 mg Trilostane BID and started .5mg/kg/day prednisone 10/22 due to edema and neurologic signs
2. Seizures, lethargy, hyporexia - suspect due to macroadenoma and regional compression - started Keppra 10/22/18
3. Focal, full-thickness dermal necrosis (2 lesions 10/3/18) - suspect ischemic dermal necrosis vs external trauma - resolved
4. Elevated mA on ETG - propensity for thromboembolic disease (likely due to unregulated hyperadrenocorticism) Angie note: Yogi now on clopidogrel
5. Moderate bilateral adenomegaly
6. History of thrombocytopenia - resolved
7. History of gastric foreign material / endoscopic retrieval
8. Elevated lipase 10/3/18 - improved 10/17/18

Vet comment re: RT: For Yogi's particular case, his clotting disorder has me (the vet) worried about doing daily anesthesia. So even through full course RT may be best for his tumor, I do not think it is best for his overall health and well-being. Instead, I strongly recommend 5 fraction SRT (using Novallas tool vs. Cyberknife). This is not risk free (he describes risks, that it is not as tested as the full course RT, etc)., but it is very well-tolerated by most dogs. It is possible that it would just stabilize the tumor, but my expectation is that this treatment protocol would lead to improved quality and quantity of life. It is very possible that this would allow him to live to his natural life-expectancy (13-14 yrs for a dog of his breed).

My additional notes on 5 fraction SRT: vet also discussed that his experience has been that the benefits from 5 fraction SRT seem to be more effective than the 1 &3 fraction SRT, though they do not have follow up on a large enough # of dogs to make firm conclusions.

My notes on discussion re: potential surgery: The radiation oncology vet spoke highly of the surgery, consistent with comments by the IMS vet. They both were willing to connect me with Dr. Owen's team in Washington State (who I believe worked with Dr. Bruyette) for an evaluation, and recommended that if I pursue that route I work with someone with extensive experience. They did express some questions/concern about Yogi's propensity for thromboembolic disease and how that would/could work with a surgery of this complexity.

Angie

[labblab]

Dear Angie,

Thanks so much for this detailed summary. And wow, you’ve got an awful lot to think over, that’s for sure.

As Lori has said, we are familiar with the decision to add prednisone alongside trilostane for dogs suffering from the inflammation and swelling associated with expanding macrotumors. Although it seems paradoxical to add a steroid at the same time you’re curbing natural steroid production, I think there is a logic there. My guess is that in order to administer a measured, consistent, therapeutic dose of glucocorticoid via the prednisone, you don’t want the natural cortisol production to run wild. At any rate, we’ve seen this strategy before.

As far as the intervention options, there is a lot to process and consider. I wish I had more time to talk right now, but I’m afraid I’ll have to wait until tomorrow to write more. The part that’s so incredibly hard when making decisions on behalf of an animal is that you can’t explain to them what’s going on, and you can’t ask them how they’d wish to proceed. So we’re entrusted with making that decision on their behalf, and that decision can feel really daunting. So that’s why we’re here to talk things over. As I say, I’ll be back myself tomorrow to try to add some more thoughts. But thanks again for such a thorough summary as to what you know thus far. You are surely doing a great job of advocating on your boy’s behalf.

Marianne

[AngieB]

I have received a copy of the MRI report. I have a question to the vet to see if evidence of hemorrhage makes RT risker. Surgery seems not so good an option with his clotting situation. Any feedback is welcome.

Pituitary mass with evidence of hemorrhage most consistent with pituitary macroadenoma. Invasive adenoma or adenocarcinoma cannot be excluded but are thought less likely. This mass causes dorsal deviation and compression of the hypothalamus with suspected mild perilesional edema.

Arising from the pituitary fossa there s a large primarily T2 weighted isointense mass with a region of relative T2 hypointensity within the rostral aspect. This mass measures 1.4 cm DV x 1.1 cm R-Cd in the saggital plane and is causing ventral compression of the hypothalamus, thalamus and ventral aspect of the 3rd venticle. In the gradient echo sequence there are multiple areas of susceptibility artifact consistent with hemorrhage. This mass is homogeneously contrast enhancing and is FLAIR isointense. Dorsal to this mass in the region of the hypothalamus bilaterally there is ill defined T2 weighted hyperintensity which does not null in FLAIR and there is no susceptibility artifact in gradient echo images at this level. The remainder o fthe brain parenchyma is normal with adequate grey and white matter distinction and no evidence of transtentorial or foramen magnum herniation. The extracranial structures are normal. The included lymph nodes are normal.

[labblab]

OK, I’m back again! I have to agree that Yogi’s clotting situation does raise a lot of question marks, especially as it relates to surgery, and also repeated anesthesia with RT. So I believe I do understand why SRT might be his best option. And in honesty, I have to think that would be far less stressful for Yogi than RT. Only five treatments as opposed to a dozen definitely would hold appeal to me. And for whatever reasons, most all of our recent macrotumor patients here have had the stereotactic treatment.

As you’ve been warned, the radiation may or may not alter the need for ongoing Cushing’s treatment. We’ve seen it go both ways. Some dogs have rebounded quite nicely and gotten a lengthy respite from traditional symptoms and medication. Others have seen improvement in the neurological symptoms but have otherwise remained status quo in terms of the need for ongoing Cushing’s medication. However, I would think the hope might be that even if Yogi’s Cushing’s symptoms were not completely resolved by tumor reduction via SRT, at least he could be more easily stabilized than is currently the case.

So there are certainly some positive reasons to consider SRT. “Cons” would obviously include the possibility of losing him during the course of the treatment/hospitalization, and then also the possibility of subjecting him to the stress of treatment without the assurance that the quality of his life would truly be improved in terms of the traditional Cushing’s issues. Cost and travel issues are not insignificant factors, either.

I can’t remember whether I’ve discussed with you the fact that I lost my own Cushpup to what we assume was an enlarging tumor, even though it was not confirmed via imaging. This was 14 years ago when the only option was traditional RT. For several reasons, my husband and I decided that we would not ask him to go through the dozen treatments that would have been required, and we had to release him when he lost the ability to eat and drink on his own. Had SRT been an option, our own decision might have been different. The much shorter course is definitely appealing, but it still doesn’t change certain risks and question marks that remain.

It sounds as though you are receiving very informed guidance, however, and that is surely welcome. That doesn’t relieve you of the burden of final decision-making, but at least the consultation sounds very thorough and competent. Gosh, so much to think over, that’s for sure!

[Squirt's Mom]

I have no further information to share with you but want you to know many of us are standing by, lifting you and Yogi in our prayers, sending healing and strengthening energies, silently holding your hand.

[AngieB]

Thank you both for your kind thoughts and wisdom. I sincerely appreciate it - this forum has been such a comfort.

This past weekend, Yogi played frisbee, went on a slow hike and was very alert. His spirit was strong, and he had his appetite back (I'm thinking thanks to the meds he's on). After deep reflection, I've decided to move forward with the 5 SRT sessions. The are scheduled to start next week, one per day, Monday - Friday. He had his mapping CT scan yesterday, and the anesthesia really was tough on him. It was heartbreaking to see him so weak. Today he's a bit better. He has trouble seeing the bowl (?tumor hitting the optical nerve) and I suspect his head doesn't feel well. He seems best when he is out on a walk, so I'll keep that up as long as he wants to. My focus will continue to be on his quality of life, meanwhile being hopeful that the time with him will be extended because of the SRT. I continue to treasure every precious moment with him.

[labblab]

Please know that your K9C family will be right there alongside you both in spirit. I know you’ll be very busy with Yogi’s treatments, but please do post updates as you’re able. We’ll be so anxious to hear how things are going. As I wrote earlier, had SRT been an option for my boy, I’d have seriously considered it, too. I do believe you’re giving Yogi his best chance at recovery, and we’ll all be hoping — so much — that he does just that!!!

Sending my warmest wishes to you and healing hugs to your sweet boy,
Marianne

[AngieB]

Last night was challenging. He had slight tremors most of the night, but not full seizures. For hours I wondered if he will be able to make it to the treatments next week. We made it through the night, and I woke up to his littermate and "twin" rescue brother who had slept the rest of the night with him. He rallied for a huge breakfast, then went on a visit to the park and long walk. It was hard to keep up with him he was walking so quickly! I think walking is his "thing" so we walk and walk and love it!

Yogi has dropped from 59 to 52 pounds in this whole process, so I am feeding him whatever I can think of to gain weight. Tonight he even ate a desert of moist cat food to try to pack in some energy. Any and all suggestions are welcome as to ideas on how to fortify him through food and supplements.

Here's hoping for a quiet and comfortable night for Yogi. We have four days until he starts his treatment, and he needs as much strength as he can get. Me too.

Angie

[Squirt's Mom]

I'm am hoping today will be a bit better for sweet Yogi!

[labblab]

Hi Angie, I’ve been thinking of you and Yogi all week, and hoping so much that his treatment was going well. When you have a chance, we’ll sure be anxious to read an update.

Continuing to send warm wishes your way,
Marianne

[AngieB]

Hi everyone,

Yogi completed 5 days of SRT Friday for drop off then pick up each day! Other than being tired in the evenings, and some panting, Yogi seemed very comfortable with a good appetite. I was nervous he wouldn't make it through all the anesthesia sessions, so relieved it is done.

This weekend, Yogi has played frisbee and even tried to play a bit with his twin brother - all good signs. Currently, he remains on 30 mg Trilostane 2x/day, Clopidrel blood thinner to deter blood clots like the ones that burst through his skin, Keppra for anti-seizure and prednisone. I am cooking some for him to try to get his weight up (he got down from 59 to 52 lbs). I am trying mostly grain-free with a focus on protein and adding fish oil. Are there any suggestions as to post-radiation diets or foods that can increase weight?

The team at NCSU Radiation Oncology was great, so kind and thorough. They discharged us to follow up with Internal Medicine in 2 weeks. While the future could unfold in so many ways and no further treatments are an option, I do feel so lucky to have had this chance. I sincerely appreciate this group for helping me become informed. I wish more people had access.

One question - I found the postings about pituitary macroadenomas really helpful. Is there some way my postings can be linked there so folks facing it in the future can refer to this thread too? I'm not sure how that works

[labblab]

Thank you, thank you, thank you for this update!! I know lots of question marks remain, but you’ve got me up on my feet and dancing for joy this morning :-)))))).

I’m afraid I can’t offer any specifics about a post-radiation diet, but I definitely can add a post to the Macrotumor thread that links to Yogi’s experience here. That’s a great suggestion, and I’ll take care of it later today.

Please give him a giant hug for me today, and please continue to update us whenever you can
Hooray for Yogi, and hooray for your loving care!!

Marianne

[Squirt's Mom]

Great news! I pray the positive trend continues! You can also add to the macro thread any time you wish to share Yogi's story. It is an important thread within itself and a great place to keep all your info concerning his journey with his tumor and treatment. Many to come will benefit from your words.

[Harley PoMMom]

Sending huge loving hugs to you both. As for help with gaining weight; carbs such as pasta, potatoes, etc. also adding in high-calorie treats and some food that is formulated for puppies.

[labblab]

OK, I’ve just now posted a link on the “Macroadenoma” thread ;-). And as Leslie says, you’re always welcome there to add any thoughts or suggestions, too.

Marianne

[Squirt's Mom]

OH something else to look into for weight gain - Satin Balls for dogs. There are several recipes and all are designed to put weight on so google and check them out!

[AngieB]

Thank you so much for the recommendations for weight gain.

Yogi went to see the Internal Medicine vet at NCSU for his post radiation checkup. After dropping to 152, he's back up to 156 pounds and she was very impressed. I took him to the park with his frisbee to celebrate - and believe it or not, he leaped with his usual altitude and ran at his usual high speed. It was unbelievable, and seeing him feeling good is my best birthday present ever! I have so much to be thankful for this Thanksgiving season.

Next steps are for me to try to wean him off of the steroids b/c they are prompting him to drink a lot. Then in 3 weeks we will have an ACTH test to see where the 30 mg 2x/day Trilostane dose is doing to him/his bloodwork.

As far as posting on the Macroadenoma post - do I post the same things I'm posting here - or would the link take someone here so they could reference if needed?

[Squirt's Mom]

What a great update on Yogi! I am so glad he is gaining weight AND regaining his strength and agility. How wonderful!

As for the macro thread, yes the link Marianne posted there will take folk to this thread. For future readers it would be easier to be able to read about the things others experienced and tried all in one place....but for folk like you who are dealing with this issue that means more work on your end. So it is up to you if you wish to share on the macro thread or have folk find Yogi's info here. Either way you will be helping others who follow.

Happy Birthday and a very Blessed Thanksgiving to you and yours!
Hugs,
Leslie

[AngieB]

Hi, Posting an update on Yogi for the thread. After 3 amazing months, this past weekend he started losing his appetite and ability to see/eat food. I suspect it's the tumor and/or the inflammation that is back. Yesterday he still had energy to trot around the dog park a little and try to catch the frisbee. However, I'm now giving him fluid via a syringe b/c he's not drinking enough and feeding him moist cat food, cottage cheese, anything that he can lick. Often he stands at his food bowl and appears confused. His is still on 30 mg 2x per day of trilostane, the blood thinners for clotting, a very low dose of prednisone and Leveticetam (Keppra) anti-seizure. His weight is dropping even with my efforts to feed him and I suspect that each day will get worse. This is breaking my heart, even as I know that every extra day I've had with him post-radiation has been a miracle blessing.

I'm going to NCSU Vet school Internal Medicine today for a check up. Any suggestions on how to keep nutrients going into his body are appreciated.

[Harley PoMMom]

Oh, I am sorry to hear this latest news about Yogi and I know how worried you must be about him, please let us know how the vet visit goes.

As for his appetite, sometimes as our dogs grow older their nose doesn't smell as good as it used to so you may want to try some "stinky" food with him such as sardines, grated parmesan cheese, tuna, or tripe. You could also give him some warm meat broth but make sure that it doesn't have any onion or onion powder, also baby food (no onions either). Slippery elm bark or Nutri-Cal could be options too.

Sending huge loving hugs, Lori

[Squirt's Mom]

Sending many hugs and prayers for you and our sweet Yogi. Let us know what you learn tomorrow.

Hugs
Leslie

[AngieB]

Thank you for the positive thoughts and ideas on stinky food. I went to the vet today and they suspect it's either that he's gone Addison's after the radiation (which would mean he's overcontrolled on Cushings and it could be causing that) or it is indeed the tumor progressing. Tomorrow he's going to have one more ACTH test to see, and then I'll know more where things are at. He was not able to walk to get in the car at the vet, and is very, very sleepy. More updates tomorrow.

[AngieB]

Hello,

Yogi passed tonight and is with the other angels. I'm heartbroken.

Thank you all for all of the support through this forum the past year and a half. Your kindness mattered so much to me. This forum gave me knowledge to give him every chance possible for a good life as long as he could. The last two weeks were even more of a rollercoaster than before. He did not have Addison's after the radiation, and it was most likely that the tumor had progressed. I believe that the prednisone helped keep the inflammation down, and gave him precious days and weeks. It was only the last week that he appeared to have more uncomfortable pain, which was intermittent, then became intense. I also believe that the radiation gave me a good 3 months with him I would not have had otherwise. Even with that - there was never enough time. It is that way with the angels we love.

[Joan2517]

There never is enough time with them. There never could be....I'm so sorry for your loss, Angie.

[Squirt's Mom]

Dear Angie,

I sit here with tears rolling down my cheeks. You and your precious Yogi fought the good fight together and together you taught us all so much. Thru your journey we all came to love your precious baby boy and today we grieve with you over his passing. Even tho I firmly believe we will see our babies again one day it is these days between then and now that are so very hard for us. Because of just what you said - it is the way with the angels we love. In time, your tears that fall today will become less as the memories you cherish begin to bring smiles in their place and that spot in your heart where Yogi remains will forever be filled with his presence.

We are here anytime you need to talk, cry, scream, whatever. We DO understand.

My deepest sympathies,
Leslie



World spinning out of grasp,
out of reach, out of sight; you are gone.
My heart, my head, my hands empty
as your spot in my lap.
Sightless eyes searched for you.
Soundless voice whispered your name.
Deaf ears listened for your breath.
In a wild place the pain roared,
burned white, and then waned to an ember.
Shadows of the night closed in.

Now a half-luminous ray breaks through.
Memories quicken, dreams take color,
and I know that love never dies.
Liberated from your temporal shell:
you are not gone.
I see your eyes glittering like faith
in every refraction of sunlight.
I hear your bark echoing like promise
in the baying of the wind.
I sense your presence rippling like energy
in all the sweep of hopeful sky.
I feel your love constant and warming like dawn
in its old comfortable place in my soul.
And I know -- as I always knew --
That I gained much more than I lost.

Anne L. Taylor

[labblab]

Oh Angie, I’m so sorry, too. On this first morning without your boy alongside you, I fear there are few words of comfort. It just hurts so much. But we’re so grateful that you’ve come here to let us know what has happened. Your K9C Family is holding both you and Yogi close to our hearts. And even though we’re physically separated, too, I hope you’ll somehow feel our hugs coming to you from across the miles.

You are a wonderful mom, and gave Yogi every chance for as many wonderful days and peaceful nights that were possible for him to enjoy. Most of all, you loved him dearly, and always will. There is no greater gift for man nor animal.

We’ll always remain here for you should you wish to return and talk about anything at all. And we’ll always join you in loving memory of your sweet boy.

Marianne