New diagnosis - Symptoms returned after 4 wks on meds

[Skylar]

Thank you so much for this amazing site! So much great info. My dog Molly just turned 10 and is a 14 pound poodle mix. In September I noticed her drinking and peeing much more, ravenously hungry and an extended belly. She also had leg muscle weakness, dry skin and occasional panting. I took her to the vet and after several tests (listed below), she was diagnosed with pituitary cushings. After the initial loading and maintenance it was like a miracle. Completely symptom free. But then almost 4 weeks later, all the symptoms returned. First the mg and then the frequency were increased, but the symptoms didn't decrease at all. The vet said it is expected that the dosage would need to be increased, but it's usually after a few months, not weeks. Even though the last ACTH was at the high end of normal at 5.6, the vet said some dogs do better at the lower end. So I'm now back to loading.

I have a few questions that I was hoping someone could answer. I think people on the forum know more than a lot of vets.:D


Have you ever heard of a dog doing great on Lysodren initially and then have it stop working in less than 4 weeks?
Would it be better to switch to Vetoryl? My vet said it's up to me. She has more experience with Lysodren.
Is pooping more normal? She poops sometimes 5 times a day. The vet said cortisol can speed up the bowels, but 5 times seems excessive.
She has major gas, mostly after eating. Is that normal? She eats Fromm Chicken a la Veg, which is supposed to be a great brand



Thank you so much for all the support!!! I've been so stressed to see my baby going through this.


10/19/17 - urinalysis (diagnosis of UTI) - put on Clavimox
10/25/17 - CBC, urinalysis, SMAC general, cortisol resting
10/31/17 - Low Dose Dexamethasone
11/8/17 - ACTH, urine creatine ratio (I don't have the numbers yet)
11/11/17 - stated Lysodren loading (1/4 of 500mg twice a day for 7 days). No symptoms on day 7.
11/20/17 - ACTH (pre 1.2, post 1.2)
11/22/17 - started Lysodren maintenance (1/4 of 500mg every 3 days)
12/16/17 - symptoms returned (drinking/peeing/hunger)
12/27/17 - increased mg of Lysodren (not sure as vet compounded it) - given every 3 days
1/5/18 - ACTH (pre 5.2, post 5.6)
1/11/18 - increased dosage to every 2 days - still no change in symptoms
2/3/18 - stated Lysodren loading (1/4 of 500mg twice a day for 7 days) AGAIN

[Squirt's Mom]

Hi and welcome to you and Molly!

It seems the Lyso dose is correct. At 14 lbs her loading dose would be 150mg 2x/day but since the pill only comes in 500mg doses that would usually be rounded down to 125mg 2x/day. So that is a bit lower than the optimal dose but should work. However - there is NO set time limit for the load to be achieved. It may happen in 3 days or it may take 2 months. So simply stopping after 7 days may mean the load was never achieved in the first place. We look at the signs PLUS the ACTH given between the load and starting maintenance. You want to see changes that indicate the cortisol has been lowered - a decrease in water consumption, the pup looking up during a meal when their name is called when before they simply would have continued wolfing the food down. These are the two most common signs we look for during the loading phase that indicate the load has been successful. So watch her carefully for signs and stop even if it has only been a few days instead of 7. ;)

Her ACTH given on Nov. 11 (pre 1.2, post 1.2) is a bit concerning. My mind has gone completely blank at the moment but there is a name for results like this and they can indicate the adrenals have been hit too hard and Addison's is a real possibility. BUT with the next ACTH being almost perfect even with continued use of the Lsyo hopefully this was just a one-off.

What signs are you continuing to see? In some pups the increased urination never resolves but appetite, panting, heat and exercise intolerance usually do improve if not completely resolve.

Did she have an abdominal ultrasound? I ask because conditions, like a tumor, can cause the cortisol to rise NATURALLY and with that rise come the signs of Cushing's. So an US is always a good bet. My Squirt was diagnosed with Cushing's but the US found a tumor on her spleen and once it was removed her cortisol returned to normal. My little Trinket was also diagnosed with Cushing's but she had many known conditions prior to that diagnosis. I always questioned the validity of her diagnosis and the necropsy I asked for following her death proved she did not have Cushing's BUT she did have a couple of new conditions that had never been found. I believe it was the combination of conditions causing her cortisol to be off the charts....not Cushing's. These cases prove that an unrelated source can cause elevated cortisol and Cushing's sign yet not be Cushing's. Something like this could also cause the signs to return even on treatment - my Trinket's signs never improved even with the Lsyodren on board because her conditions continued to progress.

It is not uncommon for a pup to need to reload but we usually see that when the dose is too low OR when the loading dose was stopped before the load was actually achieved. So being in the spot you are in now is not that uncommon....tho in my experience we do see that more often with Vetoryl (Trilostane) than with Lysodren.

As for switching - I would say no right now. First Lysodren is the drug your vet is more experienced with and I have to assume more comfortable with using....and that is crucial. Second, you would have to give Molly a minimum of 30 days drug free before starting the Vetoryl. She would HAVE to have a 30-day wash out between the two drugs to protect her from an overdose. Lyso has a long life in the body and it is never safe to rush into a switch as a result. If I were you, I would give this second load a chance then WHEN her signs improve and the ACTH says her level is between 1-5ug/dl go to maintenance giving the Lyso 3-4 times a week. Then if she loses the load again AND there are no contributing causes like a tumor, etc. you could consider a switch. It is true that some pups simply don't do well or cannot handle one or the other of the drugs used for treatment and need to switch. Just remember - a 30-day washout out is mandatory to protect Molly. ;)

Lyso is hard on the digestive system so seeing more poop at first or a bit of tummy upset is not uncommon, including gas. However, if she starts having loose stools or diarrhea that is cause for concern as is vomiting, loss of appetite, or lethargy. As for food, you do not want to switch right now. Changing foods often causes the same things we look for that indicate the cortisol has dropped too low - like loose stools/diarrhea, nausea/vomiting and loss of appetite. So stick with what she is currently eating as long as it is not causing another problem like allergies.

Was the UTI cleared up before the testing for Cushing's started? If not that could have skewed the cush tests. Would you please post the actual results of the testing done to diagnose the Cushing's - the CBC, urinalysis, SMAC general, cortisol resting, LDDS (Low Dose Dexamethasone Suppression test), ACTH, and UC:CR (urine creatine ratio)? Those results will help us a great deal in offering more meaningful feedback.

Also would you look on the bottle of compounded Lyso - it should tell you the dose even tho it was compounded. If it is a liquid, it will say X mg/ml. I personally would not be comfortable with a vet compounding either Lysodren or Vetoryl. So that is a question in my mind - was the compounded Lyso effective or not? For future reference, a very trustworthy compounding pharmacy is Diamondback Drugs out of AZ. Just FYI should you ever need another compounded drug.

Here is a link from our Helpful Resource section about Lysodren. Many members print this out and have it handy just in case. And we are always here to chat with. I'm sure others will be along soon to offer their ideas.

http://www.k9cushings.com/forum/showthread.php?181-Lysodren-loading-Instructions-and-related-tips

I'm glad you found us and look forward to learning more as time passes.
Hugs,
Leslie

[molly muffin]

Hello and welcome to the forum.

Leslie definitely has more knowledge about lysodren than I do, but I do wonder if it is the compounded lysodren that might have caused her to lose the load.

Actually the flat line of the 1.2 pre and post wouldn't make me happy either. A nice. pre 2.5 and post 3.5 is where I am happiest at safety wise. (not too low, not too high, perfect with lysodren) so I think that is the goal I'd be aiming for.

An ultrasound might be worth it, especially if she were to lose the load again, but I'm still thinking it might have been the compound. Just so hard to say for sure, but you have done everything right. The low levels on the ACTH does signal that the load was achieved on the first go round even though as Leslie mentioned, there is no set time for how long it takes to load.

Also as leslie mentioned the pooping and gas, can be from the lysodren. It should settle down eventually.
I wouldn't change to vetroyl until you know that the lysodren isn't going to work, then it could be worth it to look into. I'd only change after, having an ultrasound done, and of course the wash out phase between switching drugs.

[Harley PoMMom]

After the initial loading and maintenance it was like a miracle. Completely symptom free. But then almost 4 weeks later, all the symptoms returned. First the mg and then the frequency were increased, but the symptoms didn't decrease at all. The vet said it is expected that the dosage would need to be increased, but it's usually after a few months, not weeks. Even though the last ACTH was at the high end of normal at 5.6, the vet said some dogs do better at the lower end. So I'm now back to loading.

Her most ACTH stimulation test is a bit higher than what is recommended (pre and post 1 ug/dl - 5 ug/dl), which may be why her increased drinking and urination have returned. However, was an urine culture and sensitivity test done to make absolutely sure that the UTI is completely gone? And were her electrolytes checked to see if an imbalance occurred?




10/19/17 - urinalysis (diagnosis of UTI) - put on Clavimox
10/25/17 - CBC, urinalysis, SMAC general, cortisol resting
10/31/17 - Low Dose Dexamethasone
11/8/17 - ACTH, urine creatine ratio (I don't have the numbers yet)
11/11/17 - stated Lysodren loading (1/4 of 500mg twice a day for 7 days). No symptoms on day 7.
11/20/17 - ACTH (pre 1.2, post 1.2)
11/22/17 - started Lysodren maintenance (1/4 of 500mg every 3 days)
12/16/17 - symptoms returned (drinking/peeing/hunger)
12/27/17 - increased mg of Lysodren (not sure as vet compounded it) - given every 3 days
1/5/18 - ACTH (pre 5.2, post 5.6)
1/11/18 - increased dosage to every 2 days - still no change in symptoms
2/3/18 - stated Lysodren loading (1/4 of 500mg twice a day for 7 days) AGAIN

Could you get the results of the CBC/chemistry blood panel and the LDDS test and post them here for us? With respect to the blood panel we need to see only those values that are abnormal along with their reference ranges; for the LDDS, there will be 3 number included for that test....thanks!

With Lysodren, the maintenance dose is usually just about the same dose as you used to give in just one day of the loading but sometimes it does have to be tweaked. Since Lysodren is a fat soluble drug is Molly getting her Lysodren with some fat?

Gastric upset is common with Lysodren so giving Pepcid AC 20-30 minutes before the meal with which the Lysodren is given may help, now if it is flatulence Gas-X may be more beneficial.

I'm sorry for the reasons that brought you here but so glad you found us and we will help in any way we can.

Lori

[Skylar]

I can't thank you all enough for your wonderful information! Having this site has really reduced my stress. I know I will get accurate information. It's hard for me to believe that so many vets aren't more skilled on this disease. It seems like a pretty common illness in older dogs. I will post all the blood/urine results tomorrow after I get them.

Her UTI was cleared before the first load on 11/11. She loaded on the 7th day. The increased thirst, peeing and hunger completely went away. And that lasted for 3 weeks. Then those 3 symptoms returned. The symptoms continued even with starting an increased dosage for a week and then increased frequency (every 2 versus 3 days). I'm now wondering as well if it was from the compounding. I kind of like my vet, but her staff, including the vet tech, aren't knowledgable at all. If one of them did the compounding, I can't be sure it was done correctly. The reason I had them compound the 500 mg into four 125 capsules was that I thought if I cut the pill into fourths, I wouldn't be able to get them perfectly even.

My vet was not quick to diagnose Cushing's. She said that a UTI might be causing the increased drinking/peeing. But then when I asked if that would cause increased hunger, pot belly, dry skin, and muscle weakness, she said no. That made me question her competency. How could she say it might be only a UTI without considering all the other symptoms. When she did say it was Cushing's and told me there were 2 meds available, she said it was my decision. I would choose whichever worked the best. I wanted her to recommend one, not leave the decision up to me. She is more familiar with Lysodren, but if the other works better, I would have gone with that. When Molly's symptoms returned after 3 weeks, she said we can load again on Lysodren or switch to Veteroyl. She said the waiting time was one week. I told her I read it was 30 days and she said she would have to look it up. That concerns me. She should have known. Except I think all her patients are on Lysodren. But still.

She also said the increased pooping was from excess cortisol, not from the Lysodren. Is that your experience? She poopled 5 times the last few days. Some were soft, but not watery.

So now we're on the 5th day of Lysodren loading. No decrease in water/peeing. It's actually increased believe it or not. Her hunger seems a tiny bit decreased. Last time it took her the full 7 days to decrease the water consumption. Friday, 11/9, will be the 7th day. I'm going to bring a urine sample tomorrow to get tested for infection and electrolytes.

If the load works and her ACTH on Monday is within range, my question is:

- Should she get 1/4 pill every other day or every 3 days. She is loading at 1/4 pill twice a day. I don't want it to wear off after 3 weeks, like before. But this time I won't have them compound it. Or should it be 1/3 of a pill every 3 days. (that would have to be compounded, but I would go to a pharmacist this time).

Again, thanks for all the help! I was trying to find a certified endocrinologist, not just an internal medicine specialist. But there are none in Cincinnati where I live.

[Harley PoMMom]

I've got a couple questions about those monitoring ACTH stimulation tests. Molly started the loading phase on Nov 11th and her symptoms stopped on the 17th of Novemeber, right? If this is correct that monitoring ACTH stim test should of been performed on the 18th day of November not the 20th. Did the vet say why they perform the ACTH stimulation test in this way? The monitoring ACTH tests should be done right away so as to gauge how the Lysodren is working and to get an accurate reading of the cortisol levels.

An imbalance in the electrolytes can cause increased drinking and urinating so I think it is a really good idea to have her electrolytes checked but she would need to go to the vets to have this done as they need to draw blood for this.

Also, is Molly getting her Lysodren with some fat? Lysodren is a fat soluble drug and needs that fat to be properly absorbed. I have used cream cheese or peanut butter to hid those Lysodren pills.


Regarding the 30 day washout period; This excerpt comes from Dr. Feldman, who is a renown veterinarian that specializes in endocrinology:
DVM: So has trilostane become your first choice in the treatment of hyperadrenocorticism, or do you continue to use mitotane (o,p'-DDD)? Is there a particular protocol you use if you switch between the two medications to avoid possible complications, in light of a couple of reported cases of acute adrenocortical necrosis following a switch?

Feldman: Trilostane is my first choice in dogs with an adrenal tumor. My first choice for dogs with pituitary-dependent hyperadrenocorticism is mitotane. However, trilostane at an initial dose of 0.5 mg/kg given twice daily is an excellent second choice. No veterinarian should consider the use of trilostane before thoroughly reading the insert provided with the drug — not the insert for pet owners, the insert for veterinarians. Any dog switched from one to the other should receive no medication for at least six weeks.

You can find this info here: Cushing's disease and other adrenal gland disorders (http://veterinarynews.dvm360.com/dvm/Internal+medicine/Cushings-disease-and-other-adrenal-gland-disorders/ArticleStandard/Article/detail/672663?contextCategoryId=40534)



Dechra, the makers of Vetoryl, also recommend a washout period:
PRECAUTIONS:
Mitotane (o,p’-DDD) treatment will reduce adrenal function. Experience in foreign markets suggests that when mitotane therapy is stopped, an interval of at least one month should elapse before the introduction of VETORYL Capsules. It is important to wait for both the recurrence of clinical signs consistent with hyperadrenocorticism, and a post-ACTH cortisol level of > 9.1 g/dL (> 250 nmol/L) before treatment with VETORYL Capsules is initiated. Close monitoring of adrenal function is advised, as dogs previously treated with mitotane may be more responsive to the effects of VETORYL Capsules. This information can be found here: Dechra's U.S. Product Insert (http://www.dechra-us.com/Admin/Public/Download.aspx?file=Files%2fFiles%2fProductDownload s%2fus%2fvetoryl-5mg-pack-insert.pdf)***

Lori

[Skylar]

I have all the test results listed below. I also originally had the maintenance dosage incorrect. I changed it all to the correct numbers. The original loading was for 7 days at 125 mg twice a day, which would be around 50 mg/kg/day. The vet said after the last dose on the 7th day she should be off the Lysodren for 2 days and then an ACTH on the 3rd day. Is this right? Should it be done sooner? Plus she has to send out for test results and it could take a couple of days. So she could be not taking anything after the load for around 5 days.

The initial maintenance was 50 mg every 3 days. My vet said she determined this by 25 mg/kg/week (low end of range). Symptoms returned and was increased to 100 mg every 3 days. After 2 weeks no decrease in symptoms so increase to 100 mg every 2 days.

The vet said Molly probably needs to be on a higher maintenance dose. After the loading, if the maintenance doesn't hold she will do an ultrasound.

10/9/17 - urinalysis (diagnosis of UTI) - put on Clavimox

10/25/17
• Urinalysis - UTI gone
• Cortisol resting – 8.0 High (1-5)
• SMAC general/CBC
o ALT High 263 (12-118), ALK Phosphate High 913 (5-131); GGT High 36 (1-12), Creatinine Low 0.3 (0.5-1.6), Amylase Low 198 (290-1125), Platelet Count High 414 (170-400), Neutrophils High 83 (60-77), Lymphocytes Low 8 (12-30), Absolute Lymphocytes Low 648 (690-4500)

10/31/17 - Low Dose Dexamethasone – sample 1 High 6.4 (1-5), sample 2 Normal 0.7 (0-1.4), sample 3 High 1.5 (0-1.4)

11/8/17
• ACTH – pre 7.9 High (1-5), post 19.4 High (8-17)
• Urine cortisol creatinine ratio – 272
• Urine protein creatinine ratio – 0.9 Normal (<0.5)

11/11/17 - stated Lysodren loading (1/4 of 500mg twice a day for 7 days). No symptoms on day 7.

11/20/17 - ACTH (pre 1.2, post 1.2)

11/22/17 - started Lysodren maintenance (50mg once a day every 3 days)

12/16/17 - symptoms returned (drinking/peeing/hunger)

12/27/17 - increased Lysodren (100mg once a day every 3 days)

1/5/18 - ACTH (pre 5.2, post 5.6)

1/11/18 - increased dosage to every 2 days - still no change in symptoms after almost 3 weeks

2/3/18 - stated Lysodren loading (1/4 of 500mg twice a day for 7 days)

2/8/18 – urinalysis (no UTI), stool (normal)

[Squirt's Mom]

ah HA! The maintenance dose is more than likely why she lost the load. The maintenance dose should be the same mg used for the load, just spread out over a week VS daily. ie if a pup loads on 500mg a day (250mg 2x/day) then that dog's maintenance dose would be 500mg a WEEK. So since Molly is being loaded on 250mg a day (125mg 2x/day or 1/4 tablet twice a day) she would need 250mg a week for maintenance. The accepted protocol is to use a week but I have always gone by days. Like every other day or every 3rd day to keep the dosing even. So I would use 125mg every 3rd day to start. If it seems she is losing the load again, I would up that to 125mg every other day. OR to keep to the standard protocol you would give her 125mg on Mon, Wed, and Fri or Sat. Be sure to give with a meal since the Lyso is fat soluble and the food will assure it is absorbed and used.

[Skylar]

Thanks Squirt's Mom! If I give her 125mg every 3 days that would be 375mg per week. That is more than the 250mg.

I do give her the Lyso with her dog food.

Also, what are your thoughts on: The vet said after the last dose on the 7th day she should be off the Lysodren for 2 days and then an ACTH on the 3rd day. Is this right? Should it be done sooner? Plus she has to send out for test results and it could take a couple of days. So she could be not taking anything after the load for around 5 days.

Thanks!!;)

[Squirt's Mom]

You're right! Math is not my forte! :D So 1/4 tablet twice a week OR every 3 days is what I would try.

As for the timing - I can't stress enough that "7 days" is not how this is done. You stop the load when you see signs it has been achieved - decrease in water consumption or the change in how they eat a meal. That may happen in 3 days OR it could take months. If you stop giving the loading dose at 7 days and the load has not been achieved (no change in signs) then she will end up right back where she was before the second load - all the signs will come roaring back. So keep a VERY close eye on her and stop when you see those signs regardless of how long it has been. ;)

For as long as I've been involved with Canine Cushing's the standard for starting maintenance is just as your vet has recommended. Wait for 48 hours after the last dose, do the ACTH, and if the ACTH + signs indicate the cortisol within range then the maintenance phase starts. However a few years ago someone here questioned that "protocol" and search as we may, we have found no source that says that is how it must be done...or that it is wrong to do it that way. Lysodren has a very long life in the body so this protocol more than likely came about as a result of that fact. That length of time gives the Lyso time to reach peak level and produce the optimal cortisol level. So unless you see signs that the load has gone too far and lowered the cortisol TOO low, it will be fine as your vet has set up. The signs the load has gone too far are loss of appetite, nausea/vomiting, loose stool/diarrhea, and/or lethargy. If you see ANY of these signs STOP the med immediately and get an ACTH immediately - do NOT wait under those circumstances to get the ACTH.

You're doing a good job, Mom!
Hugs,
Leslie

[Skylar]

Thanks so much for your advice Leslie!!! Your math was correct. 1/4 of a 500mg tablet is 125mg. So your recommendation of 1/4 every 3 days would be too much I would think. If I gave twice a week that would be perfect. But how does that work? Would I give it every Monday and Thursday? That's 2 days between on the first week (mon-thurs) and 3 days in between on the second week (thurs-mon). I would think it would have to be the same amount of days in between dosages, but with the number of days in the week it's impossible.

Also, today is the 7th day of loading. This morning I had to coax her to eat her all her breakfast. But the drinking and peeing haven't changed, in fact it seems to be getting worse. The last few nights she has woken up in the middle of the night to drink water. She is drinking almost 3 times what she should. She had a urinalysis yesterday and didn't have a UTI. It is being sent out for a culture to see if anything grows. I'm going to get her electrolytes checked when she gets her next ACTH.

Have you heard that the water/peeing increase doesn't change at all during the loading phase? Should I plan on getting her tested on Monday even though her drinking/peeing hasn't changed at all? The only symptom change was that this morning I had to coax her to eat.

Thanks again! I have literally been obsessed with this. I'm hoping to have Molly around for many more years. She is the most important thing in my life. I know she's considered up in age at 10, but I keep hearing about small dogs living till 18.

[Squirt's Mom]

Since you had to coax her to eat STOP the load now! Watch her carefully for any signs the cortisol has gone too low - loose stool/diarrhea, nausea/vomiting, loss of appetite, and/or lethargy. Do you have any prednisone on hand? If you see any of these signs call the vet asap for an ACTH and electrolyte check.

As for the drinking and peeing - those could be caused by something unrelated to elevated Cushing's. Has her glucose been checked recently? Those are also signs of diabetes as is lack of appetite. Diabetes mellitus can come on very quickly too.

There is also a rare form of diabetes called Diabetes Insipidus that has nothing to do with blood sugar but rather with how the body processes water. And the signs you are seeing fit DI as well. Here is a link about DI - https://vcahospitals.com/know-your-pet/diabetes-insipidus-in-dogs

Testing for DI can be risky so most vets simply start treatment and if signs improve, there is the diagnosis. This is worth talking to your vet about soon since the drinking and peeing are not changing.

[labblab]

Hello and welcome to you and Molly from me, too! I’ve read back through your entire thread, and I do think it’s important for you to now hold up on any more Lysodren until the ACTH results are back. During the first load during an identical time period and at the same dose, Molly’s cortisol had dropped down to 1.2 both pre and post. You definitely don’t want to risk having it drop any further now which I think could be a real risk, especially since you started out at a cortisol level that was much lower than the first time around. Loss of appetite, all by itself, can signal the end of the loading period. So I think you really need to pay attention to that, regardless of the thirst/urination.



Lysodren administration should be stopped when:

1. the dog demonstrates any reduction in appetite; this might mean just pausing slightly during meal consumption, stopping to drink some water, or stopping in response to the owner's voice.

2. the polydipsic dog consumes less than 60 ml/kg/ day of water.

3. the dog vomits.

4. the dog has diarrhea

5. the dog is unusually listless.

The first two indications for stopping the medication are strongly emphasized because they are common and they precede worrisome overdosages. The occurrence of any of these signs strongly indicates that the end point in induction (loading) therapy has been achieved.

Since it will take several days for the ACTH to be analyzed, I have to say that I do think it’s unfortunate that your vet is waiting clear until Monday to test. If by some chance the load has not yet been achieved, waiting a full five days to resume dosing will set you back further again. And to be honest, given Molly’s lack of appetite and the low level of her cortisol the first time around, I might worry now that she is actually oversuppressed or that her electrolytes may be out of whack. The thing is, the excessive thirst and urination actually could be caused by something other than high cortisol. It can even be caused by oversuppression of the adrenal glands.

I must admit that Molly exhibits classic Cushing’s symptoms. But in checking her two diagnostic blood tests, the LDDS and first ACTH, they were both just barely out of normal range. Coupled with her less than ideal response to the Lysodren, I do wonder whether there’s more that’s involved here than just Cushing’s. For instance, there’s a condition called diabetes insipidus (different from the common diabetes mellitis) that can also be triggered by the same pituitary tumor that can cause Cushing’s. Diabetes insipidus results in excessive thirst and urination, too, but it has nothing to do with cortisol levels and is treated with an entirely different medication.

So all in all, I’m uneasy with the way things have been going for Molly. And even though the rebound of her symptoms is upsetting, the much bigger safety risk is a cortisol level that has dropped too low, or an electrolyte imbalance that has been caused by oversuppression of aldosterone, another adrenal hormone that can be lowered too far by Lysodren. So in summary, I would not give her any more Lysodren until she’s been tested. And if she worsens even more through the day, I’d honestly try to get her tested today. I have not been able to find any research that supports waiting for as long as your vet is recommending, and it would be good to get the info about her cortisol level and electrolytes sooner rather than later.

Please keep us updated, OK?
Marianne

Edited to add: I see Leslie and I are on the same page about this! Sorry for the duplication...

[Skylar]

I can't stress enough how blessed I am to have found this site!! Thanks for all the information on diabetes insipidus! I will have her tested for that. My vet did mention that she wasn't off the charts with the LDDS and the first ACTH. But when I started the maintenance of the Lyso, her drinking/peeing/ravenous hunger, decreased significantly.

I gave Molly 1/4 pill this morning, after coaxing her to eat all of her breakfast. I will not give her the second dose this evening. Should I ask to get the ACTH tomorrow instead of Monday? I'm concerned that if I wait until Monday morning it will be 72 hours (3 days) between the last dose and the test. But if I go tomorrow, it will only be 24 hours. Ideally it should be Sunday, but they are closed.

[Skylar]

I also wanted to let you know that when Molly was 6 she started to have small seizures. She was diagnosed with epilepsy and was on phenobarbitol. She hadn't had any seizures in years, so I tappered her off and stopped the pheno. The last dose was almost 2 years ago. The vet said this is totally unrelated to Cushings and her current symptoms.

Could she have diabetes insipidus AND Cushing's? The increased water/peeing could be the diabetes, but she also has a pot belly, increased hunger, muscle weakness, dry skin, and panting.

[Harley PoMMom]

If this were me, I would have an ACTH stimulation test done ASAP plus having her electrolytes checked should be done too. As for testing for diabetes insipidus, this includes a water deprivation period and should never be performed on a dog that is suspected of having Cushing's because those kidneys need that water. Dog's with Cushing's drink more water because that elevated cortisol causes the kidneys to work harder which in turn the dog has to make up for that loss of water by drinking more. The most beneficial way to test for diabetes insipidus is to just give a trail run of the medicine that is prescribed for it which is generally desmopressin.

Lori

[labblab]

If it were me, I’d ask for the ACTH tomorrow. And yes, a dog can have Cushing’s as well as diabetes insipidus. And as Leslie has mentioned, Cushing’s and diabetes mellitus can also occur in the same dog. I’m glad she wrote about it, because as she says, DM can come on quite suddenly and can also account for excessive urination/thirst. It can be diagnosed with a simple blood glucose level that would be part of the same general chemistry panel that tests electrolytes (most importantly, sodium and potassium levels).

Marianne

[Skylar]

Hello everyone. Thanks again for all your advice. Molly had an ACTH test and electrolyte test this morning. The results should be back in a couple days. She isn't drinking or peeing as much and her pot belly seems to be less. She is not eating very much at all though. But she is active and alert so the vet don't feel she is adisonian. The urine culture came back today and she does have another UTI, which will be treated with antibiotics.

So here is my question on the maintenance schedule.

What ever weekly dosage the vet decides to put her on (depending on the results of today's ACTH - Lets say it's 250mg per week. Would I give it every Monday and Thursday? That's 2 days between on the first week (mon-thurs) and 3 days in between on the second week (thurs-mon). I would think it would have to be the same amount of days in between dosages, but with the number of days in the week it's impossible.

And let's say she should get 200mg per week. If she got 50mg every other day, it still would work out to 4 pills one week and 3 pills the next.

This is so confusing! It would be so much easier if there were 8 days in a week. (And if each month had the same amount of days. And if daylight savings time didn't exist). hahaha

[labblab]

We’ll sure be anxious to hear how those test results turn out! I have not used Lysodren personally, but I don’t think it matters greatly if you don’t have the exact same number of days between doses. You’re aiming at an overall weekly dose that just happens to be divided into increments. So probably just adopting a regular schedule that is easy for you to follow would be best. For instance, every Monday and Thursday for twice-weekly dosing; every Monday, Wednesday, Friday for thrice-weekly dosing. Whatever schedule you pick, I believe your main goal is to maintain a consistent overall weekly total. So once again, I’d pick the days that work best for you and maintain that same schedule every week.

Hopefully, some other folks who have used Lysodren will drop by. But this is the dosing pattern I’ve observed over the years here ;-).

Marianne

[Squirt's Mom]

That always bothered me, too, and I chose to use a balanced pattern - ie every other day or every third day, and didn't worry about the "week" thing.

[Skylar]

Good news! Molly's ACTH came back at pre 2.5 and post 2.6 and her electrolytes were normal. She weighs 14 pounds (6.36 kg). The recommended maintenance dose is 25-50mg per kg per week. The vet wants to put her on maintenance at 100mg every other day.

The first time the vet calculated the dose at the low end of the scale (25mg/kg/week). She prescribed 50mg every 3 days. It was too low as her symptoms returned in 3 weeks and her ACTH after 8 weeks was pre 5.2, post 5.6

She now wants to put her at the high end of the recommended dose (50mg/kg/week), which would be 318mg per week. She said to give her 100mg every other day.
She recommends to have it evenly spaced out (every other day or every 3 days), rather than 2 or 3 times a week (ex. Mon, Wed, Friday)

So if I give her 100mg every other day, she will get 300mg one week and 400mg the next.

Do you think this is too high? The vet doesn't, but I wanted to see what your thoughts were.

Thanks again for all your advice!!!

[Harley PoMMom]

Good news! Molly's ACTH came back at pre 2.5 and post 2.6 and her electrolytes were normal. She weighs 14 pounds (6.36 kg). The recommended maintenance dose is 25-50mg per kg per week. The vet wants to put her on maintenance at 100mg every other day.

She now wants to put her at the high end of the recommended dose (50mg/kg/week), which would be 318mg per week. She said to give her 100mg every other day.
She recommends to have it evenly spaced out (every other day or every 3 days), rather than 2 or 3 times a week (ex. Mon, Wed, Friday)

So if I give her 100mg every other day, she will get 300mg one week and 400mg the next.

Do you think this is too high? The vet doesn't, but I wanted to see what your thoughts were.

Thanks again for all your advice!!!

I think this is too high given the fact that her ACTH stimulation test was performed 3 days after the last dose of Lysodren was administered and the results being pre 2.5 ug/dl and post 2.6ug/dl.

With her reloading on 2/9 with 250mg of Lysodren her maintenance dose should be 250mg weekly, which divided and given 3 days a week would be 83.3mg. Since the Lysodren pill is 500mg that 83.3mg would be impossible to achieve, so if this were me, I would give 100 mg twice a week say Monday and Friday and than 50mg on Wednesday, which totals 250mg a week.

This is just my opinion so hopefully others with more experience with Lysodren will offer their advice as well.

Hugs, Lori

[Squirt's Mom]

No I don't think that's too low at all! I would absolutely start with 100mg every other day and see how that works. Keep an eye on her for any signs the dose is too much OR too low. Then you can adjust the dose if needed. The ACTH is PERFECT and I am so glad the electrolytes are good! Keep in close touch with us over the next few weeks and let us know how she is doing, about any changes you see, or any concerns you have. You're doing great, Mom!

Hugs,
Leslie

[Skylar]

So I've given Molly 100mg of Lysodren every other day (started 2/14). I'm also giving her Enrofloxacin 22.7mg once a day for 21 days for her UTI. Twenty one days seems like a long time, but she had 3 different bacteria strains.

Since the 7th day (last day of her loading), she hasn't eaten one bite of her dry kibble dog food. I bought some canned food and she instantly ate all of it. And she will eat other human foods (turkey, cheese, carrots). So it's not like she's not hungry, but she has an aversion now to her regular dog food. I don't think her cortisol is too low because she has a lot of energy and hasn't thrown up or have diarrhea.

She is still drinking/peeing a lot, but not as much as before she was on Lysodren and the antibiotic. This could be from the UTI.

Has anyone else heard of a dog stop eating their dog food, but eat other food?

I'm so frustrated with the ups and downs. First being ravenous to not eating at all. At least she's eating the canned food and human food, but I don't want her to get used to only eating that.

I was thinking of maybe giving her some pepcid AC. Would that interfere with the antibiotic? How much should I give her? She is 14 pounds.

Thanks!!!

[Squirt's Mom]

The UTI could certainly account for the peeing and drinking so I wouldn't be too concerned about that just now. And as long as she's not refusing all foods I wouldn't worry about the appetite. It's not uncommon for a pup to simply decide they no longer care for the food they have been eating, Cushing's or not. ;) I have a Pug who used to do that fairly often. I seem to have finally found a food she likes tho. LOL At times we humans are easily trained, too...they learn pretty quickly how to get us to feed them what they want. :rolleyes: :D As long as you aren't seeing loose stools or diarrhea, nausea or vomiting I wouldn't worry about the cortisol being too low. If you see any of those and she refuses to eat anything, then there could be a problem.

Be very careful with human foods...make ABSOLUTELY sure there are no onions, "flavors", "seasonings", etc before you let her have it.

As for giving Pepcid AC along with the antibiotic, 1-800-Pet-Meds has this to say:


What other drugs will affect famotidine?

Tell your veterinarian if your pet is being given antacids, metoclopramide, Sucralfate, digoxin, or ketoconazole as interactions can occur. Give famotidine 2 hours before or 2 hours after the other medications. When given with azathioprine, famotidine may further decrease white blood cell counts. Drugs other than those listed may also interact with famotidine. Talk to your veterinarian or pharmacist before giving any prescription or over the counter medicines including vitamins, and supplements.

About Enrofloxacin, Diamondback Drugs has this to say:


Enrofloxacin Interactions and Possible Side Effects

Enrofloxacin may interact with one or more medications. Common culprits include iron supplements, antacids and stomach protectants. When given to animals, avoid giving with dairy products (such as cheese, cream cheese, or yogurt) because the calcium can bind to the drug, limiting its effectiveness. Disclosing the existing drug regimen of your pet is essential in order to prevent a possible drug interaction. This medication may cause some animal patients to experience certain side effects, generally diarrhea or loose stools. On very rare occasions, an animal may experience a seizure, while younger animals may experience swollen joints, general lethargy and in some cases, cartilage damage when dosed above the recommended range and below the recommended age.

Drs. Foster and Smith has this to say:


Drug, Food, and Test Interactions
Consult your veterinarian before using enrofloxacin with vitamins and supplements, probenecid, oral cyclosporine, since interactions may occur.

Do not use within 2 hours of giving antacids, sucralfate, or iron, aluminum, calcium, or dairy products, as absorption will be decreased.

May cause increased theophylline blood levels.

I would talk to her vet or a pharmacist about using it along with the antibiotic....but as long as she is eating ok and not showing signs of tummy upset I think I would forget about the Pepcid AC until the antibiotics were finished if it were me. ;)

[Skylar]

So since Saturday evening Molly has only eaten a few bites. I tried hot dogs, roast beef, peanut butter, even her treats. She doesn't have diarrhea and isn't listless. She is still drinking and peeing a lot. I just called the vet and she said to stop the Lysodren and give her prednisone every 12 hours.

So now what? Does this mean her Lysodren is now too high? So first it was too low and now too high? I'm concerned that stopping the Lysodren and starting predisone will now push her have too high of cortisol. I don't want to have to load her again.

How is the "right" dosage determined? It's expensive to keep getting the ACTH test. She just had the test a week ago (2/12) and started the maintenance on 2/14 of 100mg every other day.

I'm so frustrated and worried! She's been on the antibiotic since 2/14 (6 days) and is still drinking and peeing a lot. The antibiotic is prescribed for 21 days, so maybe it just takes time to work. Between that and now her not eating is taking a toll on me. Let alone her! I'm glad I have this forum to vent.

Thanks for your help!

[labblab]

Good news! Molly's ACTH came back at pre 2.5 and post 2.6 and her electrolytes were normal. She weighs 14 pounds (6.36 kg). The recommended maintenance dose is 25-50mg per kg per week. The vet wants to put her on maintenance at 100mg every other day.

The first time the vet calculated the dose at the low end of the scale (25mg/kg/week). She prescribed 50mg every 3 days. It was too low as her symptoms returned in 3 weeks and her ACTH after 8 weeks was pre 5.2, post 5.6

She now wants to put her at the high end of the recommended dose (50mg/kg/week), which would be 318mg per week. She said to give her 100mg every other day.
She recommends to have it evenly spaced out (every other day or every 3 days), rather than 2 or 3 times a week (ex. Mon, Wed, Friday)

So if I give her 100mg every other day, she will get 300mg one week and 400mg the next...

I do think it’s possible that the amount of Lysodren she’s getting now is too high. For comparison purposes, her initial maintenance dose was approx. 150 mg. per week ( some weeks it was a total of 200 mg.). Now you’ve fully doubled the dose to 300-400 mg. per week, and that may be oversuppressing her at this point.

On the other hand, the lack of appetite may still be resulting from the antibiotics. Antibiotics are notorious for causing upset stomachs in dogs and humans alike.

Under these circumstances, it probably does make sense to try giving her prednisone for a day or two in order to see if that improves her appetite. If so, you can probably conclude that it’s the Lysodren dose that is the problem, and that you need to back off on it by waiting a few more days to resume at a lower dose. You don’t need to worry that the prednisone will cause a permanent increase in her natural cortisol production — the prednisone serves only as a supplement on the days that she takes it.

Unfortunately, here’s one more complicating factor. Prednisone itself can be hard on the stomach if it’s not taken with some food. So if Molly’s stomach is already upset from the antibiotic, then she may be getting a double whammy with the pred. I know you’re kinda between a rock and a hard place here, so all you can do is experiment a little bit for a couple of days.

Hang in there! I know it’s really hard to do so, especially with a dog who’s not eating. That’s one of the toughest things to handle as a parent, I think. So come on, Molly girl, please eat something for us all!

Marianne

[Harley PoMMom]

Marianne has a really good point regarding that if the predisone perks her appetite up than her cortisol is more than likely to be too low.

I know how worrisome it is when your furbaby doesn't want to eat. Some food toppers I have used are: tripe, grated parmesan cheese, yogurt, warm meat broth, baby food (make sure it doesn't contain onion or onion powder), scrambled eggs, cat food, or fish (tuna, sardines) and boiled potatoes. Sometimes just heating up the food will entice them to eat. Dogaware has a really informative article on their website that pertains to a dog with a loss of appetite, here is the link: http://dogaware.com/articles/wdjinappetence.html

Hugs, Lori

[DoxieMama]

How is Molly doing today?

[Skylar]

Thanks so much everyone for the advice and support! The prednisone hasn't helped yet with Molly's appetite. I've tried everything. She only ate 1 hot dog (had to break into small pieces and feed by hand) and a few of her treats yesterday and today.

How long does it usually take for the prednisone to increase the appetite? I'm giving her 1/4 of a 5mg tablet every 12 hours. The last time she was weighed (2/14) she was 13.8 pounds. I'm sure she weighs less now because she's hardly eaten since Friday night. I started the prednisone on Tuesday evening, so with this morning's pill she has had 4 dosages of 1.25mg each dose. I'm not sure if her stomach is upset from the Lysodren being too much or the antibiotics. Or does she need a higher dosage of the prednisone? She is still drinking and peeing a lot.

I'm so worried about her!

I would

[Squirt's Mom]

I would stop the pred myself. If the cortisol were too low it should have helped within a few hours so I don't think that is the issue. The pred will cause more drinking and peeing in a healthy dog or humans for that matter so it isn't surprising you are seeing an increase in those. A side effect of Enrofloxacin is loss of appetite so that may be playing a role. However I would call her vet and see what they think. You can try some plain (no seasonings at all) chicken, turkey, or beef broth to see if she will take that. Add a bit of rice or pasta if she take the plain broth. Let us know how she is doing and what her vet has to say!
Hugs,
Leslie