Max test results help — Sweet Max has passed

[Elizabeth513]

Hello everyone. I am hoping you all might be able to help me interpret my boy Maximus's LDDS test. His vet said Cushing's was ruled out, but when I look at the results and have read up on interpreting it I feel like the 8 hour number is elevated. I am hoping you all might be able to shed some light on this for me. We also did a T4 panel and she feels it is hypothyroidism based on his T4 1.2, Ft4 1.0 and elevated tsh .65 and wants to start low dose meds for thyroid. He also had elevated ALP (700), low hemoglobin(12.0), and his MCH and MCHC right below normal (21.1, 30.4)

Here goes:
Pre Dex: 5.1 ug/dl (1.0-6.0)
4 hour: 0.4 ug/dl
8 hour: 6.7 ug/dl

Looks to me like pre dex cortisol was normal, he suppressed at 4 hours, but the 8 hour is above the range from IDEXX 1.0-6.0.
I am so appreciative for anyone willing to take the time to review these and chime in. I just want to make sure I understand everything and can be the best advocate for him.

[labblab]

Hello Elizabeth, and welcome to you and Max! To cut right to the chase, you are right that Max’s LDDS results are consistent with Cushing’s, and unfortunately your vet is incorrect. Max’s results are consistent with the pituitary form of Cushing’s. Here’s a link to some IDEXX test interpretation charts. If you scroll down past the ACTH stimulation test that’s listed first, you’ll come next to the LDDS.

https://www.idexx.com/files/snap-cortisol-testing-guide-en.pdf

The normal ranges printed on Max’s labsheet may vary slightly from this table. One important point: the normal cortisol range up to 6.0 relates only to the first baseline blood draw, prior to the administration of the testing agent. With the LDDS test, the baseline cortisol level is of little importance — the 8-hour level is what determines the overall Cushing’s diagnosis. Both the diagnostic 4-hour and 8-hour results are compared to a very different “cut-off” number from the baseline range. Commonly it’s either 1.4 or 1.5 ug/dL. On the IDEXX chart listed here, the cut-off number is 1.5. Since Max’s 8-hour result greatly exceeded that cut-off, the result was consistent with Cushing’s. And since his 4-hour result was *less* than both 50% of the baseline reading as well as less than 1.5, his result is consistent with the pituitary form of the disease. I know this formula may seem complicated, but if you compare Max’s results to the chart, I think you’ll see what I’m talking about.

The really unfortunate part of this is that your vet’s unfamiliarity with the correct test interpretation leads me to fear that he/she is not at all familiar with testing or treating Cushing’s patients. This is a major interpretation error. Max may well suffer from hypothyroidism in its own right, but this LDDS additionally points to Cushing’s. His elevated ALP would also be consistent with the disease.

May I ask what prompted the testing in the first place? Does Max exhibit observable symptoms that are worrisome. Any additional info you can give us about his overall health history will be very helpful. And I’m sorry about delivering the bad news about your vet, but as I say, this is a major fumble :-(.

Marianne

[Elizabeth513]

Double posted removed...sorry! :(

[Elizabeth513]

Hi Marianne! Thank you so much! He initially went in for a dental cleaning and his yearly exam. My vet was very concerned at first about his low rbc, hematocrit and we did a repeat...it came up slightly. At the same time she said his ALP is consistent with Cushing's and noted he had gained some weight ( ore on that in a bit). She added on a cort/creat screen to his urine that has been sent off and when it came back she said it was very suspicious of Cushing's to her (urine cortisol : 12.3, Urine Creatinine 41.4, ratio 93) and she recommended a LDDR test. I requested to add the thyroid panel because he was low/normal 1.2 (1.0-4.0).

I'm not sure if she misread the results?? She spoke to me in depth about Cushing's and signs of it. I chalked it all up to being a 9 year old boxer. I noted he's been shedding a good bit, he is normally tired (9 year old boxer, but has energy bursts), Drinks but not what I would call excessive (hes 82 pounds). He's gained from 75-82# since March, but I changed his food to Royal Canin HP vet diet because he has "gulpy" digestive issues thye've never been able to figure out except possible reflux, but we have never done a scope to see if it could be IBS, etc. The HP food seems to agree with him even though I do not think it is the "best" type of food out there. He does love to bask in the sun...but gets hot easliy (again he's a boxer and the summer heat gets him)...so all of these things she said yes we need to look at Cushings.

I can attach all of his lab work if it would be helpful, but I feel like that LDDR test was pretty clear. I will be calling tomorrow asking for her or another vet in the group to pull up his test and look at it and explain why they feel it is negative. I am not someone who takes what anyone tells me at face value, I read and I learn so I can understand and discuss things in an educated manner...maybe thatis the teacher in me.

I am a little terrified of Cushings, and the medications used to treat it. I have been lurking here listening and learning and I do appreciate all the knowledge and time you all give to each other. AND, I am trying to not be scared...I am trying to look at statistics and be rational...

Where do I go from here? Much appreciated!

[labblab]

Hi again, Elizabeth. This additional information does indeed make Cushing’s seem like a strong possibility.

Question: do you have the actual lab sheet with the LDDS results listed? If so, the lab sheet ought to have the exact interpretation criteria written out. Having that exact language in front of you will hopefully make it easier to talk to the vet tomorrow. Remember that the focus first needs to be on the 8-hour value, not the baseline value. The baseline value only becomes significant for comparison purposes if the 8-hour value is elevated. At that point, you’re checking to to see whether sufficient suppression subsequently occurred which would point to the pituitary form of the disease.

And I know this is far easier said than done, but please don’t feel terrified about the Cushing’s meds if they end up being prescribed. As careful and observant as you clearly are with Max, you’ll already have a great head start in terms of monitoring how he’s doing. We’ve had many success stories here, and there’s no reason why Max shouldn’t be one!

Marianne

[Elizabeth513]

Yes, I do have it. I kept looking at it thinking I was missing something. I have spent the last week researching that exact chart you linked as well as studying the types of medications and the new starting doses of those.

Max is a dog that my vet's words "does not fit the book in veterinary medicine". He has been reactive to a couple of antibiotics in the past with adverse affects, and reacted badly to a cytopoint injection given last summer for allergies. So, she is very cautious with him, but I just have so much doubt now.

Do you think there is importance to get him in with an internist to correctly diagnose? We have a wonderful group near us where he went to have obstruction surgery. So, Tmy plan is to call and ask them to recheck his LDDS results as I feel there was an error in reading them due to the fact that his 8 hour value is >1.5...and the 4 hour is less than 1.5 and less than 50% of the baseline as outlined in the IDEXX chart? Does that sound right? THANK YOU so much!

[labblab]

That sounds exactly right! And what I would do if I were you depends a great deal on the response you get tomorrow about the test interpretation. If the vet seems defensive or argumentative, I would take that as a giant red flag. If the vet is instead appreciative that you’ve been educating yourself and apologetic for missing the diagnosis, that would be better, for sure. If you do feel uncertain, though, that’s terrific that you have a good specialty group nearby. Especially dealing with the combination of hypothyroidism and Cushing’s, both you and your vet may welcome the input of an internist. As you may have read, hypothyroidism can actually be secondary to Cushing’s. If Cushing’s is the primary culprit, the low thyroid readings may spontaneously resolve once the cortisol becomes well controlled. Since Max’s TSH was elevated, I *think* that makes it more likely that he’s genuinely hypothyroid, as well. But that might be an area where you’d welcome an internist’s expertise prior to launching into thyroid supplementation. And you could diplomatically ask your vet if a consult might not be helpful, given this dual diagnosis.

I certainly don’t want to borrow any trouble for you, but I do want to mention that our experience here is that boxers seem to be over represented among the group of Cushpups who may develop a particular skin disorder known as Calcinosis cutis when their cortisol levels are untreated and running high. This disorder manifests as calcium deposits that work their way up through the skin, finally erupting as uncomfortable plaques. This might be another reason to get treatment guidance from a specialist, in order to prevent this issue from ever getting started.

But first things first — let’s get that LDDS interpretation clarified. Definitely let us know how things go!

Marianne

[Elizabeth513]

Thank you, Marianne!

In my reading I have read that with the values he is showing in his T4, free T4, and tsh that is "could be" a non-thyroid illness causing it because his T4's are not falling below range, but low average....OR it COULD also be hypothyroid. I think I do feel better knowing we could have multiple things going on here that consulting in internist would be in Max's best interest. He's always had some immune type issue and I want the time he has left to be enjoyable whatever that may be.

I have read a little on the calcinosis cutis, I believe a few posts on the forum. I will continue to follow up on and do more reading on that.

Can the LDDS test signify the progression of the disease?

I will most certainly update as I am very appreciative of you taking the time to answer my questions. All the posts I have read left me noting that everyone is very positive in their thoughts. I am happy to have found the forum! I apologize for not properly introducing myself: You picked up on my name quick! :o Max is our beautiful 9 year old boxer who is our third child...we have two human kids as well!

[Elizabeth513]

I spoke with Max's vet and she was extremely embarrassed and very apologetic about the misreading of his results. She said you are 100% correct! She feels his thyroid is primary as well b/c of the tsh. I did mention that from some readings I have found, a percentage of cushing's dogs thyroid regulate upon treatment and she said that beginning cushing's treatment then retesting thyroid later would definitely be an option.

Since she knows Max's history she did feel like me taking him to an internist who can unfold everything would be a great idea. She spoke very highly of the group near us and said they work together and will often help by running tests, etc so he can go to his home vet for easier things, but the internist treat, diagnose, etc.

We discussed that they would be helpful with looking at his immune issues (chewing paws, digestion issues/food) as well as we begin this journey.

They will be sending a referral to the specialists tomorrow by lunch time and hopefully it won't take us too long to get in. I would love any advice, reading material, in the meantime... Thank you for all reading our story!

[labblab]

I’ve been watching all day for your report, and I’m so relieved to hear about your conversation with your vet. I think it went as well as I could have asked for. Your vet’s response was what I would have hoped to hear, and I think the consultation with the internist will offer you the best of both worlds — you’ll benefit from the input of the specialist while still maintaining your ongoing relationship with Max’s regular vet who knows him so well after all her years of caring for him.

As far as preparing yourself in advance of the appointment, it sounds to me as though you’ve already done a terrific job of educating yourself about both hypothyroidism and Cushing’s. As far as the Cushing’s, you may want to focus more now on treatment, which you may already have done. However, if you visit our “Helpful Resources” subforum, near the top of the index you’ll find several threads related to the two medications, Vetoryl (trilostane) and Lysodren (mitotane). I’m assuming the specialist will recommend one of these two meds if he/she feels as though the diagnostics are sufficient to move forward.

As far as the hypothyroidism, one of the most complete explanations that I’ve read related to testing parameters is found on the website of the Michigan State Vet School Endocrinology testing lab. This blurb is quite technical, but it does discuss advanced testing options in great detail.

https://cvm.msu.edu/vdl/laboratory-sections/endocrinology/thyroid-function-in-dogs

Good luck with your specialty visit. Good job, mom, for your tenacity in advocating for Max! And I love your avatar photo of your sweet boy — what a handsome boy he is ;-).

Marianne

[Elizabeth513]

Our vet sent over the referral, but they are unable to get us in until August 11th. I am definitely worried about waiting another 5 weeks. We did have them put us on the waiting list for a cancellation. Is waiting that long detrimental or in the long run typical and ok? I know beginning treatment as soon as possible is obviously the best option. Any advice is appreciated!

[labblab]

Hey Elizabeth, I don’t think I’d worry unduly about the wait. Cushing’s is typically a disease that progresses slowly, so I wouldn’t expect to see significant worsening in another month’s time. As long as everything stays pretty much status quo, I’d think you’d be fine. The one exception is if by any chance you started to see skin lesions appearing. If there’s evidence of calcinosis cutis setting in, then starting treatment might take on additional urgency.

I’d also hold off on starting the thyroid supplementation until Max has been seen. This is because the supplementation would invalidate any additional diagnostic thyroid testing. I don’t know that the internist will be interested in pursuing any more thyroid testing right now, but if so, the supplementation would have to be discontinued for a period of time before the testing could be done.

Hopefully things will stay pretty quiet for you two, though, until August rolls around!
Marianne

[Elizabeth513]

Thanks so much!
His main issue right now is "allergies"...licking and chewing feet and licking belly area. He is on Hydroxyzine which honestly I am not sure it helps. He sometimes vomits if he takes Benadryl. We also rinse his paws and apply a mousse for calming the skin. Summer allergies are always worse for him. He does seem to cry for food as well. I thought it was just that he wasn't getting full on the Royal Canin HP since the daily feeding guidelines at 4.5 cups for his size and it is lower in protein than he's used to. Any recommendations for healthy snacks that might help? He's normally happy if I acknowledge him and give him a few pieces of kibble or a "cookie". Thanks for your input!

To all reading...please know whomever you are...we are sending good vibes to all those going through tough times! :o

[labblab]

We are indeed, and that's so kind of you to reach out to others who are struggling, too!

Reading about Max's allergies make me doubly glad that you'll be meeting with the internist. It's a bit odd that Max would be suffering so much at a time when presumably his cortisol level is elevated. As a natural steroid, you'd think that his allergies would be somewhat under control right now. The more typical scenario with Cushpups is for allergies or other inflammatory conditions to worsen or become "unmasked" *after* cortisol levels have been lowered -- not before. So Max's situation does trigger some question marks, but we shall see what the specialist suggests.

I wish I had some great ideas re: healthy snacks. I've seen green beans or carrots suggested before, but hopefully some other members will have some better suggestions in that regard.

Marianne

[Elizabeth513]

Hello everyone! We were able to get an earlier appointment for Monday 8/3/20 with the internist! So thankful to get in a little quicker, but nervous. I am spending the weekend double checking all points I would like to go over and getting a list of Max's history and supplements on paper. Anything tips as a newbie on things I might not think to ask?

My top questions are:
-Medications and amounts as he is sometimes reactive to medications (would like to start at the lowest dose possible) I have found a few articles about dogs >30kg and lower doses but would love to see solid research based articles that are recent.
-Diet (moving from hydrolyzed protein diet to a better quality kibble or home cooked)
-Supplements for his issues with his right leg at times (has happened a few times over the last few years cruciate ligament is always ok when they check, but does show an area on back for osteoarthritis in xrays) and will favor his left with a little limp at times (has done this a few times over the last few years) It doesn't keep him from running like a maniac in the yard; which I wish he'd slow down a tad. Currently takes Dasaquin with MSM chews...bumped back up to 2 a day since he seems to be having issues with his right leg over the last week. Stiff upon rising and lowering, but once he starts walking seems better. Trying to have him rest which has always helped in the past. He did the same thing this time last summer almost to the day, but we were able to give a few days of anti-inflammatory meds which helped.
-blood work from previous tests (the "anemia" or lower blood levels on some tests)
-additional tests (his urine ratio test was done incorrectly, urine from the clinic not collected over time..I know the LDDS test he took was pretty straightforward, but I want to mention the urine may not be accurate)
-hypothyroidism and his slightly raised tsh and thoughts on that

I just want to not forget any big things...most important to me is treatment plan and NOT starting a dose that is too high. I am advocating for a much lower dose to start. Any advice appreciated! Have a great weekend everyone!

[labblab]

I’m so glad to hear that your appointment has been moved up! I think you’ve got all the important points already covered— good job! But I’ll continue to give it some thought and check back again by this evening if anything more comes to mind. But for sure, good luck!!

Marianne

[Elizabeth513]

Thank you so much!

[labblab]

It’s me, back again for a quick moment. I really do think you’ve done a good job of identifying your central questions, and I still don’t have a lot to add. I’ve spent a few minutes trying to find more recent studies re: the efficacy of especially lower doses in large dogs, but all the summaries I’ve found keep referring back to that original 2012-13 research. In the process, though, I did find this 2018 Canadian literature review covering a wide range of accumulated info (and remaining questions) re: the use of trilostane, generally. I don’t know whether you want to spend time reviewing all this tonight, but it does seem to offer a helpful summary of a variety of research conducted up through that time.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855282/

Once again, good luck with your appointment tomorrow, and we’ll be so anxious for an update when you get the chance.

[Elizabeth513]

Thank you so much! I did read that study as I was looking for info in general for trilostane. I am definitely hoping that being a specialty group they are diligent in their continuing research education. I have all of my info ready and on paper to take with us. I will definitely drive home the point that I am not comfortable going over 1 mg/lb if that is the medication route he wants to go. I would rather start lower and will definitely ask. I also am also relieved in reading his bio online that his special interests include endocrine issues.

I will absolutely touch base with you all tomorrow evening...tomorrow starts the first day back to school for teachers in our area! Whew...busy next few weeks, but thankful my husband is home until October to keep an eye on Max! :) Happy Sunday everyone! Have a great evening!

[Elizabeth513]

Hi everyone! We had a pretty good visit with the internist today. I liked him very much even though with Covid they are only allowing patients in the building so we talked over the phone. I sent in all of my notes for him to review before speaking to me. He asked why my vet decided to screen for Cushings to begin with due to his alkaline phosphate being the only marker elevated to 700. I told him my vet knows Max very well and knew that was off for him. She immediately thought a blood or immune disorder/cancer or possible Cushings.

He said Max looks to be in perfect health. He said his muscle tone, coat, teeth, etc look great and his weight isn't too low or high (84 lbs). He said at this point he is not showing any symptoms of Cushings. He said in that Max may or may not show symptoms in the future as he knows that there are dogs who have Cushings "on paper", but never experience issues that require treatment...he also said or he could begin having symptoms as time goes on. He described him as being in a grey zone at this point. He said that he did not think treatment is warranted at this point with no overt clinical symptoms. He explained the whole reason to use the medication is for managing the symptoms. He felt that I am an observant pet owner and would quickly identify changes such as the ones that go along with Cushings. He calmed my biggest worry which was beginning a medication before he actually needed it. I am ok with being watchful and waiting.

Thyroid: he looked over his labs and said boxers are known for hypothyroidism, but felt that his tsh number wasn't enough to consider it at this point. He said we typically use tsh in humans to treat, but his other levels were fine and doesn't feel we should medicate at this point...again be watchful of it! There was something he mentioned about the tsh and how sometimes it can run a tad high...but again I cannot remember. I was trying to remember everything and talk on the phone. :(

We did go ahead and retest his PCV/TS which is still low normal about 39/8.6. He also wanted to check his blood pressure which once he calmed down was great as well as sent urine to IDEXX to check protein-Creatinine ratio. Since Max has had some protein in his urine at times. I cannot remember exactly why, but in his notes it says, "looking for problems (proteinuria, hypertension) that occur concurrently with Cushings disease and will treat accordingly.

As of now we will wait for the UP:C results to see if any suggested treatment is needed.

Thoughts....have there been others who has had a conservative internist that didn't rush to treat when a dog is not showing symptoms? Curious about that as my vet was ready to treat both that and thyroid. I feel that for us it is the right thing to do. We are working to boost his immune system at home just with a mushroom complex and fish oil as well as a blood support vitamin which he said was fine. Just trying to keep him as healthy as we can! I welcome any thoughts, or concerns.

[Elizabeth513]

I received an email on his UP:C which showed some protein loss. They want to start him on telmisartan to help control the loss of protein. I’m off to do research now as I’ve never heard of this. Dr will call me tomorrow to discuss.

[labblab]

Elizabeth, thanks for all these updates! I’ve really been mulling over Max’s situation and that partially accounts for my delayed reply (along with some darn internet issues...). For the most part, I cannot argue with your new internist’s recommendation to hold off on Cushing’s treatment for now. Given Max’s age and lack of outward symptoms, his comfort and quality of life are paramount. So if he’s not visibly suffering from ill effects that are hampering him in his daily life, I understand why the vet is not rushing you into treatment that requires careful monitoring, frequent vet visits, risks of side effects, and of course not insignificant financial expense.

My only reservation relates to the proteinuria. Again, I am not a vet, so my thoughts are totally that of a layperson. But over the years, hypertension and/or proteinuria are two specific conditions which we’ve seen triggering Cushing’s treatment in their own right, even in the absence of significant outward symptoms. I believe this is because, if Cushing’s is the cause, these two problems may be difficult to manage if the underlying root cause is not addressed as well. From what you’ve learned from the vet, it’s clear that he’s aware that Max’s proteinuria may be associated with Cushing’s. However, it sounds as though he wants to see whether it can be managed sufficiently without leaping into Cushing’s treatment.

Again, I cannot argue with that recommendation since he has Max’s full picture in front of him. I’m confident he’s weighing the various considerations as they currently present themselves. But if it turns out that Max’s proteinuria significantly worsens over time, Cushing’s treatment may well be back on the table (which you probably already know).

In the meantime, I hope the telmisartan will help. I’m afraid I don’t know much about the medication myself, but I do know that we’ve had at least a couple of Cushpups here who have indeed been given it for treatment of proteinuria. So good luck, and do continue to keep us in the loop!

Marianne

[Elizabeth513]

Thank you, Marianne. I am nervous about the Telmisartan especially since his blood pressure is great with not signs of hypertension...all blood chemistry values are great as well. Here is his response...I didn't have time to attach last night:

The urinalysis for Maximus returned with mildly elevated urine protein levels. We see this in association with endocrine
disease like Cushing's or even a "pre Cushing's" state as we discussed for Maximus. Historically we didn't treat this mild of
a degree of protein loss in the urine, but recently it has been recommended to do so. I would consider starting telmisartan
(20mg tablet- 1 and 1/2 tablets by mouth once daily) to help reduce the protein loss in the urine. This medication usually
has minimal side effects and isn't expensive. We do recheck the kidney values one week into therapy to make sure there
is no increase and that the electrolytes are still normal. Most of the time this degree (very mild) of proteinuria doesn't
always resolve, but we can keep it from progressing and causing a problem with this medication. In theory, once started,
this medication would be used indefinitely with adjustments based upon response with regard to urine protein levels

I am interested to see what the value of the proteinuria is. I do feel like this is the first step to make sure we "control" the loss of protein. He mentioned it may not resolve it, but hopefully keep it from getting worse. I am encouraged by the several mentions of "very mild". Now I remember that he wanted to do the UP:C test and see how his urine was and treat if needed. Very glad he ran that test! So I am guessing like you were saying, what he wants to do is see if the Telmisartin keeps the proteinuria stable. Perhaps if we notice an upward trend then he may decide to begin treatment for Cushings? All great points...thank you!

[labblab]

I think your vet is “right on” with this assessment. It does make his plan of action clear, and it does indeed reflect the treatment trends we’ve been seeing. I’m so glad to know that he’ll be monitoring the kidney values and electrolytes after a week’s time. I surely do understand your concern about starting off with the new medication, but it sounds to me as though you’re in excellent hands.

[Elizabeth513]

I am so appreciative. I hope over time I will be able to contribute more to others. Just having someone who is positive and supportive is so helpful. Reading others' posts, I see how helpful everyone is. Thank you for giving your time to others!
Will report back soon!

[Elizabeth513]

It has been a few months, but I wanted to update everyone on Max. He is holding steady with the telmisartan treatment for proteinuria. After initial work up after starting the medication all bloodwork was fine. He has had not ill effects from the medication. After the 2 month checkup his proteinuria values has not gone up and the remained low. Our internist was pleased and with the fact that Max has not other symptoms of Cushings. We will recheck urine protein to creatinine ratio in January and continue to monitor him closely.

Merry Christmas & Happy Holidays to everyone!

[labblab]

Omigoodness, this is really great news! I’m so relieved that Max has responded well to the medication thus far, and we’ll definitely be anxious to read your January update. Since we’ve only had a few dogs here treated with telmisartan, your experience will really be helpful for us going forward. Thank you *so* much for taking the time to check back in, and truly, please let us know how his labwork turns out next month.

In the meantime, I hope you guys have a wonderful holiday season, as well!!
Marianne

[Elizabeth513]

Hi everyone! Dropping by to update. Max has recently had his UPC recheck and full labs. His internal med dr said he looks great. He’s still responsive to the telmisartan and it is continuing to keep his levels controlled. All bloodwork was great except his ALP went from 700-1100. His dr said this could likely be from Cushings and said we will just watch it. Worries me , but I trust their expertise. He was not overly alarmed as he said many Cush dogs do have higher ALP. He has gained weight since changing his food this time last year. He is showing some hip discomfort and his whopping 89 pounds probably isn’t helping that. So, I’m definitely hoping to help him shed some pounds; which does normally decrease some in the warmer months. He still does not show any Cushings symptoms except on lab work so our specialists still recommend monitoring until he does. He does love food, but it’s not excessive. He only cries for extra food when I’m around and near the food bin. He spends the day with my husband at home and never “asks” him. ����*♀️

Hope everyone is well!

[labblab]

Thanks so much for letting us know how things are going, and I’m so pleased to hear how well Max is doing! It really sounds like you guys are staying on the right track, and that is great :D. Your vet is right that we’re very used to seeing even much higher ALP readings with Cushpups, so I’d encourage you not to worry unduly about that, either.

I can sure sympathize about his weight gain. Especially when food is being changed, it’s hard to keep calorie counts consistent. And different foods just seem to be metabolized differently, too. My elderly Lab girl has been having chronic GI issues all winter and we’ve changed her food several times. I’m sorry to say she’s gained weight, too, which doesn’t help her arthritic legs, either. And now, it’s really hard to get the weight off since her exercise tolerance is pretty compromised due to her stiffness. Heck, thanks to all my loaves of pandemic banana bread and our short dog walks, *my* own waist has expanded quite a bit, too...<SIGH>

But back to Max, I think your vet’s treatment strategy continues to make sense and I’m just so glad that things are going well for your sweet boy — and for you! Please keep the updates coming, it’s great to hear from you ;-).

Marianne

[Elizabeth513]

Thank you, Marianne! We switched him to Royal Canin HP and he’s done fantastic on it. We too switched due to GI and allergy issues. I fought a “science based” diet for a long time, but it has been very good for him so far. I’m just trying to trust his team and know that they are the experts...while I’ll be there asking lots of questions along the way.

[labblab]

I totally hear ya about the food! The ingredients of many of the Rx diets are often so off-putting that I’ve always kind of turned up my nose at the suggestion. But after several weeks of no-luck experimentation with different commercial foods alongside plain chicken and rice, I gave in and started my Luna on Hill’s i/d digestive care. Within 24 hours, she finally had a solid stool and for now, I’m leaving her on it. She really likes it and even though she still relapses a bit every couple of weeks, I’ve had the best luck with it of anything so far. Thanks for mentioning the Royal Canin, though, because I do think that would also be an option for us to try if she continues to backslide on the Hill’s. I’m so over having to worry every day about how poop patrol is gonna turn out!!

[Elizabeth513]

Absolutely! Max has always been on “high end” food with higher protein. I balked at the ingredients, but after him having the worst gulps and strange allergies last February we switched him and the change has been remarkable. We have to go very slow with him if I add supplements. He’s always had “gulpy” issues which our vet and ER vets finally said is reflux. Episodes have been greatly controlled with food. I moved him off of dasaquin with msm chews to movoflex and green lipped muscle powder (super snouts) because I worried about his liver and the glucosamine and msm. Oddly enough his alp levels rising I guess it hasn’t helped. I’m sorry your girl has had a rough go. This is my first dog and aging is really tough. I just want him to be happy and not be in pain. We also have luck with Prilosec when he has a gulping episode.
Another thing that is wonderful for dogs with GI issues is raw goat’s milk. We tried it, but it wasn’t a fix for us. I pray Luna’s continues to get better each day. These dogs deserve all the best!! ❤️

[Elizabeth513]

Hi everyone! It has been a while, but I still like to update as it may be helpful to others by reading different stories! Max just had his recheck with the internist and all is well. We did start him on thyroid medication in October as his thyroid was low. Our home vet and Internal docs have been watching it and agreed it was time to try a low dose of levothyroxine after viewing his T4, tsh, and pcv. He’s doing well on it. Coat is not dry anymore and his last two checks have him in the therapeutic range 2.0 and 2.6. We’ve been able to stay on the lowest starting dose!

We also started Galliprant about 8 months ago because he was limping and then began yelping when moving from back pain. It has been so helpful. He is able to run and play, jump on the bed again and no limping or yelping. His ALP is holding steady, but still higher than I like. It actually dropped a tad at this appointment. Internist said it’s probably from the galliprant and extra cortisol from Cushings.

His Cushings is still asymptomatic except for the proteinuria which has remained steady with treatment with Telmisartan. His pcv is 37 which that’s where he hovers (between 37-39) over the last couple of years. I don’t like that these numbers are lower, but I’m going to look at adding sardines and egg as a treat just for some extra iron.

Overall a good visit as my boy is coming up on his 11th birthday in April. Great shape for a boxer! We just look at every day a blessing! Hope this is helpful to some navigating through Cushings with their pup!

[labblab]

Omigish, we’re so glad to have you back and to read this excellent report! Absolutely, it’s a help to all of us to continue to read about Max’s treatment journey, and his success on these various medications. It definitely gives us helpful info in terms of offering options out to other parents. You’ve done such an excellent job of advocating for him, and we’ll surely be joining you in spirit to celebrate his upcoming birthday!

Best wishes to you and to Max, and thanks so much for the update :-)))))))
Marianne

[Squirt's Mom]

Hi Elizabeth,

What a great update on your sweet baby boy! I am so happy to hear he is doing so well and that your visit with his vet went well! How nice to have such a great vet! I hope the specialist can bring even more joy and comfort to you and Max.
Hugs,
Leslie

[Elizabeth513]

I cannot believe it has almost been 3 years since diagnosis! Here is our check in! We appreciate everyone reading our story and hope it can give hope and hep to others!

We had our 9 month check in with our internal vet. She has noted that his ALP has increased and he is showing some higher potassium and anemia (which anemia is not new, he has hovered lower for a while). His labs showed ALP 1547 in July, 1920 in Dec at our vet and 2152 yesterday at internist. Our vet said possibilities for the high ALP could be uncontrolled Cushings or a liver mass. Max is on medication for proteinuria; which has been controlled by medication and has not outward signs of Cushings except labs. He is also on thyroid meds for hypothyroidism. He has also in the last 6 months been diagnosed with ARVC and is doing well on a low dose heart anti-arrhythmic.

We are going to do a fecal occult test to see if there could be gi bleeding from galliprant which could be contributing to the anemia or if no bleeding it could be a liver or adrenal mass. Can Cushings drop hematocrit with no bleeds? I'm thinking an ulcer bleeding which would be an easier fix... no bleeding could indicate a mass (guess that's worse possible case?)

This is where I am torn. He will be 12 in a few weeks. I just want to keep him comfortable and happy as almost 12 is ancient for boxers. He is the last one in his litter. I know we just need to rule out the gi bleeding first and then go from there. I am torn about an ultrasound. He doesn't do well with procedures and has to be knocked out. An ultrasound would only be beneficial so we would know whether it is his time or not...I would not treat a mass at this point given his age. I know this is speculation at this point and I should probably only be thinking about steps from here and facts of what we know. Just wanted to share and get hear anyone's thoughts who might be willing to share.

[Harley PoMMom]

Thanks so much for the update on sweet Max, and to answer your question regarding the relationship between Cushing's and hematocrit, elevated cortisol generally raises red blood cell counts.

How is Max's appetite and how about his attitude, I mean does he seem to be happy? If he does than, if this were me and taking in account his age, I would not have any tests for Cushing's performed, and probably not even the ultrasound since he gets a lot of anxiety with it. I sure do wish you both the best of luck and please do keep us updated.

Sending you both huge loving hugs, Lori

[labblab]

Welcome back, Elizabeth, and I agree 100% with what you and Lori are both thinking. Given his age and overall situation, if Max were my own boy, I’d likely forego the ultrasound as well. Just as you say, keeping him comfortable and happy would be my top priorities. If noninvasive lab testing can give you some answers to help guide you in that regard, then I’m all for it. But at this stage, anything that will stress him unduly is probably not worth the trade-off in terms of info gained. For sure, though, we’ll be happy to continue to talk over your options with you. I do hope the anemia turns out to have a relatively easy fix, such as altering his med regimen. Please do let us know what more you may find out. And please also give Max a big hug from his K9C family here!

Best wishes to you both,
Marianne

[Elizabeth513]

Thank you, Lori! He seems great! Happy, but slowing down. I really appreciate your feedback!

We know he does have Cushing's...but in the beginning it was recommended to not treat it specifically as he did not have symptoms. All speculative at this point until we get the fecal back, but his internal Dr has said based on changes in bloodwork (high potassium, increasing ALP, anemia) he may do better with beginning treatment for Cushing's.

I know I need to just take it one step at a time to see what tests results show. No real decisions can be made until things are clearer. I am just a thinker and it's my way of working through it all! :)

[Elizabeth513]

Thank you, Marianne! I appreciate that!

I think the only reason I would do an ultrasound would be to have definitive answers. If he were to have a mass (depending on dx) I would not want to put him through pain and more suffering.

So so tough!

[labblab]

Welp, I’ve just learned something new — which proves that you *can* teach an old dog new tricks! Cuz I’m definitely an old dog ;-).

After a lot of years on this forum, I’m just now learning that Cushing’s can cause anemia. As Lori said above, we’re much more familiar with a linkage between the disease and *elevated* red cell and platelet counts. But I just now Googled Cushing’s and anemia, and see that those two conditions can be linked. I don’t know the mechanism, and definitely need to educate myself further. But there you have it. So if no other explanation for Max’s anemia is uncovered, then I understand why Cushing’s treatment might be considered.

As you’ve already said, though, it’s a tough call since Cushing’s medication requires a lot of lab monitoring which may be stressful for Max, and in addition at his age might worsen arthritic issues that elevated cortisol might actually be easing. I wish I was able to write more right now, but I’d like to educate myself a bit more about the anemia angle before continuing. But I wanted to at least acknowledge this new piece of info — at least it’s new info for me!

Marianne

[Elizabeth513]

Of course! I appreciate all of your comments so very much! I am a researcher as well. I have spent the better part of today looking over his labs for the last 3 years since initial testing. His hematocrit and rbc as well as hemoglobin slightly every six months (between .8-2 point each blood draw). He's always been on the lower end of the scale.

Dr. V mentioned that high cortisol levels can lead to GI ulcers, combine that with the Galliprant that he is on and it could worsen this. This is her theory on the reason he dropped from 37.6 in July to 34.9 in Dec and 34.0 now....bleeding ulcers or a low volume bleed somewhere else. He also has GI issues anyway.

As I have researched Cushing's and anemia, it does mention Cushing's can be a cause of anemia, but I cannot find anywhere how they are related. I have scoured articles and research documents. I would love to hear if you are able to find anything.

I feel like Max is ok with blood draws and such, but he is not a dog who will lay down willingly for scans. He also does better when I am not around. :eek: He is used to appointments with his cardiologist and internal dr every 6 months or as needed for care. BUT he's an old fella and of course not his favorite thing in the world.

Sorry for the long post, just nice to be able to think outloud!

[labblab]

It's not a long post at all -- no need to apologize! And now I'm totally interested in trying to look into that anemia/Cushing's link, too. The notion that the combo of the elevated steroids of Cushing's in conjunction with the Galliprant would make a dog more vulnerable to GI bleeds makes a lot of sense, as well.

If Max does OK with blood draws, then that eases my mind a lot in terms of Cushing's treatment monitoring. There's a lot to think over, for sure, but please keep on thinking outloud, because it's prodding me to expand my own knowledge, too ;-).

Marianne

[Elizabeth513]

Max's FOBT came back positive for blood in feces. Dr. V said given his history of slow declining PCV and Cushing's and recent labs, she feels confident that it is GI bleeding that is the cause of the slowly developing anemia. She said she did not feel an ultrasound was necessary because due to his history and labs she did not feel a mass was likely.

She went over several options:

1. Treat Cushing's with Vetoryl to help the increasing ALP levels and decrease the cortisol which should help the bleeding an anemia. She said we could continue his Galiprant because (as many of you mentioned) when the cortisol drops it can make his arthritis worse. If this option is chosen we will do an ACTH stim test to see where his levels are and then begin. I inquired about beginning a very low dose and she said she would start him low and we could every try once a day for a week then move to twice which is what she recommends. Then, of course monitor from there. She said this option could be stopped at any time if we felt it was not benefiting him.

2. Not treat the Cushing's, but stop the Galiprant which is probably contributing to some bleeding. Although I think (I forgot to ask) this would only contribute to stomach bleeding not GI bleeding...maybe not...maybe NSAIDS can cause bleeds anywhere in the GI tract? She explained that this would not help his arthritis and he may be in pain or not have as good of life quality.

3. Do nothing...we know what we are dealing with now and we could keep him comfortable and monitor him until we needed to discuss end of life plans.

Some questions I had:
-Could we try gastro-protectants? Yes, but she said it would not help the entire GI tract and we certainly could, but of course meds like sucralfate must be given at specific times to not interfere with absorption which can be hard to manage. She said his whole I track is probably sludgy and there are small bleeds contributing to the issue.
-Is his age or anemia an issue with Vetoryl? No, many dogs are diagnosed and treated between the age of 10-16 and she said that it will also help the anemia.
-Is Vetoryl fairly safe? Yes, she treats many dogs safely with the medication. Most note GI upset in the beginning. She said there is a rare chance of damage to adrenals and causing Addison's.
-Does she feel that treating the Cushing's is the best option? She felt like it was an option worth exploring and she said the great thing about Vetoryl is that we can stop at any time if it is not helping him.

I want to try treating the Cushing's. I feel like he's such a healthy strong boy given all that he has been through. I feel that I need to explore it and give it a shot rather than doing nothing. Doing nothing is a certain downhill slide and I cannot in good conscience continue to let his Cushing's go untreated and treat the arthritis knowing that I am allowing the combination of those two things to cause more damage. If it does not go well or there are things that we see are taking away from his quality of life, we will stop and know we tried.

[labblab]

I do understand why you want to give the Vetoryl a try, and it sounds as though your vet is approaching things quite reasonably. That’s huge! It sounds as though you’ve already done a ton of research, so there may not be any information on the link below of which you’re unaware. But I’ll offer it to you nevertheless:

https://www.k9cushings.com/forum/showthread.php?8925-GENERAL-GUIDELINES-for-Vetoryl-(trilostane)-Dosing-amp-Monitoring-with-ACTH-Stimulation

Let us know about any preliminary questions or issues that you may be wondering about. And for sure, please keep us updated!

[Squirt's Mom]

Hi Elizabeth,

You said something that caught my attention because of the chance of errors seen too many times. You said - "I inquired about beginning a very low dose and she said she would start him low and we could every try once a day for a week then move to twice which is what she recommends."

First - For dogs weighing over 44 lbs the starting dose is a MAXIMUM of 30 mg per day. This is based on independent studies that Dechra, the manufacturer of Vetoryl, knows about and has chosen to ignore. So the literature that vets work from to find a "low" starting dose is out of date and MUCH too high. Their literature states to start all dogs at 1-3mg per pound per day. For dogs under 44 lbs, starting at 1mg/lb/day is ok but for larger dogs that is twice the starting dose that is appropriate...which is 0.50mg (or 1/2mg)/lb/day. So be sure she doesn't offer him any dose higher than 30 mg per DAY.

Second - you never ever increase the dose unless the signs and ACTH results say the cortisol is still too high. To do so otherwise is extremely risky. SO to simply start at one dose then increase in a few days without the ACTH to support the need should not be done. The cortisol will typically continue to drop those first 30 days after starting treatment with no increase. So do not allow her to do that to your baby. Max could become very sick, or worse, if she does.

Third - dosing twice a day is often the best approach because of the short life this drug has in the body - it is usually leaving in 12 hours or less. BUT to dose twice a day does NOT mean doubling the dose and too many vets do not realize this and will double instead of halving when switching to twice a day dosing. So if the correct dose for Max is 30 mg...that is 30 per DAY and twice a day dosing would mean 15mg AM and 15mg PM. NOT 30mg AM and 30mg PM. So watch for this...twice a day means halving the dose not doubling. ;)

Here is a link from our Helpful Resource section that includes info on starting doses for larger dogs. That info is at the end of the page and there is LOTS of good info before you get there so explore!

https://www.k9cushings.com/forum/showthread.php?8925-GENERAL-GUIDELINES-for-Vetoryl-(trilostane)-Dosing-amp-Monitoring-with-ACTH-Stimulation

Hugs,
Leslie

[Elizabeth513]

Thank you so much Leslie! I actually just came her to post a couple of things I forgot!!

Dr V said they recommend .5-1mg (and I cannot for the life of me remember if that was/kg or lb...I want to say kg?? Does that sound right??) I believe that is what you are also saying in your post? He's about 38 kg. So if my math is correct ;) 38(.5) = 19...yes? Sorry....double checking! Would we begin at 20 or could I request to start at 15? I am super paranoid about any medications.

I might have been confusing the way I worded the once a day. She had said we could try once a day for a week then SPLIT the dose into twice a day! That had me thinking...wait, ok splitting the dose would be gradual instead of one big dose! So, yep...I will definitely be asking for the two dose!

Max can be sensitive to some medications...we have seen in the past. We had to decrease his sotalol because if was too much for him. He had some reactions to some things in the past (cytopoint, ciprofloxin) so I am always very very hesitant about medications.

What are the thoughts on compounded trilostane? Not good? Ok?

I really really appreciate you thinking about this and being so thoughtful to help a complete stranger and her beloved pup!

[Squirt's Mom]

Thank for the clarification! And, yes, the literature is probably using kg VS lb. I found in an earlier post where you say he weighs 89 lbs. To find that weight in kg you divide the pounds by 2.2. So 89/2.2=40.4545...kg. It is the pound weight that we will look at. He is definitely over 44 lbs so that means he needs no more than 0.50mg (or 1/2mg) per pound per day with a max dose of 30mg a day. Even with his weight of 89 lbs a starting dose of 1/2 mg/lb/day would be 44.5mg a day...which is too high. His maximum starting dose is 30mg per day. I have seen dogs weighing more than he does doing great on 10-20 mg a day. For some reason larger dogs simply metabolize this drug differently than smaller dogs do so smaller starting doses are needed for them. I would feel comfortable with 30 mg per day but don't have a problem starting even lower, especially since he is sensitive to other meds. So if you want to start on 20mg/day I would ask for that dose. It is much easier to increase than to deal with a case of the cortisol dropping too low. ;)

I personally don't have an issue with the compounded form, Trilostane. However...not all compounded meds are the same. You want to be sure the pharmacy that does the compounding is using the licensed Trilostane, ie that they are compounding from Vetoryl and not from a bulk product that contains Trilostane. Compounding allows for more dose ranges and forms like chewable or liquid that can make giving the med easier for some dogs. Some vets allow compounded drugs, some do not, so you will want to talk to the one you use about their policies.

Hugs,
Leslie

[Elizabeth513]

Thank you again, Leslie...He was 38 kg or (83lbs) at the vet...I will definitely make sure they get an accurate weight on him for sure!

[labblab]

Hi again from me. I see that Leslie has given you a ton of good information so there’s very little for me to add right now. But since you’ve specifically asked about compounded products, I do have a bit to say about that from my own perspective. Over our years here, I’ve come to appreciate the fact that compounded trilostane can be a positive game-changer for folks, either because their dogs need doses that aren’t available in brand form, or because the high cost of Vetoryl would make treatment a huge financial burden. However, the downside is that compounded products are not inspected nor regulated in the same manner as FDA-approved pharmaceutical products, and some past studies have shown some dosage/efficacy irregularities in certain compounded trilostane products.

For this reason, just as Leslie says, people need to be careful about the compounders they select if that’s the route they need or want to go. Leslie is much more generally active in Cushing’s groups than I am right now, so she may be privy to better info about the following than I am. However, I would wonder whether any compounders are currently using actual brand Vetoryl as the basis for their trilostane product. You can always ask them, and I would be very interested to know their answers. But for reasons of both cost and practicality, I’ve assumed for some time that all compounders typically use basic chemicals that they purchase from suppliers in the preparation of their products. And for this reason, the reputation of any given compounder is especially important to investigate. On the thread below, we give people some tips in that regard:

https://www.k9cushings.com/forum/showthread.php?9066-Cost-Savings-for-Owners-of-Cushingoid-Dogs

My own personal preference would be to start off with brandname Vetoryl if the dose and cost was something my dog and I could handle. I would just have greater confidence about the consistency of the dose and efficacy. Once my dog was stabilized on a dose, that would be the time I’d feel more comfortable about trying a switch to a compounded version if the ongoing cost of Vetoryl is too burdensome. At that point I’d have the experience of the Vetoryl to compare with.

One final note in that regard…if you do opt to use Vetoryl on a twice daily dosing schedule, you may not be able to exactly split the daily total into two equal doses due to the limited options in capsule size. In that situation, the maker of Vetoryl recommends giving the larger dose of the two in the morning. And having said all this, your vet may already be working with a trusted compounder and my whole lengthy blabbing here will have been unnecessary :-). But good luck with whatever you decide!

Marianne

[Elizabeth513]

Great insight! Appreciated!! This has been so helpful!
I do trust our Internist. I feel that are top notch. We have others that drive from other parts of our state to be seen there. They are a great specialty group!

[Elizabeth513]

We went in for Max's ACTH test today and his vein blew. We have set up a new test for Wednesday. My poor boy has rolling old veins...He was very well behaved and seems excited this morning as he knew I put his car towel down in the car last night. They discussed maybe inserting a catheter to help when they redo the test! :(

[Elizabeth513]

I would appreciate help with Max's ACTH results and where to go from here! Please read the email from his vet. My head is spinning a bit and I am a little scared to start treatment without doing an LDDS test again...I do not even know what to think! He did eat the morning of the ACTH test....I replied to her and asked some questions and that was one of my main ones. Please see her email below...I appreciate your advise on this!


Hi Elizabeth,

I am out of the office on vacation the rest of the week, but wanted to give you this information.

Maximus' ACTH stimulation cortisol is considered normal at 11.8. To diagnose Cushing's disease, we would want the level to be >22. I went back to look at his LDDS test results from June 2020 and they were very consistent with Cushing's disease. Generally, once you have Cushing's disease, it doesn't go away. The ACTH stimulation test can look normal in about 20% of dogs that actually have Cushing's disease, so it is not the most sensitive test. That being said, if we treat him with medication and he actually doesn't have Cushing's disease (let's say the adrenal glands have necrosed/died some), we couldm make him sick.

We have some options on how to proceed:
1. Repeat the LDDS test. This is the most sensitive test for diagnosing and if it remains abnormal, we can feel good about treating. The downside is that this is the 8 hour test.
​​​​​​​2. Start treatment with a very low dose of trilostane (as we had planned to do anyway) and monitor him very closely.

I think with his history, his clinical signs and his bloodwork changes, it makes sense that he does have Cushing's disease and it is reasonable tto try treatment, but I want you to have all the information to make an informed decision moving forward.

​​​​​​​I will be back in the office on Monday!

Let me know if you have further questions!

Regards,
Vanessa Von Hendy-Willson, DVM, MS, DACVIM (SAIM)
reply e-mail: DrV@upstatevet.com

[labblab]

Dear Elizabeth,

I surely understand why these results are throwing a bit of a “monkey wrench into the machinery.” I appreciate the fact that your internist has broken out many of the pros-and-cons about the situation. At this point, I just have a few other thoughts to add. First, it has always been my understanding, as well, that the ACTH is more likely than the LDDS to give a “false negative” in a dog that truly has Cushing’s. This failure seems to be even more likely for dogs who suffer from adrenal vs. pituitary tumors. I can’t remember whether Max’s original LDDS results pointed towards one type of tumor as opposed to the other. If not, you’d be be left with considering an abdominal ultrasound to actually view the adrenals, but I know that’s not an attractive option at this point.

Going back to the differential test results, the “flip side” of the equation is that the LDDS is more likely than the ACTH to return a “false positive” if a dog is suffering from an alternative nonadrenal illness or physical stress. Since Max’s LDDS was performed almost three years ago, you’ll know much better than I whether he was ill in any other way that might have skewed the test results at that time.

I know your decision about treatment would be much easier if this ACTH testing had also been consistent with a Cushing’s diagnosis. I think it’s very good that your internist is trying to provide as much information as possible for you to consider. Unfortunately, though, it doesn’t sound as though there is a definitive answer and you and your vet will have to go ahead and roll the dice, one way or the other. I know it’s a lot to consider, and we’ll remain here to help you brainstorm with your own thoughts about this.

Best wishes no matter what you decide,
Marianne

[Elizabeth513]

Yes, his LDDS test in 2020 was consistent with Pituitary. I believe the results are on page 1 or 2 of this thread. I guess there’s a lot of what if’s for me, but I try to just think about facts to help feel less worried. I just don’t feel comfortable giving Vetoryl unless we know for sure. I’m wondering if a retest LDDS would help. He has all the markers for Cushing’s.

My big question is: if the ACTH test is used to monitor medication, how do they do that if it can be incorrect in 20% of dogs? If his test was 11, is that pretty accurate? How would they make sure it’s accurate on Vetoryl? I may be missing something.

Thanks for your advice!

[labblab]

Starting with your last question first, I guess we have to assume that the 11 ug/dL was an accurate measure of Max’s stimulated cortisol level at the time of the test. The goal with Vetoryl treatment is to reduce stimulated cortisol levels to at least 9, and even lower than that — to no more than 5 if symptoms are still remaining at that higher level. However, I must confess that I can’t recall ever starting a dog on Vetoryl who has registered a diagnostic ACTH of only 11 since that is indeed squarely within “normal” results for a dog without Cushing’s and clearly you wouldn’t want to be lowering his stimulated cortisol a whole lot further with treatment.

One question I would have for your vet is whether there was any possibility that there could have been some problem with the efficacy of the stimulating agent or with the delivery of it. You mentioned that the test had to be repeated using a catheter since a vein was blown the first time. If the stimulating agent didn’t function properly, then that could explain the lower cortisol level. By the way, do you know what Max’s baseline cortisol level was prior to the injection of the stimulating agent? Normally we don’t care much about the baseline level, but in this case I’d be curious to know how close it was to the second cortisol reading.

I surely understand why you’re wanting more confirmation at this point. I’m going to throw an idea out there that your vet may think is nuts. But prior to subjecting Max to another 8-hour LDDS, would there be any point in going back to the beginning, in a way, and repeating a simple creatinine to cortisol ratio test of his urine (UC:CR). I looked back in your thread, and Max had one of these performed initially, but perhaps there’d be some value in repeating it. To recap, we’ve been told the best way to perform this test is for the owner to catch a urine sample at home (low stress environment) on three successive mornings. The samples are pooled and taken to the vet for analysis. An elevated result (like Max had before) is consistent with Cushing’s, but can’t confirm it. That’s when you need to move on to the ACTH and/or LDDS. But here’s the key — a normal result on this test essentially totally rules out Cushing’s. So if Max were to have a normal result on both a UC:CR in addition to this ACTH, I’d be very hesitant to proceed with treatment myself. As I say, just a thought that your vet may not think is helpful, but I wanted to throw it out anyway since it would be a lot less stressful for Max than a repeat LDDS.

Marianne

[Elizabeth513]

They did not use a catheter like I thought. They did get the samples and injection without it! :) She did not tell me the baseline and I was curious about that. This was not his first morning urine, but a sample I got at the vet as I took him for a walk outside. I have all of his papers and bloodwork over the years and can go back and look. I will definitely ask about a new UC:CR...won't hurt to go back over things!!! His initial ratio was 93.

[labblab]

Hi Marianne! Thank you so much! He initially went in for a dental cleaning and his yearly exam. My vet was very concerned at first about his low rbc, hematocrit and we did a repeat...it came up slightly. At the same time she said his ALP is consistent with Cushing's and noted he had gained some weight ( ore on that in a bit). She added on a cort/creat screen to his urine that has been sent off and when it came back she said it was very suspicious of Cushing's to her (urine cortisol : 12.3, Urine Creatinine 41.4, ratio 93) and she recommended a LDDR test. I requested to add the thyroid panel because he was low/normal 1.2 (1.0-4.0).
You’re right that the UPCR is something different, but here’s a quote from when Max was first diagnosed, and it looks like the UCCR was done at that time. I don’t know what the conditions were when he was tested back then, but from the looks of it, the test may have been done on a urine sample that was drawn by the vet or while at the vet visit. If so, the elevated result may well have been inaccurate. For this test, the dog absolutely needs to be calm and not stressed at the time you get the urine sample. Also, the pooling off samples taken on three successive days also helps to boost the accuracy of the test.

P.S. I see that you’ve just now edited your previous post, and we’re on the same page ;-).

[Elizabeth513]

Yes, I did bring up that concern initially with my home vet. Our old internist agreed that he could have been stressed. I will discuss that possibility of running a new one. I realized after I put those results that it was his protein ration not UCCR! :) Lots to sift through, but I know eventually we will get there. My main concern is the anemia we are seeing. With the occult fecal test positive the internist felt like it was increased cortisol and the combo of galliprant causing an oozy gi tract. I have decreased his galliprant and he is no longer getting 100mg. He was getting 1 day 100 mg and the next day 50mg. I am now doing 2 days at 50 mg followed by a day off. He actually seems to be tolerating it and his arthritis seems just fine.

My boy is definitely a tough one to figure out. I am so so appreciative for just good conversations and others helping me talk through ideas. I want to keep him happy with all the time we get with him.

[Harley PoMMom]

I've been doing some research with the correlation between Cushing's and anemia and found that generally this is found only in males mainly because of Hypogonadism, a condition where the gonads fail to function properly leading to reduced or no sex hormones. Is Max neutered? If not, then I would consider having a full sex hormone adrenal panel performed or at least checking his testosterone level to see if it is low...just a thought!

Hugs, Lori

[Elizabeth513]

Ohhhhh,Thank you!!! Yes, he is neutered! Very interesting!

[Elizabeth513]

Just dropping in to ask for some good vibes for tomorrow. Max will be having his LDDS test. She said we could take him home in between each blood draw to keep him happy.

She also said that a repeat urine test was not necessary and this she feels will be the best test to run. She said that she typically does that test first to rule out the need to test further for Cushings. Fingers crossed he has an easy day as he cannot eat and that will make him the most upset I think!

[labblab]

Thanks for letting us know, and wishing you guys good luck!! That’s great they’ll let you take Max home in between. I surely hope all goes well, and we’ll *definitely* be interested in the results!

Marianne

[Squirt's Mom]

How did it go? Any results yet?

[Elizabeth513]

Just got an email from the vet. She said his results are still consistent with Cushings. She did not send me the actual results, but emailed me just to touch base. She is not in the clinic today, but wanted to give me a chance to think about it over the weekend. She said she feels comfortable with treating with Vetoryl. I asked for clarification because she outlined a plan: "New medication- Trilostane, 20 mg: Give one capsule by mouth every 12 hours with food..." I asked if she was thinking 20 mg twice per day or 20 mg total. I was honest and said I would be comfortable with 20 mg per day not 40. :(

[Harley PoMMom]

Definitely would like to see those test results! And I agree with you on the dosage, 20 mg a day not 40 mg.

[Elizabeth513]

Our vet responded this morning. I appreciate her taking a minute on her time off to respond. Here was her reply. I also asked if she could send me his results for my records. I am very happy with her response and considering my thoughts. I also asked her opinion about compounded trilostane.

Max just celebrated his 12th birthday yesterday! So thankful for each day we have this old guy around!

From Dr V:

I did intend for him to be on 20 mg, every 12 hours. But if you want to reduce this it is fine. In general, dogs require around 1 mg/kg, every 12 hours to be controlled. Maximus is 39 kg, so that would be 40 mg, every 12 hours. I went with half that dose to start. But if you would prefer to start with 10 mg, every 12 hours, we absolutely can.

I use a lot of compounded trilostane and think that it does work, but sometimes we have to adjust our doses and can't follow our mg/kg guideline as closely (i.e. because maybe it doesn't absorb quite as well so they are getting a lesser dose than we think). The main reason I use compounded is needing an odd dose (7 mg for example) or sometimes cost (though some of the compounding has gotten expensive as well). In Maximus, I would prefer to use namebrand so that we can be very clear about what dose he is actually getting.

[labblab]

I’m so glad to hear how well your vet listens to you, and how cooperative she is! That is a huge plus, for sure. I’d also feel most comfortable starting Max off with the 10 mg. capsule twice a day, and then working upward if it seems appropriate. I also agree with the notion of starting him off with brandname Vetoryl if you can afford it. I do believe you can have greater confidence in the dose and efficacy of each capsule, which will be very helpful in terms of monitoring Max’s response.

I’ll be interested in the actual test numbers, too, but it truly sounds as though your vet is on top of things. Definitely wishing you guys good luck, and please continue the updates!

Marianne

[Elizabeth513]

I will absolutely continue to update. Now that we are on the road to treating Cushings I know I will have many more questions. I went ahead and submitted an order to Chewy, but realized that Costco is about $40 cheaper. I will keep that in mind as we move along. We get some of his med and food from Chewy already which may be easy. No experience with Costco and how easy they are to deal with.

[Harley PoMMom]

Happy belated 12th birthday, Max!!!!!

[Elizabeth513]

Our Vet tech promptly sent over results this morning!

Baseline 68 nmol/L
4 hour 72 nmol/L
8 hour 114 nmol/l

[labblab]

Elizabeth, thanks so much to your vet tech from us, too ;-).

I'm going to translate Max's results into units of ug/dL so that folks who are more familiar with those units can more easily understand. Also, we can additionally compare them directly to Max's first LDDS performed back in 2020.

New test result:

Baseline: 2.5 ug/dL
4 hour: 2.6 ug/dL
8 hour: 4.1 ug/dL

His first test result from 2020:

Baseline: 5.1 ug/dL
4 hour: 0.4 ug/dL
8 hour: 6.7 ug/dL

So this time around, both his baseline and his 8-hour level were lower than before, but the 8-hour remains elevated above the normal cut-off of 1.4 or 1.5 ug/dL. So once again, Max's result is consistent with a Cushing's diagnosis. The most significant difference is that he did *not* suppress at the 4-hour mark this time around, though. His lack of 4-hour suppression means that an adrenal tumor is a possibility, which seemed to be unlikely earlier on. If Max *does* have an adrenal tumor, though, that could help explain his normal result on the diagnostic ACTH. As we've talked over, the ACTH is particularly vulnerable to returning "false negatives" in the presence of adrenal tumors.

This brings us back to the point where an ultrasound would help clarify the presence of an adrenal tumor. But for reasons that I do understand, this clarification may remain of limited value to your decision-making and not a procedure that you want Max to undergo. As we've probably discussed before, Vetoryl is used to treat elevated cortisol, regardless of tumor type. So it sounds to me as though your treatment plan would remain unchanged, either way.

Thanks again for giving this additional info. And please give Max a belated birthday hug for me, too!

[Elizabeth513]

Thank you so much!
I do believe some stress could be at play with his test. He stayed at the vet all day. After his baseline draw he REFUSED to get in the car. He kept pulling back and would not even budge...all he wanted to do was walk around outside. After 30 minutes of trying to get him in the car I did not want to stress him. They did allow him a quiet room to rest and said he was a very good boy. He eagerly went straight to the car when I picked him up.

Yes, I agree that an ultrasound at this point would just be to confirm if there was a tumor. The treatment would still be the same. BUT that does leave me curious...could he be an "outlier" and still be pituitary dependent? Max after all, like to be sneaky with tests!

I did find this on IDEXX when looking up measurements...which looks as those his results could be one or the other...?
Base- Normal
4 hour >50% basal or >40 nmol/L
8 hour >40 nmol/L but <50% of basal
Pituitary or adrenal dependent hyperadrenocorticism

I also found this in my scouring vet sites (todaysvetrinarypractice.com):
*Lack of suppression does not confirm ATC b/c approximately 25% of dogs with PDH fail to exhibit suppression on LDDS or HDDS tests.

[labblab]

Yes, you are exactly right that a lack of suppression can occur with either a pituitary or adrenal tumor. When that pattern occurs, it is found more often in conjunction with an adrenal tumor, but it doesn't mean a pituitary tumor isn't a possibility. The oddity with Max -- if there is one -- is that he *did* suppress before. I don't know enough to be able to explain, physiologically, what might account for this change. My "go-to" article regarding LDDS intepretation is usually this one by Dr. David Bruyette. When I have a bit more time, I'll head back to read it once again to see if it helps make more sense of the change in Max's pattern of results. Regardless, I think you're right in believing that a pituitary tumor is still possible. It's just that the door may now be open to the possibility of an adrenal tumor, as well, whereas that didn't seem to be the case before.

https://www.dvm360.com/view/clinquiz-interpreting-low-dose-dexamethasone-suppression-test-results

[labblab]

I did find this on IDEXX when looking up measurements...which looks as those his results could be one or the other...?
Base- Normal
4 hour >50% basal or >40 nmol/L
8 hour >40 nmol/L but <50% of basal
Pituitary or adrenal dependent hyperadrenocorticism

I'm popping back, though, because one aspect of that IDEXX quote doesn't look right to me. It's the 8 hour line stating that <50% of the basal could be consistent with either a pituitary or adrenal tumor. I think that suppression to a level less than 50% of basal at either the 4 or 8-hour result is confirmatory of a pituitary tumor. Maybe you copied it down wrong? Regardless, this option doesn't fit Max because this time he wasn't less than 50% of basal at either 4 or 8 hours...

Quote from the Bruyette article given above:



If the eight-hour post-dexamethasone administration cortisol concentration is above the reference range, then evaluate the baseline and four-hour postdexamethasone administration cortisol concentrations to see whether cortisol suppression occurred during the eight hours. If at least 50% cortisol concentration suppression is present at the four- or eight-hour time points, the definitive diagnosis is PDH and additional adrenal function tests are not needed.

[Elizabeth513]

I have read that article. Lots of information! I appreciate you all taking the time to walk me through this.

And, yep I could've copied wrong...I can't figure out how to insert an image with url!!

https://www.idexx.co.uk/files/low-dose-dexamethasone-suppression-test-protocol.pdf

[labblab]

AND I'm back one more time to say that I'm probably unnecessarily muddying the water. Since Max's previous result seemed to confirm a pituitary tumor, and this new result could also arise from a pituitary tumor, I'm probably adding an unnecessary question mark to the whole situation! So please feel free to ignore all of the above ;-). The last thing you need is for me to add more stress or confusion!

[Elizabeth513]

No...no!!! We are birds of a feather!!! I too look at things in depth and question all aspects. I know in my heart if there is any sort of tumor anywhere (for all we know he could have something hiding that we don't know about that has not shown up on any test) we would not treat, but keep him comfortable. I am thankful that no matter what...Vetoryl will cover him as we just try to give him the best quality of life. We are also in agreeance that if this affects his quality of life the medication will stop and we will let him live his days happy until it is his time! :o Your thoughts are always welcome!!!

[labblab]

Elizabeth, you are a wonderful mom and Max is so lucky to have you advocating for him! At this point, you are approaching things exactly as I would be doing, too. Thank you so much for including us on your journey. We're right there beside you, shoulder-to-shoulder. Every step of the way.

(And I see from following your link that you didn't copy the IDEXX chart wrong at all, which leaves me totally baffled because the chart itself seems wrong to me <BIG SIGH>. Oh well -- ENOUGH!!!)

[Elizabeth513]

Perhaps different ways to read have been researched over the years and studies have been found that results can vary? I don't know, but very interesting to me. Here's something else I found...IDEXX seems to show a lot of variation if I am reading correctly? Just thinking as a dog's disease progresses maybe the results can vary? How many dog's actually repeat an LDDS test years later? Interesting to me!

https://www.idexx.com/files/snap-cortisol-testing-guide-en.pdf

[Elizabeth513]

Is it ok to pop the Vetoryl out of the blister packs to fill his medicine containers for the week or should they stay sealed until ready to use?

[Joan2517]

I used to cut around the packets to make them fit into the medicine containers.

[labblab]

That’s a really good question, Elizabeth, and a really clever solution, Joan. I honestly don’t how how much of a difference a few days out of the blister pack actually makes. It probably depends on the medication. For instance, Luna’s Previcox came directly from the manufacturer in a box filled with blister packs. But at the beginning, when she was only prescribed a week or two at a time, the vet gave us a bottle with the tablets loose inside. You might want to try to call Dechra directly to ask them about this — and if so, please let us know what you find out!

Marianne

[Elizabeth513]

Good morning. Let me begin with how our Internist monitors cortisol levels in treated dogs. She has found a prepill blood draw to be more accurate that repeating an ACTH test. I am fine with that considering Max's ACTH test was 11.8 and he seemed to be that 20% with a normal looking response. I cannot seem to find the technical answer to some questions I have about Vetoryl and how it works chemically in the body. Looking at Max's LDDS his baseline was 60 or (2.5). That seems to me like it is almost within range? Am I wrong about that? How do you only drop cortisol a little without dropping it too low? I know that is where monitoring comes in. Would we get to a point where we have to keep decreasing the Vetoryl or does the body naturally find a "just right" dose that keeps cortisol suppressed just enough.

So far Max seems to be just fine on the 10 mg twice a day. We are on day 4 today. We will be going back on the 23rd (day 20) for a pre-pill test. I know this is longer than the 14 days, but I am ok with that for a couple of reasons. It is what our vet said and I know this does may need a little more time to regulate his levels. I really do hope that we do not have to go up on the meds. My plan is to see what is going on day 20. Which leads me to another question....if cortisol continues to drop for 30 days, can't you predict around what his cortisol would be a week after this day 20 blood draw? And knowing where his cortisol already is, it would seem like we don't have a long way to go to get it in range? Unless...Vetoryl drops it very slowly? Ok, I am rambling, but feel sure many of you will understand what I am trying to say. :) I have been looking for a good publication that shows hoe Vetoryl works and drops cortisol, but can't find my specific answer.

[Squirt's Mom]

I don't have any links to studies, etc. but from years of observation this is what I have learned about Vetoryl. It is an unstable drug - meaning it does not work like many other drugs as far as reaching an optimal level and remaining there controlling whatever it was intended to control. Instead, with Vetoryl, the cortisol level in the dog's body can suddenly rise or suddenly drop even if the dog has been on the same dose for some time and nothing else, such as weight, has changed. This is why it is crucial to keep the testing schedule as set by Dechra...to see how well the drug is working at that point in time. It is the nature of this drug to be frequently increased or decreased. Very very few dogs I have known about found a dose of Vetoryl that worked well and were able to stay on that dose for a long time. Not saying that doesn't happen...just very rarely. ;)

As far as dropping too low...keeping the testing schedule as prescribed and learning all you can about the signs of Cushing's, both high and low cortisol, are your best defenses for this situation. One of the good things about Vetoryl is the short life in the body. So IF the cortisol does go too low simply stopping the drug will usually allow the cortisol to rise again pretty quickly with no other intervention needed.

The PVC, or the prepill testing protocol your IMS talked about, is used very often overseas but is just starting to catch on here in the US. The protocol is different, the testing schedule is different, it is usually a bit less expensive, but it is not suitable for all dogs. Here is a link on this protocol:

https://www.animalhospitalofwarwick.com/sites/site-4183/images/Vetoryl%20Monitoring%20Protocol.pdf

And just FYI...doing the first monitoring test at 20 days does not fit with the ACTH testing protocol nor the PVC protocol. So you might want to discuss this with the vet and get their perspective on why they are doing it this way VS the prescribed protocol. They may know something no one else does! :D

That's my 2 cent's worth. Sounds like you are doing a great job, Mom, so keep up the good work!

Hugs,
Leslie

[Elizabeth513]

Thank you so much, Leslie!
There are a few sites and studies I have read about the pre-pill testing...mostly vet hospital or endocrinology articles.
https://www.vin.com/apputil/project/DefaultAdv1.aspx?pId=24437&SAId=-1&catId=137421&id=9382867&ind=128&objTypeID=17

That's actually scary to me that Cushing's and regulating cortisol levels seems like a rollercoaster that at any moment can derail. I do feel as though I am pretty diligent in observing him, (haha) probably over observing at times. :) I will be sure to check in with her about her monitoring protocols!

[labblab]

Hi again, Elizabeth. I’ll keep looking, myself, for an article that explains trilostane’s working mechanism in a clear fashion as it relates to Cushing’s. I’m guessing you’ve already read the printed insert that comes in Vetoryl boxes. It includes this basic explanation of physiological action:


Trilostane (4α,5α-epoxy-17β-hydroxy-3-oxoandrostane-2α-carbonitrile) is an orally active synthetic steroid analogue that selectively inhibits 3 β-hydroxysteroid dehydrogenase in the adrenal cortex, thereby inhibiting the conversion of pregnenolone to progesterone. This inhibition blocks production of glucocorticoids and to a lesser extent, mineralocorticoids and sex hormones while steroid precursor levels increase.

I’m guessing, though, that you’re hoping to find a simpler, more straightforward explanation of the overall effect on the body, and I’ll try to keep looking. In your research, you’ve probably discovered that initially trilostane was tested for a time to treat certain human post-menopausal breast cancer patients. Again, this was due to its steroidal effect — I believe somehow in relation to estrogen conversion. However, I don’t believe it is still prescribed anywhere for this use.

At any rate, in terms of canine Cushing’s, as you already know, the benefit is the reduction in the amount of cortisol produced by the adrenal glands. To a lesser degree, trilostane can also reduce the amount of aldosterone which is the hormone that regulates the balance of potassium and sodium in the body. For this reason, dogs treated with trilostane should have their basic blood chemistries monitored alongside the cortisol level. This involves a simple blood analysis, and is easy to perform on a sample obtained at the same time as the cortisol analysis.

As far as Max’s monitoring, Leslie has already helped to explain that the pre-pill testing protocol has been adopted more widely in Europe but has been gaining more familiarity here in the U.S. Unfortunately, though, I think the veterinary world is yet to find the ideal monitoring blood test for the use of Vetoryl. That’s why the combination of outward clinical signs, basic blood tests, and monitoring cortisol levels are all important. My personal thought is that the greatest benefit that the pre-pill test provides is reassurance that the cortisol level is not being driven *too* low by the Vetoryl. From the standpoint of safety, that’s the most important issue. As far as the need for a dosing increase, though, clinical observation may be as crucial for Max as is the pre-pill resting cortisol level unless that level shows increasing elevation. I dunno, he is really kind of a wildcard for me in terms of cortisol monitoring given the fact that his recent post-ACTH level fell within the normal range. I guess this is going to be a learning experience for us all!

And yes, Leslie’s right that we’ve seen the need to tweak dosing at any point in time during the duration of trilostane treatment. That’s why vigilant monitoring is so important — especially the watchful eye of the owner. But we know you’ve already got that part totally covered ;-).

Marianne

[Elizabeth513]

Thanks to you both! I will continue to share as we go in hope that Max's story will help others as well!

[Elizabeth513]

I don't even want to write this. Max has passed. We lovingly let him go. He had a pulmonary embolism and we knew it was time to stop treating. We knew he would develop other things at his age and this for us was the hardest decision as he was still fighting. I asked the vet if he was in pain, and he said a PE can be quiet painful.

A little backstory that I hope may help others. A week ago Max got out of bed in the middle of the night and fell. I always though it was his ARVC and an arrythmia episode, but now I wonder it it was the PE beginning. Earlier in the week I woke up to him gasping a couple of times and had never heard him do that. Wednesday night he was off. I thought it was the Vetoryl. He seemed very tired and wasn't hungry as usual. I went to give him water and he was drinking funny. I emailed Dr V yesterday morning asking if it could be the vetoryl. He was "huffing" when he walked. He ate ok and went to the bathroom. My husband came home at lunch and as soon as Max got off the couch he was breathing heavily. I came home and decided to head to the ER as I knew how he was breathing wasn't good. Dr V called me as I waited in the ER and she said her worry was heart. We discussed some things and she was very compassionate and heartfelt. They did xrays and the cardiologist looked at them and they said not his heart and were unsure what was going on. His labs were ok. A critical care dr was brought in and he said PE. My husband arrived and we talked it over...we decided to end his suffering. This was so very hard because they brought Max to us and he was still his loving self and playful, but his breathing was very bad. We both felt like we were at the point of all things continuing to fall apart. If not the PE, it would be something else. We did not want to take the chance of him having an accident or medical emergency at home when we couldn't be there with him, or our children being home alone with him and having to witness his final moments and not know what to do. This was the worst day of our lives and I feel grief and guilt over it. I appreciate all you all have done to help me over the years and now the last few weeks when I have really needed it. Hugs to all!
https://drive.google.com/file/d/1iWzBIHrqgQT7Yusxb08InI4kTjocwGcu/view?usp=share_link

[labblab]

Our dear Elizabeth, my heart is with you and your family. It must have been so hard for you to write your note on this sad, sad morning. The first morning arising without your beloved boy. All of us who have experienced this pain know how hard this day will be for you, and will be alongside you in spirit to support you.

I do believe you made the right decision for Max at the right time. You may already know that Cushdogs can be more vulnerable to developing a pulmonary embolism, so given his symptoms and the opinion of the emergency care doctor, I have no doubts as to the diagnosis. So there you were, left facing such an uncertain and potentially tragic future. With both of our last two dogs, my husband and I have also been faced with the heartbreaking dilemma of making that decision at a time when our girls were still both totally themselves cognitively, but physically so compromised. It is so, so, so hard to say goodbye under that circumstance. But with the support of our own vet, we felt that the greater gift was to release their spirits with dignity, while they *were* still themselves and not suffering terrible pain. Dogs are so stoic that it can be so hard to know about that. So all we can do is listen to the vets, listen to our furbabies, and finally listen to our hearts. We have to do what’s best for them, no matter how awful that decision may be for us. Under these circumstances, I don’t believe any of us can escape second thoughts and some feelings of guilt and regret. But all we can do is make the best decision we can, armed with the information we’ve been given. And most of all, filled with our love for our pets. I truly believe that love lasts forever. Max lived on this earth cradled in love, and now his spirit will carry your love with him forever.

Again, I’m so deeply sorry for your loss. Please know that we’ll always be right here in the days to come should you wish to talk more. You’re forever part of our family, as is dear Max.

Sending many hugs of comfort to you across the miles, always in loving memory of your sweet boy.
Marianne

[labblab]

The Places We Go When We Leave
— Elle Maruska

There are worlds upon worlds all blooming with wonder
& numberless doorways between
& when we are done with mere skin & bone
we become travelers of shadow & dream
we do not need form, nor breath, eyes, or claws
to hunt through the brilliance & gleam
& all pain fades away, all fear falls to gray
when we go where we go when we leave
But memory persists & love still exists
& we wait close & we watch as you grieve
for we know you can’t know the places we go
when our bodies fall finally to sleep
but don’t hurt for us long, nor imagine us gone
though we’ve slipped into beauty unseen:
we’re waiting right here for when you finally appear
& we can both go where we go when we leave

[Elizabeth513]

Thank you so much! That is absolutely beautiful and much needed. I am filled with such such sorrow, but great love and memories.

[Elizabeth513]

Marianne,
Your words are exactly what I needed! I cannot thank you enough. I plan to stick around on the boards to offer help, encouragement, and a listening ear for others. I am thankful Max did not suffer and I am so thankful that we could give him all the specialty care he needed. May all of our angels rest and watch over us.

[labblab]

Elizabeth, it will be a huge gift to us all if you remain here to offer your knowledge, support, and encouragement. And I don’t believe there can be any greater way for you to honor Max’s own sweetness and courage than to help other dogs and parents who come to us in need.

For our own part, I hope it will bring you some comfort to know that Max has now been added to our special thread of remembrance on our “In Loving Memory” forum:

https://www.k9cushings.com/forum/showthread.php?9294-Remembering-All-Who-Have-Left-Us-(2020-2023)

If it would ever please you to have a photo link added to his name, you can simply send us a picture at k9cushings@gmail.com. We’ll take care of all the rest. There is no rush — you can think it over and send it anytime. I’m guessing that today will carry such a mixture of emotions for you. Try to rest, and take good care of yourself. That is what Max would want for you, as do we.

[Joan2517]

I'm so, so sorry, Elizabeth. Reading the symptoms that you mentioned gave me closure with my Lena's death. She had all of them and now I know why...and I also know that letting her go, even though I wasn't with her, was the right thing.

It's so hard having to make the decision for them. We want so desperately to keep them with us because of how much we love them, but sometimes that love has to go the other way and we need to do what's best for them.

My Lee died on a Friday morning 2/19/16 and I miss her every day...I know your heart is hurting terribly. It will get easier. You will never stop missing her, you will just get used to it. The memories will bring smiles...how could they not when there are so many happy ones.

Love,
Joan

[Elizabeth513]

Joan I am so thankful my post gave you a little closure. I am determined to use Max's story and his life as a legacy and do some good things...I do not know what yet, but I have time to figure that out.

I rad a lot of research and vet articles...I have done so much over the years each time Max would have an ailment: survived mast cell tumors, survived obstruction surgery, managed reflux, allergies, arthritis, anemia, ARVC, proteinuria, reactive to many medications, a newer slow GI bleed, chronic illness (hypothyroidism, Cushings). I educated myself and I was a partner with vets. I respectfully questioned them when I had current research and asked them to try new things. They always listened. I am thankful that I was able to do that for him and I absolutely know that he lived a long life because of it.

In my "comfort" reading this morning I found something you may find interesting.
2. Pulmonary thromboembolism is most commonly seen shortly after treatment. The presenting sign is sudden respiratory distress or difficulty breathing. Once this occurs the prognosis for recovery is grave. It usually requires 7 to 10 days on oxygen therapy if the animal survives.

Interesting, and it makes sense to me now!
Joan, I read your baby's story and what comfort it provided me!!!!! I know I did the right thing. I am so thankful God is giving me little glimpses!

[Harley PoMMom]

Dearest Elizabeth,

I am so terribly sorry for the loss of your beloved Max and my heart goes out to you and your family. We are here for you and always will be.

With Heartfelt Sympathy, Lori

[Elizabeth513]

Thank you, Lori!

[Squirt's Mom]

Dear Elizabeth,

I am so so sorry to hear about our sweet Max. But, like others, there is no doubt in my mind you did the only thing that could be done....and I am sure Max is oh so grateful for that. That was the greatest gift you could give him. Someone here once said that we take their pain so they no longer have to bear it. It is the ultimate expression of the love we share with our babies. And the hardest decision we ever make on their behalf. :(

My deepest sympathies to you and all who loved Max.
Leslie



I’m Still Here
By Unknown Author

Friend, please don’t mourn for me
I’m still here, though you don’t see.
I’m right by your side each night and day
and within your heart I long to stay.

My body is gone but I’m always near.
I’m everything you feel, see or hear.
My spirit is free, but I’ll never depart
as long as you keep me alive in your heart.

I’ll never wander out of your sight-
I’m the brightest star on a summer’s night.
I’ll never be beyond your reach-
I’m the warm moist sand when you’re at the beach.

I’m the colorful leaves when fall comes around
and the pure white snow that blankets the ground.
I’m the beautiful flowers of which you’re so fond,
The clear cool water in a quiet pond.

I’m the first bright blossom you’ll see in the spring,
The first warm raindrop that April will bring.
I’m the first ray of light when the sun starts to shine,
and you’ll see that the face in the moon shine is mine.

When you start thinking there’s no one to love you,
you can talk to through the Lord up above you.
I’ll whisper my answer through the leaves on the trees,
and you’ll feel my presence in the soft summer breeze.

I’m the hot salty tears that flow when you weep
and the beautiful dreams that come while you sleep.
I’m the smile you see on a baby’s face.
Just look for me friend, I’m every place!

[Elizabeth513]

Thank you so much, Leslie!

[Elizabeth513]

Just hopping on to wish all you pet and human moms a Happy Mother's Day.

Whew, I did not know grief could produce an array of emotions. I have laughed, cried, felt anger, guilt...all in the matter of a few days. I know it will get better, but I find myself worrying that I will forget all of the things. We find ourselves looking for him...Max is everywhere. I am allowing myself (and our kids 16 & 19 and their first dealings with any type of loss) to just feel what we feel. We are spending a lot of time together talking, walking, hugging...whatever we need.

I would love to hear how each of you found a little peace when dealing with grief. I know I am not alone!

[labblab]

Oh Elizabeth, I can so easily imagine what a rollercoaster you’re riding on. But I think you are doing the very best thing possible by letting yourself and your kids “just feel what you feel.” There is no blueprint to guide us on this journey, and I think we each discover our own steppingstones along the way. I’ll keep coming back to add more thoughts as they come to me. But as a beginning, I’m gonna suggest you might want to poke around a bit in the threads on our “In Loving Memory (https://www.k9cushings.com/forum/forumdisplay.php?8-In-Loving-Memory)” forum. You’ll find links to other supportive websites, as well as threads added by our members as we’ve grappled with our grief and loss over time.

Just having the chance to come here and write whatever comes to my own mind has brought me such comfort over the years. Also, a special gift for me has been the special candle-lighting site that I talk about in the post below. In previous years when our membership was more active, each day there were often several candles lit and shining for our family. Now there are not so many. But I’m still often there myself for the reasons given in my post, especially since I’ve now lost another furbaby since that time. So perhaps that would be a comfort for you, too. If so, here’s the link to the candle site:

https://www.k9cushings.com/forum/showthread.php?517-Candles-in-honor-of-our-babies-at-The-Bridge

So for now, I’ll leave you with my thoughts below. But as I say, I’ll surely be back again later on.


Oh my, that poem is so sweet and touching! Thanks so much for sharing it, Karen.

I’m so glad you found the candle-lighting site. It is such a comfort to me. I use it kind of as a diary, writing little notes to my angel babies as the mood strikes. I lost my Barkis 14 years ago, and my sweet Peg almost 3 years ago. And I still go to the candles regularly in order to leave them a note. In the glow of the flame, it helps me feel close to them to tell them what I’m thinking and how much I’ll always love them.

I think part of what makes a pet loss so especially hard is that they are the ones upon whom we always rely to help us through our other losses. Their sweet kisses and tail wags calm our souls. Their unwavering loyalty and companionship are buffers against the pain. But when they themselves are gone, it feels as though there’s no comfort to be found anywhere. The grief is overwhelming and everpresent.

When Barkis died, I cried every day until the afternoon we brought baby Peg home. My daily tears stopped not because I missed him any less, but because she needed me to focus and take care of her. And I did, and so another bond was forged. But now they’re both gone, and the tears still come at times. Lighting my candles does help. And having the chance to write and share my stories about them also helps. Karen, if you’d care to write and tell us more about Gracie and your lives together, it would be our privilege to read your stories. All our memories are so precious, and I think it’s a gift to us all to share them. It unites our little family in our love for our true and forever companions.

Sending warm wishes for peace and comfort your way,
Marianne

[Elizabeth513]

I love that! The candle site is great! I also didn’t realize that there was a grief and loss forum, and I will definitely check it out… Thank you so much.

[labblab]

I’m so glad you found the candle site, Elizabeth! I just now saw your sweet candle alongside my own for my fur angels. It warmed my heart to see both our candles there. I do want to add that if you ever want to keep your candle message private, you need not include the “K9C” and that way only you will know how to find it and view it. But for me, it has always felt like a badge of honor to include the K9C and to know that my babies are forever part of this family. I’m at the candle site quite often.

I’ve also been thinking of other things that have brought me comfort. I just lost my little Lab girl, Luna, in December. She didn’t have Cushing’s, so my thread about her is on our “Everything Else” forum. But soon after she left us, I wrote this on her thread:


Writing can be a comfort to me, and at the time of the passing of Barkis, Peg and now Luna, I’ve tried to gather my special memories and write them down. With each, I sit and I cry and miss them so dearly. And to try to soothe myself, I’ve written a note to each one when they passed, listing all the things I never want to forget about them and thanking them. Any little special habit or memory that comes to my mind. And then any time, even years later, I can pull out the list and relive our time together, if only in memory and just for a moment. I’m not finished with Lunie’s list yet. I know I’m not near done with her list yet. I’ll keep adding for a while…

In my letters, I go ahead and tell them about the guilt I have felt. Each time, there has been guilt. But somehow, by writing it down, it makes it a little easier to let loose of it. And mostly my notes are just full of my special memories. Things I’d think I’d never forget. And yet, when I go back and read my notes once again, I’m so surprised that I *have* forgotten many things. And it is a gift to remember and relive them once again. Anyway, just another little thought from me to you!

[Elizabeth513]

Our boy is home. We received his ashes and his paw imprint today. I feel comfort knowing he's home, but pain as well.

I love the idea of a letter. When I am ready I will do that...maybe for now just start a list. Max's breeder sent me some puppy pics of when he was born. I did not realize that he was the first born of the litter. First one on Earth and last to leave. :( Bless him!


Marianne I didn't realize until last week that you lost your Luna in December. I am so very sorry...I am so thankful for this community!

[labblab]

This community has always been my solace, too, Elizabeth. It is such a special family. I’m so glad Max is safely home once again. Luna is with us, too, and for that we are so grateful.