Angelina 13.5 year old/13kg Maltese Cross on Trilostane

[John II]

The adventure continues on a new server - once again, thanks to Natalie.

So after 15 days of dosing Angelina once every 24 hours with 30mg of Trilostane – it was testing day.

Four family members plus much loved dog descended on the specialist centre.

Angelina weighed in at 13.04kg – 15 days earlier she was 13.123kg. Every little bit helps :)

The specialist appeared – we had an update chat. I made sure they checked her electrolytes and I handed him a urine sample I collected that morning (not that they asked for one – but after Roxee’s recent experience with a UTI, I wanted to check things out). I also told the specialist that Angelina usually wound up back on the cool bathroom floor by about 4:30pm – around 11 hours after her dose.

Finally he led Angelina away. She was surprisingly agreeable and walked off with him – until he reached the front door – where she stopped when she realised she wasn’t leaving. Then he had to pick her up.

15 minutes later she was back. And we were given the option of waiting with her for 50 minutes until the post-ACTH injection blood sample was to be taken. I was expecting them to wait 2 hours. But I was happy that we could take Angelina outside and she was therefore getting the less stressful option. The nurse appeared after 50 minutes and took her away for another 15 minutes or so.

Then Angelina was back. I questioned the specialist regarding the sound of her heart and lungs – which he said sounded fine. Her blood pressure was still high at 190. The specialist told us he would call with the results the next day.

After we got home Angelina was panting (didn’t help that it was a very warm day for Autumn -28 degrees Celsius – that’s just over 80 degrees Fahrenheit – anything over 25 usually leads to some panting). Her respiration was clocking in at 84 breaths per minute. But her total water intake for the day was only 650mls. All in all she seemed to handle the ordeal well.

At 3pm the next day the specialist rang with a summary. But we Cushings Net people are not summary people :D – so I asked him if I could get the full results emailed to me – and they were – see below my ramblings. Also at the end of the results are the accompanying “General Interpretive Guidelines” which may be helpful to members and visitors.

As expected the specialist has recommended Angelina’s Trilostane dosage be increased to 2 doses of 30mg per day (one every 12 hours) – an excerpt from the report:
"Angie was examined for a recheck of her hyperadrenocorticism. Her blood pressure remained mildly elevated today . Her examination was otherwise unchanged, which is not surprising at present.”

I put it to him that my research (aka Leslie) seemed to indicate that the full effect of a particular dosage of Trilostane didn’t become apparent until at least 30 days after beginning that dose. He didn’t seem concerned – due to the lower dose we started with.

Now I’m feeling about the same way about the 60mg dose as I did about the 30mg – before the first day. Oh the troubled sleep I had last night!

John – what dose is 13lb Roxee on?

Today, I swung by the specialist centre to do some more brain picking (I think I do better in person than on the phone). Turns out it was the specialist’s day off – but I spoke to another one of the doctors who saw Angelina on her first consult (there were three in all). He was similarly unconcerned about the increase in dosage. When I questioned if I should have Prednisone on hand he assured me that by the time I was aware that Angelina was experiencing side effects and gave her the antidote (as I think of it) the Trilostane would already be wearing off.

Since Angelina was due to get her monthly heartworm pill today – I held off starting her second daily dose of Trilostane. I know everyone says you can give them both – and I’ll have to do just that, this time next month – but I’d just as soon keep things as simple as possible on her first 60mg day.

Now, can someone tell me about milk thistle dosage for dogs? And omega 3 (fish oil) capsules? :)

John II

14-04-2009 The Urine Test

URINE COLLECTION METHOD Voided
URINE VOLUME (ml) 50.0
URINE COLOUR Yellow
URINE TRANSPARENCY Opaque
URINE SG 1.019
URINE GLUCOSE Negative
URINE BILIRUBIN Negative
URINE KETONES Negative
URINE HAEMOGLOBIN Negative
URINE pH 6.5
URINE PROTEIN ++ (1 g/L)
URINE UROBILINOGEN Normal (less than 20umol/L)
URINE RBC/HPF Less than 5
URINE WBC/HPF Less than 5
URINE CASTS, NUMBER Negative
URINE BACTERIA Negative
URINE FAT Occasional
URINE EPITHELIAL CELLS, TYPE Squamous
URINE EPITHELIAL CELLS, NUMBER Occasional
URINE EPITHELIAL CELLS, NUMBER Negative
URINE SPERM Negative
URINE CRYSTALS, TYPE Amorphous crystals
URINE CRYSTALS, NUMBER Occasional
URINE CRYSTALS, NUMBER Negative
URINE DEBRIS Negative

Minimally concentrated urine may reflect ongoing hyperA. Mild
proteinuria is unexplained: consider a UPC to further assess.
No evidence of UTI.


14-04-2009 Biochemistry with Electrolytes- Canine

Na 145 mmol/l (139-153) (Sodium)
K 5.9 mmol/l (3.9-5.9) (Potassium)
Cl 107 mmol/l (93-122) (Chloride)
Calcium 2.82 mmol/l (1.9-2.9)
Phosphorus 1.53 mmol/l (0.8-2.1)

Bicarb 20.9 mmol/l (12-26)
Anion Gap 23 mmol/l (14-32)
Urea 13.2 mmol/l (2.5-10.0)
Creatinine 81 umol/l (50-150)
Glucose 5.2 mmol/l (3.3-6.8)
Bilirubin 7.0 umol/l (0-6)
AST 128 U/l (18-80)
ALT 590 U/l (16-90)
AlkPhos 3205 U/l (1-150)
T Protein 77 g/l (52-80)
Albumin 39 g/L (23-40)
Globulin 38 g/l (25-45)
CreatKinase 235 U/l (73-510)
Amylase 727 U/l (333-1500)
Lipase 1495 U/l (77-750)
Cholesterol 10.50 mmol/l (3.5-9.0)


14-04-2009 ACTH Stimulation Test

Cortisol, resting 157 nmol/L (15-170)
Cortsiol, 1 hour 382 nmol/L



General Interpretive Guidelines
Normal dog:
* post-ACTH cortisol 170-470 nmol/L

Hyperadrenocorticism (hyperA):
* post-ACTH cortisol > 600 nmol/L consistent with hyperA
* post-ACTH cortisol 470-600 nmol/L equivocal

* failure of cortisol levels to increase significantly following ACTH
administration in a dog with typical clinical and laboratory features of
hyperA does not exclude the diagnosis. For further assessment a low dose
dexamethasone suppression test may be useful
* adrenal function tests, such as the ACTH stimulation test, may yield
a false positive test result in a sick or stressed dog with non-adrenal
disease
* this test does not differentiate between pituitary and adrenal-
dependent hyperA (an endogenous ACTH assay, abdominal imaging or a high
dose dexamethasone test may be useful for further assessment) For the
endogenous ACTH test, please contact the laboratory for the special
sample collection protocol.

Post-medical therapy for hyperA, results should be interpreted in light
of adequacy of clinical control. Target values depend on the drug used:

Mitotane or ketoconazole:
* baseline cortisol < 100 nmol/L post-ACTH cortisol 28-100 nmol/L

Trilostane:
* baseline cortisol 28-55 nmol/L post-ACTH cortisol 28-55 nmol/L

Iatrogenic hyperA:
* baseline cortisol < 55 nmol/L post-ACTH cortisol < 55 nmol/L

Hypoadrenocorticism:
* baseline cortisol < 55 nmol/L post-ACTH cortisol < 55 nmol/L
* this test will not distinguish between primary (adrenal) and
secondary (pituitary) hypoadrenocorticism

[Lulusmom]

Hi John,

For those of us that are used to seeing acth stim results in ug/dl, I've done the conversion:

Pre 5.7
Post 13.8

Was the stim done within 4 to 6 hours of dosing? Did you have an acth stim done before starting treatment? I ask because a post number of 13.8 as compared to a pre treatment post of something like 25 or 30 is a pretty darn significant drop in just 15 days.

Given that Angelina's symptoms seem in increase in the evening, this is a pretty good sign that once daily dosing may not be appropriate. It drives me nuts that you have a drug that is known to have a short half life (12 hrs) and you have studies that have proven that twice daily dosing is more effective yet Dechra still recommends dosing once daily to start. :mad:

I may agree that Angelina would probably do better on twice daily dosing but I absolutely do not agree with the large increase your vet has prescribed. I personally am more comfortable with UC Davis protocol. They have established their own treatment protocol based on their experience with Vetoryl/Trilostane. They found a great disparity in the dosing that Dechra recommends based on weight by following that protocol, they had a great many dogs that had adverse reactions. As a result their dosing protocol is much more conservative and in my opinion, much safer. They prescribe 1mg/kg to start which means in Angelina's case, they probably would have started her anywhere from 10mg to 15mg per day. That's quite a huge difference from Dechra. :eek: They also recommend that when you go from once daily to twice daily dosing, you drop the mg a bit. For instance, if you are giving a dog 30mg once daily, you would drop the mg to say something like 20mg twice daily. This makes perfect sense to me as there is an overlap between the two doses.

One comment on the lab's comment "Mild proteinuria is unexplained: consider a UPC to further assess." The majority of dogs with cushing's have an increase in protein so mild proteinuria is not unusual. I think in Angelina's case, it is explained. My cushdog Lulu also has mild proteinuria.

Glynda

[John II]

Hi Glynda,

Angelina had her Trilostane dose (on testing day) at 06:05 and had her "Cortisol, resting" sample taken at 10am and then her "post-ACTH cortisol" sample taken at 11am.

We didn't have an acth stim done before starting treatment - but we did have an LDDS and a HDDS (what's the number to divide my figures to convert them to your again?).

LOW DOSE DEXAMETHASONE SUPPRESSION TEST
Resting Serum Cortisol : 132 nmol/L
Post-Dexamethasone Serum Cortisol (3-4 hrs) : 337 nmol/L
Post-Dexamethasone Serum Cortisol ( 8 hrs) : 440 nmol/L

HIGH DOSE DEXAMETHASONE SUPPRESSION TEST
Resting Serum Cortisol : 344 nmol/L
Post-Dexamethasone Serum Cortisol (3-4 hrs) : 290 nmol/L
Post-Dexamethasone Serum Cortisol ( 8 hrs) : 148 nmol/L

Where oh where in the world can I find a specialist who will give me good advice and information like the people of this forum do? :mad: The specialist mentioned the Mild proteinuria and suggested the extra test - to which I agreed. Results pending.

Thanks,
John II :(

[labblab]

Given that Angelina's symptoms seem in increase in the evening, this is a pretty good sign that once daily dosing may not be appropriate. It drives me nuts that you have a drug that is known to have a short half life (12 hrs) and you have studies that have proven that twice daily dosing is more effective yet Dechra still recommends dosing once daily to start. :mad:
Glynda
I realize that my thoughts about once vs. twice daily dosing differ somewhat from other members. But I do not see a problem with starting a dog off with a once daily dose, and then later shifting to twice daily dosing if the dog's response warrants it. And even though UC Davis researchers have been among those to publish studies endorsing twice daily dosing, their clinical treatment protocol to which we refer joins Dechra in recommending that dogs first be tried on a once daily regimen. :confused:

I really wish we could get a copy of UC Davis' most current protocol -- the one that we quote here dates to 2007. So perhaps their clinicians are doing things differently now subsequent to additional research studies. But if not, their recommendation doesn't seem unreasonable to me. And that is to first try once daily dosing, but if the symptom pattern and UC:CR test results indicate that once daily dosing is insufficent -- then make a shift.

http://www.k9diabetes.com/forum/showthread.php?t=745

I can imagine that with diabetic dogs, for instance, twice daily dosing might be preferable from the get-go. In that instance, there would be greater benefit from maintaining the most consistent endocrine balance possible. But for dogs without any non-adrenal illness, if the simplest arrangement works, why not "go with it?" At the very least, it may hold down medication costs a bit. Because the majority of dogs that are dosed twice daily seem to end up with a total daily dose that is at least a bit higher.

Having said all that, I totally agree with Glynda that it appears that Angelina is likely a dog who will do better with two daily doses, and also with her preference that Angelina's increase be limited to something like 20 mg. both morning and evening. And based on her ACTH results, I don't think that even Dechra would disagree.

Marianne

[Roxee'sDad]

Hi John and Angelina,
So happy you found your way here. Now if we can find JaneRoper and Lola. I just knew that was you in the members list (JohnII)

John – what dose is 13lb Roxee on?

Roxee started off on 30 mg once per day, after 30 days she was increased to 40 mg once per day.

All the best to you and Angelina
John (roxee's Dad)

[John II]

Well that's annoying. I just wrote a response and when I submitted it for preview - I was requested to log in - again! Which I did - you can't argue with software. After logging in I got a blank screen where my preview should have been. Nothing new there - happens all the time. I backed up a couple of screens thinking I'd find the raw form of the response and try preview or submit again - but it was gone! Aargh.

My post must have been so foolish that the server decided it was better to eat it than post it. :rolleyes:

[Lulusmom]

John, you timed out before you submitted your post. When you log in, remember to check the "remember me" box and that won't happen.

Glynda

[John II]

Oh! Is that what that's for? Good to know. Thanks Glynda! :)

[John II]

Hello Forum,

Would anyone have the link for the UC Davis' protocol from 2007? I think all I've ever actually read are articles or threads referring to it. I'd like to have a look at the source material, if possible.

John II

[Lulusmom]

Hi John,

You can find that information in reference material Marianne kindly posted for us.

http://www.k9diabetes.com/forum/showthread.php?t=745

Here is a direct link to the article that has the info re UC Davis protocol:

http://veterinarynews.dvm360.com/dvm/article/articleDetail.jsp?id=460965&sk=&date=&pageID=1

Glynda

[labblab]

I sure wish we would acquire a member whose dog is currently being treated with trilostane at Davis! I am REALLY curious as to what their most up-to-date recommendations are in terms of dosing.

And I must confess that some of my thoughts about dosing stem solely from my experience with my own Cushpup. It was five years ago now that we started treatment, and the studies about the advantages of twice daily dosing were just starting to appear. I felt so convinced that twice a day would be a better approach that I prevailed on my specialist to let us go that route, even though it was not "officially" recommended. We ended up having to make a lot of dosing changes along the way, and it always felt doubly complicated to me because of trying to arrive at the best combination of morning and evening doses. So I ended up wishing that we had just started out with once a day, and only increased from that if it seemed as though we needed to.

I just wanted to put my "cards out on the table," so to speak, so you'd know where my bias is coming from. ;)

Marianne

[John II]

Thanks Glynda!

Or I may start calling you "The Oracle" from now on :D

But the thread and the DVM article are the things I've read - I'm wondering where this point you mentioned below came from, that is:

"They also recommend that when you go from once daily to twice daily dosing, you drop the mg a bit."

And Marianne I wish that pesky server issue gets resolved so I can go and read up on your experiences in more detail. What timing!

Thanks for your information, as always,

John II

[Roxee'sDad]

Hi John,
How is Angelina doing? Is she on the 60 mg dose now? Is that once a day or 2 X 30 mg per day?

All the Best.
John (Roxee's Dad)

[Roxee'sDad]

Hi John,
Hope all is well with you and Angelina.
John (Roxee's Dad)

[John II]

Hello All (especially John who watches out for Angelina and me :)),

Sorry to have dropped out for a while - but I was afraid that if you knew what I was up to I might be banished from the group. :o

So - here goes, I started Angelina on 2 X 30 mg per day of Trilostane last Monday. She seemed to tolerate it well and the symptoms that tend to reappear approx 8 hours after her morning dose disappeared after her evening dose.

Monday, Tuesday, Wednesday, she seemed fine.

On Thursday Angelina was moving like she did before we started the Trilostane at 30mg once per day. Walking like an old lady dog. She only went for a very very short walk that morning (only as far as the front yard).

So I held off the Thursday evening dose. Gave her the Friday morning dose, as usual, and called the specialist, Friday afternoon for advice.

Unfortunately, he's on holiday until May 8 :eek:. So I asked for the resident also on the case - he's on holiday until next Tuesday :eek:. I asked the receptionist if there was someone else I could talk to - and she promised to have another specialist call me back.

I should mention that apart from a little geriatric leg action Angelina seemed fine. And I'm wondering if we've just unmasked some arthritis.

6pm Friday evening Angelina, though obviously quite eager for dinner, had turned up her nose at the usual food. I didn't know if that was due to:
1) the Trilostane affecting a dog's taste in food (as I've read in other threads)
2) the inappetance that can also be a warning of low cortisol or
3) the fact that I squeezed the contents of a fish oil capsule into it :)

4 hours after I called the specialist, I got a call back. :mad: Since it was now after 7pm - I'm thinking it was by a doctor whose shift had just started and had discovered my abandoned note.

Well these vets seem to all be cut from the same cloth as far as dosing is concerned. They're all telling me (despite my repeated concerns) that because Angelina's ACTH Stim numbers were quite high, her dose needed to be increased AND they have other maltese sized dogs on double that dose with no side effects. (I could almost hear him say "So there!") They would not recommend reducing her dose without an ACTH stim test. I should continue with the twice daily dose, keep a close eye on her, and bring her in if I have any concerns.

At 10pm Friday night - I offered Angelina her dinner again - which she finally ate - begrudgingly.

So today (Saturday) Angelina got her 6am morning dose with breakfast and her 6pm evening dose with dinner (at 6:41pm - I got home late) and she seems fine. She was VERY interested in the BBQ chicken I brought home. So no appetite problems - she would have eaten the whole thing if she could get to it.

In other news Angelina seems to be developing patches of slightly (so far) darker skin on either side of her abdomen.

I think that's all I have to report.

John II

[Lulusmom]

Hi John,

Regarding information on twice daily dosing, check out page two of the monitoring flowchart for dogs whose clinical signs are not controlled for a full day. It say to slowly increase the dose and divide twice a day. In other words, if a dog is getting 60mg a day, you would increase to something like 80mg divided which would be 40mg twice daily. This is also recommended by UC Davis. This information is not really clear in the article included in the Vetoryl/Trilostane information posted by Marianne, I did verify the UC Davis protocol on twice daily dosing via an audio of one of Dr. Edward Feldman's lectures. He used that exact example I mentioned above.

If a post stim number is within the desired range of 1 - 5 but the dog is still showing overt symptoms, this is a pretty good indication that twice daily dosing should be prescribed. Angelina's post stim was definitely well beyond the desired range. The correct way to determine if a dog needs twice daily dosing is to do a urine cortisol creatinine ratio which requires that the pet owner bring in a urine sample collected the morning before the acth and before meds and meal. If the ratio is abnormal, that is a good indication that the once daily dose is not lasting through the night. It looks like your vet made the call to switch to twice daily dosing based solely on unresolved symptoms that could be explained by the high post stim number as opposed to proof that the current once daily dose was not adequately controlling the cortisol overnight. However, I do recall that you mentioned that Angelina's symptoms seem to get worse at night which your felt was a good indication that twice daily dosing may be necessary.

http://www.dechra-us.com/File/vetoryl_Treatment_and_Monitoring_Flowchart.pdf

Every dog responds differently and it could be that Angelina will do just fine on a 100% increase in dose; however, I personally don't think that a post stim number 13 ug/dl after only two weeks of treatment is high enough to make me feel comfortable with that kind of an increase. Just be ever vigilant in watching for signs that cortisol may be too low.

I'm not sure about that Trilostane affects a dog's taste in food. It sure had no effect on either one of my chow hound's taste buds. Their appetite did decrease by they never turned their nose up to food. This is definitely a sign that cortisol can be too low and you should never give Trilostane to a dog that is not eating normally. If either one of mine looked the slightest bit off and wasn't doing their normal head dive into the bowl, they were off Trilo for a few days or until they were back to normal. Try eliminating the fish oil on a meal and see if that makes a difference. If not then you can rule that out as a factor which would make Trilostane the bigger suspect.

I am about as far from a medical professional as you can get but I still respectfully disagree with your vets and don't think that Angelina's numbers were that high after only 15 days of dosing. All dogs respond differently to Trilostane so the fact that another Maltese has done well on the same dosing regimen is irrelevant. A perfect example is my two cushdogs. My 4.5 lb Pom was on 30mg once daily for two years and my then 10 lb Pom was on 15mg twice daily and both were effectively controlled.

You know Angelina best so if you think something is not right, and a cushdog that doesn't eat normally is not right, then don't continue to dose her.

Hope this helps.

Glynda aka The Oracle :p:D:p

[John II]

Glynda to the rescue! :)

So, going by the flowchart you basically stick to the initial dose for a full month, unless there are signs of:
1) Post-ACTH serum cortisol <1.45 μg/dL (<40 nmol/L) and clinically well
2) Corticosteroid withdrawal syndrome
3) Hypoadrenocorticism
(If its points 2 or 3 you discontinue the dose and have an ACTH stim test done to determine the problem).

However if:

Post-ACTH serum cortisol >1.45 μg/dL (>40 nmol/L) and clinically well*

But wait! I see an asterisk on the flowchart - which leads to:

* If the post-ACTH cortisol is >9.1 μg/dL (>250 nmol/L) and the clinical
signs of HAC are marked then you should consider a dose increase
at this stage. Increase dose by smallest increment possible.

So an increase after day 14 is advised? Since this is Dechra's chart the "smallest increment possible" they would be talking about would be 30mg? That's the smallest they are making now (from memory). If that's the case, unless I'm completely confused, then a 30mg to 60mg jump is what they are advising?

Note all the question marks? :confused:

So the problem at this point is not the increase in dose, but the splitting the dose in two? Which should only happen after day 30? Which leads to:

[QUOTE=Lulusmom] In other words, if a dog is getting 60mg a day, you would increase to something like 80mg divided which would be 40mg twice daily. [QUOTE=Lulusmom]

So, eventually the dose is likely to be bigger?

And as far as determining twice daily dosing:

[QUOTE=Lulusmom] The correct way to determine if a dog needs twice daily dosing is to do a urine cortisol creatinine ratio which requires that the pet owner bring in a urine sample collected the morning before the acth and before meds and meal. If the ratio is abnormal, that is a good indication that the once daily dose is not lasting through the night.[QUOTE=Lulusmom]

[QUOTE=Lulusmom] Just be ever vigilant in watching for signs that cortisol may be too low. [QUOTE=Lulusmom]

This morning after breakfast - and her morning dose - I took Angelina out for a short walk. The way she was walking was painful to watch. But I couldn't be sure if it was signs of "Corticosteroid withdrawal syndrome (“relative” cortisol deficiency characterized by weakness, stiff gait)" or Hypoadrenocorticism (e.g.weakness) - I hate the way the symptoms overlap! So. should I discontinue for a few days or rush Angelina off for another ACTH stim test? Or just cut back to the 30mg per day?

Last night's dinner was fish oil free and although Angelina paused to consider it - she did finish every bit of it.

Thanks Glynda for such a thorough response!

John II

[Lulusmom]

Hi John,

Here in the US, a lot of vets (including UC Davis) use compounded versions of Trilostane when needing to adjustment a dose that isn't available from Dechra. Lulu was too small for the 30mg available from Dechra so we had no choice but to have her 20mg compounded. We ultimately increased to 30mg which is where she stayed until we switched to Lysodren almost two years later.

I'm glad that you took the time to check out the Dechra flowchart. The chart is meant to be a general guide but as my vet explained to me, you have to look at the big picture. She had never treated with Trilostane but after researching, she decided that it was best to have an acth stim test before starting treatment so that she would have a baseline to compare to the 14 day post stim test. This told her how quickly and how much the cortisol had dropped in a two week period. I hadn't found the cushings forum yet so I hadn't witnessed all the disparities from dog to dog when monitoring treatment so I was very grateful that she was so thorough. Jojo's cortisol continued to drop after the 2 week stim so had she increased his dose right away, his cortisol would undoubtedly have dropped too low. She did a great job considering Jojo was her first Trilostane patient.

Trilostane has a short half life and its enzyme blocking abilities start to diminish after 8 to 12 hours. This is why some dogs will eventually require twice daily dosing if symptoms don't resolve on a single dose. Since every dog is different, you don't know at which hour the Trilostane begins to wane so when you go to twice daily dosing, there are hour(s) in the day that there can be an overlap in dosing. This is why it is recommend that you up the dose a bit and split in two. Like I mentioned before, if a dog was at 30mg once daily, you'd up that to maybe 40mg and split it into 20mg twice daily. In essence you could have an overlap of a total of 40mg. If you simply double the dose like your vet did, a possible overlap would be 60mg. That's a big difference in my opinion.

Jojo was a mess when he first came to us and not only was he extremely weak in the hindquarters, he walked with an incredibly stiff gait. This is a rare symptom of cushing's called pseudomyotonia and sometimes it resolves once the cushing's is controlled and sometimes it doesn't. Jojo still walks like he is on pegged legs but his IM doesn't seem to think it has progressed or will be a problem for him in the future.

I hope all this makes sense but if not, Marianne is excellent in explaining much better than I can and hopefully she can clear the fog I've created in your head. I trip over my own words sometimes, become too verbose, lose my place, need access to spellcheck and eventually put people to sleep or maybe just into a catatonic state. :D

Glynda

[Roxee'sDad]

Hi John,
Glad to see you back. Can't help much with the once or twice a day dosing. I'm still trying to figure out what the best route is for Roxee. Thinking about a UTK panel but will make that decision within the next few weeks.

Regarding her apetite....When the trilo kicked in, Roxee got very, very picky about what she will eat. It has to smell good otherwise she would and still does walk away. Worried me at first but this was a good sign that the trilo was having a positve effect. I have her to 4 meals a day now trying to keep the weight on her. The more and more I read, this (weight loss) seems to be an unspoken side effect of trilo. Oh BTW - her potbelly is completely gone now.


Jojo was a mess when he first came to us and not only was he extremely weak in the hindquarters, he walked with an incredibly stiff gait. This is a rare symptom of cushing's called pseudomyotonia and sometimes it resolves once the cushing's is controlled and sometimes it doesn't. Jojo still walks like he is on pegged legs but his IM doesn't seem to think it has progressed or will be a problem for him in the future.

Glynda just gave me some homework, (pseudomyotonia) this is exactly Roxee's symptoms. Since starting treatment, it has improved somewhat. She doesn't hardly fall over anymore so hoping it continues to improve.

Well, keep up the good work with Angelina and keep us posted.

All the best to you and yours including a belly rub for Angelina (if she'll let you)
John (Roxee's Dad)

[John II]

Hello All,

Even before I read the 2 new posts, I just want to submit my apologies all round for my earlier post because I should not be trying to think this through on 3 hours sleep!

John II :o

[John II]

And now to continue...

I think that if Glynda is "The Oracle" then John must be "The Guardian" :D

This is tricky stuff and I wish I could find one of these "think outside the formula" vets that some of you have been lucky enough to find. Anyone know of one in Sydney?

Anyway - just a update about today. It's cool and windy here - which helps Angelina. Back on a single 30mg dose of trilostane. As the afternoon wore on, the trilostane wore off and the cortisol kicked in, she was walking straighter - still not great, but improved.

Angelina insisted on dinner at 4:30pm. Same stuff as yesterday - and the day before - but she didn't hesitate. And shaved about 15 seconds off yesterday's time.

After which she went for an afternoon stroll down the street and back. Less of an old lady dog than this morning. :)

From Roxee'sDad:
"When the trilo kicked in, Roxee got very, very picky about what she will eat. It has to smell good otherwise she would and still does walk away."

I knew I read that somewhere!

And I'm wondering if there's an Australian version of a UTK panel?

Actually Glynda, here in Australia we're in the same boat - our Trilostane is compounded too. Although I did find (on my wanderings this morning) a submission to the government to import Vetoryl into Australia dated just last February:

www.apvma.gov.au/gazette/0902downloads/page_16.pdf

"The Australian Pesticides and Veterinary Medicines Authority (APVMA) has before it applications from Dermcare-Vet Pty Ltd for approval of the active constituent trilostane and registration of products containing the active constituent trilostane. The products are VETORYL 120 MG CAPSULES, VETORYL 60 MG CAPSULES and VETORYL 30 MG CAPSULES. The products are for use on dogs."

We may be getting access to the name brand soon? Now we just need to convince Dechra to make it in 10mg and 20mg capsules! It also goes on to answer a few of those pesky exposure and environmental questions I had.

And apologies again to Glynda - my earlier sleep deprived brain misunderstood your reference to 60mg and 80mg doses - which I should have realised translated to 30mg SID becomes 20mg BID.:o

Believe me Glynda, as far as I'm concerned - nobody could be too verbose for my liking. Tell me more, tell me more! :D

John II

[BestBuddy]

Hi John,
I was lucky that I was close to the University of Melbourne and the specialists there, surely Sydney has something similar.
Dermcare-Vet was importing Vetoryl early in 2006 when Buddy was first diagnosed but they ran into problems and stopped being reliable so compounding was the only option. It was still possible to order from the UK for a short time but that loophole was soon closed unless you got through all the red tape and imported it yourself.
Jenny

[John II]

Hi Jenny,

Do you mean you got a UTK-type adrenal panel done in Melbourne? Or that the Melbourne University vets are the kind who actually do the right thing without having to be prompted?

John II

[Lulusmom]

Hi John,

The University of Tennessee Knoxville (UTK) is the only facility in the world that does the adrenal panel. They also do the panels for patients all over the world. Shipping must be done properly so the cost to you would be higher but your vet can contact UTK and get instructions on what to do. Just remember that Angelina would have to be off of Trilostane for about a month before doing the panel.

Quite honestly, if I lived in Australia and my dog was not doing well on Trilostane for any reason or I suspected that my dog had elevated sex hormones, I think I would forego the expense of a UTK panel and consider switching treatment to Lysodren. Lysodren is very effective in controlling cortisol as well as the other adrenal steroids/hormones. Estradiol is the only sex hormone that can also be found in other bodily tissues outside of the adrenal gland but Lysodren is only effective in controlling this hormone if it is confined to the adrenal glands. I personally wouldn't be too concerned about that as I don't recall any members treating with Lysodren reporting that despite routine acth stim tests showing post cortisol within range, their dogs symptoms remained unresolved for over six months.

If you are still interested in the UTK panel, here is a link to their website and be sure to share this with your vet:

http://www.vet.utk.edu/diagnostic/endocrinology/index.php

If you are using a compounding pharmacy then I am unsure as to why they can't package 20mg capsules. Some pharmacies will also repackage for you so that might be an option if you and your vet decide to lower the twice daily dosing to 20mg. By the way, Dechra manufactures Vetoryl in 10mg, 30mg, 60mg, and 120mg capsules, however, the US has only approved the 30mg and 60mg capsules. I believe they are working on getting the FDA to approve the 10mg and 120mg.

Glynda

[LuvMyMunchie]

Hi John,

Although I've been following Angelina's story, this is the first time I've posted to your thread. Basically, I've just stopped by to say, "Hi...how are ya".

I wish I could find one of these "think outside the formula" vets that some of you have been lucky enough to find.

Good luck on your vet quest! I've been searching for 2 years....and I'm still searching for one who doesn't think one dog is an exact clone of all others!!! :(

Glad to hear Angelina was feeling a bit more chipper for her stroll. That's a good sign.

Take care,
Louise

[BestBuddy]

Hi John,
I have nothing but nice things to say about Buddy's treatment and care at Melb Uni and especially the specialist in charge of Buddy. I didn't know anything about the UTK type testing when Buddy was dx so I never asked but my special specialist was silly enough to give me his email address so I am going to ask. I will be back if I can get an answer.
Jenny

[John II]

Hello All,

Glynda,

Isn't it odd that only one place in the world does the UTK type Adrenal panel? If we weren't all losing our life savings paying medical bills :p we might otherwise be able to pool our resources and establish a grant to get more specialist hospitals the funds to incorporate this test into their practices. I'll keep that in mind for when I win the lottery. :)

I'll keep Lysodren on hold as an option - I'm beginning to think I may need a new vet to point me at a new specialist. Time will tell - but after sinking $2000 into this specialist so far (not to mention another $600 to the vet before that) I'm worried about starting over. Especially if you don't know what you're getting. New mantra: lottery lottery lottery lottery lottery lottery. I hate to be thinking about money - but seriously everytime I see a bill it's like the receptionist punched me in the stomach!

I haven't been directly to a compounding pharmacy - the specialist simply handed me a jar of 100 x 30mg capsules of Trilostane. The original label - including handling instructions was obscured by the new printed label for Angelina to take one per day. The only warning on the new label was "Keep Out Of Reach Of Children". :(

Louise,
Thanks for keeping tabs on Angelina's Tale (Angelina's tail keep curling up - so she doesn't seem too unhappy about things :)) and stopping by to say "Hi". As for me - I'm cramming information into my skull, confused, sleep deprived, frustrated, worried, sad, 8 kilos lighter since Christmas (forget the Atkins Diet! The Cush Dog Owners Diet is way more effective! :D)

Jenny,
Thanks for your help as always!

Thankfully Yours,
John and Angelina.

[BestBuddy]

Well I got a reply about something similar to the UTK panel from the best specialist in the world (in my opinion). It is not available in Australia but he did try to have run what he called the "17 OH progesterone" and was messed around by the pathology company and could not get the results. I guess it will be something hopefully that can and will be done here in Australia but it seems like it will be a long way off.
Jenny

[John II]

Well Jenny thanks anyway for checking.

Does it seem to anyone else as though the universe moves in mysterious ways to thwart Cush Pup Parents? Or am I just getting paranoid.
It should be much simpler than this!

John II

[John II]

Hello All,

I think my hair turned grey (greyer :() today.

Angelina was lying next to the fridge. Eventually, I wanted access to the fridge. Angelina tried to get up - but couldn't. She started screaming. Not a sound I EVER want to hear again. I helped her to her feet and the screaming continued. She could not use her front, right leg!!! :(:(:(:(:(

Had she somehow broken her leg? It was that bad! Had her bones become that weak? Had the Cushings advanced to the point where "weak and wobbly" had become much much worse? Had she lost the use of that leg? Was this the beginning of the end?

After a few minutes she settled down. Limped around a little. Went to the loungeroom and assumed the sphinx pose. I lured her forward with some mince meat. The gait was wobbly, but the front right foot was working again.

She had had such a good, quite energetic day last Thursday - I thought I was on the right track - finally. But since then, mostly geriatric again.

Angelina has always loved to rest against something. If you're sitting at a table, you will find ber resting against your foot, or your chair leg, or such. But if you make the slightest move, her self-preservation kicks in, she will over-react, yelp, and make a good attempt at biting your foot. Even if it was only the breeze created by the shifting of your foot, slightly ruffling the hair of her back. Heaven help you if you actually step on her hair! We don't know what would happen if you stepped on her.

It's not surprising - in retrospect - that she would scream the house down upon discovering that her foot had gone to sleep. :o I hope that's all it was.

My specialist is still missing in action - today I learned he's overseas. "Call me if you have any questions" he says! :mad: I'm going to take her in tomorrow, get her electolytes and biochemistry checked out. Probably get an ACTH Stim test done as well if I can. Her liver enzymes have me worried.

The weekend reception can't take appointments - so I'll have to call bright and early tomorrow. Just have to decide if I want to enlist another one of their specialists as well as the resident I've been dealing with.

Since reading Roxee's Dad's thread about good days/bad days on Trilostane, I'm wondering if I jumped the gun by dropping Angelina back to 30mg per day. At 60mg she was good for 3 days - then she was an old dog - now back at 30mg she's become an old dog anyway! Argh!

If I ever meet Mother Nature she will have some explaining to do!

Angelina has developed darkening patches of skin on both sides of her distended lower abdomen (Does anyone know what that might be?) looking like large light bruises.

I was looking at her, once she had calmed down and it seemed as though some of her hair is becoming darker - tanner? Might have been a trick of the light. It only seemed to be happening on the right side of her back.

What a day!

John the Grey

[Roxee'sDad]

Hi John,
Sorry to hear Angelina is in some pain. Hope her leg gets better soon and doesn't turn out to be anything serious. If the acth comes back within the desired range, it could be that the lower cortisol levels have made Angelina start feeling her aches and pains that come with age.:(

Regarding the dosing - I believe the acth stim results should guide you. If you think she is feeling the aches and pain of being a senior, you might want to consider a trial/test run of some pain meds or supplements. I had Roxee on metacam for over 3 weeks but saw no changes or improvements, so I discontinued use. I wanted to see if it was muscle weakness or pain that caused her walking problems. Still can't rule out neurological problems but really can't afford 1500 dollars for an MRI and what would that tell me to do for my almost 14 year old pup? My number one priority is her comfort and quality of life. We are about a week or 2 from our next acth stim test. I didn't want to wait the full 90 days so we are going in a little early. (I am still buying lottery tickets):D Hoping to hire my own full time vet:rolleyes:

The skin pigmentation thing.... I have read this as a side effect of using the meds. Roxee's skin was really pink at one time and has now tuned darker in spots around her sides and belly. The hair regrowth seems to be mostly her white hair but very little regrowth of the black hair:confused: I have also read that some others experience a change in color, and texture of the hair. Around here it is commonly and affectionately called "Cush Fuzz"

I hope that Angelina's test results help your decision and thought process. From the many threads I have read on cc.net, some pups do better on the higher end and some do better on the lower end of the desired results range. So there comes in the tweaking, once a day, BID, how many mg's in the am and how many mg's in the pm??????:confused::confused::confused:

If you have been following "Jesse's thread, this seems to be the million doallar question, I believe we are all waiting to see what updated info that Katherine "Border terrier and Lysodren-UC Davis" can get regarding an updated UC Davis protocol on Trilo dosing.

Keeping good thoughts and Prayers for you and Angelina.
John (Roxee's Dad)

[frijole]

John,

A couple thoughts. Remember that the excess of cortisol in the system BEFORE treating helps to mask pain. (arthritis, old age joint issues etc.) so when you treat the cushings and lower the cortisol level the pain sometimes is revealed. Many of us use glucosamine, fish oil etc. to supplement and aide with pain management. Others have found help with arthritis medication.

Re the skin discoloring - I have been told this is just common old age spots. I didn't notice it til the cushings either however my other dog now has the same thing so I tend to believe that's what it is. They have spots of all shades of dark and sizes. They are schnauzers - white and silver.

Hang in there. My cush dog is nearly blind and deaf now and she likes to stand by my feet at the frig too (piggie she is) and I have hit her with the door and nearly stepped on her a hundred times... so you aren't alone.

Hugs
Kim

[forscooter]

Hi John...

I feel your pain.....and Angelina's pain....and the gray hair....it's a side effect of being a Cush parent ;). I have blonde hair, or used to, so I just call them my "highlights". :cool:

The arthritis thing can be tricky and it sounds like that may be the issue. I used the glucosamine and fish oil supplements and they seemed to help a little. But there were still days....others have used different medications and supplements and it's just a matter of what will work for you. It can take 4-6 weeks to see a difference with the glucosamine route but I think worth it.

On really bad days, I give Bailey a dose of Metacam. Only with a full belly of food though to coat his stomach. It seems to help him a lot. I used to have to do the same with Scooter.

I am not an advocate of doing this....BUT....with Bailey, I do dose him where I think it keeps the Cushing's in the best control we can while helping not bring out the worst of the arthritis. It's been quite rainy here and he has been hurting the past few days. I am not backing off the Lysodren though bc of the Cushing's but rather using the Metacam sparingly.

If you get the ACTH done, and Angelina is at the low end, you may want to discuss the possibility with your vet's input about letting her run a little higher.

Sending my most soothing thoughts to you both!!!
Hugs, Beth, Bailey and always Scoobie

[Lucygoo]

Hi John....Sorry to hear Angelina's got some pain. I just wanted to pass along what really helped my dog when she went through a bout of bad arthritis about a year ago, when we were trying to get her trilostane dose worked out. My vet prescribed Cosequin, which is a prescription only heavy dose of glucosamine. They come in chewables as well as regular pills. It took about a month to 6 weeks to work, but it helped her 100 percent. She was like a new dog. If you haven't already tried this, I would check it out. It's a little expensive, but it really worked for my Lucy.

Good luck...
Gina & Lucy

[John II]

Hi Everyone,

Thanks to all for your helpful replies. I'm calmer today, and although Angelina insists on sleeping on her right side - the lameness hasn't recurred (phew) - I've opted for a little more observation, rather than testing just yet. Fingers crossed and knocking on wood. :)

Gina & Beth & Kim & Brother John - thanks for the medication advice. My aim is the best quality of life for Angelina - this just keeps getting trickier and trickier! Lower the cortisol - but not too low! Sheesh! :)

Kim & Brother John - thanks for the reassurance regarding the worrying spots!

Brother John - I like your lottery plans - full time Cushings vet (I'll add in residence to the scheme)! Now there's a plan! :D

Can't wait to see new UC Davis info - hope Katherine can her her hands on it.

Thanks again,

John the Grey

[John II]

Hello All,

Not much to report at the moment.
5 Weeks into treatment, at (except for a brief increase) 30mg of Trilostane a day Angelina:
* Has gone from demanding breakfast at 4:30am to calmly awaiting breakfast at 7am (less calm as 7am approaches).
* Water intake has gone from a litre (plus) per day to around 700mls per day.
*Energy levels are erratic - more one day - less the next.

Took Angelina for an ACTH Stim test today - results hopefully tomorrow.

John the Grey

[Roxee'sDad]

Brother John,

Good to see some positive signs:D:D:D:D

Keeping fingers and 16 paws crossed for good stim results.

John (Roxee's Dad)

[John II]

Hello All,

The Specialist called with the ACTH Stim Test results today:
7 May 2009 results:
Cortisol resting 78 nmol/L (or 2.82 u/L) (normal range is 15-170 nmol/L)
Cortsiol at 1 hour 337 nmol/L (or 12.21 u/L)

Previously on 14 April 2009 the results were:
Cortisol resting 157 nmol/L (or 5.69 u/L)
Cortsiol at 1 hour 382 nmol/L (or 13.84 u/L)

Electrolytes on 7 May 2009 were:
Na (Sodium) 144 mmol/l (139-153)
K (Potassium) 5.6 mmol/l (3.9-5.9)
Cl (Chloride) 108 mmol/l (93-122)

Previously on 14 April 2009 the results were:
Na (Sodium) 145 mmol/l (139-153)
K (Potassium) 5.9 mmol/l (3.9-5.9)
Cl (Chloride) 107 mmol/l (93-122)

So not a lot of difference with the Electrolytes.

Other points during the phone call:

• The Specialist advised going back to the dosing of 30mg of Trilostane every 12 hours. I told him about Angelina’s weakness after 3.5 days of double dosing and said I would prefer us to try 20mg of Trilostane every 12 hours. He replied that would not be his recommendation (and I should have come in for an ACTH test at that time to try to ascertain the cause of the weakness) but if that was my wish – he would order the 20mg capsules for me (they would take a couple of days to come in). So I don’t know if that was a victory or not. A daily increase of Trilostane – but a small increase. Am I going too slow?

He also gave me the option of ordering the Trilostane in liquid form – which would make dosing changes easier – should they be necessary. But, I thought, at least with capsules, I know when Angelina has swallowed them.

• I mentioned her leg problem last Sunday – he said that the disease made them more susceptible to blood clots. BLOOD CLOTS!!! :eek:


I think the 2nd ACTH Stim Test has hit Angelina harder than the first.
Yesterday, Angelina:
• seemed quite weak when she was walking outside to do the necessary.
• Was behaving a little oddly – in that she was trailing me from room to room.
• Panting more than usual – but that’s to be expected with the stim.
• Seemed confused.
Today she:
• Slept in to 06:55am – the latest so far
• Seemed duller – except when food is offered
• Didn’t want to go for a walk (only went as far as the patch of grass in the front yard – which she anointed – twice). I walked on – she stayed put – I walked back and she followed me home.
• Continues to follow me around today - trailing me from room to room. Sleeping next to my foot right now.

Regards,

John the Grey

[Roxee'sDad]

Hi Brother John:)
Have to run and groom some pooches but I wanted to say that I think the conservative approach is good one. Angelina's post acth didn't drop much but at the same time with a slower drop, she won't or shouldn't experience the quick cortisol withdrawl. Just my opinion.

Yeah and Stim days are always rough on Roxee:( but she has did recover quicker on the last stim day.

Check in with you later. Belly rubs to Angelina (if she'll let you):)
John (Roxee's Dad)

[John II]

Hi right back at ya Brother John,

Thanks for stopping by!
You and Roxee are the touchstone for me and Angelina :)

John the Grey

[Squirt's Mom]

Hi John,

I don't post to you much as I don't have much to offer but I do keep up with you and Angelina.

Brother John is right on the mark with starting slow, tho, and I agree with him on that approach. We often see Trilo pups go through the withdrawal of a rapid cortisol drop and by going slow, Angelina may well be spared this.

I did want to let you know that some pups do have problems with the stims the day after or so. The purpose of the test is to stimulate all the things we are trying to control to see how they react under treatment. So, in essence, it is a stress test for the adrenals and they don't always appreciate it! Over simplified, but you get the idea. :rolleyes:;)

You're doing a great job, John. Keep up the good work!
Hugs,
Leslie and the girls

PS. "John the Grey"....I just gotta know; is that a reference to Gandalf the Grey?

[Roxee'sDad]

Hi Brother John II (The Grey) or is it Gray?

Long day today, did a mercy groom today, a 14 year old lab that's never been groomed or had a bath:(. Felt really bad for him, did a shave and removed about a million ticks that have been living in those mats for years. Soon as he got out of my van, he went and rolled around in the grass, I swear he was smiling, gave me a few licks before I left. Guess I made a friend for life:D

Anyway, I was wondering about cushings and the blood clot thing, haven't ever read about that anywhere so was wondering if anyone else has had that experience or knowledge? :confused::confused::confused:

Roxee has become very clingy also, follows me around, cries and moans (blood curldling scream) if we're not in the same room with her. Besides being totally spoiled, I think it just gives her a comfortable feeling to know we are here with her. Probably the same for Angelina, after all, you are her hero. Roxee does like to hang around wherever the food might be:p

How is Angelina's weight, have you noticed any decrease in her belly? We're still trying to keep the weight on Roxee, she get 4 full meals a day:eek: Managed to put a quarter pound on her in the last week. Up to 13.25 pounds now.

I guess you and Angelina are going to be a case study.:eek: I know alot of us will be watching to see how it goes. Starting with 30 mg per day (not enough), going to 30 mg twice a day (too much) and now 20 mg twice a day. Please do keep us up to date on any changes and results.

Hoping Angelina is doing better and continues to do so.
Take care.
John (Roxee's Dad)

PS: Have you heard from Scot and Yanni the other Sidney(ite)?

[AlisonandMia]

Anyway, I was wondering about cushings and the blood clot thing, haven't ever read about that anywhere so was wondering if anyone else has had that experience or knowledge?


You saw that in that power point too. My understanding with the Cushing's and blood clot thing is that it is really quite rare in dogs although just occasionally a Cushing's dog will throw a clot - or it is thought that this is what has happened. However with cats clotting with high cortisol levels (or when on high doses of steroids like prednisone) is quite common and often is the first tip-off to the fact the cat is Cushingoid. I get the impression that cats are a particularly clot-prone species and seem to suffer from clots as a result of quite a few medical conditions, not just Cushing's. They particualry get something horrible and agonizing called "saddle thrombosis". With Cushingoid humans, clots are far more of a risk than they are in dogs but possibly not quite as likely as for cats.

Interestingly humans with high corticosteroid levels are very likely to develop psychiatric disturbances (mania, severe agitation, intense irritability and even rages etc.) whereas, thank goodness, dogs are not particularly prone to that type of symptom - beyond a bit of restlessness in the evenings they almost always remain more or less their usual sweet selves.

Alison

[John II]

Hello All,

Hi Leslie and The Girls :)
Thanks for the information with regards to the stim test. And the hugs - need the hugs! :D The John The Grey is just a reference to my own growing greyness (although I have seen the movies so... maybe it stuck in my head ;))

Hi Brother John The Good,

In Australia I'm John the Grey, if I was visiting the US I'd have to covert that to John the Gray :D

Nice work on the Old Lab! :) You are truly a good man!

I hadn't heard about the blood clot thing either so it was all a bit "What next?" to me. I'm hoping she was just lying on the edge of the rug, it dug into her leg enough to cut circulation and put it to sleep. I'm hoping.

I think I read somewhere that Trilostane can cause behavioural changes - but whichever article it was - they didn't give examples. Of course, since late January, I've been taking over ALL the feedings - so that could be a factor ;)

But then again - it's only been happening since the last testing. (sigh) lots of questions - few answers!

Angelina's weight was almost exactly the same as last time 13.02kg last Thursday versus 13.04kg the time before that. Her belly seems to be the same football it has been.

I'd much rather Angelina was a success story than a case study - but we have to wait and see how this all turns out. It's good to know a lot of fingers and paws are crossed for her. :)

Since Scott and Yanni's first contact, I haven't heard from them - which is a pity because I think Scott has a story to tell.

And Alison,
You are simply amazing with your inter-species cushings knowledge! ;)

John The Grey & Angelina the White
(who is amazed that he managed to write all that before his computer could crash for the 7th time!)

[labblab]

Hi John,

Here's a link to a study that I had seen a while back that discusses the association between Cushing's and blood clots. It is directed towards the implications for humans, but as you will see, the study was performed on dogs with naturally-occuring Cushing's Syndrome. So if you are interested in plowing through it, it may help clarify the linkage between the disorders:

Biochemical Basis for the Hypercoaguable State Seen in Cushing Sydrome (http://archsurg.ama-assn.org/cgi/reprint/136/9/1003.pdf)

I was interested to see that "our" Dr. Feldman (the UC Davis specialist who we so often quote here) was one of the authors.

Marianne

[Roxee'sDad]

Thanks Marianne and Allison,
I learn something new everytime I visit here. I had to read the paper a few times to begin to comprehend :o but managed to get the jist of it.:)


John II AKA The Grey - How about a case study of a success story:D

John (Roxee's Dad)

[AlisonandMia]

The weird thing with both dogs and humans showing the same biochemical changes re being in a hyperchoaguable is that clots are so rare (but not unheard of) in Cushing's dogs whereas in humans it is a very real danger that makes the risks of using heparin worth taking. There must be other factors at work. High cortisol levels seem to affect different species in slightly different ways.

Alison

[John II]

Hello All,

Update Time.

On Monday afternoon, I got a call from The Specialist's Office that the 20mg capsules of Trilostane had arrived. I went to collect them shortly after - and resisted the urge to give her a dose that evening.

Breakfast time Tuesday morning, I started the 12 hour dosing of 20mg.

This morning (Wednesday) Angelina was interested in going for a walk, and walked with some improvement, compared to the last time (on Sunday). She seemed fine all day.

But... 30 minutes ago, after lying on her side for a while (post dinner snooze- and about 2 hours since her second dose of the day) she got up and was walking with difficulty. I'd say with a limp, but I'm unsure which leg to blame a limp on.

I just watched her get up to change position, and the limping continues. Very old lady. :(

This hasn't really happened to date.

Could this be:
* A slight increase in Trilostane?
* Progression of the disease?
* Arthritis being unmasked?
* A clot?
* A reaction to colder weather (currently 15 degrees celsius/ 60 degrees farenheit)?

I didn't want to be hopeful so early after a change in dose - but it's really unfair for things to get worse so quickly! :(

She wanted to go on the couch and I lifted her up and covered her up to keep warm - but a few minutes later she wanted to be lifted down again, and is back to lying on the floor. Seems she can't get comfortable.

John the Greyer and Angelina :(:(

PS: Thanks to Marianne for the clot homework :)

[John II]

An update to my update:

I forgot to mention that Angelina's abdomen seems to have more of a bulge to the left side. Is this familiar to anyone? I initially thought it might be a trick of the light (like when I thought her hair was changing colour) or just the way it appeared when she was moving - but now I'm not so sure.

Angelina has gone to bed now - but keeps changing position as if she can't get comfortable.

And I'm worrying that Trilostane is reacting with a pre-existing condition.

[AlisonandMia]

I forgot to mention that Angelina's abdomen seems to have more of a bulge to the left side. Is this familiar to anyone? I initially thought it might be a trick of the light (like when I thought her hair was changing colour) or just the way it appeared when she was moving - but now I'm not so sure.


I think if you think you are seeing something then it is there - that has been my experience overwhelmingly. Some things are so subtle especially at first that you begin noticing them on an almost subliminal level but almost invariably it becomes clear that there really is something there. If she is sore it could be a result of how she is carrying herself - ie curving slightly to one side so a leg doesn't hurt. Do you notice it more at some times that others such as after meals or whatever? It sounds like something to draw your vet's attention to.

I believe that front-leg lameness (this is what Angelina has isn't it?) can be a result of a neck problem: http://www.dolittler.com/2009/05/12/Collar-safety-in-dog-training-and-in-real-life-A-veterinarian%E2%80%99s-take.html (This is specifically about neck injuries from collars but it mentions symptoms of neck injuries and I'd think the same would apply with arthritic/degenerative neck problems.) Her inability to get comfortable sort of fits with neck pain/discomfort - there is nothing like an uncomfortable neck to make anyone restless.

Hope this helps.

Alison

[Roxee'sDad]

Hi John (The GREY)

Could this be:
* A slight increase in Trilostane?
* Progression of the disease?
* Arthritis being unmasked?
* A clot?
* A reaction to colder weather (currently 15 degrees celsius/ 60 degrees farenheit)?


I wish I could help you but it sounds like it could be any one or more of the above. This is so wierd because Roxee has the same type problems.

ie curving slightly to one side so a leg doesn't hurt. Do you notice it more at some times that others such as after meals or whatever?

Roxee stands with a curve and it seems one side behind her ribs is caved in or one side is a little more plump. Vet took x-rays a few months ago, of her hind leg and pelvis but could find nothing wrong :confused::confused::confused: Bad day yesterday, she could barely stand without falling over. Looked like she hurt her left front leg. We are doing a stim on Thursday and I was afraid we might be changing from stim to crossing the Bridge. She got a good nights rest and is walking better today :)

Regarding covering with a blanket, I've read and also by experience with Rox that cush pups have a hard time dealing with the heat. Roxee prefered to sleep and rest on the coldest part of the floor even in the winter. I was wearing 3 pairs of socks but Roxee just prefered the cold floor to a warm spot or a blanket.

So Roxee is still having good days and I get so hopefull, then she has a bad day and I get depressed but then remember what Leslie said. "On the bad days, remember the good days." and I regain hope.

Now Allison seems to have given me some homework and I need to check out the link she provided.

BTW- has Angelina ever had any leg, more specifically ACL (knee) problem? Roxee blew out her ACL some years ago and it seems this is fairly common in cush pups. She now carries that leg stiff as a board, as Glynda calls it a peg leg.

And I'm worrying that Trilostane is reacting with a pre-existing condition.

Yes, I have been wondering the same thing about Roxee. With the constant struggle to keep her weight on her, 4 meals a day. The struggle to keep her balance and walk, I wonder about the other hormones the adreanal puts out. I've read so much about this and that's why I was and still am considering the UTK panel. The ultrasound was good to have done, but in retrospect, I should have spent the extra dollars to do the UTK panel in addition. I think it's the only way to be absolutely sure. Just my opinion, but I think alot of us get lucky with the standard testing and ultrasound but the UTK results would eliminate alot of the what if's and would most probably give me / us some peace of mind.

Well, sorry I was so long winded, I really hope you see improvements in Angelina. I know you must feel so confused and helpless sometimes as I do but we do the best we can. If only they could talk to us and tell us what hurts.

Keeping good thoughts and prayers for Angelina and You.
John (Roxee's Dad)

[John II]

The following was written about 5 hours ago...

Hello All,

I spent last night in cat-nap mode, alert to any sound, real or dreamt.

Angelina spent the night on the queen-sized bed of another member of the household. I was up every hour or less to check on her. Whenever I did I was worried to see her position on the bed changed and her eyes wide open.

At breakfast time, I skipped the Trilostane dose.

A few hours later, Angelina let it be known that she would be interested in a walk, if anyone was interested in taking her. But she only went about half the distance she did yesterday.

I was out grocery shopping for a couple of hours – all the while worrying what I would find on my return. But – I found her improved. Her lameness seemed to have eased.

Especially when offered her favourite lunch of BBQ chicken. Excitement seems to ease the symptoms.

The downside of giving Angelina her favourite lunch, is her turning up her nose at the dinner of canned food. I tried tempting her with some more chicken bits on top – she ate the chicken, but left (most) of the rest. We skipped the dinnertime Trilostane dose as well.

Oddly, now as day turns to night, it seems as though the lameness is starting up again!

So now I don’t know what to think.

Alison – you’re feeding my paranoia! So far I’ve only noticed the abdominal bulge at random times – just when I happen to be watching her walk – I haven’t found a pattern as yet.

Neck problem? EEK! I can think of three incidents in the last 9 months or so. The dog attack where the vicious (censored) dog had her by the throat – while the other (censored) dog had her by the ribs. And two separate tumbles she took (Angelina is not always the most graceful girl) – one of these falls a foot or so drop onto concrete (she was watching the food – not the ground). Of course the cortisol may have been masking all this until now.

Thanks for the link!

Brother John – sorry to hear that Roxee had a bad day. It just tears your heart out doesn’t it? Hope she has many more good days!

Having read all these Trilostane “the miracle drug” testimonials online, the reality of it is kind of underwhelming. I keep wondering what would have happened if I’d taken the path my Vet suggested and gone with Lysodren in the first place? Would Angelina be better off? Or would she be gone already? Second guessing myself as always!

I don’t think Angelina has an ACL problem – in her early days she would launch herself off the couch or the beds without regard for the consequences. A few years into dog ownership I started using a couple of couch (seat) cushions (wide and rectangular and flat) as Angelina landing zones. She avoided these obstacles at first, but gradually realized it was a softer landing. I hope this means less impact to her joints.

However her other tumble (a few months back) was off these cushions, when I had stacked the two on top of each other – trying to make steps from the floor to the bed (when she was still making the attempt herself). Getting up later that night she hadn’t expected the additional height! Double eek!

So neck problem? Maybe. ACL problem? Maybe.

Thanks for the good thoughts and prayers!

John (the confused and greyer) and Angelina.

[John II]

And now, 5 hours later I'm wondering if I'm onto something.

Angelina's lameness seemed to decrease as the day warmed.
And then it seemed to increase as the day cooled.
Maybe there's no relation to the Trilostane at all?
Maybe it's all just the cold getting into her old bones?

Which, if it's true would be just ironic - I spent all Summer wishing for Winter - now I may just spend all Winter wishing for Summer... or central heating.

John & Angelina

[Patricia ann Wh]

Hi John,

I've been keeping up with your story.

My guy, Jesse is going through the same ups and downs.

When he collapsed on the 5th day of trilostane -(we started at 15 and 15 mg a day when we went to 30 - 30 he collapsed. I stopped and he got better and better.
I restarted about 5 days later ( my notes aren't in front of me) at 15 mg. (he's 85 lbs) a day and the first 3 days he was great, on the 4th day he could barely get up.!!!

So, I thought the 15 mgs was the ticket.
But because he got so weak on day four of the 15 mgs. that also had to be too much.

Now, 2 days off and he is better.

I don't know - I just don't know.

Patti and Jesse:p:)

[Patricia ann Wh]

Have you seen this below - just to add to our confusion:confused:

http://www.justanswer.com/questions/135mx-dog-weight-45lbs-taking-vetoryl


Question
My dog weight 45lbs and taking vetoryl 60mg every 3rd day. His clinal sign is good with the meds. that he is on. Should I lower the dosage to 10mg per day instead for 60mg every 3rd day?

Patti and Jesse

[Patricia ann Wh]

Hi John, I thought this was interesting too. The paragraph is from the link below.

http://www.dcavm.org/04sept.html

Currently, the recommendations of this author are based mainly on those of Dr. Reto Neiger who has the most experience in using this drug.20 Recommendations are to start administration of trilostane (2-10 mg/kg) once daily. If minor side effects are seen, stop the drug for 3-5 days and then restart giving trilostane every other day for one week before continuing with the initial dosing scheme. An ACTH stimulation test should be performed at 10-14 days, 30 days and 90 days after being on a full dose of trilostane. The test should be performed 4-6 hrs post-pill. If the post-ACTH cortisol concentration is <20 nmol/L, stop the trilostane for 48-72 hrs.20 At this point, Dr. Neiger recommends restarting the trilostane at a lower dose20, but given the long-term suppression seen in some cases, I believe that, ideally, an ACTH stimulation test should be performed and trilostane should not be reinstituted until cortisol secretion has recovered. If the post-ACTH cortisol is >200 nmol/L, increase the dose of trilostane. If the post-ACTH serum cortisol concentration obtained is between 20 and 200 nmol/L but the clinical signs are continuing, then twice-daily therapy should be used. The same dose that was given once-daily should be given twice (e.g. if giving 30 mg once daily then double it to 30 mg twice daily). Once the clinical condition of the dog and the dose have stabilized, an ACTH stimulation test should be performed every 3-6 months and serum potassium concentration should be measured to check for hyperkalemia.

RESTART EVERY OTHER DAY FOR ONE WEEK.

HAVE YOU HEARD OF THAT ONE?
Whew - its endless

[Roxee'sDad]

Hi Patti and John,
Hope I'm not hijacking your thread John;) but yes, this can and sometimes is so confusing. Like has been said so many times, every pup is different and maybe just maybe, Jesse and Angelina may need more exact dosing. maybe 10 instead of 15 for example:confused::confused::confused::confused:

Roxee doesn't show any symtoms of overdosing, her or our problem is that she went untreated for over 2 years and was very weak and lethargic before we started treatment. I am just hoping it isn't too late for a decent recovery. We are off to the vet's now for her stim, it's about a month early but I've noticed some increased panting in the evenings and increased thirst. But still, she is better today than she was in Jan.

Will check back later, we are off to the vet for a stim and electrolyte check.

John (Roxee's Dad)

[Squirt's Mom]

Hi John,

You may have missed this info posted by Kathy about Trilo (Vetoryl):

http://www.fda.gov/cvm/CVM_Updates/D...ingDisease.htm

http://www.fda.gov/cvm/FOI/141-291o120508.pdf

These studies are more current than the links posted by Patti and are associated with the approval of Trilo in the US.

I am sorry Angelina is having so much trouble getting on her feet. I hope you see an improvement soon in all areas.

Hugs,
Leslie and the girls

[Patricia ann Wh]

Hi Leslie and Girls and John,

Please don't get me wrong with my info. I just spend every minute it seems reading and trying to understand this whole thing and try to understand more for my guy Jesse. It seems some have such great luck with trilostane.
So - I'm looking at what the possibilities could be when things don't go quite so perfect for us.
So, do you think if the 4th day of trilo and the legs get weak - stay on it??
His legs are weak already - they are definitely more weak after the trilo.
I've read stories where people say their dogs legs are weak before - but after time they do get a little better - but they didn't say if the legs got worse and they stuck with the trilo or if they did not see weakness at the beginning of the trilo. Can anyone understand what I'm talking about?? I'm not sure I'm clear.

Thanks, Patti and Jesse

[Patricia ann Wh]

Hi John,

Jesse and Angelina may need more exact dosing. maybe 10 instead of 15 for example

Have you ever read where a dog Jesse's weight has been on something as low as 10 mg. a day??

Patti and Jesse

[labblab]

Hi John, I thought this was interesting too. The paragraph is from the link below.

http://www.dcavm.org/04sept.html

Currently, the recommendations of this author are based mainly on those of Dr. Reto Neiger who has the most experience in using this drug.20 Recommendations are to start administration of trilostane (2-10 mg/kg) once daily. If minor side effects are seen, stop the drug for 3-5 days and then restart giving trilostane every other day for one week before continuing with the initial dosing scheme. An ACTH stimulation test should be performed at 10-14 days, 30 days and 90 days after being on a full dose of trilostane. The test should be performed 4-6 hrs post-pill. If the post-ACTH cortisol concentration is <20 nmol/L, stop the trilostane for 48-72 hrs.20 At this point, Dr. Neiger recommends restarting the trilostane at a lower dose20, but given the long-term suppression seen in some cases, I believe that, ideally, an ACTH stimulation test should be performed and trilostane should not be reinstituted until cortisol secretion has recovered. If the post-ACTH cortisol is >200 nmol/L, increase the dose of trilostane. If the post-ACTH serum cortisol concentration obtained is between 20 and 200 nmol/L but the clinical signs are continuing, then twice-daily therapy should be used. The same dose that was given once-daily should be given twice (e.g. if giving 30 mg once daily then double it to 30 mg twice daily). Once the clinical condition of the dog and the dose have stabilized, an ACTH stimulation test should be performed every 3-6 months and serum potassium concentration should be measured to check for hyperkalemia.

RESTART EVERY OTHER DAY FOR ONE WEEK.

HAVE YOU HEARD OF THAT ONE?
Whew - its endless
The varying research recommendations regarding trilostane do seem pretty overwhelming, don't they?? And there certainly has been some evolution along the way. The "Dr. Neiger" who is referenced here conducted some of the very first research that was performed at the Royal Vet College in London, and his study results were among those upon which the first Vetoryl dosing recommendations were based. Many of the recommendations contained in the 2004 paragraph that Patti has cited remain part of Dechra's current Vetoryl dosing protocol. But there are some that have been revised as a consequence of subsequent studies.

For instance, you'll see that the 2004 recommendation was that if the decision was made to shift to twice daily dosing, you actually DOUBLED the daily dose (rather than dividing the once daily dose in half). Since my dog started on trilostane right at that time, that is precisely what we did with him. The recommended once daily dose for his weight was 120 mg., so we added another 120 mg. at night (can you believe we were giving a 70 lb. dog 240 mg.?). Even at that whopping dose, he never had an ACTH "post" result that was less than 6 or 7. (But that is a whole other story...). I absolutely CRINGE now when I think that we were giving him that high of dose. But that was the protocol at the time, and he actually did very well on it for several months.

Anyway, that is one of the reasons why we are trying to track down and document for our members the most recent studies and clinical protocols. Because there have been changes along the way, just is the case with any evolving medical treatment.

Marianne

[Patricia ann Wh]

Hi Again,

Did I tell you Jesse is 85 lbs.

Oh - and I once read about a dog that was on 33 1/2 mgs.

Yeah, the article said that 30 was too low and 35 was too high!!!!!!!

But 33 1/2 was perfect!!! It was an article written by a vet. (Have no idea where I read it)

But - I found that amazing. Actually, almost scary. The fact that such a small dose could make such a difference!!!:eek::eek::eek:

Patti and Jesse

[Roxee'sDad]

And now, 5 hours later I'm wondering if I'm onto something.

Angelina's lameness seemed to decrease as the day warmed.
And then it seemed to increase as the day cooled.
Maybe there's no relation to the Trilostane at all?
Maybe it's all just the cold getting into her old bones?

Which, if it's true would be just ironic - I spent all Summer wishing for Winter - now I may just spend all Winter wishing for Summer... or central heating.

John & Angelina

Hi John the Grey,
Sometimes we may over think things. Sometimes we just need to take a day to enjoy our time with our pups. Pretty much what you did with Angelina, I did with all my pups today. They were treated with a trip to Burger King. You would have thought they got the lunch of their lives:D:D:D They enjoyed it and I enjoyed watching them enjoy it.
All the best to you and Angelina, Belly rubs from me if she'll let you:D
John (Roxee's Dad)

[John II]

Hello All,

My, hasn't there been a lot of activity here on Angelina's thread! :)

Patti - Jesse's story of an 85lb dog collapsing on 60mg per day is the stuff my nightmares are made of! :o I see Angelina's numbers still being too high, but I fear the dose increases. Angelina gets wobbly - starts limping... which of several possible reasons is it? On the other hand we have 13lb Roxee on 40mg per day!

So far at the first sign of a negative reaction - I've shut the experiment down! Haven't figured out if I'm cowardly or prudent ;)

I took Angelina to the local vet this afternoon - just to get her leg checked out. After an examination, he suspects an old dog with an old joint. She was so worked up about being in her least favourite place that her limp disappeared :o - I asked the vet about a limp being the sign of a possible neck injury - he said that if that was the case, the limp would persist regardless of her stress levels. He gave her a shot of Meloxicam and suggested I start giving her glucosomine (at a quarter of the human dose).

I asked him about the bulge (I'm not sure I'm seeing) on her left side - he felt her abdomen and reported a very large liver and a very large spleen :(.

I share your confusion Patti - big time!

Leslie - as always thanks for the links and the hugs!

Marianne - I've been thinking about your preference for SID versus BID - and I initially thought that logically, keeping the cortisol levels fairly constant via BID dosing was the better option. But now I'm wondering if upping Angelina's dose to 40mg SID rather than 2 doses of 20mg would actually be easier on her system somehow? She would have the 24 hours for it to wear off...
All I know, is that she handles 30mg once a day well - but both times we've gone to twice a day dosing, whether it was 30mg twice a day or 20mg twice a day - she started getting the wobblies. What do you think?

And Brother John - I hope Roxee's results will be perfect - please let me know.;)
I am the king of overthinking things :D Waking or dreaming I'm thinking about this. You are wise - let us all take the time to enjoy our puppies! And give them special treats whenever possible. Angelina prefers KFC :D

Whatever the outcome I know Angelina has had a good and happy life - I just wish we could have made it to the finish line with a perfect record of happiness. To see her like this breaks my heart. :(

Thanks again one and all,
John the Grey and Angelina.

[Squirt's Mom]

Hi John,

Bless your heart! What is happening to you is your twitcher has gotten stuck wide open! A twitcher is what makes us look at every little thing and say, "What's that?! What does that mean?! What am I supposed to do?!"

When Squirt was first diagnosed and I didn't understand much about this condition, my twitcher was wide open, too. Every little thing she did, or didn't do, made my little mind go into overdrive with worry about the possibilities. "Was that just a normal sneeze, or .....? Why is her nose dry...oh no, what if....? OMG! She's sleeping with one leg curled up....why?!" On and on and on... Poor thing, I drove her nuts the first few months constantly checking on her, looking in her mouth, squeezing her belly, inspecting her skin and coat, waking her up to be sure she was ok. And then they found that tumor, she had surgery and my twitcher went into high gear again!

It's been about 15 months since I first heard the word "Cushing's" and although I am much calmer than I was at first, my twitcher still stays ready to go full steam ahead at the drop of a hat. But having super-active twitchers is a good thing for cush moms and dads as long as we don't let it get out of hand. So twitch away, my friend! That just means you are a watchful, concerned dad. As time passes, you will settle down some and your twitcher will go on stand-by.

I, too, have learned the lesson Brother John spoke of...to enjoy those moments when I see Squirt doing something she used to do, when I see her happy and energetic, when she gives me one of her rare kisses, when she smiles, when I see her little butt sashaying down hall, when she rolls over for me to rub her belly...the little things I used to take for granted are now extra special.

I do hope Angelina gets regulated soon and that you start to see some real improvement. Meantime, remember to enjoy her when you can. You are doing a great job, dad!

Hug from a sister twitcher :p ,
Leslie and the girls

[Roxee'sDad]

Ah Haaaaa!

It's my twitcher that's the problem :eek::eek::eek:. I wonder how I can turn it off from time to time:confused::D

John (Roxee's Dad)

[Squirt's Mom]

Wine, margarita, pina colada,..... :D:D

[Roxee'sDad]

Hi John the Grey,

Is there a recipe section here somewhere?
I've been dabbling with some home cooking for Angelina - but I always worry about it lacking the right ingredients

You might want to check with Angelina's Auntie Leslie:p:). I believe she has some recipies and is studing nutrition.

John (Roxee's Dad)

[John II]

Hello All,

Leslie - so while all the kids are playing with Twitter these days, I wind up with Twitcher? :D
- Also, is there an Auntie Leslie cookbook somewhere? ;)

And Uncle John - thanks for pointing me in the right direction :)

John & Angelina

[John II]

And for my next question :D

I went off to buy some Glucosamine and found a Glucosamine, MSM & Chondroitin powder - which I figured would be easier to measure accurately than tablet cutting. However - looking at the ingredients I'm wondering if there is anything below not suitable for dogs (especially dogs on Trilostane)? The human dose is 5mg (1 teaspoon) twice a day - so quarter of that for Angelina?

Formulation per 5 grams:
Glucosamine Hydrochloride (mg) 250
MSM (mg) 250
Chondroitin Sulphate (mg) 200
Vitamin C (mg) 50
Citrus Bioflavonoids (mg) 50
Zinc (mcg) 400
Manganese (mcg) 200
Copper (mcg) 33.32
Boron(mcg) 50
Sodium (mg) 3.95

Thanks in advance,
John & Angelina

[Squirt's Mom]

Hi John,

We use gluco/condroit w/msm here, too. I don't thing any of the ingredients should be an issue, even with the Trilo on board.

About diet...most of the books and info you find on the web is geared toward healthy dogs and the info that isn't, is often too generic. It is always best when dealing with an ill pup to have a diet designed especially for your pup based on her particulars. Here are two ladies I would recommend:

Catherine Lane
http://www.thepossiblecanine.com/

Monica Segal
http://www.monicasegal.com/

They both have discussion groups, too, which you can join and learn a lot about diet and nutrition in general.

Cat’s discussion group
http://pets.groups.yahoo.com/group/ThePossibleCanine-Nutrition/

Monica’s discussion group
http://www.doggiedietician.com/aboutus/discussions.php

Monica has two books that I would recommend over anything else out there that I have seen so far. They are Optimal Nutrition and The K9 Kitchen.

We had a thread on Diet and Nutrition at the old site and I need to get it started here again. So, thanks for the nudge, guys! :)

I am more than happy to help with diet where I can, but my knowledge is very limited at the moment and the more I learn the more I don't know. Nutrition is a very complicated subject if you want to do it correctly, especially when dealing with pups that have health issues. For example, someone here said their vet told them that all dogs really need is protein and carbs. Wrong. Carbohydrates are not listed as a dietary requirement for dogs by the NRC (National Research Council) which is the unbiased source for canine nutrition. (The AAFCO is an organization that was developed by and reports to the dog food manufacturing industry, so their recommendations are geared to meet the approval of the industry.) In the wild, canids eat the whole prey usually, meaning they eat the stomach and gut of their kill, including the content thereby providing a limited source of carbs. The key nutrients for dogs are protein and fats. Don't get me wrong, carbs are important to the functioning of the body, but it doesn't take much to let the body do what it needs. Carbs are more important to true omnivores, but the dog is not a true omnivore even tho they can eat and digest plant materials to some degree.

Ok, I'm rambling. :o

The supplement you got should be fine. ;)

Hugs,
Leslie and the girls

[John II]

Thanks Leslie!

I'd gone to the pharmacy and bought a jar of Glucosamine tablets first. Then went to the supermarket and checked out their range - finding the multi-supplement powder. It was actually thanks to reading your thread that I thought the Glucosamine, MSM & Chondroitin powder would be a better choice - since you were using something similar. It wasn't until I got home and read all the other things in it and wasn't sure. It was the boron that threw me! :D

And as usual - thanks for the links - got some reading to do! ;)

Angelina had a pretty good day - that pain shot the other day may have made all the difference. She broke into a trot on a few occasions :D

Her water intake has been pretty low the last 2 days only 520mls yesterday and 460mls today... there's still an hour worth of today left - but since she's already gone to bed - that may be it for her today.

Thanks for taking the time to do all the rambling - you can never ramble too much for me!

Hugs for you and the girls :)
John & Angelina

[LuvMyMunchie]

Hi John,

I'm glad Angelina had a good day yesterday and that the pain shot has given her some relief.

I'm being a worrywart here but since your vet recommended glucosamine and the powder contains several "extras" I'd recommend checking the product out with your vet for his approval just to be on the safe side.

Give Angelina some extra pets from me!

Louise

[John II]

Hi Louise,

I am also a worrywart (and a twitcher :)) and popped into the Vet's yesterday. Who, after glancing at the container for a second said it should be fine.

I've yet to figure out the Vet roster - I was hoping to talk to the nice one - but got the evil one ;). Well I suppose he's not actually evil. He's just not the nice one. :)

Today I started the 2nd attempt of the 12 hour 20mg dosing of Trilostane. A quarter dose of the Glucosamine, MSM & Chondroitin powder mixed in with food. And the contents of a fish oil capsule mixed in with another meal.

Now I just have to figure out a time to give her some milk thistle!

Thanks for keeping an eye on us,

John & Angelina.

[John II]

I have to admit that I’ve been avoiding reading the updates of forum members who have announced the passing of their Cush Pups. Because I’m trying to keep positive and not think about the eventual outcome of Angelina’s story.

But recently I did look over the list of losses for 2009.

I was saddened to see how many have “crossed the bridge” just this year alone.

But what shocked me most was that among those who have lost so much and so recently, were those who have taken the time in the midst of their grief to lead me by the hand and guide me through my own fear and confusion.

I just find this level of kindness and selflessness amazing. So I just wanted to stop, take a moment and say thank you so much for all of your help! You are all doing so much to help Angelina and me and to restore my faith in humanity. It means more to me than I can say.

I would have been John the Bald without you all :).

[forscooter]

John,

I know what you mean....the people here do restore your faith in humanity! It is the best place on earth!

When I lost Scooter right after Christmas, I wasn't sure what I would do. But then, I still have Bailey who also has Cushing's. But more importantly, if something happens to Bailey, I can't not seem myself being here. We like to think of it as "paying it forward"....we each got help when it was our turn, we still need help, and so we help whoever we can as much as we can.

I found this place, or the old board and now this place, to be a place where there would be meaning for my pups and their stories. I was so upset when they were diagnosed with Cushing's...I questioned "why?"....and this is a way to give meaning and purpose to that question....so maybe I can help someone else who is struggling. That through their battle, and then through me, will their lives and struggles bring even more meaning than the scope to which their lives have brought just to me.

I hope this makes sense. I'm still very tired, LOL. When a pup loses a battle, it upsets us all tremendously...but we go on to help those who come after us as we were helped by all of those who came before us.

Sending lots of hugs....Beth, Bailey and always Scoobie

[John II]

Speaking of one of the devils! :D

[Roxee'sDad]

Hi John the Grey,
Just checking in and see that Angelina is doing better. :) Hope you continue to see improvements.

And Yes, it's great to exchange idea's, information, experiences, stories and sometimes just vent with our frustrations. As I have said before, Roxee wouldn't be here today if I didn't have the help and support of cc.net and Natalie's support through k9diabetes site.

It's good to be able to communicate with "like minded" people.

Belly rubs to Angelina.
John (Roxee's Dad)

[forscooter]

Who?? MOI???? A devil?? :rolleyes:

Naaah...just ask Scott! He'll vouch for me!!! :cool:

Now you keep your hair....I have enough gray hair to cover you though just in case....seems I have earned it over the last year!

Hugs, Beth, Bailey and always Scoobie

[John II]

Hello All,

I need an icon for "frustrated".

Angelina has had her 3rd 12 hourly dose of 20mg of Trilostane and I'm sure she already seems weaker than she has been in recent days (too much Trilostane or too little?). She's been spending a lot of time lying on the cooler floors - including getting up in the middle of the night to do so (too little Trilostane?).

Her water consumption yesterday was only 400mls (too much Trilostane?) (although so far today - to 2pm - she has already drunk 290mls). I just watched her walk from the kitchen to the loungeroom and she was doing the "every foot is an individual" thing (too much Trilostane?) .

Now I'm wondering if I should give her the 7pm dose of 20mg or revert to the 30mg dose at 7am and just continue with the 24 hour dosing? I'm getting a lot of mixed signals from her and she still refuses to tell me how she's feeling. :o How much easier that would be!

John & Angelina

[AlisonandMia]

"every foot is an individual" thing (too much Trilostane?) .

Would you describe it also as walking very carefully, almost as if on eggshells - because that is how my little girl looked when her cortisol was too low. For me it was probably easier to see and easier to sheet home to cortisol as she was younger than Angelina and had no other muscular/skeletal age-related stuff going on - but it was an unmistakable sign with her as she went from bouncing around quite recklessly really to being ultra careful and being weak and would fall over when I was putting her winter coat on her for the night. Mia was on Lysodren and did go just slightly low a couple of times in the course of her treatment and each time a little dose of prednisone perked her up within the hour.

I think that if she is looking like she is too low now that you should probably skip tonight's dose altogether. Possibly (and I'm just thinking out loud here) you could discuss with your vet using a dose that you are pretty sure won't be entirely effective (say 10mg bid) for 10 days and, providing you get no signs of low cortisol, do a stim test at that point and, if the symptoms and the numbers are not right just ever so carefully incrementally increase the dose at 10 - 2 week intervals until you are happy with the symptoms and the numbers - with the symptoms being the main thing and the numbers being a sort double check. Being an oldster Angelina may be rather sensitive to what is called "cortisol withdrawal" which has more or less the same symptoms as low cortisol but is actually caused by a sudden change in a downward direction in previously high cortisol. A dog (or person) can get this even when the cortisol is actually still a little higher than a healthy level but has recently decreased significantly.

I believe Dechra says somewhere (and I'd dig it out but won't be able to because I've got a v-e-e-e-e-ry slow connection at the moment - need that "frustration" emoticon, too!) that with Trilostane treatment the way to discriminate between cortisol withdrawal and absolutely-low cortisol is to take a look at the electrolytes - I'm pretty sure it's in the latest US product info if you want to be look it up for yourself (see Trilo FAQ's). This is because, with Trilostane, if the cortisol really is too low then the aldosterone (the adrenal hormone that balances the electrolytes) will also be too low and this will show up as an electrolyte abnormality.

I think with Angelina trying to sort whether you are seeing cortisol withdrawal or low cortisol might really help you work out what dose suits her best.

Alison

[labblab]

I believe Dechra says somewhere (and I'd dig it out but won't be able to because I've got a v-e-e-e-e-ry slow connection at the moment - need that "frustration" emoticon, too!) that with Trilostane treatment the way to discriminate between cortisol withdrawal and absolutely-low cortisol is to take a look at the electrolytes - I'm pretty sure it's in the latest US product info if you want to be look it up for yourself (see Trilo FAQ's). This is because, with Trilostane, if the cortisol really is too low then the aldosterone (the adrenal hormone that balances the electrolytes) will also be too low and this will show up as an electrolyte abnormality.

I think with Angelina trying to sort whether you are seeing cortisol withdrawal or low cortisol might really help you work out what dose suits her best.

Alison
John, I think these are the Dechra excerpts that Alison is talking about (taken from: http://www.dechra-us.com/File/prod_vetyrol.pdf):

A small percentage of dogs may develop corticosteroid withdrawal syndrome within 10 days of starting treatment. This phenomenon results from acute withdrawal of circulating glucocorticoids; clinical signs include weakness, lethargy, anorexia, and weight loss.1 These clinical signs should be differentiated from an early hypoadrenocortical crisis by measurement of serum electrolyte concentrations and performance of an ACTH stimulation test. Corticosteroid withdrawal syndrome should respond to cessation of VETORYL Capsules (duration of discontinuation based on the severity of the clinical signs) and restarting at a lower dose.

and also:

If the ACTH stimulation test is <1.45 μg/dL (<40 nmol/L) and/or if electrolyte imbalances characteristic of hypoadrenocorticism (hyperkalemia and hyponatremia) are found, VETORYL Capsules should be temporarily discontinued until recurrence of clinical signs consistent with hyperadrenocorticism and test results return to normal (1.45-9.1 μg/dL or 40-250 nmol/L). VETORYL Capsules may then be re-introduced at a lower dose.

Marianne

[Roxee'sDad]

Hi John II, the Grey, and almost bald,

I truely feel your frustration and pain.:(:confused::mad: All we can do is keep the faith and keep working on it.

Hope it get's better with Agelina this evening.
Belly Rubs if she'll let you;)
John (Roxee's Dad)