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  #11  
Old 04-27-2009, 09:13 AM
matea matea is offline
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Default Re: Please help - bad reaction with Trilo - don't know what to do next?

Thanks so much for all your info. First off here are the results that I have:

Endrocrinology test:

Urine Cortisol - 704
Urine Cortisol - Creatinine Ratio - 221.1

I've attached the others as images:



She's not currently on any heart medications.
Currently she's weaning off the prednisone, and we're thinking of trying a lower dosage of Trilo after about a week or so. I have an appt to talk to our vet on Wednesday about it.

So Metacam could be hard on her stomach? I'll have to look into that as well. I just want her to be pain free and comfortable.

Please let me know what the results tell you. I know the cortisol is high.

Thanks,

Matea
  #12  
Old 04-27-2009, 10:40 AM
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Default Re: Please help - bad reaction with Trilo - don't know what to do next?

So it looks like the only test they did for Cushings was the UCCR urine test?

Do the results you have show the normal range for urine cortisol?

Did they collect the urine for the test at the vet or did you bring it from home?

This is very important for an accurate test - it has to be taken stress-free.

I would never want a dog diagnosed solely on a urine test! It can be used to help rule out Cushings but is not diagnostic for it. So I hope they did an ACTH or, preferably, an LDDS.

Until we can sort this out, I would not give any more trilostane even if the vet wants you to until the Cushings folks here weigh in her diagnosis.

Metacam, like all NSAIDS, can be hard on the stomach. And like most of the NSAIDS, it seems like some dogs have no problem and others have big problems. Our Chris was on Metacam daily for more than four years and tolerated it beautifully. It seems like a bad reaction either happens right away or never happens, not much in between.

Natalie
  #13  
Old 04-27-2009, 11:37 AM
matea matea is offline
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Default Re: Please help - bad reaction with Trilo - don't know what to do next?

The endocrinology lab report actually says:

Ratios > 60 are supportive of a diagnosis of Cushings.

She also has almost all the symptoms of cushings.
  #14  
Old 04-27-2009, 11:38 AM
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Default Re: Please help - bad reaction with Trilo - don't know what to do next?

When was the urine sample for that test taken?
  #15  
Old 04-27-2009, 11:41 AM
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Default Re: Please help - bad reaction with Trilo - don't know what to do next?

From: http://www.kateconnick.com/library/cushingsdisease.html

Quote:
Diagnosis:
Initially, Cushing's may be generally suspected based on the typical clinical picture described above: a middle-aged or older, potbellied, hungry, thirsty dog with a sparse haircoat. Routine bloodwork may reflect elevated liver enzymes (especially serum alkaline phosphatase), cholesterol, and blood glucose. Some white blood cells may be elevated (neutrofils), and others decreased (lymphocytes, esinophils). A urinalysis may reflect high levels of protein and low specific gravity (dilute urine). X-rays or ultrasound may show an enlarged liver or either enlarged or atrophied adrenals. 50% of adrenal tumors may appear mineralized. Although one could do a CT scan to search for a pituitary tumor, this is not a common diagnostic procedure. All of the above suggest the presence of Cushing's, but specific lab tests can help to further pinpoint a diagnosis. These tests include a urine cortisol/creatinine ratio test, an ACTH stimulation test, and low and high dose dexamethasone suppression tests. There is no single test to diagnose Cushing's, and Cushing's disease is often difficult to accurately diagnose.

Urine Cortisol/Creatinine Ratio Test:

Considered a screening test, this cannot diagnose Cushing's, but it can rule it out. A urine sample is examined for the relative amounts of cortisol versus a normally excreted protein metabolite, creatinine (the latter is used to control for the degree of dilution of the urine). The greater the ratio, the higher the cortisol level. High cortisol in urine is suggestive of high cortisol in the bloodstream. Many conditions other than Cushing's disease can cause false positives, so this test is not considered diagnostic. Nonetheless, if the cortisol/creatinine ratio is okay, the dog is not likely to be Cushingoid, so this is a good screening test.
  #16  
Old 04-27-2009, 11:49 AM
matea matea is offline
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Default Re: Please help - bad reaction with Trilo - don't know what to do next?

The test was taken in February.

She also has the hind end weakness/shakiness, dry and pigmented skin and coat, eats and drinks a lot, has little tumors and other Cushings signs.

The vet said that because the cortisol level was so high, she was 99% it had to be Cushings.
  #17  
Old 04-27-2009, 11:57 AM
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Default Re: Please help - bad reaction with Trilo - don't know what to do next?

I mean what time of day and where was it taken?

If they took it at the vet's office, the results can be false due to stress raising the level of cortisol in the urine.

If you collected a sample in a calm environment at home before you left for the vet appt, then the results might be accurate.

I am not saying she doesn't have Cushings but she has not been adequately diagnosed and I've seen far too many dogs who actually do not have Cushings at all and have been misdiagnosed...

There's really not a rush to start Cushings treatment. It's much much safer to do adequate testing to confirm the diagnosis.

Low cortisol is a life-threatening condition so you don't want to give a dog with normal cortisol levels a drug like Trilostane that drastically reduces the cortisol. Plus you can induce the opposite of Cushings - Addisions, low cortisol - when treating with this drug.

Natalie

Last edited by k9diabetes; 04-27-2009 at 12:02 PM. Reason: clarify third paragraph
  #18  
Old 04-27-2009, 12:10 PM
matea matea is offline
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Default Re: Please help - bad reaction with Trilo - don't know what to do next?

Oh sorry, we took the test at home (first pee of the morning) and then rushed it to the vet.

Two vets so far are certain that she has it. I'd like to start treating it ASAP though, because it probably wasn't diagnosed for a while. I know that's common, but for a long time we thought it was just 'old dog' symptoms.

I'm going to see if we can restart the Trilo at 15mg once a day and then move up if necessary. I've talked to a lot of people who say that often the dosages are very different than what the manufacturer recommends. I know some dogs who are taking half the prescribed amount of Trilo and doing fine.

I just feel so bad that she's had it for a while and nobody caught it. That's the worst thing about this illness, all the signs seem so subtle at first...
  #19  
Old 04-27-2009, 12:23 PM
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Default Re: Please help - bad reaction with Trilo - don't know what to do next?

Hi Matea,

I'm not familiar enough with Trilo or heart meds, but IMO, I agree that futher testing is needed to confirm a Cushing's diagnosis.

You did what is typically the first screening test for Cushing's – the UCCR test. As Natalie said, this test can rule out Cushing’s, but it cannot confirm it. If the UCCR test can’t rule Cushing’s out, further screening is typically done. The ACTH stim test is often the second test done, where they inject ACTH to stimulate the adrenal glands to produce cortisol and they measure the levels pre- & post-injection. However, since you are using Trilostane, many of us believe the UTK (Univ. of Tenn., Knoxville) full adrenal panel should be done instead. The UTK panel is basically an ACTH stim test, but in addition to cortisol, they measure 5 other hormones - Estradiol, Androstenedione, 17-Hydroxyprogesterone, Progesterone and Aldosterone. Your vet would draw the blood, do the injection, prepare the samples & send them to UTK for evaluation. The reason why this (UTK panel) is so important is for several reasons:

1) To find out her cortisol levels (what you would get with a regular ACTH stim test) – if the levels are within range, you may be able to rule out regular Cushing’s at this point.
2) To find out if her other hormones are out of range – meaning Atypical Cushing’s – meaning it’s a different diagnosis (or an additional diagnosis) and the recommended treatment may be different. The symptoms of regular Cushing’s and Atypical Cushing’s can be similar. Again, if the levels are within range, you can rule out Atypical Cushing’s.
3) If her Estradiol levels are high, and she does have regular Cushing’s, you probably won’t want to treat with Trilostane as it is known to increase Estradiol levels.

Even if you decide to not use Trilo because of the heart medication, you should still screen further for Cushing’s & Atypical.

If regular Cushing’s cannot be ruled out after doing the UTK panel (or ACTH stim) you should do at least one other test or have an ultrasound done to confirm the Cushing’s diagnosis and find out if she has Pituitary (PDH) or Adrenal (ADH) dependant Cushing’s – the treatment and/or dosage may be different depending on this. We can discuss this in more detail when you get to that point.

I’m not sure if screening for other diseases (like Hypothyroidism) should be done before or concurrent with the UTK panel (or ACTH stim test). I would see what others think about it.

-Susy
  #20  
Old 04-27-2009, 12:30 PM
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Default Re: Please help - bad reaction with Trilo - don't know what to do next?

Quote:
Originally Posted by matea View Post
I'd like to start treating it ASAP though, because it probably wasn't diagnosed for a while. I know that's common, but for a long time we thought it was just 'old dog' symptoms.
Trilostane (and Lysodren) can do more harm than good if your pup doesn't really have the disease. Cushing's is typically a slow growing disease, so please take the time to be more sure of the diagnosis.

Don't feel bad...my former vet said my pup was just getting old even after the UCCR and ACTH stim test suggested further testing for Cushing's. My pup was showing signs about 1-1/2 to 2 years before being diagnosed.

-Susy

Last edited by Wylie's Mom; 04-27-2009 at 01:08 PM.
 

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