Coolidge...

[AlisonandMia]

I'm thinking (and waiting for it to be confirmed) that my vet pointed out that Coolidge is very sensitive to lysodren. So he probably recommended at that point to switch it to flaxseed or melatonin or Trilostane. However, reading up on the trilostane, we really don't want to go there because its not recommended for dogs with the higher progesterones. So I think the flaxseed and melatonin will be our course of action.

If Coolidge is indeed particularly sensitive to Lysodren this does not mean that she can never take it - it could simply mean that she is best served by a much-lower-than-usual dose. Occasionally an individual dog does seem to be inordinately sensitive to Lysodren (or Trilostane for that matter) and in those cases unusually low doses are used - which is actually a good thing rather than a problem. If nothing else it saves money.

I believe that Trilo can lower progesterone but that it raises 17 OH Progesterone so would probably cause problems on that front. It also lowers cortisol and if her cortisol levels are so nice and normal then Trilostane could very well result in a low-cortisol situation much as you saw with the Lysodren overload.

When just a maintenance dosing of Lysodren (no loading) is used in Atypical Cushing's the aim is to give a dose that is sufficient to just gently damp down the adrenal overactivity but not to actively erode adrenal tissue which is what the aim is with a dog with Cushing's where the cortisol is elevated. When this is done a low-end maintenance dose is usually trialled at first, particularly with a larger dog. I believe Dr. O usually advocates 25mg/kg per week to start with and for a dog that could be sensitive to Lysodren starting considerably lower would probably be the way to go. Your vet could consult with Dr. O should it look like Lysodren treatment is in the offing and he could advise based on Coolidge's history and your concerns.

It is possible that Coolidge went very low after just one dose of Lysodren simply because she did not actually have elevated cortisol to begin with. Larger dogs often need a smaller mg/kg dose than do smaller dogs and will often load very fast on the regular 50mg/kg so that may have been a factor too.

I do share Susy's thought that the normal (very normal) cortisol levels on the UTK panel may be because the adrenals have not yet regenerated fully after the Lysodren overload. If that is the case then the production of other hormones may still be lower than it was pre-treatment too. How long adrenals take to regenerate is a real how-long-is-a-piece-of-string thing so time will tell if this is the case. Fingers crossed that what you have now is indeed a true picture though.

Alison

[Coolidge]

She underwent lysodren loading in Oct of 2008. She wound up with very, very low numbers on the ACTH test immediately following the loading.

Another followup ACTH test at the end of November showed the numbers till low.

Another followup ACTH test (Coolidges thirst had increased two fold) was done at the end of Dec. Numbers were rising, (don't have them but will get them), so my new vet thought we should begin maintenance. Gave her one pill on new year's day. Period. She immediately became very lethargic.

Mid Jan she had an ultrasound done at UW Madison Vet School. Adrenals were normal. (She was taken there because she had lost over 20 pounds between Oct and Jan 1st.)

While there, they discovered Coolidge had a UTI. Took three different antibiotics to get rid of it. Thirst decreased.

Never had a ACTH stim test done before Coolidge was loaded because the "specialist" said it wasn't necessary. She was basing her decision off of the Creatine Test and the LDDST. So I had no ACTH preloading numbers to reference.

So, it's now the middle of May. It's been over 4-1/2 months total since her last lysodren tablet. Can lysodren stay in the system that long?

added:

Crap. Can a dog have both atypical and pituitary based cushings at the same time? Just when I thought we had "the final answer"?
If things aren't bad, what is causing her symptoms? She was tested for Diabetes at the end of December.

All I know is this. I have spent $3000 on tests that have given me absolutely no answers.

[stardeb55]

Lyso normally peaks about 48 hours after the dose is given. Frankly, I don't think there's any way that Coolidge would even still have a trace amount of lysodren iin her system after this extended period of time, even if she is highly sensitive.

Debbie

[Wylie's Mom]

Originally Posted by Coolidge

Crap. Can a dog have both atypical and pituitary based cushings at the same time? Just when I thought we had "the final answer"?

Yes, it's possible (my pup is one of them). I'm not a vet, but given the recent UTK panel & given how little Lysodren was used & how long it's been since Coolidge had any of it... I would think he does not have regular Cushing's...just a non-vet's opinion.

-Susy

[stardeb55]

Yes, Harley is another Atypical + Pit Cushing's. I'm in total agreement with Susy that I, too, think that the problem for Coolidge from the beginning was Atypical, not Pit Cushing's, thus the bad reaction to the Lyso.

Debbie

[Squirt's Mom]

Hi Becky,

Another PDH/Atypical parent here.

Based on Coolidge's reaction to the Lyso and the UTK panel, I think you are dealing with Atypical only! YEAH! If I were you, I would not let the vet use any Lyso for now. Try the melatonin and lignans first for a good while, then if it seems the signs are not controlled, check the cortisol again. But I feel you may have just lucked out and Coolidge is simply Atypical! Just another "non vet" opinion!

Hugs,
Leslie and the girls

[Wylie's Mom]

I think it's still questionable whether the flaxseed lignans are necessary... he doesn't have elevated estradiol levels - I'm not absolutely positive, but I thought the lignans were more for controlling the estradiol levels.

-Susy

[stardeb55]

Susy, I believe you are 100% correct about the purpose of the lignans.

Debbie

[Harley PoMMom]

On the Treatment Option Considerations Paper I got back for Harley it has under option # 3:

Note: Melatonin and flaxseed oil with lignans are used together when estradiol is increased.

I seen from older sheets that it used to say may be used together, so, I guess Dr. Oliver changed it?

[Coolidge]

Just thought I would post the results of the ACTH stim test done at the end of December, when my new vet said I should start Coolidge on maintenance.
Of course one test lab does it in ng/ml and this one did it in ug/dl. (Math has never been a strong suit).

December Results:

Pre-ACTH: 5.5 ug/dl (norm: 2-6)
Post- 8.8 ug/dl (norm: 6-18)

However, I noticed that the notes in the reference range (from Idexx) says 1-5 is the desired pre and post cortisol on lysodren therapy (which I assume means that's the numbers you want to keep it at during maintenance.

Perhaps that one pill put her over again.

The endocrinology report on her thyroid (done also at the end of Dec) has everything in the normal range except for:

Free Thyroxine (FT4) 7 pmol/l (8-26 norm)
Free Triidothyronine (FT3) 1.5 pmol/l (4.5-12 norm)
T4: 2% (Norm 0-20%)
T3: 3% (Norm 0-10%)

The thryrogobulin antibody results were:
<20% Negative
20-35% inconclusive
>35% positive


The endo guy at Michigan State said "The free fractions are borderline to low, but total fractions look good. TSH is not elevated and the specific TgAA is negative. Hence, not real indication of primary thyroid disease."

I don't know about all of you, but I'm getting pretty tired of "we will treat it as if" and "not real indication". It's like it's purely a guessing game at the expense of our animals. One would think this guy on this test would have said, hmmm, that FT3 number is really low, I wonder what is causing that... and do a Dr. House on Coolidge. Where is Dr. House when you need him?

Coolidge's panting, drinking, hunger, and urination is getting worse by the day. Her cough is getting huskier and more frequent.

I'd like to think that one day we will have this all resolved. And a final determination made. I'd like to think it's just Atypical, and we do the melatonin routine. I will keep the lysodren just in case we do need to go there. But I will tell Hope Safehouse, a rescue in our area, that I have pills in the event a pup needs some. I will be able to share.