Miss Millie Mayhem (Eng Bulldog) - NEW Dx: Cushings PDH and AWFUL Calcinosis Cutis

[khockman]

What a wonderful forum I have had the chance to scour for endless information as my baby girl went through lots and lots of testing to receive a final diagnosis of Cushings (PDH) and Calcinosis Cutis (AWFUL!!!). I can’t thank everyone enough for all of the posts that have helped me to become more informed and a better mama for my girl. Millie Louise (almost 10 yr old English Bulldog), was diagnosed on 6/28/13 with Cushings (PDH) after an ultrasound was performed. She weighs 55 lbs and started on Trilostane 6/29 – 60 mg every morning with food. What is just visually awful is her calcinosis cutis – I have such sympathy to all of you out there who are also dealing with this horrific skin issue as well as Cushings itself. Miss Mille has had open, oozing wounds and scabs from her neck all the way down her trunk (a good 8-12 inches wide) and on her cheeks – face cheeks that is. I pray that this quickly gets under control and am treating with DMSO and an antibacterial mousse in addition to Clindamycin and Rilexine due to staph and strep infection. This was the most aggressive skin disease I have ever seen and at the very onset took her to a dermatology specialist (went from a couple spots to the entire neck/trunk and sides of face in 2 weeks). So I thought I would post what seems to be protocol as it relates to symptoms and test results and would appreciate any thoughts or things I should be asking/looking for…I want to be the best I can for my girl. She is also taking Previcox, Phenobarbital and Tramadol (and yes, I have a spreadsheet to manage her meds and as recommended by a couple of you out there, a journal outlining any irregularities). Oh – poor thing also has an interdigital cyst that likes to keep re-appearing as well.
Symptoms:

•Excessive drinking
•Heavy urination but no accidents in house
•Big appetite
•Thinning hair coat turning into awful calcinosis cutis (determined by biopsies) – open oozing soars
•Weakness in rear legs – no more jumping up favorite “low chair”
•Little bit of a pot-belly
•Lack of desire to go on even short walks

Testing Done:

Urinalysis: Sp. Gr. 1018 (?), Color: lt. yellow, PH: 6.5, Protien: Trace – Reading handwriting so hope I got this correct…no other values noted.

LDDS: Pre-Dex: 2.5 ug/dL, 4Hr: 2.4 ug/dL, 8Hr: 2.3 ug/dL – I thought it was strange her baseline was within the normal range, but both vets said that it can fluctuate through the day. Also thought since baseline was somewhat normal, I was surprised her calcinosis cutis was SO EXTREME.

Bacterial/Skin Test: I cannot decipher these results, but it was determined she had staph and strep infections.

Biopsy: Clinical Summary – Three week history of erosions, dorsal neck, spreading along the back. Lesions are surrounded by erythematous plaques. White irregular serpiginous plaques on lateral neck. Two punch biopsies of erythematous plaques and one of white plaque. History of allergic disease. Suspect calcinosis cutis. Skin scrapings negative. Cocci seen on cytology. Patient is PU/PD with increased appetite. Gross Description - One container labeled “Millie,” three specimens, six sections in one cassette. 3 skin punch biopsies, bisected and totally submitted as six sections in one cassette, specimens inked blue, yellow, unlinked identification of halves. Diagnosis – Skin biopsies, dorsal plaques: calcinosis cutis, multifocal. The epidermis is acanthotic and suffers multifocal edema and vacuolar degeneration. There is a thick layer of loose orthokeratotic keratin on skin surface. Somewhat cystic follicular keratosis with follicular casts is also evident. The dermis is becoming mineralized. This has incited a granulomatous response and fibrosis. There are also small fragments of mineralized bone in the affected tissue (SHOULD I BE CONCERNED ABOUT THIS…BONE IN TISSUE??). Comment – Clinical Diagnosis of Calcinosis Cutis is confirmed…

ACTH: Time 1: 3, Time 2: 4, Cortisol Sample 1: 2.1 ug/dL, Cortisol Sample 2: 8.5 ug/dL (I believe the vet said this test was inconclusive?)

Superchem: Just reporting “abnormal” – Albumin: 2.1 (LOW), A/G Ration: 0.7 (LOW), Alk Phosphatase: 1704 (HIGH – this seems off the charts to me…normal is 5-131 U/L), Magnesium: 1.4 (LOW), Potassium: 5.6 (HIGH)

CBC: Just reporting “abnormal” – Platelet Count: 595 (HIGH), Differential Neutrophils: 11097, 81% (HIGH)

OK - so wow, I know this is a lot, but I just don’t know what else I should be looking for, what additional questions I should be asking. You all have helped me wipe away my tears over the past few weeks as I feel you are all an amazing support group. This has been very difficult and I just hope to do my best for my little girl. THANK YOU ALL in advance for and words of wisdom you can offer, I know I am in good hands with all the wonderful support I see flowing through this forum. Sorry to be so long-winded but didn’t want to miss anything! ACTH Test scheduled in 9 more days to see how she is doing on the 60 mg

P.S. We call her “Millie Mayhem” cause she has such an attitude and such sass! She is so stubborn and I look forward to helping her get back to her old crazy self!

Sincerely,
Millie's Mama (Kerry)

[Budsters Mom]

Hello and welcome :)
I am sorry for the reason that brought you here, but so glad you found us. You have come to the right place! There are many K9Cushing's angels standing by to help and stay with you every step of the way. They love details, test results, any information you can get your hands on. It looks like you've already made a good start with that.:) We will do all we can to help. Others will be popping in to welcome you also. Be ready for lots of questions. :)So again welcome to you and Millie,

Hugs,
Kathy

[Mel-Tia]

Love her name, my angel Tia had some sass of her own so your comment made me smile.

I don't know lots about the test results but I do know our experts like the reference ranges against the results to determine what that lab classes as normal range (you can edit the original post save typing it again)

I do have first hand experience of Calcinosis cutis as my little girl suffered from it too, I am so sorry she has it on her face, Tia got it down her whole back panel and it is wickedly bad to look at.

We shaved her back in the end so we coud keep it clean. We also used salt water from the sea and sudocream to help the itch and soreness. One of our members is also using manuka honey with success.

Big hug to you and kisses to Millie Mayhem

Mel
Xxxxxx

Ps I love her picture she looks like she is wondering what the heck you are doing!

[khockman]

Thanks Mel and Kathy,
Appreciate the welcome, and of course as I write this, Miss Millie managed to rip the scabs off the side of her face...arghhh...just opens up again. She certainly does not have a beauty pageant title in her near future, but she will always be the best looking girl to her dad and I. I appreciate the recommendations as my goal is to help use something that may soothe her and prevent itching. The one thing we have going for us is her bulldog body, so she can't really bite at things, but she can paw her face (can't wear cone cause of sores on neck). I just wish she could talk to me and tell my if it itches bad, and then if I put something on her, I just don't want it to sting or burn and I want her to say "oh mama that feels good" or "hey, get the heck away from me with that stuff." I will research the items you noted below. What kind of pup is Tia? I will also edit my response with refernce ranges per your recommendation

PS - Millie is always wondering what the heck I am doing...this pic was pre-disease. The dermatologist said it is the worst case of CC she has ever seen, and I have not even shared pics with family and friends because I fear it would horrify them :eek:.

Thanks much!

Kerry and Millie

[Harley PoMMom]

Hi Kerry,

Welcome to you and Millie from me as well! I am so sorry for the circumstances that brought you to us but so glad you found your way here.

Sorry, again, but I have no experience with calcinosis cutis but there are members here that do and I am sure they will be along soon. One of Moderators, Angela, is very knowledgeable about calcinosis cutis since her beloved Vizsla, Sabre, had it too, I will shoot her a PM and let her know you are here. ;) In the meantime here are some links to other member's Threads regarding calcinosis cutis: http://www.k9cushings.com/forum/showthread.php?t=5108

http://www.k9cushings.com/forum/showthread.php?t=5316

http://www.k9cushings.com/forum/showthread.php?t=3956




ACTH: Time 1: 3, Time 2: 4, Cortisol Sample 1: 2.1 ug/dL, Cortisol Sample 2: 8.5 ug/dL (I believe the vet said this test was inconclusive?)

Sincerely,
Millie's Mama (Kerry)

One question I have is, when this ACTH stim test was done was Millie on Trilostane or was this done before treatment started?

Please know we will help in any way we can so do not hesitate to ask any and all questions, ok?

Love and hugs, Lori

[khockman]

Thanks Lori!

The ACTH Test and all other tests were done prior to Trilostane (we just started her on this yesterday – the day after the ultrasound ruled out adrenal tumors). Still need to get full blown ultrasound report faxed to me tomorrow from IMS, but adrenal glands were both enlarged, no tumors appeared present and narrowed it down to PDH. Is there some concern you have with the ACTH :confused:? I very much appreciate your welcome and your input and am also thankful for the links you provided! I hope you never have to deal with CC...Cushings is tough enough With everything that comes along with that...

xoxo,
Kerry

[Harley PoMMom]

I must admit that I am quite baffled that Cushing's is suspected for the CC. According to those ACTH stim results Millie's cortisol is not elevated at all.

Cushing's is when the cortisol is way higher than normal. So I am a bit concerned with Millie taking 60 mg of Trilostane because Trilostane will lower her cortisol more and if it lowers it too much it could create an Addison's crisis.

[Mel-Tia]

Staffie...

When she had it around her neck I got the stretchy bandage and cotton wool stuff for underneath and put sudocream on before but it can stick if it dries out so needs changing a fairly regular otherwise the scabs can come off before they are ready.

It starts out like stretch marks then bumps then scabs which will fall off and then when the medicine starts working it will be new skin. Tia did get all her hair back, we had to shave her from her neck to her bum, get the vet to be very careful if you do get her clipped cause Tia defo found that uncomfortable but I think it helped me keep it clean and infection free

Big hug

Mel
Xxxxx

[khockman]

I did bring up the same concern you had as when I looked at both the LDDS and ACTH results it seemed that baseline cortisol levels fell normal. With the LDDS it appeared that even though baseline fell in normal range, she was unable to suppress at 4 and 8 hrs, but with the ACTH, I was told the results were inconclusive. Both vets said that cortisol have hit peaks and valley throughout the day depending on when the baseline is taken? I also brought up my concern of Addison’s given too high of a dose. Understanding both UC Davis and Dechra protocol (because of this GREAT forum), it looks like the 60 mg falls at the low end of Dechra given her weight of 55 lbs. What else can CC be caused from…any thoughts :confused::confused::confused:?

[Mel-Tia]

So possibly Petey and now maybe Millie....

I thought cushings was the only thing to cause CC. Might have to do some reasearch....

I think I read once diabetes but can't remember, will look!

[Mel-Tia]

I have done some reading and apparently in one case it was caused by leptospirosis. Usually they are vaccinated against this but might be worth an ask especially in light of what Lori thinks about the tests

Mel
Xxxxx

[khockman]

I will definitiely look into that. We have always been very good with vaccinations, etc... I think that in addition to the tests, all of the symptoms she had also helped support diagnosis. I just worry so much when placing faith in another individual (such as vet since I am not one) that every i is dotted and every t is crossed. I am sure in her medical record, they have a star at the top of the page that says "Millie's mom is crazy watch out for her." I would really be curious if anyone else who pops into this thread has had similar ACTH and LDDS results.

[Mel-Tia]

You are in good company. We all probably have notes of a similar ilk at our vets :D

[khockman]

I did read about Peety and the questions re: atypical cushings (can only be diagnosed through certain lab measuring the additional hormone levels...I believ I just wrote that correctly). In light of that I also though read that treatment would be the same for atypical and typical? I am just hoping that the doseage is right and if there are any additional questions I should be asking, that I do so!

PS - FYI Millie did have lepto vaccination

xoxox,
Kerry

Appreciating all the input!

[khockman]

Oh I am so confused...just read post in Peety's case that treatment is not the same between typical and atypical cushings...wondering if I need more testing cause her baseline cortisol was not overly elevated.

[Mel-Tia]

That was what Lori was getting as the vetoryl lowers cortisol, if it's not that elevated then it may cause Miss Millie other issues. Atypical s treated by melatonin and flax ligians I think.... Sometimes lydrosen as a maintenance dose

It's so tough as her skin needs a solution but I think if it were me given her cortisol isn't that high I would speak to the vet again. Are you scheduled for an ACTH in 10 days?

[khockman]

Yes - we are scheduled a week from Tuesday - July 9th. Neither vet (general and derm) were concened about this even when I brought it up! Hoping to get IMS perspective tomorrow - he did ultrasound.

[Mel-Tia]

When did she have the vaccine?

Good idea the the IMS, I think you have to ask questions just in case

It's stupid o'clock here so I must sleep, am sure others will be along to input soon. I will be back tomorrow to see what the IMS says

Big hug

Mel
Xxxxx

[khockman]

Not sure exact date - will check with vet tomorrow...I have it written down from old vet before moving...4 years ago, but I also think this was something she may have had recently as well? Going to check on this - is this vaccine given more frequently (like a distemper/parvo booster)? Shes not showing general symptoms of this either. Thanks for all of your brainstorming and questions! Nite-Nite

[Harley PoMMom]

Glynda, one of our Administrators, has searched for other conditions besides Cushing's that can cause calcinosis cutis and appartenly Hypoparathyroidism, systemic blastomycosis, leptospirosis and paecilomycosis are disorders that can be the reason for CC.




Both vets said that cortisol have hit peaks and valley throughout the day depending on when the baseline is taken? I also brought up my concern of Addison’s given too high of a dose. Understanding both UC Davis and Dechra protocol (because of this GREAT forum), it looks like the 60 mg falls at the low end of Dechra given her weight of 55 lbs. What else can CC be caused from…any thoughts :confused::confused::confused:?

Unfortunately there is no test that is 100% accurate at diagnosing Cushing's. When other non-adrenal illnesses are present the LDDS test can create a false positive result.

With the ACTH stimulation test, although it can also create false positive results, it is more unlikely to do so.

There are two blood draws that are taken for the ACTH stim test. The first one is the pre or baseline blood draw, which can fluctuate. The second blood draw is called the post, this is when the dog is injected with a small amount of the synthetic form of ACTH and it stimulates the adrenal glands to produce Cortisol.

Trilostane inhibits the production of cortisol, so when one is giving a prescribed dose to their dog every day the production of cortisol from the adrenals will be limited.

Since a dog with Cushing's has an overabundance of cortisol running through their system, the goal of therapy is to keep the amount of cortisol produced limited to within the therapeutic ranges.

Millie's post cortisol is already in the normal ranges and the Trilostane will lower it more. Signs of too low cortisol are: diarrhea, vomiting, lethargy, and/or the dog just not acting them self. If any one of these is noted than the Trilostane needs to be stopped, and in some cases prednisone should be administered.

Hope I haven't confused you more.

Love and hugs, Lori

[Sabre's Mum]

Hi and welcome to you and Miss Millie Mayhem,

I have been doing a little research to see what new information has come to fruition over the past couple of years with regards to calcinosis cutis.

What concerns me in Millie' case is that the ACTH test is normal. We had a wonderful flowchart link on interpreting the LDDS test but that link now no longer works so I can't remember where the LDDS results point to (I have always referred to this flowchart as it was just so wonderful and I never imprinted into my mind!).

I found this link for calcinosis cutis http://www.vetbook.org/wiki/dog/index.php/Calcinosis_cutis. Generally calcinosis cutis points directly to cushings syndrome. There have however been rare cases of calcinosis cutis which have been caused by other factors which Lori pointed out above.

With the management of calcinosis cutis you are on the right track.

I must admit I am a little perplexed with Millie's test results and the calcinosis cutis given that her ACTH is normal. However an ACTH stim may be normal in some cases of ADH .... which is why I wanted a good explanation of the interpretation of the LDDS test (which has disappeared unfortunately).

What other blood tests has Millie had and what were the abnormal values?

Angela

[labblab]

Hello and welcome from me! Thought I'd go ahead and throw my thoughts into the ring, too. ;)

This is just my personal opinion, but I do believe that Millie's list of classic Cushing's symptoms, the calcinosis cutis, and the positive LDDS all "trump" the ACTH and point to a genuine Cushing's diagnosis. Even though the ACTH is less prone to "false positives" than is the LDDS, it is far more prone to "false negatives," especially for dogs having the adrenal form of the disease. So in a situation such as this, where Millie is so symptomatic but has turned up with a negative on the ACTH, the recommended protocol would indeed be to turn to the LDDS for further confirmation. The abundance of false negatives on the ACTH is probably the main reason why many specialists discount the ACTH as the initial Cushing's testing tool, although I do believe there are situations where the ACTH has a testing advantage (but I won't bore you with an explanation here).

On their own, Millie's LDDS results do not distinguish between the pituitary and adrenal forms of the disease. But her ultrasound is consistent with PDH since both adrenals were enlarged. So if it were me, I would feel as though your vets are making the right decision in pushing ahead with treatment given Millie's entire symptom and testing profile.

One quick question for you: you mention that she is also taking phenobarb. Does she have a seizure disorder? I will come back and add another reply about the phenobarb, but it may end up having an effect on the trilostane dosing down the road.

Marianne

[khockman]

Thank you to everyone! So - as to the question when was her last lepto vaccination - it was in 2009 before we moved. Just talked to the vet and they said they don't really push it anymore because there are so many strains of lepto :confused:? As it relates to the phenobarb, she has been on it a while - 64.8 mg (on pill in morning one at night). She has what was diagnosed to be mild seizures (biting at the air, staring off into space, head tremor).

Back to the ACTH test and LDDS...with the LDDS, I was worried by the fact hat the baseline fell within normal as did the 4 hr and 8 hr (baseline:2.5, 4 hr: 2.4, 8 hr: 2.3 respectively)... The results indicated it is consistent with hyperadrenocorticism but further testing required to determine ADH or PDH (4 hr: >1.5 and >50% of baseline; 8 hr: >1.5 and >50% of baseline). I think the biggest thing was that she did not really supress at all?

All test results for everything are below:

Urinalysis: Sp. Gr. 10.18 (?), Color: lt. yellow, PH: 6.5, Protien:

Trace – Reading handwriting so hope I got this correct…no other values noted.

LDDS: Pre-Dex: 2.5 ug/dL, 4Hr: 2.4 ug/dL, 8Hr: 2.3 ug/dL – I thought it was strange her baseline was within the normal range, but both vets said that it can fluctuate through the day. Also thought since baseline was somewhat normal, I was surprised her calcinosis cutis was SO EXTREME.

Bacterial/Skin Test: I cannot decipher these results, but it was determined she had staph and strep infections.

Biopsy: Clinical Summary – Three week history of erosions, dorsal neck, spreading along the back. Lesions are surrounded by erythematous plaques. White irregular serpiginous plaques on lateral neck. Two punch biopsies of erythematous plaques and one of white plaque. History of allergic disease. Suspect calcinosis cutis. Skin scrapings negative. Cocci seen on cytology. Patient is PU/PD with increased appetite. Gross Description - One container labeled “Millie,” three specimens, six sections in one cassette. 3 skin punch biopsies, bisected and totally submitted as six sections in one cassette, specimens inked blue, yellow, unlinked identification of halves. Diagnosis – Skin biopsies, dorsal plaques: calcinosis cutis, multifocal. The epidermis is acanthotic and suffers multifocal edema and vacuolar degeneration. There is a thick layer of loose orthokeratotic keratin on skin surface. Somewhat cystic follicular keratosis with follicular casts is also evident. The dermis is becoming mineralized. This has incited a granulomatous response and fibrosis. There are also small fragments of mineralized bone in the affected tissue (SHOULD I BE CONCERNED ABOUT THIS…BONE IN TISSUE??). Comment – Clinical Diagnosis of Calcinosis Cutis is confirmed…

ACTH: Time 1: 3, Time 2: 4, Cortisol Sample 1: 2.1 ug/dL, Cortisol Sample 2: 8.5 ug/dL (I believe the vet said this test was inconclusive?)

Superchem: Just reporting “abnormal” – Albumin: 2.1 (LOW), A/G Ration: 0.7 (LOW), Alk Phosphatase: 1704 (HIGH – this seems off the charts to me…normal is 5-131 U/L), Magnesium: 1.4 (LOW), Potassium: 5.6 (HIGH)

CBC: Just reporting “abnormal” – Platelet Count: 595 (HIGH), Differential Neutrophils: 11097, 81% (HIGH)


P.S. - believe me I am all over the poor girl watching for signs for too low cortisol as I am a bit nervous.

[addy]

Hi and Welcome,

I cant help with the test results. I can give you a link to a case study of a dog with calcinosis cutis on his body and face. He did recover, it took six months. I dont want to scare you but rather give you hope. In this case study the dog is being treated with Lysodren but still developed the calcinosis cutis. I thought you might glean something from reading it even though you are using Trilostane.

http://veterinarymedicine.dvm360.com/vetmed/article/articleDetail.jsp?id=659278

My Zoe has mild calcinosis cutis and other skin issues as well. Her skin issues go a lot worse before they got better because our specialist led me down the wrong road for nine months or more regarding her skin.

I know the administrators will be by to recheck your lab work.

Glad you found us.

[khockman]

Yes - you did give me hope! I quickly scanned through (of course analyzing the pics and my girl has same face issues but a little worse down the trunk - it is just awful) and am going to print and read. I know everyone said it is going to be a long haul, but I am ok with it as long as I feel there is hope and as long as I am doing everything possible to make her comfortable. How did your specialist lead you wrong? Right now I am using DMSO and an antibacterial mousse...

Mel also mentioned she used Sudocrem and someone is using Manuka Honey - going to look at both options as well.

[addy]

Mine discouraged me from frequent bathing, did not identify the mild bacteria and yeast though I repeatedly asked if she had it. She just did not know much about skin issues. Many dont here in the States. Ironically she recognized that and told me recently she was attending a conference in June and they had a class on 'Things Internal Medicine Specialists should know about Skin":):):)

Read as much as you can, I cant stress it enough, even if you may not think you understand the articles or technical terms, somewhere down the road, the information may give you an "AHA" moment.

hugs

[labblab]

Me again! As far as Millie's baseline cortisol, your vets are right in saying that the baseline reading does not have any significance for making a Cushng's diagnosis on either the ACTH or LDDS. It is only the subsequent blood draws -- after the testing agents have been administered -- that determine the diagnosis.

Also, in the case of the LDDS, the "normal" reference range is entirely different for the subsequent blood draws than it is for the baseline reading. For most labs, the normal "cut-off" is somewhere around 1.4 or 1.5 ug/dl. This means that if the 8-hour result is greater than the cut-off point, the test result is "positive" for Cushing's. At that point, you take a look at the 4-hour result, as well, in seeing whether the test points the finger at the pituitary rather than the adrenal form. Here's a link that explains the test interpretation in far more detail:

http://veterinarymedicine.dvm360.com/vetmed/Medicine/ClinQuiz-Interpreting-low-dose-dexamethasone-suppr/ArticleStandard/Article/detail/580093

And thanks for the info about the phenobarb. I'll come back and add some more about that in a little while.

Mariannne

[labblab]

Me again, again. :D :D

OK, first a question: I just want to double-check that second number for the ACTH test result. You've written 8.5 ug/dl, and I'm just wondering whether it might instead have been 18.5 ug/dl? That higher number still wouldn't have been conclusive for Cushing's, but it would seem less surprising than the 8.5 which does not reflect any elevation at all.

But regardless, switching to the phenobarb, I have a non-Cushpup who is treated with phenobarb for grand mal seizures. Boy, I have surely discovered that phenobarb interacts with a whole bunch of other drugs! It can be a real pain, sometimes, to find alternatives that don't interfere or compete with it. Phenobarb is known to interact with mitotane (brandname is Lysodren), which is the other commonly prescribed Cushing's med. And while phenobarb is not listed as actively interacting with trilostane, apparently some dosing alterations may be recommended along the way. Here's a related reply that I posted to another member some time ago:


OK, I just spoke with one of Dechra's technical reps, and what he told me pretty much coincides with what you were already thinking. Even though there is no documented interaction between trilostane and phenobarb (he is unaware of any clinical trials that specifically addressed that drug combination), dogs who are being treated with both drugs need to be monotored very diligently both in terms of liver function and also trilostane efficacy. He is aware of dogs that are currently being treated with both drugs, and no particular problems have surfaced thus far. But theoretically, phenobarb's effect on the liver could alter the way in which trilostane is metabolized by any given dog, leading to the potential for trilostane overdosing in the absence of appropriate dosing adjustments.
I believe there has been some discussion that perhaps potassium or sodium bromide might be a better "match" with trilostane because the bromides do not have the same effect on the liver as does phenobarb. But I've recently been reading that the bromides are linked with a higher incidence of pancreatitis, and I think that Cushpups may already be more vulnerable to pancreatitis without adding in another complicating factor. So I don't know that there is a perfect answer in terms of drug preferability.

However, the bottom line is that I'd encourage your vets to call a technical rep at Dechra (manufacturer of brandname Vetoryl) in order to see what their most current advice is re: dosing recommendations for dogs taking phenobarb. That way, you'll know you're getting the most up-to-date advice in this regard.

Marianne

[khockman]

Thanks Marianne…you can offer advice and replies again and again and again! Yes I was correct in stating 8.5 (reference range was 8-17) it did state as you have mentioned, for HAC post results would be greater than 20. Perhaps this is why vet said inconclusive given all other symptoms? I appreciate your comments and information on phenobarb…I will be asking my vet questions regarding that and making sure a call is placed to Dechra

Everyone is offering such good insight and I am doing all I can to read, read and read some more. I would not call myself a dummy, but until all of this, if you asked me what the pituitary does, where the adrenal glands are and what cortisol is, I would have looked at you like a deer in headlights (I know I learned all of this years ago, but have some reason managed to bury it away)!

Positive note is that I think I am still capable of learning :D:D:D

[labblab]

And obviously you are doing a great job re: all that new learning!!! :) :) :)

One more thought does occur to me. I know that increased thirst, urination, and lethargy can also be side effects of phenobarb. Do you think there was any relationship in the timing of the symptom onset for Millie? When we started our non-Cushpup on phenobarb, she really looked and acted just like my pre-treatment Cushing's dog for a while. Fortunately, for us, those symptoms dropped away once she was stabilized on the phenobarb. But it does cross my mind to ask about that since we are basing Millie's diagnosis partly on those symptoms being part of her profile.

[khockman]

Well - I would not be even close to knowledgeable without all of you!!! You bring up a great thing to think about phenobarb, but, she has been on it a LONG time – I would guess 6-7 years.

P.S. Noticed we are in the same state too! Hope your puppy is doing well!

[Budsters Mom]

Hi Kerry,
Just popping in to tell you that you're doing a great job! :)I warned you in my welcome that there would be lots of questions!;) Yes, Marianne asks a ton of questions, but you can really learn a lot from her! I certainly continue to do so.;) My life is so much richer since I found this wonderful group of angels. Hugs to you and a belly rub for Millie.
Kathy

[Mel-Tia]

Hello there

How you both doing today? hope she hasn't been at her face again and that you are having a good day today

Big hug, belly rubs to Miss Mayhem

Mel
Xxxx

[khockman]

She loves all her hugs, belly rubs and kisses coming her way. She’ll be most excited I am sure when one day we can actually tickle her back, neck and face. So the update on calls today – We have a GP, Dermatologist and IMS that have all looked at her (IMS did ultrasound and I asked Dermatologist to consult with him as well on other test results and Trilostane dosage). All three vets are in unison with the 60mg to start, so hoping we are on the right path! Dermatologist wants my local GP to treat the Cushings as determined and monitor through testing (ACTH is scheduled a week for tomorrow – 11 days after initial Trilostane was started), and she will follow treatment of Calcinosis Cutis – stating they will work in coordination. Do you all feel like this sounds like a good plan? I also asked Dermatologist about possibility of Atypical Cushings and she was very fluent as to her response as to why it would not be that (although I really need to call her back and clarify as I was not in the right state of mind to listen to her answer).

I also asked her about the possibility of using Sudocrem or Manuka honey. She asked me to stay the course and said no to the Sudocrem and said honey did cross her mind, but given the extent of the problem, thought it would be an unbelievable mess – which I probably can concur with – although it would smell a heck of a lot better than the rotten garlic smell of DMSO…I will never get garlic on pizza again! When I say stay the course, she is a little too difficult to bathe right now and makes her so uncomfortable, so we are using an antibacterial mousse (once a day on all lesions: face, neck, trunk) – It is DUOXA Chlorhexidine + Climbazole Mousse with phytoshingosine. She is not thrilled when this goes on her face cheeks and I feel it may be hurting her – anyone have experience with this? She also gave us Comfort Spray by Animal Pharmaceuticals which she recommended spraying on face 2-3 per day. Millie will have nothing to do with a spray bottle coming at her face, so she recommended soaking a paper towel and dabbing. We tried this and felt like she was irritated by this as well –again, anyone have experience with this?

Love to all of you kind souls. How blessed I am to have you on my side – looking forward to getting to know your puppies better. I feel like all you are doing is taking care me right now and I know you all have many things you are dealing with as well!

Xoxox,
Kerry

[Mel-Tia]

Hey, I should have added that Tia didn't have open sores when we used the sudocream so it may still be an option once you have got to the stage where it dries up as it will, then scab then those scabs should fall off and eventually I really hope you will see hair and that's such a great feeling...

I have to say that I would watch Millie like a hawk for change in behaviour and if she refused food, seems off or whatever hold her vetoryl, get her in for the ACTH as her cortisol wasn't raging on her tests. Read the vetoryl insert and make yourself familiar with what to look out for. I don't want to scare you just want to help

Diarreah is also another sign that the cortisol is low

Big hug, hoping Mille can get kisses soon

Mel
Xxxxx

[Mel-Tia]

And ask here any time if you are worried. We have awesome people like Marianne Glynda Lori Leslie Debbie Sharlene Addy and John who have way more knowledge than me. There is always usually someone who will help :)

[khockman]

Thanks Mel - yes, watching her like a hawk! I am fortunate enough that my office is out of my home. All signs are good thus far, but I am looking for any of those signs which would show low cortisol as you mentioned. I've been reading more and have seen info on Cortisol:Creatine Ratio - any idea if this is something done during a urinalysis - I cannot find this in any tests that were done for Millie (or maybe vet just did not give to me). I guess I would be interested to see if that was relatively normal - If so it should have ruled out cushings...I guess my new motto is question everything!

I know she has all the signs, I just worry, worry, worry!

P.S. she is lerthargic, but for the past year she has done alot of lounging around and since the weakness in legs, she is not very active...not sure how I would tell if she gets MORE lethargic.

xoxoxo

[StarDeb55]

In answer to your question about the UCCR ( urine cortisol: creatinine ratio), it is not part of a routine urinalysis. You have to request this test separately. It is a screening test for Cushing's, negative means you ARE NOT dealing with Cushing's, positive simply means that Cushing's is a possibility, further testing required. IMO, since you have started trilo, I think you are past the point of a UCCR providing useful information. Let's see what other members have to say.

Debbie

[Sabre's Mum]

Hi Kerry,

It looks as though you have had some good advice and feedback since the lady from down under is able to get back online (ie me from NZ). I have not used DSMO (not available in NZ) but I would just note a word of warning with the use when I did research it that they do not recommend to use it on more than a certain percentage of the body. For the life of me I am not able to recall what it is but just wanted to give you a heads up just in case your vet did not enlighten you on this. You may find that Millie's areas are well within this.

You are doing a fantastic job in educating yourself ... well done!

Angela

[Mel-Tia]

Morning Kerry

I forgot we also used a topical steroid spray called cortavance to dry up her scabs when they were bad. That might be an option. Same rules as Angela mentioned though only can use on a certain % of the body

Tia was a lazy mare too, so I always used to say not sure how I could measure that!

Big hug

Mel
Xxxx

[khockman]

Thanks All - yes we alternate DMSO application - 1 day she gets neck and face, the next day she gets trunk/back. I will look into cortavance too. I am sending the following to the vet just to get some more documented answers, which she has probably already given to me, but I seem to only retain half of what verbally comes to me...emotions getting in the way. Are there any other questions I should ask?

1) Why atypical cushings has been ruled out?

2) Why baseline cortisol level for LDDS was not elevated as would be expected with cushings, and why 4 he and 8 hr were almost the same as baseline - can you help me decipher the meaning you took away from this?

3) why the ACTH was considered inconclusive?

4) was a cortisol: creatine ratio ever measured by yourself or general practitioner that you are aware of?

5) the ultrasound states for kidneys - bilateral dystrophic mineralization, small non-obstructing nephroliths - what does that mean?

[khockman]

So this was what I got back from the vet re: my questions - was curious if anyone has a comments or thoughts - HELP...anything else I should be asking?:

1) Why atypical cushings has been ruled out? Atypical Cushing's is when sex hormones are elevated only, without elevation of cortisol. (Some people also use this terminology for dogs that don't have typical Cushing's symptoms such as increased urination and drinking). We don't know if the sex hormones are elevated, but it doesn't matter, because the cortisol is elevated and that's what we monitor.

2) Why baseline cortisol level for LDDS was not elevated as would be expected with cushings, and why 4 hr and 8 hr were almost the same as baseline - can you help me decipher the meaning you took away from this? Baseline cortisol is not always elevated, we are usually more concerned with the cortisol after the injection is given. The cortisol should go below a certain value in a normal dog. In a dog with pituitary dependent Cushing's usually the cortisol suppresses, then escapes. In dogs with adrenal tumors we very often see that the cortisol does not suppress at all (like Millie's) but this can sometimes also happen with pituitary dependent.

3) why the ACTH was considered inconclusive? In a dog with iatrogenic Cushing's, the cortisol does not go up (or stimulate). With naturally occurring Cushing's, the cortisol goes up over a certain value, typically 20. The reason I say inconclusive instead of negative is because we still had a strong suspicion for Cushing's even though the test was not obviously positive for Cushing's.

4) was a cortisol: creatine ratio ever measured by yourself or GP that you are aware of? No. This is a screening test that isn't very reliable. A negative means they most likely don't have Cushing's. A positive result means that they might have Cushing's (which we already had a strong suspicion for). No need to add this test now.

5) the ultrasound states for kidneys - bilateral dystrophic mineralization, small non-obstructing nephroliths - what does that mean? Dystrophic mineralization means that there is calcium (presumably vs other mineral) being deposited into the kidneys diffusely, just like it is occurring in the skin. Nephroliths means that there are kidney stones, but they are not in an area that is obstructing urine flow.

Thanks so much for any input!!!

[labblab]

I think all the answers are right on the mark. This vet sounds like a keeper. ;) :)

Marianne

[molly muffin]

I was just thinking that too Marianne. :)
Your vet answered your questions promptly and knowledgably. That can be a real rarity in the cushings world.
I am hoping that this means that her game plan to get the cc under control will also pan out. Just realize that it does take time. It is one of the hardest symptoms to get under control and usually one of the last.
I have high hopes though. :)

Sharlene and Molly Muffin

[Mel-Tia]

Sorry I didn't check in yesterday we had a very sad day, I saw you posted on each of their threads am sure both Vicki and Kathy will appreciate that.

Just wondered how you were both getting on today?

Big hug and stored kisses for Millie

Mel
Xxxxxx

[khockman]

Yes - very sad day in the forum yesterday - can't even imagine the pain they are both feeling. But amazing the love and understandning that strangers connected by one thing can share. Such things renew my faith in humankind! Sharlene and Marianne brought some positive vibes to us last night and helped us to know that it looks like we are in good hands. Today is the 5th day on Trilostane and not seeing that much of a difference. The CC is not progressing as rapidly but the poor girl looks like a hot mess. She sleeps alot, is a little slow when we take her out, but good thing is no accidents in the house. The biggest issues are her lack of energy, the CC, and weakness in rear legs - she can go down steps, just not up a flight. I have a spreadsheet that helps me keep up with all of her drugs and various spray/cream/gel applications as well as a journal. I was hoping to see a little more spunk, but I know I have to be patient which I am not good at :mad::mad:! Appreciate you checking in on me.

xoxox,
Kerry and Miss Millie

[addy]

You might not see spunk right away. Sometimes when their cortisol is dropping, and Trilostane can make it drop like a ton of bricks, they may feel yucky until they get used to the lower cortisol, kind of like withdrawals. The hind leg weakness can take awhile to improve if they have lost a lot of muscle.

[khockman]

The tramadol and phenobarb probably don't help either, but she has dropped from 3 to 2 tramadol a day... So maybe that will help!

[Mel-Tia]

It's such a great feeling when you do, it's a long road with the cc. Tia's took over 6 months to clear up properly but it did so there is no reason why Millie's shouldn't.

Hope you are both having a good day today

Mel
Xxxxx

[Budsters Mom]

Hi Kerry,
I have noticed that you have been following Buddy's thread very closely and I'm honored.:) Having said that, you are a newbie and I don't want you to get spooked by what you have/are reading. Buddy had a pituitary macro-tumor. Most of our fur babies do just fine with treatment. Please remember that as you continue to read Buddy's thread. Big hugs to you and our precious Millie.

[molly muffin]

I was thinking just today that it could take longer to clear up the cc since there is also staff present which can be quite hard to get rid of too. Millie is on antibiotics for that right?

Sharlene and Molly Muffin

[khockman]

Wow Kathy - even in a time where you need not be worrying about anyone else, you do! Know how very special you are. You were the first to welcome me with open arms to let me know there are people to help. I can't even explain how comforting that was as I have sat around shedding endless tears worrying. You are completely selfless and that is another reason I follow your journey. I thank you for being such a great example of kindness...I bet Buddy taught you some of that cause I can see it in his eyes :)!

I am not spooked - I am grateful there is a group to share experiences and support!

xoxox,
Kerry

[khockman]

Hi Sharlene - yes she had Staff and Strep - she is on Clindamycin and Rilexine. On second visit to Dermatologist, the Derm said infections were getting better but to still stay on the meds.

Thanks for checking in!
Kerry

[Trixie]

Hi Kerry,
Been meaning to chime in and say welcome. Seems like everyone's been on giving you good advice. Millie looks like such a sweetie. Sorry the skin problem is is so stubborn and causing Millie discomfort.
My dog's symptoms were pretty slow to subside...we're still tweaking the dose and things are starting to get a bit better.
I hope Millie starts to improve really soon! :)
Barbara

[Peety's Fur-mom]

Hi Kerry, I just read all your posts. So sorry you are dealing with everything. It becomes all consuming. You want to know all you can as fast as you can. Everyone here has great advice, and with that you add in your own research and you end up never feeling like you can relax. It's like overload from day one, :eek::eek::eek: when you find yourself thrown into this crazy world. I have had dogs all my life and I have never heard of any of this until now. But from day one you know what you have to do and you just keep doing all you can until you see some positive results.

With regard to the CC, I have been told and have also read that this could last a very long time. And as long as Peety is doing good I can see past the CC. In the beginning I didn't think that. His first Vet overloaded him with meds and he was so sick. Wouldn't eat, I tried everything. I finally took him off all the meds and he finally came around. Then I changed Vets, and the next one didn't have any practical experience with skin disorders, so put him on prednisone. That proved to be a disaster. And the Vet couldn't really offer me anything that I didn't already know. So referred me to a Derm Dr. Huge disappointment for me and Peety. We are now going to a reliable, trustworthy Dr. I've know many years. She does not believe he has cushing's but thinks his CC came from the prednisone. We are watching him closely for any signs. So far no symptoms at all. But Peety is almost 12 so we are looking at any senior health issues. I am happy that he is doing so well. He gets a vitamin, omega3 and brewers yeast, and lots of hugs and kisses. I don't make myself crazy analyzing everything he does everyday, but I do watch for any changes in any of his routines. And I make every day count for him. That's all I can do right now. He is my crazy lil guy that makes me laugh when he's not even trying to.

Hang in there, tomorrow is another day, with more information and even more questions. But we can do it because our precious lil ones are counting on us. Big hugs for Millie

hugs, Pat

[Sabre's Mum]

Hi Kerry,

Just a word of warning with the calcinosis cutis .... it is likely to worse before it gets better. The biggest thing is to control any infections and you are doing the right thing with the antibiotics. Personally I would recommend that all infections are clear before you stop the antibiotics.

Generally it takes 4 - 6 months before it just "remains there" without causing issues.

Angela and Flynn

[khockman]

Thanks Angela - I appreciate the input on the antibiotics. Do you know if there are any issues that would arise from keeping her on too long - if not, the longer the better in my eyes...I do not want to have to continue dealing with infection on top of everything else!

And Angela, Pat & Barbara - would be interested in your thoughts on this - as things are drying up, her pinkish colored skin seems so dry (maybe it is actually the calcium that's causing it to look this way?). If it were me I would want soothing cream rubbed all over - we have never given any types of supplements like omega3/fish oil...would this help?

Want to do everything I can!

xoxox,
Kerry

[Tina]

Hi Kerry,
A very belated welcome to you and Millie. I am so sorry you are dealing with this, it is a tough thing to get under control. I am sorry that I can't offer any advice on if there is any cream that would help her skin, hopefully some of the others that have dealt with it directly can advise you. I do know that fish oil supplement is good for their skin and coat overall, as well as promoting kidney health, joint function and health immune system, among other things. It is certainly something you could ask your vet about. My pup Jasper gets it on his food twice a day specifically for kidney and cholesterol issues, but it has really helped his dry skin.

Your avatar pic is so cute, she is adorable.

Hugs,
Tina and Jasper

[khockman]

Thanks Tina - I am going to sound really ignorant, but is it a pill you put on the food, or drops?

Jasper is a mighty fine looking looking lad as well!

xoxox,
Kerry

[Tina]

You don't sound ignorant at all! It is a liquid, the brand my vet prescribes is Welactin, but there are many different brands of omega-3 supplements for dogs. Mine comes with a little spoon and I just measure 1/2 a spoonful on his food twice a day. There probably are pills that could be punctured and put on the food but I think that would be messy.

Thanks Kerry, I wish I had a better pic of Jasper, but he doesn't like his picture taken, he has become afraid of the sound my phone or camera make. When I try to get a picture he runs off and hides. So the avatar pic is the best I have unfortunately!

Hugs,
Tina and Jasper

[Peety's Fur-mom]

Kerry, you can also try using coconut oil on her skin. I use it on Peety and it does keep the skin moist. Make sure to get pure coconut oil. I have Peety on omega3. I bought on line at 1-800-petmeds. It's a capsule, that I puncture. I like the idea that Tina has a liquid. But this works ok, maybe next time I order I'll look into that. Aloe Vera is also good. The one I have I got at the pet store and it is especially for dogs. There's a lot of things you can use. I try to stay as close to natural as I can. When his sores were real bad, I would bath him in Hibiclens and then put Neosporin on the sores. It was a while before I could use anything else. You will get very good at knowing what is good and what makes her feel better. And as the disease gets better you will even change your routine again. Right now, though just focus on keeping her clean and free of infections. That's real important. You're doing great and your love for her will also help you make right choices for her.

Hugs, Pat and Peety

[Sabre's Mum]

Hi Kerry,

We used a couple of things along the way with Sabre... we started off supplementing with Fish oil .... and then we then tried EPO (evening primrose oil). There are some research studies on the use of EPO for skin issues in dogs but last time I searched I had difficulty finding them!!! We also added Flaxseed oil to his food. Sabre was fed a raw diet.

Angela and Flynn

[khockman]

Thanks for all the input! I just emailed our Dermatologist and asked her what her thoughts on Cocunut Oil and Fish Oil given Millie's condition. I am so happy my Derm is not ready to kill me yet with everything I email her way...oh well - gotta do what we gotta do :D!

I will ask about EPO and flaxseed in my next email to her. Thanks again to all of you.

Was also just told about a vet who also practices acupuncture and has a mobile veterinary hospital (and is located only about 50 minutes from us). She came highly recommended and I thought wow, this is interetsing. Looked up vet and saw:

Dr. Betz offers several types of alternative medicine such as acupuncture and “veterinary” chiropractic. She has completed over 200 hours of coursework in acupuncture and recently graduated from the only U.S. Department of Education accredited Veterinary “chiropractic” school.

Any one have anythoughts on cushings, calcinosis cutis and acupuncture (as a supplement to everythig else we are doing)?

xoxox,
Kerry

[Budsters Mom]

Hi Kerry and Millie,
I mailed tons of stuff to my vet, because they didn't know diddly squat about Cushing's protocol. My personal vet was the only one that knew, but he was on leave at the time.:o You are protecting your baby. That is a mother's job! Do not ever worry about contacting them with questions or concerns. That is their job! You are doing a terrific job Kerry! If they mess up, it's not gonna be with your baby!XXXXX

[molly muffin]

Several of our members have used acupuncture. I know Jackie has used it with Ugga, a french bulldog with cc also.

this is her thread:

http://www.k9cushings.com/forum/showthread.php?t=3956

Sharlene and Molly Muffin

[jackiev]

Hi Kerry. I don't get on here as much as I'd like but your thread caught my eye so I wanted to pop in and say hi. I am so sorry you are going through this with your girl. My frenchie, Ugga, has CC as well. He takes Vetoryl (30mg BID) and I take him for acupuncture. The acupuncture has done wonders for his skin, it's really quite fascinating. He doesn't look and feel like an alien anymore, he actually has hair! Most people think I'm nuts for taking my dog for acupuncture but I don't care, it works. I did post some pics on my profile, some of them are pretty gross so if you do look, do so at your own risk ;). Some other things we've used are: ketochlor shampoo, humilac spray, and an herbal salve (I think i posted some pics of that as well). The super stinky brown chinese herbal salve worked the best (in conjunction with the acupuncture). Best of luck to you and Miss Millie Mayhem :)

Hugs,
Jackie and Ugga

[khockman]

Thanks everyone, I very much appreciate the input!

Jackie - what a sweet frenchie - how soon did you start taking ugga to an acupuncturist? Did you wait until open sores were cleared up?

Also would appreciate any words of advice or input - I take Millie Tuesday for her ACTH test (it will be 11 days since her first does of Trilostane. Are there other things that I should ensure are tested at this point - I've read electrolytes (can someone explain?), potassium? Other? Want to make sure while she is there that I get every possible thing done that will help us to continue to manage! THANK YOU ALL!

xoxox,
Kerry

[molly muffin]

Give Millie her regular does of med in the morning with a bit of food. The ACTH test needs to be completed at about the 4 hour mark, start, redraw an hour later. Completed all together within 4-6 hours of that first dose.
Electrolytes, like sodium and potassium is one of those things that can get out of wack if the cortisol gets too low or anything. Just a good idea to train your vet to do those every time they do the ACTH test.
Have a good weekend.

Sharlene and Molly Muffin

[khockman]

Thanks Sharlene - so I should just make sure that when dong the ACTH test, my vet also tests for potassium, sodium and electrolytes? Correct? Would these be tested through a blood sample before the ACTH test is done?

[molly muffin]

Just ask for electrolytest to be checked too. They do the blood draw for that prior to the ACTH test.

You'll be just fine you have all your ducks in a row so to speak.

Remember to get copies of all test results, past and future, train them to just give them to you, so you have them. We all basically keep files on our furbabies these days. It is soo much easier and the couple times I have had to go to the ER for various reasons for Molly, I go with file in hand. :)

hugs,
Sharlene and Molly Muffin

[khockman]

Thanks Sharlene - I may have all my ducks in a row so to speak, but I think sometimes I am losing my marbles!:D

[Budsters Mom]

Most of us have already lost our marbles. Join the crowd!:D xxxxxx

[molly muffin]

Hmmmm Isn't there a game you play with marbles LOL Does that mwan we can oe can!t play with our head ROFL

(couldn't resist) :D:D

sharlene and molly muffin

[jackiev]

Hi Kerry! We did not wait until his sores healed but my vet had to get a little creative with some of the acupuncture points as the needles cannot go into the lesions. Ugga was in bad shape and the acupuncture was our last hope, we just wanted to start him ASAP. We are so thankful we've had such great results! I hope all goes well with Miss Millie's stim test today :)

Hugs,
Jackie and Ugga

[khockman]

Hello all - Millie had her ACTH test done today (11 days after start of Trilo), I also requested electrolytes be tested...here are the results:

Na - 152 mmol/L (normal range: 144 - 160) - right in the middle of normal
K - 5.7 mmol/L (normal range 3.5 - 5.8) - she was at high end of normal
Na/K - 27 (no refernce range given)
Cl - 126 mmol/L (normal range: 109 - 122) - she fell under HIGH but at the lower end

So, what am I supposed to be looking for??? Should I be concerned with the HIGH Cl?

Would love any of your opinions and thoughts as this is too new to me! Will also post ACTH results tomorrow for input. Just bought some USDA certified organic extra virgin coconut oil...should I bathe her and then gently rub some on her? keep in mind she is half hairless from this awful calcinosos cutis...any advice...pretty please :D

xoxox,
Kerry

[Harley PoMMom]

Millie's high normal potassium (K) is what I am a bit concerned with but Trilostane can increase potassium levels, I would just keep a close eye on both sodium (Na) and the potassium to make sure they do not get too unbalanced.

Did the vet mention when her ACTH stim test results would be in?

[khockman]

Results hopefully in tomorrow! Thanks for input on electrolytes...

[molly muffin]

Lori, covered the elctrolyte results for you.
What I would say is that tests are there to not only give you current information but as a source by which to compare how treatments are working. That is one of the reasons that we all keep records of all our tests.
It's taken me Months literally to see a positive change in Molly's liver values, based on the liver supplements she is on. It's a way to gauge from where you are to where you want to be and how you are going to get there.

Hugs
Sharlene and Molly Muffin

[khockman]

Vet called...Just got the results back from her 11 day ACTH test following Millie's start on Trilostane. For reference I am posting the ACTH results pre-treatment as well:

Pre-Treatment:
Cortisol Sample 1: 2.1 ug/dL
Cortisol Sample 2: 8.5 ug/dL

11 Day ACTH:
Cortisol Sample 1: 0.8 ug/dL
Cortisol Sample 2: 5.0 ug/dL

Vet seems to think this all looks good? Thoughts? I have not seen much improvement in her clinical signs other then she is not as ravenous eating (still a healthy eater though). Still drinking a lot, Calcinosis Cutis still horrible, hind legs still weak. She has shown bits of he personality here and there, but just not where I was hoping she would be after 12 days :( We are sad that we have not seen much improvement, especially when i read that majority of dogs show good improvement within first 14 days...

Thanks,
Kerry

[spdd]

Don't get discouraged with lack of improvement. My dog was 18 days in and then some - on meds and we still aren't sure about the diagnosis. You are doing all you can and the people here are great with test results. They will tell you what they think... hopefully Miss Millie will be feeling better real soon.

[addy]

Vet called...Just got the results back from her 11 day ACTH test following Millie's start on Trilostane. For reference I am posting the ACTH results pre-treatment as well:

Pre-Treatment:
Cortisol Sample 1: 2.1 ug/dL
Cortisol Sample 2: 8.5 ug/dL

11 Day ACTH:
Cortisol Sample 1: 0.8 ug/dL
Cortisol Sample 2: 5.0 ug/dL


Do you have the lab's reference range for the pre ACTH test?
I am no expert but something is off somehow. Is that the original ACTH test to diagnosis is inclusive as it shows normal cortisol?

Coritsol sample one after 11 days is pretty low. Dechra prefers it not go below 1.45ug/dl.
Cortisol sample 2 is fine.

I am sure one of the administrators will stop by with thoughts.

[khockman]

Oh no, that's what I thought. Now I am so worried...just called Dechra..:confused::confused::confused:

[addy]

Yup call Dechra and check, I could be wrong, I am at work.

[Trixie]

Wish I could help with numbers...but I'm no expert. Just posting to say I hope all is okay with Millie and that you're able to find out about this result today.
Barbara

[addy]

Interpreting acth tests goes along with symptoms and history. I may just be nervous of a .8 pre after 11 days of dosing. What I don’t understand is the pre treatment numbers.
I’ll bump this up.

[khockman]

Thx addy... Would it be helpful if I emailed the actual test result papers so they can be uploaded? Should I send all as one file if so?

[Harley PoMMom]

Interpreting acth tests goes along with symptoms and history. I may just be nervous of a .8 pre after 11 days of dosing. What I don’t understand is the pre treatment numbers.
I’ll bump this up.

I was a bit baffled about those pre treatment ACTH results but Marianne had explained it well in the quote below:

Hello and welcome from me! Thought I'd go ahead and throw my thoughts into the ring, too. ;)

This is just my personal opinion, but I do believe that Millie's list of classic Cushing's symptoms, the calcinosis cutis, and the positive LDDS all "trump" the ACTH and point to a genuine Cushing's diagnosis. Even though the ACTH is less prone to "false positives" than is the LDDS, it is far more prone to "false negatives," especially for dogs having the adrenal form of the disease. So in a situation such as this, where Millie is so symptomatic but has turned up with a negative on the ACTH, the recommended protocol would indeed be to turn to the LDDS for further confirmation. The abundance of false negatives on the ACTH is probably the main reason why many specialists discount the ACTH as the initial Cushing's testing tool, although I do believe there are situations where the ACTH has a testing advantage (but I won't bore you with an explanation here).

On their own, Millie's LDDS results do not distinguish between the pituitary and adrenal forms of the disease. But her ultrasound is consistent with PDH since both adrenals were enlarged. So if it were me, I would feel as though your vets are making the right decision in pushing ahead with treatment given Millie's entire symptom and testing profile.

One quick question for you: you mention that she is also taking phenobarb. Does she have a seizure disorder? I will come back and add another reply about the phenobarb, but it may end up having an effect on the trilostane dosing down the road.

Marianne

With Millie's recent ACTH results I hope that the dose of Trilostane was not increased because the numbers can continue to decline.

[labblab]

Hello again, and darn! I'm sorry there's any question at all about those ACTH results. But I'm glad you're contacting Dechra because I'd like to get their "take" on things, especially given the fact that Millie is also taking phenobarb. I think I wrote earlier that a Dechra technical rep had warned me in the past that trilo dosages may need to be adjusted due to phenobarb's effect on the liver and therefore the way in which other drugs may end up being metabolized. So do be sure to mention the phenobarb to them.

We never used to worry very much about the "pre" ACTH number, but it does seem as though Dechra is not happy about results that drop below 1.45 ug/dl on either the pre or the post. So I'd welcome their input. With a "post" of 5.0 and electrolytes within range, I don't think Millie is in any immediate danger of oversuppression, but Dechra may advise you back off on the trilo dose somewhat. Which I realize will be disappointing since you are not seeing much improvement thus far. I do have to warn you that issues with the skin and muscle wasting can take weeks to improve -- not just days :o. So even when trilo is at a therapeutic dose, it is usually the thirst, urination and hunger that improve before the rest. Since excessive thirst and urination can also be a side effect of phenobarb, I'm still wondering whether that can be confounding her symptom pattern at all. But I think you told us earlier that she had not had those issues while taking phenobarb before her diagnosis, so I guess that's probably a dead end.

It is certainly true that Millie's diagnostic ACTH remains a bit of a puzzle in that it was so far below the level associated with a Cushing's diagnosis. I was kinda hoping that everything would go swimmingly with the trilostane and you'd be seeing symptom improvement such that we'd feel as though we had additional confirmation that we're totally on the right track. And maybe with just a bit more dose tweaking, that will still be the case. But regardless, I'm really glad you're consulting Dechra and I'll be very interested in what they advise you to do in moving forward.

Marianne

[molly muffin]

You said you called Dechra? What did they say?

Sometimes when the pre number is on the low end, they will recommend, lowering the dosage, so as to have no risk of over suppressing. Personally I don't like that pre number being that low since cortisol levels can continue to drop even up to and sometimes beyond 30 days. Since her cortisol wasn't particularly high to begin with, I'd like the pre number around the Dechra recommended range of as Addy mentioned 1.45. With the post number around 3. - 5. if I had a preference. I seldom get exactly when I want especially with little ones with a mind of their own. That is just my own personal thought on the numbers. I'm sure some of the administrators who have a vast amount of experience will chip in with their thoughts.

Don't be discouraged by not having symptoms of cc cleared up yet. That along with muscle weakness can take the longest to clear. Months even. So hang in there.

Hang in there!!!
hugs,
Sharlene and Molly Muffin

[molly muffin]

I see Marianne and I were typing at the same time. :) Glad she saw this and was able to respond.
I agree, it would be great to know what Dechra's interpretation is, especially in relationship to the phenobarb

hugs,
Sharlene and Molly Muffin

[khockman]

Hi all! And thanks for your encouragement and guidance - I just hate that my girl is going through all of this!

Update – Called Dechra,

So I called Dechra and spent about 30 minutes on the phone with one of their “techs“ (she even reached out to one of their on-staff Doctors to confirm a question I had about her Chloride level that she wanted to make sure she got additional input on!). She started a case for Miss Millie and now has all of her medications, notes on test performed, dermatology specialist contact info, general vet contact info, and notes on our discussion. So here are some of the key points I learned in my most non-technical understanding

1 – as it relates to her taking phenobarbital, she doesn’t feel that there will be much impact, however, for Cushing dogs that did show more of the elevated cortisol levels, sometimes reducing those levels can cause seizures to come back (cortisol can sometimes help suppress seizures with the phenobarb). Because Millie was not significantly high to begin with, the drop will probably not impact her tendency for small seizures.

2 – As it relates to checking electrolytes, I learned the following…when treating dog, one thing that they look at it through electrolyte testing that causes a warning flag to be raised is if Sodium decreases and Potassium increases (if Chloride tested, if that decreases is looked at). This can be compared to previous electrolyte test and the ratio of sodium/potassium (Na/K) can also be compared. If ratio goes down (meaning sodium is going down and potassium is going up), that is something to keep an eye on and can (I believe) be a warning that dog is trending toward an Addisonian state (which is life threatening)

3 – Millie’s ACTH baseline 11 days after Trilostane treatment was 0.8 and post ACTH was 5.0 (this baseline is considered low for a dog being treated – they do not like to see lower than 1.45 for pre or post ACTH), however, given Millie’s other testing, she was not overly surprised by this as her first ACTH test she really presented within normal ranges and hence the test was ruled inconclusive. She did say 0.8 would be in the normal range for a “normal” dog not being treated for Cushings. She said unfortunately, Millie is not a textbook Cushings Dog when it comes to the testing results, but all of her clinical signs and some testing signs certainly indicate Cushings.

I will be contacting my vet tomorrow as she did say that it is highly recommended given the results that Millie return for another ACTH test in 2 weeks and that she be monitored well in those two weeks. Any adjustments to dosing could take place then...as for now - no change (especially because I have the good fortune to really monitor her since I work from a home office - the Dechra Rep did state that she would be more concerned with someone who did not have the ability to be so vigilant). She also said she would be calling me to follow-up soon thereafter (was amazed to hear that and very appreciative). Just another voice that can help me be more educated managing this awful disease.

I know many of you were interested in how the call went, so I tried to learn as much as I could while I had her on the phone!

Thanks for all the encouragement as this is SOOOO frustrating as I just want a magic pill...make that 2...one for Millie and one for me. I honestly think I have gained 10 lbs in the past 3 weeks cause I can't stop popping M&M's in my mouth as a stress reliever! I fear stepping on the scale!

xoxox,
Kerry (Millie's Mama)

[molly muffin]

It sounds like you had a good call with Dechra. It is great that they will be calling you back to check on her. I agree if you weren't working from home it would be more risky than since you are and are able to keep an eye on her.

Sounds like you found a pill for you (m&m) just not the right one maybe. LOL Stay away from the scale!!

Just watch her and if anything looks off, back for an ACTH and elctrolyte test. :)

You're doing great!
hugs,
Sharlene and Molly muffin

[addy]

I am so glad you called. :):):)

It sounds like a good conversation. Great job , Mom:):)

[khockman]

Thanks Addy and Sharlene,

FYI, I have finally gotten up the courage to post my girls journey thus far with Calcinosis Cutis. It is AWFUL, but I figure if anyone else is out there needing to see pics, this may help (please let others know if you come across anyone struggling with this). I know I always wanted pics to look at to see if there were any similarities.


http://www.k9cushings.com/forum/album.php?albumid=704

xoxox,
Kerry

[addy]

I know it was hard for you to post the pictures but it may help someone else, you are so right. Zoe's hair loss was down her back through the spine area as well, almost the exact spots. Her cc did not progress to what Miss Millie's did. She just has the hyper pigmentation and small hard pimples looking bumps and on top of that she got brownish oily spots with scales and it looked like crusty spots, hard to explain. Zoe had two surgeries as well so was shaved in two different spots, that did not help her either. Then the back feet and legs got bad after the last surgery,they had also shaved her thighs, her butt, etc.

The pictures I posted last year of her hair loss are nothing compared to how she looked in March and April after her surgery.

Miss Millie's came on so fast, from one spot. In the last photo, her skin is not as red and angry looking.

I know how hard it is. You have a beloved pup with a beautiful coat and all of a sudden they look so painful and we just want to make them better as fast as we can.

Keep the faith, sweetie. It is what we all must do:):)

[khockman]

Thanks addy! It is hard to keep the tears back and was hard for me to post those pictures. I appreciate the words of encouragement... Definitely helps!

Xoxox,
Kerry

[MBK]

A belated welcome from me and Alivia. A lot of our dogs here have had difficult skin problems. Alivia's were much more worrisome to me than her Cushing's symptoms. Her backend looked awful for awhile and broke my heart just looking at it. I totally understand what you mean when you say you wish she could tell you what helped her and what caused more discomfort. It was very brave of you to post Millie's pictures. We all learn from each other. I so hope you are able to find what works for Millie and that your beautiful girl recovers quickly. You obviously are doing everything in your power to help her. She is lucky to have you.

Hang in there.

[Budsters Mom]

Kerry, you were so brave posting those photos. :o You love Millie so much that you were willing to do anything to help her. We totally understand and are right there with you. It is okay to cry, to meltdown, or start to crumble. It is perfectly understandable. This forum has picked me up and dusted me off a few dozen times after I have hit bottom. We are here for Kerry. Even if you don't feel like talking. Post a message that you're there, and we'll send you tons of love. Xxxxxx

[Harley PoMMom]

Hi Kerry,

I am so sorry Miss Millie is having skin issues :( and I hope that it will soon improve, this Cushing's is a dratted disease.:mad:

It is so very hard to see them not feeling well, and we so do understand how you feel...we are here for you both.

Thanks so much for posting the conversation you had with Dechra, I am always so interested in what they have to say and what they recommend, so Thanks again.

Love and hugs, Lori

[molly muffin]

Amazing that it progressed that fast in 5 weeks. I do agree with Addy that it doesn't look as red in the last or first photo of 5 weeks. I don't know if that is the angle or what though. What do you think? to me it doesn't.
What did it first start out as? that first bump? small white, or a sore type of spot?
It really can take awhile for the cc to resolve. The idea, seems to be that the cortisol levels need to be low enough that she isn't having any kind of build up in her system, allowing calcium deposits to go away.
It is a bugger, but I do think you are on the right track here. Just a matter of keeping an eye on her so she doesn't go too low. You didn't start out with any high numbers, so that is real important. Give it time! patience grasshopper! LOL
Posting the pictures is a very good thing though. Thank you!

hugs,
Sharlene and molly muffin

[Peety's Fur-mom]

Kerry, the pictures made me cry. I'm so sorry for Miss Mille and for you my dear. You are doing everything you can and she knows how much you love her. Is this painful? Peety was sore in the beginning and he just didn't want me to touch him. In the beginning I would hold him and cry as I "promised" him I would make it better. The one thing I relied on and still do to keep the infections down was the Hibiclens. And now he loves his baths, every other day. We are not healed but he is not in distress anymore.

Her beauty will always be in your eyes, no matter what and you have the ability to see past the disease and into her beautiful soul. Thanks for posting the pictures, it will help others see CC for what it is. And your lil Miss Mille is such a sweetheart. Sending prayers for healing and strength. Give Miss Mille a big hug from me and Peety and tell her that Peety says "Hang in there Miss America, it's gonna get better."

All the best, Pat and Peety

[Sabre's Mum]

Hi Kerry,

You have had great advice from Dechra with regards to the ACTH stim test results. As I have said earlier ... things do not happen quickly with the healing of the calcinosis cutis and in fact it can get worse before it gets better. I do recall with Sabre that things happened fast from the point of seeing spots to him losing his hair ... in the same areas as Millie.

Take care
Angela and Flynn

[addy]

Good Morning Millie and Kerry,

New day dawning, hope it is a good one for both of you.:):):)

One good thing a day always helps to keep up the confidence:):)

Sloppy hugs and kisses to Millie and big hugs to you.

[khockman]

Hi All,

Thanks so much for your continued encouragement and putting me in my place (in oh so kind of a manner!) when it comes to the progress I want to see NOW. I did send pictures of Millie to our Derm Vet and she actually said she thought everything was looking great…me, dumbfounded, yes! She was happy to see a lot of the scabbing going away and we go back to visit her in about a week.

Noticed today that the edges of her ear flaps were a bit crusty/hard and am wondering if that is part of the CC. Of course, sent off another email to the Derm Vet on that. I am breathing a little easier today, and shared with Marianne my one other piece of excitement which y’all may laugh at…Miss Millie kicked her hind legs after she pooped…woo-hoo…she always did this before this dreaded Disease took over, and I was happy to see her even get her legs lightly in the air. Never thought I would be getting excited about that, but I will take it…so mantra of the day…Patience, Patience, and more Patience...and yes Sharlene...Patience Grasshopper (that made me laugh)!

I am glad I shared the pictures and as awful as they are, I hope others who experience the same journey will be able to see just how bad it can get….I know those of you have dealt also with CC and I have looked at your pics, it is just heartbreaking, yet on the flip side is encouraging to find out it can get under control! It did start as just one little oozing sore on her neck and within 3 weeks BAM - total mess! My Little Miss America will prevail (and yes there is a story behind “Miss America”!) 

Thank you all so much - so lucky to have you all here!
xoxox,
Kerry

[labblab]

DOUBLE YAY!!!!!!!!!!! See, Addy, Kerry has posted TWO good things for the day: good derm report, and stamping like a bull after pooping!! :p :p :) :) :)

Yes, it is a good day! ;)

Marianne

[molly muffin]

Hahahah, I call that the Kick Off! I love it when they do that and then tear of running. You can tell they feel a whole lot better. Molly walks slow and funny when she has to take a poop, but once it's over, she's legs going and tearing off. I'm so glad that Millie is able to do that again! It just is one of those big smile things. LOL

Okay, was it a hard white bump before it oozed? or just it was an oozing sore. I'm going to learn plenty about cc one way or another :)

You are having a good day! yay!
You know one of our members has been away for a bit and came back and she said, when you are there, every day, looking at what is going on, it is hard to see the slow changes for the better. Go away and then come back after a week or so and you'll know that the changes have occured. Not that I want you to go away for a week! But it is harder to see what might be improving when you are seeing it all the time constantly. So....
having said that....

What about taking just a bit of video a day on the camera. Then at the end of every week, you can review the weeks changes and see if you notice anything that way. Just a thought, not sure if it would work or not, but worth a try and might be interesting for you too.

huggers
Sharlene and Molly Muffin

[Budsters Mom]

Love the Derm report. As far as stamping like a bull after pooping, we've all been there!:D Hey whatever it takes! Sending you both tons of love and healing energy. You're doing a great job Kerry, keep it up!:)

[Arizona Boston]

Hi Kerry and Millie,

Lucy and I are also fighting the calcinosis and so I have been interested in reading your journey.

Thank you for taking the time to post, you never know how many people it may help.

Millie is totally Miss America to me, especially now that I know her about her "talent" performance (the backwards bull stamp with a flourish).

Shelly and Lucy

[molly muffin]

Hi Kerry!
Saw you had posted on Lucy's thread. Wow, what a week you must be having. Hope it gets better and the bleeding stops. They do say, it gets worse, then it gets better. So, I am hoping this is the worst and the next step is the "get better" part. Millie must be going crazy sometimes. You are so good with her. :)

Hugs!
Sharlene and Molly Muffin

[lulusmom]

I will be posting this on four members' threads, all of whom are dealing with calcinosis cutis. Kerry, Millie's Mama; Crystal, Annabelle's Mama; Shelly, Lucy's Mama and Pat, Peety's Mama.

I've seen too many dogs on Trilostane who have either had little to no effect on Calcinosis Cutis or a worsening effect while on the drug. Based on the frequency with which we've seen calcinosis cutis on this forum, there seems to be a correlation with the increased popularity of Trilostane for treatment of cushing's. I've had a gut feeling for a very long time that Trilostane is responsible for worsening calcinosis cutis due to it's effects on the sex hormones. Dr. Oliver, was the leading expert on adrenal steroids and he firmly believed that 11-deoxycortisol levels build-up in dogs being treated with Trilostane as did other intermediate steroid such as androstenedione, 17-hydroxyprogesterone, estradiol and progesterone. I've never been able to find anything in layman's terms that explains the affect, if any, these steroids have on calcium metabolism. While searching for that connection, I stumbled upon something even better. It was an abstract of a study entitled, "Canine hyperadrenocorticism: effects of trilostane on parathyroid hormone, calcium and phosphate concentrations". The last sentence of that abstract was eye opening.


[B]Despite no significant difference between calcium concentrations in the pretreatment HAC and control groups, calcium concentrations increased significantly with treatment....and....These results show that adrenal secondary hyperparathyroidism resolves with treatment and suggest that increased calcium and phosphate levels have a role in its pathogenesis./B]

It looks to me that cortisol isn't the only adrenal steroid that can cause elevations in blood calcium levels. Dr. David Bruyette, a renown endocrine expert, readily admits that he has had bad luck in resolving cc with trilostane. That's pretty telling coming from a high profile specialist who is a contributor to Dechra's continuing education program for veterinarians. This is not a new study. As a matter of fact, I believe it may have been published before Vetoryl was approved by the FDA.

You can find the complete abstract here: http://onlinelibrary.wiley.com/doi/10.1111/j.1748-5827.2005.tb00283.x/abstract

I'm just sharing my thoughts with those of you who may want to start asking more questions of your vets....or you may even consider calling Dechra, the manufacture of Vetoryl (Trilostane). I'd be very interested to hear what they have to say about this study.

Glynda

[frijole]

Good job Glynda! What you say makes totally good sense... for those of you who are new to the disease - 8-10 yrs ago trilostane was not legal in the US.. lysodren was the sole drug of choice really... and we never saw cc. All of a sudden it seems like it's everywhere. And you are right - the majority are with dogs using trilostane. Thanks for all the research you do. Kim

[Trixie]

Kerry,
Glad to hear the derm vet is happy with Millie's progress, that's great news. It is hard to have patience when you just want your pup back to normal. I have trouble waiting for symptoms to abate..have to constantly remind myself too..all in good time! Millie just has such expression on her face in her photos. I hope she's feeling better and that her skin issues will soon clear up. :p

Barbara

[labblab]

For folks who want to share general thoughts and comments about this study that Glynda has found, I've created a new thread in which our comments can be consolidated all in one place:

http://www.k9cushings.com/forum/showthread.php?t=5509

Marianne

[khockman]

Just checking in! Have had to travel for work this past week, and husband has taken care of Miss Millie…she had her dermatology appointment on Friday, and the dermatologist said she looks amazing…really??? I think she looks terrible, but I guess it is all relative and since the Derm had not seen her for a few weeks, she could see the progress that I do not see day by day. I am taking Sharlene's advice (thanks!) and taking pics just once a week and will compare week by week. The Derm was also open to seeing how coconut oil may help and we will use it on just her cheeks and see if any improvement. Millie goes in for her next ACTH test on Tuesday, so given her non-standard test results previously, I am interested to see how she is doing this time…making sure Cortisol not too low. She's been on Trilo for 22 Days now, and still a little slow, but taking things day by day... I have to also understand she is a 10 Year old English Bulldog so I shouldn't expect her to start galloping around the yard!

Most messy thing now is she may just start randomly bleeding from something as small as a pore and then it just bleeds and bleeds. In my next post, I am going to do my best to explicit detail her CC from start to today....so many details that I want others who may be new to this to read - I know I always wondered what next? How do I know if it's getting any better? What products are being used? etc...

xoxox to all!
Kerry (Millie's Mama)

[Peety's Fur-mom]

Hi Kerry, I am so glad that your Derm Dr thinks Millie is improving. Like you I see Peety everyday and I use to wonder if he was actually improving. But I know he is. He has no sores now, he has two places that are hard black skin but the hair is growing there. Occasionally when I bath him (every other day) when I rub the black part it will sometimes bleed a bit. I put some Neosporin on it and that is all that I ever see. I don't know what is under the black, it is not like a scab just black hard skin. :eek: :eek:
I am the exception to the rule in that he is not Cushing's and he is not on any meds. So his CC most likely came from the prednisone and now that he is off of it I am not seeing anything new and what he has is very slow at going away. He is not interested in it anymore either. No scratching. Which is good. To see him now you would not really see the skin issues because they are almost hidden again by the regrowth of hair. But in the beginning he did have the pimplely lil wart like bumps that easily bled. I dealt with open sores for a few months and I was always scared of infections. After my Derm Dr. tried to put him on DMSO I just started reading everything I could to find what worked for others. Someone suggested Hibiclens and to me that was the one thing I had the most confidence in because of the medicinal qualities. I did the Hibiclens every day at first. Neosporin for sores and then I started taking him to the beach or making salt baths to put him in. Then I did the Manuka honey when the sores were sores and now that there are no sores I just use the coconut oil after his bath with Hibiclens. I shed a lot of tears over this. I honestly did not know if anything would ever work. At first he was so sore and raw that I put pants on him and long sleeved shirts just to keep him covered. I will see if I can post his "first day of school" photos. He looked pretty pitiful but I was trying to keep the sores covered as much as I could. I am so sorry for those that are dealing with Cushing's and CC. But this is the best place to be. I think there is more knowledge here than any of the previous Vets I went to. Hang in there. If I think of anything else I have experienced I will post it. Sending big hugs to you and Millie. Pat and Peety

[Budsters Mom]

Kerry,
Just dropping in to give you a great big hug and Millie a nice tummy rub. You are doing a awesome job taking care of her skin issues and it can't be easy. Xxxxxx

[molly muffin]

Good idea to document it all. I use Molly's thread to keep track of what is going on with her. I can go back and look to see what I thought something was on any given day. If there isn't much change, then I just do the stories of life with her, but recently I went back to see what I thought about a couple bumps on her and I'd forgotten about a bump that I now can't even find. So that is another way to keep track of things too (using the thread). Plus the pictures of course.
hugs,
Sharlene and Molly Muffin

[Budsters Mom]

Kerry, I learned to document EVERYTHING! You never know what might end up being important. Documentation helps you to see any patterns that may be forming. You are doing great! Xxxxx

[alfred]

My little boxer girl Ruby has the calsinosis just as bad as your Miss Milly. I am trying to figure out ho to navigate this site but finding it a bit difficult. I am now using only diaper cream as nothing has worked.
How have you made out , please reply.
Sandra

[molly muffin]

Hi Kerry, yes indeed it is about time for an update on Miss Millie. :) How is she doing?
hugs,
Sharlene and Molly Muffin

[Mel-Tia]

Hi Kerry

Just wondering how you both are?

Hoping that you are starting to see a small improvement?

Big hug, belly rubs for Millie

Mel
Xxxx

[molly muffin]

Hi Kerry, hope this note find you both doing well.

Just wanted to check in with you and hopefully get an update on you and Miss Millie.

hugs,
Sharlene and Molly muffin