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My 2 cents worth - I would choose the Lyso maintenance over Trilo any day if that is the route I decided to go were Molly mine. I would probably go ahead and keep the melatonin and lignans treatment along with it as recommended by UTK. BUT you know I'm partial to Lyso. ;)
Jeepers, if that LDDS went up even a wee bit it would help clarify the course of action for Molly. Hopefully Dr Peterson will get back with some advice, or maybe even you could try Dr Bryette as some have had replies from him.
Sorry your local vet appears to have dropped the ball a little, that is surprising as she has always been so receptive. Hopefully that gets sorted out soon xxx
Dr. Peterson has responded:
Spoke with my vet today, who called me. I think she was just busy, but she has looked into food and ordered omega 3 for me, which I already received from the IMS, but I have now another bottle that I can pick up later.Quote:
Dr. Mark E. Peterson said...
If your vet has done the proper testing for Cushing's (ACTH Stimulation, LDDST, and urine cortisol:creatinine ratios) and it is positive, then I would start treatment. If the tests are normal, then the "complications of Cushing's" you are talking about are likely secondary to another problem.
The ALT and AP are not specific tests for Cushing's, and the finding of large adrenal glands could be due to nonadrenal illness (such as primary kidney disease).
My vet is not on board with treating for cushings as she doesn't think now that cushings is the main culprit or that the cortisol is constantly high, and her worry is that we could make her cortisol go to low.
Both IMS and vet have discarded lysodren as a choice, going with trilostane.
I think both the IMS and vet seem to think that the kidney disease is primary and the cortisol is secondary to that. I am not so sure, but don't know what the best option is. At the moment, I want to know what the cortisol is now and see if it has changed in either direction, up or down. Although I've been told that it might have gone higher in response to the advancement of kidney disease.
If she has cushings and constant high cortisol, I'd think we would want to bring it down a bit and the IMS does seem to be thinking that but wants the ACTH first, as do I.
This is so frustrating.
hugs
sharlene and molly muffin
Well, phooey on Dr. Peterson for missing the central issue: your vets have done the proper testing and the results are contradictory! Don't know whether it would be worth following up with another question to him, seeking that specific clarification: your dog has had significantly elevated ACTH tests two years apart, but two negative LDDS tests within that same timeframe. Of the two tests, the ACTH is supposed to be the most "specific" to Cushing's, so what gives??
I wonder what leads your vet to conclude that Molly's cortisol is not consistently high when she has had two significantly elevated ACTH tests fully two years apart? What evidence does she have of a normal cortisol? I worry a bit about her because I think I remember her making reference to Molly's basal cortisol as being normal as though that had diagnostic significance for Cushing's, which it does not. Plus, as is the case with maintenance Lysodren for "Atypical" cases, there are situations when trilostane is prescribed for dogs with even normal cortisol (including Alopecia X, I believe).Quote:
My vet is not on board with treating for cushings as she doesn't think now that cushings is the main culprit or that the cortisol is constantly high, and her worry is that we could make her cortisol go to low.
I also have been puzzling in my own mind about the notion that it is a kidney problem that has been elevating Molly's cortisol all along. I know it is written everywhere that other, nonadrenal illness can elevate cortisol, and Dr. Peterson mentions primary kidney disease as a possible cause of swollen adrenals as do your vets. But I've been trying to figure out exactly what the connection would be. In doing some searching, I came across this article relating to humans. And if anything, it seems as though the worry being investigated relates more to the reverse -- that human patients experiencing renal failure might need glucocorticoid supplementation. At any rate, here's the study's conclusion (one warning, though, this is an older 1998 study, so more recent research may be different):
http://martinclodi.at/downloads/25-r...nts-with-c.pdfQuote:
It is surprising that neither changes of cortisol metabolism due to renal insufficiency, the effects of uremic toxins on the HPAaxis, nor the modalityof renal replacement therapy alters cortisol response to ACTH in patients with end-stage renal failure. Thus, in general, glucocorticoid replacement therapy in CRF patients does not appear to be necessary under everyday circumstances and only a minority of patients migh benefit from glucocorticoids in stressful situations, such as major surgery...
In summary, the low-dose ACTH [stimulation] test elicited a normal adrenal response in a well-selected group of patients with CRF [chronic renal failure] who were receiving hemodialysis or CAPD. This finding suggests that neither renal insufficiency itself nor the modality of renal replacement therapy has a major implication on adrenal function.
I sure am not trying to be Miss-Smarty-Pants, acting like I know more than Dr. Peterson and your vets (although I'm afraid that's exactly how I'm coming across! :o :o :o). And even though it may seem otherwise, I also don't know whether trilo is the right way to go. But I definitely think it's worth it to perform another ACTH to see where Molly stands now. If it is still high, then maybe your IMS would be willing to garner some additional opinions among her colleagues about Molly's very perplexing situation.
Just for the heck of it, would you mind if I sent Dr. Bruyette an email asking his thoughts about a situation like Molly's?
No my vet never mentioned a normal pre cortisol level. Thank god she wasn't of that mind. I don't know why she doesn't think the cortisol is consistently high but it has to do with not testing positive on the LDDS. It didn't make sense to me since they are two different test.
3 LDDS in last couple years. Two last year.
They are all worried that if it isn't cortisol that we will send her low but I think we have to try. Maybe we will know more after the next ACTH test? I hope anyhow.
She still doesn't have the appetite or drinking urinating of a Cush dog. Skin and hair fine. It is all the internal organs being affected in her case. :(. Which is bad.
I think we Have to try something but I am the only one advocating it. Now I have to check the urinalysis reports as my vet didn't think she had oxalate sones and I am sure that I had read she did. I want to add potassium citrate to any food we use and they think potassium could be a problem as it is an issue with renal function.
Some days they drive me nuts. No I don't mind if you email dr. B. I wish that Dr. P had addressed that the test were done and it is the contradiction between them that is the problem. No UC:CR has been done. I am thinking of that too.
Thanks Marianne
Addy you are such a sweetheart. I so remember Zoe eye problems. Cortisol. Bp. Proteinuria all are issues for the eyes.
Hugs
Sharlene and Molly muffin.
Well, I sent off an email this afternoon to Dr. Bruyette listing the specifics of Molly's original presentation (elevated ALKP and pot belly but no other external symptoms), her contradictory LDDS and ACTH testing history, and also included the same current summary you had written to Dr. Peterson, including continuing lack of outward symptoms. Within a half-hour (on a Saturday afternoon!), I already got a response back. Here it is:
So another opinion to consider as we await the next ACTH test...Quote:
Hi. It not uncommon to have discordance between the test results and given the whole picture I think the dog has PDH and I would treat. It may help with the blood pressure and proteinuria.
Dave
Yes, Dr. B is amazing with the speed of his replies. :p He responded to me right away too, but it wasn't the news I really wanted to validate.:o His recommendation is what was used to partner his vet with his consulting neurosurgeon. Someone who I couldn't afford to see on a regular basis because she was over the top expensive, but consulted daily for me anyway. This is a doctor who lectures all over the world in neurosurgery and still took the time to monitor Buddy for nothing. There are doctors out there who really care about our pups and are willing to help, even when they aren't getting paid. :p
I am so sorry that all of this is so darn complicated.Molly has been doing so well for so long without heavy duty Cushing's meds. I understand your reluctance to start on them.:o I'm not so sure I would want to do it either, particularly if you're not sure whether she needs them or not. :confused: I wish I could be of some help.
Big gentle hugs to you, hubby and out little diva,
Hi Sharlene, hoping that you and hubs and Molly are having a peaceful Sunday and that you can push all the worry in a drawer for now. You've got a very reasonable plan in place and in my book, just figuring out the plan is half the battle won! ;) :)
Sending lazy Sunday afternoon hugs your way,
Marianne
We are definitely being lazy. Just haven't been home much to do so as much as I'd like. Lol. All the errands from being away last weekend and then away next weekend too. All things we already had flights and plans for prior to this coming up with Molly. The high bp and sight thing.
Yes I think we will get the ACTH and if that is still high, then start trilostane at 1mg/1kg. Ratio. Which would be around 8mg so have to have it compounded.
Let's see what that is.
Thanks for checking in on us.
Hugs
Sharlene and Molly muffin.
i hope everything works out fine for you and molly.
when is molly's acth test?
luckily she is still feeling fine.
strong girl!