Have I finally found my friends? (Palmer has crossed over the Bridge)

Quote:

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Originally Posted by Palmer's Mom

:eek::eek::eek: My little doggie is slowly loosing his hair. He's gonna look like one of those hairless whatever they are-s. Oh I'll love him just as much as ever, I just wish it weren't so.

:(:(:(:(

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Susan,

Losing hair is not normal.

I also think that given the labs you have posted that the Trilostane could be causing the loss of hair.

Scott

Hi! I have been following along and I have to chime in and join the others that have mentioned that the trilostane could very well be hurting Palmer. I hate to put it so bluntly but after 3 years of reading here we see a whole lot of cases. We have seen what you are going thru happen before. And it can be prevented possibly by testing to see if in fact your dog has atypical cushings.

It is easily overlooked as a lot of vets just don't know about it. The good news is that if it is atypical - you might not need any harsh drugs but rather flaxseed and melatonin which are lots cheaper too.

The hair loss occurs when cushings is not under control or there is another reason for it. This is not normal. Sorry, but I am feeling sorry for Palmer and it seems like you are frustrated... it could be as simple as looking into this. Is there a reason you don't want to go there? Just trying to understand, I know this is complicated. Just trying to help. Kim

I went back further and read ... I apologise... I didn't realise you had already determined that Palmer is atypical. I am pretty sure you could end the problems by going off of the trilo. I understand if you want to hear it from a vet... since you are concerned about yours, why not email Dr. Oliver with all of the symptoms you have mentioned to us? It doesn't cost a dime and he is the expert. He is also a great person. A thought?

Kim

Thanks to all of you for your input. I have just sent an email off to Dr. O. :D:D I gave him the history, the stim test results and list of medications.

I know a number of you (many) think the Trilostane is not the answer. I appreciate the fact that you continue to give me your input. I do listen and consider all you have to say.

Thanks.

Susan

Hi Susan,

We listen to you as well and have learned a few things from your journey with Palmer.

I hope you understand that our concern is that the Trilo may be getting the cortisol under control without question. But it may also be causing the other hormones to elevate as it lowers the cortisol which kinda puts Palmer in a catch-22 situation. The damage from elevated cortisol for him may not be as big a concern on the Trilo, but the damage due to elevation of the other hormones may be increased.

Looking forward to Dr O's reply...the last one was eye-opening for me! :);)

Hugs,
Leslie and the girls

Susan,

Thanks for the update! I am sure you will feel better getting feedback from Doctor O... as he truly is the best. Glad you decided to do it. He is very approachable. Nicest vet EVER. Good luck! Kim

Okay folks...I have my responses. His responses are in red, where I could get this program to do that. For some reason a color change would not "take" on all of them.

I gave Dr. O. a list of all of Palmer's medications and asked him to review them. His response-
Flax Seed oil - 1000 mg One daily
>>May not help much with the lignan, since lignan content is only about 2%. The flax oil can also raise triglyceride levels, which can sometimes cause pancreas issues.
Lignans - 40mg One every other day
>>I’m suggesting lignans given at approximately 1 mg per lb now. If this is a product that has 20% content of lignan per 40 mg of product, then the lignan content is only about 8 mg (20% of 40). If so, I’d give it every day.

Regarding Trilostane -
I don’t know that much about trilostane at this point, except that it usually increases both androstenedione and estradiol levels. This doesn’t always cause the dog any problems, but in some, clinical signs of Cushing’s will re-occur at some time point; presumably due to the increase in these sex steroids.

Regarding stim test numbers -
These are good numbers for the cortisol, but this is expected with the trilostane. If estradiol and androstenedione were determined, I can almost guarantee you that they would have been increased.

My next observation/question - I told her –okay-but his symptoms have returned. He has distended stomach, much increased water consumption, lots of panting and now I can tell he is losing his coat. We usually have him clipped every 4 weeks because the heat bothers him so. I had to cancel the last appointment because there wasn’t enough there to clip. That was 2 weeks ago. Today, he could use some “neatening up” but on his body there really isn’t enough there to justify a clipping.
>>I would say that the sex steroids have increased a considerable amount, like they almost always do with trilostane.



I asked the vet if we might be headed for Lysodren and she said she did not think so.
This sometimes has to be done, when the sex steroids increase to the point that clinical signs return, when the dog is on trilostane.


Do you think he is still Atypical?
It would look that way if you did our adrenal panel while on trilostane. The sex steroids are almost always (I’d say always) increased when a dog is on trilostane. Many dogs tolerate this for long periods; others come back with clinical signs of Cushing’s, and a switch to Lysodren may be indicated at that time.
and....finally -

If you do our canine adrenal panel (sex steroid panel) at some point, I’d suggest going off the trilostane for 2 or 3 weeks. Otherwise, you won’t be able to tell if it’s increased adrenal disease, or more likely, sex steroid build-up due to the effect of trilostane

I'm waiting for my vet call today. They did tell me that the urine culture came back good. I'll let you know about my conversation with the vet whenever that happens.

When the panel was done, Palmer was not yet on Trilostane.

-Susan

Susan,

I have to tell you straight.

There is no reason to fear Lysodren. It is clear to me that your Dr. does not favor Lysodren and I really cannot understand why.

It is clear that Trilostane increases the hormones which contribute to the symptoms you are reporting.

The good thing is that Palmer is largely Atypical and would most likely not require a loading of Lysodren, which is the most difficult phase.

If this was me, I would suspend the Trilo, do a new UTK panel and then start the Atypical treatment of lignans/melatonin and then consider adding a maint dose of Lysodren after a period of time.

Best. Scott

Susan, I tinkered with your post to put Dr. O's comments in red including the ones you had difficulty with, in the process some of the >>> were lost but I think I have Dr. O's all in red, please let me know if I didn't get it right.

Susan, 3 yrs ago when my dog was diagnosed I was clueless and scared. I had to fire my first vet and move on to a 2nd one. By then I had read about both trilostane and lysodren and I was really preferring trilo. Problem is the vet had never used it and I wanted his experience.

So I went the lysodren route. I was scared but it is really not a big deal. It is dangerous when a vet doesn't follow the protocol and communicate clearly with the pet owner. If both take it seriously (which should be done with any chemo drug) there is no reason to fear.

After reading here for 3 yrs I am not relieved that I went with lysodren because I have seen many dogs like yours that go on trilo thinking it is a cure but learn later that they must switch. Plain and simple I lucked out.

Do not fear - we will help you thru this should decide to switch. I am glad that you heard back so quickly from Dr O. Hang in there! Kim

Heard back from the very busy vet - we are going in on Monday for a blood pressure check and to discuss what's ahead.

Hi Susan,

I'm glad you got the response from Dr. O with all that great info and that you have an appointment with Palmer's vet on Monday for a discussion. This info will certainly help your vet in determining a course of action/treatment for Palmer that will relieve those symptoms he has been experiencing.

Hope you have a productive appointment on Monday and that Palmer's bp readings are good. Take care and will be watching for your update.

Louise

Hi Susan,

Thanks for posting the response from Dr O. Isn't he great? It would be so easy for him to just blow us off as pests, but he always responds and is always so kind.

I hope you have a great session with your vet Monday and that Palmer can get to feeling better soon!

Hugs,
Leslie and the girls

Hi-
I only have a moment. When the vet's office called to set up the appointment the vet (Jennifer) passed along answers to my 4 questions.
#1 Would it be advisable to run a UC:CR test?
Answer-she can do it, but doesn't feel it is necessary.

#2. Discontinue flax seed oil.
Answer-agreed.

#3 Is she able to run an adrenal panel?
She thinks so-she has to check.

#4 I want to try Lysodren.
Answer-make an appointment for Monday, we'll discuss treatment options then. She thinks it may be premature.

She is consulting with an Internist and another vet person over the weekend.

Okay-back to just me. I don't know why she is resisting the Lysodren. At the very beginning it was mentioned as an option.

I would really appreciate (I know I've been told before) getting some "ammo" to support my case on Monday. Any comments anyone can offer will be greatly appreciated. (Especially UC:CR)

Thanks.

Susan

PS-yes Dr. O IS great. :D:D:D I'd like to meet him. He's thorough and prompt and talks so I can understand him.:):)

(I love these little icons!!)

-s

Hi Susan,

I have only a moment to post right now, but I did want to give you some thoughts regarding a couple of your questions. First, as to the advisability of performing the UC:CR test: It is a simple test to run, and the results might give you a more complete picture as to whether or not Palmer's once-daily trilostane dosing is keeping his cortisol level well controlled throughout a 24-hour time period. If you do decide to run this test, however, it has been suggested to us that the most accurate approach is to collect and pool urine specimens on three successive mornings:

Quote:

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Originally Posted by David Bruyette

Many studies have shown that the only way to accurately gauge urine cortisol levels is to obtain the first morning voided urine sample on 3 consecutive days and then pooling the urine to run a UCCR. When done in this fashion it is likely an accurate test. Otherwise there is likely too much day to day variation to make a single random cortisol very helpful.

Dave Bruyette DVM DACVIM

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Dr. Bruyette is a member of our forums, and has further elaborated that if you do choose to collect and pool urine samples, they should be refrigerated until you take them to your vet for analysis.

From what Dr. Oliver has written, however, I think the broader issue is whether or not trilostane is currently a good treatment option for Palmer at all. If it is not, then the question of once vs. twice daily dosing for optimal cortisol control really becomes a moot point. And in that vein, should you choose to perform another full adrenal panel, your vet really needs to coordinate the testing with Dr. Oliver. I see that in his reply to you, Dr. Oliver's suggestion is to stop the trilostane altogether for two to three weeks prior to performing the test. Otherwise, it is impossible to separate out the dog's naturally occuring adrenal hormone profile from the elevations caused by the trilostane itself. You do not want to go to the effort and expense of performing the test until the results will be meaningful.

Having said all this, I have to agree with the other folks here who are encouraging you to consider shifting to Lysodren and discontinuing the trilostane altogether. So I hope that is an option that you will be able to discuss more thoroughly with your vet on Monday.

Good luck!
Marianne

Hi Susan,

The biggest argument in favor of switching to Lyso is Dr Oliver himself. Dr O is the premier researcher in the area of Atypical Cushing's and therefore is the one source to be relied on. If he says, and he has, that Trilo will always cause these other hormones to increase, then you can bank on it. "The sex steroids are almost always (I’d say always) increased when a dog is on trilostane. "

This one statement is all I would need to hear in order to make the decision to stop the Trilo immediately and make the switch to Lyso after the UTK panel is run - no debate necessary.

Your vet can make the blood draws for the UTK panel but cannot run the test itself - unless something has changed very recently, the Uni. of TN in Knoxville (UTK) is the only lab in the country, perhaps the world, that currently does this testing. I know it will be difficult to let that month pass with Palmer receiving no treatment, but you are already dealing with cush signs so it won't be such a change. The wash-out period is crucial, tho. Especially since he has been on the Trilo for so long. His adrenals need time to return to their untreated state for the test to be accurate so that wash-out is very important.

I think you are making the right move, Susan, and Palmer will be much better for it.

Hang in there!
Hugs,
Leslie and the girls

Hi Susan, boy have you been a busy camper this week. ;) Good job and know that we all needed coaching on this stuff in the beginning....


#3 Is she able to run an adrenal panel?

Leslie is correct - she only has to submit the sample. Make sure she submits it directly to the Univ of TN and doesn't send it to her regular lab as they will just mark the price up and send it to the univ of tn!!

#4 I want to try Lysodren.

I would print out some of our posts where we have pointed out that trilo can cause problems within atypical cushings dogs do you have it handy. Tell her you know that the Univ of Tenn is the only lab that does the testing for atypical and that you made direct contact with the Dr. there that advises vets on what to do. Print out his email and read it to her. She cannot argue with this world expert.

I think she is unfamiliar with lysodren or had a bad experience. Please make sure that she does not give you any lysodren yet. This is important. There needs to be a washout period between trilo and lysodren. So first get the test done and see what Dr. Oliver writes out on the results sheet for your vet. Then, assuming he will recommend lysodren... go with the dosage amount that HE recommends and the timeframe HE recommends. This way HE is telling your vet what to do. This is a win/win for your vet as she will have her hand held by an expert. You get peace of mind that he knows what he is doing!

Good luck and great job. Kim

Y'all are sooooo nice :cool::cool::cool:
Thanks very much for the encouragement. I will get my notes ready. I may be back before Monday with a question or two.

=Susan

Ask away, honey! We are all here for you and Palmer!

Hugs,
Leslie and the girls

Hi-
I sent "Jack" (that's how he is signing his emails now) the question about my vet being able to "do" the panel. He says she can-(get the samples) and sent me a link to detailed instructions on how to do it.
(He even responds quickly on weekends!):D:D:D:D:D

Leslie and the girls-
"The sex steroids are almost always (I’d say always) increased when a dog is on trilostane. "
Why is this a "bad" thing?

Also-one of my concerns is that the vet now thinks that Palmer is regular cushings'. Jack said that if Palmer was on Trilostane when they did the panel-he is. Well, he was not on the Trilostane then. I know we've had part of this discussion before.....can we again?:confused::confused::confused:

-Susan

Hi Susan,

Why is it a bad thing if the other hormones are elevated even tho the cortisol may be controlled? Because the other five hormones will cause the same damages in the body as the cortisol will if not controlled. They also cause the same signs as cortisol. The Trilo is more than likely NOT controlling those other hormones and is, in fact, causing them to be even higher than they would be in an untreated state (this is based on his continuing/worsening signs). The Trilo will lower cortiol, but it also elevates the other hormones that Palmer is over-producing naturally. For a pup with hormones OTHER THAN cortisol (like Palmer), Trilostane is a two-edged sword...helping one area (cortisol), while making another area worse (Estradiol, Androstenedione, 17-Hydroxyprogesterone, Progesterone and/or Aldosterone).

In looking at Palmer's cortisol history, it is kinda puzzling to me. Has he had an ultrasound lately? If not, I highly recommend he have one soon. Based on the first ACTH through UTK, he does not have true Cushing's, but that post number has jumped all over even after treatment with the Trilo. So if it were me, I would want to be sure there isn't some other cause for his cortisol to be elevated - and fluctuating. You may remember that Squirt was diagnosed as PHD (true Cushing's) but since that splenic tumor was removed, her cortisol has returned to normal levels. Dr O was saying that if he was already on the Trilo when that test was done, then it would have lowered the cortisol giving a much lower reading than it would have if not treated - therefore leading to a diagnosis of conventional/true Cushing's. Since he was NOT on Trilo at that time, his cortisol levels do not support that diagnosis at that time. That could have changed over time, tho.

If it were me and my pup, I would stop the Trilo immediately - today; schedule an ultrasound asap; set up the UTK test for a month from now assuming the U/S is good. I am not sure of the life of melatonin and lignans in the body, but I would also stop them within a week to be sure the UTK panel reflects his true, untreated state. Then, assuming the UTK results still support the Atypical diagnosis even if the cortisol is elevated, tell my vet we would be switching to Lyso. IMHO, the experiment with Trilo has failed miserably for him and he continues to suffer as indicated by his continuing signs which means damage continues to progress.

I hope this helps.
Hugs,
Leslie and the girls

Medical complications from untreated Cushing's:
http://www.k9cushings.com/forum/showthread.php?t=195

Susan, I don't have much to add to what Leslie has already told you. The other hormones are still considered to be various types of steroids. Excess steroid, whether it is cortisol or one of the intermediates, does damage to the internal organs over the long term. This is why with a diagnosis of Atypical it's extremely important to get those intermediates under control. Lysodren will do that for you. The "catch 22" here is going to be estradiol as estradiol is also produced in non-adrenal tissue, such as adipose & I believe brain tissue, also. This is why the lignans + melatonin is used to control the non-adrenal production of estradiol. All adrenal produced hormones will be controlled by lysodren. I would almost bet that you will not have to put Palmer through a typical lysodren loading phase, & will simply need to add a maintenance dose of lysodren to his melatonin + lignans. If you & your vet want to see just how serious the effects of trilostane are on the intermediate hormones, you can have that UTK panel done right now. If you need to see what the levels are in an untreated state, Palmer will have to have a "washout" period of 30 days before the UTK panel can be done.

Debbie

Hi folks-

Now, let's all take a deep breath...............:(
First, Palmer's blood pressure is just fine.:D

Now-this is where we stand. We have agreed to give Palmer Trilostane, one capsule in the AM (30mg) and 1/2 capsule in the PM. We tried that before and Palmer had an immediate reaction. If the same occurs, we will immediately stop the Trilostane and that will be the end of it.

Regardless of how that turns out, we now have an appt. with an Endocrinologist. Sadly, not until 9/1. I'm not sure if he'll choose to run any tests or not, but Palmer will be fasting before we go. I know with Trilostane in his system it may skew the results.

If the Endocrinologist agrees with the Trilo. treatment.....I don't know what. (Well-yes, I do. The vet will not support us if we go against the two of them.) If he agrees with the Lysodren, after a wash out period we will start that. The vet will support that. So I guess the bottom line is this dude gets to determine whether or not we're going to need to change vets. (Anybody still with me?)

(I really hate having to write this to you guys. I got boxed in a bit here. There are no good viable options for a different Vet nearby.)

Jennifer states she does not have a problem with Lyso. She feels we had such good results when we first started the Trilo and that to switch now ("that we may be so close to having this solved") is just not the right thing to do. She also said she feels she is being pressured into doing something that goes against what she believes is the best treatment, at this time. She said that if the Lyso did not work, we'd be right back trying to find an answer with the Trilo. I reminded her that she offered Lyso as an option in the beginning. She remembers that....but it gets back to giving the Trilo a good chance.

The endocrinologist is at the place where we went for the UTK sample to be drawn the first time, so if we want to do that, we'll be all ready to go ahead with it. She is sending us to a different doc from the one we went to originally. I think the first go round we got the luck-of-the-draw amongst the Internists.

I gave her a modified transcript of the emails from Dr. O. (I removed any references to her.) His words were highlighted. She says she wants to and will read that. I think she was quite surprised to learn I had been conversing with Dr. O.

She made reference to my research. She said she admired all I had done. BUT-she could tell from my questions that I did not understand it completely. :mad::mad:She said some of my questions just did not make sense. :confused: :confused: (I do think this was a defensive reaction.)

My husband has not taken part in all this stuff, so when she asked him what he thought his response was that he did not want to run a lot of unnecessary tests. She had said the UC:CR was one example of a test she felt was unnecessary. She said it would not really tell us much at this point. She said it was a tool to determine if the pet had Cushings' at the start.

I don't see the harm in getting a second opinion. I know it will cost more time if we wind up going to the Lyso. I feel it would be much more costly, dollar and time wise, if we had to switch vets now.

I wish I had different news, but that's where we stand for now. I will take all of the volumes of documentation I have to the Endo. I will especially point out Dr. O's responses.

Please don't think I don't have the backbone to fire the vet or that I lack wanting the best of care for Palmer....for dollars or for any other reason. Perhaps this will resolve itself in the next day or two if Palmer has the same reaction to the increased Trilo. If we end up sending a sample to UTK, I will alert Dr. O that it is coming.

I hope you all will stick with me as we try to figure this out. I DID NOT ignore your many suggestions. As I said before-I really appreciate all you have to say and all the time you have taken.

-Susan

Hi Susan,

Of course we will stick with you! I am very concerned about Palmer, tho, and will continue to advocate stopping the Trilo. It really blows my mind that your vet will not take the word of a world renown doctor concerning the effect of Trilo on the other hormones involved in Atypical Cushing's. With Palmer's continuing signs I fail to understand what more she is looking for as an indication it is not doing the job. It is my fervent prayer that Palmer does not suffer as a result...well not much longer anyway before she listens to those who know more than she - meaning Dr. Jack Oliver.

I am sorry you are being torn like this and hope you understand that our goal is what is best for Palmer. Hopefully there are many things we don't understand in his whole picture.

Hang in there!
Hugs,
Leslie and the girls

Leslie and the girls-
Thanks so much. I'm glad you understand.

I was just thinking about the topic of replacing my vet. Another consideration I have is that if something of an urgent nature were to happen to Palmer, I'd have to go another 45 minutes to find the nearest qualified vet. It is best for Palmer to have that resource available. Hopefully this 3 weeks will not be harmful to him.

He had his extra 1/2 capsule tonight. No reaction so far.....but it did not happen until the following day the time we attempted to increase his dosage before.

-Hangin' in here.....................

Hi Susan,

I'm sorry you're going thru such a rough time with Palmer and your vet...I wish she would of let you run another UTK panel tho. :o

But what is done...is done...I also wish there was a cushing-computer out there...all you have to do is type in all of your pups numbers and poof it tells you what to do.

We know you love Palmer very much and no one doubts that, we just don't understand the logic of vets sometimes.

I'm hangin here with ya. :)

Love and hugs.
Lori

Susan,

We are here to share our experiences and research. It is our goal as a group to help people not place burden on them.

You do not need to justify your descisions to any of us, all any of us here really owe another is common courtesy.

There will be people here who no doubt may disagree with Palmer's treatment based on what you have related to us. No one does it to berate you or your Drs.

I continue to wish you the best in your treatment of Palmer and hope the new Dr. brings clarity to his treatment.

Scott

Thank you Lori and Scott.
It is possible we will run another UTK test when we go on 9/1. I just plan to take all the information I have; all the test results and see what happens. I also plan to present my case, if necessary.

-Susan

Question-I spoke today with a woman who use to groom dogs. She asked if I could still pick Palmer up. I thought she was referring to weight. She told me Cush dogs get to a point where it hurts them to be picked up. Any idea if that's one of the symptoms? I've never read nor heard of that before. Palmer did yelp when I picked him up over the weekend.....and I had/have no idea why. I picked him up very carefully as I always do.

Thanks.

s

Hi Susan,

I know I have to be careful on how I pick Harley up...the overall tenderness of his tummy area...I think this is bc of his enlarged liver and prior bouts of pancreatitis that showed up in his U/S. Their skin gets paper thin too sometimes...our poor pups. :(

Love and hugs.
Lori

Susan;
As far as picking up a cush dog, I cant comment, I have giant schnauzers that wt 90 lbs so there is no picking them up. I do however help lift Nike into the truck and I pick up her hindend by putting my arms under her belly close to her back legs and it does not seem to bother her at all.
You mention that you give 1/2 cap of trilo. It is not recommended to open the caps, in fact it can be dangerous. I know with lysodren it can be a carsinogenic and can be dangerous to pregnant women. When cutting the lysodren tabs gloves should be worn, a seperate pill splitter should be used, papertowels should be used to clean up so it can be thrown away. I would guess Trilo would be the same. With Trilo being in caps I am concened. You can take your caps to a compounding pharm and they can split your pills for you into the dose that you need.
I understand you concern about your vet, as you say it may not be an issue anyway. It is important to have a vet you can talk to as treating this condition takes the expertise of the vet and the eyes of the owner and both are as important.
Doing a UK panel with the dog on trilo may not show anything helpful. Hopefully if they want another test they will have you do a hold on the trilo to be sure it is washed out of the system before doing the test or It will skew the results.
Good luck
Sharon

Sharon-
I am aware of the danger with the capsules. I was hoping not to need compounding......hoping we'd be off Trilo now.
Dr. O did say to wait three weeks with Palmer off Trilo before doing another test. I am glad you mentioned that.....I had temporarily forgotten.
I guess we're just stuck on hold until we see the Endocrinologist. Palmer had his first extra 1/2 capful tonight. Tomorrow might be when we'll see a reaction....if there is one.

Hi Gang-

Just thought I'd give an update on Palmer with his increased 1/2 capsule of Trilostane. He has had no apparent adverse reaction to the increase. His water consumption has decreased remarkably. I think the panting has lessened as well. It appears his tummy has gone down 1/2".

So far, so good. :):)

Susan,

I am happy to hear that symptoms are better.

Please continue to be vigilant.

Thanks for letting us know.

Scott

Susan,

I am glad too that Palmer's symptoms have gotten better.

1/2" less on the tummy, Wow, this has to make Palmer feel better.

Here's hoping for continued improvements.

Love and hugs.
Lori

Hi Susan,

Good to hear that his signs seem to be getting better! Hope there is no adverse reaction and that he is feeling better soon. I measure Squirt
's belly, too, and hers fluctuates by 1" but she's never had the pot-belly common in Cushing's. I'm just a worry wart. :p

I know you are watching him like a hawk...just keep it up! If any of his cush signs remain, get worse, come back, etc.....well, you know what I'm gonna say I'm sure...;):)

Keep up the good work and let us know how Palmer is progressing on the new dosing schedule.

Hugs,
Leslie and the girls

Hi,

All is well here in Palmer Land. Improvement on symptoms continue. Friskiness has picked up.

I am probably going to need to contact someone on compounding of medications. I've looked a little on the web. Can anyone who has done this tell me how they started? I know the vet can get it done but her markup is horrendous.
Thanks,
Susan

Susan, a lot of us use Diamondback Drugs, diamondbackdrugs.com. They have a uniform shipping fee & will ship anywhere in the country. They are local for me, so I'm not exactly sure what their procedures are for out of state, but it's probably on the website.

Debbie

Hi Susan,
Seems many here use Diamondback pharmacy. It's on line and your vet can call in or fax a prescription.

Very glad all is well in Palmerland. :):D:):D