10 days on lysodren and need your guidance

[molly muffin]

hmm, I see the hyperechoic nodule on the left adrenal gland, it doesn't mention one on the right. I'm really bad at making sense of these sometimes, but the adrenal glands are surrounding by hyperechoic fat, so I wonder if it means it's a fatty nodule and that is why they said noncancerous.

Did they say if they thought the drinking and peeing could part of the kidney disease? Rather than a direct result of cushings?

When do they want to test again for cortisol? or are they waiting on symptoms to show a load?

[labblab]

Hi! Ok...so I went to the vet and physically picked up the report from her ultrasound. Here is what it said:

Adrenal glands: Left-cranial pole 7.1mm, hyperechoic nodule, rounded margins. Right Maximum 6.6 mm in thickness normal echogenicity.

liver: mildly enlarged, diffusely hyperechoic with a single hyperechoic nodule (1.5cm) on the right. Gallbladder wasll is normal, with mild debris, some of which is adherent. no organization. Biliary tree is normal.

kidneys: left 2.6 cm, right 3 cm, decreased cmd with multiple cortical cysts (4.6mm maxiumum) pelvis is normal.

conclusions:
1. mild nodular hepatopathy.
-This may be vacuolar change or hyperplasia, but given high bile acids an inflammatory or infectious hepatopathy is also possible. Neoplasia is unlikely.
2. Bilateral chronic renal degenerative changes with cortical cysts.
3. mild adrenomcgaly. Cushing's disease is a reasonable differential diagnosis.


Thoughts?

I'm so glad Sharlene has brought our attention back to the ultrasound report today, and I'm going to quote the report again here so we don't have to scroll back to the previous page to see it.

Like Sharlene, I don't know exactly what to make of the "hyperechoic nodule" in the right adrenal gland. However, the written "conclusions" don't mention that nodule, so apparently is not thought to be particularly significant nor sinister.

"Mild adrenal adrenomegaly" is noted, however, which I'm assuming is referring to mild enlargement of both adrenal glands. If so, this would be consistent with Cushing's caused by a pituitary gland tumor, and I'm guessing that's what the third conclusion is pointing towards.

Bottom line: when you have a chance, I'd confirm with your vet that he/she thinks the Cushing's is caused by a pituitary tumor (as opposed to an adrenal mass) because that info can affect the overall treatment plan.

Marianne

[jzkeegan]

For all that are following Cali, and being SO SO SO helpful...I wanted to update you. I did check with the vet, and yes, this is a pituitary cushings (not adrenal). It has been 7 days since we upped the lysodren dose. Cali is 6 lbs. We started her on 40mg 2x day and after a acth confirmed no change we upped her dose to 65 mg 2x a day.

I see NO change in her drinking (still spending a LOT of time at the water bowl). Therefor, I do not expect that her next ACTH draw will show any change.

Where to go from here if this is the case? Do I continue to raise the Lysodren dose and continue loading until we see an ACTH level within normal range? Do I stop Lysodren and wait a month and move to Trilostane? Or do I stop treatment all together because she is a 14 year old maltese?

From a quality of life standpoint, she is very thirsty and drinks a lot, her hair has lost a lot of volume but does not bother her, she has many skin tags on her body which have become crusty and a little bloody that don't seem to resolve. She seems a little weak when she walks...sometimes takes a small stumble for no reason. She seems to lack energy but nothing worrysome.

I'd love to be prepared when/if the vet calls tomorrow to tell me the ACTH has no change.

The cost of these ACTH tests every time we run one is $155...so it is not cheap.

Thank you in advance for yoru thoughts and guidance. It is MUCH appreciated!

[labblab]

I surely understand your frustration, and I'm so sorry you guys are having a tough time. It sounds as though you've just now had another ACTH performed after the week on the higher dose, and you're awaiting results. Is that true?

I know you're hoping to arrive at a gameplan in advance, but I think we need to wait to hear the test results before making more decisions. This is because it really does seem to me that it "all depends"... First and foremost, we'll be wanting to know whether there's been any downward movement at all on the cortisol level.

May I ask the source and form of the Lysodren? Is it a compounded version, and is it in a liquid or a tablet form?

Marianne

[molly muffin]

Unfortunately it is hard to make a game plan until you see the ACTH results. Seeing movement downwards in the post number would be a good sign.

Strange that we have 2 dogs, both on the smaller side, having problems with lysdoren loading. You are definitely not alone on this journey.

The vet will be calling you tomorrow with results?

[jzkeegan]

Hi! I thought I would start a new thread since I am not sure if my older thread will get lost.

Just to fill you all in...my smaller 6 lb maltese has been diagnosed with cushings (confirmed pituitary), and we have been on a lysodrin journey trying to load her for over 2 weeks.

Started her on 40mg 2x a day. For those that are wondering...this was purchased through a pharmacy in Arizona, and it was nearly the ONLY one I could find that would compound such a small dose and it is in LIQUID form.

After seeing no change, we moved her dose to 56 mg 2x a day.

I have seen no change in the amount of water intake (maybe...just maybe...less in the last day...but as a busy mom of three children, I am admittedly not there every moment and I have another dog who shares the water bowl.)

Anyhoo...test results are in from the new ACTH. pre was 3.5 and post was 5.5! (7 days ago pre was 6.1 and post 21.5)

I thought this was amazing and wonderful! The vet, however suggested we move to 60 mg 2x a day becasue she said that the goal is post number of 5 (not 5.5).

Cali went from post numbers at 21 and 21.5 (during loading at 40mg) to now 5.5 on 56 mg lysodrin. Doesn't it seem dangerous or overkill to move up even a little just to get that last .5? Or is the vet correct?

If I move up the lysodren by 4mg...I have to test again at 3 to 5 days (another $155). I don't mind the money if necessary and will make a difference in how she feels...but I am starting to question whether this is really necessary (or will put Cali at risk for addisons)

sorry for long post.

THANKS FOR ALL YOUR SUPPORT!
J.Z.

[labblab]

Hi again! You'll see I went ahead and merged your new post into your original thread. It's important for us to be able to review a dog's complete history when we talk things over, and I think especially so in Cali's case. Whenever you post a new reply to your original thread, it will always bump it back up to the top of the index page, so you don't have to worry about your thread being buried.

The reason why Cali's history seems especially important to me is because it seems as though your vet is stabbing at extremes in terms of the Lysodren loading protocol. She first started out with a dose that was too low, and now I would personally feel worried about her instructions not only to continue the load, but to even increase the dose. I agree with you -- I think the post-ACTH level of 5.5 is probably a satisfactory ending point for the load, given the fact that Cali is 14 years old and extreme lowering of cortisol might unmask some other problems for her (like arthritis, for instance). I would really worry that continuing the load for several days (especially at an increased dose!) is risking Addison's.

If it was me, I'd want to halt the load now and shift to maintenance dosing. One thing I might feel comfortable about would be to increase the maintenance dose a bit (moving up to 120 mg. from 112 mg. for the weekly total). That ought to keep the cortisol from increasing any higher and might lower it a tiny bit.

Please bear in mind that I am not a vet, and I hope that others with Lysodren experience will weigh in. But these are my worries and thoughts.

Marianne

[Harley PoMMom]

Those treatment ranges for the Cushing's medication are guidelines and are not set in stone. I believe one can not treat by numbers only and have to take in account how the dog is feeling, acting, and how the symptoms are.

Has is Cali feeling, acting, and how are her symptoms?

[lulusmom]

Hi and a belated welcome from a fellow Maltese lover.

For someone who has no first hand experience with Lysodren, Marianne is very astute and spot on in her opinion. I think she must know my dogs' internal medicine specialist because her suggestion to start maintenance at an increased dose is exactly what our specialist instructed me to do. One of my dog's post stimulated cortisol after loading was a bit higher than Cali's and we definitely got the post stimulated cortisol below 5 ug/dl with an increased maintenance dose. My other dog's stimulated cortisol post loading was 8 or 9 so we did a mini load for two days and that did the trick.

If you go with a 120 mg maintenance dose, which I think is a reasonable choice, you should split the weekly dose into three or four doses per week. Never give it once a week as a dog is much more likely to relapse. It's been awhile but as I recall, I gave my dogs their maintenance doses on Monday, Wednesday and Friday. You can choose whatever days work for you as long as Cali gets the entire 120 mg in any given week. When my dog switched to maintenance on an increased dose, I think we did an acth stimulation test after two weeks to make sure cortisol was within range.

You may still be seeing less than desirable improvement in the drinking and peeing because the post stimulated cortisol is not within range or it could be that Cali's kidneys are taking a bit more time to concentrate her urine. This is not uncommon.

Liquid mitotane makes it a lot easier to do dosing adjustments and dogs usually love the taste. One of my cushdogs would almost suck on the syringe to get every drop. The only down side is that the longer it takes to use it, the more likely the liquid is to get gooey.
Hopefully they've made strides in preventing that in the last decade.

I really think you are seeing a very bright light at the end of the tunnel. Just a wee bit longer.

Glynda

[jzkeegan]

I have so much to fill you all in on...and I DESPERATELY need your help.

So...we ultimately over supressed my little girl. at .7 ml of 80 mg lysodren. She was on this for 2x a day for 7 days and after a ACTH test, she came in at pre 3.7 and post at .9 (I hope that I remember these nubmer correctly) but baseically the vet said that while she is not full blown in addisonin crisis, she is near it. She presented with waking in a pool of her own urine and not moving from it. When I took her to bath her, she did not fight me (not normal) she had no appetitie. She was lethargic and disoriented. We stopped lysodren right away and put her on 5 mg of prednisone once daily for 3 days, then took it to 1/4 pred for three days.

The vet then suggested we resume lysodren today at .5 ml of 80 mg 2x a week. HOWEVER, my little girl has miraculously become a different dog. She is eating. Dringking normal. Playing. Climbing stairs. She is a new dog! I am so thrilled I don't want to change a thing.

However my vet said that we can't continue the prednisone becasue THIS could also put her into addisons. What? How can this be? The VERY drug that saved her from an addisons event while on Lysodren could now put her in addisons? I am so confused? I shared this with my vet but her explanations continued to confuse me.

She suggested we wean her off the prednisode for four days, then test her to see if her adrenal glands are working. Then from there, we watch her to be sure she isn't addisonian, and test again one week later, then decide if we need lysodren, pred, or nothing.

I am losing faith in my vet. She is SUPER responsive to me...I have her cell...she loves my dog...she texts me day and night...but I am confused and scared.

Thoughts? Please? any and every. Thank you!