10 days on lysodren and need your guidance

[labblab]

I am hoping you can give us more details about exactly what has been happening with Cali. When you wrote last, your vet was recommending that you increase Cali's Lysodren dose and continue loading even though her post-ACTH cortisol had already dropped to around 6 or so. Did you go ahead and continue loading for a full week after that point in time before testing again? If so, and if Cali is truly oversuppressed, I am going to be perfectly blunt and tell you this is 100% your vet's fault. She may be very caring, but she does not understand the proper use of the medication and has jeopardized Cali's health and safety. But perhaps --hopefully-- I am misunderstanding things.

Also, you need to find out exactly what these most recent ACTH results are. I do not believe that a pre-ACTH of 3.7 and a post-ACTH of .9 can possibly be correct. Do you have the numbers reversed by any chance? If so, a post of 3.7 is actually OK, and that would relieve our worry considerably. However, if the post is truly .9, then your vet is actually finally giving you a reasonable gameplan with this recommendation:

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.

If Cali's adrenal function is only temporarily oversuppressed and it starts rejuvenating over time, you will ultimately want to begin maintenance Lysodren dosing. If you continue giving prednisone when it's not really needed any more, you risk artificially shutting down the body's natural cortisol production (thus perpetuating an Addison's condition). However, a third alternative is that Cali may remain permanently Addisonian due to a Lysodren overdose -- her adrenal glands may never properly recover and naturally produce cortisol again. In that event, she will need to remain on prednisone for the rest of her life. The only way you can determine which of these three options is true is by testing again as your vet has suggested above.

But once again, we need to know exactly what Cali's most recent ACTH results were. Knowing those numbers will make a big difference as far as how things stand and the path forward.

Marianne

[jzkeegan]

Hi! I am sorry about the confusion. Yes, I had the numbers backwards. I believe her last blood draw had her at pre of .9 and post of 3.6. The vet said the pre number was a little too low (they want around 1.6) but the post number was good.

So just backing up for a bit. Once we upped her dose of lysodren to .7 from .5 (because .5 was not doing the job), we kept her on the loading dose of .7 for 7 days. We tested her then, and the results were somewhere in the 3's for pre, and post was 5.5. The vet then moved us to maintenence dosing. I gave her last loading dose on a tuesday, and was to give her first maintenence dose the following saturday. However, by that thursday (two days of receiving no lysodren), I noticed her lethargic and acting off. By Saturday, I found her in the morning (on my bed) laying in a pool of her own urine. I got her up to bathe her and she did not fight me on this (she normally hates her bath). She would not eat. I gave her the first maintenence dose thinking that she was acting this way becasue she needed more lysodren since she hadn't had it since tuesday. But once I did this, I took her to the vet to have her weigh in on whats going on. They put her on pred right away and tested her acth. Her numbers came back at pre of .9 and post of 3.6. I was advised to continue the pred at .5 for three days then move down to 1/4 tab of .5. It has now been a week and Cali is doing better than I have seen her in over a year! Like amazing. So the vet is suggesting weaning her off the pred, by every other day for this week and testing her on Sunday, then testing her again with nothing one week later than determining if we start up the pred again or start the lysodren. I am just terrified to start lysodren again because she is doing SOOOO well now, and she started doing so badly on it. So, I hope this made my story easier to understand. Any thoughts?

[labblab]

Hmmm....I am very relieved that Cali's post-ACTH was 3.7, because that would tend to take her out of a genuine danger zone in terms of being Addisonian. But I'm still a bit confused.

First off, what was the size of the maintenance dose of Lysodren that you gave on Saturday? Also, you say that the vet proceeded to give Cali prednisone that same day? To the extent you can remember, what was the exact timing of all these events on Saturday -- the maintenance Lysodren, the supplemental prednisone, and the ACTH testing? The timing of all this is important because the two medications would have had an "oppositional" effect on Cali's cortisol level. The Lysodren would perhaps have lowered it while the prednisone would have increased it. So it may be hard to know exactly what her natural adrenal function was on that day, and this is why it is important to retest once the prednisone is out of her system and before you begin dosing with Lysodren again.

Just to clarify, until that Saturday, Cali had received no additional Lysodren subsequent to the post-ACTH result of 5.5? If not, it seems very surprising to me that her cortisol level would have dipped to 3.7 after only one single maintenance dose, and that she would already have been behaving as though her cortisol was too low by Thursday -- before any maintenance dose was given at all.

Anyway, once we have the answers to these questions, hopefully we can make some better sense as to what is going on. Also, just to offer a general explanation as to why maintenance dosing is important, the adrenal tissue will begin to rebound in most dogs once the loading phase has ended. If no more Lysodren is ever given, the dog will end up returning to a Cushinoid state. So the solution is to continue to dose the Lysodren on the maintenance schedule in order to keep the adrenal function under control. Assuming that Cali's adrenal glands have not been permanently overdosed by the Lysodren load, you will need to resume the maintenance Lysodren dosing at some point in order to keep her cortisol production from shifting into overdrive again. However, as your vet says, you will need to perform some more monitoring testing before you know whether you are yet at that stage.

Marianne

[molly muffin]

You do want to be able to get her off the pred and then see where her levels stay at. If they start to go up, you go back to a maintenance dose, but at a lower dosage than the one you where on when she went low.

The goal is to be able to keep her feeling good at the least medication possible.
If she is ever lethargic like that or not eating, don't give the lysodren as it is a sign of low cortisol and ask to be able to keep emergency dosages of prednisone on hand to give her if needed.

[jzkeegan]

Hi. Ok...so here are the exact course of events and her testing. We started her on a higher lysodren loading dose on May 14 of .7 ml of 80. 6 days later, on May 21 she had her blood draw for ACTH. This was on a Sunday. I was advised to continue lysodren at the loading dose until we got results. So I gave a dose on Monday and Tuesday, and on Tuesday night I got the results of the pre (I think 3.6 or something like that) and post at 5.5. I was told to stop and go to maintenence. It was that Thursday that she began to fail. she stopped eating and was lethargic. She was due for her first maintenece dose on Saturday (.7 ml of 80 mg lysodren) and I gave it to her in the morning. About 2 hours later I took her to the vet out of concern for how she was acting. They did a electrolyte test which came back normal, then ran the ACTH. Because it was memorial weekend. The vet sent her home with Prednisone. We gave her 5 mg that Saturday night and Sunday night. We got the results of her ACTH Monday afternoon and that was when the pre was .9 or there abouts, and post was around 3.6ish. We were advised to continue pred at 1/4 tab of 5 mg until further notice. She was doing MUCH MUCH better...in fact the best I have seen her in over a year!! We continued pred at 1/4 tab of 5 mg until this past Monday where we are weaning her off at 1/8 tab of 5 mg every other day. Today is last day (friday june 9) and my vet thinks I should run another ACTH on Sunday and then go from there (possibly restart lysodren maintenence at .5 ml of 80 mg). I am not so sure...thoughts?

[labblab]

Thanks for this additional info, and now we have a better understanding as to what happened. The fact that you continued loading Cali for two days subsequent to the first ACTH explains why she was feeling poorly and registered still lower results upon retesting. Under these circumstances, I agree with your vet as far as checking her ACTH one more time now that she'll have been "off" the prednisone for 48 hours (testing while actively giving prednisone will skew the results).

If Cali remains perky and healthy after the prednisone is finished and her pre-ACTH value has risen above 1.0 and her post-ACTH has gone no lower than that 3-4 ug/dL range, then I agree with the prospect of moving forward with maintenance after another week or so.

However, here are some questions I have about the specifics of your vet's plan. To recap, you had ended up giving Cali a loading dose of .7 ml twice daily, correct? That would be a daily total of 112 mg (56 mg x 2). In shifting to maintenance, were you planning to break that 112 mg total into 2-3 doses spread throughout the week? A few vets do give the full maintenance total in one single dose, but it is far more common to break the weekly total into two or three smaller doses given 2-3 days apart. This provides a more consistent pattern of adrenal control.

If Cali is indeed now ready to proceed with maintenance, I'm concerned that your vet is advising you to back off from the .7 x 2 dose (112 mg total) to the .5 x2 (80 mg.) as a weekly maintenance dose. It seems as though she would be running the risk of being overly cautious again, just as she was in the beginning when Cali did not load properly on the .5 x2 daily dose. It seems to me that the problem was not that .7 x 2 was too high -- she finally loaded effectively on that dose during a week of treatment. The problem is that your vet told you to continue the loading dose for a full two days subsequent to the test. So you were continuing the load, and then even immediately beginning maintenance without knowing the effect of those two additional loading days. By the way, you will now know that Lysodren should never be given to a dog who is acting lethargic, inappetant, or has vomiting/diarrhea since these can all be signs of low cortisol.

So it seems to me that it was your vet's protocol and not the size of the daily dose that created the problem for Cali. Since she did not initially load properly on 80 mg. daily, my worry is that she will not remain well-controlled using that as a weekly maintenance dose, either -- over time, her adrenal cortex may rebound to the extent that you'll have to revert to reloading all over again. Cali actually loaded properly on the 112 mg. daily dose. If you had just stopped the loading until the test results were back, I think she would have felt OK and been able to begin maintenance dosing the subsequent week.

I think we've given you this link before, but please please PLEASE read over the recommended treatment and monitoring protocol for Lysodren use so you'll be better able to discuss your vet's recommendations with her. Also, you'll know what signs to watch out for in terms of under or overdosing.

http://www.k9cushings.com/forum/showthread.php?t=181

Marianne

[jzkeegan]

Just wanted to give you an update. Cali's last dose of prednisone was on Friday at 1/8 5mg. tiny dose. We tested on Sunday (yesterday) and her numbers came back at pre 1.2 and post 3.5

While the vet was VERY happy with these numbers, Cali is acting lethargic and does not have a great appetite. The vet suggested we go back on a teeny tiny dose of prednisone for a couple months since we know that she is not in addisons and we also know that her adrenal glands are well supressed but still functioning.

She is not recommending any lysodren. She feels like this supression may last a while and when we see symptoms again we can treat with maintence dosing.

What do you guys think of this plan?

[Harley PoMMom]

Some dogs feel better when their cortisol runs a bit higher that what is recommended so this may be true for Cali.

The problem with not giving the Lysodren and waiting until symptoms rebound is that you may have to reload her so my opinion is to lower her maintenance dose a tad to allow those adrenal glands to produce just a little more cortisol.

Lori

[labblab]

If Cali is acting lethargic again now that the prednisone has been discontinued, I can see continuing with a tiny dose for a very short time period -- like for another week or so. As Lori says, some dogs may feel more comfortable when their cortisol runs a bit higher, so giving a bit of prednisone short term may act as a bridge to tide her over until her natural production begins to rebound again (assuming that it will), and you begin maintenance dosing.

However, your vet's recommendation to continue the prednisone for months while awaiting a return of symptoms totally cancels out the point of loading with the Lysodren in the first place . Unless Cali is truly Addisonian without an expectation that her adrenals will naturally produce cortisol again, there is absolutely no reason for dosing her with prednisone on a long term basis. Giving prednisone to an actively Cushinoid dog is like pouring gasoline on a fire. It makes absolutely no sense to me, and can open Cali up to a host of other problems. If she remains on prednisone long term, you may actually interfere with the ability of her adrenal glands to ever resume natural cortisol production. Or, in the reverse, you may create a situation where her Cushing's symptoms rapidly flare out of control and you'll be long past managing it with only a maintenance dose of Lysodren.

A huge red flag for me is that you say your vet feels as though Cali's adrenal suppression will be long term. It may be true. The extended loading period may indeed have permanently damaged Cali's natural adrenal function. But there is absolutely no way to know whether this is true without ongoing blood testing, and really no basis for your vet to make that assumption right now. I know the ACTH testing is very expensive, but in combination with Cali's behavior while prednisone-free, it is the only way to know what is truly going on with her natural cortisol production.

If Cali were my own dog, I'd perhaps go ahead and resume the prednisone for a bit longer, but for no more than another week. I would then discontinue it again, see how she behaves, and then reconsider my options once again based upon her behavior.

Marianne

[molly muffin]

Prednisone is one of those drugs that seem like a miracle at the time, but the longer it is used, the worse the side effects from using it can be. It can cause the adrenal glands to not produce enough cortisol on their own and too much of a build up can cause cushing type symptoms.
So it is something you want to be careful with, even in small doses for prolonged use. I'd probably try what Marianne suggested. Another week on small dose (very small) and then a retest and try to have it off pred completely.

There is also a kind of withdrawal from having higher cortisol that dogs feel, which is like being lethargic, not interested in anything, feeling their aches and pains more. It's usually will pass as natural cortisol levels are maintained, if it is a withdrawal.