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Thread: Newbie Helicopter Pet Mom needs help/support - 12 yr old American Bulldog Part 1

  1. #11
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    Default Re: Newbie Helicopter Pet Mom needs help/support - 12 yr old American Bulldog Part 1

    Update on LDDST inquiry

    Hello y’all. Thanks Marianne for your encouragement. Went for my scheduled meet & greet Monday with the local Vet for inquiry abt. his experience and Cushing’s testing. Was not interested in anything about Patch’s history or prior testes. It was a daunting 3 minute interaction, if that. Only confirmed did Cushing’s testing and treatment. Then exits stage right. No apology. I left scratching my head. I don’t team play with opportunist’s. First impressions are lasting impressions, even giving credence to someone having a bad day.

    Inquired with the front desk folks before I left, can have an LDDST done next Monday. They don’t test for pheo, UCP ratio, BP or adrenal panel.

    Feel this experience is a red flag, not meeting my needs and I’m uncomfortable bringing Patch in. Trying to be realistic, not emotional. My mindset; if a Vet can’t even be bothered to have a healthy, fundamental interaction during a scheduled appointment, what kind of care would they give to your pet?

    Ultimately, it appears to go back to Auburn UN again for more conclusive thorough tests and adrenal panel for sure. (Heck, I'll take any hormone testing at this rate!) Other than time consuming, it seems to be a more logical and practical route overall. I can have many tests covered in one step. I’m hoping for an appointment soon around Labor Day. My poor Patch isn’t going to be a happy camper being “pawed” over again! But I should at least have some definite answers afterwards. Hopefully.

    Even though I am more than anxious to do the LDDST now locally, it wouldn’t be cost effective, nor include other testing. I’m tired of being frustrated and scared of running out of time to help Patch.
    Trying to stay calm and focused. My goal - to help Patch and get a diagnosis asap.

    Any words of wisdom are welcomed. I am grateful for the much needed support.

    Donna
    "It is important to remember that you are your petís advocate, your petís voice, so no one can tell you what you will and will not do when it comes to making health based decisions for your loved ones."

  2. #12
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    Default Finally got a Cushing's diagnosis for Patch

    Itís been an arduous, 3 weeks journey, with repeated trips to Auburn UN small animal clinic. Patch had many tests, including an orthopedic exam, to check for muscle tone, strength, loss or weakness, and to rule out any possible pain issues he may be experiencing due to his arthritis and a back leg injury he received prior to my rescuing him. Patch fared very well during the examination. I am extremely impressed with the new Internist now assigned to handle his care, in attempts to thoroughly evaluate Patch. In case someone wants to know, Auburn does not do any urine cortisol to creatinine ratio testing (UCCR) or pheochromacytoma testing. One can save some expense and bring in free catch urine for testing. I also didnít want to risk Patch to undergo another invasive needle to bladder urine draw.

    After two long years of frustration and testing, Patchís recent LDDST confirmed he is HAC positive. It is a combined relief and a stress. Complications arose initially, in that his potassium levels were extremely high (worrisome) but his protein levels had come down somewhat. Patchís sudden excessive potassium was due to Augustís increased dosage of benazepril medicine to lower the protein, so a decrease back to original dosage was warranted. Itís back to normal thankfully as well as his BP. Still an issue to monitor is his protein values and a small rise in cholesterol. Low fat diet here we come.

    This Internist pointed out to me that it was imperative to get a definite Cushingís diagnosis before placing Patch on any medís, it could be quite dangerous otherwise and the prior trilostane dosage recommended by the other Internist I brought Patch to, of 90 mg 2x daily, was more than excessive. It was refreshing that she commended me for using common sense and not following through.

    Now although itís reassuring that the Internist agreed that Patchís body weight is shy of 64 lb (29 kg) and a dosage of trilostane would be 1 mg per pound, (60 mg daily, being 30mg BID), Iím inclined to want him started on a low dosage of 30 mg per day, not 60 mg. In advocating for Patch, I explained I was not undermining her suggestion and explained Dechraís U.S. literature reflects a difference in dosage here vs Europe and that they havenít revised it for the U.S. as yet. I also pointed out that Patch is considered a large dog and that oftentimes, large dogs need and do well, on a much lower dosage as in 0.5 mg per lb (1 mg per kg). I stated I will forward her validated reference material over this weekend (the Davis info and links yíall previously posted in the forum) to back up my assertion. I stressed I was being more than reasonable in my request for Patch to start on 30 mg daily, either once or divided 2x daily total dose, as we can always increase if needed. Not to mention Patch has a history of being medicine intolerant. I can only hope my concerted efforts will convince her that this is the safest way to go. I so hate conflicts! I also realize Iím dealing with a University protocol, even though Dr. Ellen Behrand, the faculty head, is very knowledgeable about Cushingís. I was also informed that sometimes death could occur in taking trilostane which is concerning and scared me.

    I could just simply fill a prescription for (2) 30 mg bottles, and only give Patch the one 30 mg dose daily, but Iíd be more comfortable with having the Internistís cooperation. (Or combine a 5mg and a 10mg BID which would equal 30 mg total daily if a prescription). I feel that twice daily may be more beneficial overall, but safety and lower side effects is my number one priority for Patch. My concern is that Patch fares worse at night than daytime and a single morning 30 mg dose may not help him as much, since it wears off within 12 hours.

    I also mentioned to the Internist, the pre and post trilostane testing vs ACTH. They arenít quite on board with as yet, but have been entertaining it. Still appears I have some more hoops to jump through and am on the mission to find a Cushing experienced, local Vet to work in triage with Auburn and myself in treating Patch.

    I welcome any thoughts or suggestions. Thanks in advance.
    Donna
    "It is important to remember that you are your petís advocate, your petís voice, so no one can tell you what you will and will not do when it comes to making health based decisions for your loved ones."

  3. #13
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    Default Re: Finally got a Cushing's diagnosis for Patch

    Hello, Donna, and welcome back to you and Patch. Youíll see that Iíve merged your update into your original thread about Patch. This way, weíll be able to keep his entire history consolidated in one place.

    Gosh, it sounds as though you guys have been very busy since the last time we spoke! But Iím really glad to hear that youíve finally gotten greater clarification about Patchís diagnosis, and also that youíre feeling comfortable with the folks at Auburn.

    Two questions: Did the LDDS results lead you all to believe that Patch may be one of the rare dogs with a pituitary tumor as well, or were the results consistent with his known adrenal tumor? And are the Auburn vets still discounting the likelihood that the adrenal tumor is a pheo?

    As far as the trilostane dosage, hereís a suggestion I might make. I do encourage you to keep your internist fully informed of your gameplan. But if Patch were mine, I believe Iíd tell the internist Iíd like to temporarily start out with just 30 mg. once daily in the morning for the first week in order to gradually introduce his body to the lowering cortisol. If he tolerates that with no ill effects, Iíd be inclined to then go ahead and add in the other 30 mg. dose in the evening, with retesting in another week or two ó again assuming he exhibits no ill effects in the meantime. Combining the gradual increase with prompt retesting would give me more peace of mind about trying, and evaluating, the full 60 mg. daily dose as the internist has recommended. Assuming that Patch does have a functional adrenal tumor, he may indeed require that amount of medication to provide more complete symptom relief. With an adrenal tumor, he may end up needing even a higher dose. But the prompt cortisol monitoring will help insure that heís not being overdosed, which of course is the greater safety risk.

    But whatever you decide, weíll surely be anxious for any and all updates! Thanks so much for heading back to us now.

    Marianne

  4. #14
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    Default Re: Finally got a Cushing's diagnosis for Patch

    Hello Marianne. So happy to hear from you! Thanks for responding. Haven't meant to be silent lately, just off the charts busy. It is believed Patch has adrenal Cushing's, not pituitary, I think based on his recent Ultrasound showing the tumor there. But will double check with Auburn today for clarity. I do believe they mainly diagnose based on surgery. Not a way I'll go.

    As to the pheo, disappointedly, although I pushed hard for it, Auburn no longer does that testing and couldn't suggest anyone that does. I've been calling around to find someone to do this testing, to positively rule this out no matter. No luck as yet, even though I believe it is simply a blood or urine test. Auburn bases their opinion on no pheo because he doesn't have all the "signs". Hey, he doesn't have all the "signs" of Cushing's either I told them! Exactly why I still want to rule it out.

    I agree with you to initially start Patch on 30 mg once a.m. daily, for a least the first week, although I'm still inclined to want to do 15 mg a.m. and p.m. I worry as to him having side effects period as he has shown so many with other drugs used in the past. If things go well the first week, yes, then increase with a 30 mg evening dose. By the end of two weeks he'll be tested again and I can go from there. I certainly don't want his cortisol to drop too quickly in any event and I'm pushing for the lowest dose period! Haven't heard back from the Internist as yet to see how well they'll cooperate, if at all. I figure give them a few days to digest (or discount) all the literature I forwarded as we all should know, us "school of hard knocks" people don't have any "degrees" under our belt. I'm also in the mist of securing an educated Vet in my area, as not just anyone will do.

    His LDDS score was -
    pre-dex 93 nmol/L
    4 hr post-dex 115 nmol/L
    8 hr post dex 109 nmol/L

    They consider Normal Values -
    Pre Dex 20 -160 nmol/L
    4 hr post, less than 30 nmol/L
    8 hr post, less than 30 nmol/L
    and a decrease in either 4 hr and/or 8 hr post Dex of 50% or greater compared to Pre shows "suppression".

    So stay tuned for my next update. I'm sure it won't be long.
    Donna
    "It is important to remember that you are your petís advocate, your petís voice, so no one can tell you what you will and will not do when it comes to making health based decisions for your loved ones."

  5. #15
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    Default Re: Finally got a Cushing's diagnosis for Patch

    Hi again, Donna, and thanks for posting those LDDS results. The pattern is one that we would expect to see in a dog with a functional adrenal tumor. Dogs with pituitary tumors typically exhibit suppression to below 50% of the baseline reading at either the four-hour and/or eight-hour mark. If that degree of suppression is present, then a pituitary tumor is diagnosed definitively. A lack of suppression can sometimes occur with pituitary Cushing's, but it is much more commonly found in the presence of an adrenal tumor. So Patch's test results do correspond with the existence of the adrenal tumor that has already been revealed via ultrasound.

    So "carry on," and we'll be watching for your next update.

    Marianne

  6. #16
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    Default Re: Finally got a Cushing's diagnosis for Patch

    Thanks again Marianne! Recently located pheo testing for Patch, but need more information if someone can help me to better understand. I was informed it would be a urine normetanephrine/creatinine ration and a metahephrine creatinine ratio. My research suggests a 24 urine catch or a 1st morning void. I was also informed that Cushing's and pheo can be concurrent. I found that the best testing uses the HPLC MS/MS method. Have yet to get the particulars from the clinic.

    As to trilostane, I find a once daily usage doesn't lead to a significant decrease in catecholamines and their metabolites. Yet treatment for pheo is usage of phenoxybenzamine. Couldn't locate anything discerning treatment if a dog had both diseases. This clinic internist stated didn't matter if Patch had pheo, the treatment would be the same as for Cushing's. I beg to differ, but I could be wrong.

    So now I'm left scratching my head if I should pursue the pheo testing. I still feel it needs to be determined if Patch's adrenal tumor is from this, even if concurrent with Cushing's. Auburn doesn't know which adrenal layer is affected. Naturally, I inquired.

    I also have a possible Cushing's Vet within my area, that I'll meet with tomorrow. I'm hopeful it will be a positive move in any case and end this stressful part of my journey for Patch's care.

    If anyone can help direct me with credible links or anything else to offer, I'd be more than grateful. Thanks in advance.
    Donna.
    "It is important to remember that you are your petís advocate, your petís voice, so no one can tell you what you will and will not do when it comes to making health based decisions for your loved ones."

  7. #17
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    Default Re: Finally got a Cushing's diagnosis for Patch

    Happy to report, Patch has a new local Cushing's Vet! Patch and I had a positive consult meeting yesterday with this new Vet and I'm impressed. This is a huge weight lifted from my shoulders. She was super receptive to the information I provided about large dogs dosage. We've decided to start Patch initially on 15 mg's QD for week one and increase to 15 mg's BID week two if things go well and no side effects. Since he is so sensitive to most medications, this should help his body adjust in a more reasonable manner hopefully. It may take longer to see any changes, but safer for Patch all around. Naturally we'll increase dosage as we go and testing will be of great help. The goal is to possibly stabilize at 60 mg's over time.

    Auburn internist will still be involved, acting in triage fashion thankfully. It is such a comfort to know I can now move forward in helping Patch and have the support I need. I'm awaiting answer on whether or not to have him tested for pheo in any case.

    I'll post an update on Patch after he has started the trilostane.

    Donna
    "It is important to remember that you are your petís advocate, your petís voice, so no one can tell you what you will and will not do when it comes to making health based decisions for your loved ones."

  8. #18
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    Default Re: Finally got a Cushing's diagnosis for Patch

    Dear Donna, YAY Iím so glad youíve found a trustworthy local partner for Patchís care! Iím sorry that I didnít yet reply to your earlier post, but Iím afraid Iím just not very knowledgeable at all about pheo specifics. If the folks at Auburn tell you they think itís an unlikely possibility, though, I probably wouldnít dwell on additional testing right now if it were me.

    I wish you the best of luck with your Vetoryl treatment, and weíll definitely be anxious to hear how things are going for you. Thanks so much for both your updates, and weíll be watching for more!

    Marianne

  9. #19
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    Default Re: Finally got a Cushing's diagnosis for Patch

    Sorry it's taken me a while to post an update on Patch, as I have had way too much going on lately. The good news, Patch's 1st ACTH test showed he is tolerating the vetoryl at 15mg twice daily. Pre test was 1.5, post was 4.6.
    As of late Patch is having difficulties in getting up from a lying position which appears he is having some muscle weakness in his hind legs. He also seems to have some problems in climbing up the 3 steps into the house. Also, his once bushy awesome tail has recently been losing fur and it is upsetting to see his boney end tail. Being quite concerned over this, the Vet lowered his vetoryl dosage down to 15mg in the morning and only 10mg at night. Haven't seen any changes as late. He also started galliprant 60mg at night recently for his arthritis. Makes him less alert during the day and tried only 30mg with no changes.

    Not sure what is going on, just that I was more than excited with his first ACTH testing, and now to see Patch most likely is having side effects from the vetoryl. I've temporarily discontinued his galliprant to see if that is causing Patch's weakness. Haven't seen any changes.

    Can anyone offer some ideas or suggestions here? I'm at a complete loss.
    Donna
    "It is important to remember that you are your petís advocate, your petís voice, so no one can tell you what you will and will not do when it comes to making health based decisions for your loved ones."

  10. #20
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    Default Re: Finally got a Cushing's diagnosis for Patch

    Hi Donna, so glad to see you back here with an update! Iím sorry to read that youíre having some new concerns, though.

    First of all, that initial ACTH result really did look good. Can you tell us more about the timing of the test ó how long ago it was taken, and for how long had Patch been taking the trilostane? Cortisol levels can continue to drop during the first few weeks of treatment even when the dose has been left unchanged. So itís possible that Patchís cortisol has subsequently dropped to an uncomfortable level for him. Now that youíve lowered his dose, do you have another ACTH scheduled in the near future? That will be the only way to know whether or not his cortisol level is where you want it to be now.

    If his cortisol level remains within the desired range, then I know it can be hard to sort out the true cause of his new mobility issues. Since we know he has some pre-existing leg issues, itís indeed possible that the lowered cortisol is causing them to flare a bit due to the loss of that ďnaturalĒ steroid. Of course, aside from the Cushingís, natural aging may also be catching up with Patch. At age 12, many big dogs do start exhibiting increasing orthopedic issues. With my own non-Cushingís Labs, that age range of 11-12 has really seemed to be the time period when aging mobility issues have emerged, and rather quickly. I would hope that the Galliprant would help with pain control over time. So you may want to go ahead and start back with that since discontinuing it hasnít seemed to help. Also, as an aside, hereís something that I just wrote to another member yesterday:

    As far as pain medication, I'll defer to your specialist. I see that Jet is already taking Galliprant, and that's supposed to be one of the newer, safer pain meds. You do have to be careful with traditional NSAIDS when treating Cushpups due to risks to the kidneys and liver. Also, when cortisol levels are high and uncontrolled, the risk of GI bleeding due to NSAIDs can be elevated. However, once cortisol levels have been stabilized within therapeutic range, some of the newer NSAIDS such as Meloxicam or Previcox may be considered a worthy trade-off in terms of quality of life. As I say, though, that's a question I'd pitch to your specialist. I've asked my own vet about Galliprant, and he says that, based on owners' anecdotal reports, he thinks it sometimes doesn't offer as much pain relief as do some of the traditional NSAIDS. But the safety issues may be an over-riding factor that makes it the better choice.
    One thought about the fur loss on his tail: one irony is that weíve often seen Cushpups suddenly lose fur for a time after cortisol levels are lowered into therapeutic range. This seems very strange since balding areas are a classic symptom of uncontrolled high cortisol. Why would dogs start shedding after the cortisol is lowered? The explanation weíve been given is that untreated Cushingís can disrupt the normal hair growth cycle ó kind of putting it to sleep. Once cortisol is lowered to a more normal range, the hair growth kicks back in again, and can result in a rather sudden shedding cycle. This happened with my own Cushpup. He had developed large bald areas on his flanks where no hair regrew prior to treatment. But after starting treatment, he suddenly started massively shedding even more! I was really freaked. But when I examined his skin, I saw that there was fresh soft baby hair underneath the shedding. And sure enough, before long he started filling back in with a new fluffy coat. I donít know whether this is what is going on with Patch. Itís a bit odd that only his tail would be affected, since hair loss along the flanks and haunches is also typically involved with Cushingís. But I wanted to at least mention this possibility.

    OK, thatís about all I can think of for now. It does seem as though youíre in a bit of a holding pattern for the moment, awaiting further ACTH results from the dosing decrease. Once you have a better idea as to where his cortisol level is settling, you may also be better able to judge whether the mobility problems are related to the medication or instead to something else. Please do continue to keep us updated.

    Marianne

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