Java Bean

[lulusmom]

Hi Kelly and welcome to you and Java.

Others have given you some good feedback and I'd like to add my own to theirs. I confuse easily so in order to keep myself from rambling and stay on track, I've typed my comments and questions in blue text within the body of your last post. Before I start, I'd like to thank you for saving Java and her siblings from a certain ugly death. I'm a rescuer so I'm acutely aware of how evil people can be. Abandoning pets at a shelter is bad enough but abandoning them in the desert to die in the hot sun or be killed by prey is beyond disgusting. You mentioned Lake Havasu and my eyes lit up. I spent every other weekend at Havasu Springs during the spring and summer months when I was a sweet young thing. I have many great memories of those times. I was a bikini clad babe (even if I do say so myself) skiing behind some really bad ass boats, baking in the sun with no sunscreen...just baby oil to make sure I was well done.

Ok, down to biz. Got copies of everything today. My vet is nice, but I do not feel she has a lot of experience with Cushings. I found a site, Marvistavet.com, which gave a lot of info and compares the different meds - worth a checkout all-. They are in LA, CA and I am in Orange County, CA - 45 to an hour depending on the time of day. I am going to call them tomorrow.

I had two cushpups, both passed who treated with a great internal medicine specialist in O.C. I live in San Bernardino County and drove to Fountain Valley because I could not find anybody in my neighborhood who was experienced enough to treat or diagnose a cushdog. Sounds like your vet is like most I've met in my area. The fact that your vet suggested ketoconozale is pretty good evidence that her experience with cushing's is very limited. A good number of dogs (1/3) don't absorb it into the GI tract and it is tough on the liver. So efficacy is iffy and it's probably tougher on the liver than Trilostane or Lysodren. If it were all that and a bag of potato chips, my dogs would have been treated with it. Out of hundreds of members, I can only recall one or two who opted for keto. I seem to recall that one of them eventually switched to Trilostane or Lysodren. Perhaps other members can recall.

VCA All Care is a specialty hospital open 24/7 so I made my appointments on Saturday or Sunday. My favorite specialist is Dr. Michael Moore, who is the Director of the Internal Medicine Department. Specialists are always more expensive and you usually get what you pay for. My first cushpup went undiagnosed for more than a year and it was an IMS at VCA All Care who finally diagnosed her and he left no stone unturned in confirming a diagnosis. After the diagnosis and starting treatment, I went to a regular gp vet to get the stim tests done as it was a lot cheaper. There is no reason why a specialist and a gp cannot work together. The one thing I think your vet should have done was order an abdominal ultrasound to validate the LDDS and check the status adrenal glands, liver and other surrounding organs. There is no doubt that Java has overt symptoms associated with cushing's and some vets may think a positive LDDS test is enough but a specialist usually doesn't as they want to know exactly what they are dealing with. I personally prefer to know that too.

The mfgr of vetoryl, Dechra, says that formulary pharms are not FDA approved in US.

Compounding pharmacies are governed by the State Boards of Pharmacy, not the FDA; however, they are subject to periodic FDA inspections. My dogs were tiny and all of their meds had to be compounded and did quite well on them. Compounded Trilostane is usually a third of the price of Vetoryl and can only be compounded for doses other than the Vetoryl doses manufactured by Dechra and approved by the FDA.

Java is hungry, thirsty, weak, pot bellied (hardly fits thru doggie door). At her vet visit in July 2012, I told the vet she could no longer get up on the bed. She has extreemly deteriorating muscle mass on her hind legs, her back is dipping like a lame horse. She stopped being able to get on the couch in January, when I noticed her extreme thirst and took her to the vet for that. Note- in May 2012 I started fostering my grandpuppy Missy. She is a 4 1/2 pound teacup silky terror. (no, I mean terror!!!) Missy and Java used to play like crazy on visits, but when she moved in, I thought Java was depressed. I think this is when her symptoms really started- hindsite 20/20.

Testing and timeline:
1/5/13 -Blood- I will only list the high counts, as there are so many listed-
ALT (SGPT) 340, Alk Phosphatase 716, Phosphorus 6.4, sodium 152, potassium 5.4, differential "absolute", monocytes 1035, T4 .06,
urine - spec grav 1.006, pH 7.0, occult blood "trace".

Can you please provide the normal reference ranges for these abnormalities

3/6/13 - Dex sup test:
cortisol sample 1 - 9.0 9:45
cortisol sample 2 dex 10.6 1:46
cortisol sample 3 dex 9.0 5:48

As Marianne has already mentioned, these results don't tell us which form of cushing's Java has. An abdominal ultrasound should be done to make that differentiation. It's not an inexpensive test but it provides so much information and even if I couldn't afford surgery if an adrenal tumor was identified, I'd want to know as adrenal tumors can metastasize and cause extremely high blood pressure.

Current status:
Vet gave me Ketoconazole to start today until she can get the Vetoryl, as Java is declining - she fell on the door jam going out to tinkle last night - she's so weak - it's killing me, I'm crying in my kraft dinner. Upon research of the Ketoconazole, it seems as if it has fewer side affects, and no chance of Addisons syndrome, and it is cheap, and no tests are needed after initial month check. No problem giving her pills 2xd as she always is up for a treat! I haven't seen anyone listing the Ketoconazole on your site as a treatment. Has anyone used it??? Oh, one more thing, I can get my Dr. to give me an RX for it, to "treat my excema" (don't tell anyone I said that). I think I would like to try it first before the more dangerous drugs.

As I mentioned earlier, Keto is not without risks and its efficacy is questionable. It used to be used routinely by UC Davis to lower cortisol levels in preparation for adrenal surgery but they dropped it like a hot potato in favor of Trilostane.

Frankly speaking:
From what I have read, I don't really see the outstanding benefit of Vetoryl vs Lysodren for the cushpup. It seems to be of more benefit to the Vet, as my vet intends to sell it to me and peform expensive tests for the the rest of the Bean's life.

Vetoryl and Lysodren are serious drugs and their ability to improve a dog's quality of life has been proven time and time again. There is a reason why these two drugs are the treatments of choice by experienced vets. They work! I am intimately familiar with both as my dogs treated with both and did beautifully. Treatment with either can be safe and effective if prescribed by an experienced vet and an educated pet owner.

Periodic testing to monitor treatment is expensive but it's necessary to insure the safety of our dogs while trying to determine if treatment is adequate, too much or too little. Not all vets put money above their patients and many work with pet owners to contain costs. For instance, Dr. Moore and would call in my dogs' prescription to a compounding pharmacy who shipped directly to my home and charged my credit card. My current gp vet not only does that but shops the price for me so that I get the best price from trusted compounding pharmacies. They don't make one cent on my dog's medication.

My current vet also stays abreast of the latest advances and saved me money by using a fraction of the stimulating agent used to do the acth stim test. The stimulating agent is called Cortrosyn and vets have no control over the obscene cost of one single vial but they can control costs for the pet owner who have small dogs. Java is small so your vet can save you a lot of money by learning how to reconstitute and store the remaining cortrosyn for future tests. We can provide that information to you

Ketoconazole was never even mentioned until I pleaded to start treatment today and my vet could not find any Vetoryl anywhere today. She handed me this bottle and told me to start when I get home. The Lysodren and Keto are available at any pharmacy - easily price compared on Goodrx.com.

As I mentioned previously, my dogs treated with compounded Trilostane and Mitotane (Lysodren) and the annual average cost of both was about the same. My dogs weighed 4.5 lbs and 6.5 lbs. One thing I wanted to mention is that Java's ALT is a lot higher than we usually see on the many labs posted here and while it may be 100% attributed to excess cortisol, if it were my dog, I'd want to know if something else was pummeling the liver before I started treating with Keto.

This is the end of "The Life and Times of The Bean" a cushpup novel available at your bookstore soon.............

By Beanielover Kelly143 catchy pen name, huh??

[kelly143]

My vet told me that she went on facebook and had a forum with many professionals that she respected. They included internists, dermatologists, surgeons, endocrinologists and vets who had a lot of experience with cushpups. It seems that the vets have limited experience with the drug since the FDA approved it in 2009, and they are finding that the dosages listed by the MFGR are extreemly high, and that the lower dose is a better way to go. I think that the big issue here is that the dosage question is the downfall of the use of this drug, as the dosages listed in UK are different than the ones here. Since it is still pretty new here, vets are still working out the kinks with the dosage. As a result, I would like to start with the keto, if no results, I will go with the Lysodren, and keep an eye on the progression of the Vetoryl dosage situation. I have not seen any info as of yet to show that Vetoryl is greatly superior to the Lysodren, Lysodren is cheaper, more redily available, and once a week dosage is easier. I would also like to talk to the Marvista vet to get their take on Java. I really don't feel comfortable with my vet's experience with this disease or with the Vetoryl.

I must stop for now. My eyes are rolling back in my head again!!

kel

[kelly143]

Thank you for your input! I wrote my last post before I saw it.... Thanks for the info on VCA. I was told the ultrasound was $1600.+ from my vet. I have been out of work for 3 of the last 4 years, with little hope for the near future. I just can't do it right now. My vet understands this and is trying to help us by keeping the big ones as a last resort. If (WHEN) things turn around in my employment, we will go forward with the big guns. It is understood that 80 to 85% of cushings is Pituitary based, chances are quite good that Lysodren will work well. I don't know, I guess I am still trying to digest the whole situation. It's been 3 whole days since the diagnosis and my brain is fried and I am exausted from dealing with this whole thing. I am totally confused now, I guess I will simmer a while longer in my tired brain juices and research a little more. But first....I need a nap. Think I will go cuddle a while with my sweet beanie.

I am so grateful to all of you for being there. Animal lovers are such great people. You are all so supportive and kind. It's so nice to know there a nice people left in the world.

Kel

[labblab]

Dear Kel,

You are absolutely right that newer research and experience is trending towards much lower doses of trilostane than were originally used when the drug was introduced for veterinary use in the U.K. a decade ago. However, even with that in mind, an initial daily dose of 12 mg. for a 50 pound dog is far lower than any current revised protocol of which I am aware. Since you are not opting to treat with trilostane, that is seemingly a moot point in your case. But I just wanted to mention that, for future reference, in case circumstances should change for you. If you're ever interested, here's a 2011 research study out of UC Davis which summarizes their current thoughts and dosing recommendations:

http://www.k9cushings.com/forum/show...0146#post80146

Since you've already started with the keto, I think your strategy to give it a try and then move on to Lysodren (if need be) sounds reasonable. If you do end up opting for Lysodren, however, be prepared to dose a bit more frequently than once a week once you reach the "maintenance" phase. Others who are more familiar with Lysodren can clarify further, but I think the recommendation is to split the weekly maintenance dose into 2-3 administrations over the course of the seven days. And as I said, the one issue that might arise with Lysodren treatment relates to whether or not Bean has an adrenal tumor -- if so, how high a dose of Lysodren might be needed for effective symptom control.

Of course, from your perspective, it sounds as though the best and easiest solution will be the keto if it proves effective. Over the years, we have had at least one other "keto dog" who did well on the medication, and we'll surely hope that will be the case for your Bean.

Do keep us updated, OK?
Marianne

[molly muffin]

Hi Kel, I think you have a plan and you can certainly see how the keto works and then plan to move on to lysodren if it isn't optimal.
You sort of have to take this learning about cushings in moderate amounts. It can be over whelming. There is just so much to learn. I think you're doing really great though.

And yes, I do think the pen name is catchy!

Sharlene and Molly Muffin

[mytil]

It does sound like you have a plan for your sweetie pie. Please do keep us posted on how things are going.

Also, this may be redundant (sorry) but with Lysodren there is a loading period where it is given every day until the cortisol levels are within accepted ranges and then you go on maintenance dose (weekly).

Terry

[lulusmom]

Hi again.

Since you have decided to move forward with Ketoconazole, I want to share some additional information that you should also share with your vet. I have cut and pasted an excerpt from a paper written by Dr. Mark Peterson, a renown endocrine specialist. Apparently my number regarding efficacy was at the low end of the range he has experienced in his practice. Since you don't know how much experience your vet has, this will help make sure dosing and monitoring is done properly.

Ketoconazole is an imidazole antifungal drug that also inhibits the synthesis of glucocorticoids and androgens. It effectively lowers the circulating cortisol concentration but has minimal effect on mineralocorticoid production. Ketoconazole controls hyperadrenocorticism in some dogs, but unfortunately, the drug is not efficacious in many dogs with the disease. In our experience, one- third to one-half of dogs fail to adequately respond to treatment.
Initial Dosage—Ketoconazole is started at a dosage of 5 mg/kg given twice a day for 1 week. If the drug is well tolerated (i.e., no decrease in appetite or icterus is seen), the dosage is increased to 10 mg/kg given twice a day for 2 weeks.
Monitoring Ketoconazole Dosage—The efficacy of the initial 14-day course of treatment is determined by an ACTH stimulation test. To ensure adequate control of hyperadrenocorticism, both the basal and post-ACTH serum cortisol concentrations must be lowered into the basal reference range. If the serum cortisol concentrations remain above this range, the dosage is increased to 15 mg/kg twice daily, and an ACTH response test repeated in 14 days.
Most dogs require a daily dose of 30 mg/kg for a long period for good clinical control. The disadvantages of ketoconazole are the expense, the requirement for twice daily administration for life, side effects, and the drug’s lack of efficacy in some of the cases. In one report, less than 2% of veterinary specialist (internal medicine and dermatology) use ketoconazole for treatment of canine hyperadrenocorticism.

Please do post the normal reference ranges for the abnormal blood values. As I mentioned, most cushdogs have mild elevation in ALT and even without the benefit of seeing the normal reference ranges, Java's appears to be a lot higher than we're used to seeing here. Plus, you mentioned that her condition seems to be in deep decline recently and while all dogs are different, sudden and deep decline isn't the norm. Please ask your vet about that and if he doesn't have an appropriate answer, perhaps he can call an internal medicine specialist to see if there are any concerns. Most gp vets have an internal medicine specialist they call when they have an unusual case and cushing's is unusual for a lot of gp's. I'm a worry wart who understands the financial constraints of this horrible economy but asking questions doesn't cost anything.

[Squirt's Mom]

There is another drug sometimes used in cush pups that doesn't have a high efficacy rate either but did help my Squirt for about 9 months. That drug is Anipryl, generic is Selegiline. It is only effective if the pup has the pituitary form, PHD, and the tumor is in the pars intermedia portion of the pituitary gland - which applies to about 25% or less of PDH pups.

I don't know that it is less harsh on the liver but your vet or a pharmacist could tell you that more than likely. It is more expensive to use than the Lysodren (Mitotane) she is now on but has many fewer possible side effects. However, the trade of is in the effectiveness of the two - Lyso far more effective than Anipryl. The same would hold true for Trilostane (Vetoryl) VS Anypril. But it is another option if the Keto doesn't work out and you aren't ready to try the Lyso or Trilo.

Hugs,
Leslie and the gang

Some links on Anipryl -

Anipryl info*

http://www.marvistavet.com/html/body_anipryl.html

http://vetmedicine.about.com/cs/dise...rylseniors.htm

http://www.lbah.com/anipryl.htm

http://www.selegiline.com/

http://www.petplace.com/drug-library...ryl/page1.aspx

http://www.drugs.com/vet/anipryl-5-mg-can.html

[kelly143]

Hi All,

Thank you all again so much for all of your support. I have decided to go with the Lysodren. I will start her on it this afternoon.

Now the next question: Who has info on the cheapest ACTH test in the Orange County, Ca area? I came across a thread with this info, and it seems that the prices vary A LOT depending on where you go. I am looking to compare "out the door" cost. Some people list test only, some include visit cost (if any), meds, etc. I am wondering if the prices reflect the Diagnostic Lab charges to the vet. My Vet used Antech for the low dose dex test and charged $170.00 for the test and $15.00 for the dex. The total bill was $185.00, no charge for Java spending the day there. My vet said the ACTH would cost between $300. and $400. dollars. That seems VERY high in comparison to most of the posts in various areas.

We will make it thru this. I took my nap and I am strong again!

Kelly143

[lulusmom]

Hi Kelly

The reason why the acth stim test is so expensive is because the stimulating agent, cortrosyn, is ridiculously expensive. There is good news for those with smaller dogs because studies show that while instructions on the .25 mg (250 mcg) vial is to inject the entire vial, only 5 mcg per kg of weight is necessary for an accurate result. While Java isn't small, her weight is still low enough to get two stim tests out of one vial. If you do the math, she'd need a bit over 113 mcg so your vet could just split the vial exactly in half.

I have provided the url to instructions on how to split, reconsititute and store for future use. This info is brought to us by a highly published and well respected endocrine specialist, Dr. Mark Peterson. Either give the url to your vet or print out the article for him and ask for a revised quote.

http://endocrinevet.blogspot.com/201...cortrosyn.html

At 50 lbs, Java should be getting the recommended daily loading dose of 50 mg/kg which equates to about 1113 mg. Most vets would round down to 1000 mg which makes for easy dosing. You would give Java one 500 mg pill in the morning and one in the evening WITH FOOD. The average time to achieve loading is between 5 to 8 days but we've seen some load in two days and some taking months. Unless your vet is open 24/7, I would suggest that you wait a few more days before you start dosing. The reason for this is that because of Lysodren's cumulative effect, it's unlikely that a dog will have a crisis in the first two days of loading. If you start today, there's a much greater likelihood that you're going to need your vet when he's closed for the weekend.

If your vet has not given you prednisone to use in case emergency, do not start loading until it is in your hands. Having had two cushdogs treated with Lysodren, I'm a seasoned veteran of loading and I can tell you that if you watch Java like a hawk and look for signs of loading, like the least little change in eating behavior and/or decrease in water intake, you and Java will ace it without incident. Many of our staffers are also seasoned Lysodren vets so expect them to chime in and want to help you and Java.

If your vet were experience with cushing's, which I don't get the impression he is, he should be calling you every day to check on Java's progress. If that's not the case, we'll gladly take the case and lead you through everything. You just need to check in frequently, okay? Before you start, please, please read the Lysodren Loading Instructions and Helpful Hints. Print it out and keep it handy while loading so you don't forget anything. I've provided a link below.

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

Read through your homework and let us know if you have any questions.

Glynda