>From:    Bruce Williams <[log in to unmask]>
>Subject: More on Lupron
 
Dear Dr. Williams.  Thank you for taking your time to look into Lupron.  I
hope you'll hear a few more comments, and a request.
 
>This is a totally incorrect explanation of Lupron's effects in the body.
>If I am wrong, or my research has missed something in the literature,
>please let me know.  I want to be wrong on this one, I really do.
 
Thank you Dr. Williams.  Though you've apparently done an extensive
medical-literature review and talked with an endocrinologist, still... it
would seem vets using it must have found some justification and result, or
why would they continue?  *Sigh* - so many differing opinions in medicine.
I'm not for or against Lupron, but if surgery weren't an option and my
ferret was failing on Lysodren, I'd sure like a shot at something else if
had worked for others.  Is there any chance a conversation with a vet might
reveal something the literature hasn't?  Dr. Johnson-Delaney, who used it as
adjunct to Lysodren with her own ferret, has indicated willingness to
consult about adrenal disease with other vets, and I could give you her
e-mail.  She mentioned Dr. David Kupersmith as someone using it with success
for ferrets who are failing on Lysodren alone.  I don't have his address,
but Modern Ferret mag probably has it.  The vet who posted about it a few
FML issues back must have some reason to believe it would work... hm.
 
Personally I can't cite cases, except a friend of mine whose ferret was
given Lupron.  It "appeared" to work (progress was tracked through clinical
tests).  Estradial went down, blood (I think it was hematocrit) went up,
hair regrew, and, best of all, frequent urinating returned to normal.
Coincidence?  Perhaps, but this is a lot of change soon after starting
Lupron.  Unfortunately after a few months, adrenal symptoms returned.  But
Lupron was used without Lysodren as an experiment because the owner was
hoping to avoid surgery or Lysodren.  He opted for options other than
surgery (for now anyway) with the advice of a board certified surgeon (a
left adrenal has already been removed), and was hoping to not have to use
Lysodren due to marginal blood sugar (he's now starting Lysodren).  Of
course this case isn't conclusive of positive results.  But I've believed
Dr. Johnson-Delaney's statements that ferrets who weren't doing well on
Lysodren are showing improvement when Lupron is used too.
 
>I have reviewed the available literature on Lupron <SNIP> There is no
>evidence from any of these sources, that Lupron has any effect on adrenal
>tissue.  <SNIP> Adrenal tumors are autonomous, they do not respond to the
>pituitary in any way.
 
Dr. Johnson-Delaney doesn't write that Lupron "directly" affects adrenal
tissue, but rather shuts down processes causative of abnormal adrenal
growth.  While you conclude adrenal tumors are autonomous, she obviously
believes or theorizes the pituitary is involved in the disease process, so
that, when there is abnormal adrenal gland tissue, there is also some
function that is stimulating the abnormal growth that Lupron helps shut down
(while Lysodren would be used to kill off the abnormal adrenal tissue).  I
can see that if you are decisive that adrenal tumors are autonomous, you'd
conclude Lupron wouldn't help.  But is autonomy proven?  If it were, I would
think Dr. Johnson-Delaney would know that, since she is well studied, and
research oriented.
 
>While I also maintain that Lupron will not physically harm a ferret, the
>fact that it does not treat the root cause of the problem, an adrenal tumor,
>allowing it to continue to grow, is harmful in itself.
 
I understand, though, that it is mainly being recommended as an adjunct, or
assistant, therapy to Lysodren when surgery isn't an option.  I agree that
therapies that mask the symptoms are dangerous.
 
>Most ferrets can have surgery these days - surgical technique has improved
>greatly in the last five years, thanks to the efforts of people like Dr. Joe
>Bock, who pioneered techniques in bilateral adrenalectomy, and Dr. Scott
>Citinas, who proved that you can ligate the vena cava in ferrets with
>previously deemed "unremovable" tumors.  These have become standard
>treatment modalities these days, and we can treat many more ferrets
>surgically now that just a few years ago.
 
>Tumor size and placement is relatively irrelevant in the hands of a
>ferret-experienced surgeon these days.  As far as monetary considerations,
>a cheaper, less effective treatment is actually a much poorer investment
>than a more expensive surgery with a higher potential for cure.
 
And, in the Adrenal Disease FAQ, updated last month, you write: "Adrenal
disease in the ferret is common, and if detected by a watchful owner or a
knowing practitioner, can be easily treated."
 
BUT THEN YOU WRITE:
>I too, would love to find a surgical alternative for ferrets with adrenal
>disease; I have lost four in the last six years to it or to it's
>complications.
 
Dr. Williams, I feel the need to point out that I think you overvalue the
efficacy of surgery in curing adrenal disease, and, perhaps in relation to
that, undervalue the difficulty of treating this disease, at least by your
words in the FAQ.  People need to be emotionally and technically prepared to
fight this illness and not expect it's easy.  It can be a very rough path,
despite watchfullness and skill.  I'm sorry you lost your ferrets.  I have
lost one to this disease, too, and am fighting for the life of another.
Despite good, ferret-experienced surgeons (which are difficult to find even
in metropolitan Seattle, Wa.), many ferrets are still dying from adrenal
disease.  I still think that in many cases surgery should be the first
option tried.  But right adrenal tumors are still sometimes too dangerous to
remove, or surgeons don't know the techniques.  Tumors aren't always found
or the disease arrested (even after three surgeries), or vets don't know
what to look for.  And surgery prices, especially if surgery is needed two
or three times, can grow astronomical, and be incredibly discouraging if the
ferret is not helped.  Plus, repeating surgeries are hard on pets and pets
age as the disease continues.  It's just not simple... I read about these
problems regularly on my Ferret Adrenal/Insulinoma Mailing List (FAIML),
though my stories are probably skewed toward the negative results, since
non-problems don't get asked about.  But I sure have come across a lot of
stories (including my own) where trying to treat the disease is complex,
terrifying, confusing, and full of hopelessness and heart break... despite
hunting very hard for the good and right answers, and searching for the
best, most experienced vets.
 
>and Dr. Scott Citinas, who proved that you can ligate the vena cava in
>ferrets with previously deemed "unremovable" tumors.
 
It can be done, but my vet says is very risky.  She didn't want to attempt
with Wally's huge tumor, which was so encapsulated in the vena cava she
couldn't even safely biopsy it; considering vena cava ligation, she was
willing to try but said she couldn't give me any estimate of the risk... but
he could easily die.  At that moment I was thankful that chemical options
were available, even if not perfect.  His tumor was so huge that he couldn't
sleep in a normal ferret position.  I'm sure the tumor would have killed
him.  He grew back all his hair on Lysodren and has been very bouncy, though
there are complications that I'm concerned about.  There are just no easy
answers.  Dr. Johnson-Delaney, a VERY ferret-experienced vet, and ferret mom
(who meets regulary with a group of other ferret-experienced vets in
Seattle) advises against vena cava ligation, saying it's too dangerous and
not conductive to longterm health.  It can be done, and ferrets have
survived, and I'm not for or against it, but I think it should be considered
VERY carefully, and, from interviewing about ten vets in town who treat
ferrets, I wouldn't agree that ligating the vena cava is a "standard
treatment modality".
 
>Lynn, I think you are oversimplifying my qualification to speak...
 
Point well taken Dr. Williams.  Your time and effort toward learning about
and helping ferrets is very much appreciated.  I'll always be grateful for
the time you've volunteered to talk with me about ECE, and, most of all,
about my neural tube baby, Squeek.  And I'm glad you're looking into Lupron
out of concern that ferrets might not get the surgical help they need.  I
hope there are no hard feelings.
 
>>So there you have it... Thank you for listening!
 
>Lynn, I am listening.  I am not being argumentative here, but this is too
>serious a subject to for me to ignore.
 
That's the problem with e-mail, sigh... things get misinterpreted... I
didn't mean to sound argumentative either - I was more relieved than
anything to have reached the end of my long post!  :)
 
Dr. Williams, I started an adrenal (now adrenal/insulinoma) support group
and digest list because of all the conflicting information about adrenal
disease.  I would love to stop spending my time putting out the list, if
ever surgery or chemistry offers a curative and straightforward standard
treatment.  My list is a only a support group and informational exchange
among fuzzy owners who are very much struggling to save their ferrets, but
sometimes losing.  Sometimes a thoughtful vet speaks up.  The list raises a
lot more questions than solid answers.  As Sukie Crandall recently pointed
out, something more objective is needed as a forum for discussion and
exploration of adrenal disease.  Perhaps a web site where surveys could be
gathered and documented, and adrenal papers from prominent vets could be
exhibited along with unpublished clinical data being explored by vets.  Does
something like this exist?  If so, I'd like to know more.  If not, I'd help
out in creating it, but I'm not up to it alone.
 
Really Dr. Williams, I believe in your sincerity.  I also believe that
differing opinions among vets will continue to make it difficult to chose
treatments, and that, though surgery is the fastest solution, when it works,
it is only part of the solution.  I don't know if Lupron will join Lysodren
as a standard treatment, or will peter off, but hopefully more study will
reveal this and no harm will be done.  I appreciate the time you've already
taken in this matter, Dr. Williams, very very much.
 
Sincerely,
Lynn
[Posted in FML issue 2213]