Gucci - 12 year old Shih-Tzu on trilostane for 2 years

[TiffanyMokhtari]

Hi everyone...
I have an 11 year old female spayed dog who has been treated with 30mg of trilostane once a day for the past year & has started having clinical symptoms of Cushings again. (Panting, Excessive Drinking, Peeing everywhere, etc)
So i brought her back to the vet on Oct.6 and they recommended doubling her dose of trilostane....
Well I did that for 4 days and I had to stop. It just seemed like she was on deaths door! She was very lethargic, mentally confused, non responsive, etc....
The vets here in New Brunswick, Canada have no experience whatsoever in treating this disease and seem to only read from textbooks. They are completely clueless so it can be very frustrating.
So, I decided to stop her trilostane all together for the past 4 days.
She did snap out of whatever she was feeling and seems to be feeling upbeat again. But her clinical symptoms are still there and I just dont know what to do next.
I did ask the vet for her levels and they told me....1 year ago her post acth cortisol was over 800 nmol/l (there machine only goes up to 800 so it might have been higher)
In January, the levels were 49.9 nmol/l,
and Oct.6 they were 47.6 nmol/l.
I appreciate any advice you could give me...
thank you.

[AlisonandMia]

Hi and welcome!:)

A quick question: That stim test on Oct 6 - was that done before or after the doubling of the trilostane dose? Looks like it was before but just want to be sure.

Alison

[TiffanyMokhtari]

Hi Alison..
Yes, it was done before doubling dose.
Tiffany:)

[Harley PoMMom]

Hi Tiffany,

Welcome to our cushings family, I am so sorry for the circumstances that brought you here but I am so happy that you found this forum with these amazing and knowledgeable people.

Some pups on Trilostane that have been on it an extended period of time will usually have the clinical signs of Cushing’s syndrome come back, because Trilostane blocks the pathway of the intermediate steroids and therefore their levels increase dramatically. The intermediate steriods I am talking about are androstenedione, estradiol, 17-hydroxyprogesterone, progesterone and aldosterone.

You might want to talk to you vet about running the UTK full adrenal panel with the ACTH stim and checking if these intermediates are elevated.

If you have any questions about the UTK full adrenal panel, or any questions about anything, please don't hesitate to ask, we are here to help you anyway we can.

Hugs.
Lori

[TiffanyMokhtari]

Hi...
What is the UTK Full adrenal panel? And can I get it done from Canada?
thanx!

[Roxee's Dad]

Hi Tiffany,

I would also like to welcome you. It does sound like your vet may be clueless.:(

What is you pups name and how much does she weigh?
Which cushing's was your pup diagnosed with? Pituitary, Adrenal or Atypical?

Can you post the test that were performed to diagnose cushing's? ACTH Stim Test, LDDS, UC/CR, HDDS? If you don't have the results, please ask your vet's office to provide you with a copy.

You did absolutely the right thing by stopping the meds given the signs your pup was showing. :) Very good heads up on your part. :) You probably saved her life!

Most of the damage or ill effects of treating cushing's comes from vet's with little or no experience and sometimes cush parents that don't pay attn to the symptoms to watch for when treating. If you don't have access to an experienced vet, then you and your vet need to work together as a team. Educate yourself by reading the info in our resources section, ask as many questions as you need right here in your thread.

Did your vet perform an ACTH stim to check the cortisol level before doubling the dose?

Other issues that Lori is reffering to that can also lead to cushing's sypmtoms can be an elevation in one or more of the intermediate hormones. These can only be detected by the UTK adrenal panel.



Here is a link to the UTK (University of TN, Knoxville) adrenal panel information:

http://www.vet.utk.edu/diagnostic/endocrinology/articles.php

There is also more information in our "Helpful Resources for Owners of Cushing's Dogs" section.

http://www.k9cushings.com/forum/forumdisplay.php?f=10

See post titled Congenital adrenal hyperplasia-like syndrome/ Hyperestrinism/ "atypical Cushing's" in the above link.

Or go to that thread directly by clicking here:
http://www.k9cushings.com/forum/showthread.php?t=198


Sorry to ask so many questions and there will be more.;):) The more we know, the better the more experienced members will be able to help you and guide you thru this and help your pup.

[labblab]

Hi and welcome from me, too!

I just wanted to elaborate a tiny bit more on the good information that you've already been given. As you already know, trilostane is one of two drugs that effectively lowers cortisol levels in dogs suffering from Cushing's. However, as has been said above, trilostane also INCREASES certain other intermediate adrenal hormones. For many dogs, these increases do not pose a problem and this is why trilostane is now widely prescribed. But for some dogs, these increases are problematic and cause a return of the same types of symptoms that prompted treatment in the first place. For those dogs, their cortisol levels may remain well-controlled by the trilostane, but further testing in addition to a standard ACTH will show significant elevations in these other hormones. This is where the UTK testing comes in. And I am guessing that your vet shouldn't have any problem sending a blood sample from Canada if the testing seems advisable. However, the first step in the process would definitely be asking your vet to call or email Dr. Oliver at UTK, because the timing and usefulness of the test depends upon a dog's trilostane treatment history. Any dog that is being actively treated with trilostane will inevitably show certain elevations in intermediate hormones. The question is determing whether or not those elevations are the source of the rebound in symptoms.

Given the ACTH results on Oct. 6 of 47.6 nmol/l (1.7 ug/dl), it is surely not elevated cortisol that is causing a return of your pup's symptoms. This result is right at the low end of the treatment goal for a Cushpup being given trilostane. So since you increased the trilostane dose AFTER Oct. 6, it is no wonder that your dog showed symptoms of overdose!!! So I think your vet needs to look elsewhere for the rebound of the Cushing's symptoms. And elevated intermediate hormones seems like a reasonable issue to consider.

Dogs for whom trilostane presents a problem may do better switched to the other Cushing's medication, Lysodren. Lysodren also controls cortisol nicely, but it does not cause the same elevations in other adrenal hormones.

For right now, you're doing the best thing possible, which is to educate yourself :)! And that will also help you to discuss the situation more knowledgeably with your vet. You may even want to print out some of these articles to show your vet. And then if it were me, I'd really encourage my vet to contact Dr. Oliver. He is a wonderful resource and very easily approached.

Marianne

[Squirt's Mom]

Hi Tiffany,

Just wanted to welcome you and your baby to K9C! :) You are a super mom!!! Your instinct to stop the Trilo was right on the mark! :cool::cool::cool::cool: Like John said, you probably saved her life by doing that. Way to go!!! :D:cool::D:cool::D:cool::D

What is your baby's name? And what breed(s) if you know?

Can't add much to what has already been said, except to reinforce the fact that Trilo increases some or all of the other hormones that cause Atypical Cushing's.

So glad you are here and hope to learn much more about the both of you in the coming days.

Hugs,
Leslie and the girls

[TiffanyMokhtari]

Hi Everyone...
Thanx for the great info...
My dogs name is Gucci and she is a 11 year old spayed female (Shih Tzu) who weighs 15 lbs.
She was diagnosed with pituitary Cushings last year with an ACTH stim test....Her results were over 800 nmol/l....
In January 2009, Her pre result was 49 and her POST result was 81...
Now as I posted to you yesterday, she was tested again on October.6. Well I told you her post level was 46....Well that was actually her PRE level and they lost the post level.
So with a pre level of 46, the vet ordered me to give her double trilostane (35mg) twice a day and that was when I noticed the state she was in.
I found out this today when I went to the vet and demanded answers. It was a different vet and she apologized saying this never should have happened. MY dog looked like she was on deaths door! :(
So Gucci was given the double dose (70mg) for 5 days and I hope it wont have any long term effects on her. They didnt even test her electrolytes.
Gucci has been off meds comletely for about 5 days...I gave her her regular dose of trilostane today (35mg)
So basically the other vet wants me to stop the trilostane until Monday, then give her 1 - 35mg pill in the morning and bring her in for testing.
Does this sound right to you guys?
Thanx a bunch:)
Tiffany & Gucci

[Harley PoMMom]

Hi Tiffany,

I really do think Gucci's electrolytes should have been tested. But most importantly, how is Gucci feeling and responding/looking now?

Hugs.
Lori

[gpgscott]

Hi Tiffany,

It does sound like the advice to double the Trilo was not good advice. I am going to let others talk about their opinion of the upcoming test and the dosing prior to the test as I have no first hand experience with Trilo.

The full adrenal panel which has been mentioned is where I think I would want to go with a pup which was controlled for a period of time and then developed recurrance of symptoms with a largely normal cortisol.

Here is a link to information about Atypical Cushing's in our resourses area. Elevations of hormones other than cortisol even with elevated cortisol require different treatment than elevations of cortisol only. There are also links within this information to UTK and the full adrenal panel.

Thanks for joining, Best wishes. Scott

http://www.k9cushings.com/forum/showthread.php?t=198

[TiffanyMokhtari]

Hi Lori,
Gucci is feeling a lot better since being taken off the trilostane after the overdosing and she will get her electrolytes checked on Monday.
Thanx for the kind wishes:)

[Harley PoMMom]

Hi Tiffany,

I am so happy to hear she is feeling much better, and that her electrolytes are going to be checked on Monday. :D

You're doing a wonderful job Tiffany...you're such a good mom.

Please keep us updated, ok. :)

Hugs.
Lori

[labblab]

Gucci has been off meds comletely for about 5 days...I gave her her regular dose of trilostane today (35mg)
So basically the other vet wants me to stop the trilostane until Monday, then give her 1 - 35mg pill in the morning and bring her in for testing.
Does this sound right to you guys?
Tiffany & Gucci
Hi again, Tiffany.

I must tell you, I am puzzled by the vet's advice to test Gucci after a dose of trilostane today, none tomorrow, and a dose on Monday. I am not a vet, but it seems to me as though you would want to leave Gucci completely off the trilostane until she is tested so that the true effect of the overdose can be evaluated. Her cortisol level may not yet have rebounded to a point where she should be given any trilostane at all.

Further, the manufacturers of Vetoryl (brandname trilostane) recommend that 7-10 days of consistent treatment be undertaken before performing an ACTH to evaluate the effectiveness of any given dose. So even if Gucci's cortisol HAS rebounded from the overload, testing her on Monday after dosing her only today and Monday morning really will not give you the information that you need in determining whether 35 mg. is the appropriate dose for her to be taking long-term. And honestly, it concerns me that your vet let Gucci go from January to October without performing any interim ACTH tests at all. During the first year of treatment, all of the protocols with which I am familiar recommend testing every 3 months even after a dog has theoretically been stabilized on a particular dose.

Right now, the vet's office "owes" you an ACTH after botching the test on Oct. 6. Unfortunately, when you compound that error with their dosing overload, you really are in need of TWO tests: one prior to beginning the trilostane again in order to make sure that Gucci has rebounded sufficiently, and one after ten days of consistent treatment in order to evaluate the true effectiveness of the 35 mg. dose.

But just to throw in one more variable...:o Since Gucci had already been off her trilostane for 5 days prior to today's single dose, you might want to hold her off the trilostane for another ten days or so and then ask that a combined ACTH and full adrenal panel be performed by UTK (this is the test of the other intermediate hormones that we all keep talking about). This would permit Dr. Oliver to assess Gucci's natually-occuring levels of cortisol and intermediate hormones -- without the influence of trilostane. If some or all of the intermediates are also high even without the trilostane, then this may be the source of Gucci's recurrent symptoms even when her cortisol is controlled, and additional or alternative treatment recommendations may be made. Once again, I feel certain that Dr. Oliver would be happy to consult with your vet as to whether or not this type of testing would be valuable, and also as to the timing.

I hope I haven't confused you too much with my rambling. And fortunately, you still have tomorrow to think things over and to gather other opinions. Hang in there!! You're doing a great job advocating for Gucci.

Marianne

[lulusmom]

Hi Tiffany,

For purposes of monitoring treatment, the pre stimulation number is meaningless. It is the post stimulation number that guides a vet as to whether or not an adjustment in dose is necessary. You mentioned that the vet lost the post number. I'm not quite sure how that could possibly happen; however, if it really did happen, your vet should have ordered a new test before recommending any adjustment to the Trilostane. For a vet to recommend doubling a dose without knowing where a dog's post cortisol levels are would be unconcienable. Are you absolutely sure that your vet said that the post blood draw was lost and were you billed for the acth stimulation test?

Glynda

[labblab]

Tiffany, one more quick question from me, too. When the vet told you to double Gucci's dose, does that mean that you went to 35 mg. twice a day (for a total of 70 mg. per day)? Or was it even more than that?

Thanks for the additional info!
Marianne

[TiffanyMokhtari]

Hi,
Well the first vet got confused and thought the pre number was the post number and went off of that. (that was Oct.6)
Then when I went yesterday, a different vet was there and she discovered that it was the pre number the first vet was looking at and she has no clue to where the post number went.
The double dose was 2X35mg tablets a day for a total of 70mg...
As I said before, I hope it had no long term effects on her.
The vet did say the testing tomorrow would be free, but as you mentioned, I think a few more tests should be no charge.
All of the vets here seem to be very incompetant.

[TiffanyMokhtari]

And does anyone have a phone number for Dr.Oliver?
thanx!

[acushdogsmom]

And does anyone have a phone number for Dr.Oliver?
thanx!Dr. Oliver's contact info is listed on the treatment options sheet that they have online at the UTK site:

http://www.vet.utk.edu/diagnostic/endocrinology/pdf/Treatment%20Info,%20Atypical%20Cushing's,%20revise d,%20Aug.,%202009.pdf


For clarification regarding test results, Contact Dr. Jack Oliver (865-974-5729; Email: joliver@utk.edu).

They also give the names of his two assistants, Kellie Fecteau or Hugo Eiler who are available in Dr. Oliver’s absence. (865-974-5638) but if I were you I'd want to get Dr. Oliver's opinion and input if possible.

On the test submission sheet on their site http://www.vet.utk.edu/diagnostic/endocrinology/pdf/endosubform06.pdf Dr. Oliver's contact info is listed as:


Jack W. Oliver, DVM, Ph.D., Director, University of Tennessee Clinical Endocrinology Service
(865) 974-5729 or 974-5576 Email: joliver@utk.edu

Not sure if you wanted his contact info for yourself or for your Vet, but Dr. Oliver will very likely be glad to consult with either one of you or both of you on Gucci's case, especially regarding return of clinical signs while on trilostane.

You may both have better luck getting through to Dr. Oliver via e-mail than by phone. (He has sometimes replied to members here about their dogs' cases even while he was away on vacation or on a short leave of absence from the lab.)

You should give him as much info as you can (including relevant test results) and probably also mention that you are in Canada and that you are considering having the ACTH stim/adrenal panel sent to his UTK Lab to see if maybe the return of clinical signs may be due to an increase in the intermediate hormones which are made by the adrenal glands.

P.S. I am in Canada too, and my Internal Med Specialist does send blood samples to Dr. Oliver at UTenn (ACTH stim plus adrenal panel) and I know for a fact that he does consult with the Vets and the owners of the dogs in Canada whose blood samples have been sent to his Lab for testing.

[labblab]

Tiffany, I'm so glad acushdogsmom has given you such complete contact info for Dr. Oliver. As she has said, many of us here have emailed him any number of questions, and he is always very prompt and kind with his responses.

I can only imagine how frustrated you must be feeling right now. But it is still possible that Gucci's symptoms were returning simply because she needs a slightly increased dose of trilostane (but not the double dose.) If only the Oct. 6 ACTH test had been completed properly, the information about her cortisol level at that time would have been so helpful. :(

Also, we've neglected to ask you whether there was any particular pattern to the increase in her symptoms -- for instance, did they reoccur more often in the afternoon/evening? If so, it may be the case that she'd do better with splitting her dosage in half, and shifting to twice daily dosing at something like 20 mg. and 20 mg.

But all you can do right now is move forward. And once again, you're doing a great job of that!!!!! As frustrating as this all is, I do believe you will be able to sort out the cause of Gucci's symptoms and arrive at an effective treatment strategy. :)

Marianne

[TiffanyMokhtari]

Hi Everyone...
So today Gucci had another vet appointment...
I did what the vet said and gave her the 1 X 35mg of trilostane this morning, then brought her in for the ACTH stim test and the results were:
pre = 24.8 nmol/l
post = 71.7 nmol/l
Which = 2.58 mg/d

So, as you can see she is pretty well controlled with the one pill and it appears that the overdose is out of her system.
I also have results of her electrolytes test:
ALT 41
GLU 5.0
BUN 5
CRE 68
NA+ 146
K+ 5.0
CL 97 <----this level is out of normal range
tC02 28 <------this level is out of normal range

I also gave my vet the contact info for Dr.Oliver and I am taking everyones advice and taking Gucci off of trilostane for 10 days, then send the blood work to the Univ. of Tenn.
Hopefully he will be able to find a good solution for my little baby:)
Thanx for all of your help!
Tiffany & Gucci

[labblab]

Hi Tiffany,

I'm afraid I can't help you with the interpretation of those two abnormal test results, but I do want to make sure you ask your vet to communicate with Dr. Oliver prior to sending off the blood sample for the full adrenal panel. That's in order to make sure that Gucci is "off" her trilostane for whatever time period Dr. Oliver thinks is best. In the past, he has made a general recommendation of 2-3 weeks. So that's how I arrived at my 10-day suggestion (5 days earlier, plus an additional 10 days). But it would be much better to get a time frame directly from Dr. Oliver based on his assessment of Gucci's specific situation.

Please do keep updating us as to how things are going.

Marianne

[TiffanyMokhtari]

Hi Everyone....
I came on here last year when my Gucci was starting to develop signs of Cushings again and your advice was good.
We did the Univ. of Tenn. panel and that seemed to help things...
Well now, after 2 years of being on trilostane (30 mg - once a day), I have noticed that Gucci has started having bowl movements on the floor every single day. She can't seem to control herself well. She also pretty much sleeps all day and doesn't have very much energy and her appetite isn't that great.
She will be 13 in March and I'm just not sure if it could be old age or something else.
Does anyone have any advice on what I could do?
Thanx!

[Harley PoMMom]

Hi Tiffany,

A loss of appetite and being lethargic are signs that Gucci's cortisol may be too low. Has a stim test been done recently? If so could you post these numbers here for us. If a stim test has not be done, I believe I would have one done ASAP.

About her bowel movements; is it diarrhea? Is there any blood or mucus in it? Any details about her poop are important so don't worry about grossing us out, ok? ;):D

Maybe you can call your vet and ask about giving her some prednisone.

Please keep us updated and I hope Gucci feels better soon.

Love and hugs,
Lori

[apollo6]

welcome you and Gucci
I am Sonja and Apollo
Hope Gucci feels better soon.

Please read below as to correct dosage , depends on weight.
Apollo is on trilostane. Double dosing does not mean doubling up the medication quote from the actual manufacturer -Decha
1. Individual dose adjustments and close monitoring are essential. Re-examine and conduct an ACTH stimulation test 10-14 days after every dose alteration. Care must be taken during dose increases to monitor the dog's clinical signs and serum electrolyte concentrations. Once daily administration is recommended. However, if clinical signs are not controlled for the full day, twice daily dosing may be needed. To switch from once daily to twice daily dosing, increase the total daily dose by 1/3 to 1/2 and divide the total amount into two doses given 12 hours apart.

The UC-Davis current recommendation is to initiate trilostane therapy at 1 mg/kg once daily. That dose is continued for about one week until a veterinary re-check can be completed.
1 kilogram = 2.20462262 pounds
Apollo is 10lbs:10lbs w/be=4.53 kg x1= 4.53 mg.
he was on 10mg from June until now. Vet wants to me to go to 12.5mg(compounded liquid) as you can see, I would never double up the dosage. It is just to hard on their system and can cause them to crash. Which sounds like what is happening to your little one with all the symptoms.
Below is the name , phone number of Decha vet who can help, also you can go on their website email your question and Dr. Allen should call you back.24. Dr Allen-Decha/Vetoryl 1-866-933-2472 (toll free/1-913-748-4836
You should never change dosage without tests before hand. Hope this helps.
Hugs Sonja and Apollo

[TiffanyMokhtari]

Hi...
A stim test has not been done recently and her poop is sometimes runny and sometimes solid.
She just seems to have a hard time controlling herself.
When she needs to go, it's immediatly.

[labblab]

Hi Everyone....
I have noticed that Gucci has started having bowl movements on the floor every single day. She can't seem to control herself well. She also pretty much sleeps all day and doesn't have very much energy and her appetite isn't that great.

Tiffany, if Gucci has not had an ACTH test done recently, I agree with Lori and Sonja that it is REALLY important that one be done. All the symptoms you describe could be caused by her cortisol dropping too low on the current trilostane dose. It is not unusual for dogs to require dosage adjustments over time. The thing is, if you don't get this checked and low cortisol is the problem, Gucci can get into very serious trouble. I think you need to speak with your vet as soon as possible.

Marianne

[jrepac]

Symptoms point to cortisol being too low....lethargy and diarrhea are common when that happens....hopefully she is not vomiting....I'd get her checked out pronto....you may need to cut down the trilo a bit and/or give some pred

It has been found that some dogs do a bit better when their cortisol is a shade higher than "perfect"....what good is lowering the cortisol so much that the animal sleeps all day...that is a clinical accomplishment that yields no practical worthwhile outcome based on quality of life..