Starting Vetoryl and Need Some Positive Support

[Sophie]

Hello all....I am going to start my dog on Vetoryl and am very scared of the side effects and would like to hear from people who have had positive experiences with this drug.

My doggie Biscuit is a 10lb Jack Russel Terrier and was diagnosed in March after I noticed her drinking increased. After the diagnosis I realized that was the cause of her recurring skin infections, pot belly, muscle thinning, which before I just attributed to her being older.

She is the sweetest little dog. I rescued her about 10yrs ago and she was in such bad shape. We think she came from a breeder situation. She was skin and bones, her teeth were rotting, her hair was bare in patches and she had flea bites all over her body. She must have been terribly abused because she was terrified when anyone came near her, it took years for her to trust people. But she hit the doggie lottery and is treated like a queen now and I really want her to have the best quality of life as possible in her final years.

I am so worried the excessive amounts of cortisol is damaging her body and the dangers of having a suppressed immune system. Her muscles are getting thinner and thinner and she gets bad skin infections every month and has to go on heavy-duty antibiotics to clear them up. She also has a heart murmur and is being treated with Enalapril which is an ACE inhibitor. Supposedly Vetoryl can enhance the effects of ACE inhibitors, so that has me even more worried! Does anyone have a dog on Enalapril and Vetoryl?

I know I will never forgive myself if her condition worsens and I haven't tried all options, but I am so afraid of what could happen if her cortisol levels get too low when I am not home. I have to work and can't supervise her for about 8hrs out of the day. I will be on pins and needles the first few weeks till I know how she handles the medicine.

Thanks for listening. I welcome all positive comments and will post her progress.

Biscuit's Mom

Moderator's Note: Biscuit's Mom, I have manually approved your first post. Please check your e-mail, especially your spam folder, for a note for k9cushing's that we would like for you respond to, so we can get your membership approved.

[littleone1]

Hi Sophie,

Corky and I want to welcome you and Biscuit.

Corky has been taking the compounded version of Vetoryl, Trilostane, for almost 2 years. He's also on other meds, but none for the heart. Other members with more knowledge about this should be on shortly.

Terri

[Sophie]

Hello Terri,
Nice to meet you. I would be very interested in hearing Corky's experience with Trilosane. Has it resolved his symptoms?
Sophie

[labblab]

Hi Sophie,

Welcome to you and to Biscuit! We have many members who have had positive results with Vetoryl (trilostane), and hopefully a few more will be joining you shortly to share their stories. You are right that the manufacturers of Vetoryl do issue cautions about combining the medication with ACE inhibitors such as Enalapril. However, we have had members who have successfully used both drugs. Key to the success is the careful monitoring of the dog's electrolytes in order to make sure that the basic blood chemistries are not being adversely affected by the combination. This involves a simple blood test that should be performed alongside monitoring ACTH tests (to check the cortisol level) at regular intervals after treatment has begun.

Can you tell us how much Vetoryl Biscuit will be starting out on? At a weight of approx. 10 pounds, I'm hoping you'll tell us that she won't be starting on a dose much higher than 10 mg. Even though the published guidelines for Vetoryl list a starting dose that ranges between 1-3 mg. per pound, technical representatives at Dechra (the manufacturers) are verbally advising that dogs begin at the lower end of the range. In this way, the risk of adverse side effects is minimized.

Once again, welcome! And please feel free to ask any questions that come to mind.

Marianne

[addy]

Hi Sophie and welcome,

My Zoe started on 10 mgs of Vetroyl in June. She also has colitis so we started on a very low dose and have gone very slowly and she is doing fine so far. She is having a hearing problem right now but I doubt it is from the Vetoryl. Her last dose change was a bit harder for her as we are closer to what it should be 20 mgs and she weighs 19 pounds. But tonight I can home from work and she turned and looked at me when I came through the door and has been running up and down the hallway throwing her Kong in the air.:):):)

Those are the moments that count and they are when I know I am doing the right thing.

Hugs,
Addy

[ThreeJacksMom]

Hi Sophie and Biscuit,
I have a 10 year old JRT, too, Sassy, and she has just been diagnosed with Cushing's. I am still debating about starting her on Trilostane or not. I am very scared of it as well.
This forum has the kindest, most caring group of folks I have ever seen and the most information I have come across, so you have found the right place.
Hang in there.

Lauri and Sassy

[Sophie]

Hello labblab,

Thank you for your response. Biscuit is about 10lbs, we're going to be starting her at 10mg dose. I would rather it take longer to take effect than to risk an overdose. IMO 30mg is way to high for a 10lb dog.

My vet, Dr. Bob, said that he uses urinalysis to monitor the cortisol levels. He said that it is as accurate as a blood test and a lot less stressful on the dog. If he wasn't such a great vet I would question this method. I don't know that I can afford multiple ACTH test at $150 a pop. If she has adverse reaction or negative side-effects, I will get the more comprehensive tests. But I will let ya'll know how the urinalysis goes.

BTW, he knew from Biscuit's initial blood test that revealed she had high cholesterol and high liver enzymes that she either was cushings or hypothyroid. Sure enough she had cushings.

Sophie

[Sophie]

Hello addy,

Glad to hear Zoe is doing well on Vetroyl. I need to hear that. I am so scared to start Biscuit on it even though I know it's for the best. Her symptoms aren't too severe right now. She is a tough little bugger! Though I am noticing her muscles getting thinner and thinner and she is tripping more often. That has me really concerned because once you lose muscle it's hard to rebuild. And her infections are also a big concern even though they resolve themselves with antibiotics.

Please keep me posted on Zoe's progress. I think it really helps to hear real world experiences with this drug.

Sophie

[Sophie]

Hi Lauri,

Sassy is adorable...of course I have a fondness for JRTs. :)
I'll keep you posted on Biscuit's progress. As scared as I am about it, I would feel awful if I let the disease progress without trying treatment options.

How long has Sassy had Cushings? What kind of symptoms does she have?

Take care,
Sophie

[jrepac]

Hi there....

Sassy is very cute, Lauri! I am a big terrier fan....I am on Aussie Terrier #4 and I have a Rat Terrier in the house as well....and a Pom, and a Chihuahua. Needless to say, it's pretty lively at times. :p

I have not personally used Trilostane [only lysodren & anipryl] but you should not be afraid of it...arguably, it's safer than Lysodren and you will find many here who have had great success with it. It is pretty much becoming the "standard" treatment nowadays. [there ARE other options, but Trilo is gaining a lot of traction right now and appears to be very effective relative to other options]

Sophie, re: checking cortisol levels via urine, this can be done. It's not considered "standard", but I did it as well to avoid the stress of an ACTH every 3 months. It will give you some idea if the drug is working---cortisol levels should be consistently low if the treatment is having some effect (otherwise cortisol would be spilling over into the urine). It's just not as precise as other methods. But, it's pretty low stress and much less costly.

A bit of advice however. You want to catch the urine at home (to avoid stressing the dog which will then jack up the cortisol), and get it first thing in the morning and, if you can, gather it in equal amounts over a 3 day period. Cortisol levels in the urine are very variable, so if you take the urine for 3 consecutive days, you'll get a more accurate reading (i.e. it "averages" out). I used to catch the pee in a foam dish and draw it with a syringe, so I could measure the amount accurately each day. :o

I am sure others will have input on this.

Just take one day at a time, monitor your pups closely during the initial days of treatment and I am sure you will do fine. Ask your vet all the questions you want/need to...it's their job to make you comfortable with the treatment.

Jeff, Angel Mandy, Pebbles, Pepper plus Pinky and Honey Bear....LOL

[Sophie]

Hello jrepac,
Thanks for your response and the reassurance about starting Biscuit on Vetoryl. Wow that is more info than my vet gave me about taking the urine sample. I didn't know I needed to take 3 samples over 3 days or to take the sample in the morning.

Few questions...
Should I take the sample before or after her morning dose of Vetoryl? How do you store the urine once you catch it? Do you have to store it in the fridge or is it ok to leave out? What kind of container do you put it in? Do they sell something at the drug store? The syringe idea sounds like a good one.

I am hoping to start Biscuit on Vetoryl this weekend. I have Friday off so I can monitor her closely the first few days. I am so glad I found this site ya'll are so helpful.

Sophie

[addy]

We go to the health supply store and by sterile plastic urine cups, they are inexpensive and I believe you would store the urine in the frig. It is to be the first urine of the day so I am not clear about that being before or after the drug administration as Vetoryl is given with food.

I just read a paper on this and it did not mention it. I don't think I book marked the article. Hopefully on of the administrators will know.

I think we all get nervous when we start treatment, these are serious drugs. Starting at a low dose and going slowly is best.

Hugs,
Addy

[labblab]

Sophie, I have only a few moments to post right now, so I will come back later today to elaborate a bit more. But I must tell you that I am honestly concerned that your vet plans to monitor Biscuit's response to Vetoryl solely on the basis of urine UC:CR testing, especially given the fact that she will be taking Enalapril alongside the Vetoryl.

As I wrote earlier, the cautions about combining ACE inhibitors with Vetoryl stem from the danger that a dog's aldosterone level may drop too low, resulting in a life-threatening electrolyte imbalance. The only way in which the electrolytes can be checked is via blood testing. And if you are going to be drawing blood for the electrolyte check, why not also perform the much more precise ACTH monitoring test rather than relying on urine UC:CR's? If the cost of a complete ACTH is truly prohibitive, then even just taking a baseline cortisol blood reading may give you more precise information than the urine testing. I'll come back and tell you more about that later.

Given Biscuit's situation, the greatest danger at this point is that the combination of the Vetoryl and the Enalapril will suppress hormone production too much. And you really cannot rely solely upon Biscuit's physical appearance to give you adequate warning prior to a dangerous "crash." Here's a quote from Dechra's U.S. Product Insert for Vetoryl:


A post-ACTH stimulation test
resulting in a cortisol of <1.45 μg/dL (<40 nmol/L), with or without electrolyte abnormalities, may
precede the development of clinical signs of hypoadrenocorticism. Good control is indicated by
favorable clinical signs as well as post-ACTH serum cortisol of 1.45-9.1 μg/dL (40-250 nmol/L).
If the ACTH stimulation test is <1.45 μg/dL (<40 nmol/L) and/or if electrolyte imbalances
characteristic of hypoadrenocorticism (hyperkalemia and hyponatremia) are found, VETORYL
Capsules should be temporarily discontinued until recurrence of clinical signs consistent with
hyperadrenocorticism and test results return to normal (1.45-9.1 μg/dL or 40-250 nmol/L).
VETORYL Capsules may then be re-introduced at a lower dose.

As I say, I will return later on to better explain my thoughts about this, but in the meantime, here is a link to that Product Insert. You'll find it contains a lot of helpful information about Vetoryl treatment and monitoring.

http://www.dechra-us.com/files/dechraUSA/downloads/Product%20inserts/Vetoryl.pdf

Marianne

[labblab]

OK, I'm back again with a few more thoughts to add. To start off, here's Dechra's warning about combining Vetoryl with ACE inhibitors such as Enalapril (it's contained in that same Product Insert). Again, this highlights the need to keep close tabs on Biscuit's electrolytes and probably also her renal function. Blood testing is required to monitor the electrolytes.


Angiotensin-converting enzyme (ACE) inhibitors should be used with caution with VETORYL
Capsules, as both drugs have aldosterone-lowering effects which may be additive, impairing the
patient’s ability to maintain normal electrolytes, blood volume and renal perfusion.

The UC:CR urine test is used most often as an initial screening test to see whether or not Cushing's is even a possibility. Once dogs are diagnosed and started on trilostane treatment, it is also used at times to help determine whether or not a dog would benefit from receiving the medication twice daily rather than just once a day. If a dog has a monitoring ACTH result that is within the desired treatment range but Cushing's symptoms start to rebound again later in the day or evening, a UC:CR sample may be evaluated in conjunction with the ACTH testing. In that situation, urine may be collected in the morning (prior to the dog receiving it's daily trilostane dose) in order to guage whether the cortisol level has risen to a high level again before the end of a 24-hour time period. In that situation, a high morning UC:CR in conjunction with a therapeutic ACTH reading can point to the need to shift to twice-daily dosing.

However, I am not aware of any specific protocol or "cut-off" number whereby a UC:CR result is precise enough to indicate the reverse: to tell you with confidence when the trilostane dose is too high and the medication needs to be discontinued or lowered. And that's what I'm most worried about in Biscuit's situation. Dechra recommends that monitoring ACTH tests be performed between 4-6 hours after the morning dose of trilostane has been given (with food). This is the time period when the drug is having its maximum effect, and thus it is possible to judge the cortisol level at its lowest and make dosing changes accordingly. However, I do not know of any established protocols that recommend the use or timing of a UC:CR for this same purpose.

I had mentioned earlier the possibility of at least taking a blood sample to look at her resting cortisol at the same time that the electrolytes are checked. There is some recent research suggesting that baseline cortisol readings may turn out to be useful, at times, in monitoring trilostane treatment. The study was published by Dr. Audrey Cook and Karen Bond: "Evaluation of the use of baseline cortisol concentration as a monitoring tool for dogs receiving trilostane as a treatment for hyperadrenocorticism."

http://avmajournals.avma.org/doi/abs/10.2460/javma.237.7.801

This approach is a departure from the more traditional standard trilostane monitoring protocol whereby ACTH stim tests are performed at each of the recommended testing "windows" along the treatment path (e.g., after 10-14 days at a given dose, after 30 days, then every 3 months, etc.). As the authors state, this approach would only be safe and reasonable under certain conditions, and I do not believe it is yet being commonly utilized. However, it appears that some specialists may already be recommending it in lieu of full ACTH testing on some occasions. In Biscuit's case, if her baseline cortisol reading came back higher than 1.45 ug/dl, it might give you greater comfort that her cortisol level is not dropping too low on the medication. The baseline cortisol would be much less expensive than a full ACTH, and also involves only a single blood draw at the same time that the sample is pulled for the electrolyte check. As soon as I have the chance, I will also return and give you a citation for a method by which you may also be able to save money when complete ACTH testing is performed.

I do want to emphasize that I am not a vet, so all my comments represent my own experiences and my own reading. But prior to relying solely on UC:CR tests to monitor Biscuit's treatment, I strongly encourage you and/or your vet to contact one of Dechra's technical representatives. Many of our members have spoken directly with Dr. Tim Allen at Dechra's office in Kansas. If you tell Dr. Allen or one of the other reps that Biscuit will also be taking Enalapril, I'm confident that he can help you sort out the best and safest monitoring protocol for her. Here's contact info for Dechra:

http://www.dechra-us.com/Default.aspx?ID=365

Marianne

[Sophie]

Hi Marianne,

I look forward to your response later. Now you are scaring me...those are the reasons I am hesitant to try this drug.

What are symptoms of electrolyte imbalance and is there something you can give a dog in case of immediate emergency?

My vet was very casual about the negative aspects of this drug, he said they "sounded bad on paper" and also told me he has patients that are on Enalipryl and Vetoryl.

If I didn't trust his opinion, I would definitely question his methods. And believe me I have been to some crummy vets and I have spent thousands of dollars in the past to save my beloved Nico. In retrospect it was a distemper vaccination and the overly invasive treatments to try to save her that led to her early demise. So I have a dilemma between doing too much and not enough.

He has been my vet for 7yrs. He came recommended by the head of a rescue organization that I adopted one of my previous dogs from and who knows every vet in the Cleveland area. In fact I drive 25 miles to see this guy. There are dozens of online reviews on him and the other docs the Gateway Animal Clinic in Cleveland. No other vet in this town has that kind of overwhelmingly positive response.

I am not saying Biscuit doesn't need more extensive testing. Believe me if anything is out of the ordinary I will demand one immediately. But I gotta trust him or I will never start her on these meds.

Sophie

PS...I just wanted to add...I did discuss my fears of using both drugs at the same time and he seemed to not be too concerned about it.

[labblab]

Sophie, I want to make sure that you did see my second, "later" reply -- I had posted it right before your own reply. So perhaps we were typing at the same time. But please do scroll back up the page to take a look at it, since it adds more information to what I said earlier. And it also supplies contact info for the veterinarians who serve as technical reps for Dechra, the manufacturer of Vetoryl.

By no means do I want to suggest that your vet hasn't been doing a great job for you. But because of our special interest in Cushing's on this forum, we probably hear about more Cushing's dogs here than most GP vets see during the normal course of their regular practices. It is great if your vet has not had any problems with his Vetoryl patients in the past. But from our experiences here, it seems as though there is a greater likelihood of problems developing when standard monitoring protocols are not being followed. The goal of the monitoring is to do everything possible to avoid an emergency in the first place, rather than to try to salvage a dog from a bad situation.

Since your vet is departing from standard monitoring protocol, I feel obligated to suggest that you or he consult with the vets at Dechra in order to avoid potential problems down the line. There is no reason at all for you to feel terrified about starting treatment as long as the proper safeguards are in place. And that is why I really hope that you or he will double-check with Dechra about the protocol that he is planning to use. If Dechra says it is "OK," then you'll have that extra peace of mind as you start out.

Also, here is a link to an endocrinology "blog" in which an ACTH cost-saving methodology is described for vets. It might turn out that ACTH testing could be much more affordable for you and also your vet's other Cushing's patients.

http://endocrinevet.blogspot.com/2011/03/how-to-extend-your-supply-of-cortrosyn.html

Marianne

[littleone1]

Hi Sophie,

Corky's clinical signs did go away with his treatment.

I have the stim test done along with a full blood chemistry panel everytime he has it done. I personally feel much better knowing what Corky's blood values and electrolytes are. I have his stim test done everytime his dosage changes, or if clinical signs start to surface. If none of the clinical signs start to surface, I have a stim test done every three months.

[ThreeJacksMom]

Thanks Jeff! You have a lively assortment of pups at your house:) - I used to have two Poms - they were so sweet.

Sophie,
Sassy just got diagnosed a few weeks ago, so I am still trying to take it all in. Her legs seem much stronger now and she has stopped tripping. It seems like the symptoms of Cushing's can come and go. I keep reading that there are so many good results with Trilo, but then I read something scary and it gets me all worked up again.

Good advice about the urine testing - I would rather do that than stress them out having to go to the vet.

[jrepac]

Hello jrepac,
Thanks for your response and the reassurance about starting Biscuit on Vetoryl. Wow that is more info than my vet gave me about taking the urine sample. I didn't know I needed to take 3 samples over 3 days or to take the sample in the morning.

Few questions...
Should I take the sample before or after her morning dose of Vetoryl? How do you store the urine once you catch it? Do you have to store it in the fridge or is it ok to leave out? What kind of container do you put it in? Do they sell something at the drug store? The syringe idea sounds like a good one.

I am hoping to start Biscuit on Vetoryl this weekend. I have Friday off so I can monitor her closely the first few days. I am so glad I found this site ya'll are so helpful.

Sophie

The 3 day urine sampling protocol was raised by one of the vets who visits the board from time to time. Until then, I had never heard of it either. It would depend on when the last dose of Vetoryl was given, I would think. I'd ask the vet about the preferred timing. I'm not sure how fast Vetoryl "kicks in" so it may not matter. I was told to put the sample in the fridge; vet gave me syringes and clean test tubes to use. I know you can buy some of this stuff at the drug store as well. As others have noted, this is not the most precise method, but a way of getting some directional guidance in tandem with observing clinical signs/response.

One good thing about Vetoryl, is that if you are observing adverse reactions, typically from over-suppression of cortisol, you can discontinue the drug immediately and it leaves the system pretty quickly. Your vet may also give you some prednisone to use in case of a situation like this (which is a cortisol substitute).

At the end of the day, you will have to assess your options and decide what is best for you and your baby.

Keep us posted on your progress.

Jeff and the "Gang"

[labblab]

One good thing about Vetoryl, is that if you are observing adverse reactions, typically from over-suppression of cortisol, you can discontinue the drug immediately and it leaves the system pretty quickly. Your vet may also give you some prednisone to use in case of a situation like this (which is a cortisol substitute).

At the risk of being a harpie, I do feel as though I have to make one more comment. Because of the concurrent use of both Enalapril and Vetoryl, the risk for Biscuit is not solely low cortisol, but also an increased risk of low aldosterone. Prednisone alone may not be sufficient to counteract a serious event of overdosing in such a situation. Once again, here is a direct quote from the Vetoryl Product Insert:


In case of overdosage, symptomatic treatment of hypoadrenocorticism with corticosteroids,
mineralocorticoids and intravenous fluids may be required.

Sophie, I am not trying to scare the crap out of you with these quotes. But from what you have written, it does not sound as if your vet is taking these warnings seriously. It may be that Biscuit's dose of Enalapril is so low that a lot of extra concern may not be warranted. And I have to agree that in the majority of cases, most dogs who are overdosed on trilostane do rebound once the drug is simply discontinued and their systems are allowed to normalize once again.

But trilostane is a serious drug and if it were me, especially since Biscuit will be left unattended for lengthy periods of time, I would want to have more precise information about the effects of the medication upon both her cortisol level and also her electrolytes. We are all here to learn, so if your vet can point us in the direction of research that supports the use of UC:CRs for trilostane treatment monitoring -- in the absence of any bloodwork whatsoever -- then we can all benefit from the information.

Marianne

[littleone1]

Hi Sophie,

I totally agree with Marianne. This is why I have all of the bood work done on Corky. I definitely want to be safe than sorry. The wonderful people here have always steered me in the right direction.

[Sophie]

Marianne,
Thanks for the concern. That's what scares me about this drug. I did raise the concern about the interaction of Vetoryl and Enalipril and Dr. Bob said that he had other patients that were using both drugs with no adverse reactions. I will definitely question his testing methods more thoroughly once Biscuit gets started and it's time to test her. It is so overwhelming at first it's hard to know what to ask.

We are starting her on 10mg dose. She is 10+ lbs so that is the low end for her weight. Hopefully the low dose won't be as extreme on her system. But any sign that she is acting the slightest bit unusual I will take her to the vet immediately.

BTW, she is taking 2.5mg 2x a day of Enalipril. I don't know if that is high or low for her weight.

What are the side effects of low aldosterone and what can be done to reverse the effects?

Sophie

[Harley PoMMom]

Hi Sophie,

You may want to mention to your vet about this study done on monitoring Trilostane with an UC:CR: Urinary Corticoid : Creatinine Ratios in Dogs with Pituitary-Dependent Hypercortisolism during Trilostane Treatment (http://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.2009.0374.x/abstract)


Conclusion and Clinical Importance: The UCCR cannot be used as an alternative to the ACTH stimulation test to determine the optimal dose of trilostane, but might be helpful in detecting dogs at risk for developing hypocortisolism during trilostane treatment.

[Sophie]

Harley Pommom,
Good find. I will print that out and question my vet about the findings. I don't believe he is opposed to the ACTH test and I'm sure if I told him I felt more comfortable doing the test he would do it. If Biscuit starts exhibiting any unusual symptoms I know he would recommend the blood test.

Dr Bob's clinic caters to alot of low income folks so his philosophy is to provide people with the most affordable solutions. I'm sure that there are alot of people who would be discouraged about treatment if they had to pay for all those blood tests and may choose to not treat their pet or put them down. This stretches me to the financial limits so I appreciate a lower cost alternative.

Now that I have more knowledge about things I can ask more thorough questions.

Sophie

[jrepac]

Hi Sophie,

You may want to mention to your vet about this study done on monitoring Trilostane with an UC:CR: Urinary Corticoid : Creatinine Ratios in Dogs with Pituitary-Dependent Hypercortisolism during Trilostane Treatment (http://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.2009.0374.x/abstract)

in reading the abstract, they are essentially saying over long term, UC:CR can tell you if hypo-cortisolism is present (ie. too little cortisol) but is not helpful in determining OPTIMAL trilo dosage. I'm emphasizing the word optimal as that speaks to getting the precise dosage down. I'm not shocked by that.

But, I find it a bit unusual that they are essentially saying long-term, it can tell you if cortisol is too low, yet it can't tell you if it is too high? It works in one direction, but not the other? That is more than a little strange :)

If my memory serves me, I think it was Dr. Bruyette who provided the details on how to get a good urinary cortisol reading some time ago on this board.

I wish there was more follow up research on stuff like this....Cushings related matters seem terribly UNDER researched. 1 or 2 guys do some research and it's as if that becomes gospel. In most academic research, only when work is verified by others in successive follow up research does it truly carry weight. [I am a researcher myself, but not a vet :)]

The vets really need to find cost effective, non-traumatic ways to test the fur babies. Let's face it, a full blood panel, plus an ACTH--to cover ALL of the bases--is an expensive proposition for some folks. Even more if you want to send it down to UTK. For some of us, cost is not a problem, but not everyone is so blessed. I keep waiting for someone to invent a cushings "test strip" system....like what humans use for testing their blood sugar. I think that would be a welcome tool for those who 1) can't afford quarterly (or more) ACTH test or 2) don't want to put the pup thru the day long ACTH test. I've been thru the ACTH drill numerous times and I think I was more disturbed by the day long "lock up" than I was with the cost of the test [which I've learned that some vets grossly overcharge for, sadly].



Jeff & Pals

[labblab]

Jeff, your memory serves you well :). It WAS Dr. David Bruyette who offered us advice about urine collection for performing UC:CRs. Here is what he said. Please keep in mind, though, that he was talking about using urine testing as an initial Cushing's diagnostic, and also in conjunction with ACTH testing when a shift to twice-daily trilostane dosing is being considered. He did not speak about using UC:CRs in place of ACTH testing for general medication monitoring purposes, and as far as I know, he does not recommend doing so. So I don't think we can assume his comments about the timing of the urine collection are directly applicable.


Urine cortisols can be a problem. Many studies have shown that the only way to accurately gauge urine cortisol levels is to obtain the first morning voided urine sample on 3 consecutive days and then pooling the urine to run a UCCR [Ideally 3 morning pooled urine samples collected by the owner at home and refrigerated]. When done in this fashion it is likely an accurate test. Otherwise there is likely too much day to day variation to make a single random cortisol very helpful.

Like you, I was also surprised to read Lori's study results, but mainly because I had not previously heard the suggestion that UC:CRs can be helpful long-term in identifying dogs at risk of low cortisol. So I stand corrected on that point. However, I still don't think this study suggestion has yet translated into any formalized monitoring protocol. But if anybody would know about such research, I'd think it would be Dechra. That's one of the reasons why I'm encouraging Sophie or her vet to contact them, to see if there is new research of which we're unaware.

And I definitely agree that it will be a godsend if cheaper, effective monitoring methods are devised! In the meantime, Sophie, I hope you'll also print off the two articles that I mentioned so that your vet can see them, too. Both of them could save you and his other Cushing's patients a lot of money (performing the ACTH more economically, and using baseline cortisols for monitoring purposes). Also, just to clarify, ACTH tests should not be all-day affairs. The test should only take 1-2 hours to perform. Jeff, are you maybe thinking instead of diagnostic LDDS testing? That test does take 8 hours, but it is never involved in treatment monitoring once a dog starts on medication...

And finally, Sophie, you asked about symptoms of low aldosterone. Here is a description of "Addisonian" symptoms which can arise when a dog's cortisol/aldosterone levels drop too low. Low aldosterone accounts for the more serious cardiac and renal problems that result when the potassium level in the body goes awry. You will be wanting to watch for any hints of early issues so as to avoid the likelihood of a full-blown crisis.


Initially, the dog may be listless, or seem depressed... Lack of appetite is a good indicator...Other symptoms include gastrointestinal problems like vomiting and diarrhea. Pain in the hind quarters, or generalized muscle weakeness such as a dog that can't jump onto a bed or couch... Shivering or muscle tremors may also be present... [If deterioration continues], ultimately the dog will have an acute episode called an Addisonian crisis. Potassium levels elevate and disrupt normal functions of the heart. Arrhythmia can result and blood pressure drops to dangerously low levels. BUN and creatinine levels, generally indicators of kidney function, are often elevated. At this point many animals are diagnosed with renal failure, as the kidneys are unable to function properly. Typically animals are given IV solutions for rehydration [and are also given replacements for the missing cortisol and aldosterone in order to relieve the crisis]...

Sorry for writing yet one more "book" of a reply. But I hope that at least some of this info may be helpful. :o

Marianne

[Sophie]

Thanks for your replies. All of this information is so helpful. I am definitely going to ask more questions about the urine test method of monitoring cortisol. Now that I have all this info I know what to ask. I do remember him saying tho that the urine test was pretty accurate. I don't know if he is basing this on his experience or on research.

I have a few more questions for ya'll.
How long after being on Vetoryl do the cushings symptoms disappear? I know the drinking and eating are usually reduced in the first week. But what about the infections and the muscle weakness? Also, since cortisol is anti-infalmatory, is she going to be more irritable from her arthritis and allergies? She was quite the little crabby-pants before I started her on those Cushex drops. Which of course did nothing for her cortisol levels but did chill her out and allowed her to rest through the night. Oh yeah and her hair grew in places she never even had it before.

BTW...Bisky's medicine came in today. I am going to pick it up tomorrow and start her on Friday. Thankfully I will be able to have someone watch over so she won't be alone for long periods. I am so scared to give her these pills! I am going to be a nervous wreck on Friday...heck I am going to be a nervous wreck for a few weeks till I know she isn't going to have an adverse reaction. I know it's the right thing to do tho her symptoms are getting worse.

Please send good vibes Bisky's way...I will report her progress on Friday.

[Sophie]

Ok all...I got Bisky's medicine today and talked to Dr. Bob and got a chance to ask him about his testing methods.

First off I asked him about the accuracy of the urine test and he said, and I am sorry I can't remember what institution did this study, but they measured the urine cortisol test against the ACTH test and the urine test was a pretty close measurement of cortisol levels compared to the ACTH test.

He said the first test, in two weeks, he will do a urinalysis and see where she is at but the next test will be the ACTH test. So he isn't going to be relying solely one the urinalysis. He will use both methods. He also said if anything was unusual we will do the ACTH test.

He also said that Trilosane is very safe and he hasn't seen any severe adverse reactions to it. He said it is slow acting so that you have time to react if your pet has an adverse reaction and that it's best to start at the lowest dose possible (which most of you know). On the other hand he said he has seem many problems with Lysodren, but has never seen a dog die from it.

He gave me prednisone and said if she has ANY symptoms like lack of appetite, lethargy, vomiting, weakness, diarrhea give her the prednisone immediately, discontinue the Vetoryl and call him.

I asked again about the Enalipril and he said it was fine. Though that still is a big concern to me. Especially after reading the warning about it plastered on the back of the box. I did forget to ask what I should do if her aldosterone got too low. I would imagine at that point I would be rushing her to the emergency vet.

Less than 24hrs till the first dose. On one had I am scared as heck to give Bisky these pills, but on the other hand I see her condition worsening every day and would never forgive myself if she deteriorates from this disease without atleast trying to help her.

[labblab]

Sophie, sending you and Bisky best wishes and positive energy!!!

I'm betting that she'll do just fine, and we'll be anxious to hear all your updates.

Many hugs,
Marianne

[Sophie]

Thanks Marianne... :)

[jrepac]

Just keep an eye on Bisky the first few days of dosing and I'm sure you'll do just fine. Sounds like you had a productive conversation with your vet, which is good. Just take it one day at a time; the disease is very manageable, and it's better to treat than not to treat, regardless of which medication(s) you choose. ;)

Good luck!

Jeff & the Gang

[Sophie]

Thanks Jeff....:)

[Sophie]

Hi everyone. Just wanted to update you on Biscuit's first day on Vetoryl.

So far so good. I gave it to her at about 6 am with her breakfast and she is acting her normal self. She followed me around the house while I was cleaning, we went outside several times and walked around the yard. She was rolling in the grass. She napped comfortably. She ate a bunch of snacks and ate her dinner like normal. Still drinking about the same.

Whew...I feel a little bit better tho I know it's too early to tell anything really...but it's good that all went well today. Just takin' it one day at a time. Will keep you posted on Biscuit's future progress.

[labblab]

Sophie, sounds like a great start! And I love your avatar photo -- Bisky is such a cutie-pie!! :o :) :)

Marianne

[addy]

It gets easier and we are here with you every day:D

Hugs,
Addy

[Sophie]

Hello all...just checking in on day 2. So far so good. We had a good day today, nothing out of the ordinary. Biscuit is resting comfortably next to me on the couch right now. Hopefully she'll continue to do well on the Vetoryl and get better.

Thanks all for your concern.
Sophie :)

[kapohotricia]

Hi Sophie,

Welcome to this kind group. They have been so supportive to me in these first months of my little Boston Terrier, Kirby's Vetoryl treatment. I know exactly how scary you feel about starting Vetoryl as I felt that way only a few months ago.
I am interested in how the urinalysis works because the ACTH tests are very stressful on Kirby so will ask my vet about that alternative on the next visit. Perhaps someone on this forum can explain it in more depth so I can share that information with my vet. She has only treated one dog for Cushings before, with Lysodren, before Vetoryl was available, and that didn't turn out well. She actually prescribed 60mg for Kirby at first. I gave him one dose and he trembled all day long. I called her and she agreed to give him a day off and then resume at 10mg. Now he's on 9mg but every dog responds differently.
It sounds like you have a much more experienced vet than I do with Cushings (I love her dearly but she is just a one woman, all animal, country vet). Biscuit is so lucky to have such a loving mom and good vet. We, too, have to leave my dogs while we are at work. I was so scared to leave Kirby when he first started the dose, in case of a bad reaction. I started dosing Saturday morning so we could watch him over the weekend. I do sometimes pop home at lunchtime and check on him but I don't really think it's necessary.I also have a neighbor who is here a few months of the year (it's her second home) and she watches him when she's here. On a few occasions, at first, I have taken him to work and set him up with a bed under my desk. Now I just watch him carefully when I am home and keep a journal. If he starts to show signs of over-suppression, I would notice before the situation got critical. Sadly, it seems that my Kirby might have a larger pituitary tumor ("macro")growing because he is now having neurological problems but the Vetoryl is controlling his cortisol levels so he is doing better than if we weren't treating him at all. We can only treat this disease, not cure it, but Biscuit's life will be better for the treatment and maybe he's one of the lucky ones like Corky and others who are doing so well. You are doing the right thing so take a deep breath and you'll feel more relaxed once you have started treatment.
Hugs to you and Biscuit.
Aloha,
Tricia

[addy]

Hope day 2 goes as well as day 1:):):):):):):)

Hugs,
Addy

[Maya]

Hello Sophie, welcome from me and Maya.:)
Maya was diagnosed with Cushings in March and was immediately put on 30mgs of vetoryl a day. I was petrified after all I had read about these kinds of drugs, but it was either that or let Maya's Cushings progress, which I had no intention of doing. Maya is doing great on Vetoryl. She had to have an increase of another 30mgs after the three month ACTH test. She now has 30mgs in the morn and 30mgs in the eve. Sometimes I have to remind myself that she has Cushings because she is doing so well I forget! She has regained the strength in her muscles and the terrible shaking in her hind legs has stopped. Her fur has grown back lovely and thick, the sparkle has come back to her eyes. Her water consumption and appetite are back to normal- no stealing food. Her enthusiasm has returned and she is a happy little stinker.;) Yes, these drugs are scary, but they are also life savers. Up to now, I have had a very positive experience with Vetoryl:)
I wish you all the best...try not to worry too much and go with the flow.
Hugs, Leah

[Sophie]

Hello all...day 3 went great for Biscuit. Went for a walk at the park today and for the first time in a long time I didn't have to coax her to walk. Usually I end up carrying her most of the way and she walks for the last quarter mile. Today she walked the whole mile. Everything else was pretty much the same which is good. Every day things go well I feel a little better. :)

Sophie

[Sophie]

Hello Tricia,
Thanks for sharing Kirby's experience. Sending good vibes his way. It really helps to hear others experience with this powerful drug and I am glad to hear it has helped his symptoms. Even though Biscuit has done well these first few days, you never know what tomorrow will bring.

She will have her first urinalysis in two weeks. I will share the results and will get more information from Dr. Bob on this method of testing.

Sophie :)

[Sophie]

Hello Leah,
That's fantastic Maya is doing so well on Vetoryl. I need to hear success stories like that. Despite my fears I know this is what's best for Biscuit. Thankfully she was diagnosed early. But I do see her legs getting weaker and her muscles getting thinner and I don't want her to lose her mobility.

How long has Maya been on Vetoryl and how long was it before you saw improvements in her symptoms? Particularly the muscle weakness.

Sophie :)

[apollo6]

Dear Sophie
Welcome. Biscuit is cute as can be. Starting on 10mg. of Vetroyl is a good choice. My Apollo is a 12.7year old mini dachshund, weighs 10lbs and is on 10 mg. also. He was diagnosed January 2010. He has done well on this dosage and has been on it for a while. The muscle wasting sometimes resolves itself after a while. The skin issues should start getting better within a few months. Each dog is different as to what treatment is best for them. There is always hope. What kind of cushing does Sophie have. see below link.
There are three types and this determines which treatment you will decide on.
http://www.kateconnick.com/library/cushingsdisease.html
http://www.vetinfo.com/canine-cushings-disease.html
Hugs Sonja and Apollo

[littleone1]

Hi Sophie,

I'm glad that Biscuit is doing good with the treatment. I hope everything continues to improve.

[addy]

See, it does get easier:D:D:D:D:D:D

I am so glad to hear Biscuit is doing well. Keep up the good work.

Hugs,
Addy

[Sophie]

Another good day for Biscuit on the fourth day of Vetoryl. Again she was eager to walk today, we walked a mile. This has very much impressed me, I didn't know the Cushings was making her so reluctant to exercise. She even seems to be drinking a bit less water tho still more than normal for her. Every day I am feeling better.

Sophie :)

[Sophie]

Hi Sonja,
I have been following Apollo's experience with Vetoryl. He's a cutie...reminds me of Bisky...even tho they are different breeds. Glad to hear he is dong well on the 10mgs. I am hoping that lower dose works for her.

Thankfully her latest skin infection is almost gone after a course of antibiotics. She usually does ok for about a month after treatment, so i am hoping her immune system gets a boost and she can fight off any more infections. They scare the heck outta me cuz they just seem to grow and grow and won't heal without antibiotics.

She has the pituitary cushings so I am hoping the Vetroyl works for her as it seems to have the least side-effects.

Sophie :)

[Sophie]

Thanks for your concern Terri and Addy. I have noticed that it seems there are more smaller breed dogs with cushings on this forum. Is cushings more prevalent in smaller breed dogs?

Sophie

[Sophie]

Hi all....just wanted to check in and let you know how Biscuit has been doing. It has now been over a week on Vetroyl and she is doing great so far. She seems to be drinking a bit less than usual, tho still more than normal for her and her stamina seems greatly improved. Friday I will be gathering a urine sample and bring it to the vet and will let you know how the test goes.

I am really glad I have started her on this medicine and feel bad that I let my fears get in the way of starting it sooner.

[Squirt's Mom]

Hi Sophie,

Good to hear that Biscuit is doing well on the Trilo. I hope you see more and more improvements each day. Do continue to keep a close eye on her. Even tho your vet, and others, unfortunately keep saying Trilo is "safe", it is no safer than Lysodren, especially when protocols are not followed. ;) I am very glad you have the pred on hand just in case. And you are doing a great job, which is just as, if not more, important than anything a vet can do.

Let us know what the urine tests shows and what the vet has to say about her progress. Oh! And if you can get the info on that study your vet is using to support the urine tests VS ACTH for monitoring, I would be interested in reading it. Cushing's has opened a never ending avenue for learning - even for old dogs like me! :rolleyes::p

Enjoy the new found energy in Biscuit! Isn't is wonderful to see your baby acting more like her old self? I don't think I will ever forget seeing that after Squirt started the Lyso. I sat and cried for joy!

Keep up the good work, Mom!
Hugs,
Leslie and the gang

[labblab]

I want to "second" Leslie in thanking you for this update. I'm so glad to hear that Biscuit is doing well! :)

Marianne

[Sophie]

Hello all just though I'd update you on Biscuits urine cortisol test.

I brought a urine sample to the vet last Friday and there was a mix up. They ran a full panel urinalysis instead of the cortisol test. I told the receptionist what the test was for and even put a note on the sample. Ugh! Interestingly this is the same receptionist that has alot of complaints. Anyway...it was actually a good mistake because they found she had a urinary tract infection so she is baytril for 2 weeks.

So I brought another sample back on Monday and they still haven't called me back with the results yet which is really starting to tick me off. It shouldn't take that long to get the results. I have a feeling they are waiting for Dr. Bob to get back from vacation next week. Of course I would prefer to talk to him, but I would really like to know the results of the test as soon as possible.

Thankfully she is doing well on this dose. I am going to call tomorrow to see what is going on. Hopefully I will be able to elaborate further on this test soon.

[Harley PoMMom]

If it were me, I would not have taken Biscuit's urine sample in to be tested for cortisol because having an UTI will create the cortisol to be higher in her system, so the UC:CR will be falsely higher than if she did not have an UTI. Hopefully your vet will take this into consideration when evaluating the UC:CR.

Love and hugs,
Lori

[Sophie]

Thanks for the info Lori...I didn't know that. I will discuss that with my vet. I am apprehensive about upping the dose unless I know for sure the results are 100% accurate.

[leigh]

Sophie,

Sounds like you are doing a great job.

My dog Lily has been on Vetoryl for 3 + months now. I always thought I would have raise her dose (she's 10mg 2x a day - and 20 pounds) But everytime she got tested the levels were lower and lower - (took months).

My vet had originally prescribed 30 mg, but after getting advice here, and Dr. Allen I started her lower. My vet said "you were right, and I am really glad you looked into it".

So if you don't feel comfortable raising the dosage if the results come back not the way you want - in my opinion it's ok to wait, as with Lily they continued to drop over time.

But kudos for the research and keeping on top of everything, I know it's very stressful.

[Sophie]

Hello all...just wanted to update you on Biscuits urine cortisol test. It came back NORMAL! I am so happy at the results so far and glad I don't have to up the dose.

I am definitely seeing improvements in her condition. This weekend we went on 2 hikes in the Metroparks. Saturday we walked about 2 miles and Sunday about a mile and a half. Biscuit was so feisty. When I tried to put her in her carry pouch on some difficult parts of the trail she struggled to get out. Before she barely walked half a mile and wanted to be carried. Then on the way home she looked out the window the entire drive. Usually she'd nap in her basket.

She is also drinking less. Still a bit more than normal, but definitely a reduced amount. Her appetite is still the same...but she's always been a little piggy with food. I'm keeping my fingers crossed that when she's off the baytril she won't have another infection, but that seems to be her biggest challenge with this disease. Any good immunity supplement advice would be greatly appreciated.

So Dr. Bob said another urine test in a month. Will let you know how that goes. Unfortunately he just left a message on my answering machine so I didn't get to talk to him directly and ask any further questions.

Looking back I feel bad I didn't start this medicine sooner out of fear of the side-effects. I just hope that sharing my experience will help newbies to this disease to put fears aside and give it a try. Thanks to all here who have shared their knowledge with this disease, it really helped to ease my fears.
Hugs,
Sophie

[Sophie]

Hi Leigh,

That is very good to know. Luckily Biscuit's test results came back normal this time. So far I can see improvements so I know it's doing something. Though I realize it will take months to see improvements with some of her other symptoms.

Good luck with Lily and her continued success with Vetoryl.

Sophie

[ThreeJacksMom]

Hey Sophie & Biscuit,
Just wanted to stop by and say hello. Glad to hear Biscuit is doing so well. Sassy's 8th day of Trilo today - so far so good.
Hope you have a great weekend!

Lauri & Sassy

[Sophie]

Hello all...it has been awhile since I last posted. I have had to deal with some personal issues.

Just wanted to let you know that Biscuit is doing well though she had a bit of a setback. She is still on 10 mg of Vetoryl and her cushings symptoms have remained under control, but a few months ago she started to lose weight and her poop was yellowish-grey and she started to have many accidents in the house. She also had a voracious appetite and was eating her poop (YUK!). Dr. Bob knew right away from her symptoms that she had Pancreatic Insufficiency. Her pancreas is not producing enzymes to digest her food, so she basically was starving. Luckily it is treatable with pancreatic enzymes and her symptoms improved immediately once she started them. It's been about 2 1/2 weeks since starting the enzymes and she appears to have gained some weight tho it will probably take some time for her to get back to her normal weight.

I don't think pancreatic insufficiency is in any way related to the cushings or Vetoryl, but you never know. I just wanted to let people be aware of the symptoms because it is hard to recognize the symptoms until the disease is very advanced. It does get frustrating because it seems like one thing after another, but guess you have to take it one day at a time and cherish every day with them.

Hope all is well with everyone and their fur babies.

[Cyn719]

Hi

So sorry Biscuit hasnt been feeling well. Thanks for the update and for the symptoms...good to hear Biscuit is eating better and putting on weight....that's good news:)

Sending lots of thoughts and prayers for a smooth recovery

Hugs xoxo