Cushing disease..LDDST and ACTH test result

[discuss99]

My dog 10 years old, 5kg, my vet said she have Cushing disease.

Initial test prior to treatment:
LDDST
Cortisol 0hr + 381 (25 - 75) nmol/L
Cortisol 4hr + 23 < 20 nmol/L
Cortisol 8hr + 107 < 20 nmol/L

Then vet said base on above, she have this diseases, she then have trilostane 30mg per day for 10 days. My dog nows look okay, very active. drink less and urine less.
after that 10 days, have a ACTH test

ACTH Stim after treatment started.
Time (hrs) Cortisol (Nmol/L)
0 80 (30-100)
1 96

Then they said my dog need to increase to have 60mg per day.
However, base on my research on internet, if 40 - 250Nmol, we should keep the same dose. moreover, 60mg normally for a dog which weight more than 10kg.

I not sure why they said need to double her dose.

Also even the LDDST result, how to know if the the figures really prove my dog have this disease? is theere any one familiar about
the figures of LDDST and ACTH?

Please help. thanks.

[mytil]

Hi and welcome to our site.

Just wanted to comment on a few things. I see a LDDS was performed and I have converted to another value many are familiar with here (in blue color). The results of the LDDS are indicative of Cushing's and you did mention below your girl was also having the outward symptoms as well (increased thirst, urination and hunger) and these are signs as well.




Initial test prior to treatment:
LDDST
Cortisol 0hr + 381 (25 - 75) nmol/L -------- (13.8 ug/dl)
Cortisol 4hr + 23 < 20 nmol/L---------------( .8 ug/dl)
Cortisol 8hr + 107 < 20 nmol/L--------------(3.9 ug/dl)

Then vet said base on above, she have this diseases, she then have trilostane 30mg per day for 10 days. My dog nows look okay, very active. drink less and urine less.

after that 10 days, have a ACTH test

ACTH Stim after treatment started.
Time (hrs) Cortisol (Nmol/L)
0 80 (30-100) ----- (2.9 ug/dl)
1 96 ---------------(3.5 ug/dl)

IMO, I do not see the need increase the dosage if the symptoms are decreasing and this value is within range area recommended by the manufacturer.


Then they said my dog need to increase to have 60mg per day.
However, base on my research on internet, if 40 - 250Nmol, we should keep the same dose. moreover, 60mg normally for a dog which weight more than 10kg.

That is a big dose for a dog weighing only 5 kilos, I agree.

I not sure why they said need to double her dose.

Did they tell you exactly why this was recommended - very detailed explanation?

Also even the LDDST result, how to know if the the figures really prove my dog have this disease? is theere any one familiar about
the figures of LDDST and ACTH?

Take

Please help. thanks.

I know others with direct experience with Trilostane will be popping in shortly.

Did your girl have a full blood chemistry testing to check the values with respect to the liver etc?

Terry

[lulusmom]

Hi and welcome to the forum.

I'll address your immediate question in a moment but I would like to ask a few questions first so we can get you started off on the right foot.

What symptoms did your dog have that prompted you to take your dog to the vet? Did your vet do a blood chemistry, complete blood count (CBC) and urinalysis? If so, can you please post the results of those tests? With reference to the bloodwork, we would only need to see the abnormal values and please include the normal reference ranges.

The results of the LDDS you posted are consistent with pituitary dependent cushing's; however, nonadrenal illness or severe stress can yield false positive results. For this reason, one cannot rely solely on the LDDS to confirm a diagnosis. An abdominal ultrasound is usually done to 1) validate/confirm the diagnosis; 2) differentiate between pituitary and adrenal disease; and 3) take a look at surrounding organs for any abnormalities that are usually consistent cushing's or possible non adrenal problems that could cause hyperadrenal activity. Did your vet do an abdominal ultrasound?

Now that the twenty question session is over, I'll address your question. :D For those of us that are used to seeing the results of an acth stimulation test and the LDDS test in ug/dl, I have converted those values below:

LDDST
Cortisol 0hr + 381 (25 - 75) nmol/L - 14 ug/dl
Cortisol 4hr + 23 < 20 nmol/L - .8 ug/dl
Cortisol 8hr + 107 < 20 nmol/L - 3.9 ug/dl

ACTH
0 80 nmol (30-100) - 2.9 ug/dl
1 96 nmol - 3.5 ug/dl

It is optimum to do an acth stimulation test before starting treatment to both validate a postive LDDS as well as establish a baseline for comparison post treatment. The goal of treatment is to lower the post stimulated cortisol level to within a therapeutic range of 40 to 207 nmol (1 - 7.5 ug/dl). If symptoms have resolved and the dog is doing well, the post stimulated cortisol level can be as high as 250 nmol (9.1 ug/dl).

Vetoryl (Trilostane) will continue to lower cortisol after the first 14 days so if the first post cortisol number is between 72 nmol (2 ug/dl) and 207 ug/dl, you continue the present dose. So to answer your question, your vet should ABSOLUTELY NOT increase the current dose because to do so could place your dog at great risk. I am at a loss to understand your vet's rationale because the results of the acth stim test are perfect...at least they would be if the dog had been treating for at least 30 days. Since it was only 10 days, there is a real possibility that cortisol will drop too low, in which case your dog could get very sick. Even at the current dose of 30mg, you need to keep a very close eye on your dog for signs of low cortisol. Those signs would be loss of appetite, vomiting, diarrhea, extreme lethargy, tremors and even difficulty walking.

It is extremely important that your vet do routine bloodwork to check electrolytes every time an acth stimulation test is done. Do you know if your vet did this? Did your vet give you a small supply of prednisone to use in the event your dog gets sick?

I am so sorry for the circumstances that brought you here but I'm really glad you found us. We're here to help you and your dog in any way we can. Ask any questions you may have and remember the more information we have, the more meaningful feedback we can provide. Please be sure to check out our Helpful Resources section. I've included a direct link to our information on Vetoryl which will help you better understand the dosing and protocol for monitoring treatment. Your vet should be following this protocol but based on the current recommendation to increase the dose, I am afraid that is not the case. Please do not increase the the dose per your vet's recommendation with a full explanation as to why s/he is deviating from the manufacturers protocol. If s/he questions your decision, I would suggest that you provide him/her with a copy of the PDF file I have attached below. This will provide your vet with a lot of information on Vetoryl (Trilostane), how to monitor treatment to include when to do acth stim tests, when to adjust dosing, timing of acth stim tests, etc.

TRILOSTANE/VETORYL INFORMATION
http://www.k9cushings.com/forum/showthread.php?t=185

627

Glynda

P.S. I see that Terry and I were typing at the same time and I'm glad to see that our conversions are almost identical.

[frijole]

These two ladies have done a great job of summarizing... I just have one bit of info to add. Glynda mentioned that your dog could perhaps show sign of too much of the drug. It is protocol here in the US to give patients PREDNISONE to have on hand in the event of an emergency. You only give it if the dog gets really sick. Did you get prednisone from your vet? If not - you must have it just to be safe. Kim

[discuss99]

Thanks everyone.

Last year my dog have a liver issue, did few times ultrasound, stay in hospital for 1 week. everyday they take her blood out to check if her liver function good.
(they do it everyday, i always feel they just want my dog's blood)
When my dog stay in vet, she always not eat, don;t drink and don;t urine, so finally we take her home(vet not allow, we insist), once my
dog back home, she eat, drink, play straight away. totally different than when she was stay in the vet.

After she recover from the liver problem, my dog started to always eat a lot, drink a lot urine a lot. A month ago, my dog
not as active as before..always sleep, after 2 days, i think
she's look like very weak(before i though she just lazy and want to sleep), so i take her to visit the vet again, the vet mentioned last year
actually they think our dog may have the cushing disease, that why my dog have the liver issues(last year not a good time to check if she have cushing disease, because need to wait until her liver back to normal), so she recommded us to do a LDDST.
Once they have the LDDST result, they said my dog have cushing diseases, then we start to feed her the 30mg medicine everyday.

after 11 days, have a ACTH test, then the vet said
"the hyperadrenocorticism (cushings disease) is not quite 100% controlled on this dose of Trilostane. We would like to increase the dose to 2 capsules (60mg) ONCE daily."

Sometimes i feel they just want to do some experiement on my dog, however, they are the best vet in my area...confusing.

[mytil]

Hi again,

Here is a link to locate a specialist who are typically more versed, experienced in Cushing's - http://www.k9cushings.com/forum/showthread.php?t=182 (for NAmerica etc) and http://www.k9cushings.com/forum/showthread.php?t=183 (for Europe)

Terry

[labblab]

I strongly agree that it would be very dangerous to double the dose of trilostane, and I cannot understand why your vet would recommend that you do so. If you would care to give us a general idea as to where you live (even just what country you live in), we can help find the telephone number or address that you or your vet can use to directly contact Dechra, the manufacturers of brandname Vetoryl (trilostane). They have veterinary specialists on staff who are very willing to offer feedback and suggestions regarding proper dosing of the medication.

I would be very, very worried about increasing the trilostane before having the chance to talk with Dechra!

Marianne

[discuss99]

I am from Australia - SYDNEY.

[labblab]

Thanks so much for letting us know you're in Australia. I'm awaiting a telephone call-back from Dechra's U.S. office, hoping that they can give me info about any Australian contacts that I can pass on to you. I'll be back as soon as I hear from them.

Marianne

[BestBuddy]

Hi.
I am in Australia too. I live in Victoria so quite a way from you so I don't know of any contacts in your area. Some of the university hospitals have very experienced staff and specialists and are not any more expensive than local vets overall.

With a post of 96 I would not even consider raising the dose of trilo. It may even drop even lower over the next few weeks so it is important that you keep an eye on her and if your dog starts to act unwell then it is time to get to the vet again.

How is your dog now? Any symptoms still?.

Jenny

[discuss99]

No, she very very active after have the medicine for 10 days.

keep playing and barking if I don't play with her.

I ignore what my vet said to give her double dose.