Trilostane Dosage/return of symptoms and rashes (Bea) 7 y/o Jack Russell

[Bea's Dad]

My seven year old Jack Russell, Bea, was recently diagnosed with pituitary cushings following a battery of testing. She had all of the usual symptoms, very severe muscle atrophy, weakness (she falls down when chasing a ball, can't jump any more, can't use her back legs to stand) lethargy, water intake and urination, sitting by the fridge and scratching at the cupboards where food is kept.

She is 15.5 lbs and not spayed. She really is the love of my life and I want to do all that I can to make her comfortable and well.

My referring vet started her on 5mg of Trilostane. I've looked at what other dogs have been started on - dogs who are 5lbs smaller being started on 10mg, and further, I've taken a look at the compendium of veterinary Products which states it should be administered to start at 1-3mg per lbs.

Bea did well and started showing improvement almost immediately in the drinking and urinating department. She stopped begging for food, became happier, and her skin seemed to thicken because her stomach shrunk.

We Went for a ACTH response test in 10 days and there was no measured change in these levels. Apparently the drug has a cumulative effect, and I am scheduled to return for the 30 day ACTH test, however, about 7 days after the 10 day test, the thirst/hunger/urination returned. I assume that we will be increasing the dosage at the 30 day mark - but should I return sooner and request to up the dosage given that smaller dogs are started on higher dosages and respond well?

In addition, Bea seems to have developed this skin condition around her anus (she has licked all of the hair off the part of her tail closest to the anus) above her vagina, above her ears, under her legs where they meet her torso and around some of her nipples, where pink elevated skin forms and turns scabby... could this be some allergic reaction to the drug? I took her to my vet who couldn't diagnose it but prescribed Clavamox - which has not done anything to remedy the issue.

Any help would be appreciated.

[Harley PoMMom]

Hi and welcome to you and Bea!

So sorry for the reasons that brought you here but glad you found us.

I was wondering if you could do us a favor and check your emailbox (or spam folder) for a communication from us. Once you respond to that email, your membership will be finalized, and anything that you post will become visible on the the forum immediately. Until that time, your replies must be manually "approved" by a staff member before they are visible to the public -- so there may be a bit of delay between the time that you write your replies and the time that you actually see them...Thanks!

Also, if you could get copies of all tests that were done on Bea and post any abnormalities listed that would really help us to provide you with more meaningful feedback.

Starting low and going slow is a protocol that we suggest and so does UC Davis.The UC-Davis 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.

Trilostane/Vetoryl has a short half-life, it's peak effectiveness is anywhere from 2 to 4 hours after dosing and then it's effect starts to noticeably wane any time after 8 or 9 hours. It is very possible that the dose Bea is on is not adequate in controlling her elevated cortisol and needs an increase.

Trilostane/Vetoryl needs to be given with food to be properly absorbed, is Bea getting her dose of Trilostane with food? The timing of the ACTH test is critical and has to be done 4-6 hours after the dose is given, is this protocol being followed?

Is Bea on any other herbs/supplements/medicines?

Sorry for all the questions but like I mentioned before, the more information we know about sweet Bea the better we will be able to help you help her.

Please know we are here for you and Bea so do not hesitate to ask any and all questions.

Love and hugs,
Lori

[Bea's Dad]

Thank you so much for your response! This is such a great community and the information available is so expansive. I tear up a bit knowing that so many of our little friends are affected by this disease. :(

I have the copy of her initial blood test, I unfortunately don't have the results of the low dose dex or the ACTH Stim test: http://www.scribd.com/doc/89756346/2012-04-17-01-27-09-Redacted

The initial blood test prompted a referral to another clinic for an abdominal ultrasound. the ultrasound showed that Bea's liver was "pink", and I think that this meant not doing so well in dealing with toxins?

Here is the case summary:

Diagnosis: Presumptive hyperadrenocorticism

Diagnostics: Abdominal ultrasound, Low dose dexamethasone test

Treatments: No treatments required in hospital

Medications: No medications required pending the low dose dexamtheasone test

Diet: No diet change required at this time

Exercise: Please allow Beatrix to dictate her own level of activity

Follow up Appointments: An appointment will be scheduled once the results of the low dose dexamethasone test become available

case Summary: Beatrix, a 6 year old, female Jack Russell Terrier was presented to the xxx Veterinary Referral
Clinic for progressive lethargy, polyuria, polydipsia and elevated liver enzymes. The signs have been progressive over the past 4 months. Recently the owner has noted that the lethargy and weakness has become worse and she has developed severe muscle wasting. She
was presented to xxx Animal Hospital and a serum biochemistry revealed marked elevations in the liver enzymes. Beatrix was referred to xxx for further evaluation.

On presentation Beatrix was bright and alert. The vital parameters were within normal limits. The physical examination revealed a large pendulus abdomen, severe temporal muscle wasting, poor hair coat and cranial abdominal organomegly. An abdominal ultrasound revealed subjective hepatomegly with a diffusely hyperechoic
hepatic parenchyma consistent with a steriod hepatopathy. It was also noted that there were multiple non-obstructive cholyliths within the gall bladder lumen. Bilateral adrenomegly was noted with the caudal pole measuring 0.9 em and the caudal pole of the right measuring 0.88 em. Due to the high suspicion of hyperadrenocorticism a low dose dexamethasone test was perfromed and the results are pending. Beatrix was discharged to the owners with the above instructions.

The ACTH test was performed within the prescribed time and Bea has been taking her Trilostane with food in the morning.

As for supplements, I recently began putting small amounts of spirulina and bee pollen in her food, along with milk thistle extract. Sometimes she receives a bit of Epresat liquid multivitamin.

Prior to taking the Trilostane I was giving her about 1mg of melatonin once and a while, but stopped on the advice of my vet with a view to properly measuring the effect of the Trilostane.

The pink spots seemed to have developed soon after starting treatment with Trilostane and started on her anus and above her ears... it has since progressed to other areas and seems to be getting worse.. here is a photo.

http://imageshack.us/photo/my-images/571/img0030uh.jpg/

Moderator's Note: As Lori mentioned, please check your e-mail, especially spam or junk folders, for an email from k9cushings. Please respond to that email so we can get your membership automatically approved. Once approved, your posts will start appearing automatically with no delay.

[labblab]

"Your account has been activated but you are currently in the moderation queue to be added to the forum"
Your membership has now been finalized, so there will no longer be any delays in your ability to post replies. Welcome! :)

Also, here's a few thoughts to throw into the mix. First, I am stumped by the newly emerging skin issues. Of course, every drug has the potential to produce an allergic respose, so perhaps that is the case here. I'm also wondering if it might be some sort of yeast infection since several of the locations are areas of the body that could remain warm and moist. Just a thought...

As far as Bea's trilsostane dosing, it is true that she has been started at a dose significantly lower than the range given by Dechra in that "compendium" (Product Insert) that you've been reading. Under most circumstances, I do think it's wise to hold off on dosing increases until the 30-day mark. This is also per Dechra's monitoring flowchart, whereby the expectation is that the cortisol level will continue to drift downward during those first weeks of dosing. However, if her initial ACTH did not show a decrease in her cortisol level on that very low dose and her symptoms are already returning, if it was me -- I'd ask for an increase sooner rather than later and then test again in a couple of weeks on that increased dose. Dechra does discuss an "early" increase in situations such as this.

Also, since Bea is such a small dog, here's a method to share with your vet by which the expense of ACTH testing can be minimized by "stretching" the vial of stimulating agent:

http://endocrinevet.blogspot.com/2012/03/how-to-dilute-and-store-cortrosyn-for.html

Marianne