New member needs advice

[Casper's mom4]

Casper, my 12 year old 22 pound shih-tzu mix, was diagnosed with Cushings in late October and started on Trilostane 30mg per day. He's had two stim tests since then. The first showed he was within the healthy/normal range but at the low end of the spectrum. His latest, taken four days ago, came back with excellent results (sorry, I don't know the numbers). Since that second test he's been very weak and has had several soft stools. I wasn't too concerned until yesterday when I came home to diarrhea and urine all over the house and him shivering and weak in the hindquarters. I called the vet who told me he may be overmedicated (even though the test results were good) and to take him off Trilostane for 3 days and then put him on an every other day regimen and to get another test in 2-3 weeks. He has never missed a meal in the two years I've had him but hasn't eaten since yesterday morning. His shivering comes and goes and he has been drinking but only a little. Does this sound normal, or should I be concerned?

[labblab]

Yes, I'm afraid you do have definite reason to be concerned. It seems very odd that Casper's discomfort started in conjunction with the testing four days, and I'm very bothered by your vet's instructions given how ill Casper sounds. Under no circumstances would I resume the trilostane until you can get things sorted out. And if your vet knows that the ACTH results from four days ago were "good," then he ought to be digging a lot deeper to figure out what is going on. Do you know whether Casper's electrolytes were also checked alongside the ACTH? This is a simple test of blood chemistries, and recommended by the manufacturer of Vetoryl in conjunction with every ACTH. This is because low cortisol is not the only issue that can arise with trilostane treatment. Levels of aldosterone can also be lowered, resulting in imbalances in potassium and sodium in the blood.

Do you have any emergency prednisone on hand in the event of a cortisol crash? Although once again, if the cortisol level was truly OK four days ago, there may be entirely some other issue going on. If Casper does not improve as the day goes on, I'm afraid you may need to take him in for emergency assessment. Please do keep us updated!

Marianne

[lulusmom]

Hi and welcome to the forum.

Your vet may not think Casper is in crisis but every symptom you mention are symptoms of an addisonian crisis and I am shocked that your vet did not tell you to take Casper in asap. If your vet is not open today, please get him to an er. He may need to be on IV fluids and be given cortisol and mineralcorticoid supplementation.

FYI, it is known that even a dog that has been stabilized on treatment for months and even years can have cortisol plummet, causing an addisonian crisis so the fact that Casper's acth stim test was good doesn't mean it's good today. Trilostane not only effects cortisol, it can have serious impact on aldosterone levels. Aldosterone is the adrenal hormone that regulates the body's salt and water balance. If too low, electrolytes are thrown out of whack and can be life threatening. Trilostane's effectiveness is short lived and a dog will rebound rather quickly by withholding the dose. The fact that Casper is still unwell is of great concern and he needs to be seen by a vet asap.

Please keep us posted and please get copies of the acth stimulation tests done so far and post the results here.

Glynda

P.S. I see Marianne has posted while I was typing. This is one time when duplication of information is a really good thing and can save a life.

[lulusmom]

I also want to mention that it is known that even dogs who have been stabilized on Trilostane for long periods of times, months or years, can have cortisol drop too low at any time. Therefore, just because an acth stimulation test four days earlier shows levels to be acceptable doesn't mean they are okay today.

P.S. I just noticed that I did mention this in my first post. Duh! My concern for Casper was great and I was definitely addled.

[labblab]

Glynda is absolutely correct that cortisol levels can change abruptly. But additionally, it still seems odd to me that Casper was OK until undergoing that ACTH test four days OK. Did he truly seem "off" from the time you brought him home from the testing? Because we do know from the test what his cortisol level was that day, and if he was already unwell that evening there must be something else also involved in the mix.

Marianne

[Casper's mom4]

Yes, it seemed to start right after that, but slowly got worse. I wasn't concerned because he's usually pretty worn out after a trip to the vet. The shivering and non-eating are what really worry me. I'm heading to the vet now and will update this post soon.

[labblab]

I'm really glad you're taking him in and will be really anxious for your update!

[lulusmom]

I'm really glad you're taking him in and will be really anxious for your update!

ME TOO! I'll be checking in later for your update. Keeping fingers and paws crossed for good news from the vet.

[Casper's mom4]

Back from the vet, where he was x-rayed and nothing abnormal was found. They did some more bloodwork and an electrolyte test and his potassium and sodium are out of whack. He's staying there for at least one night and they'll recheck him tomorrow. There is some concern it's turning into Addison's so he's being closely monitored. I didn't get the test results but will get a copy of everything when I pick him up. Thanks for your concern, advice and information. I'm glad I found this site!

[frijole]

Glad you got him to the vet. Curious why they did an xray? Did they think there was a broken bone? Seriously that has nothing to do with cushings...

I'm going to do my best to give you a cushing's primer so you can best ask the vet questions when you pick him up. I'm not sure based on what you wrote earlier that your vet really knows how to treat cushings. It could be that you are new to it and misunderstood what they were saying so I'll give them the benefit of the doubt for now. ;)

Cushings is the result of the body over producing cortisol. (think adrenaline) The body gets signals to produce it but it is too much. It causes dogs to be restless, feel starved even though they just ate, and sometimes they drink buckets of water. It is not a life threatening disease but if left untreated it can lead to other problems.

Trilostane is a chemo drug. It works very quickly to reduce the cortisol. Cortisol is measured by the ACTH test. So when you start trilo you usually have that test done beforehand so you know where you are and then you give trilostane and measure to see how it is working.

Signs of overdose are vomit and diarrhea. Any vet who know anything KNOWS that you immediately cease giving trilo should a dog get sick. You stop and have the acth test done to check the cortisol levels as well as electrolytes.

It sounds like your dog's dose was way too high. Can you tell us your dogs weight as well as the dose he was on?

When a dog goes addisonian it means he has no cortisol and he CAN DIE. That is why we sent you to the vet. He should probably be on an IV to get his electrolytes back up to normal. (the potassium and sodium being out of whack as you called it) I hope that they know to do that.

You said they did some bloodwork - I would phone them and make sure that they did an acth test. If they have not then they should be fired on the spot. It is the only way of knowing how low your dog's cortisol is.

Please get a copy of everything that has been done since this started - every single test. And post it here. I want to make sure your dog has cushings. It is very often misdiagnosed.

I'm glad you found us too! I don't mean to scare you but I want to make sure you understand that you should have been told how the drug works, to stop when you saw the early warning signs and this crisis could have totally been avoided. They should be doing all of this testing and hospitalization at their expense since they were negligent.

Please keep us posted. Kim

[labblab]

Hi again, and how is Casper doing today? I've been thinking about you guys and hoping that things have improved.

I also wanted to stop by to show you this quote from a recent research paper published by Dr. Edward Feldman from UC Davis:


It also appears possible that, in some dogs, trilostane may more effectively block the synthesis of mineralocorticoid [aldosterone] than glucocorticoid [cortisol]. This would explain how severe clinical signs (dehydration, weakness, hyponatremia, and hyperkalemia) could develop in a dog that becomes ill during trilostane treatment despite having pre- and post-ACTH stimulation serum cortisol concentrations that may not be as low as the values in other dogs that seem to be underdosed or that have responded well.
This is an explanation that might well account for Casper's electrolyte imbalances even though his cortisol level may not have prompted any "red flags" of warning. Anyway, please do update us when you have the chance.

Marianne

[Casper's mom4]

He's at the animal hospital for one more night. He's eating and drinking again but his potassium is still a bit high. We're keeping him off trilo for a few more days and then will put him on an every other day regimen and get another Stim test in a week. We're also switching the med he's on for his heart failure, as the one he's been taking for the past year could potentially counteract with trilo and lead to Addison's. thanks again for all the advice - I think if I had waited much longer it would have been much worse news.

[molly muffin]

Hello and welcome to the forum. I'm so glad that you found us and that our very supportive group has been helpful. That was a very scary situation you just went though.
I have to tell you that the people who have been helping you through this have a lot of experience with cushings and these medications. Years worth. You are in excellent hands with their advice. :)

So, I want to encourage you to have your vet call Dechra. This is the maker of Vetroyl, the Trilostane medicine. They work often with the vets who are treating cushings dogs. Now as to why, this every day dosing thing. Not recommended. Trilostane doesn't stay in the body itself long enough to be able to do an every other day dose, the recommendation is that after a crisis is over, and based upon how long it takes for cortisol levels to start to go back up, the dose would continue to be daily would be lowered so as not to again over medicate. It was the amount of dosage given that was the problem, not the frequency. It is completely different from lysoderm the other drug used to treat cushings. Also, Casper shouldn't be restarted on Trilostane (at least I'm pretty sure he shouldn't, the others will know better than I) until his cortisol levels have gone back up.
So, I know it is terribly difficult to stay on top of and to know what to do, but the more knowledge you have going in the better it will be. You might want to start a daily journal, so you'll be able to reference it on how Casper is acting, how much drinking, accidents, eating ,and when.
The other thing is to just make sure every time any test is done that you have a copy of the results to add to your Casper medical file. This will be handy for you to look at when needed to check dates, tests, results, etc and also to have in case you have to go to an ER for any reason.
Again, Hello and welcome to you and Casper.

Sharlene and Molly Muffin

[labblab]

I'm so relieved to hear that Casper is doing better and I'm glad you are switching his heart med, but I agree 100% with Sharlene that shifting to every other day dosing with the original 30 mg. does not make any sense. Since trilostane exits the body of most dogs after around 12 hours, this means that he will be receiving too big a dose half the time, and no dose at all half the time -- a very inconsistent dosing pattern for his body to undergo. I suspect that your vet may be trying to allow you to continue to use the 30 mg. capsules that you already have on hand. But I do not think this is in Oscar's best interest since it is not a dosing protocol endorsed by any specialists or researchers who we know about here.

I also endorse Sharlene's suggestion that you or your vet contact Dechra directly. Since it appears as though Oscar's cortisol level did not give you warning of this crash (although we don't know this for sure until we see the actual test numbers), you may need to monitor his dosing in additional ways such as very frequent electrolyte checks. I believe that Dechra's dosing and monitoring guidance may be very important for your vet. Here's a link to Dechra's contact info:

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

Marianne