10 yr lab mix with Cushings, trying trilostane

[Rural doggie]

hello all - I've already gotten some good information from this forum - thank you.
My dog is a 10 year old, 90 lb lab mix. After several months thinking he had kidney problems, he was diagnosed with pituitary dependent Cushings based on a low dose dex test several weeks ago. He drinks 40-50 C of water a day and gets us up twice a night to go outside to pee. He has always had a big appetite. He doesn't have any other symptoms like hair loss or pot belly. He did have slightly elevated liver enzymes on his geriatric blood panel, but nothing else.

We live in a very rural area with a veterinarian that is not always in town, so we have some added challenges in treating our pet. We were concerned about trying trilostane when the vet wasn't in town, so we gave ketoconozole a try for three weeks over the holidays. It didn't change his drinking at all, but he definitely lost his appetite - wouldn't let dry food or dry treats cross his lips. We also think he slowed down a bit and was more reluctant to climb stairs, etc. while on the keto. We did an ACTH stim test and his cortisol levels looked a little better, but our vet and the internist he's been talking to about this think that is typical for ketoconozole - makes the tests looks better, but doesn't control the symptoms.

So now our vet is back for a bit and we are going to try trilostane at 30 mg twice a day. I'm concerned about side effects of the drug - particularly an addinsonian crisis. Anyone with experience here that can tell us the very earliest signs of trouble we should be watching for?

Of course, we're also concerned that we'll uncover arthritis problems, but we'll cross that bridge when we get there.

I'd appreciate any advice or thoughts that you all have on our case. Any thoughts about the dosage of trilostane? I've been pushing to be very conservative in our treatment.

[Harley PoMMom]

Hi and welcome to you and your boy,

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

Ketoconazole is really hard on a dog's liver so I am relieved to hear that this medicine is no longer being used. Trilostane/Vetoryl and Mitotane/Lysodren are the two drugs that are mostly Rx'd for the treatment of Cushing's.

Here is a link with info about Trilostane/Vetoryl: Trilostane/Vetoryl Information and Resources (http://www.k9cushings.com/forum/showthread.php?t=185)

The 30 mg starting dose, IMO, is a conservative dose to begin with for a 90 lb dog but we have seen that dogs do better, meaning less side effects, from starting out at the lower end of the dosage scale.

Could you get copies of all tests that were done on your boy and post any abnormalities that are listed. We are especially interested in any tests for Cushings too.

What symptoms, besides the excessive urination, does your boy display?

Please know we will help in any way we can so do not hesitate to ask any and all questions.

Love and hugs,
Lori

[frijole]

Hi from me too! I live in a small town in Nebraska so I know it can be challenging but not having a vet in town is scary! So we'll do our best to help you out :D That is a very low dose - a normal place to start would be 90 mgs a day but that's fine for now.

I too would like to see the test results just to make sure the diagnosis is confirmed.

Re signs of overdose - vomit, diarrhea and extreme lethargy. If you see any please post details and withold drugs til we can get back to you ok?

Kim

[Rural doggie]

You all are so wonderfully supportive - thank you!

I will look for the test results. To clarify, we're going to try 30 mg twice a day, so 60 a day total. One thing I read suggested that 40 mg twice a day would be the ideal place to start for a 90 lb (40 kg) dog, but the vet said it would cost twice as much to add that additional 10 mg tablet! Another thread here suggested that 60 mg/day should be an upper limit, even for a large dog. I did read a paper showing that larger dogs might need fewer mg per lb than smaller ones...

[Rural doggie]

Hi from me too! I live in a small town in Nebraska so I know it can be challenging but not having a vet in town is scary! So we'll do our best to help you out :D
Kim

Frijole - we are in a small town on an island in Alaska, so the nearest vet is a plane ride away when our vet is gone. Nerve-wracking with these drugs and their scary side effects!

[frijole]

Wow that is awesome! I'll come visit this summer. :D

Do you have a vet in town that can be there when you need to do an acth test? Normally you start the drug and at a set point in time (a week or two) you do another acth test to see how low the cortisol has gone. It then takes a couple days for the results to come back. Just curious and want to make sure you have support there! Can you phone your vet even though he isn't on the island?

Kim

[Rural doggie]

Yes, I made sure our vet will be in town 12 days after we plan to start the Trilostane (not until next week because we'll have a friend's dog with us until then and won't be able to monitor his water). We already have that scheduled. Yes, he is in phone contact when off the island. He leaves again right after that for 10 days, though, so we'll have to get the results by phone, I guess.

I found some of his test results:
On 11/12 he had low (30.8) MCHC (normal is 32-36) and low lymph (850 when normal is 1000-4800). He also had high ALP (680 when range is 10-84) and ALT (126 when range is 5-65). High cholesterol (464, when normal is 150-275) and lipase (691, when normal is 0-425), also. Those numbers were all high in July, when he was drinking half as a much water as he is now, although still way more than normal.

In November, His urine specific gravity was 1.003, when normal is 1.005-1.055. Makes sense with all the water he's drinking! In July, we also did a cortisol/creatinine ratio. It was 17 then, when the lab said anything under 20 made cushings unlikely. We haven't done another of those since.

The main diagnostic was the low dose dex suppression test, which was 5.2 at 0 hr, 1.8 at 4hours, and 2.6 at 8 hours. The lab said anything over 1.4 at 8 hrs showed cushings and that, because the 4 and 8 hr numbers were less than 50 percent of the baseline, it meant cushings. That test was on 11/10/12.

I haven't seen the results of the ACTH stim test he got while on the ketoconozole, will post those when I can.

I did remember another symptom, because he just showed it again tonight, after not having done it for a bit- he shakes, either in just his back legs or all over his body immediately after he eats. Goes away after 10 minutes or so. Anyone else seen anything like that?

[Rural doggie]

Oh, another question: it seems like my dog is more active at night than during the day. Is there any link to Cushing's?

(I have to admit that this could just be our perception, since that is when he is waking us up, but my husband thinks he read something about Anipryl helping with nocturnal activity, so it might be connected to Cushing's).:o

[frijole]

Yep cush dogs tend to be more active/hyper at night. Best way I can describe excess cortisol is to "think adrenaline rush". That is what is going on in their bodies. I don't know why evenings are worse but my dog used to pace the bed... sometimes walking over my face. That's when I knew something was up. :D:confused::D Once treated this should go away. Kim

[molly muffin]

Oh one thing I just thought of, before you start the trilostane, and your vet is off island is to make sure that the vet gives you some prednisone to have on hand. That way in case for any reason there is a reaction and the cortisol drops, you have the emergency prednisone to give until the vet can be there or other arrangements can be made.

Sharlene

[Rural doggie]

Oh, great to know about the prednisone! Would that actually solve the problem, or just keep doing okay until we could get him somewhere? Of course, I'm planning on nothing bad happening at all and that the Trilostane will be just the thing he needs;)!

Any idea what percentage of dogs actually have a crisis like is? I know lots need dosage changes?

For now, we're waiting until Friday, when our visiting dog friend leaves to give it a try. He has had some better days these last three days -drinking more like 35 cups of water a day and only getting us up once a night! I felt like I'd won the lottery the one morning when I woke up and he'd only gotten me up once at 1am! Strange how your perspective changes. I wish we could figure out what, if anything, we did on the days when he drinks less. Does more exercise or just plain less stress make a difference with cushings? He has panic attacks with fireworks or the smoke detector going off.

[molly muffin]

It could just be that those days you were outside more and he went potty more during that time? It's hard to say but cortisol does do spike and ebb at times.
Well, I don't know what sort of percentage it is that would have a crisis because every dog is different and each reacts different to medication.
We all hope that it is never needed, but you know, as soon as you don't have it that's when you'll want it. So, best just to get it.
Depending on how bad the crisis is as to whether you could carry him over till the vet came on a regular scheduled visit. Usually trilostane will leave the body after about 12 hours, it's peak effectiveness is at about 2-4 hours after it's given in the morning.
So, hopefully you won't even need it, but always better to be safe.

Sharlene and Molly Muffin

[Rural doggie]

So many questions! Thanks all for being so helpful with all these things that must run through everyone's mind when they get this diagnosis.

I'm wondering what all of you do if/when you have to be away from your pet? We don't have a kennel here, so when we leave town, we usually ask a friend with a dog to take ours in. We do the same for our friends when they leave town. Now that our dog has Cushing's, thou, I wonder if this will be possible. Do things ever get stable enough that you can be fairly certain he'll be okay for a week or so?

[molly muffin]

Once you have the cortisol stabilized then hopefully there won't be any issues on a regular basis. You always have to keep an eye out for symptoms to start returning, meaning that you might need to do a dosage adjustment. Once he is stable though, I'd just make sure that your neighbors who would keep him are familiar with cushings, his treatment and anything to watch out for. Also, that they have your phone number to reach you if needed.
I'll let some of the other tell you about what they do for their dogs when they go out of town.
We leave ours at the vets kennel when we're away, but that is easier when you live in a city.

Sharlene and Molly Muffin

[SoggyDoggy]

Absolutely! I asked the same question in one of my first posts here. I thought things were going too smoothly within that first week and was waiting for the other shoe to drop. I was assured that there are MANY who get things working smoothly and live normal lives without much hassle, and I have to say, now I believe it.

The other shoe did drop for me, but now I have the pair and things have been sorted out. My boy is now going great guns (still early days I know - but the tests and lack of symptoms cant lie). I have every belief he will continue on like this!

As for going away, I don't get a choice. In a couple of months I have to go overseas or 8 days for work and will be leaving both of my boys with my mum. She is going to have to manage the pills for that time, but I don't see any issues. I'd say, once you have things well controlled and the only thing out of the normal is giving a pill after breakfast and dinner, there shouldn't be any issues with a friend looking after your lab. The only thing is, you should be pretty happy that he is in good shape and stable before going, just to take the additional worry off your mind while away.

Anyway, good luck with starting on the trilostane. Hopefully you will start to see results quickly and manage to sleep through the night! :D

[Rural doggie]

Baxter gets hill's k/d dry with some k/d wet food in the morning, and just wet at night (we thought wet food at night might help him drink less). Anyway, he also gets, ahem, a fair amount of dog treats and carrots, lettuce or whatever protein we're having for dinner. :o
Aside from the other non- cushings reasons for not feeding table scraps, do we need to make sure he maintains exactly the same diet from day to day when he is on Trilostane?

I'm definitely planning to measure his water intake each day, but am kind of a softie when it comes to salmon skin and chicken pieces...

[frijole]

The reason you don't want to change the diet when start trilostane is because vomiting is a sign of overdose. If you give something that makes the dog's stomach upset you won't know if its the drug or the food... Not worth it! Kim

[SoggyDoggy]

Then again, if he's anything like my two who stop eating when they get bored with the same thing, (and that can go on for days - I've tried it) then you also wont know if its the drug or the food. I would say, the diet doesn't have to be exactly the same from day to day, but stick with things he has had for a long time and that you are entirely comfortable knowing don't upset him or his stomach. If he is used to variety that's fine, just don't make radical changes that you haven't tried before. Consistency will be your key.

[Rural doggie]

Thanks for your quick responses! He rarely vomits, but I'd say he has slightly loose stools pretty often. So I think I'll call the vet if he vomits for certain and keep a close eye on what he eats and what his stool looks like. I'm obviously nervous about this, but hopeful it will help him - hopefully without too much trauma. We did get some prednisone (10 caplets of 20 mg) and the vet will be in town up until our scheduled stim test in 10 days, so I feel like we've prepared pretty well. Maybe get some pedailyte? Is there anything else we can do or should know before starting?

[SoggyDoggy]

Sounds to me like you are pretty right actually, certainly more prepared than I was! Just watch him closely, monitor him and hopefully you will start to see results within a few days. The other thing I found with Fraser, is that he would on occasion get a bit nauseous and lick the air, but I've found it now only tends to happen if he doesn't eat enough food with his trilo, so I make sure he has a pretty reasonable quantity of food before I will give him his pills. This way he doesn't turn a hair.

Anyway, good luck with it all, hope it's smooth sailing all the way. Give us the updates, note down anything strange, good and bad and know there is always advice a few clicks away.

[addy]

Just remember, when in doubt withhold the Trilostane. You 'll be fine, you have quite a few of us holding your hand.

[Rural doggie]

So far, so good. After two 30 mg doses - one with breakfast, one with dinner- everything seems the same, which I'm taking as a good sign at this point. Bax has kept up his appetite, which was so immediately bad with the ketoconozole, and has the same energy level. Looking forward to seeing if he calms down anymore tonight. We're hoping for just one middle of the night awakening tonight!

[molly muffin]

Sleep is never as precious as after you aren't getting a full night of it! I hope that eventually you'll see a full nights rest and Bax keeps up the good energy levels.

Sharlene and Molly Muffin

[Rural doggie]

Well, we're not noticing any bad effects in Baxter on his third day of Trilostane. He only got us up once each of the last two nights, though, so that is an improvement!

Which leads to another question: do dogs that are being successfully treated for cushings ever concentrate their urine? I haven't been able to find much explaining how cushings causes the increased urinating and drinking we've been seeing. Anyone had a dog with both cushings and kidney disease? That's what we originally thought he had, even though his creatinine and BUN were never high. I'm trying to figure out if it is safe to assume he does not have kidney disease at this point, maybe take him off the expensive kidney dog food?

[Squirt's Mom]

If his BUN and creatinine are normal and have been, I would know of no reason to think he has or had kidney disease.

And, yes, as the cortisol is better controlled we typically start to see the urine regain some color, meaning the pup is concentrating the urine again, tho there are always those exceptions. As for why this disease affects the kidneys, somewhere in the dark, twisting corridors of my mind I probably have the answer....but it is inaccessible at the moment. :rolleyes: So hopefully, someone will be able to tell you that soon.

Hugs,
Leslie and the gang

[Rural doggie]

Baxter has been on Trilostane for 7 days now, and his drinking has gone down quite a bit, but I haven't seen any more yellow in his urine - still basically clear. He is still drinking 24 - 32 cups a day, but that is a big improvement from the 50+ we were seeing before we started the trilostane. Hoping that will continue to go down a bit, but we can handle that amount, if it doesn't. Our first ACTH stim test is next Tuesday.

[NoonelovesmelikeNorman]

Hello Reggie's Dad!

Great to hear how well he is doing thus far. I just wanted to wlecome you to the group and let you know your in great hand with the wealth of knowledge, experince and encouragement this group has to offer.

Wishing Reggie and your family the best in 2013.

Sharon and Norman :)

[Rural doggie]

I read another thread about a possible ACTH reaction and got to thinking about my experience with our first test, while Baxter was taking ketoconazole. When we first started him on the keto, it seemed like it was causing a slight improvement in his water consumption (although he was also very sick to his stomach). The day we gave him the ACTH stim test and for every day after until we quit the keto (actually, until we started the trilostane), his drinking went way back up. I remember wondering if the test itself could have provoked this.

Since we are having guarded success with the trilostane so far, I don't want to ruin it by giving him the ACTH if it is going to cause a similar reaction this time around. Has anyone else experienced anything like this after the stim test?

[molly muffin]

Usually any reaction to the ACTH test of increased water drinking, wears off in about 24 hours. Depending on how controlled the cortisol is, you may not see a reaction at all. The ACTH won't cause an overall setback though as you are treating, so the adrenal glands are not constantly producing as they are without treatment.

Hope that helps a bit. :)

Baxter is still doing good then?

Sharlene and Molly Muffin

[addy]

It should be temporary side effects from the ACTH test if Baxter should experience any. My pup has had so many stims in the last two years:rolleyes: Sometimes she has side effects, some times not. Every pup is different and every ACTH test can be different

I am glad Baxter is already showing improvements; excessive peeing and drinking are usually the two symptoms that can start to improve within two weeks. Some pups do take more time with it, however.

Keep up the good work!!!!

[Rural doggie]

Thanks for the encouragement and information! Baxter is doing better - in the past 9 nights, he has had 5 nights without needing to go outside at all. The others were just once, when we were dealing with twice a night prior to the Trilostane. He also seems a bit perkier and is willing to go up the stairs and jump on our bed without complaint. (I know some may think the bed-jumping is a bad thing, but we welcome it! :)) He still really enjoys his water - after a few great days of drinking only 24 cups, he's back up to around 30. That's still less than the 50+ before we started, but I'd think it should be lower. And, his pee is still completely clear.

Tomorrow, the test. I'll report results when we get them. Good to know that, if we do see an increase in water consumption, that it should be brief.

[molly muffin]

Hoping for an excellent test!! :) Sounds like progress is being made. You've had some full night sleeps! whoo hoooo!


Sharlene and Molly Muffin

[SoggyDoggy]

Good luck with the test! Sounds like there has been significant progress and Baxter is on the right path. Glad to hear he is able to get up on the bed again, nothing like doggie snuggles or that snuggle in the crook of your back :D

Do let us know how it goes tomorrow.

[addy]

Dogs on bed= good thing in my book.;):)

It sounds like Baxter is coming along quite well and that is wonderful news. We'll look forward to his test results. Just stay calm and positive durring the test and then Baxter will as well.

[Rural doggie]

Well, we were up twice last night to pee. I lost track of how much water he drank, but I think it was definitely up from the average over the last week or so. Hopefully that was a side effect of the ACTH and not a sign of the trilostane losing effectiveness.

Otherwise, the stim test went fine. Baxter is walking around with a shaved leg as testament to all the torture we're putting him through, poor guy. He is a trooper, though, just sitting calmly with his ears down while he gets blood drawn.

He is "blowing his coat" like crazy. This has happened his whole life, but maybe not this much all at once. Any connection to trilostane, cushings, or getting off the ketoconazole that anyone knows of? I don't THINK this is the hair loss that can come with Cushings? He is not bald where the tufts come out, just has thinner hair there.

[Squirt's Mom]

We have often seen Trilo pups blow their coats among the members here. Sometimes they regrow an altogether different new coat afterwards! :) I wouldn't worry to much about it right now and would put it down to a side effect of the Trilo.

Hugs,
Leslie and the gang

[SoggyDoggy]

I've read that they can blow their coats with Trilo too. However Leslie saying they can grow different coats as a result is news to me, but explains a lot! Fraser has for the first time in his life a downy undercoat now too! He is due for a haircut tomorrow, so I guess I will get to see the difference after that, but it's now a light silver colour (more like his ears).

So the good news is, that although Baxter may be blowing his coat, it sounds like it will grow back in too!

[labblab]

Just wanted to add that my private theory is that it is not the trilo, per se, that is causing this (cuz I think we've seen the same thing with dogs taking Lysodren, too). But rather, it results from the resumption of a more normal hair growth cycle after the cortisol is normalized once again. Before diagnosis, my own boy had horrible bare patches on his sides and haunches from the Cushing's where the hair growth had gone totally dormant. A little while after starting treatment (in his case it WAS trilo), I was initially horrified when huge chuncks of fur started falling off him. But when I looked carefully, this time I saw new little baby "fluff" underneath in those spots, and before long, all his bare holes had filled in, too. It was such a wonderful sight to see!

Marianne

[Rural doggie]

Very frustrating -basically all of Baxter's symptoms seem to have come back, even though he is still on the same dose of trilo. He is up at night, water consumption is increasing, his back legs fell out from under him twice yesterday, and that panicked hunger is back. I can't help but think it is the ACTH stim test, since it seemed like something similar happened when we gave him one while he was on Ketoconazole. That is scary, because he never seemed to recover from that until we started trilo.

If this is something to do with the stim test, is that diagnostic of anything? Could he have adrenal rather than pituitary?

Anyone else see something similar with the tests? Any hope that it will get better? It has been 2 and a half days since the test, seems like it should have worked its way out of his system by now.

[Squirt's Mom]

What were the results of the stim? It may be that he is no longer in range and needs a dose increase but the ACTH will tell the tale. Let us know what the results are when you get them. ;)

[SoggyDoggy]

Do you have the test results back yet at all? I'm wondering if there might be a clue in there as you said Baxter had increased his drinking a little in the few days before the test as well? If his cortisol levels have not yet dropped sufficiently that could account for the revival of symptoms, as levels can continue to fluctuate in the early days.

Now for some additional questions for those in the know:
Is there more than one type of stim agent for the ACTH? I think I've heard of at least two different versions, one a gel or something? I know both are injections still, however I'm wondering if there has ever been any reports of a particular sensitivity to one type of stim agent and if we should try to find out which was used on Baxter, then try a different option the next time round.

Obviously this is just a question as I truly don't know myself, but am wondering if this could be a possibility that he has a particular sensitivity to the stim agent that causes his system to go overboard for an extended time. :confused::confused::confused:

[labblab]

Here's a link to an article by Dr. Mark Peterson in which he discusses ACTH testing options as well as his personal preferences.

http://endocrinevet.blogspot.com/2011/03/what-acth-preparations-should-be-used.html?m=1

Dr. Peterson does field questions on his Blog, so perhaps he might respond to a question re: lingering testing effects...

Marianne

[Rural doggie]

No results yet, I'm afraid. Thanks for them link to the information on different kinds of ACTH. I will ask what kind was used when I get the results (tapping fingers on counter, I am not known for my patience)

[SoggyDoggy]

Just wondering how Baxter was going today? Any improvement or is he still drinking excessively?

[Rural doggie]

Hi Naomi, thanks for asking about Baxter. He was up twice last night and drank more water yesterday than he has since we started the trilo (41C) He also didn't eat his entire breakfast, which is a little unusual, bit I'm not overly concerned about that.

Good news is that we got the ACTH results, which I have no idea how to interpret -would love some help!
Pretest was 4.4, when the reference range is 0.0-10 (I think this is micrograms per deciliter)
Post test was 13.7, with a reference range of 8.0-22.0
In both cases, it says that the sample was lipemic and ultrafuged before analysis - no idea if that is important. He had his pill at 8:30 with breakfast and the first draw was taken at 11:30, ACTH administered IM, and second draw at 12:30. The IM specialist my vet has been talking to said the test should be 3-4 hours after eating, but I saw here that at least 4 hours after eating is recommended. Hopefully this doesn't throw things off too much.

The results also say "post values greater then 25 are consistent with Cushing's".

I think we are going to keep him on 30 mg twice a day and see if things improve -thinking this current setback is just an extreme reaction to the stim test. What do others think?

[Rural doggie]

Anybody know what this means?: "Monitoring of trilostane therapy with the ACTH stimulation test may be difficult because ACTH can override the competitive inhibition of steroidogenesis."

I found it in the resources section on the "current controversies" document. Just wondering if it could explain Baxter's troubles with the stim test (assuming that is what is going on with him).

[Harley PoMMom]

Good news is that we got the ACTH results, which I have no idea how to interpret -would love some help!
Pretest was 4.4, when the reference range is 0.0-10 (I think this is micrograms per deciliter)
Post test was 13.7, with a reference range of 8.0-22.0

Has it been just a little over 2 weeks since Baxter started his Trilostane treatment? If so, if it were me, I would keep him on his current dose even though his post number is not within Dechra's recommended range of 1.5 ug/dl - 5.5 ug/dl.


In both cases, it says that the sample was lipemic and ultrafuged before analysis - no idea if that is important. He had his pill at 8:30 with breakfast and the first draw was taken at 11:30, ACTH administered IM, and second draw at 12:30. The IM specialist my vet has been talking to said the test should be 3-4 hours after eating, but I saw here that at least 4 hours after eating is recommended. Hopefully this doesn't throw things off too much.

Lipemic means that there were excessive amounts of fat and fatty substances in the blood.

The vet's timing of Baxter's ACTH stim test was correct. Some endocrinologists suggest 3-5 hours post pill while Dechra's recommends 4-6 hours post pill.


The results also say "post values greater then 25 are consistent with Cushing's".

I think we are going to keep him on 30 mg twice a day and see if things improve -thinking this current setback is just an extreme reaction to the stim test. What do others think?

The actual therapeutic ranges for a dog being treated with Trilostane is 1.5 ug/dl - 5.5 ug/dl or a post as high as 9.1 ug/dl as long as clinical symptoms are controlled.

You're doing a great job!!

Love and hugs,
Lori

[Harley PoMMom]

Anybody know what this means?: "Monitoring of trilostane therapy with the ACTH stimulation test may be difficult because ACTH can override the competitive inhibition of steroidogenesis."

I found it in the resources section on the "current controversies" document. Just wondering if it could explain Baxter's troubles with the stim test (assuming that is what is going on with him).

The way Trilostane works is it inhibits the production of cortisol.

I believe what this sentence is saying is that the ACTH stimulation test might not be the most accurate test to gauge a dog's cortisol level that is on Trilostane therapy since it may override the way Trilostane works.

[SoggyDoggy]

Hi, Just wanted to explain a couple of things that may confuse you when reading Lori's post regarding ranges. Not that she is confusing mind you, just that when you first come across it, you may, as I did, think whaaaaaaaat?

Ok, so the ranges posted on the blood test results are for a normal healthy dog without cushings and not on trilostane treatment. A dog that is being treated should have a range of 1.5 - 5.5 ug/dl. This is what Dechra recommend. They are the manufacturers of the brand name Vetoryl. However they also say that dogs can have a range as high as 9.1ug/dl if their symptoms are controlled. The first time I saw someone post with those normal ranges listed, it confused the wotsits out of me! I thought, "How can the labs make these mistakes?" and even questioned at one point if it was a different unit of measurement :o so that's why I wanted to explain what they were.

To stay on tha 30mg twice daily sounds like a good idea at this point in time. The cortisol levels will continue to drop past that early 14 day mark and may even continue past 30 days I've found out, so Baxxter's still got time. Also, the fact that he didn't eat all of his breakfast this morning, may be a good sign that the hunger is abating and the thirst may soon follow. (At least he didn't have that panicked hunger you mentioned earlier :p)

It does sound like you are doing a fantastic job for Baxter, and he is a lucky boy to have you :D. Keep us updated on how things go. I'm eally looking forward to that day when you get to sleep through the night!

[Rural doggie]

Thanks, you guys are so awesome! We are very lucky to have Baxter, too! He is my first dog (other than the ones I grew up with). When he was a puppy (and getting us up several times a night to pee, ironically), I remember a guy who had had several dogs saying," they just get better and better as they get older, until, by the time they are 7 or so, they are doing things you didn't even know you wanted them to do." He was so right, Baxter reads mind on a regular basis!

I was confused about the "reference ranges," so thanks for clarifying. So, even though the lab's range for post testing has 8.0 as the low end, we should still be working toward 5.5 or would the 9.1 target make more sense with this lab?

Can you folks tell from just these results if the Trilostane is having an effect, or do we just go by symptoms?

I'm glad to hear you all say that the cortisol can still go down after two weeks. There are so many ups and downs with this disease, as I'm sure you all know. It's easy to get discouraged after a few bad days - especially when you add in mild sleep deprivation, I guess!

Yes, this test was done 11 days after starting the trilo.

[Harley PoMMom]

Pretest was 4.4, when the reference range is 0.0-10 (I think this is micrograms per deciliter)
Post test was 13.7, with a reference range of 8.0-22.0



The post reference ranges that are quoted are for a healthy dog that is NOT being treated for Cushing's.

I believe a dog's symptoms should be taken in account with the ACTH stim results.

If a dog has a post of 9 ug/dl and all symptoms are being controlled then this is a good post number for that particular dog.

Did Baxter have an ACTH stim test before the start of his Trilostane therapy?

[Rural doggie]

[QUOTE=Harley PoMMom;9

Did Baxter have an ACTH stim test before the start of his Trilostane therapy?[/QUOTE]

He did have an ACTH while on the Ketoconazole. I'll see if I can get it.

[SoggyDoggy]

If you can get hold of it, comparing the results of the two tests will answer your question about the trilostane having an effect. With that and the hopeful decrease of symptoms together, you will be able to see his progress continue.

[Rural doggie]

The way Trilostane works is it inhibits the production of cortisol.

I believe what this sentence is saying is that the ACTH stimulation test might not be the most accurate test to gauge a dog's cortisol level that is on Trilostane therapy since it may override the way Trilostane works.

Sounds like it might make sense, then, that the ACTH he is given during the test would make his Cushing's symptoms worse. And I suppose, the better controlled the cortisol levels, the less severe those side effects are likely to be?

I did find out what kind of ACTH he is being given: .25 mg of Cortrosyn. It comes in a powder form and the vet dilutes it and administers it intramuscular. Baxter weighs about 90 lbs.

Still waiting to get the results from the first ACTH test.

Baxter is doing a bit better - only getting us up once a night these past two days and his water consumption was down yesterday, too. Haven't noticed any leg weakness, either. His appetite has decreased from extremely ravenous back to down being a tiny bit picky about the dry food. It seems like he actually has a bit of trouble eating it, coughing it back up every now and then. I've also noticed him stopping in the middle of eating to drink, which he never used to do. Makes me wonder if this is just an old dog thing, or something to do with the drugs or Cushings?

[Rural doggie]

Dang, Baxter is still on the same dose of Trilostane, but his water consumption is creeping right back up to where it was before we started - 40 cups over the past several days, and 51 cups yesterday. I'm starting to wonder if we are on the wrong track... He's been on this dose for 3 weeks. Is it too soon to think his dose is too low or that it is actually not Cushing's?

[Harley PoMMom]

With the increase in drinking it is quite possible that Baxter will need a dosage adjustment upwards in his Trilostane; however an UTI can cause a dog to drink and urinate more. How are his other symptoms, such as his appetite?

[addy]

It is possible the dose may need to be changed. Sometimes the cortisol will continue to drop during the first 30 days and sometimes it goes back up; my Zoe's went back up. It can take some tinkering to get them adjusted to the correct dose. As Lori already asked, are you seeing an increase in any other symptoms? Dogs will usually get an ACTH again 30 days from starting treatment (about two weeks after the first one).

[Rural doggie]

The drinking and peeing are his main symptom, plus maybe a little leg weakness and strong appetite. He gets us up at night to pee, but don't know if that's from all the water or from some extra nocturnal energy that 've heard comes with Cushings. We noticed more leg weakness for a few days after the ACTH test. His water is really up and down since we started trilo (and before). We've been keeping track:
Day 1 -39 c
Day 2 - 36 c
Day 3 - 32 c, slept through the night, a bit peppier
Day 4 - 24 c, best we've seen in months, slept through night
Day 5 - 24 c,
Day 6 - 31 c
Day 7- 38 c
Day 8 -35 c
Day 9-35c
Day 10-36 c (average up to test=33c)
Day 11-39 c, ACTH stim test, up twice at night
Day 12-40c,
Day 13-44 c, up twice at night
Day 14-46c, up twice at night
Day 15-43 c, didn't eat all his dry food
Day 16-33 c
Day 17-46c, a bit lower energy
Day 18-38c
Day 19-45c
Day 20-44 c
Day 21-51c, up twice at night
Day 22-48 c
Day 23-35c, slept through night
Day 24-40c (average since test =41.8)
Average since starting trilo = 38.4

His average water consumption last summer was around 21 c. We saw a huge jump in consumption after we left for 10 days and had a dog sitter, from then until we started ketoconozole the average was 46 c. On keto, it dropped a tiny bit to 40c, but went back up after the ACTH stim test to 45c.

Anyone see anything here that tells you anything?

As you can see, right now it looks we MIGHT be going in the right direction, so I am hesitant to do another stim test, since it seems like it really impacts him. Are there any other ways to get a read on cortisol? Or could we get away with waiting longer? Could we JUST go by symptoms?

[labblab]

I'm sorry I did not have a chance to reply to you yesterday, but I just noticed your own reply on another thread in which you reminded us that you are currently dosing your 90 lb. dog with 30 mg. of trilostane twice daily. You know, in honesty, if you still have seen little or no symptom improvement at the end of 30 days, I would be tempted to go ahead and increase Baxter's dose even without another ACTH test. People may throw tomatoes at me for suggesting this :o. But since you started out with such a conservative dose and Baxter's first ACTH at the two-week mark was approx. 14 ug/dl, I am guessing that you have room to safely increase his dose to the 90 mg. daily total that Dechra would have recommended as a starting point to begin with. If you do make an increase without the benefit of another ACTH now, I would perform the ACTH two weeks after the increase.

I am assuming you have only 30 mg. capsules on hand. If so, one strategy would be to add another 30 mg. capsule to his morning dose. Or, in the alternative, you could purchase some 10 mg. capsules and add 10 mg. to each his morning and evening dose to arrive at a daily total of 80 mg.

Just some thoughts to throw out there for your consideration. As I say, though, other folks may think differently.

Marianne

[Rural doggie]

Thanks, Marianne. That is kind of what I was considering. We do have some 10mg capsules, so could easily up him to 40 mg twice a day. Our vet has one more dose of the stim test on hand, so we could also easily up it for two weeks and then do the stim test. I'll talk it over with my vet, although, to be honest, I know a lot more about this than he does at this point (thanks to you all!). He does have an IM specialist he can call.

I'd love to hear others' opinions on this course of action.

[Harley PoMMom]

Since Baxter is still displaying signs of Cushing's, I would agree with Marianne that an increase of an additional 10mg BID sounds very reasonable. Having an ACTH stim in two weeks after this dose adjustment should also be performed.

You're doing a wonderful job!

Love and hugs,
Lori

[addy]

I'm on board, seems the logical next step for Baxter.:)

[SoggyDoggy]

Hi, just checking in to see how things are going. Did you end up boosting the dose the 10 mg? If so, any progress over the last few days?

let us know how things are going.

[Rural doggie]

Thnks for checking in on Baxter!

No, we haven't upped his dose yet. He had a couple good days this weekend (no begging for food, sleeping through the night) so we were hoping maybe we wouldn't need to, but he seems to be having a bit more trouble yesterday and today again (begging for food, getting up once at night to pee). We will have a friend's dog with us for 8 days starting tomorrow, though, so are thinking we might wait until after that to try the higher dose, so we can monitor his water.

Making these calls is tough. Should we try for something closer to perfection (sleeping through the night every night, water consumption closer to 20 c/day)? Or be happy with up and down days? The symptoms are never as bad as without the Trilostane, so everything feels like an improvement. Add to that my reluctance to use the stim tests...

I'm wondering if the fact that he has a strong reaction to the stim test is evidence that his dose is too low. The flip side of that would then be, if his Cushing's is well-controlled, we won't see such setbacks after the stim test. What is you folks' experience with this?

[addy]

I dont know that we can say because he had such a reaction to his stim that shows he is not controlled. I used to try to guess my pup's results based on her actions durring the stim, most of the time I guessed wrong:o:o:o

Wasn't he around 13.7 post? He's on a fairly low dose for his weight, his stim was high, you see an increase in his symptoms, kind of bouncing around, imo, he's going to most likely need a dose change. I know that pups can still continue to go lower the first 30 days and sometimes longer but, I think you are going to be looking at a dose change. My Zoe had a few bad stims, she threw up one time, very lethargic. That was in the beginning of her treatment.

[Rural doggie]

As if we don't have enough medication decisions in front of us - still thinking to give Baxter another week at the current dosage, as he is doing very well (although not perfect) at the current dose: Now I get an automated message from the vet saying he was due for a "Vanguard Plus" vaccine a year and a half ago.

I'm hesitant to do this, since I understand dogs with Cushings have weaker immune systems (is this correct?) Do you all vaccinate?

[Boriss McCall]

I know everyone is different. But, I no longer get vaccines for Boriss. Boriss's IMS sent in a letter to our county exempting him from further shots.

[labblab]

My personal opinion is that revaccinations for Cushpups, just like for all dogs, should be based upon individual heath status, prior vaccination history, geographic risk factors, and lifestyle. There is no single right answer for all dogs. Having said that, I would hesitate revaccinating my own dog right while I was in the midst of trying to stabilize him on trilostane treatment. You are hoping to minimize as many "wildcard" variables as possible right now, so unless there is a special concern about Baxter being at particular risk for contracting a particular disease right at the moment (like a local parvo outbreak?), I'd likely put revaccination on the back burner for the time being. You can revisit the question once Baxter's cortisol is well controlled and you feel more comfortable about his overall health status.

Marianne

[Rural doggie]

Well, it has been a bit since I checked in. We've kept Baxter on 30 mg of Trilostane twice a day, and he is still doing fairly well according to his symptoms. He sleeps through the night, but still has clear urine and drinks between 25-35 cups of water a day. His back legs may be getting weaker, although that is kind of hard to judge, since it really seems to go up and down.

He has not had another ACTH stim test. He did just have a canine geriatric panel I was hoping you folks might help me interpret. Here are the abnormal values:

MCHC 31.4, range 32.0-36.0
lymphocytes 630, range 1000-4800
Alb/glob ratio 1.3, range 0.6-1.2
ALP 253, range 10-84
ALT 80, range 5-65
Cholesterol 351, range 150-275
Lipase 490, range 0-425

BUn and Creat are in range, so I feel pretty good about his kidneys.
BUN is 12, range 6-29
Creat is .6, range .6-1.6

Those ALP and ALT numbers are lower than before we started treatment, when they were 680 and 126. I'm thinking that's a good sign. The lymphocytes number is a bit concerning to me, though, since it has gone from 1950 last July to 850 in November to 630 this time.

Basically, I'm trying to determine if we are under treating him at his current dosage (without another stim test, although I haven't ruled it out completely.) Anyone see anything here that would indicate that?

[Harley PoMMom]

Basically, I'm trying to determine if we are under treating him at his current dosage (without another stim test, although I haven't ruled it out completely.) Anyone see anything here that would indicate that?

A canine geriatric panel really can not tell if a dog needs an adjustment in his Cushing's medication because even though a dog may become stabilized on a current dose the geriatric panel will not reflect this as some levels just do not normalize within their reference ranges.

The only test that can show if a dog needs an increase/decrease in their Cushing's medication is an ACTH stimulation test. I surely do wish there was another way to judge a dog's cortisol levels that was less expensive.

Love and hugs,
Lori

[lulusmom]

As Lori has already mentioned, a senior blood chemistry cannot be used to properly evaluate treatment; however, I believe most of the abnormal values you posted are a pretty good indicator that Baxter's cushing's is not controlled.

I can only find the results of one acth stimulation test since Baxter initiated treatment back in January. The results of that test revealed that his post stimulated cortisol was well above the therapeutic range and while symptoms had improved, they were not completely resolved. Your vet should have followed up with a second stim at the 30 day mark and if cortisol was still too high, Baxter's dose should have been increased at that point. Based on the abnormal values on bloodwork, the unresolved PU/PD, no apparent improvement in muscle weakness and no adjustment in dosing, despite the high post stimulated cortisol level back in January, I don't think there's much doubt that the most likely suspect for all of this is that Baxter's cortisol is too high. I know the cost of an acth stimulation test can be a back breaker but unfortunately, the stim test should have been done well before the senior panel. Until you know for sure that Baxter's cortisol is within the therapeutic range and all symptoms have resolved, you can pretty much expect blood and urine abnormalities to persist.

Glynda

P.S. I share the concern about the low lymphocytes as this appears to be much lower than what you would see in a dog with cushing's. Have you asked your vet for an explanation?

[SoggyDoggy]

I know you are worried that Baxter will have another reaction to the ACTH, but as the others have said, it's the only real way to find out what those levels are doing. You may even find that the reaction (if any at all) is less severe this time as he has stabilised on his current dose of Trilo anyway. It does sound though that he is not fully controlled if he is still drinking that much and his urine is still clear.

As for the lymphocytes, I have no idea there so will leave that to others. Was great to hear from you again though, I was just wondering about Baxter the other day but couldn't find the thread to check in and ask.:)

[Rural doggie]

Checking back in after a long time away. Baxter has been doing pretty well on 40 mg Trilostane twice a day. He still drinks more water than normal, so we are going to try adding another 10 mg either once or twice a day. Will probably start with just once a day. He visited the vet yesterday and we asked about the weakness in his back legs. He suggested trying Tramadol and re-loading him on the Dasiquin. Just wanted to hear if anyone else has had experience with pets on both Trilo and Tramadol. Any side effects to watch out for? Was it helpful?

[addy]

I give Zoe Tramadol, I give her a very low dose at bedtime, she cannot take much of it, sensitive to it. It helps her back legs when I give it to her. If I give it to her consistently she eventually has balance problems from it so we will do 3-4 nights then back off for 2 or 3 nights, or whatever schedule seems right for her, I dont give it everyday but every dog is different, you might not have that problem.

She is on Vetoryl twice a day so I try to give it to her 3-4 hours after her Vetoryl dose. She is 17.5 pounds an gets 1/4 piece of Tramadol .

She take 30 mgs Vetoryl am and 20 mgs pm.

Hope it helps your pup.

[goldengirl88]

Hello:
I just wanted to ask if you are increasing the dosage based on clinical signs, and the blood panel results without an ACTH test? I Would want to know the numbers now, and then 30 days from now I would have another ACTH. Not doing the ACTH when it is called for is like flying blind to me, and I would not do it. If I were you I would follow protocol on this drug. Blessings
Patti