Snowy - increase dose? (13 y/o lab mix) Trilostane (Snowy has passed)

[Snowy here]

Snowy is a thirteen year old, 50 pound, lab mix who has been taking trilostane for 6 months. She is currently taking 90 mg once daily. I was referred here by my brother Larry, whose dog Scarlett actually did not have Cushing's but was treated for it. snowy is urinating and drinking a little bit less since she started on the vetoryl, and her appetite is good, but not ravenous. On the basis of her recent labs (below), the vet wants to bump her dose up to 120. Do you think this is wise?
Adult Screen
ALB 2.4 g/dL 2.5-4.0
ALKP 1132 U/L 10-150
ALT 418 U/L 5-107
AST 75 U/L 5-55
BUN 8 mg/dL 7-27
CA 9.2 mg/dL 8.2-12.4
CHLORIDE 109 mEq/L 105-115
CHOL 386 mg/dL 112-328
CK 164 U/L 10-200
CREA0.4 mg/dL 0.4-1.8
DBIL 0.1 mg/dL 0.0-0.2
GGT 271 U/L 0-14
GLU 117 mg/dL 60-125
PHOS 5.0 mg/dL 2.1-6.3
POTASSIUM 4.4 mEq/L 4.0-5.6
SODIUM 149 mEq/L 141-156
TBIL 0.1 mg/dL 0.0-0.4
TP 5.3 g/dL 5.1-7.8
GLOB 2.8 g/dL 2.1-4.5
ANION GAP 20 mEq/L 12-24
BICARB 24 mEq/L 17-24
IBIL 0.0 mg/dL 0-0.3
A/G Ratio 0.8 0.6-1.6
B/C Ratio 20
Na/K Ratio 34 27-40

Hematology Results
HCT 40.8 % 37-55
HGB 14.6 g/dL 12-18
MCHC 35.8 g/dL 32-36
WBC 17.0 K/uL 5.7-16.3
LYMPHS 5.1% 12-30
MONOS 6.0 % 3-10
EOS 0.1 % 2-10
BASO 0.0 0-1
RBC 6.22 M/uL 5.5-8.5
MCV 66fL 60-77
MCH 23.5 pg 19.5-26
NEUT SEG 88.8 60-77
AUTO PLATELET 390 K u/L 164-510 0.5 %
% RETICUULOCYTE 0.9%
RETICUULOCYTE 56 10-110 K/uL
ABS BASO 0 u/L 0-100
ABS EOS 17 /uL 100-1250
ABS LYMPHS 857 /uL 1000-4800
ABS MONOS 1020 /uL 150-1350
(URINE - Urinalysis)
Collection Method (cystocentesis)
specific gravity 1.003
Color straw
Clarity clear
Glucose neg
Bilirubin neg
Ketones neg
Blood trace
pH 6.5
Protein 2+ (200-300 mg/dL)
WBC 0-2 0-5HPF
RBC 2-5 0-5HPF
Bacteria none
Epi Cells 1+ HPF
Mucous none
Casts none
Crystals none
Other: amorphous debris
ACTH STIMULATION
PRE ACTH CORTISOL 6.0 Ref Range 2-6
POST ACTH CORTISOL 16.4 Ref Range 6-18
Charles, Snowy, 13 year old lab mix, NorCal, Cushing's, Lung Inflammation
amlodopine 2.5 mg am
enalapril maleate 20 mg am, pm
benadryl 50 mg every 8 hrs
milk thistle 175 mg, am, pm
vetoryl 90 mg am

[Harley PoMMom]

Hi and welcome to you and Snowy,

Could you tell us what symptoms Snowy displayed before starting the Vetoryl?


ACTH STIMULATION
PRE ACTH CORTISOL 6.0 Ref Range 2-6
POST ACTH CORTISOL 16.4 Ref Range 6-18

Is this her most recent ACTH stimulation test? Was the ACTH stimulation test done 4-6 hours after her morning dose of Vetoryl? Also is the Vetoryl being given with food?


Charles, Snowy, 13 year old lab mix, NorCal, Cushing's, Lung Inflammation
amlodopine 2.5 mg am
enalapril maleate 20 mg am, pm
benadryl 50 mg every 8 hrs
milk thistle 175 mg, am, pm
vetoryl 90 mg am

Did Snowy have the lung inflammation when the ACTH stim test was performed? The amlodopine and enalapril maleate, is she taking these medications due to elevated blood pressure?

Thanks for providing all those details in your post and I am sorry for the additional questions I have asked but the more we know about sweet Snowy the better able we can provide you with information pertinent to Snowy.

Love and hugs,
Lori

[Trixie]

I'm too new to answer your question on the increase as my dog is only 3 weeks on the medication.
I'll just say welcome and let you know that there are many helpful people here who will give you great advice and I'm sure they will see your post shortly and make suggestions, plus you gave them all the numbers which is great! You came to the right place!
Barbara

[Budsters Mom]

Hello and welcome from me too! :)
I am sorry for the reason that brought you here, but am glad you found us.:)
You have come to the right place! There are many K9Cushing's angels standing by to help and stay with you every step of the way. Others will be popping in shortly to help answer your questions and interpret your tests.
So again welcome to you and Snowy,
hugs,
Kathy and Buddy

[Snowy here]

Hi and welcome to you and Snowy,

Could you tell us what symptoms Snowy displayed before starting the Vetoryl?

Is this her most recent ACTH stimulation test? Was the ACTH stimulation test done 4-6 hours after her morning dose of Vetoryl? Also is the Vetoryl being given with food?



Did Snowy have the lung inflammation when the ACTH stim test was performed? The amlodopine and enalapril maleate, is she taking these medications due to elevated blood pressure?

Thanks for providing all those details in your post and I am sorry for the additional questions I have asked but the more we know about sweet Snowy the better able we can provide you with information pertinent to Snowy.

Love and hugs,
Lori
Lots of dilute urine, huge thirst, pot-bellied appearance.
1)Yes, done 4/26, 2)Yes 4-6 hours after morning dose, and 3)Yes, it is given with food.
Yes, she did have the lung imflammation when the test was done, recently diagnosed but had it for a while, and those meds are for high blood pressure.

[Harley PoMMom]

Does Snowy seem to exhibit the increased drinking/urination towards the evening or are these symptoms occurring all day?

[Snowy here]

Does Snowy seem to exhibit the increased drinking/urination towards the evening or are these symptoms occurring all day?Occurring all day. Forgot to mention, Snowy seems weaker the past month, but she did not become weaker on starting vetoryl; it seems to be due to the lung inflammation.

[Harley PoMMom]

If this were me, I wouldn't increase the dose from 90 mg to 120 mg. Her post ACTH stim number is still high (16.4 ug/dl) but some of that could be due to the lung inflammation, and until that inflammation is cleared up I wouldn't feel comfortable increasing her dose.

You or your vet can contact Dechra (makers of Vetoryl) and ask for their insight on Snowy. Here's contact info for their Kansas office. They have veterinarians on staff whose sole job is to provide consultation to clinicians and pet owners. http://www.dechra-us.com/Default.aspx?ID=365

[Snowy here]

Thanks so much for your quick replies. I'll keep you posted after Saturday's appointment, and will contact the manufacturer to bring their input to my vet.

[Squirt's Mom]

Hi and welcome to you and Snowy! :)


ALKP 1132 U/L 10-150
ALT 418 U/L 5-107
AST 75 U/L 5-55
GGT 271 U/L 0-14

These are liver enzyme values - has the vet said anything about her liver?

We are a Lysodren house, so I will let the Trilostane (Vetoryl) parents talk to you about treatment but this caught my eye in reading the lab results so I had to open my mouth. :D

I'm glad Larry sent you to us and look forward to learning more about the both you as time passes.
Hugs,
Leslie and the gang

[molly muffin]

Hi and welcome from me too. Awww, we remember Scarlet fondly around here. Your brother and Scarlet sure did go through a lot.
Were they like to see the Post ACTH number at is 9 if symptoms are controlled and below 5 if they are not. However, saying that, the lung inflammation can cause that to be off and the cortisol could be beneficial to Snowy.
The others have all given you good advice, about contacting Dechra and make sure they are aware of the lung inflammation issue too.

Again, welcome to the forum
Sharlene and Molly Muffin

[Snowy here]

Snowy apparently got an insect bite that was hidden under the fur on the top of her head, noticing her itching I took her to the vet. The bite had become infected and created about a 1 1/2 by 2 1/2 inch sore. She is now on Clavamox 375 mg twice a day for a week. An ultrasound revealed a likely benign, but fairly large tumor on her kidney. The vet feels that after the course of Clavamox, she should increase the dose to 120 because she would be better able to fight off infection. Dechra has not yet replied to the email, would it best to call them? At least a week to ponder the dose increase, unfortunatley like Scarlett Snowy has more than one issue although I can see by looking at other folks and their babies' problems here, we're not alone!

[molly muffin]

Yes I think I would call Dechra instead of email. Most of the ones who have had the best luck with them have called.
I'd let them know exactly what is going on, what dose you are at and the increase the vet wants to do.
oh poor thing with the insect bit. Hope that gets cleared up pronto. Oh dear, sorry to hear about the mass on her kidneys. Any kind of mass or infection can also make the cortisol levels rise. Which is probably another good reason to give Dechra a call.

hugs,
Sharlene and Molly Muffin

[Snowy here]

Meant to type adrenal, rather than kidney, must be the stress of dealing with all the problems. It has grown since the last ultrasound. Got through to Dechra and will probably go with vet's recommendation after this course of Clavamox - it seems to be a real borderline case. Will, of course watch for loss of appetite if we do bump it up. Sadly, this lung problem is serious, too. If only there could be one issue at a time!

[Trish]

HI there
Is the vet suggesting anything other than Trilostane for the adrenal tumour?

I gave a big sigh when you spoke about how it would be nice to just deal with just one thing at a time!! I have told my dog, he needs to pace his diseases a little better to let us get control of one (not to mention the effect on the wallet!) before launching in to the next illness! Hope everything settles down for Snowy :)

[Snowy here]

HI there
Is the vet suggesting anything other than Trilostane for the adrenal tumour?

I gave a big sigh when you spoke about how it would be nice to just deal with just one thing at a time!! I have told my dog, he needs to pace his diseases a little better to let us get control of one (not to mention the effect on the wallet!) before launching in to the next illness! Hope everything settles down for Snowy :)Hope yours takes your advice! I switched vets a little less than a year ago, if I had been seeing her longer I might have caught the tumor earlier and surgery would have been an option. I'm so glad I joined this site - I'll have to find out which adrenal the tumor is on, until reading the links I didn't know it mattered. I'm thankful for everybody's help, all I've been giving is love and money! It will be nice to throw some knowledge in the mix.

[molly muffin]

Oh dear, you must have either had a heart attack or thought I'd lost my mind when I said kidney tumor. :eek::eek:

So have they now said that the tumor is too large and that surgery is not an option?
Do they know if it has invaded the vena cava at all and if it is actively secreting cortisol all the time or if it has inactive periods? One would be a pheo (not always secreting) vs one that hasn't invaded the vena cava and is secreting cortisol at a regular rate.

I'm so sorry that you are dealing with this all at once. I hope that the lung infection can be cleared up at least. One less thing to have to worry about and an infected bit on top of that. Did they also give you anything topical to put on the bite? Assuming that it is in a spot that Snowy can't lick it. I'm thinking even the neosporin, antibacterial might help as long as it isn't a reachable spot.

What is causing the lung infection any idea? Is snowy coughing at all?

I do hope we can get this all down to a manageable level for you. Love is the best thing you can give and money of course is a constant demand with our furbabies when they are sick. But here you'll at least have a support network, along with your brother of course. :)

hugs,
Sharlene and Molly Muffin

[Scarlett'sdad]

Sharlene, I know Chuck is taking Snowy in this coming week and he'll post an update after. I'm in my 50's and Chuck a little older :) so keeping current on the boards is not as automatic for him as with those who grew up with smart phones. I'm glad he took my recommendation and posted, the group has been just great to me even though Scarlett never actually had Cushing's. Snowy was a "frenemy" of Scarlett, since she was four times her weight once when we visited Chuck's house, she knocked Scarlett on her back following a disagreement over who should get to look out the screen door. I never saw Scarlett so angry!

[Scarlett'sdad]

Sadly, after an episode of labored breathing that was too much to be explained by the chronic lung inflammation, Snowy went into the vet at 11 AM today. An X-Ray revealed that in the month since her last chest X-Ray fast-growing cancerous tumors had spread throughout her lungs; they were probably there a month ago, but too small to be seen. Even with oxygen, Snowy was having lots of trouble breathing, and there was no hope of treating the cancer with as much lung tissue as was involved. My brother Chuck is too broken up at the moment to update the thread, I am sorry that I do not have a happy ending to this story. Thanks to all who chimed in here with helpful advice and encouragement, and always Good Luck in your struggles on behalf of your babies.

[Trixie]

I'm so very sorry to hear the heartbreaking news about Snowy. What a terrible day for your brother.
Barbara

[Budsters Mom]

Thank you for updating us on behalf of your brother. I am so sorry for his loss and yours. Sending love and prayers as Snowy crosses the rainbow Bridge. Please tell Chuck that when he's up to it, we would love to hear more about Snowy and that we're here for him.
Many hugs,
Kathy an Buddy:cool:

[doxiesrock912]

My sincere condolences to you and your brother! Rest peacefully and breath easy sweet Snowy.

[Simba's Mom]

So sorry to hear about Snowy, sending prayers and hugs....

[molly muffin]

o
Oh no I am so sorry to hear of Snowy's passing. My condolences.
Sharlene and molly muffin

[addy]

I am so sad to read about Snowy.

Rest in peace sweet pup.

((((((((hugs))))))))

[Squirt's Mom]

Dear Chuck (and Larry),

I am so sorry to hear about sweet Snowy. It is almost beyond my comprehension the sorrow in your house(es) today - two babies lost in a short time. :( I know Scarlett was waiting for Snowy as she crossed The Bridge, overjoyed to see her buddy again, frenemies now friends forever.

Snowy is whole, strong, and well today, running in the Rainbow Fields, her lungs filling with sweet fresh air, released in joyous barks as she frolics with loved ones and friends, new and old. She carries in her Soul the love you gave her and she knows that one day, when your job here is done, she will be waiting for you to cross over and she will once again be in your loving arms, this time for all eternity, never to be parted again. Snowy will be watching over you until then just as you watched over her with such tender care.

Snowy's name has been added to the In Loving Memory thread for 2013 where she will always be remembered and honored by her family here at K9Cushings. http://www.k9cushings.com/forum/showthread.php?t=4794

When you are ready, we would love to help you celebrate her life through your memories. You can write a tribute or memorial to Snowy here anytime - http://www.k9cushings.com/forum/forumdisplay.php?f=8

Our deepest sympathies to all,
Leslie, Squirt, Trinket, Brick, Sophie and our Angels, Tasha, Crystal and Ruby


I Will Wait For You...

I will wait for you...
Though we never wanted to say goodbye,
Remember me...
When winter snows are falling through a quiet sky
I'll remember you
When, in our darkest hour,
You held my hand and prayed I wouldn't go,
But a silent voice called out to me;
My time had come, and I had to travel Home...

Since then, I know your life has never been the same,
For I visit you each day:
So many times I've felt your pain:
I've watched you cry:
And I've heard you call my name...

But now, further along life's road I stand
In a timeless world, just beyond your sight,
Waiting for the day when I can take your hand and bring you across
to this land of Golden Light...

Till then, remember me, you understand-and try not to cry.
But if you do:
Let your tears fall
For the happiness and joy we knew,
And for the special love we shared,
For love can never die.

~Stephen O'Brien

[Boriss McCall]

I am so sorry for your loss. :(
hugs

[Scarlett'sdad]

Thanks for all the supportive messages, much appreciated in this trying time. Chuck has had to deal with the unexpected death of one of his cats. She was 13, but coming out of the blue the very day after Snowy and less than a month after Scarlett has made this a tragic 30 days. I still have a cat, and he has two dogs and three cats, so there is lots of love in our lives, and of course friends, family and the great people in this group, but each loss leaves a hole that can't be filled. Chuck didn't have an autopsy done on Snowy to determine if the lung cancer was caused by the valley fever like inflammation Snowy suffered from, or if the adrenal tumor may have spread. If the latter, you could go down the what if I'd done surgery instead of trying to medically mange, and as everyone here knows, the choices that confront you aren't easy ones (a dog with trouble breathing going under anesthesia) and it's best not to torture yourself. When some time has passed, I'll be sure to remind him to post in the memorial section. I had so hoped he'd be posting in the weeks ahead for information to help keep Snowy healthy. Best of luck to all and their babies, I'll keep checking in to see if I can ever help with my experiences and to get some comfort from the many success stories here!

[SoggyDoggy]

I'm so terribly sorry for both of you, losing not only one but three loved ones in such a short space of time is just horrible. My sincerest condolences to you both and to your families.

[jmac]

I'm so sorry to hear about Snowy. You're all in my thoughts.

Julie

[Bo's Mom]

So terribly sorry to hear about Snowy's passing. It is extremely difficult to lose one of our babies and we are all here for you and your family whenever you may need us. Please come back often....
RIP Snowy...and go and make all the pawprints in heaven that you can.