complete loss of appetite on Trilostane

[Bluestar]

After being on 60 mgs of chewable (compounded) Trilostane daily for 1 week (30 mgs given twice daily), my 14 year old part cocker spaniel, part pekingese 25 lb dog stopped eating.

My dog began Trilostane on Tuesday, June 25, in the evening. Over the course of that first week on Trilostane, I noticed that he was eating less, and sleeping more.

On Wednesday, July 3, we left town. Our neighbors took care of our pets while we were gone. In the morning on July 3, prior to leaving town, I attempted to feed my cushing's dog, but he didn't eat. I assumed it was because it was much earlier than his normal meal time, so I put the food (with the pill still in it) back in the refrigerator and let our neighbors know so they could come over mid-morning and feed him then. They called that evening and said our dog had not eaten all day. They'd attempted to feed him, but he just didn't want to eat. I told them to forget about the pill, and just try to get him to eat.

He didn't eat much, if anything, in the morning of Thursday, July 4, either. All he wants to do, they said, is sleep. I instructed, "No more pills for now. Getting him to eat is more important right now."

Thursday evening, he began to eat - just a little. Friday morning he ate better. Friday evening he ate well. Today (Saturday, July 6) he ate well.

The last Trilostane pill he actually took would have been Tuesday, July 2.

Let me tell you about his ears too. All his life, his ears have gotten itchy in the spring and the fall. Our vet said it was seasonal allergies. This spring was the first year his ears were not itchy and red. The extra cortisol his body was making was keeping his ears healthy. After starting on the Trilostane, his ears (particularly one of them) became very itchy and inflamed again. When I looked at his ears tonight (after getting back in town), I noticed the skin on one was actually coming off, leaving a very red, raw area. I put "Animax Ointment" on it. Does that have a steroid in it?

I don't have copies of his lab results, but know that on the first day they gave him a urinalysis, to see if he had a urinary tract infection (he didn't). They they did a blood test, which indicated that he might have Cushings. Next they did a low dose dexamethasone test, which showed he probably does have Cushings. Then the did an ultrasound of his abdomen and couldn't see anything wrong with his adrenal glands, although I was told that my dog was very squirmy during the test. Next our vet ordered the Trilostane from a compounding pharmacy, and we started our dog on it when it came in a week later.

We also changed my dog from a diet of dry food to canned and raw food. (The raw food is purchased frozen from a local pet store.) He's also taking some herbs which are supposed to offer additional support for Cushing's dogs. We made the diet changes, and added the herbs, while we were still waiting to find out if he had Cushing's, so these changes were made prior to starting the Trilostane. He seemed to be doing fine with the diet and herbs. I think it's the Trilostane that caused him to become so lethargic and stop eating.

Should we wait a period of time and then begin the Trilostane at half the dosage he was taking earlier? If so, how long should we wait? Perhaps until his ears look clean and healthy again, indicating his cortisol levels have risen again?

[Roxee's Dad]

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[frijole]

Oh boy did you luck out by telling your neighbor not to give him any more trilostane. That dose is more than 2 times the recommended starting dose for a dog his size. No doubt the lack of energy and appetite were a result of the trilostane. I'm surprised your vet didn't forewarn you. I am going to give you a link so that you can read what the manufacturer says about the drug.

Also you had it compounded by a 3rd party and they are not all created equal. There is a lot of controversy in the drug world these days both human and critter - you might want to rethink that strategy or at least go with a compounder that is known to be safe and reliable. Diamondback Drugs is one I read about alot on here. (online company)

Anyway back to your dog and what to do next - you need to have an acth test done. Since you've been off of the drug a while it won't be representative of where the dose had him but his cortisol could still be low and you want to make sure it's safe to restart. When you have the acth test you need to have the electrolytes checked. What happened is his cortisol went TOO low and dogs can get very very ill and even die from this. Trust me, we've seen it all. Cush dogs make too much cortisol so the trilostane reduces it... but if the dose is too high they go too low too fast and they get sick as a result. Signs are no appetite, thirst, diarhea, vomit, lethargy as in they can't get up and in some cases they can't lift their heads.

It's not a drug to mess around with - the dose needs to be adjusted DOWN. Nowadays the starting point is 1 mg per pound of weight so your dog would have started at like 25 mgs a day - probably two 10 mg pills a day.

Here's the link I promised as well as one on cushings for beginners. :) Kim

http://www.k9cushings.com/forum/showthread.php?t=185
http://www.k9cushings.com/forum/showthread.php?t=180

[Budsters Mom]

Hello and welcome:)
I am sorry for the reason that brought you here, but so 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. They love details, test results, any information you can get your hands on. We will do all we can to help. Be ready for lots of questions. So again welcome to you and your fur baby.

We read time and time again about vets not being up on the current Trilostane dosage recommendations and fur babies suffering for it. Trilostane is a very serious drug. Overdosing it can cause severe complications. Please read through the links that Kim provided for you below. The current dosage recommendations to start is no more than 1 mg per pound, total per day. You were giving your baby more than twice the recommended daily dosage. That is extremely dangerous! Do not be hard on yourself. You did not know. There are many things we didn't know when we first started too. Hugs,

[Bluestar]

Hi Kim,
Thanks so much for responding!

It was a very scary thing on Wednesday when we were told by our neighbor that our dog wasn't eating. I knew it was the Trilostane though, as I'd read about the side effects before we ever started the drug.

When his appetite reduced at first, I thought that was a good sign, since he had been overeating. But when he didn't eat at all on Wednesday, I knew the medicine was the cause and that we needed to get him off of it, at least for then.

I did NOT know though, until we got back home tonight and I started doing further research, that the dosage the vet gave us to give him was so high! She's the one that ordered it from the compounding pharmacy. I have no idea which pharmacy. I don't see a name of a pharmacy on it, but there is a phone number. I may try to call the pharmacy on Monday, to find out who it is.

I'm also going to go weigh my dog again, and make sure the weight I told you is correct.

[Bluestar]

Just weighed him again. 24 lbs. I think about 2.5 weeks ago, (just prior to starting the Trilostane) he was 27 lbs.

I used the phone number to find out which pharmacy was compounding the medicine for him. It's this one: http://www.svpmeds.net/_index.php Does anyone know if this is a good one or not? It's the one my vet picked out.

[frijole]

You really don't need to use compounded drugs as your dog is 'normal' size and you can purchase pills in either 10 or 20 mgs. Usually we see compounding when a dog weighs like 7 lbs and so they need much smaller doses. I think you mentioned chewables and I'm not convinced they have the same efficacy as the capsules - just something I've noticed with others that have struggled with them.

Regardless - you did the right thing and you know now. You are your dog's voice so reading and getting up to speed is very important. Vets make mistakes and frankly we see quite a few that have no idea how complicated this disease is - they read a paragraph or two on it and prescribe meds and that is how this site got created. :D I landed here with a clueless vet over 8 yrs ago.

Kim

[molly muffin]

We have another member who uses SVP Meds out of Texas. I don't know anything about it personally. Many members use Diamondback with good success.
But as Kim said, you really don't Need to use compound unless you choose too.
I'm glad you stopped the dosage that he was on though. We see this all to often. It is always better to start low and work up if needed than to start high and run into problems.

Sharlene and Molly Muffin

[Bluestar]

I looked at the links you gave me, Kim. Thank you. My vet was following the Dechra recommended dosing, as 60 mgs is what they recommend for a 25 lb dog. Yet obviously, this was too much!

Will my vet likely have at least heard of the Veterinary School at the University of California at Davis and know what I'm talking about if I mention it? If not, how do I describe who that is, and why we should follow that protocol instead?

I am in complete agreement that the previously tried 60 mgs was too much. I just want to know how to best explain to my vet why I want to try the 1 mg / kg instead.

Thanks so much for your help, everyone!

[labblab]

We are so frustrated at that darn dosing table in the Dechra Product Insert, because it represents dosing recommendations that originally were in place a decade ago when the initial research trials had been completed. Subsequent clinical experience has shown that dogs seem to experience less side effects and less outright overdosing when they are started at lower doses and worked up if need be, rather than vice versa. And you actually need go no further than that same Product Insert, because the written recommendation above the chart references an initial dosing range of 1-3 mg. per pound. I will come back later with a specific Dechra recommendation to start at the low end of the dosing range whenever possible.

But aside from the written info, your dog's experience should more than warrant a dosing decrease in your vet's opinion! Those initial dosing recommendations based on weight are only guidelines. Every dog's response can be different and doses frequently need to be adjusted either upward or downward based upon side effects, symptom resolution, and monitoring blood tests. So your goal now is to find the individualized dose that is best for your dog. Very clearly, the 60 mg. was too much.

Marianne

[Squirt's Mom]

uh, you tell him this is YOUR dog and that is how YOU want to start treating him. ;)

[labblab]

OK, I'm back with that link that I just mentioned. This is a very recent publication from Dechra, and here's a quote:


Ideally, the starting dose to aim for is 1.0 to 3.0 mg/lb (2.2 to 6.7 mg/kg) once a day based on body weight and capsule size. When calculating dosage, it is suggested to round down. Start at the low end of this range. If you have any questions on dosing, contact Dechra Technical Support at 866-933-2472 or support@dechra.com.


Here's the link:

http://www.dechra-us.com/Cushings-Syndrome/Veterinarians/Prescribing-VETORYL-1.aspx

Marianne

[Bluestar]

Thanks!

I noticed the quote you gave me says "once a day." I read online that smaller amounts twice a day was usually better than larger amounts once a day. Do you all agree that it's best to give half the amount twice a day rather than the full amount all at once?

[labblab]

There is no definitive "right" answer about that. Different researchers and clinicians have different preferences, and there seem to be pros and cons both ways. In terms of ease of dosing and cost, once-a-day dosing simplifies things and many dogs seem to do fine and exhibit symptom resolution on just one dose each morning. Other dogs can exhibit symptom rebound later in the day, and for them, twice-a-day dosing is preferable. Diabetic dogs definitely may benefit from twice daily dosing that corresponds with their insulin injections and also provides tighter endocrinological control throughout an entire 24-hour time period. Early research conducted by the company that first marketed Vetoryl did not show any significant benefit from twice daily dosing. However, recent research out of UC Davis suggests that dogs being dosed twice daily may end up needing a lower overall daily total. And some clinicians theorize that twice daily dosing may offer better control of some of the systemic problems that are associated with Cushing's.

On the other side of the coin, it appears as though dogs who are dosed twice daily may have a greater risk of adrenal oversuppression and therefore may need to be monitored even more closely to insure that cortisol levels are not dropping too low.

I started out dosing my own Cushpup twice daily from the get-go, and in retrospect, I wish we'd started out first with a once daily dose and only increased the frequency if he had not been sufficiently stabilized that way. But we have many members here who do dose twice daily and have had good results. Unfortunately, a lot of this remains trial-and-error and what works best for one dog may not be best for another. We've learned that patience can sometimes be the greatest virtue of all! :o

Marianne

[labblab]

But yes, you're right, if you dose twice daily you are splitting the once-daily total rather than doubling it.

[lisamak]

Hi there - you've already realized the dose was too high for your pup...hoping a new dose resolves itself quickly. I'd encourage you to call Dechra yourself to create a case file - I did that before starting trilostane (they don't ask if you buy it name brand or compounded FYI). They were very helpful confirming my dose beliefs, etc.

Also, I've been using SVPMeds for a couple of years for meds for my guy and been very happy with them. Their pricing is very competitive (often less than the name brand that I priced out at Drs. Foster & Smith). You can get 'scrips from them directly which will probably help reduce the costs (since your vet is probably adding a bit on for their efforts).

~~Lisa and Vince

[labblab]

Also, I've been using SVPMeds for a couple of years for meds for my guy and been very happy with them. Their pricing is very competitive (often less than the name brand that I priced out at Drs. Foster & Smith). You can get 'scrips from them directly which will probably help reduce the costs (since your vet is probably adding a bit on for their efforts).

~~Lisa and Vince
Hi Lisa,

Just checking to see what you mean when you say that SVP is providing their own Rx's for your dog. :confused:

It really is not safe or ethical practice for any MD or vet to be writing prescriptions for a patient whom they've never examined nor have a professional relationship with. So this troubles me if SVP has a vet on staff that is providing Rx's solely upon customer request. Great for their business, but not really safe practice and a bit of a red flag to me...:(

[lisamak]

Hi Lisa,

Just checking to see what you mean when you say that SVP is providing their own Rx's for your dog. :confused:

It really is not safe or ethical practice for any MD or vet to be writing prescriptions for a patient whom they've never examined nor have a professional relationship with. So this troubles me if SVP has a vet on staff that is providing Rx's solely upon customer request. Great for their business, but not really safe practice and a bit of a red flag to me...:(

You misunderstood my comment. I, as a consumer, can receive my prescription medications shipped directly from them - I do not have to have my vet purchase and then purchase from my vet.

[labblab]

Duh!!! Gotcha...:o :o :o

[Bluestar]

Regarding the prescriptions, that's great to know, Lisa! Thank you!

Can you tell me more about what it means to have a case file? How is this beneficial? How is it used?

Janiece

[Bluestar]

I've seen three different dosing recommendations for Trilostane. List members here let me know the one my vet had put our dog on was way too high, but I'm unsure which of the other two recommendations it'd be best to follow.

One is 1 mg / kg, and the other is 1 to 3 mgs / lb.

My dog is continuing to lose weight. (Or else my scale keeps fluctuating.) Several weeks ago (before we started Trilostane) he was 27 lbs. The last time I posted here, he was 24 lbs. That was after a week of being on too high a dosage of Trilostane. Today he was 23 lbs. (That's after a week of NOT being on Trilostane, as we're letting his body rest a little before putting him back on a lower dose.) Maybe this is normal weight loss though, for a dog who's switched from kibble to canned food with no grains. Maybe it's like going on a low carb diet...although that's not why we switched!

So at the moment he is 23 lbs. 23 lbs = 10 kg. So should I give him 10 mg of Trilostane a day? Or 23 mgs of Trilostane a day?

Start off with the smaller amount, perhaps, and increase later if the lab test says he needs more?

[labblab]

I'm afraid there's no way in advance to know exactly what the optimal dose will turn out to be for your dog. But before talking about dosing, let's back up a bit. I realize that we never had a chance to talk with you about the symptoms that prompted the Cushing's testing in the first place. What was going on with him that made you and your vet suspicious that something was wrong?

And whatever those symptoms were, how has he been since being off the trilostane for an entire week? Are you seeing any symptom rebound whatsoever? These are all pieces that could play a role in selecting when to start back up with the trilostane, and how high a dose to give.

But I also need to ask whether you've talked yet with your vet? I had assumed you were preparing to get in touch with him/her earlier in the week, but now I am wondering about that. Your vet really needs to know what is going on -- how your dog reacted to the trilostane, why you stopped it, and how your dog is doing now after having been off the drug for this week. It's unfortunate that Dechra's darn dosing chart got in the way of the initial treatment. But after hearing how your dog responded, I will surely hope your vet will endorse a dosing decrease, and it is a conversation you need to have before restarting the medication.

So please fill in some of those blanks re: your dog's history and symptoms, and then we can talk some more about dosing, OK?

Marianne

[Bluestar]

In May, he started wetting the floor, almost daily. After a couple of weeks of this, I began putting him in the kitchen and outside. Interestingly, once I stopped letting him into the living room, he stopped wetting the floor. I have no idea why he stopped. I wondered if he had a urinary tract infection, or if he was just getting old and losing his bladder control, so I took him to the vet. The vet did an urinalysis, and said he didn't have an infection. Next he did a test to see how dilute my dog's urine was. It was too dilute to be normal. I think the next test was the low dose dexamethasome (sp?) suppression test. Followed by an ultrasound.

I may be leaving out a test - I'm not sure. They just kept asking us to bring him back for yet another test, and so I did. (At the same time, our cat was severely injured (he hurt himself on something outside) and needed emergency surgery....so we were back and forth to the vet every other day or so, for one pet or the other, for a couple of weeks! (The cat's okay, and is recovering well.)

Pre-trilostane, my dog's symptoms included excessive thirst, irritability, and guarding his food bowl (when there was food in it, but he wasn't hungry enough to eat it). He's a little overweight...but has been getting that way for a while. He was very demanding, wanting to be feed instantly, or let out instantly, the second he asked. (He didn't use to be this way.) After the vet asked me about panting, I realized he was panting a lot too.

Earlier this year, he developed glaucoma in one eye. The vet tried to treat it with drops, but they didn't work and finally the vet recommended that we allow her to remove his eye, because it was causing him a lot of pain. So we did. He already could barely see, due to his cataracts in both eyes, yet I suspect that losing the eye may still have caused him extra stress, which may have been a contributing factor in the cushing's disease. (I don't now that for sure. I'm just guessing about that part. The vet assured us it was the best thing for our dog though.)

I think I mentioned in a previous post that every spring and fall my dog's ears have become red. Seasonal allergies. The vet gave us something to put on them whenever they got inflamed. Well, this spring it didn't happen. My dog's ears did NOT become inflamed. I was amazed. Then we got the cushing's diagnosis, and I realized it was the extra cortisol in his body that was keeping his ears healthy looking. When we returned from vacation (it was while we were gone that my dog began not eating because of the Trilostane.), one of my dog's ears was the worst I've ever seen it!!! It was awful. So I've been using that - the condition of his ear - as a sign of when he might be ready to go back to the vet to get a recheck. His ear is starting to get better, but is still redder, and itchier, than I'd like.

Other than completely stopping eating, he was sleeping all the time, while on the Trilostane. He's more alert now, and is eating a lot, demanding food several times a day.

His panting has returned. (It never really left, I think, but I noticed it more today.) And his irritability has returned (in terms of demanding to be feed that instant). I've only filled his water bowl up one time today, and it's not empty yet....so he's not gone back to drinking as much water as he used to before the Trilostane.

[molly muffin]

I just want to say that when you have a dog with dilute urine, then you need to have a culture done to know if they have a UTI or not. It won't show up in a regular microscopic slide test due to the dilute urine. So he could very well have had a UTI and you wouldn't know if a culture wasn't done.

Can you check your test results and see if a thyroid test was done (T4), as that can mimic the same symptoms as cushings and one of the symptoms for thyroid is aggression. Aggression while not eating his food, is not a cushing symptom. They hog their food down And protect it. Any food they can get usually.

As far as your earlier question about benefit of having a case file with Dechra is that they have all the information about your dog, test results, medication on file and can easily consult with you and your vet about what is going on, dosage, etc, without having to start all over each time.

While I see that some signs Might point to cushings, nothing yet has shown a definitive diagnosis for cushing.

Did any of the drops, creams for eye, ears, contain cortisteroid? As that can also affect symptoms, if it was given recently and when symptoms of peeing were occurring.

Currently I would want to know any lab values that were high/low and the ranges the lab used before I would proceed with more trilostane. That's just my take on it.

Sharlene and Molly Muffin

[Budsters Mom]

Not the cat too! :o I am so sorry. Getting trilostane regulated and finding the perfect dose can be a real bugger! ;) sending you strength for your journey and belly rubs for your precious fur baby. He has certainly been through a lot!:o Big hugs,

[Bluestar]

Hi Sharlene,
Really?? It might not even be Cushing's? I just took my vet's word for it. Although I don't know the numbers, I do know she said his low dose suppression test was very high. I do not know if they checked his thyroid or not.

(There is both a male and female vet in our practice. Although we normally see the female, our first visit for the Cushing's disease was with the male, because that's who we could get in to see first that day. Just explaining this in case anyone wonders why sometimes I refer to the vet as a he and other times as a she.)

I will try to get actual copies of his lab tests either tomorrow or Monday and post them.

I wouldn't call his behavior aggression though. He is demanding, but he wouldn't bite us or growl at us. He just barks - one quick but insistent bark - to let us know he wants something. If we don't respond right away, he does it again. It's like he's saying, "NOW!" He reminds me of a child who's impatient, and wants what he wants the second he wants it. But this is new behavior, within the last year or so. It's not something he's done his whole life. In fact, I remember telling my husband a couple of months ago that our dog has become more demanding ever since his eye surgery. We both wondered if his impatience was related to his not being able to see.

I imagine we were feeding him too much earlier (before we found out about the cushings), because he'd insist. It was dry food, so it was easy to pour some in his bowl. Then if he didn't eat it all, he'd lie there beside it and growl if our other dog came near. Now that we've switched him to wet food, he gobbles every last bit down as quick as he can...and asks for more a couple of hours later. (Except when he was on the Trilostane).

The first set of drops for his eye were antibiotics. There could have been a steroid in it too; I don't know. That was last summer - late July or August, for an eye infection due to a scratch from walking into something because he couldn't see well. It healed quickly. A month later, the same eye became inflamed, but the vet said this time it was glaucoma. She gave us other drops -two different types. I have no idea what was in them, but they were to lower the pressure in his eyes. His eye got worse and worse though, so the vet suggested we remove it to spare him the constant pain he was experiencing.

The stuff for his ear is: Animax ointment. It contains: nystatin, neomycin sulfate, thiostrepton, triamcinolone acetonide, and mineral oil. Although we began putting this in his ear about a week ago (when we got back from vacation) he had not had any of this for months prior to this, as he hadn't needed any. We use it on an "as needed" basis.

What other signs (for Cushings or thyroid) should I be on the look out for? Is the thyroid a blood test? They did test his blood that first day, in addition to his urine. I don't remember them saying anything about his thyroid one way or the other though. I do remember them saying if it wasn't cushings it might be diabetes, but they checked for cushings first as they felt it was more likely that.

Thanks, Budster! Our cat's going to be okay now, but we were very lucky with him. It was a very bad injury. He fell onto something, leaving a really big hole in his side. The vet said the only reason he lived is that whatever impaled him went in at an angle rather than straight back. He had to stay in the animal hospital for several days after his surgery.

[molly muffin]

Lets start off with you getting a copy of all test results. Then if you could just post anything that is abnormal high/low with the range, that will be a good starting point. You'll be able to see if the T4 test is on there or not. Cushings is sometimes the first thing they look at, in reality it should always be the last. It is the hardest to diagnose, while the others can usually be eliminated by blood work.
We'd really like to the LDDS test results too.

My molly, can stand at her food bowl and bark and bark with food in it. This is because when she was doing the not eating thing, I would take a piece of dry kibble out and throw it and make it into a game, then she'd eat piece by piece and eventually go to her bowl and eat. She obviously thought that was great fun, as now she is barking so someone will go throw some food pieces for her to jump and attack, then eat. We have to cut that out for awhile or she gets way to demanding about it.

I'd think having an eye removed and loss of sight in general, could cause some behavioral changes, like food guarding, or wanting it and letting you know. So it's possible.

It's possible that this is cushings, but we always like to have the other options like diabetes and thyroid ruled out. The symptoms are the same. So, what is the glucose and what is the T4 results. That is a start, then what is LDDS. Keep in mind, if there was a UTI (which without a culture you wouldn't know), then the LDDS could be incorrect. You don't want to run cushings tests unless you KNOW that there is nothing else going on as results can be scewered.

If everything else looks fine, glucose and T4, then we revisit the cushing diagnosis, based on the LDDS results that you will be posting and you start at a MUCH lower dosage. Much less risks that way and sometimes their bodies just do better starting low. That is what the studies out of University of Davis has shown.

Hang in there! :)

Sharlene and Molly Muffin

[4doggiesmom]

I don't see any recent additions to your stories and was wondering how everyone was doing. I have a baby with cushings and just learning to deal with it. Today was her first day on Trilostane. I have been trying to manage her without it but her skin has gotten so bad and she is losing all her muscles. If you are still on here please respond.

Administrative Note: For anyone wishing to reply directly to this new member, she now has her own thread located here: http://www.k9cushings.com/forum/showthread.php?t=8244