Food challenge

[Nscott]

Hi everyone! My 9 year old boxer named Buster has been diagnosed with cushings. He was on 120mg vetoryl but that didn't seem to have the desired effect so we've just increased it to 150mg a week ago. Buster is still miserable and has now gone off his food. Can anyone please help me and let me know if you've faced a similar situation and how you got your dog to eat. Thx a million:)

[Trish]

Hi, welcome to you and Buster :)

The first thing that is worrying me in your post is that Buster has lost his appetite. That is a big sign of overdose of Trilostane. It can be an emergency situation and can mean he is going Addisonian. Did your vet give you any Prednisone to take in this kind of situation? If they did, I would give it now. Plus I would take him to the vet, an emergency one if necessary considering it is the middle of the night and the weekend. He needs his electrolytes checked and sometimes they need IV fluid support if they have got out of whack. I would certainly NOT give anymore Trilostane until you get an ACTH and electrolytes checked. You need to know this can be dangerous so I would advise you to seek veterinary assistance asap!

Unfortunately because of the time now, the posters who are most versed with this type of situation will be sleeping so you only have me and I am not an expert in Triolostane, but I have seen enough of these overdoses to be worried for Buster.

It would really help the others to help you if you can provide the answers to a few questions:
1. How much does Buster weigh?
2. What were the symptoms that made you head to the vet in first place?
3. What tests were done to diagnose his cushings, specifically urinary cortisol, ACTH, LDDS? Please type in any of these results plus the normal reference range that will be on the forms. If you have not got copies I suggest you get them asap from the vet and always keep a copy of them
4. Any results from other blood tests, like electrolytes, renal or liver? For these ones only type in any abnormal results and again include the reference ranges.
5. Has an ultrasound been done? As that is helpful in these cases too
6. When his Trilostane was increased an ACTH should have been done before the increase, so type that in too please.
7. Any other symptoms of distress other than no appetite, like diarrhea, unsteadiness, change in drinking?

Sorry to hit you with so many questions, but it is really important we have as much info as possible to give you the best advice we can. I hope he is feeling better and please let us know what happens.

Trish :)

[spdd]

Hi and welcome to the forum. My dog is on Trilostane and I am having the same issues. I've tried, beef, chicken, liver, and just about every other variety of foods with and without his kibble. He will come to his dish, sniff, walk away or take a nibble and walk away again. I'm no expert here, but there are many here that are. I have had some success with actually hand feeding him. I'll give him a sample of meat from my hand put more in the dish with no success. I then take the dish and literally scoop some out and he'll eat from my hand but definitely not the amount he should be. I understand it's a side effect from this drug and I'm still looking for answers myself. It's frustrating I know, but if I come up with a sure fire solution, I'll let you know. I've heard you can try sardines (not salted) and horrible smelling tripe, or you can warm his food to increase the aroma and sometimes that works.
Others on here may have better solutions. Good luck, this is a challenge for sure at times.

[Trish]

If Buster were mine, I would not be fiddling about trying to get different foods into him right now, I would be taking him to the vet asap for ACTH and electrolytes! Once you know he is safe from cortisol dropping too low then you can worry more about his food... just my opinion of course :)

[labblab]

Welcome to you and Buster although I am sorry that you two are not having such a good time of things right now. I'm glad to see that you've already gotten two helpful replies, both of which may come into play either earlier or later down the road. It is indeed the case that a side effect of trilostane can be inappetance, especially at the beginning of dosing. So if Buster is otherwise stable on the drug, then dietary changes may be a help, or Buster's appetite may just naturally return as his system becomes more accustomed to the drop in his cortisol level.

But as Trish has said, the immediate concern would be whether or not his cortisol has been oversuppressed by this dosage increase to the point that there are more serious issues involved. All of the questions that she has asked you are very important in terms of judging how serious Buster's lack of appetite may be. You may not know the answers to all the questions this morning, but please do tell us anything that you can. If Buster were my own dog, I would be making the judgement as to whether or not he needs emergency attention based on how he is otherwise behaving this morning. When you say he is "miserable," what does that mean? Is he having any vomiting or diarrhea? Does he seem to have any trouble standing up and moving around? How is his breathing?

If his only new worrisome symptom is a lack of appetite, I would withhold his trilostane today and see if there is improvement overnight. And then you can contact your vet tomorrow to talk about the best path forward (and this will depend a great deal on Buster's previous monitoring ACTH history, so that's why it will help us if you can provide that info). If he is having other problems consistent with overdose or if he worsens through the day today, then it becomes a different matter and emergency consultation may be necessary.

So do check back and update us, OK? I'm really relieved you've found us!

Marianne

[goldengirl88]

Welcome to you and Buster. I just wanted to second what Trish is saying. I would not be playing around about a diet right now. It would seem your boy is overdosed on Trilostane if he is not eating. How much does he weigh? is the Vet you have experienced in treating Cushings? That is the number one factor you must correct asap if he is not experienced. You need someone who knows how to treat this disease. Please get you dog to a qualified Cushings knowledgeable vet asap. Your dog may be going into Addisons. What tests were done to diagnose Cushings? Please post the results on here so you can get help for your dog. Blessings
Patti

[doxiesrock912]

PLEASE stop the Trilostane and call your vet asap.

The members here have more experience than many vets do and you can learn so much here.

Every dog responds differently to the medication and the tests results indicate a specific dose but that is not always agreeable to the dog. Too much can result in Addisons which can be life threatening.

Loss of appetite is a HUGE sign that the dosage is too high or Buster can't tolerate that much Trilostane and if you don't make the necessary adjustments and determine whether or not Buster is now going into Addisons, this really can become fatal very quickly.

My dog, Daisy Mae does not respond well to what the doctors consider to be the ideal dosage for her weight and ACTH numbers. We've had to make adjustments several times just since May when she was first diagnosed with Cushings. At one point, she was not given Trilostane for an entire week.

No one here is trying to scare you, but each dog responds differently to Cushings treatments and it is imperative that you educate yourself so that you can partner with your vet and let them know exactly what is going on with Buster at home.

Often, it is a bit of trial and error before you find the dose that works best for your dog.
Once Buster is stable, I encourage you to visit the "Helpful Resources for Owners of Cushing's Dogs" section and read through the information there.

[Squirt's Mom]

Hi Nscott,

We are a bit concerned about your baby so when you get a chance, please update us! ;) I hope Buster is feeling better today.

Hugs,
Leslie and the gang

[goldengirl88]

I too am worried about you, we don't mean to scare you on here, but sometimes you must act quickly if things are going south and we don't want anything to happen to your baby. Please let us know how your baby is doing. Blessings
Patti

[Nscott]

Hi everyone. Sorry I haven't been in touch. We took Buster to the vet and they did more blood work. His electrolytes are fine and they did another 'cushings' blood test and now I've been advised to split his dose- 60mg twice a day. He's started eating (yippee) but is still very lethargic. I got his test results to get a second opinion in the UK ( we live in Abu Dhabi, UAE). Pre ACTH - cort01=52.4 nmol/L - baseline cortisol=52.4 nmol/L=1.9 mug/dal.
Cort08=99.3nmol/L. Post -ACTH cortisol (for therapeutic monitoring)- cortisol=99.3 nmol/L = 3.6 mug/dl.
I'm not sure what any of this means but if any of you do, please share.
Now I'm waiting for a week to see if the new split dose of 120 is going to make a difference. I just want my buddy back.
I'll keep you all posted and thanks again for your concern and advise - I REALLY appreciate it.

[Nscott]

Me again! I've realised that I haven't answered all your questions so I typed it all out but it hasn't posted so here we go again :D
The history is as follows:
About 6-8 months ago I noticed that Buster was drinking a lot more water than usual (he always drank a lot more than my other boxer, Bailey). At the same time, we adopted a small dog and Buster started urinating in the house. I thought at first that he was just unhappy with the new dog and telling me so by being naughty! Then the excessive panting started too along with the excessive hunger. We went to the vet and they put him on meds for diabetes but none of the symptons went away so we went back again. Finally they did a test for cushings which came back positive.
Whilst this was happening he was getting really lethargic and seemed very depressed. He stopped playing, being interested in treats, etc.
so they started him on 60mg once a day - then 120mg since he was still not 'himself' even though the excessive drinking and urination stopped on the 60mg dose - then recently he went up to 150mg since hes still VERY lethargic.
On 150mg is when I noticed he wasn't really interested in his food so he went back to the vet again on Saterday and they have put him back down to 120 (2 x 60 per day - 1 pill in the morning and 1 at night). They also took an xray of his lungs since we're still concerned about his laboured breathing especially after his short walks outside. There were some small white dots around his lungs which we'll keep an eye on cause it could be the cancer spreading or could be his age (he's nearly 9years old).
I've been told that if it is the cushings causing the lethargy then this new dose should be better since its split (he weighs 36.4kg) and we should see a change in about a week so I'm keeping everything crossed! If he doesn't improve or get back to his old self, then there is nothing they can do (or so they say) since we don't know what else might be effected by the tumor.

Anyway, hopefully this will help you to understand our situation and help anyone else who is seeing these symptoms in their dogs.

Thanks again for all your help and advice - I'm so glad I found this forum.

[goldengirl88]

I am thinking from your posting that your dog had cancer??? The small white dots on the xray may be calcifications. When dogs get older they develop calcifications in their lungs. This can cause problems with the breathing in older dogs as their lungs are not as elastic as when younger and it is harder to breathe and push the air back out. I am not totally convinced Cushings does not have something to do with the breathing however. My Tipper has breathing problems also, and never had this before Cushings. She does not have any calcifications in her lungs either. I am convinced there is some mechanism that Cushings affects that causes breathing problems, possibly tracheal. As far as the dosage goes, you can't keep guessing on this dosage and switching it around willy nilly. You have to get the recommended dosage for your dogs weight and stick with it. I believe a lot of problems are caused when the dog is put on to high a dosage to start out with instead of letting his body adjust to the drug on a lower dosage and only increasing when shown to be necessary by testing & clinical symptoms . The symptoms you are talking about represent too high of a dosage. You need to get a vet that understands Cushings, get you dog the ACTH and check the Electrolytes, then get on the correct dosage. Do you have prednisone at home? If not you need to get some asap in the event your dog goes into Addisons from too much Trilostane/Vetoryl. If you review your postings you will see Addy gave you really good advise on this to follow. Blessings
Patti

[labblab]

Hi everyone. Sorry I haven't been in touch. We took Buster to the vet and they did more blood work. His electrolytes are fine and they did another 'cushings' blood test and now I've been advised to split his dose- 60mg twice a day. He's started eating (yippee) but is still very lethargic. I got his test results to get a second opinion in the UK ( we live in Abu Dhabi, UAE). Pre ACTH - cort01=52.4 nmol/L - baseline cortisol=52.4 nmol/L=1.9 mug/dal.
Cort08=99.3nmol/L. Post -ACTH cortisol (for therapeutic monitoring)- cortisol=99.3 nmol/L = 3.6 mug/dl.
I'm not sure what any of this means but if any of you do, please share.
Now I'm waiting for a week to see if the new split dose of 120 is going to make a difference. I just want my buddy back.
I'll keep you all posted and thanks again for your concern and advise - I REALLY appreciate it.
Since Buster's new test results ended up on the bottom of the preceding page and were easy to miss, I'm going to "quote" them again here so that everybody will see that you've just had them done. If I'm reading your reply correctly, his electrolytes were all fine and his ACTH results (for those of us in the U.S.) were 1.9 and 3.6 ug/dl.

Generally, those ACTH results would be very good, but a lot depends upon how long Buster has been treated at each of the dosing levels. Can you please give us the time frame for his dosing thus far? The reason why I'm asking is because cortisol levels can continue to fall downward throughout the first several weeks (even months) of treatment, even when the dose is kept the same. So giving us the time frame for Buster's treatment will better help us to evaluate these test results.

Also, how many hours before this test did Buster have his last dose of trilostane, and was it given along with a meal?

Thanks so much in advance!
Marianne

[kaibosmom]

Hi and welcome. I am glad you found the forum. Everyone here is so knowledgeable and supportive. It doesn't sound like your vet is too experienced with Cushing's disease. I was on a roller coaster myself when it came to vets. What empowered me was the advice and knowledge I gained from this forum and other reading on the Internet. Start asking for copies of every test and keep them together. My journey has lasted over a year so it gets important to be able to look back and see everything. My dog wasn't treated with Trilostane but if I remember correctly, the ACTH stim results seem to be in the right range. I'm on my iPad now so I can't look back as I type. Anyway, I'm sure someone with more info will be along shortly! Again, welcome and good luck to you. If you can find time to read other threads, that is also helpful.

Ha ha. Oh see...as I was typing others were here with more advice ;)

[Nscott]

Hi again. I've reached out to my vet and this is the response I've received:
[I]The recommended dosage for Vetoryl varies dependent on the source. The original recommendation from the drug company was 3-5mg/kg once daily. More recent recommendations from endocrinologists suggest 0.5-1mg /kg twice daily.
We started with a lower dose than 3mg/kg once daily, which improved the urinary and thirst issues. However he remained lethargic and not himself. So Dr Charlotte increased that to see if it was due to poor Cushings control.
The test we performed this week indicated that we have good control of the Cushings. The post ACTH cortisol level was pretty much in the middle of the range we are aiming for. The electrolyte levels were within normal range, so I am not concerned that we have induced hypo-adrenocorticism.
Hence I suggested 60mg twice daily as a compromise between maintaining the control we currently have, and seeing if switching to twice daily dosing helps to improve his demeanour. I suppose you could try putting it down to 30mg twice daily, but am not sure if that will maintain the cushings control.

[goldengirl88]

I had Tipper on twice daily dosage. just remember if you split the 60mg dosage, that means there is only 30 mg working in your dog at a time because you split the dose. It is gone out of his system in approx. 12 hours so the next time you dose him it is only 30 again. Do you feel 30 is enough to control the symptoms when it was barely controlling at 60? I had to put my dog on a higher dosage once a day as the split was not getting her enough of the drug if that makes sense to you? If you are in the US I strongly suggest you call Dechra and discuss this with them, they have vets there to help you with these problems. 1-866-933-2472 Blessings
Patti

[labblab]

I have only a moment to post and will be gone again for most of the day. But once again, can you please tell us exactly what time frame Buster's dosing history has followed? Lethargy can be a symptom of cortisol withdrawal as easily as it can be a symptom of the disease itself (meaning a reaction to rapid lowering if cortisol). So that should not be a sole reason for increasing a trilostane dose early in treatment. Depending upon how quickly Buster's cortisol lowered, this could still be too high a dose for him.

Marianne

[Squirt's Mom]

What we are looking for is a time line.

What date did he start treatment and on what dose? What were the results of the ACTH following the start of treatment?

When was the first dose change? How much was this dose? What was the subsequent ACTH after this change?

When was the next dose change? How much was this dose? What was the subsequent ACTH after this change?

When was the next dose change? How much was this dose? ........and so on. Include any and all behavior changes you saw with each change, like changes in appetite, urination, drinking, sleeping, etc.

This will help us see patterns that may be present.

Thanks!
Hugs,
Leslie and the gang

[Nscott]

Ok, I asked for Busters history so here goes:

14 May - "cortisol results:
pre-dex: 151.7 nmol/l (5.5mug/dl)
post-dex: 99.3 nmol/l (3.6mug/dl)

consistent with cushing's disease. Still high cortisol at 8 hours but suppression present (<50% pre) so diagnosis of PDH"

will plan to start on vetoryl at low end of dose - 3mg/kg. so ideally start at 100-120 mg once daily. If can obtain 60mg will give 2 tablets daily. If 30mg will give 3 (because of cost!!)
"Vetoryl 30 mg

Give 3 Tablets, 1 times Daily for 10 Days"

20 May - "Vetoryl 30 mg

Give 3 Tablets, 1 times Daily for 20 Days"

15 June [/B]- O reports doing better on meds, still on 90mg daily, but complete bladder control now, and panting less than before. O concerned still v.lethargic and also noticed heavy breathing at rest. O mentioned occasional muscle tremors? Good appetite, drinking less than before.
On examination BAR, mm pink, not panting as much as usual today, aus heart concerned possible audible grade II murmur? V.difficult to be sure as heavy breathing too. Previous xrays showed no abnormalities on heart or lungs. Abdo palp ok. Has gained 2kg, and suspect as barely exercising now. Only eats and sleeps.
Plan to get 60mg tablets tomorrow, so will increase dose immediately to 120mg daily. Will see if 1 month at this dose helps. If clinical signs of heavy breathing and exercise intolerance continues, will recheck with aus and possible repeat xrays. Explained to o will still be at low end of dose, and can be increased if required.

20 July - Plan to increase Vetoryl dose as still showing some clinical signs. Considering depression related to tumour on pituitary gland - related to PDH?? Will increase dose by half, so to give 150mg per day (highest dose is 180mg) - ie. 2 x 60mg and 1 x 30mg.
Recheck in 1 month, if still no improvement in clinical signs, consider Comp blood to check for abnormalities in Ca, K or Na levels (cause behind tremors) or indications of other possible mets.

29 July - another blood test
Canine
Comprehensive Diagnostic

ALB - 2.5 to 4.4 G/DL = 4.0
ALP - 20 to 150 U/L = 96
ALT - 10 to 118 U/L = 98
AMY - 200 to 1200 U/L = 514
TBIL - 0.1 to 0.6 Mg/DL = 0.4
BUN - 7 to 25 Mg/DL = 13
CA – 8.6 to 11.8 Mg/DL = 11.0
PHOS - 2.9 to 6.6 Mg/DL = 5.5
CRE - 0.3 to 1.4 Mg/DL = 0.9
GLU - 60 to 110 Mg/Dl = 99
NA+ - 138 to 160 mmol/L = 146
K+ - 3.7 to 5.8 mmol/L = 5.7
TP - 5.4 to 8.2 G/DL = 7.2
GLOB – 2.3 to 5.2 G/DL = 3.3

30 July - pre ACTH Cortisol = 52.4 nmol/L = 1.9 mug / dL
post ACTH Cortisol = 99.3 nmol/L= 3.6 mug / dL

Have advised o to begin twice daily dosing of 60mg morning and night.
cortisol results suggest we have good control of the cushings, but obviously dog is not his usual self at all. Not sure if this is due to drug reaction or pituitary tumour.
Blood chemistries and electrolytes all normal. No evidence of hypoadrenocorticism.

[Rocky]

I've got a Boxer going through Cushing's, too. He is almost controlled on Vetoryl with 30mg twice a day, but he is nowhere near how he used to be. :( I've started wondering if it's side effects of Vetoryl.

Hope things work out for Buster!

V

[Nscott]

Thanks a million and glad to hear that Rocky is better.

I wonder if you're right that our old 'crazy' boxers won't be the same with cushings and the meds.

I see that your dog is a lot lighter than mine. Mine is 36.4kgs which is about 80lbs so i'm not sure if 60mg is too low for Buster.

Well, I'm going to keep trying until we get it right :)

Take care and wish you all the best with Rocky.

[Rocky]

Thanks! Rocky just turned 7 and is at about 52lbs now; he used to be 70lbs - really stocky and big with quite a personality!

He's had some major ups and downs with Cushing's. Mostly, we think, because of the mismanaging treatment with our old vet :( We were hoping to see some improvement personality wise as he got under control, but so far, it's not happening.

The only thing to do is to keep going! :)

V

[labblab]

Thanks so much for posting this additional information! Some things seem clearer to me now, but others are actually more confusing. So if you'll bear with me, I've inserted some more comments and questions in the red type within the body of your quote. Before getting to that, though, one thing I'm confused about is that you've told us that Buster started out taking 60 mgs. once daily. The records here, though, say that he first started out taking three 30 mg. capsules once daily (total of 90 mg.). So that's my first question: what dose did he start on? And also, how much does Buster weigh?


Ok, I asked for Busters history so here goes:

14 May - "cortisol results:
pre-dex: 151.7 nmol/l (5.5mug/dl)
post-dex: 99.3 nmol/l (3.6mug/dl)

consistent with cushing's disease. Still high cortisol at 8 hours but suppression present (<50% pre) so diagnosis of PDH"

From the numbers and description, it looks as though Buster had a diagnostic LDDS test performed. But that test typically has three numbers: a pre-dex, a 4-hour post-dex, and an 8-hour post-dex result. You are listing only one post-dex result. Is there a result that is missing? If not, I'll have to assume that this post-dex result was at 8 hours since that is the number that is used to make an overall Cushing's diagnosis. But 3.6 is NOT <50 of the baseline of 5.5, so no conclusion can be drawn as to whether Buster's Cushing's is the result of a pituitary or an adrenal tumor.

will plan to start on vetoryl at low end of dose - 3mg/kg. so ideally start at 100-120 mg once daily. If can obtain 60mg will give 2 tablets daily. If 30mg will give 3 (because of cost!!)
"Vetoryl 30 mg

Give 3 Tablets, 1 times Daily for 10 Days"

So this would be 90 mg., right?

20 May - "Vetoryl 30 mg

Give 3 Tablets, 1 times Daily for 20 Days"

15 June [/B]- O reports doing better on meds, still on 90mg daily, but complete bladder control now, and panting less than before. O concerned still v.lethargic and also noticed heavy breathing at rest. O mentioned occasional muscle tremors? Good appetite, drinking less than before.
On examination BAR, mm pink, not panting as much as usual today, aus heart concerned possible audible grade II murmur? V.difficult to be sure as heavy breathing too. Previous xrays showed no abnormalities on heart or lungs. Abdo palp ok. Has gained 2kg, and suspect as barely exercising now. Only eats and sleeps.

At this point, Buster is one month into treatment, and should have had two monitoring ACTH tests performed according to standard treatment protocol. This is to ensure that his cortisol level has not dropped too low, especially in a situation where a dog is so lethargic that he is doing nothing more than eating and sleeping. But instead, your vet is INCREASING Buster's dose, with no idea as to what his cortisol level is. :eek: :eek: This is incredibly unsafe!
Plan to get 60mg tablets tomorrow, so will increase dose immediately to 120mg daily. Will see if 1 month at this dose helps. If clinical signs of heavy breathing and exercise intolerance continues, will recheck with aus and possible repeat xrays. Explained to o will still be at low end of dose, and can be increased if required.

20 July - Plan to increase Vetoryl dose as still showing some clinical signs. Considering depression related to tumour on pituitary gland - related to PDH?? Will increase dose by half, so to give 150mg per day (highest dose is 180mg) - ie. 2 x 60mg and 1 x 30mg.
Recheck in 1 month, if still no improvement in clinical signs, consider Comp blood to check for abnormalities in Ca, K or Na levels (cause behind tremors) or indications of other possible mets.
Buster is now over 2 months into treatment and not doing well after two significant dosing increases, but your vet has not performed one single ACTH monitoring test until you requested it yourself this week??? In fact, they were going to hold off for another whole month before testing the electrolytes alone? It is incredibly lucky that Buster's blood testing is all normal, because dosage increases without any monitoring testing is an invitation for disaster.

29 July - another blood test
Canine
Comprehensive Diagnostic

30 July - pre ACTH Cortisol = 52.4 nmol/L = 1.9 mug / dL
post ACTH Cortisol = 99.3 nmol/L= 3.6 mug / dL

Have advised o to begin twice daily dosing of 60mg morning and night.
cortisol results suggest we have good control of the cushings, but obviously dog is not his usual self at all. Not sure if this is due to drug reaction or pituitary tumour.
Blood chemistries and electrolytes all normal. No evidence of hypoadrenocorticism.
I am going to include a link to Dechra's U.S. Product Insert for Vetoryl (brandname trilostane) so that you can read for yourself what constitutes safe monitoring protocol, and also the serious, life-threatening treatment risks that are associated with a lack of testing. Even when a dog appears to be doing OK, it is impossible for anybody to judge the safety and effectiveness of trilostane based solely upon behavior alone. But in this case, Buster was not even doing well, and for reasons that could have been associated with low cortisol. I am beyond worried about the veterinary oversight that Buster has been receiving. I am not sure what is indeed going on with Buster to cause his extreme lethargy, but it is only through incredibly good luck that your vet did not push him into Addisonian crisis by increasing his doses without any knowledge whatsoever as to how the medication was affecting Buster's cortisol level or his electrolytes. :( :( :(

http://www.dechra-us.com/files/dechraUSA/downloads/Product%20inserts/Vetoryl.pdf

Marianne