Otto

[Mark]

Hello,

I just found this forum today. We have a soon to be 14-year old wiener named Otto who was first diagnosed with Cushings the fall of 2010. He has done fine, but seems to be spending most of his time in bed. Granted, he is old and blind, but he seems to have slowed markedly.

I will paste in a long history, but what I would like to do is cut his trilostane in half - give the same dose (30 mg) I was giving but every other day instead.

My thinking is that his blood sugar seems controlled and some adranl cortex function may help, instead of having it heavily suppressed with trilostane.

Any others with a similar situation?

Time line:

OTTO: dachshund born Nov 1999, about 25 lbs

September 2010
Diabetes - human Insulin N
Cushings - Pituitary, not adrenal tumor - start trilostane (compounded)

December 2010
Blindness

Feb 8 2011
Increase trilostane to 50 mg per day by adding ½ pill to nightly dose.

Monitor behavior concerning bladder infection (increase water intake, accidents)

1 unit insulin per pound is considered max dose per 12 hr injection.

March 2011
Good values, good skin, good appetite, more normal water consumption
30 mg tab twice daily with food, 20 units insulin twice daily

Jan - March 2013 - occasional cases where Otto is sluggish, slow to respond.

March 10, 2013: decrease insulin from 20 u twice a day to 16u 2x.

March 22 8:00 PM: Otto is in yard twitching and unable to stand. Also very cold (about 35 degrees outside). Two hours under blanket. Give Karo syrup - he responds hungrily. Offer food - he eats but is clumsy. Sleeps thu the night, eats in morning after voiding on his own. Vet checks blood and urine - most markers OK - blood sugar 150, higher in urine, slight (if any) sign of bladder infection.

Decide: put on antibiotic for 1 week, decrease insulin to 12u 2x and decrease Trilostane to 1 pill (30 mg) one time per day. Logic - Cushing better than Addison.

My interpretation: After 2 years on 20u insulin (2x) and 60 mg Trilostane, GC (glucocorticoid) levels are very low. Pancreas or insulin-responsiveness improves w/o pressure of high GC. Otto became more likely for hypoglycemia with time-release insulin. Overall (rebound?) sensitivity to GC stabilized after heavy suppression of GC production. 30 mg for maintenance may allow for some GC activity - will watch for Cushing/ diabetes signs - such as water consumption.

April 12- 20: trip to NY - Otto does fine. Overall activity level seems OK. Rarely 'sluggish'. Explores outside the fence on occasion. Other dogs interact playfully.

September 2013: Current- low activity level but still has good attitude, appetite, water, skin. Decrease insulin to 10 units 2x per day (20 units per day for 10 kg dog)

[frijole]

Is Otto a weiner dog? If so how much does he weigh because those are MASSIVE doses you have been on (vetoryl)!!!! When you describe the apathy, inability to get up etc those are signs that the dose is too high.

I didn't see a single mention of an acth test. Have you been having them done to measure the cortisol? It is the only way to know whether to decrease or change a dose. I am really interested in knowing what Ottos cortisol level is.

Lastly you cannot give this drug every other day. It doesn't stay in the system but for a few hours so if you give it today the cortisol is lowered and then you wait two days the cortisol will soar and then you'll cut it way down - in other words you are really really messing with your dog's metabolism.

If you need to decrease the dose you need to buy smaller mg pills. YOu can't open the capsules and do half a days either - it is stated on the drug by the maker.

Please tell us how much Otto weighs and confirm the current dose and the date/results of the last acth test. Thanks! Kim

[Mark]

Yes he is a wiener and is about 25 lbs. We did all those tests years ago when we got him stabilized.

He was on 2x 30 mg per day for over 2 years. 6 months ago, we took him down to 30 mg 1x per day.

Yes, with a half life of 8 hr, it would be better to go to 15 mg per day than 30 every other day. They are chicken flavored compounded tabs - also not recommended to split in half.

After 3 years on this drug, I am not sure how fast his ad cortex can still respond.

[frijole]

You have a whole lot to balance (as you know) with all the illnesses you are dealing with. I wouldn't change the dose unless I had another acth test. Yes you do it to get regulated but I've been on this board longer than vetoryl has been on the market and we have seen time and time again where a cumulative affect occurs and a dose that was once perfect becomes too much. Obviously in your case I wouldn't change a thing without checking with the vet - again you have so many variables to consider. Kim

[molly muffin]

Hi. I just want to welcome you to the forum and second what Kim said. I'd have an ACTH test done and see where those levels are at now and how well the adrenals are responding still. We do see sometimes after a couple years, sometimes after 4 years a need to lower the levels of medicine because the adrenals aren't producing as much as they use to. So, worth it to have that checked out, even if at a stable rate of doing so every 6 months of so. With managing the other things as well, it could make a difference to know.

Welcome again
Sharlene and Molly Muffin

[Squirt's Mom]

We did all those tests years ago when we got him stabilized.

uummmm...I wanted to make sure you understand that the ACTH is NOT a one time test. It MUST be done everytime you suspect the dose is too high or too low and MUST be done 2 weeks after each dose change, then at the 30 day mark, then every 90 days after for life as long as the pup's behavior is good - behavior as in cushing's signs. So after being on the this drug since 2010, Otto should have had numerous ACTHs performed. ;)

[Mark]

Thanks for the welcome and the comments.

So dogs on trilostane and insulin for 3 years are not that uncommon?

I should also mention that he is on one baby aspirin and fish oil each day, more for arthritis though.

I get a new computer this morning - hopefully I will be able to check back in later today...

[lulusmom]

He and welcome!


So dogs on trilostane and insulin for 3 years are not that uncommon?

Most dogs are up there in years when diagnosed with cushing's so in the majority of cases, I'd have to say that maintaining control of cushing's and concurrent diabetes for three years is certainly possible but is not the norm as some of these dogs pass from old age or other complications. One of my cushdogs was diagnosed with cushing's at three years old but never developed diabetes. She did quite well on treatment for almost eight years. What is not common, in your case, is the fact that you don't appear to be routinely testing glucose or cortisol and are relying on your own observation to make necessary dosing adjustments. This is a dangerous path as not all dogs let us know if something is awry until they have a major crash. My other cushdog had dangerously low cortisol on a routine acth stim test, yet showed no sign of an impending Addisonian crash. Had I relied on my own astute observation, continuing to dose would have most certainly lead to an Addisonian crisis.

With your dog having concurrent diabetes, it is imperative that you do proper testing in order to properly assess your dog's cortisol and glucose levels for optimum control. Having had two dogs with cushing's, I am extremely sensitive to the cost involved to have these tests done; however, there are ways to save money. Members of our sister site, www.k9diabetes.com are extremely knowledgable and can share information on doing home testing and where to purchase what you need at the best price. ACTH stim tests are quite expensive due to the high cost of the stimulating agent (Cortrosyn). However, having a smaller dog has it's advantage, as less of this stimulating agent is required for an accurate result. Many vets are unaware of this so we routinely provide this information so that members can discuss this with their vets and negotiate a reduced rate. Most gp vets are usually amenible to splitting the vial of the stimulating agent and freezing for your future use. Some members have realized a huge savings by doing this. You can find this information for your vet at Dr. Mark Peterson's blog site where he provides instruction to veterinarians. Dr. Peterson is a world renown endocrine specialist and his credentials are impeccable. I doubt that any vet has completed their education without reading at least a few chapters in veterinary text books authored by Dr. Peterson. I have provided the url to his blog below:

http://endocrinevet.blogspot.com/2011/03/how-to-extend-your-supply-of-cortrosyn.html

It's pretty amazing that you've been able to give Otto, what sounds like a good quality of life for the last three years, without proper testing, and we'd love to see that continue with but by following proper and safe testing protocol, as finances allow. You're one of the family now and we look forward to having you and Otto with us for a long time to come.

Glynda

[Mark]

Hello everyone and thanks for the comments.

After 3 years on trilostane without missing a dose, we gave Otto a little time off last week, where he did not get a dose on alternate days. No real difference in activity level or water consumption.

Three years ago as we spent months trying to get his trilostane and insulin balanced, I found that his water consumption was the best indicator of how he was doing. His lab tests were never 'textbook', and finally when his behavior, water consumption, skin/fur appearance all were good, we stayed the course until last spring when we backed off on both the insulin and trilostane (both had been relatively high doses for a 23 lb dog). His appetite has always been good (he is a dachshund after all).

It seems that he is content to sit and listen/smell his surroundings from the comfort of his bed. Being blind, he likes to be in familiar surroundings - so we have to travel to his area to give him attention. His brother Louie likes to lick his face and keep him company as well.

He will be 14 in Nov, and was diagnosed with diabetes September 1 2010.

[goldengirl88]

Mark:
I just wanted to say God bless you for the wonderful job you have done with Otto. I hope Otto continues on to celebrate his birthday again next year. Glad you found the forum, but you have done an excellent job. Blessings
Patti

[molly muffin]

That is so cute about Louie liking to lick his face and just hang out with Otto. It is hard when they lose their sight and some take to it differently than others. Some are little adventurers wanting to figure things out in their new sightless world while others are content to just sort of hang in the familiar and be comfy. You never know which you'll have. Sounds like Otto is into being a laid back chap.
I agree that you are doing a wonderful job of managing both issues for Otto. Have you gone to a split dose yet?

Sharlene and Molly Muffin

[goldengirl88]

Mark:
I too would be concerned about the dosage of Trilostane you are giving as some signs you described are showing the dosage is way too high. Blessings
Patti