15 year old poodle on trilostane - frequent dosing increases not helping

[mitsua]

Not sure if I should treat. Vet wants to do 8 hr test, ultrasound and then treat with vetroyl sp? Vet agrees age is a factor with treatment and said would understand if I decided not to treat. Dog is drinking, panting and peeing excessively. Currently pn theophylline. Anyone have any experience with treating a senior dog? She is a mini poodle andenjoyed relatively goodhealth until now.

[lulusmom]

Hi and welcome.

Most dogs are senior when diagnosed with cushing's so a good deal of us have experience with treating senior dogs. Is your dog in good health otherwise and if so, treatment can be a good option for both you and your dog. I see that you have your dog on theophylline, which is a bronchodilator. Did your vet prescribe it for the panting or is there another problem? Did your vet already do a blood chemistry and urinalysis? If so, can you get copies and post the results here? You need only post the highs and lows on the blood chemistry. A urinalysis, with a culture should have been done to rule out a urinary tract infection and to check urine specific gravity. Dogs with cushing's have low urine specific gravity, dilute urine, and a good number have a urinary tract infection at diagnosis.

Cushing's is a very graded disease, moving at a snail's pace so there is usually no rush to make the decision to treat, especially if you don't yet have a diagnosis. There is no cure for cushing's so the goal of treatment is to remedy the symptoms that are usually more problematic for the pet owner than the dog. I've treated three cushdogs and know first hand how frustrating it is to have a dog that was once housebroken start to pee in the house. It's also not easy to watch our dogs pant all the time. My first cushdog was only three years old when diagnosed and she sounded like a little freight train chugging up a mountain. Having multiple cushdogs, I am also intimately familiar with the expense of diagnostic tests, the drugs used to treat and the acth stimulation tests that are necessary to monitor treatment. It's not cheap but because I watched these dogs come alive again and live a good quality of life on treatment, I'd do it all over again. Once a dog is stabilized on an effective dose of Vetoryl, the ongoing cost does go down. There are also ways to save money which we can share with you, if you ultimately decide to move forward with a diagnosis.

If you do decide to move forward with testing, I would suggest that you start with a rather inexpensive urine tests called the urine cortisol creatinine ratio. This is a common screening test that can rule out cushing's if the ratio is within normal range. If the ratio is high, cushing's could be the cause but additional tests, like the eight hour test and abdominal ultrasound should be done. All you have to do is to collect a urine specimen from your dog, preferably the first pee of the morning before a meal and meds. Drop it off at your vets within a few hours of collecting and if you can't get there within that time frame, keep the urine refrigerated. The reason for collecting urine at home is that you want the dog to be relaxed and stress free. The adrenal glands will dump cortisol in response to stress so if your vet tries to collect a urine specimen, the results would be unreliable.

I'm sorry for the reasons that brought you here but I'm glad you found us. We're here to help you and your dog in any way we can.

Glynda

[mitsua]

Thanks for your reponse. This is my second dog with cushings so am familiar with all that is involved and the expense. The last dog was under the care of Animal Medical Center in NYC and a specialist in Cushings so received excellent care. Where I live now, is a rural area and the closest vet who is familiar with cushing and has a larger practice with specialized equipment is almost 70 miles away. I got nervous when this local vet said I don't have to test for pituatary or adrenal because the medication is the same. She did xrays, not an ultrasound because she doesn't have an ultrasound machine.

My little poodle was diagnosed 3 years ago with atypical cushing by U of Tenn and was on lignans and melatonin and Denamarin. She was on this for about a year and then her symptoms (loss of hair) subsided. She didn't have the panting or excessive drinking and urination that she is exhibiting now. Although this vet was familiar with atypical cushings she wasn't familiar with lignans and she never treated a dog with atypical cushings. I don't remember how frequently you need to get blood work done when first on medication. She didn't have a UTI, no infection, I think she said her ACTH was in the 3000 range. I need to know from someone who has treated such a senior pet if it was successful. I kinow this is a strong medication which puts a tremendous burden on the dog's system. My vet told me mini poodles life span in 13-18 but most die within the 15-17 year range. I live in the central coast near Santa Barbara. Anyone have experience with vets in that area that know about cushing?

[mitsua]

Forgot to add that the cardiologist put my mini poodle on Theophylline about 1 year ago for panting issues due to an enlarged heart and mitral valve issues. Helped enormously.

This latest panting started about a month ago and has gotten worse rapidly along with excessive drinking. Because she was diagnosed with atypical cushings 3 years ago, I worry that just to put her on Veteroyl (which isn't recommended for atypical cushings) would do more harm than good. Need a referral to a "specialist" who knows about both types of cushings. This vet said she didn't need to do any other tests but the 8 hr.

Anyone have any referrals to vets in and around Santa Barbara, CA

[molly muffin]

Hello and welcome to the forum.

That doesn't sound right for an ACTH to be 3000. Maybe the ALKP? Do you have copies of the tests as Glynda mentioned, this would be enormously helpful. You'll need to know if the cortisol is high in addtion to the atypical, which would take her into regular cushings now and normally they recommend lysodren for that, if the ligans and flax isn't controlling.

I don't know of a vet personally in the Santa Barbara area, but some of our other members might know of someone. If not we have a search tool, you can put in zip code, or city, etc to search.

http://www.acvim.org/PetOwners/FindaSpecialist.aspx

Using Vetroyl, you test at the 10 - 14 day mark and then at the 30 day mark to start with. If there is a dose change, then you start over. Always start out low and go up if needed. No more than 1mg/1lb, especially with an older dog I would think.

They did rule out diabetes and thyroid? Might be worth finding a specialist and having an ultrasound done too if that is feasible for you.

[lulusmom]

I did a bit of research and found what appears to be an excellent 24/7 specialty hospital in Santa Barbara. It's called Advanced Veterinary Specialist. Please see link below for contact information. It appears that they will need a referral from your gp vet. I checked them on Yelp too and they are the only five star rated specialist I have ever seen. I've also included the link to reviews on Yelp.

http://www.avs4pets.com/internal-medicine/
http://www.yelp.com/biz/advanced-veterinary-specialists-santa-barbara

[mitsua]

Thanks for checking for me. My vet bill for blood work, 3 xrays (don't know why the vet did xrays to check for cushings??) urine analysis, and a senior exam came to almost $600!!! She said an ACTH test is "very expensive". Will call the office you found and get their fees "upfront". Appreciate your help. The melatonin and lingans seem to be helping with the panting a bit, but not at all with the excessive drinking, peeing and appetite. We shall see what happens next. The other vet said she would put her on trilostane but I read that it is NOT the drug of choice when a dog has atypical Cushings. I understand atypical can progress to typical but seems the drug treatment is different. I do miss my NYC vets!!!

[Renee]

In my experience, ACTH tests are rather expensive.. because of the darn cost of the cortrosyn (sp). At my vet, the ACTH is only $100... but, the cost of the cortrosyn is $150, so it totals out to $250 per test. :mad: If I was only paying that once, I'd be thinking it was no big deal.. .but, in the beginning, so many of these tests are needed, it adds up quickly!

$600 for all the work you had done does not sounds out of line to me. Just getting to the cushings diagnosis for my pug was over $1,500.

[Harley PoMMom]

Those ACTH stimulation tests are expensive but there is a cost saving method if one has a small dog, read this article: How to Extend Your Supply of Cortrosyn and Lower the Cost of ACTH Stimulation Testing (http://endocrinevet.blogspot.com/2011/03/how-to-extend-your-supply-of-cortrosyn.html)

Hugs, Lori

[mitsua]

Thanks to everyone who responded. The costs for these tests and retests once treatment is started is really beyond me. For now I will keep my little mini on the protocol for atypical cushings which she was diagnosed before -- lignans, melatonin, and denamarin. Her panting seems to have lessened, but not the drinking or urination. She is 15 last month and unless symptoms significantly worse, I will let her enjoy her time here. I don't think the local vets are experienced enough and to drive 45 miles to a vet one way and then possibly have an emergency while on the medication -- I don't think we would make it. My former cush dog went into kidneyfailure within 2 or 3 days on Trilostane. If I had not been close to a vet, he would have died. It's a tough decision, but finances unfortunately do rule when you're retired. Good luck to everyone dealing with this. It's scary not to know how your dog will react to any of the treatments for Cushings and you really need a vet close by and experienced with treatment.

[molly muffin]

We all just do the best we can with what our options are. These tests are very expensive and you have to weigh benefit vs quality of life too when they reach seniors age.
We are still here any time you want to have a chat or talk about anything.

[mitsua]

Here's here #s from her blood work. Posted all the out of normal range #s

platelet count 577
ALT 120
ALK Phosphalase 3375
BUN/Creatine 32
Cholesterol 337
Tryglyceride 667

T4 1.0

Urinalysis
ph 7.0
Protein 2+

RBC 11-20
Occult Blood 3+

My mini poodle just had her LDDS test done today -- results next week.

the note on the test results said "urine protein creatinine ratio testing is recommended to determine clinical significance of proteinuria."

When I asked the vet about this, she said she wasn't famliar with this test and never did it and suggested I go to an endocrinologist. Problem is that the closest endo is 47 miles away. So am waiting for the test results from LDDS.

Any comments, insights, greatly appreciated.

[lulusmom]

I've merged your two threads so that we can keep all of your girl's history in one place. Sometimes our threads get buried on back pages so I'll PM you a link that you can use whenever you want to get to your thread.

I would really help if you could edit your post and provide the normal reference ranges for the blood results you just posted. With respect to the proteinuria, it is not uncommon for cushdogs, especially an uncontrolled one, to have a +1 or +2 urine protein. My little Lulu's urine protein was +2 consistently and she did not have kidney disease. Can you check your papers and see if there are results for BUN and creatinine? If so, can you please post those results with the normal reference ranges? When cushing's is suspected, a vet should check the urine specific gravity. That is usually a component of a urinalysis. Can you please check to see if you have USG results and post the result for us? It is not unusual for a dog with cushing's to have a high BUN, due to the increased urine output. If the BUN is high with a normal creatinine, that will yield a high BUN/Creatinine ratio. Normal range for this ratio is usually 4 to 27 so I would assume that the result posted is high, which is usually consistent with cushing's.

I'm more than surprised that your vet has never done or ordered a urine P:C ratio, as this is a common tests most vets do if they suspect kidney dysfunction. Most vets are set up to do P:C ratios inhouse but if not, a urine specimen is collected and sent to an outside lab. I'd be very concerned about a vet who has to send patients to internal medicine specialists for a urine P:C ratio. If I had to drive 40 miles and pay specialist prices to run a test that another gp down the street could do, I'd probably print out lab instructions and walk her through it. :D For this test to be abnormal, 70% of kidney function is usually gone, and based on the results you've posted so far, I don't think you're dealing with kidney disease. I think you're probably dealing with cushing's, but we'll have a much better idea when you post the results of the LDDS test.

Glynda

[mitsua]

Here's all the #s out of range and what the normal #s are. THis vet was HIGHLY recommended. I've been through several of the local vets here and most of them said the same thing -- your poodle is at or near the end of her life expectancy. I would do nothing. This vet said that with all the urination my poodle does, it wouldn't be the "first' urine in the morning as she has a door to go outside in the night. She would have to send the test out. I have to work with what's here. THe closest board certified endo vet is 70 miles away. The vet in santa barbara is an internal medicine; not endo.


BUN 19 6-31 normal
Creatine 0.6 0.5 - 1.6 normal

platelet count 577 170-400 normal
ALT 120 12-118 normal

ALK Phosphalase 3375 5- 131 normal

BUN/Creatine Ratio 32 4-27 normal
Cholesterol 337 92-324 normal

Tryglyceride 667 29-291 normal

T4 1.0 0.8-3.5 normal

Urinalysis
ph 7.0 5.5-7.0 normal

Protein 2+ Negative normal


RBC 11-20 0-3
Occult Blood 3+ Negative

Specific gravity 1.033 1.015-1.050 normal

THanks for the pm and link.

[Trish]

Hi, while I am certainly no cushings expert I have had a bit of experience with renal problems. I too am surprised your vet has such a lack of knowledge with UPC ratio testing and they wants to send you to an endocrinologist for the test :confused:, that is not even the right specialist!! My vet cannot get real accurate tests for the UPC ratio and sends them out to an external lab. But an endo is not even the right specialty for renal tests, cushings sure but not kidneys that belongs with IMS or renal specialist. Usually the IMS are qualified to look at both cushings and the renal side of things so it might be a good idea even with the drive, to visit them if your vet is worrying you like they are worrying me!



I'm more than surprised that your vet has never done or ordered a urine P:C ratio, as this is a common tests most vets do if they suspect kidney dysfunction. Most vets are set up to do P:C ratios inhouse but if not, a urine specimen is collected and sent to an outside lab. I'd be very concerned about a vet who has to send patients to internal medicine specialists for a urine P:C ratio. If I had to drive 40 miles and pay specialist prices to run a test that another gp down the street could do, I'd probably print out lab instructions and walk her through it. :D For this test to be abnormal, 70% of kidney function is usually gone, and based on the results you've posted so far, I don't think you're dealing with kidney disease.

Glynda, I have always been told it is once the serum creatinine and BUN start rising (when other issues such as dehydration are ruled out) that 75% of renal function has been lost, but I have not seen that figure applied to an abnormal UPC test. So I would be real interested in any articles related to that. As it worries me with my dogs previously eleveated UPC. Thanks.

In both cushings and renal failure the urinary specific gravity is low and your pup's urine is concentrating nicely at 1033, you have not mentioned creatinine in your list so I presume that is normal, so that is good to see!

[Tina]

Glynda, I have always been told it is once the serum creatinine and BUN start rising (when other issues such as dehydration are ruled out) that 75% of renal function has been lost, but I have not seen that figure applied to an abnormal UPC test. So I would be real interested in any articles related to that. As it worries me with my dogs previously eleveated UPC. Thanks.

Trish, thanks so much for posting this, as this is what I have also been told regarding the serum BUN and creatinine rather than the UPC. I am quite worried now also as my pup has been struggling with elevated UPC too, and it seems to be on the rise again. Glynda, any additional information that you can provide will be greatly appreciated so I can discuss with my vet. Thank you.

Sorry for the thread hijack. :o

Tina

[addy]

For others reading this, I just want to add, my Cush pup suddenly started throwing protein in her urine. It is not always just from Cushings and sometimes there is something we can do about it. Dogs can start throwing protein from anywhere. In our case, it was from Zoe's GI tract- she has inflammatory bowel disease and was on a high protein diet. Once I lowered the amount of protein she was eating, better controlled her IBD and kept her cortisol within theraputic range- her UPC lowered until it was normal.

I just wanted to share our experience for any memebers reading this.:)

[mitsua]

Here's the creatine #, again.

Creatine 0.6 0.5 - 1.6 normal

I concur with all the comments about the seemingly lack of knowledge with the vets, but as I said, I have to work with who is here. I am worried that if she should have a crises on any medication, if Im not working with the vets, they won't treat her. Yes, its' true. There are only 2 or 3 vets local to me. So although I have more knowledge re cushings I am trying to work with her and "encourage" her to confer with a IM specialist. Im waiting on the results from the LDDS.

Re the protein in the food --- Missy has been on Low Fat/Low Digestive Royal Canin for many years and does well on it. She gets a supplemental tablespoon or so with cooked hamburger or turkey or , pasta or rice as she won't eat just the dry food. Prior to this year's blood work, all her #s have been within normal range. THis panting and thirst came on about 2 or 3 months ago. I posted the #s to see if this are #s for a cushionoid dog and will the LDDS give me (or the vet) a conclusive diagnosis for cushings.

Missy weighs 15 pounds and I know the veteroyl comes in 10mg. This vet also was not familiar with the 2x a day dosing at a lower amount. She said she just prescribes the 1x a day at the closest dosage available. I read the UC Davis (where she graduated) now suggests the 2x a day dosage. Anyone familiar with that? So Im thinking should Missy be put on 10mg 1x a day to see how she's doing with the f/u blood work (which she tells me is $250 each ACTH test). YIKES!!

Also was hoping to hear from anyone who has treated a 15 year old poodle for Cushings. Thanks for reading this long post.

[labblab]

Missy weighs 15 pounds and I know the veteroyl comes in 10mg. This vet also was not familiar with the 2x a day dosing at a lower amount. She said she just prescribes the 1x a day at the closest dosage available. I read the UC Davis (where she graduated) now suggests the 2x a day dosage. Anyone familiar with that? So Im thinking should Missy be put on 10mg 1x a day to see how she's doing with the f/u blood work (which she tells me is $250 each ACTH test). YIKES!!

There are pros-and-cons to dosing once v. twice daily, and different clinicians have different preferences. The manufacturer of brandname Vetoryl still recommends starting with once daily dosing and only moving to twice daily dosing if it appears as though the effects of the morning dose are wearing off too quickly and symptoms are rebounding later in the day or overnight. From the standpoint of owner convenience, once daily dosing is probably easier, especially because every dose needs to be given along with a meal in order to assure maximum absorption. Plus, it may be less expensive since only half as many capsules are needed (regardless of the fact that the single dose is larger in strength). But some dogs do end up with more consistent symptom control when dosed every 12 hours.

Having said that, I think a single daily dose of 10 mg. would be a reasonable place for you to start if you do begin treatment. Adjustments can be made later down the line depending upon your dog's response to the medication.

Marianne

[goldengirl88]

I have done both dosings and say I prefer the once a day. The higher dosage once a day seems to blast the cortisol level down enough so it does not climb back up by nite if you are on the right dose. Also if you think your baby is having renal issues that would fall under a specialist in urology, I don't think you would be looking towards an endocrinologist as that would be more about the Cushings itself or thyroid, hormones etc. Blessings
Patti

[Trish]

. Also if you think your baby is having renal issues that would fall under a specialist in urology
Patti

This is incorrect, unless the cause of deteriorating renal function is caused by something like a renal cancer or stones in the kidney that can be surgically corrected by a urologist. But if the actual function of the kidney ie renal failure is the problem most vets should be able to investigate and treat deteriorating renal function but sometimes IMS support is required. The equivalent specialty in human medicine is nephrology which is quite different to urology and I am sure there are probably specialist vets in that area too.

[mitsua]

Thanks everyone, but can someone get back to me re the #s from her blood work which someone asked me to post.

The vet said her LDDS test indicated she had cushings and before she went on Trilostane, she wanted me to bring my dog in for "blood pressure check" and a urine check for UTI. I said I thought we checked her urine and she said this time she would want to culture it. I never heard of needing a blood pressure check for Cushings and told the vet that she would have to confer with my dog's cardiologist for that.

I asked the vet if the LDDS indicated if it was pituatary or adrenal and she said it didn't tell that and anyway it didn't matter because Trilostane covers both.

She also said if I was going to order the Trilostane on line I would have to sign a waiver with her office that she did not have any liability for "wrong dosing" from the on line pharmacy or any other issue. And that she would have no way of knowing if the dose my dog was getting was correct if the ACTH tests showed that there were problems. Any one have this experience?

I've ordered from this on line pharmacy for years. When I told her the price, she said she would not give me a script until she checked what her price was. THen she asked about the shipping charge I told her that the shipping was free and she was very surprised. I thought it was the law in CA that you can get the medication from anywhere and your vet has to give you or the online pharmacy the prescription if you request it. She didn't have the medication in stock and said it would take about a week to order it. Anyone else have this experience with vets?

[Harley PoMMom]

Here's all the #s out of range and what the normal #s are. THis vet was HIGHLY recommended. I've been through several of the local vets here and most of them said the same thing -- your poodle is at or near the end of her life expectancy. I would do nothing. This vet said that with all the urination my poodle does, it wouldn't be the "first' urine in the morning as she has a door to go outside in the night. She would have to send the test out. I have to work with what's here. THe closest board certified endo vet is 70 miles away. The vet in santa barbara is an internal medicine; not endo.


BUN 19 6-31 normal
Creatine 0.6 0.5 - 1.6 normal

platelet count 577 170-400 normal
ALT 120 12-118 normal

ALK Phosphalase 3375 5- 131 normal

BUN/Creatine Ratio 32 4-27 normal
Cholesterol 337 92-324 normal

Tryglyceride 667 29-291 normal

T4 1.0 0.8-3.5 normal

Urinalysis
ph 7.0 5.5-7.0 normal

Protein 2+ Negative normal


RBC 11-20 0-3
Occult Blood 3+ Negative

Specific gravity 1.033 1.015-1.050 normal

THanks for the pm and link.

There are three things that catch my attention: the high tryglyceride, the protein loss with blood seen in the urine, and an USG of 1.033. Dog's with Cushing's usually have a low USG. With the blood in the urine I suspect your girl might have an UTI, which would cause an increase in drinking and urinating. If this were me I would ask the vet about an UTI.

Hope that helps.

Hugs, Lori

[molly muffin]

Lori is right, I'd want a urine culture.

Sharlene and Molly Muffin

[mitsua]

vet said poodle had no UTI. But now she wants to do a urine culture. Anyone hear of blood pressure being a factor here? Im more concerned about her refusal to give me script. I though that wasn't legal.

[labblab]

Here's a link that confirms your understanding that California requires vets to provide written prescriptions upon request in lieu of directly dispensing medications themselves:

https://www.avma.org/Advocacy/StateAndLocal/Pages/veterinary-prescription-orders.aspx

Marianne

[Squirt's Mom]

Maybe I'm blind, but I don't find any results for cushing's tests - no ACTH, no LDDS, no adrenal panel from UTK (Tennessee). Am I missing them somewhere? :confused:

[goldengirl88]

Blood pressure is a big factor especially with a Cushings dog. I have been warned that is it very important that their blood pressure be kept as normal as possible to not affect the kidneys etc. Every Dr. I went to had this concern right up front and told me how important this is for a Cush dog. Blessings
patti

[mitsua]

Didn't post LDDS as don't have them from vet. Will ask for results on Friday. UTENN panel done in 2010 so current vet said they are not good anymore. Because of the excessive drinking, panting, eating she thought Cushings. Claims the LDDS test proves it. Will post #s when I get them. Thanks.

[mitsua]

Started Vetoryl today at 10 mg. Dog weight is 15.2 pounds. Vet will not write a script for a compounding pharmacy which could be a problem if we have to go to 2x a day, IMO

Blood pressure was normal
No uti inflection with the culture

LDDS test results after 8 hours was 1.5. I think the range went up to 1.4 sorry don't have the #s in front of me.

Only thing I saw was diarrhea after 2 hours taking the Vetoryl. Still panting and drinking and HUNGRY but maybe too soon to notice??

[frijole]

I hate to alarm you but the diarrhea is a sign of overdose. Since you just started it ,it could be something else but you shouldn't give vet oryx to a sick dog......so you need to cease giving it til diarrhea is gone. Also call the vet. Should you continue giving the meds you will have no way of knowing if the dog is overdosing or sick. Kim

[mitsua]

Well, I did call the vet yesterday and report the diarehha but she didn't call back so I thought it was just an ajustment to the medication. She is on the lowest dose 10mg. THis vet will not use a compounding pharmacy and told me she will not write a script for me to give to them. She said she sticks with the name brand pharmaceutical companies. So this will be a problem for me if we have to go lower. I will keep an eye on her today to see if she has diarehha today. She hasn't stopped drinking, panting or eating yet so am not sure what to do at the present. The vet said it takes a few weeks before you see results. I have an ACTH stim test scheduled in 14 days.

ANyone else have input?

[goldengirl88]

If the next dose is too much for your dog and the vet won't write a script go to someone else. You can't overdose your dog for the sake of this vet using only name brands- which I do understand. I feel your dog is overdosed if it has the diarrhea. Stop the Vetoryl until the dog is checked. You need to get it to a vet as you need to get electrolytes checked. Did this vet give you prednisone? If not you need to get some of that too. It will all be ok as soon as you get this dose straightened out. We are here to help you so don't worry we are all in the same boat. Blessings
Patti

[lulusmom]

The vet said it takes a few weeks before you see results.

This is absolutely not true. Dogs are very sensitive to the drug initially and cortisol can drop like rock in a day or two. For this reason, some dogs may feel really crappy initially due to cortisol withdrawal and sometimes it's difficult to determine the difference between withdrawal, cortisol that has dropped too low or even an intolerance to the drug. If your dog is not eating, has diarrhea or vomiting, you should discontinue dosing until her appetite returns and diarrhea clears up. If she continues to vomit, have diarrhea and become more listless, I would recommend that you get her to an er clinic.

Glynda

[frijole]

I was out all day so am glad the others chimed in. I know you aren't familiar with us and we are just internet folks but please trust me we have been welcoming people in your situation for decades and nothing is harder than to watch a dog get into trouble when you see it coming and there is nothing you can do about it.... The drug works very fast and my concern is that the dog could have been misdiagnosed and therefore the instant diarrhea. This happens frequently. Simple solution is to cease the med until diarrhea clears up then start again and if it happens again you know the meds are the culprit and will have to start doubting the diagnosis.

Is the diarrhea gone or still here today? Thanks! Kim

[mitsua]

Thanks, everyone. Diarhea gone today but today she was very lethargic and barely could keep up on her walk. Didn't want to have anything to do with the other dogs in the park. Folks asked me if she was sick? She slept most of the day and now about 10 hours later is back to her perky self. Tomorrow will be day 3 on meds. Panting has diminshed tremendously but still was panting a bit on her walk and when she thinks she;s getting food. Still very hungry and drinking water but maybe not so frequently as before as she's sleeping a lot. I was wondering if she needs to adjust to the meds. I thought pregnisone was only used when the dog was on Lysodren. For vetoryl, I thought you just stop giving the meds. She weighs 15.2 pounds and is taking 10mg of Trilostane 1x a day.

[mitsua]

Can someone get back to me with their thoughts on the LDDS test results which I posted.

The last # was 1.5 which was above the range of 1.4. The vet said it was this # which gives the diagnosis of cushings. I don't recall the other #s. She said the clinical sgns of overeating, panting, excessive urination and no UTI, no high blood pressure is sufficient to diagnose cushings.

Any thoughts from anyone?

[molly muffin]

With the LDDS you need to look at the over all picture. What was her initial cortisol level, then did she suppress at all at 4 hour and 8 hour, with the LDDS being just out of range, you'd need to include that with symptoms which she does have but most vets would have done an ACTH to verify that indeed it is cushings and not something else. It's hard to say without seeing the entire LDDS test and make any kind of determination.

A dog can go into crisis on either of the medications, and with vetroyl as long as you don't go too low, you can stop it and they will usually perk back up, but if they don't, then you could need to administer prednisone to help them out. If she gets wobbly where she can't stand, stop the vetroyl immediately. It could be that she might not do well on 10 even, but you don't know until the ACTH test, unless she crashes.

No dog is exactly the same, and they react in their own way to the medication, sometimes they are very sensitive to it. Sometimes, when the cortisol comes down fast, they just don't feel too good. So many things have to be taken into consideration with the whole.

Sharlene and Molly Muffin

[mitsua]

Vet wants to continue on Trilostane until day 11 when she will do ACTH test. Said she isn't worried about diarrehea as it subsides.

Day 6 of treatment -- still has diarrahea in am walks but not lethargic anymore -- in fact she is back to panting (not as much, though or for as long) and drinking lots of water. when I told vet, she thought my dog might be candidate for 2x a day dosing. BUT isn't 20 mg too much for a 15 pound dog? Last night she panted so bad you would have thought I never gave her medicine.

Urine culture came back negative. Blood pressure was fine.

[goldengirl88]

I really hate to say this, but a vet that is not worried about diarrhea while the dog is taking trilostane worries me sick!!! Blessings
Patti

[Harley PoMMom]

Diarrhea is always a concern especially when a dog is being treated for Cushing's. Diarrhea can be a sign of cortisol dropping too low but also a symptom of cortisol withdrawl syndrome and the only way to differentiate from the two is with an ACTH stimulation test.

Is her appetite normal? Any vomiting?

[molly muffin]

Twice a day dosing, you don't double the dose, you split the dose. That is textbook for vetroyl. Instead of giving 10mg once a day, you would give 5 mg, twice a day, morning and 12 hours later.
This then comes into the realm of compounding since Dechra doesn't make 5mg vetroyl tablets. But we don't know what the cortisol level is doing yet to say if that is what needs to be done or not. Typically though if you see signs subsiding after giving the pill, but then coming back later in the day, often you would consider, twice a day dosing.
Sharlene and Molly Muffin

[mitsua]

No vomitting, just am diarehhea. Still hungry and still does a lot of drinking and peeing but not so much as before. Vet said that means she has to up the dose since it isn't controlling her symptoms enough plus the panting comes back in the late afternoon. Since it only comes in a 10mg pill, vet said plan on dosing 2x a day with a 10 mg pill. That's what I think is too much. The ACTH stim test is schedule for Tuesday but the vet already told me based on the clinical signs Im telling her that she will need a higher dose. Any thoughts?

[Harley PoMMom]

I would not increase the dose until the ACTH stimulation test results are known and even then I might be reluctant to adjust the dose upward. We have seen here that cortisol levels continue to drop even further within at least the first month of treatment even while remaining on the same dose.

Hugs, Lori

[Renee]

Don't raise the dose just yet. And question the vets competence when they want to raise the dose without benefit of an ACTH.

Also, I would never raise the dose without being on the first dose at least 30 days.

[goldengirl88]

If it were my dog I would withhold trilostane because of the diarrhea to be safe you never give these drugs to a sick dog. I am wondering why you are not getting and ACTH test before doing anything? I never do anything dosage wise without an ACTH first. Blessings
Patti

[mitsua]

not changing the dose until results of ACTH test which will be done tomorrow. Vet said she is just letting me know what's coming so I will be prepared. But I think if she is suggesting upping the dose or giving 10 mg 2x a day based on the clinical signs and acth results, I may get a second opinion from the cushings expert in LA even though he over 100 miles from me. This vet is competent enough but readily admits to not being an internal medicine specialist. And she absolutely will not use a compounding pharmacy. I will have to tread lightly to tell her I am getting a second opinion but will want her to test locally. I don't have a lot of vet options here. She has already said that what I am considering to be lethargic is normal behavior in a 15 year old dog and my expectations may be unrealistic. I replied that it wasn't normal behavior for my 15 year old and she dropped it.

Diarrehea varies from day to day -- some morning almost water; other morning soft stool but only in the am about 1 hr or so after administering trilostane. She is still panting like a steam engine by the early evening and sleeping most of the day and dragging on her walks after administering. THis is day 10 of treatment. Thanks for any input on this.

Will post the results of the LDDS test since someone wrote that I need all the #s, and the ACTH tests when i get them.

[Harley PoMMom]

Trilostane has to be given with food to be properly absorbed, she is getting her Trilostane with food, right?

Canned plain (no spices added) pumpkin may help with diarrhea, just adding a small amount, like a teaspoon, could aid in firming up her stool, one doesn't want to add too much pumpkin because it can act as a laxative too.

[mitsua]

yes, giving with food. Vet called today -- says fluctuations may be her body getting used to the steroids. Willm ake an assessment after the ACTH tomorrow. Seems unconcerned about the diarrehea as it doesn't occur every day. Every day seems to be different reaction with her. Will post results of ACTH tests when received.

[mitsua]

LDEX Test Results

Can someone please comment.

TIme 1 PRe 2.7 norm is 1.0-4.0
Time 2 Post 4 hr 2.7 norm is 1.0-5.0

Time 3 Post 8hr 1.5 norm is 0.0- 1.4

Vet said she has pituitary dependent cushings based on these #s. We just did ACTH stim test today.

[labblab]

LDEX Test Results

Can someone please comment.

TIme 1 PRe 2.7 norm is 1.0-4.0
Time 2 Post 4 hr 2.7 norm is 1.0-5.0

Time 3 Post 8hr 1.5 norm is 0.0- 1.4

Vet said she has pituitary dependent cushings based on these #s. We just did ACTH stim test today.
Based on these results, your dog barely tested positive for Cushing's because her 8 hour value (1.5) was slightly higher than the upper value for the normal reference range (1.4).

However, from these results, I don't think you can distinguish with certainty between pituitary and adrenal Cushing's because neither the 4 hour nor 8 hour value is truly less than 50% of the baseline value (although the 8 hour value is very close, and maybe close enough for your vet).


When interpreting LDDS test results, first evaluate the eight-hour postdexamethasone administration cortisol concentration. If it is above the reference range, the dog probably has hyperadrenocorticism (false positive results may occur in dogs with nonadrenal illness). If it is within the reference range, either the dog does not have hyperadrenocorticism or there is a 5% to 10% chance that the dog has PDH. (The dog may have early pituitary disease and the pituitary gland is still responding to a pharmacologic dose of dexamethasone by decreasing ACTH production, thereby reducing serum cortisol concentrations.) In those cases, an ACTH stimulation test is warranted.

If the eight-hour postdexamethasone administration cortisol concentration is above the reference range, then evaluate the baseline and four-hour postdexamethasone administration cortisol concentrations to see whether cortisol suppression occurred during the eight hours. If at least 50% cortisol concentration suppression is present at the four- or eight-hour time points, the definitive diagnosis is PDH and additional adrenal function tests are not needed.


http://veterinarymedicine.dvm360.com/vetmed/Medicine/ClinQuiz-Interpreting-low-dose-dexamethasone-suppr/ArticleStandard/Article/detail/580093

Marianne

[mitsua]

Thanks for your comments. I had asked her how she knew and she read me the interpretation -- she also said she has to look it up as she doesn't remember. Im beginning to worry that this vet is not sufficiently experienced in treating cushings for my senior 15 year old to continue with her.

ALthough today, the bill for the ACTH stim test was over $400!!! She said i had to buy the entire bottle of the Cortrosyn which came to $265 and the ACTH test is $148. Also she is saying that we don't have to repeat the test in another 2 weeks which would make it a month. She couldn't say when we would have to retest. We're now talking about compounding pharmacies and she is telling me that that will cost me more than the 10mg tablet does now, plus there is usually a minimum amount of 6 months that you have to buy. She asked me if I was comfortable with splitting the capsule in half to save money as we are now thinking to dose her 2 a day because by dinnetime she is panting again.

Can someone check in here and tell me if this is all legit? I've never dealt with componding pharmacies. She is the local country vet; not board certified and I wonder about her pricing.

Thanks, everyone!!

[doxiesrock912]

She is completely wrong about the compounding pharmacies. Many of us use Diamondback and they are considerably less expensive than local pharmacies or certainly the vet. http://www.diamondbackdrugs.com/

In fact, our IMS specialist used Diamondback when she lived in California.

When you dose twice a day, you don't double the amount prescribed, you give 1/2 in the morning with food and 1/2 twelve hours later again with food. Some dogs can't tolerate the entire dose at once, our dog is one of them but she's done well on twice a day dosing. (Ex: 10mg once a day would be 5mg twice a day).

Diarrhea is a major concern.

[mitsua]

Thank you so much. I think she is making up the answers as she goes along never thinking that I would research them. She said that the only compoundinig pharmacy she ever used but not for trilostane is roadrunne?? But since she wouldn't give me a written prescription for the 10mg but had me sign a 3 page waiver first and then asked for the fax# of the online pharmacy so she could fax them directly, I don't know how Im going to know what the price is for compounding. Does the pharmacy sent it to the vet or does it come to the client?

[molly muffin]

I think the vet normally does call in to the pharmacy or fax them the prescription, to the pharmacy that you have chosen, after having researched pricing. The pharmacies usually are directly in contact with you and charge your credit card and send directly to you. This at least is how I understand that Diamondback and some of the other pharmacies do this.
We on the forum, recommend pharmacies that others have used with good results.
Your vet just continues to astound me. She does by law have to provide a prescription if asked.
If one uses a reputable online pharmacy, then one greatly reduces the risk associated with compounding.

Sharlene and Molly Muffin

[doxiesrock912]

Since the brand name Vetoryl comes in 10mg capsules, legally a compounding pharmacy can't make the same strength. This may be why your vet refuses to write a script for that dosage. If you do split the dose, which I recommend trying, Vetoryl doesn't come in that strength and there is no reason why your vet should refuse to call it in for you. Honestly, I would change vets. I wouldn't take a chance that she's learning on the fly. Not with Cushings. Please try to find a specialist in your area. It is worth it.

Our IMS vet calls Diamondback with the prescription and they call you for payment information and can give you a quote then.

[mitsua]

I am equally astounded as well. Especially when she required that I sign that 3 page disclaimer/waiver before agreeing to fax in the presctiption. She still would not give it to me personally.

THis is a very rural area and I think the vets here are just not that well informed but nor do the locals rack up these kinds of bills trying to "treat" their dogs. There are no specialists in my area until I go about 70 miles to a vet clinic that has ims. But if Im going that far I might as well head down to LA to a vet that that treats cushings on a regular basis. Dr. B. something.

Thanks for confirming what I believe is that this vet really has little or no experience with cushings and sees that I pay whatever she charges.. I had hoped to get away with just the 10mg 1x a day, but with my mini's excessive panting and drinking after about 10 hours or so, it's time to move on to a vet who is more knowledgeable about dosing and compounding pharmacies. And believe me, she is one of the better vets around here.

[lulusmom]

I just wanted to validate Marianne's last post and say that I agree with her that the results of your pup's LDDS test cannot be used to differentiate beween pituitary and adrenal dependent disease. Either an abdominal ultrasound or an endogenous acth test should be done for this. If I had to choose between the two, I'd definitely choose the ultrasound as it gives the vet a good look at the surrounding organs as well as the adrenal glands. Sadly, I believe you are right about your vet's inexperience. A number of us have had the same problem and fortunately, most of our vets were open to learning. If your vet is open to learning, you can help her do just that. Safe and effective treatment takes teamwork so you want a vet who understands that.

Your pup is a mini poodle right? I have two mini poodle mixes and both are under 20 pounds. If they had cushing's, I would make sure my vet knew that you do not have to inject a small to medium size dog with an entire vial of cortrosyn. There are 250 ug in one vial of cortrosyn and you only need 5 ug per kg. For a 20 pound dog that equates to 45.45 ug, rounded up to 50 ug. That means if your dog is 20 pounds or under, you are going to get at least five stim tests out of one vial. You can do the math and you'll see that we are talking several hundred dollars in savings. I would suggest that if you stay with this vet, you sit down with her and discuss this. She can easily learn how to dilute and store the cortrosyn properly for future acth stim tests. Instructions are made available to vets on Dr. Mark Peterson's veterinary blog. He is a renown endocrine specialist who has contributed to veterinary textbooks used by most of the teaching hospitals so your vet should know he is. I've included a link below to that page and recommend that you print these instructions and take them with you to the vet. It would be in your best interest to get a commitment from your vet before you start treatment because you are going to have to have at least two acth stim tests done in the first 30 days. If she says she won't do it, I would seriously find a vet who will.

http://endocrinevet.blogspot.com/2012/03/how-to-dilute-and-store-cortrosyn-for.html

[mitsua]

Thank you so much for this info. I am familiar with Dr. Peterson as I went to him years ago with this same dog for suspected cushigs which she did not have. I emailed Dr. Peterson asking for a referral in this area but the office didn't respond. THis vet originally said she was familiar with treating cushings so I went with her.

I did email her an article about the ACTH test which Dr. Peterson performs and she blew me off. She said she read it but that was it. i asked if she knew who he was and she said she didn't.

She didn't do any ultrasounds originally; she did 3 xrays. When i asked her why she said that the xrays would show if there were tumors and there weren't any

I don't think this vet is open to anything but charging me. I did ask her how many doses we can get from this vial and she said 2 or 3 and then started in on how expensive treating this disease is and that she told me that upfront. When I asked her do we do the ACTH test in 30 days from the date of starting Trilostane or 30 days after the 2 week test, she said that shes doesnt think we have to do another ACTH test in 30 days. That didn't answer my question. I think it's time to find a new vet even though it may involve traveling.

Yes, she is a purebreed (pet store variety) mini poodle and weighs 15.2 pounds and is 15 years old.

[Renee]

Get a new vet - one that is either experienced (and can prove it), or one that is willing to research & learn with you.

[mitsua]

Low dext results


pre: 2.2
post: 13.6

vet wants to double the dose up to 20mg per day. Mini poodle weighs 15.3 pounds. She sleeps almost the entire morning and then by early evening is panting like a steam engine.

Any thoughts? She won't use a compounding pharmacy.

[molly muffin]

I'm in Canada and both my vet and my specialist know who Dr. Peterson is. Crimey.
FYI, that is an ACTH test pre and post. You won't need an LDDS now that you are started on medication. LDDS is diagnostic only.

No, 13. 6 is too high post results, you want up to 9.0 if symptoms are controlled and under 5.0 if symptoms are not controlled. However, your pre is already at 2.2 so you need to be careful about too high of a dose.

So you want to know if it is okay to go to 10/10 a day instead of just 10. I'd be nervous with a pre of 2.2 to be honest. I like to increase slowly so as not to risk any adverse affects. If your vet won't use a compounding pharmacy like diamondback, etc, then I'm not sure what the answer is, other than to stay at 10mg and see how she does for another couple weeks.
Frankly, I don't really have anything positive to say about your vet who seems to be quite useless when it comes to cushigs and any knowledge of cushings and certainly isn't updated on any recent cushings related studies if she doesn't know Dr. Peterson. Does she by chance know University of Davis (California) and Dr. Feldman? Maybe she could call them for "advice".

Sharlene and Molly Muffin

[lulusmom]

It's obvious that your vet has treated few cushdogs and if she won't use compounding pharmacies, I wonder what she does when she has tiny, tiny patients who have to have most of their meds compounded because small doses are not available. I've always had tiny dogs and I'd say that about half of their meds over their lifetimes had to be compounded.


Thank you so much for this info. THis vet originally said she was familiar with treating cushings so I went with her.

I believe she may be familiar with it, as in she's heard of it, but she seems to be clueless as to proper protocol in diagnosing and treating.


I did email her an article about the ACTH test which Dr. Peterson performs and she blew me off. She said she read it but that was it. i asked if she knew who he was and she said she didn't.

If she has no idea who Mark Peterson is, then that's pretty much an indication that she slept through her endocrine classes in vet school and has done no continuing education on anything endocrine related. Maybe you could jog her memory by printing out a page from Dr. Peterson's site which lists the amazing, and not all inclusive, papers and transcripts from veterinary conference lectures, etc.

http://www.drmarkepeterson.com/book-chapters/


She didn't do any ultrasounds originally; she did 3 xrays. When i asked her why she said that the xrays would show if there were tumors and there weren't any

Good heavens. Firstly, adrenal glands are little buggers hidden in a bunch of fat and is difficult enough to visualize both of them by even the best radiographer on ultrasound but they don't even show up on x-rays unless they calcified or a mass is is very large. Even the most seriously diseased liver can appear normal on x-ray. Secondly, most dogs with cushing's don't have a tumor on their adrenal gland and even if they did, an xray isn't the tool for that. Lastly and more importantly, an experienced vet uses the ultrasound as a tool to not only validate a diagnosis by looking for histological changes in the adrenal glands and other organs that are associated with abnormalities cause by steroid excess, but to determine whether it's pituitary or adrenal. Your vet never made that determination and I promise you that you can't use the x-rays or the results of the LDDS test to do that. The law of averages says your pup probably has pituitary dependent disease as that's what 80% to 85% of cushdogs have.

If your vet wants to learn more about using ultrasound as a diagnostic tool, tell her she can pick up a second hand two volume set of Ettinger and Feldman's Textbook of Veterinary Internal Medicine (Fourth Edition Volume 2) where she can find this quote in Chapter 118, page 1553:


In hyperadrenocorticism, abdominal ultrasonography serves three major functions. First, it is part of the routine data base used to evaluate the abdomen for unexpected abnormalities (e.g., urinary calculi, masses, cysts). Second, if an adrenal tumor is identified, ultrasound is an excellent screening test for hepatic or other organ metastasis, tumor invasion of the vena cava or other structures, and compression of adjacent tissues by a tumor. Third, the study is used to evaluate the size and shape of the adrenals. If bilaterally normal sized or large adrenals are visualized in a dog or cat otherwise diagnosed as having cushings, this is considered strong evidence in favor of adrenal hyperplasia caused by pituitary-dependent disease. Visualization of a normal or slightly enlarged left adrenal is nonspecific evidence that weakly points toward pituitary dependence. Visualization of only the right adrenal is considered suspicious because this adrenal usually is more difficult to see. If either adrenal is remarkably enlarged, irregular, or invading or compressing adjacent structures and the opposite adrenal cannot be visualized, suspicion of an adrenal tumor is heightened.

She can also pick up a used Small Animal Diagnostic Ultrasound (Fourth Volume 2) textbook where she'll find lots of information on Adrenal Glands in Chapter 10, page 196.


I don't think this vet is open to anything but charging me. I did ask her how many doses we can get from this vial and she said 2 or 3 and then started in on how expensive treating this disease is and that she told me that upfront.

I think you are right. She seems to be acutely aware of how expensive it is for us pet owners but what she doesn't understand is that we pet owners, with ignorant vets, usually end up paying much more than we would have had we gone to a specialist in the first place. For instance, it sounds like you paid for three unnecessary xrays and an entire vial of cortrosyn when only a fraction was necessary. With your pup weighing just a bit over 15 lbs, your vet could get six or seven acth stim tests from one vial so when she said she can get 2 or 3 tests out of one vial, she either can't do the math or she's taking advantage, neither of which is acceptable.


When I asked her do we do the ACTH test in 30 days from the date of starting Trilostane or 30 days after the 2 week test, she said that shes doesnt think we have to do another ACTH test in 30 days. That didn't answer my question. I think it's time to find a new vet even though it may involve traveling.

She not only didn't answer your question, she revealed more of her ignorance. Vetoryl is a serious drug and treatment protocol was established for a reason and your vet needs to be intimately familiar with proper protocol. When somebody answers a question with "I don't think", that usually means they don't know or they aren't sure, neither of which is acceptable. Your vet needs to be sure about this and so do you because your pup is the one to pay the price if something goes very wrong. So for future reference, your dog needs to have a stim test no later that 14 days after starting treatment, 14 days after any dosing adjustment and if no change in dosing, another stim test should be done at the 30 day mark.

Glynda

[mitsua]

Thanks for taking the time to answer. This vet graduated from UC Davis and "claims" that she and Dr. Burdette were at UC Davis at the same time.

In any event, I've made an appt tomorrow with Dr. Burdette and am driving the 190+ miles to get there. I think she is completely clueless about Cushings despite what she says and I certainly would NOT just double the dose based on her say so. Again she refused to send out records directly but said she would email them to me and would tell the referring vet office that I have all the records.

I hope he can provide a better solution. I should have gone to him first, but I believed her when she said she has treated Cushings and her degree from UC Davis influenced me as well.

I'll keep the forum posted. Thanks for everyone's input.

[lulusmom]

I believe you are going to see Dr. David Bruyette at VCA West Los Angeles Animal Hospital and if so, I'm really glad that you are literally going the distance for your pup. He's a very well respected endocrine specialist who treats thousands of cushdogs. I have one of his audios and I can't remember the number of diagnostics he said his hospital ran every year for suspected cushing's but it was a staggering number. Dr. Bruyette was kind enough to join our group a few years ago and answer a lot of questions. I think we pooped him out because we haven't seen him around here for quite some time. :D

Dr. Bruyette is a huge advocate for Vetoryl as well as a huge contributor to the continuing education program Dechra, the manufacturer of Vetoryl, offers to veterinarians. I believe he used to be fine with compounded Trilostane until Vetoryl was approved by the FDA so you may meet with resistance from him as well. The good news is that there is no doubt that Dr. Bruyette has treated thousands of dogs from teacup chihuahuas to giant breeds and he'll know what to do and he'll do it right.

[mitsua]

I Don't know why he would be resistant to compounding if he doesn't think that my mini dose should be doubled to 20 mg. My vet just flat out refuses to use compounding pharmacies for any drug. Personally I think she just doesn't know anything about them except that she feels they are not accurate in their dose formulations.

I understand that a compounding vet can't duplicate an existing mg.

Hopefully Dr. Bruydette will do an ultrasound as well to rule out any other possible abnormalities. It's supposed to rain tomorrow -- I hope I can get there in under 3.5 hours; the office told me he is booked for the afternoon and if Im not on time, I won't be seen. I have to give her the dose of Trilostane in the am & breakfast before we leave.

I sure hope Dr. Bruydette gets it right the first time.. I've already spent almost $2000 with this vet including paying for the entire vial of cordrysine (sp) that she now tells me we can only use twice. I hope to be able to do at least one more ACTH test with this bottle that I bought from her once Dr. Bruydette formulates a plan.

[labblab]

Good luck with your vet visit today! I'm really glad you'll be seeing Dr. Bruyette and I hope he'll soon have you settled on a reasonable path forward.

We'll be very interested in his recommendations. As Glynda says, it has been around five years since he directly posted on our forum. But based on what he told us back in 2009, don't be surprised if he prefers to remain on once daily dosing (with an increase if necessary) until your dog's post-stim cortisol level has decreased below at least 9. Once within therapeutic range, if the late-day symptom rebound is still occurring, that may be the point at which he'd be more likely to recommend the shift unless he has changed his protocol.

As far as what he told us then about compounding, he believes there are risks any time a brand drug is reformulated or a new product is prepared out of a bulk chemical that a compounder has purchased from their own supplier. However, if a dog truly needs a dose that is not available in brand form, he did not state it but I suspect his preference might be for the compounder to reformulate Vetoryl rather than use a bulk chemical that they've purchased themselves. Even prior to FDA approval and direct availability of Vetoryl in the U.S., it was possible for vets to import Vetoryl from the U.K. on a limited basis by completing an application for a special import waiver. So I would be surprised if he has ever favored a compounded bulk version of trilostane over the brand product. But I will be very, very interested in hearing what he tells you today. He may have changed his mind during the intervening years. Just so you'll be prepared, though, this is what he told us back then:


This also brings up the issues of compounding medications and not using the veterinary approved products. A couple of facts/comments that might help -

· Compounding pharmacies are not purchasing trilostane from Dechra. Dechra has an exclusive supply arrangement with the Italian company that holds the MDF (Master Drug File). This European company is the only manufacturer approved by FDA. That means the probable source of compounders bulk trilostane is an uninspected manufacturing facility in China or India.


Sources of Problems w/ Compounded Drugs

o Reformulation of any drug product into a compounded drug product alters the behavior of the finished version of the drug.
o Compounded drugs are not equivalent to generic drugs.
o Compounded drugs are not subject to external quality control measures with regard to consistency of the manufacturing process, amount/potency of drug, consistency of formulation, lack of contaminants, and evaluation of inactive ingredients or incipients.
o The stability, bioavailability and bioequivalence of compounded drugs has not been evaluated.
o Several samples of US compounded trilostane products were analyzed by Dechra and contained <90% of the labeled content.

· Key Points from the AVMA Position Statement on Compounding (Available on the AVMA website)

o Compounding is the manipulation of a drug, other than in accordance with the FDA approved label, to make a different formulation of the drug to meet the needs of a specific patient.
o Compounding may impact the absorption of a drug. The use of a compounded drug may result in drug concentrations that lead to the development of an adverse event, including therapeutic failure.
o Use of a compounded drug should be limited to those drugs for which both safety and efficacy have been demonstrated in the compounded form in the targeted species.

· According to the AVMA PLIT if a veterinarian uses a compounded drug where there is an FDA approved animal drug, their professional liability (malpractice) insurance coverage may be voided.

Dave Bruyette


Marianne

[goldengirl88]

Good luck today from me too. I am hoping you get the answers and the information you want to help your baby. As I said before I have nothing but the very best things to say about Dr. Bruyette and his knowledge. Belssings
Patti

[mitsua]

Dr Bruyette is as wonderful as everyone said he would be and the hospital is great. We are staying on a one time a day dosing but increasing slightly for now and using a compounding pharmacy that I forgot to ask which one but his Vet tech said I should be hearing from them today or tomorrow. We ended up doing an MRI to see what size pituaray tumors my poodle has and it turned out they were microscopic. But the MRI showed other changes going on in her brain so he went ahead and did a spinal tap and Im waiting on results today or tomorrow. Once i get the new meds, Im to make an appt for a blood recheck. Since my vet charged me for the entire bottle of cortrosyn (sp?) I need to get it done there and HOPEFULLY, she will agree to send the results down to him. I wished I lived closer. Thanks to everyone here. Will keep you posted.

[lulusmom]

You spelled cortrosyn correctly so hey, you are doing good! I'm very happy that you liked Dr. Bruyette and that he is leaving no stone unturned. I'll be checking in for your updates.

Glynda

[doxiesrock912]

I'm so glad that you went to Dr. Bruyette!
Your vet scares the crap out of me and to refuse to send the records for you is beyond rude. Honestly, I would find another general vet to use. One who will work with Dr. Bruyette for the best care of your dog.

[mitsua]

I do want to find another vet. But the thing is I paid almost $300 for the ENTIRE bottle of cotrosyn and would like to be able to use it. I will ask the vet if she is willing to do the ACTH stim and share the results with the vet. Maybe I will ask her for the bottle if she refuses. Any ideas?

The other problem is that I've already exhausted the few # of vets in this area which would mean a trip 45 miles away to the next city where there are more vets.

For right now Im good until I get the new meds from the compounding pharmacy.

[goldengirl88]

I am thrilled you saw Dr. Bruyette and glad you found him to be every bit as good as I said he was. I am so happy he is treating your dog and you will get some concrete answers. He is a wonderful man and a God send to many I am sure. Blessings
Patti

[labblab]

I'm so glad you had a good trip, too! I'll be anxious to read your further updates. Do you remember what dose he is increasing you to?

Marianne

[mitsua]

from 10mg to 15mg and then another blood test in 2 weeks to see how she's doing. Im waiting to hear from the compounding pharmacy

[molly muffin]

Well I'm just thrilled that things went well with the visit to see Dr. Bruyette. Everyone just usually raves about him and he seems to be a very caring individual and vet.
Hopefully, considering the alternative, you can say to your vet, Dr. Bruyette will be directing dosage and directions. We just need to follow them and btw, you should be able to get several tests from one vial, is there a problem why you are not able to do that? :)

Can't wait to hear the further results.
Sharlene and Molly Muffin

[Renee]

Is it possible Dr Bruyette will intervene on your behalf and call your regular vet? Maybe if he calls, professional to professional, your vet would be willing to learn from him and work with him to get things right. I know it's a long shot, but worth asking! I opted to stay with my less experienced vet, but to her credit, she has called every specialist she knows and talked extensively with the only IMS in Alaska, in order to get things right.

[mitsua]

I think it's important to have a good working relationship with a knowledgeable vet and we don't have this here. She has a thriving practice; her parking lot is full and her clinic is large. I just want to get my money's worth for the cordrosyn. She charges a 1/2 day board fee and an exam fee every time you bring your dog in for any blood work in addition to the fees she charges for the tests she runs. She also charges if you ask for copies of records and shes doesn't send them directly to a vet; she gives them to me. Frankly I would rather give my money to a specialist with the experience and necessary equipment to treat a disease. I will look up IVM vets; thanks for the link. Im hoping once we get my little poodle on the correct dose --- blood tests will be less frequent unless we have dosage adjustments.

[mitsua]

ps just got updated withthe results of the spinal tap done on my little mini. Seems there is no infection; and what they are seeing in her brain minus any physical signs -- I don't have to anything medically at the moment but to let him know if she exhibits behavioral changes, or other as he explained to me. THen they may do another spinal tap. Im waiting on the compounding pharmacy and will f/u with him as he instructed.

Should have gone there first and saved a pile, or at least have gotten my monies worth up front. With as many dogs as I have had, you think I would know better; but it is such a long drive there and back in 1 day. Glad I did it though. Will be looking for other vets for yearly checkups for my other dogs.

[Harley PoMMom]

Sometimes it is impossible to find a vet that is willing to work with you, just ain't right :(:mad:

In our Resource Thread we do have links that will help one find a vet in their area and here is one ;) : Finding an Internal Medicine Specialist Vet (ACVIM) (N. America and other countries) (http://www.k9cushings.com/forum/showthread.php?t=182) You only need to type in your State and hit search. ;)

[goldengirl88]

Sorry but it sounds like your vet is in it only for the money like mine.

[mitsua]

Hi, wanted to update all re my mini poodle's cushings status. ACTH stim tests show still not low enough #s post. Plus by dinner time, she is panting like a steam engine. We started at 10mg per day, then went to 15 mg per day and now we will start 15mg 2x a day. She weights 15.3 pounds. Will keep you posted and thanks for all the suggestions and advice.

[mitsua]

My mini poodle is up to 30 mg (2) 15 mg pills a day. She weighs 15 lbs. She has had 4 ACTH stim tests because we've increased the dose 4 times and she still is panting about 2 hours after the first pill and drinking lots of water and by 7-8 hours later she is panting again and I give her the second pill and she pants for another 2 hours until she goes to sleep.

It seemed like each stronger dose works for a short time and then by the second week, she is back to panting and drinking water and starving. These ACTH stim tests are getting very expensive plus I have to get the dose compounded. Im not sure how many more ACTH stim tests I can afford.

Im working with a well known vet for cushings and he says here is no guarantee of when a dose will work. I expected to do maybe 2 ACTH stim tests, but 4 so far and Im guessing we will have to increase dose again.

Has anyone else had this problem with getting the correct dose?

[Harley PoMMom]

Unfortunately it can get frustrating getting the dose just right, and yes, on the forum I have seen this happen. One that stands out is Trixie, you can read Trixie and Barbara's thread here: almost diagnosed (http://www.k9cushings.com/forum/showthread.php?t=5155)

Is your vet using the whole vial of Cortrosyn (250 μg)? With small dogs the vial can be diluted, split up and frozen for up to 6 months which is a huge cost savings. Dr Peterson has written an article about this on his blog: How to Extend Your Supply of Cortrosyn and Lower the Cost of ACTH Stimulation Testing (http://endocrinevet.blogspot.com/2011/03/how-to-extend-your-supply-of-cortrosyn.html)

[mitsua]

My vet said I had to buy the entire bottle of Cortrosyn (almost $400) and then she charges me $260 for each ACTH test. That includes the injection; her office visit charge; the ACTh stim test and she was also charging me for 1/2 day board for keeping my mini for the hour because she says she has to clean and disinfect the cage before and after just like she were boarding. Then she said if I come to take the dog for the hour she wouldn't charge me the 1/2 day board but all the other charges remain the same. i asked her why she is charging me for the injection if I already paid for the medication and she says she has to prepare it. I did read Dr. Peterson's article and told her and she said she had already done that but the charges weren't neogitiable beyone my picking up my dog for the hour so it wouldn't have to stay in the cage..

She also said we will only get 5 or 6 injections from the bottle and so by next week we will have used 5 injections. I can't see continuing at these prices.

[Harley PoMMom]

I would think if she is doing it the way Dr Peterson states than the agent is already prepared and all she needs to do is take it out of the freezer to thaw...hmmm :confused:

[lulusmom]

Your vet is either using a supplier who has ridiculous prices or she's not being honest. Either way, her clients are being ripped off.

It took me two minutes to find a site that has a vial of cortrosyn for $133.35.

https://www.vita-rx.com/products.php?Pid=2031

Neither my gp vet nor internal medicine specialist charged me an office visit for a stim test and they most certainly didn't charge me for boarding. That's ridiculous. If I were you, I'd find a vet who cares about their client and is willing to work with them.

[Squirt's Mom]

Ditto to what Glynda said - you are being ripped off big time in a variety of ways sadly. See if you can get the stim agent yourself. ;) It is also unfortunate that it is the nature of the beast Vetoryl (Trilostane) to quite often require frequent dose changes and with each dose change the ACTH testing schedule starts all over. If you haven't already, you might look into something like Credit Care - a CC card that has little to no interest if the balance is paid within a certain time frame. That might take some of the immediate pressure off. You might also ask the vet to let you work off some the expenses - tho from the way she seems that may be out of the question. :rolleyes:

Keep your chin up, Mom! You're doing a fine job!
Hugs,
Leslie and the gang

[mitsua]

Yes, I sadly believe I am getting ripped off as well. I keep going back to her because I already paid for the Cotrosyn and don't want to have to buy another vial with another vet. I did check out a vet who folks raved about but he said he "doesn't believe" in treating Cushings with any medication; only holistically with lignans and melatonin. I will keep checking around. Most of the vets within a 30 miles radius have no experience with treating cushings (can you believe that?) or refused to treat a 15 year old. The only one I found said I would have to buy another bottle of cotrosyn since they don't keep it in stock.

Looks like her dose will have to be adjusted again as she is hyperventilating and panting like a steam engine about 6 hours after her first dose. Vet said I can dose again with evening meal instead of waiting for the 12 hours to pass. Blood work again tomorrow and another almost $300 bill and I have to take her for the hour we wait before the second draw of blood.

I'm using Care Credit -- thanks for the suggestion. Couldn't have done this so far if not. The first exam was over $600 and she didn't do any ultrasound, just xrays. I figure close to 3 grand so far on this disease and no improvement yet. I thought 30mg for a 15 pound dog would work as did the vet, but he says from her clinical signs he thinks we will have to up it again pending the results of the blood work. Don't know how much longer I can continue if she's this bad clincally and she already on Veteroyl not sure what to do if I have to take her off for financial reasons.

[mitsua]

Vet just upped my 15 pound mini poodle to 40 mg per day because ACTH stim test still shows elevated cortisol. Getting nervous. Anyone else has a little dog on such a high dose?


Also, vet just told me there is only enough cortrosyn left for one more shot so I have to buy another bottle. We've had 5 shots so far. She said that there is a lot of waste everytime you stick in the needle. And also that you can't really empty the bottle. Seems she just sticks the medication back in the freezer and then thaws the vial in order to get the medication for the ACTH stim test. Does this sound right?

[Harley PoMMom]

Vet just upped my 15 pound mini poodle to 40 mg per day because ACTH stim test still shows elevated cortisol. Getting nervous. Anyone else has a little dog on such a high dose?

If you would get copies of those ACTH stimulation results and post them here we would be able to provide you with more meaningful feedback.



Also, vet just told me there is only enough cortrosyn left for one more shot so I have to buy another bottle. We've had 5 shots so far. She said that there is a lot of waste everytime you stick in the needle. And also that you can't really empty the bottle. Seems she just sticks the medication back in the freezer and then thaws the vial in order to get the medication for the ACTH stim test. Does this sound right?

No this does not sound right, and here's a quote from that article I posted to you before from Dr Peterson:
However, by following the protocol outlined below, you can easily dilute, aliquot and store Cortrosyn after reconstitution for up to 6 months. She should be diluting the Cortrosyn, splitting it up, putting the split contents into individual vials and then freezing them. She only needs to pull from the freezer a single pre dosed vial to be thawed out.

Hugs, Lori

[My sweet Ginger]

4. Freeze each of the syringes at -20oC. Avoid storing these syringes in a frost-free freezer, which must periodically warm up to de-frost. Repeated freezing and thawing cycles would compromise the integrity of the Cortrosyn.

I don't know how much of the integrity of her ACTH tests have been comprised by her Dr. not following Dr. Peterson's protocol each time but it doesn't sound like she's been following his protocol.

[goldengirl88]

How about this one. I believe my vet is using Dr. Petersons protocol, and getting 5 or 6 uses out of a vial, but still charging me full price for the tests!!!
Also, to say something about the 40 mg dosing. Are you giving the dose all at once in the morning or are you splitting it up? It seems when I split Tipper's dose she does not do well. Dechra told me that some dogs do netter with one total dose in the morning, so I guess Tipper falls into that category. If you are splitting the dose maybe this would work. Tipper was a hard one to get the dose right too. Make sure you get the ACTH when changing doses. Are you giving Vetoryl or trilostane compounded? Blessings
Patti

[mitsua]

I don't know what you mean by full price for the shots. My vet charges me $230 each time I have her do an ACTH stim test in addition to the initial charge of almost $400 for the cordrosyn.

This is becoming unmanageable. It would be higher but I refused to pay a half day board and so take my Mini out of the office for the hour otherwise it would be another $25 board charge.

I don't know to believe her anymore. When I asked her if was freezing individual syringes she said yes. Now she said what I wrote above that you don't get all the amount out of the vial. I can't get the ACTH tests unless I pay her $10 for the record each time she has the test. Shes says she only does professional courtesy for free which is vet to vet. Im scared to think she might be compromising the results by not using the ACTH correctly.

Im starting Missy on 20 mg two times a day. The vet went to twice a day dosing because she was panting so bad by the early evening. I was giving 15 mg compounded -- since we changed the dose again, the vet said he would order 5mg compounded so to combine it with the 15 mg capsules I have left and based on the results of the next blood test will decide it she has to be upped again or can go on the mfg 20 mg capsules.

We started with 10 mg one time a day; then went to 10 mg 2x a day; then went to 15 mg 2x a day; and now we are at 20mg 2x a day

Anyone have a 15 or under pound dog that is getting 40 mg of veteroyl per day?

[lulusmom]

Both of my cushdogs were much smaller. Lulu weighed 4.5 lbs and stabilized on 30mg once daily. Jojo was 6.5 lbs and stabilized on 15mg twice daily. Every dog is different so you just never know.

If I were in your shoes, I would have been looking for another vet long before now. I couldn't believe how much you are paying for an acth stim test, on top of paying for a vial of cortrosyn that your vet has marked up by two to three hundred percent. Now after paying a ridiculous amount for that vial of cortrosyn, she hasn't even followed instructions and stored it correctly, which could compromise the accuracy of the test. If that's not bad enough, she is charging you $10 for a copy of test results which you've already paid through the nose for? Talk about adding insult to injury. I don't even know what to say except shame, shame, shame on her.

[mitsua]

I will be looking for another vet now that we've gone through the cordrosyn. I had hoped that my mini would stabilize and I had already paid for the original bottle so stuck it out. But now that we're done, I can start looking.

I checked with 2 local vets and they haven't treated a cushing dog. They both referred me to 2 specialty vet clinics which are about 45 miles away. I believe one of the vets in one of these clinics is a friend of my vet as my vet has mentioned her by her first name before. So Im a little leary about going there. But this time I will ask PRICES BEFORE I make the appt. Plus it was a problem with working with another vet in LA for dosing guidance and having the local vet do the blood work. One vet said if I was going to LA for advice, I could go there for blood work. THis is a very rural, very country, very small minded community Im currently living in.

[lulusmom]

If you have two specialty hospitals within 45 miles, you're lucky. My dogs' IMS was over 50 miles away and in So Cal, that is an hour and a half drive one way on a good day. The last time they did a stim tests, it was $268 and that included the cortrosyn. I had two cushdogs so that was times two every ninety days. I did eventually find two local vets over the course of seven years who gladly did the acth stim tests for me for $160 and $195.

I now live in a very,very rural mountain community and have noticed that the vets I've met seem to be limited in their knowledge of anything past the usual broken limb, UTI's, spays, neuters, etc. They are not, however, small minded and are open to working with me as much as possible. I can't imagine any gp vet telling me that if I went to L.A. for a consult with Dr. Bruyette, I should drive there for the stim tests. Apparently, the ego is more important than working with and learning from a renown endocrine expert. That's not narrow minded, that's closed minded and beyond arrogant......and certainly not acting in the best interest of your patient and client. I would have been hard pressed to keep my temper in check.

[goldengirl88]

I thought I had the worst vet of anyone on here, but sadly I think yours enjoys gouging owners for as much as she can get too. When greed takes over instead of the welfare of the animal I find it so sad. All my vet cares about is how much he can get out of you. Tipper is his number one cash cow. I would be going somewhere else too. Unfortunately out here in the country where we live there is no one else or I would have been gone long ago. I hope you get a kind, and caring vet for your baby. Blessings
Patti

[mitsua]

Actually the two vet clincs are 45 and 47 miles from my home, but you're correct, that distance in CA takes almost an hour and once you hit SB you crawl through traffic and lights. I related to the rural rural limited knowledge/experience vets who practice in the country. She takes the cake, though. I've never dealt with a vet with such an attitude. She actually said, oh, you will drive to LA to pay LA prices for vet services but you're complaining about mine? It was difficult to keep my temper. Now that Im almost done with the Cortrosyn ( so she says) I told her office DO NOT order another bottle.

Im calling the other vets around to see if anyone can do these tests at a more reasonable rate without having me buy a bottle of the medicine. My focus is my animal; she is just bothersome and temporary.

Just started with her 20 mg 2x a day. She is panting 4 hours later as I write this, but the LA vet said she has to be on the increased dose for a couple of days.

[Renee]

Yikes, your vet is a piece of work.

I have an inexperienced vet when it comes to cushings too. The biggest difference is that my vet is willing to learn, respects my opinion, and has worked with me as a team to manage Tobey's cushings. She readily admits what she may not know, and has researched everything along the way.

At this point, for you, I think it is not so much finding a vet with cushings knowledge (as you are unlikely to find), but that you need a vet that is not offended by your knowledge and is willing to learn about cushings. And is not price gouging you. And to charge for copies of test results? Inconceivable.

I had to buy the bottle of cortrosyn upfront ($250), and now I only pay $110 for each stim test. We get 5-6 uses out of each bottle, then I'll buy another. My vet has no other cushings patients, which is why I have to buy the entire bottle. Otherwise, I could share the cost with someone else.

[goldengirl88]

I hope you found somewhere else you can go to. You vet has very poor skills for being in business. Charging someone for copies of something they have paid for is disgusting. I would run as fast as I could to someone else. Let this new vet request the file and see what she does then. What a piece of work this woman is. You dog is just a number to her, just another cash cow. She thinks her license is for robbing people not for helping pets. Blessings
Patti

[mitsua]

Thanks for all your input. Yes, a cushings-knowledgeable vet may be hard to find but more important is a vet who will work with me. Im not originally from this area and these local vets are very put out when you either question or flat out tell them something other than what they told you is correct.

Im shopping vets. Meanwhile we're seeing how my little mini is doing on the 20mg twice a day At least I now know what questions to ask up front what the charges are. So it was an education; albeit an expensive one. I did find another vet who backed down when I said by law he has to give me a prescription when he first refused; but he doesn't treat nor does he want to treat cushings, so we keep searching.

[goldengirl88]

I understand completly. I have to get in an argument every time I want my vet to do or not do something. I think it is all about the ego! You will find someone so just take your time and make sure they will work with you and for your dog. Blessings
Patti

[mitsua]

My 15 year old 15 lb poodle is up to 40 mg veteroyl a day and her cortisol level is not dropping. She is panting like a steam engine, drinking almost a quart of water a day and still has a voracious appetite. We checked out her heart for possible reasons for panting but her heart was OK. Her thyroid is OK. The vet wants to raise it to 50 mg a day. How high can we go with dosing for a 15 lb dog? Shouldn't I be seeing changes already? She is drinking lots of water and eating everything. So there's been no improvement since we started on Trilostane.

Suggestions???

[Iraklis]

LDDS or ACTH results?

MRI or ultrasound results?

[Harley PoMMom]

Hi and welcome to you and your girl,

If you could get copies of all the tests that were done on your girl and post any abnormalities that are listed along with the reference ranges and units of measurement that would help us...thanks!

We are especially interested in the results of all monitoring and diagnostic tests that were performed on your girl for Cushing's. How long has your girl been on Vetoryl and what symptoms led you or your vet to test for Cushing's in the first place? I see from your post that her thyroid checked out ok but diabetes shares many of the same symptoms of Cushing's, was this ruled out? Was an urinalysis done, and if so could you post those findings?

I am sorry for all those questions but the more we know about your girl the better our feedback will be, ok? Please know we will help in any way we can so do not hesitate to ask all the questions you want. ;)

Hugs, Lori

[goldengirl88]

With a 15 pound poodle on this high of a dose, I would be calling Dechra asking their advise on what to do here. I know some dogs on here have taken really high doses for their weight, but there are exceptions to everything. I would want to see the test results as asked for above. This is a high dose so I would want absolute reassurance there is not something else going on here. Most of the Cushings dogs pant. Usually that goes away with treatment. You can search the different causes of panting, mostly from enlarged livers, and fat redistribution pressing on organs that then press on the diaphragm etc. I would be on the phone to Dechra and have copies of all test results. Are you getting ACTH testing between dosage changes? Blessings
Patti

[labblab]

Does Dr. Bruyette know about and approve of this most recent dosing increase? From what I can see, it looks like around a month ago you jumped to 40 mg. with his knowledge. Does he know about this new increase to 50 mg.? In the grand scheme of things, 50 mg. is not astronomically high since it is approx. 3 mg. per pound and that is the high end of the initial dosing range originally published by Dechra. Some dogs ultimately require even higher doses than that.

But unless Dr. Bruyette has OK'd this, these are my two concerns. First, we don't know how accurate the monitoring ACTH results have been since we don't know whether your vet properly handled the freezing of the stimulation agent. Secondly, your dog's cortisol level may have continued to lower even had the dose remained unchanged for a while longer. What are the actual numbers for the monitoring ACTH results?

Marianne

P.S. You'll see that I've merged your new question into your original thread and also edited the title a little. This way, all the history about your dog will be consolidated in one place.

[molly muffin]

I agree, that I wouldn't raise anything without Dr. Bruyettes knowledge and okay.

Sharlene and molly muffin

[mitsua]

Thanks to everyone.

We've ruled out diabetes and cardio for the panting. We've done MRI for tumors and spinal tap for possible infections.

I've decided in view of no abatement in clinical signs to stop treatment with veteroyl. Even if the ACTH stim were not done correctly, the drinking, peeing and ravaneous appetite has not diminished at all since she went on it. And she started whining, circling and became very restless, confused and very clingy which were new behavioral signs. We were already at a pretty high dose for a 15lb and although the vet was comfortable increasing her dose, I was not. We are going to try a medication for canine senility to see if these new symptoms area indicative of senility or were side effects of the high dose of Trilostane.

ALthough I don't doubt she has all the clinical signs and blood work results of a cushing dog, sometimes the cure is worse or as bad as the disease. So for better or worse, this 15 year old dog is going off the cushings meds.

[molly muffin]

Sometimes it is the best solution.

hugs
Sharlene and molly muffin

[lulusmom]

I just wanted to say that you never know how much Trilostane it's going to take to stabilize your dog. My tiny Pom, Lulu, weighed four pounds and stabilized on 30mg which equates to 7.5mg per pound. My other Pom, Jojo, was 6.5 lbs and stabilized on his starting dose of 15mg twice daily. I can certainly understand your decision to discontinue treatment but wanted you to know that my dogs were much smaller than your pup and were on much larger respective doses.

[Renee]

I just wanted to say that you never know how much Trilostane it's going to take to stabilize your dog. My tiny Pom, Lulu, weighed four pounds and stabilized on 30mg which equates to 7.5mg per pound. My other Pom, Jojo, was 6.5 lbs and stabilized on his starting dose of 15mg twice daily. I can certainly understand your decision to discontinue treatment but wanted you to know that my dogs were much smaller than your pup and were on much larger respective doses.

I agree with this statement, and also want to say that your pup has only been on vetoryl for 2 months.. and, there are some dogs on here that have taken longer than that to see consistent improvement. My own pug was one step forward two steps back for the first 2 months, and only the last 2 -3 weeks would I consider her 'stabilized'.

[mitsua]

I can certainly understand your positions that she could have been on it longer or it could have been a higher dose which might do the trick but at some point you have to consider the finances as well. Since November when we first started testing, it's been almost $5000 in tests, medication, injections, blood work, etc. And no clinical improvements but side effects like whining excessive panting, clinginess, restlessness behaviorial changes. And the blood work showed the level going up. And the vet said I had to buy another bottle of medication at almost $400 to do more testing.

She is an old dog at 15 -- I haven't had one reply to my question on did anyone have a dog 15 on veteroyl. Most of the dogs were younger when diagnosed from the posts Ive been reading So my decision, while may not be a popular one, is the one I feel comfortable doing. We'll see how she does on the senility medication which is off-topic for this forum. Again, thanks to everyone who contributed and especially for the referral to Dr. Bruyette in LA.

[molly muffin]

I am sure that with almost 3000 members world wide we have had some dogs who were treated when they were 15. I am never great at remember ages of specific dogs though so I can't name them for you. I remember a 17 year old maltese mix. Some 13 and 12 year old dogs.

However, every decision has to be based upon your personal experience and what is going with your dog and what you think it is best. Without having a knowledgeable good vet on your side, which you don't, it is even more difficult.
I think always the answer comes down to quality of life and what do you think will keep her the most comfortable.
I know finances are a consideration for many, if not all or most with cushings. One option is to do base line cortisol tests and electrolytes and not do full ACTH as often. When you do a full test, go a vet that is treating other dogs, as the medicine on hand and doesn't have to buy a bottle just for you, or charge you for the bottle.

Sharlene and molly muffin

[Renee]

I never meant to 'call you out' or shame you. It just seemed that maybe you might have been giving up too soon, but based on your reply and the other factors at play, I can certainly understand and respect where you are coming from.

Please don't take offense, because none was meant.

[doxiesrock912]

Daisy was diagnosed in February of 2013 and we still aren't at the ideal dose. Every dog responds differently. Hugs.

[molly muffin]

Oh I did want to comment that you aren't off topic at all. Senility medication is often needed when our pups get older. Which medication will you be using? We have had a couple use Novofit.

Once you join our forum, we consider you family, whatever may come, cushings or non cushings. You certainly don't have to leave because you aren't medicating. We will be right here, any time you want us or feel you want to have a chat.

hugs
Sharlene and molly muffin