Are these effects of Vetoryl normal?

[Murphysmum]

Hi,
I am the very proud mum of Murphy, a 12 year old Jack Russell/Border Terrier cross who is a diabetic dog.
Over the last week Murphy has had various tests & the result was that as well as being diabetic (which is very well managed) he now also has Cushings:(
Our vet prescribed 30mg of Vetoryl per day on Friday and he has just has his 3rd dose. Unfortunately since he started the Vetoryl Murphy seems very depressed and not his normal self at all. Is this normal? Should I get him back to the vets tomorrow?
Thanks in advance for your help.

[Junior's Mom]

Welcome to you and Murphy. Can you tell us what tests were run to diagnose cushings. If you could please post any abnormal results from bloodwork, along with the reference ranges, that would be very helpful.
Vetoryl will make the cortisol levels drop, sometimes drastically. It may be a case of him having to adjust to it, or he may be dropping too low.
How much does Murphy weigh? The recommendation is start with no more then 1mg per pound.
Did your vet give you any prednisone in case of emergency? Did they tell you side affects to watch for, such as lethargy, lack of appetite, vomiting and/or diarrhoea.
This is a great place for information and support, glad you found your way here.
Tracey

[lulusmom]

Hi and welcome to you and Murphy.

I have manually validated your membership so that everyone can now see your post. You can disregard the email you receive from k9c asking you to respond.

I'm sorry for the reasons that brought you here but I'm glad you found us. Before I answer your question, I have several of my own, the answers to which will help us greatly understand everything leading up to this point. We are a very curious lot and ask lots of questions so that we can become very familiar with the history of every dog. Fact gathering is like an initiation for new members. :D So let's get started.

When was Murphy diagnosed with diabetes and when did you gain effective control of his blood sugar? What prompted your vet to pursue a cushing's diagnosis after the diabetes was controlled? Was it symptoms that did not resolve and if so, which symptoms? What tests were done to diagnose cushing's and can you please post the results of those tests? Was an abdominal ultrasound done to validate the diagnosis and/or differentiate between adrenal and pituitary dependent disease? How much does Murphy weigh? Did your vet explain that Vetoryl must be given with food for proper absorption? Did s/he also tell you that Murphy should be scheduled for his first acth stimulation test no later than 14 days after starting treatment?

Now to answer your question. Dogs are extremely sensitive to Vetoryl initially and cortisol can drop like a rock. You have to be very careful because that can greatly affect insulin requirements so blood glucose levels can drop like a rock too. Even dogs that don't have diabetes can feel pretty crappy in the first week due to cortisol withdrawal. Their body has been swimming in a sea of a feel good steroid and when levels drop so rapidly, they body feels like crap. Depending on how much Murphy weighs, 30mg could be too much for him and drop cortisol too low rather quickly. So you have three scenarios that could possibly be going on with Murphy....hypoglycemia, cortisol withdrawal and/or cortisol has been dropped too low by Vetoryl. If Murphy's condition worsens, do not wait until tomorrow and get him into an er asap. By worsen, I mean extremely lethargic, no eating and/or drinking, vomiting, diarrhea, inability to get up or walk. Cortisol withdrawal is not an emergency but low glucose and low cortisol can be life threatening if not addressed quickly. Do let your vet know what is going on.

We have a sister site, www.k9diabetes.com, and I highly recommend that you consider joining there. A lot of us are also members there so that we can work hand in hand in helping our mutual members. You would definitely have the best of both worlds.

Again, so sorry for all the questions but the more information you can provide, the more meaningful feedback you will received from us. We're here to help in any way we can and you can never provide too much information nor ask too many questions.

Glynda

[Murphysmum]

Thank you for your replies, it makes me so happy that there are people who understand when I am such a newbie to it all! Murphy was diagnosed with diabetes over 2 years ago after he became very ill very quickly and ended up having to stay at the vets for several days. We were very lucky and managed to get his caninsulin dose at the right level very quickly and other than a bout of Pancreatitis about a year ago his diabetes has remained very well managed other than having to slightly up the caninsulin a couple of times. 10 days ago we dropped off a pee sample for a routine check of his diabetes, we got a call as soon as the result came back as it showed extra fluid in his pee and extra sugar & the vet wanted to check if there could be something non diabetes related. We explained that he had been drinking and peeing a lot more recently and was panting and pacing a lot at night (at about 1.30am for 30 minutes to an hour). We took him back for a blood test which the vet said was to check for absolutely everything that routine tests don't check for (she didn't say what they were checking for or what type of blood test it was). The day after we got a call saying that the test showed suspected Cushings (she didn't say why they thought this) and we had to take him in and leave him for an hour while they did the test. The next day they phoned us and said it was confirmed that he had Cushings as well as his diabetes & we have to give him 30mg of Vetoryl a day with his tea, he is 21.6llbs. She didn't give us any readings, she never seems to do this, maybe this is a UK thing! The vet wants to see him again a week on Monday which will be 10 days after his original dose but I am so worried about him as he seems so down and I hate seeing him so miserable!

[molly muffin]

It could be that the 30mg is too much for him if he weighs 21.6 lbs. Dechra now recommends starting at 1mg/1lb, especially till they see how he is going to react. I would be more comfortable with 20mg. Specifically Dr. Peterson, one of Dechras contributing vets and world reknown in his field with cushings, says that a diabetic dog should be on a split dose, of for instance 10mg in the am and 10mg in the pm, (if you are doing 20mg) for better control of cortisol in relation to the diabetes.

So put together that and this doesn't seem to be perhaps his best dosage solution.

Now having said all that, you can ask the vet for the values. If you don't ask they usually don't tell. So, was his blood sugar controlled when they did the other blood work for testing for anything else?

It sounds like they did an over all blood test, probably got back some high liver enzymes and then did an ACTH. (my guess based on what you said and the 1 hour wait)

So, those are my thoughts. 30mg might be too much for his system and a lower dosage on a split dosing schedule would likely work better.

and hello and welcome to the forum :)

Sharlene and molly muffin

[Murphysmum]

Thank you. I will ring the vets tomorrow when they open and I will ask more questions. I was so shell shocked when they told us I didn't ask any of the right things. I just want him to be well and I feel awful that the pills I am giving him seem to be making him feel terrible.

[Junior's Mom]

I'm not sure what you mean by giving him the vetoryl with tea.
It needs to be given with a meal, in order to be properly absorbed.
It's best to feed first, then give the vetoryl after. That way, it could still be with-held if a dog shows signs of not wanting to eat.
Not giving it with food will also affect the monitoring tests that need to be done at 10-14 days, 30 days, then every 3 months as long as the dose isn't changed.
Tracey

[jxeno13]

Hi and welcome to you and your baby, Murphy. I'm sorry that he's having problems. :( But please call your Vet tomorrow and please question the dosage your Vet is giving Murphy. To have his cortisol level drop too low, too fast..is NOT good! Trust me, I've been there. 30mg of Vetoryl for a 21 pound dog is a lot. If he becomes sick at all...STOP giving it to him immediately! Please call your Vet tomorrow. As the others have already said it is recommended 1mg per lb. ...It's best to start low and slow...and work up from there if needed, depending on the cortisol level after the first ACTH Stim test 10-14 days after taking the drug.

You've certainly come to the right place.

Good luck and let us know what your Vet said.

Jo Ann and Eli

[Murphysmum]

Tracey, I am sorry for some confusion. In northern England we call an evening meal "tea". He has his vetoryl as soon as he has finished his meal. I am now also going to ask the vet what effect it will have on his tests as it will be 12 hours after he has his dose before they do the acth test, he eats his evening meal at 10 and his test will be at 10.30 the following morning.
Thank you and prayers to you all
Debbie

[Spiceysmum]

Debbie,
I've not got much time now as I'm just off to work but wanted to say that UK vets will usually give you the test results if you ask for them. Also, vetoryl is usually given in the morning, after breakfast. That way the ACTH can be performed within 4 hours after dosing.
Linda

[goldengirl88]

You always want to give the dose in the morning after they have eaten. This is my routine and maybe it will help. I take Tipper to potty and makes sure she poops and I check it to make sure she does not have diarrhea. You never give it to a dog with diarrhea. Then she eats her breakfast and I give her 1/4 teaspoon of coconut oil as Vetoryl is fat soluble. If a dog is on an uneven split dose for some reason, you need to give the larger portion of that dose in the morning and then have the test. I wanted to give the larger part of Tipper's split dose ( she does not split anymore) at nite because I felt that is when she got bad. Dechra told me if I did this I would have to get my vet to stay open at nite to do the testing as it has to be after the larger dose. Your best bet is to do it in the morning. Another thing I just wanted to mention you should use the same routine every day, and when you get ACTH testing done go at the same time of the day for all the tests. That way you are comparing apples to apples. Good luck to you and your baby. Blessings
Patti

[lulusmom]

Please see my comments in blue text below.


10 days ago we dropped off a pee sample for a routine check of his diabetes, we got a call as soon as the result came back as it showed extra fluid in his pee and extra sugar & the vet wanted to check if there could be something non diabetes related.

This is concerning as blood glucose in the urine would indicate that the diabetes is no longer controlled. At this point, how much insulin was Murphy getting? By fluid in his pee, I am assuming that his urine is completely dilute?

We explained that he had been drinking and peeing a lot more recently and was panting and pacing a lot at night (at about 1.30am for 30 minutes to an hour).

These are symptoms that are associated with cushing's and diabetes so in the absence of other symptoms associated with cushing's and glucose in the urine, first suspect would be diabetes. At this point did your vet check blood glucose levels and were they acceptable?

We took him back for a blood test which the vet said was to check for absolutely everything that routine tests don't check for (she didn't say what they were checking for or what type of blood test it was). The day after we got a call saying that the test showed suspected Cushings (she didn't say why they thought this) and we had to take him in and leave him for an hour while they did the test.

I'm sure the blood test was a blood chemistry and hopefully a complete blood count. An acth stimulation test takes an hour so I'm pretty sure that this was the test your vet did to confirm the cushing's diagnosis. It would be very helpful if you could please ask your vet for copies of all testing and post the results here. If Murphy's diabetes was not under control, you would expect some of the same blood abnormalities as those associated with cushing's. Cushing's is very difficult to diagnose under the best of circumstances which is why it is a risky proposition to do testing for cushing's until blood glucose is under control. Uncontrolled blood glucose can cause false positive acth stimulation test results.


The next day they phoned us and said it was confirmed that he had Cushings as well as his diabetes & we have to give him 30mg of Vetoryl a day with his tea, he is 21.6llbs. She didn't give us any readings, she never seems to do this, maybe this is a UK thing! The vet wants to see him again a week on Monday which will be 10 days after his original dose but I am so worried about him as he seems so down and I hate seeing him so miserable!

Did your vet instruct you to give Murphy his dose in the morning with a meal? Did she also tell you that you need to have Murphy to the office within three to five hours of dosing?

[Murphysmum]

Hi, thank you for all of your messages.

Murphy seemed a little better today, he even wagged his tail! I have spoken to the vets (the receptionist as the vet wasn't available) and they have said that they will get me his readings when we take him in on Monday.

When they did the 1st pee test the vet said that the results showed some sugar and a lot of fluid (his pee is almost clear). She said that she thought it was possibly his diabetes but she wanted to run extra tests as she was concerned that if we only checked for his diabetes then we could be missing something else that was going on.
I am no good at maths but we use the 0.5ml Caninsulin syringes & we have to go up to the number 8 line on them, we use the 40iu per ml Caninsulin, Murphy has his Caninsulin twice a day at 10am & 10pm. We had to make it at 10am as he doesn't appear to like eating anything before that time! The vet had said it was best to inject him either while he was eating or just after and he then goes for a walk after he has finished his breakfast.
Normally if Murphy's diabetes has gone a little bit wayward then he will be very lethargic and not want to eat but that wasn't happening, he was quite spritely for an old chap and had a very good appetite, he was however peeing and drinking a lot which can also be signs his Caninsulin dose needs to be changed.

When the 1st blood test came back the vet phoned and said that the results showed that his diabetes was still well managed, I didn't think to ask how they knew this but hopefuly they will tell me on Monday, but that they suspected that Cushings was creating the diabetes type symptoms even though his diabetes was seeming to be under control.

When we had the next test (from what you have all said it would have been the ACTH test) and they diagnosed the Cushings they rang and said we had to pick up some Vetoryl for him. When we got there (in about 10 minutes flat after finding out my little guy needed something to make him better!!) the vet wasn't available. The receptionist gave us a paper bag with the medication inside, there was no box or instructions, just one of those strips of tablets that you have to pop the capsules out of. On the front where it had Murphy's details it just said 30mg, to be taken once a day. I asked straight away when we were supposed to give it to him & should it be with food. The receptionist looked at his notes on the computer & said that we should give them to him with food and we could give it to him at night or in the morning. In my wisdom I thought it would be better to give it to him at night as his symptoms (the pacing and panting) are always worse at night, and the notes on the vets computer said that it would be ok. We weren't warned about any side effects or what to look out for which is why I found you guys on here! The vet has also stipulated that his test always has to be at 10.30 in the morning so that he can have had his breakfast and insulin immediately before we take him in. From what I am reading on here we would have to give him his Vetoryl at about 4.30 - 6.30 am which I don't think we can do as there is no way he would eat a thing at that time of the morning, he is far more interested in dreaming about chasing cats at that time.

Since I have been reading about things to look out for on this forum that he does have a little pot belly and a little coin sized bald patch on his tail, also the fur on his stomach has got a bit thinner.

I really wish I had found this forum when they 1st mentioned Cushings as I would have been so much more prepared.

Thank you again for all of your help. You are in my prayers every night.
Debbie

[molly muffin]

If the testing is not done within the 4 - 6 hour period of giving the vetroyl, then the results will not be inaccurate. This is included on the brochure and information pack that comes with vetroyl and the vet should know it but it doesn't seem like they do. :( that isn't good. You should be able to schedule the tests. If you give him meds at 8am, you'd go in for test at 12 (noon) and the second draw would be at 1pm. 4 hour interval. If this vet is definite that he has to do a test at 10:30 then he is no cushings vet that's for sure. There really is no if ands or buts about it.

And diabetic dogs should be on a split dose. I think you need to clarify with your vet how much experience he has with cushings. I hope he isn't messing up a bunch of dogs with this sort of testing regime. There are reasons for the way things have to be done and it is because of the way the medication reacts in the body.

Hang in there.
Sharlene and molly muffin

[Harley PoMMom]

This excerpt is from Dr. Peterson's blog. Dr Peterson is a renown canine Cushing's expert and who also is a contributor to Dechra's continuing education site:
Remember that the ACTH stimulation test is the most useful test for monitoring dogs being treated with trilostane (Vetoryl) or mitotane (Lysodren) see my blog entitled, Diagnosing Cushing's disease: Should the ACTH stimulation test ever be used? Both medications are fat-soluble drugs and must be given at time of meals, or the drugs will not be well absorbed.

With trilostane, it’s extremely important to give the morning medication with food, and then start the ACTH stimulation test 3 to 4 hours later.

Fasting these dogs on the morning in which the ACTH stimulation test is scheduled should be avoided since it invalidates the test results.

When a dog ‘s food is withheld, the absorption of trilostane from the gastrointestinal tract is decreased. This leads to low circulating levels of trilostane, resulting in little to no inhibition of adrenocortical synthesis. Therefore, serum cortisol values will higher when the drug is given in a fasted state than when it is given with food.

What's the Best Protocol for ACTH Stimulation Testing in Dogs and Cats? (http://endocrinevet.blogspot.com/2011/03/whats-best-protocol-for-acth.html)

[Murphysmum]

Thank you again for the comments, they really are so helpful, I wouldn't have had a clue without them.
I have spoken to the vets again today. I had to pass messages via the receptionist as the vets were all very busy and couldn't speak to me directly. I asked about why they had told us we could dose him at night & why we weren't told he had to have the Vetoryl within a few hours of his test. The receptionist apologised (a lot!) and said that it had been in his notes & they must have missed it when I asked about dosing him. The vet has said we can take him at 12 on Monday now and I have to gradually change his feeding times over the next few days so that his meal & Vetroyl will be at 8 on Monday morning.
Murphy is still very lethargic and hardly eating anything, I explained this & I asked if we could reduce his dosage and split it based on Dechra's advice, the vet has said no, we have to keep him on the same dose of 30mg once a day until we get the result of his Monday tests. The vet said that it is normal for him to be lethargic and to have reduced appetite at this point & to only get worried if he stops eating anything at all & we should contact them straight away if that happens. I have managed him to get him to eat a bit of chicken this afternoon, I had to put it in a bag & rustle it a lot so he thought something exciting was on the way (he loves anything that comes out of a plastic bag!). I feel a bit better than when he only ate a tiny mouthful this morning.

Thanks & prayers to you all
Debbie & Murphy

[goldengirl88]

That is true about staying on the same dosage until the testing I think Dechra told me about 2 weeks. If you dog is struggling though and you are afraid he is getting low cortisol, stop giving it immediately.

[Murphysmum]

Thanks Tipper's mom. Knowing you got the same advice about not changing the dose has made me feel better.

Thanks and prayers Debbie and Murphy

[molly muffin]

Definitely keep an eye on him as I have some concerns about his not wanting to eat and you already needing to entice him to eat the chicken. It really isn't normal for them to just stop eating. With the vetroyl and diabetes, if he doesn't eat, then call that vet back immediately and tell them they need to schedule a test, he isn't eating. I am worried about continuing him on this dose till monday when he is already lethargic, not eating much, and is diabetic, and a 21lb dog on starting 30mg vetroyl.

http://endocrinevet.blogspot.ca/2012/12/low-dose-twice-daily-trilostane.html

This is something you can print off and take to your vet. It discusses the starting dose, appropriate time to test, give with food, and twice a day dosing for diabetic dogs. Dr. Peterson is well known in his fielding and leading researching and contributer to Dechra, continuing education. (Dechra Makes Vetroyl, that means for me, Dr. Peterson over rides any GP vet) :)

Nothing wrong with having some ammo when you do go in. :)

Hang in there
Sharlene and molly muffin

[goldengirl88]

How is Murphy doing today? I hope everything is ok. Just keep a close eye on that one! Blessings
Patti

[Murphysmum]

Hi, Murphy is a bit brighter today. He ate a little bit this morning and has just wandered to his bowl and looked at us as if to ask why we hadn't filled it yet. Needless to say the bowl was filled very quickly and he has had some more to eat. Its not at his normal feeding time for his diabetes but we fed him before he had chance to change his mind! I am really hoping this is the beginning of an improvement as I haven't slept for worrying and checking on him through the night! Thank you all for your concern. It really means a lot .
Thanks and prayers to you all
Debbie and Murphy

[molly muffin]

I am so pleased to hear that Murphy is doing better today than yesterday.
I know I am a worrier too, most if not all of us on here are. This is good though. I like to hear that he is eating and it maybe yesterday he was feeling off from the cortisol levels dropping which can happen too.

hugs
sharlene and molly muffin

[goldengirl88]

So glad to hear your Murphy is doing better. I hope he continues to improve as I know what it is to worry , I am one of the worriers Sharlene described! Blessings
Patti