Chloe our almost 10yr old daschund recently diagnosed. Question about ACTH test

[csernablanco]

Hello,
My name is Christina and our family has 2 miniature daschunds Zoe (brown) who is about 11 yrs and Chloe (black) who is about 10yrs old. Zoe our first baby had to have spinal surgery in late January this year bc of a herniated disc that popped and almost left her paralyzed. The surgery was a success and she is active just as before. Then in march Chloe started to pee in the house and on short car trips when this was never an issue. She has always drank a lot but never had issue with peeing in the house. I eventually took her to the vet and they treated her for a urinary tract infection. She still continued to pee in the house and was drinking a lot after the treatment was completed. I had also realized she kept gaining weight and her belly looked huge. I was thinking she had a mass or fluid inside so I took her to the vet again they did xrays and blood work and besides a slighty elevated ALT and cholesterol, everything else was normal. The doctor left it up to me to just keep watching her and seeing if other signs occurred. Another month passed and her drinking increased, peeing in the house and her appetite and weight increased. She was always normal weight 12-13 lbs until this year. She is now 15.7lbs. She also couldn't tolerate her walks anymore. So I googled all her symptoms and realized she fit the picture of cushings. I called the vet the next day and insisted I knew she had cushings and I wanted her tested.
Soon after she had the LDDS test done and had elevated cortisol levels with all three samples. She was started on vetoryl 10mg and has been on it for about 2.5 wks. No major changes on the meds yet but maybe just less drinking and peeing in the house and more tolerance for walks.
She just had her first ACTH test at 10 days and her results stumped the vet and she had to consult a specialist. Her pre test cortisol value was <1.0 mg/dl, this was drawn two hours after I gave her meds that morning ,then her 2nd cortisol value was 27.3 mg/dl which was drawn 2 hrs after the ACTH was given. After consulting with the specialist she decided that it was best that my dog should stay on the 10mg for now and we will reevaluate at her 30day test because her clinical signs were slightly improved.
My question now is would we have gotten more accurate results if they had drawn her pretest blood at 4hrs post vetoryl as opposed to 2hrs post then dosing her with the corticotropin then drawing the second value 2hrs after that. Her 2nd sample only ended up being 4hrs from when I first gave her morning vetoryl. I was ok with this bc I don't want to go up to fast but,
Now as the weekend has come she has had more accidents in the house and a little more restless and I feel like I think she needs to be on 20mg and I want to start her on it before the 30day mark. Should I suggest this to the vet. Can someone please give me an opinion on this. thank you.

[Harley PoMMom]

She just had her first ACTH test at 10 days and her results stumped the vet and she had to consult a specialist. Her pre test cortisol value was <1.0 mg/dl, this was drawn two hours after I gave her meds that morning ,then her 2nd cortisol value was 27.3 mg/dl which was drawn 2 hrs after the ACTH was given. After consulting with the specialist she decided that it was best that my dog should stay on the 10mg for now and we will reevaluate at her 30day test because her clinical signs were slightly improved.

According to Dechra, the makers of Vetoryl, when a dog is being treated with Vetoryl/Trilostane, which has to be given with food to be properly absorbed, an ACTH stimulation test needs to be performed 4-6 hours after the Vetoryl dose is given. So knowing this I am really concerned with the way the vet performed the ACTH stim test on Chloe.

In the ACTH stimulation test two blood draws are taken; one is the baseline/pre number and the 2nd one is the post number. After the pre blood draw is done a stimulating agent, usually Cortrosyn, is injected and 1 hour later the second blood draw is done. Now, the second or post draw is dependent on the stimulating agent used. Could you ask the vet if they are using Cortrosyn or ACTHAR gel.


My question now is would we have gotten more accurate results if they had drawn her pretest blood at 4hrs post vetoryl as opposed to 2hrs post then dosing her with the corticotropin then drawing the second value 2hrs after that. Her 2nd sample only ended up being 4hrs from when I first gave her morning vetoryl. I was ok with this bc I don't want to go up to fast but,
Now as the weekend has come she has had more accidents in the house and a little more restless and I feel like I think she needs to be on 20mg and I want to start her on it before the 30day mark. Should I suggest this to the vet. Can someone please give me an opinion on this. thank you.

Chloe's pre was taken way too soon, but it seems that her post draw was done within the allotted time, but I am a bit confused with the units of measurement for Chloe's cortisol (the mg/dl) we are used to seeing cortisol measurements in ug/dl, could you confirm what the units of measurement are for her cortisol? Thanks!

As for raising her dose, we have seen a dog's cortisol continue to drift downward during the first 30 days when the medication is started, and since I'm confused with her units of measurement I'm not sure what to make of her post number. :confused:

If you have any questions at all please do ask them, ok?

Hugs, Lori

[goldengirl88]

Welcome to you and Chloe. First you are all over the board with things that are questionable. Firstly why was the testing started before the 4 hour mark and her Vetoryl had a chance to work? This could really mess things up. Secondly I am not understanding the measurements you have after your testing numbers?? Lastly you never change a dose on a dog without testing their number first and never before 30 days as the cortisol will continue to fall and maybe beyond the 30 days. You could overdose your dog this way. I am thrilled though that you have a vet that started your dog on a low dose. That is a much safer approach to start with. Hoping to get some answers to help you straighten this out. Blessings
Patti

[labblab]

Hello Christina, and welcome from me, too!

I just wanted to stop by and add a couple of thoughts into the mix. First, I agree that we really, really need to clarify the units of measurement that were reported with Chloe's monitoring ACTH test. The units of measurement will make a huge difference in our ability to assess the results.

Secondly, as Lori has asked, we need to know which stimulating agent was used in performing the test. If it was Cortrosyn, then typically there is only a one-hour delay before the second blood sample is drawn. So it will help us to know whether a different agent was used, or if not, why the window was two hours rather than one hour.

I am not as concerned about the fact that the testing was begun two hours after breakfast/dosing. It is absolutely true that Dechra recommends that the testing be done within a window of 4-6 hours. But different researchers and clinicians, including Dr. Feldman and many specialists at UC Davis, prefer that the testing be commenced closer to the 2-3 hour mark after dosing. Presumably, this is based upon the observation that trilostane tends to reach maximal strength in the bloodstream by 1.5 hours after administration. So I don't think there is anything necessarily "wrong" about starting the test at that time, but you will want to make sure that you do stick to one consistent protocol with all subsequent monitoring tests so that you are truly comparing apples-to-apples in terms of the results. And you definitely will want to clarify why the second blood draw was performed two hours after injecting the stimulating agent rather than one.

Marianne

[goldengirl88]

I would also be taking her the same time of day for all subsequent tests so it is really a true comparison.

[csernablanco]

Thank you every one for your input.
Now knowing that cortisol levels can still decrease within her first 30 days on the medication I will not push the idea that I thought she may need a higher dose at this point. I will wait to her 30 day monitoring results.
So as far as the testing I am so confused why the lab she is using which I think is called ANTECH is reporting their values in mg/dL instead of ug/dL. I had been reading the dechra info on monitoring also and realize it only shows results in ug/dL and nmol/L after rereading it. I just had not realized my results were in mg/dL until I typed it and you guys pointed this out. Im so glad I shared this on here and I will be asking my vet about this. So this is how my results read.
Cortisol Sample 1 <1.0, 1.0-5.0 mg/dL (Adult Reference Range)
Cortisol Sample 2 27.3, 8.0-17.0 mg/dL (Adult reference range)

I looked and she was given corticotrophin ACTH gel. Now looking back I am not 100% sure how far out her second blood was drawn after giving the gel because on my results it just shows the time of 1235p on time 2. No other time is listed. It was when I picked her up on the day of testing that the checkout person gave me a quick rundown of what they had done and I just recall them saying her first blood was drawn at 1035, then something else and another time I don't remember and that her 2nd level was drawn at 1235. I told them I gave her med with food that morning at 805.
When the vet was giving me the results 5 days later she did say she would draw her first level at 4hrs post vetoryl from here on out so I will make sure it stays consistent and that I have her there the same time. I want this to be done right if I am paying so much.
By the way can someone recommend a good pharmacy that I can buy vetoryl I want to buy another box before I am stuck buying the one at the vet for 52.50$ 10mg

Thank you for all you input!

[goldengirl88]

With the gel that draw is to be taken 2 hours after the corticotrophin gel is given. I did read Dr. Peterson's blog and you can do the test after the Vetoryl and food have been given in 2 hours he said will produce good results so that is ok. I usually do 4 with Tipper, but may switch it up. As far as purchasing the Vetoryl go to Lambert Veterinary Supply or California Pet Pharmacy for the cheapest prices but you must purchase like 2 boxes to get free shipping, it is still cheaper than the vets most of the time. Hope all is going well. Blessings
Patti

[csernablanco]

I have merged your post about the ultrasound into Chloe's original thread. We normally like to keep all posts about each pup in a single thread as it makes it easier for members to refer back to the pup's history when needed. Thanks!


I wanted to know if u/s is really necessary if surgery is not an option for us because of cost. I know it could help confirm diagnosis of an adrenal tumor but if I'm not going to have my dog operated is it really necessary. The u/s would be 450$. Id rather spend the money on all the monitoring tests that she needs while on vetoryl.

[Harley PoMMom]

Hi Christina,

The ultrasound may be able to distinguish ADH from PDH, however it can also be a very useful tool as it can provide so much info and an "inside look" to the other major organs.

Financially the ultrasound does cost a lot, also not all ultrasounds are created equal. A good quality ultrasound/interpretation depends on a few things; the tool used, the technician performing it, and the physician interpreting it. There is a great difference in the quality of U/S machines.

If this were me and I needed to chose between an u/s or ACTH stim testing, I would save the money and spend it on the monitoring ACTH stimulation tests.

Regarding the reporting units for Chloe's ACTH stim test could you ask the vet to confirm those units of measurement, this is very important information that we need to know so we can provide you with more meaningful feedback, ok?

Hugs, Lori

[goldengirl88]

I second that as I would opt for the stim test. I had an ultra sound done on Tipper several times at my vets and they saw nothing. Then took her to Pittsburgh to the hospital that had a state of the art high definition machine and her adrenal tumor was found. At the time I did not realize the difference in machines or would have not paid for the one at the vets as it gave me incorrect information either by the lack of a good machine or the Dr. interpreting it. It gave me a false sense of security that nothing was wrong, and it could not have been further from the truth. Blessings
Patti

[molly muffin]

Hello and welcome to the forum.

I too would opt for the ACTH testing if I had to choose between that and an ultrasound.

Lambers, California Pharmacy, Diamondback are all good pharmacy options. I'd give each a call and find out their pricing. They should all be fairly quick to ship.

Sharlene and molly muffin