New guy here: My Airedale has been diagnosed w/Cushings

[camval1]

Hi all,
New here.

My name is Mark. I live in Central New York.

My Airedale, Brick, has just been diagnosed with Cushings.
He is 10 2/3 years old.

I've learned a lot by doing searches online, but I'm looking for more info.
This is what brought me here.

While his current symptoms began at the beginning of this month, when I look back, I think he's been borderline Cushings, dipping his toe into the Cushings waters, for the last 2-3 years.

His current symptoms include the excessive thirst, excessive urination, voracious appetite, maybe excessive panting, maybe coat changes, and I can see & feel his bones more easily.

His UCC test showed him to be 156:32.
And I think his last blood test (in August) showed his liver enzymes to be elevated.
He had the LDDS test and that confirmed Cushings but couldn't point to which form.
He then had an ultrasound that revealed only slightly enlarged adrenals and a slightly enlarged liver, which are consistent with Cushings.
Because no growths, masses, or tumors were noted, the vet diagnosed him with PDH.

She went over both medical treatments (Lysodren & trilostane) and I decided to go with trilostane. It seems like it's easier to give, easier to manage, and less harsh on the dog's body.

Then I read the safety and efficacy data from the manufacturer and they said that something like 8-10 dogs out of 100 died during their testing. That's not too confidence inspiring.

And I've also read a little bit about alternate dosing protocols. Mainly from UC Davis.
I think the manufacturer recommends 2 mg/kg (he's about 26-27 kg (58 lbs)) while this alternate protocol says 1 mg/kg, which would be a 30mg dose instead of the 60mg dose the manufacturer recommends.

I'm at odds with this. My vet hasn't steered me wrong all these years but something in my gut says we should go with the lower dose, considering the number of deaths during the trials.

What's the harm in starting with a lower dose and working up to a higher dose if needed?

And then I'm worried about monitoring him. I'm off this week because of Thanksgiving, but I'm back to work on Monday. How do I monitor him while I'm at work?

I'm sure I'll have more questions, but lets start with these.

Thanks.

[camval1]

And does it make a difference that I found an engorged tick on his muzzle on 10/25?
I had the tick checked and it tested positive for anaplasmosis and negative for Lyme disease.

Out of caution, my vet put him on doxycycline for a month. That was 10/31.
I noticed the increased thirst & urination on 11/2.
Brick was tested for anaplasmosis on 11/11 and it was negative. It was then I told my vet about the increased urination, increased drinking, and voracious appetite.

Could the doxy somehow have brought these symptoms on or pushed him into Cushing's?

[Renee]

Some of the experts will be by to address your questions in regards to how the tick may or may not affect the results of your cushings test, but I wanted to jump in and give my opinion on the dosing.

The makers of Vetory, Dechra, have recently updated their dosing protocols to a starting dose of 1mg/1lb. If your dog is 58 pounds, then you are well within range to start at 60mg dosing.

That said, many people feel much more comfortable following the UC Davis recommendations of 1mg/1kg.

You'll need to decide which you are more comfortable with. I think the only 'downside', so to speak, in starting much lower is that you *may* have to spend a bit more time monitoring and adjusting the dose. We are all for conservative dosing around here... but, you'll see in some threads where overly cautious dosing led to months and months of minimal progress and wasted money. It sure is a consideration either way. Feeling safer is priceless, that's for sure.

As for monitoring while you are at work -- I understand your concern there. I stayed home the first week my pug started vetoryl. She never had a bad reaction, but I didn't want to leave her alone either.

Could you please post the actual results from the LDDS?

[Dixie'sMom]

Hello Mark and welcome to the forum. You have come to the right place to get help for Brick. There are many experts on this forum who have real life experience and considerable medical knowledge. I am fairly new to being a cushpup Mom myself so I hesitate to answer your questions, but others will be along soon who can help.

I'm glad to hear that you have been educating yourself about Cushings. That is one of the most important steps to helping your pup.

Again, welcome to our family. You are not alone with this confusing and scary diagnosis anymore. We will be with you every step of the way.

I look forward to getting to know you and Brick. :)

In addition, I see that Renee and I were responding at the same time. I did want to add that my doxie weighs 20.6 lbs and she had a starting dose of 20 mg/day. Two ACTH stim tests later are showing her cortisol is in the proper range. We were very lucky to get the dose right the first time. I agree that 60 mg/day starting dose would be a great starting point for Brick. :)

[Harley PoMMom]

Hi Mark,

Welcome to you and Brick! So sorry for the reasons that brought you here but glad you found us.

Regarding the Cushing's medications, Trilostane is no safer than Lysodren and vice versa. Adverse effects are usually only seen when the proper protocols are not follwed. Also, with Trilostane dogs do seem to handle this medication better when started out at a low dose, so if this were me 30mg or 40 mg would be the hightest dose I would start at, you can always bump the dose up if the ACTH stim test results are showing that the cortisol is not responding and the symptoms are not lessening.

Could you get copies of all tests that were done on Brick and post those values that are marked abnormal along with the reference ranges and units of measurement...thanks! Also, would you post those LDDS test results too?

When using Trilostane an ACTH stimulation test should be performed 10-14 days after treatment has started, the ACTH stimulation test is performed to monitor a dog on treatment and can also be used as a diagnostic test for Cushing's.

At the end of my post I will provide you with links to information from our Resource Forum regarding Cushing's and the treatments.

Please know we are here to help in any way we can so do not hesitate to ask all the questions you want. ;)

Hugs, Lori

Helpful Resources for Owners of Cushing's Dogs (http://www.k9cushings.com/forum/forumdisplay.php?f=10)

Trilostane/Vetoryl Information and Resources (http://www.k9cushings.com/forum/showthread.php?t=185)

[Squirt's Mom]

Hi and welcome to you and Brick! :)

I also have a Brick, a male Chihuahua who has Hydrocephalus and is the single happiest little guy you will ever meet! :)

One other thing to keep in mind on the meds - Vetoryl (Trilostane) can be more expensive to use than Lsyo. Vetoryl frequently requires dose changes and with each dose change up or down the monitoring schedule starts all over at 2 weeks. So something else to keep in mind. We were a Lysodren house and if I ever have another cush pup Lyso will be my first choice. BUT I am one who dose not like anything "new and improved"; I find it seldom if ever is an actual improvement so I prefer to stick with things that are tried and true. ;)

Glad to have you and look forward to learning more about the both of you as time passes.
Hugs,
Leslie and the gang

[camval1]

Here are the levels/measurements you guys were asking for:

April 4, 2012:
ALP = 139

August 19, 2014:
ALP = 573
ALT = 370
GGT = 27

September 30, 2014:
ALP = 685

November 12, 2014:
UCCR = 152

November 17, 2014:
LDDS:
0 hour = 7.9
4 hour = 7.8
8 hour = 11.8

[camval1]

I picked up his trilostane this evening.

She's got us at 120 mg, once a day, starting on this Friday.

I'm nervous about that dosage. I expressed this to her. She said she is using the protocol that is most widely used and accepted by most endocrinologists and the most proven.

[My sweet Ginger]

120mg trilostane on a 58 lbs pup?:eek::eek::eek: I'm scared.
What happened to the 60mg you were talking about earlier?

[flynnandian]

for your 26-27 kg [58 lbs] dog, 120 mg is way too much to start with!
don't do this!
the new dechra [manufacturer vetoryl] protocol is max. 1 mg/pound.
there are several members here on the forum who can tell you horror stories about their dog crashing because of too high a dosage of vetoryl.
please wait for their comments and think again!

[Harley PoMMom]

Dechra, the makers of Vetoryl (Trilostane is the active ingredient in Vetoryl) have changed their initial dosing protocol, which is:
The new, lower recommended starting dose is 2 mg/kg once daily Maybe Brick's vet hasn't seen this new protocol, here is the link to the article stating this: New lower starting dose for Vetoryl (http://www.vetsonline.com/news/product-news/140722-new-lower-starting-dose-for-vetoryl.html)

120mg of Trilostane seems way too high to me. If this were me, I would print out that article and show it to Brick's vet.

Hugs. Lori

[camval1]

Hi Lori,
Thanks for the link.
I'll share this with her tomorrow.

I might call Cornell, since they're close, and ask their opinion.

[molly muffin]

Hello and welcome to the forum.

I would definitely go with no more than 1mg/1lb at the most.

My dog doesn't show the normal cushings symptoms, so we started with the Davis protocol of 1mg/1kg, because we felt it was a bit of an unknown as to how she would react to the treatment and because we would have a harder time with her watching to see less drinking or less eating which could indicate her going low. Otherwise, I would started her at 1mg/1lb, which would be around 18mg a day. As is, we started at 8mg and will see where it takes us.

I think that is what I would feel comfortable with based on your LDDS results and blood test and symptoms. Not 120mg. If nothing else and she discounts the print out from the link Lori provided, then just say you aren't comfortable with starting higher.

Normally around day 10 is when you notice a major difference. Every dog being different it can be sooner or later, but that is a common average day from what I've noticed on the forum.

[camval1]

Thanks to all for all the info posted.
I will pursue in the morning.

In the meantime, is there a nighttime watering protocol I should be following until the medicine kicks in? Such as, no water 1 hour before bed?
Brick had a little accident last night. Don't know why he didn't wake up and tell me like he normally does.

[Renee]

Please do not limit water intake. Cush dogs need the water, as frustrating as it is.

I am disappointed your vet jumped the dose so high. There is ample research supporting starting lower. If she does not agree with you, then I suggest you find another vet.

[Dixie'sMom]

I'm another chiming in to say, PLEASE DO NOT give him the 120 MG. That is waaaay too much to start him on and he could get very, very sick. Also the capsules cannot be divided So please send your vet the link to Dechra's new recommendations and ask her to swap the 120's for a lower dosage. The name brand comes in 10, 30, 60 and 120. 60 should be fine to start since it is the closest to his weight.

Also do not withhold water from a Cushing's dog. They need the water to help their kidney's flush out the excess cortisol. As far as his accident last night, I would put down waterproof pads or a heavy towel or something where he went in case it happens again. Just take him out as late as you can before bed and as early in the morning as you can if he doesn't wake you. Hopefully, when he gets on the right amount of Vetoryl, the nighttime waking you and accidents will stop. You're doing good, Dad. :)

[Squirt's Mom]

Never, ever withhold water from a cush pup. They do NOT pee a lot because they drink a lot. It is just the opposite. The disease has a hard effect on the kidneys and they are going to pee regardless of the amount of water they take in. So to prevent dehydration, they drink. Please do not withhold nor restrict water.

[camval1]

Does anyone think the tick bite or the subsequent round of doxycycline has/had anything to do with this or is affecting anytjhing?

He tested negative on his first Snap 4DX Plus test on November 12th.
He has another scheduled on December 8th.

[camval1]

I called Dechra U.S. and they told me the recommended dose is 1 to 3 mg/lb. However, they tell owners & vets, when they call, to start at the 1mg/lb dose unless there are serious issues that demand the Cushing's get under full control as soon as possible.
Dechra UK is updating their inserts to the 1mg/lb spec.
The girl I spoke with believes that the U.S. spec will be officially updated to 1mg/lb, too.

I called Cornell and they wouldn't talk to me unless I was a patient.

I also called the local internists and they can't talk to me either without an initial visit & records review.
The earliest they could get me in is December 3.
They need a referral from my vet & his records.
I'm sure that will start a s*** storm with my vet.

What's the risk of leaving him untreated for a few more weeks?

[lulusmom]

Hi Mark and a belated welcome to you and Brick.

I once rescued a blind, tiny adorable chihuahua that the shelter named Brick. His color was red; hence the name. I didn't rename him, thinking his new family would rename him but she didn't. Leslie (Squirts Mom) adopted Brick and she kept his name. A lot of people think that's an odd name but not us....it's perfect. :D

I'm very happy to hear that you called Dechra and they recommended that you start dosing at 1mg/lb. It's a shame that your vet didn't call before you spent the money on 120mg capsules. You may want to call any compounding pharmacies in your area to if they will repackage them for you in 60mg capsules. It may cost a bit but you'll have two months worth of capsules.

I haven't had time read your entire thread here or on facebook and am wondering if you had an ultrasound done. I ask because Brick did not suppress on the LDDS test which is more indicative of an adrenal tumor rather than a pituitary tumor. If there was an ab ultrasound done, I'd like to know how the adrenals looked. If Brick has a functional adrenal tumor and he is a good surgical candidate, an adrenalectomy could be a complete cure.

If your vet gets angry at you for wanting a second opinion and refuses to give you a referral, I would definitely look for another vet. Cushing's is not a benign canine disease and it is grossly misdiagnosed. If your vet can't appreciate that you have legitimate concerns about a proper diagnosis as well as treating with serious drug like Vetoryl, then one can only assume that he is putting his ego above Brick's welfare. It's as simple as that.

You may want to educate your vet with some very important information. Dechra has been derelict in getting the word out to US vets about their new dosing recommendations. I recently learned through my own conversation with Dechra that they've had an application into the FDA for a few years but they move at a snail's pace. I explained to the tech I spoke with that we have seen many, many dogs overdosed because inexperienced vets simply use their recommendations in the packaging insert. We, therefore, routinely warn new members of the very real risk of overdosing if starting with a dose higher than 1mg/lb. That is especially true of bigger dogs. There has been a study that showed that bigger dogs may actually require smaller doses. I think our experience here supports that. I don't have time now but if you would like, I can provide a link to an abstract of that study. Just let me know.

Glynda

[Harley PoMMom]

Does anyone think the tick bite or the subsequent round of doxycycline has/had anything to do with this or is affecting anytjhing?

He tested negative on his first Snap 4DX Plus test on November 12th.
He has another scheduled on December 8th.

There are three types of Cushing's: adrenal dependent hyperadrenocorticism (ADH) which is caused by a tumor on the adrenal gland; pituitary dependent hyperadrenocorticism (PDH) where a tumor is on the pituitary gland, sometimes, although rarely, a tumor can grow on both at the same time; the last one is known as iatrogenic, this is when Cushing's is caused by an extended exposure to steroids.

I have never read or heard where a tick bite and/or doxycycline was the origin for Cushing's.

The Snap 4DX Plus test is used to identify ticks, right?

Hugs, Lori

[camval1]

Hi Glenda,
He did have an ultrasound, on November 20th.

Nothing terribly remarkable noted.
Adrenal glands slightly enlarged, liver slightly enlarged.
No masses, growths, or tumors found.

[camval1]

Hi Lori,
Yes, the Snap 4Dx Plus tests for tick borne diseases.

[camval1]

Is a symptom of Cushing's more bowel movements?

Since the other symptoms popped up 3 weeks ago, Brick seems to be pooping a lot more.

Not bad poops, but really quite nice ones <lol>.


Before this, he might have pooped 2-3 times a day.

Now he seems to poop about 2-3 times an outing.

[Harley PoMMom]

What's the risk of leaving him untreated for a few more weeks?

Since the majority of dogs affected with Cushing's are seniors, their symptoms are attributed to old age so some dogs may go years before a confirmed diagnosis of Cushing's is made.

Cushing's is a slow progressing disease, it moves at a snail's pace, which does give a person time to get a confirmed diagnosis for their furbaby. The goal of treatment is not to cure the disease because it is not curable, the goal is to alleviate symptoms that become troubling, not so much for the dog but for the pet owner, so waiting a few more weeks for a confirmed diagnosis and to treat, IMO, will likely be ok.

Hugs, Lori

[Harley PoMMom]

By chance is Brick getting more to eat than before?

[camval1]

Hi Lori,
I might be feeding him approx. a half cup more per day since the symptoms set it, but other than that, nothing I can think of.
Nothing is missing or opened up in the house.

Although he's always got his nose to the floor or ground looking for something to eat.

I think he may have eaten some dirt a few times when he was outside.
He's been chewing his nails more (he's always done this, but much more prevalent lately).

[Harley PoMMom]

I know how hard it is to watch your baby feeling so hungry all the time, frozen green beans can be a low calorie treat to give to Brick to help "fill" his tummy.

[doxiesrock912]

I can understand Cornel not advising you without seeing Brick. Is it the one in Stamford, CT?

If so, please make an appointment with Dr. Forman. He is amazing!!!!!

[camval1]

Hi all,
Bricky had another accident this afternoon. :(

Kinda our fault (I should say it was my brother's fault). He gets so upset when the dogs get under foot during dinner, he puts a gate up so they can't get to us. I tell him to stay home if the dogs bother him so much.
That blocks their path to the back door. He couldn't get to the door to tell me he had to go, so he went in the dining room. Thankfully it's tiled, so easy clean-up.

I'm praying I can get the dosage question settled with the vet tomorrow. Even if I do, he wouldn't start the meds until either Saturday or Sunday.

I just wish I could help him faster.

[camval1]

Just so that I'm armed with proper info when I talk to the vet, there are no negative consequences in starting with a lower dose of trilostane, correct? Other than on my wallet as more testing will be needed. :)

Even if the dose is too low, wouldn't the dog get some relief from the drug?

And it's not like it would hurt the dog, correct?

[lulusmom]

I'm praying I can get the dosage question settled with the vet tomorrow. Even if I do, he wouldn't start the meds until either Saturday or Sunday.

You are the one who will be starting the meds so you control when he starts the meds, and I sincerely hope you refuse to put even one 120mg capsule in your dog's mouth. The fact that the manufacturer advised you to start treatment at 1mg/lb is the only discussion you need to have. If I were you, I wouldn't ask the vet to change the prescription, I would demand it.

Glynda

[lulusmom]

Just so that I'm armed with proper info when I talk to the vet, there are no negative consequences in starting with a lower dose of trilostane, correct? Other than on my wallet as more testing will be needed. :)

Even if the dose is too low, wouldn't the dog get some relief from the drug?

And it's not like it would hurt the dog, correct?

All dogs respond differently so there is no way for any of us predict how your dog will respond. A lower dose will absolutely not hurt and it is much safer. It is not a given that you will have to spend more on acth stimulation tests. You may end up having to increase the dose or you may ultimately have to decrease the dose.....or your dog might just stabilize on 60mg in which case, you will be very lucky. If the dose is appropriate, you will notice an improvement in symptoms fairly quickly...usually within a week.

Glynda

[molly muffin]

As glynda very accurately said there is no way to determine what your final dose will be and how any dog will react. This is one reason to start low. Some dogs are quite sensitive to the drug and some are more resistant.
What you won't have to worry about as much is an over dose. That is our biggest fear with the large starting dose before you know how he will react. The vets all seem to say. Don't worry you can over dose on vetroyl/trilostane. They are wrong. Deadly wrong. It is why dechra is changing their inserts and why the leading specialist all advise starting lower now.

[camval1]

Finally talked to the vet today.
Reiterated my concerns with the dosage and that I wanted to start lower.
Told her that I contacted the manufacturer and they said to start lower rather than higher.

She said she consulted 3 professional monographs and had spoken with an internist to determine his dosage.
She then paused and then asked me if she had ever done anything in the past that would make me not trust her professional expertise.

I said absolutely not. That they've never steered me wrong in the past.

She then asked me why I'm pushing for the lower dose.
I said I'm ultimately responsible for Brick's health & welfare and that I really don't trust the medicine.
She then asked me "then why are we talking about it".
I said because there was no better alternative.
I also reiterated that there was no risk at starting lower.

She capitulated and said she would get the 60mg capsules.
I had found them locally at a few other vet offices. They said they would sell to me as long as my vet sent a script to them.
My vet said she absolutely would not do that; that it was illegal and unethical. I didn't push that part.

But that means he won't go on the meds until sometime next week.
My poor boy. :(

I just hope my actions haven't ruined the relationship with the vet & her office.
I really do trust & like her & everyone at the office.

[Squirt's Mom]

If fighting for Brick's safety has damaged the relationship, it wasn't nearly as good as you thought it was. You must have a vet that will work with you as a team, not a dictator. ;) Ego, personal feelings have no place when it come to the health of our babies. You done good, Dad!

[molly muffin]

It is a terrible position to be in, but you did the right thing. It is better to wait and get it right and be safe, than take risks.
I wish she would have just gotten hold of one of the other vets and have you pick it up from them, but it is what it is.
I think you did the right thing. No matter where you end up in dosage, always take the safest route. She could have called the manufacturer herself and gotten her answer.
I didn't start my dog on the 30mg my vet wanted to start her at but rather on 8 mg that the IMS said to start at and cortisol continues to drop, and I'm even concerned now about the pre number at that dosage, so don't think you did anything wrong by being the advocate that you Brick needs you to be. Hopefully this will be the last bump with your vet and things can progress along nicely. If you have to change vets, well, you know you have options in town at the vets you called.

Hang in there!

[lulusmom]

Hi Mark.

I am so sorry that your visit with the vet went so badly. I'm still reeling from the rudeness with which she received your very legitimate concerns about the Vetoryl dose she prescribed for Brick. Please see my further comments below in blue text.


Told her that I contacted the manufacturer and they said to start lower rather than higher.

She said she consulted 3 professional monographs and had spoken with an internist to determine his dosage.

So what? Could it possibly be that the publications she subscribes to and the internist she consulted with don't have the latest recommendations from the manufacturer? Most board certified internal medicine specialists treat a lot of cushdogs and know this stuff, either from continuing education or personal experience so I'm not sure why the internist she uses isn't up on the latest.

She then paused and then asked me if she had ever done anything in the past that would make me not trust her professional expertise.

How incredibly self serving of her to try to distract you with "you're not worthy so why are you questioning me?"

I said absolutely not. That they've never steered me wrong in the past.

Maybe no before but they have now. I thought my vet who took care of my dogs for years was the bees' knees and could do no wrong. I placed blind faith in him and never questioned a thing he told me. My dog paid the price for that and after an internal medicine specialist diagnosed her properly and directed treatment, I realized what an idiot he was and I never stepped foot in his office again.

She then asked me why I'm pushing for the lower dose.

I said I'm ultimately responsible for Brick's health & welfare and that I really don't trust the medicine.

Given that you had just told her that the manufacturer recommended that you start Brick at 1mg/lb, there was absolutely no reason for her to ask such a ridiculous question except to shame you for being so audacious as to question her about anything. Does she seriously think she knows better than the manufacturer of the drug who, based on their vast experience, have already revised dosing recommendations in the UK and are waiting for the FDA to approve the same here in the states. She may want to lift a finger to call Dechra herself to learn something and quit putting her patients at undue risk. What incredible nerve. How did you manage to stay calm?

She then asked me "then why are we talking about it".

I said because there was no better alternative.

Oh my gosh, I don't even know what to say to that except how incredibly patronizing. How about telling her that you can't believe she's asking such a stupid question but that since she asked, you're talking about because you're an excellent advocate for Brick and an active participant in his care who was just counseled by the manufacturer of Vetoryl who disagrees with your recommended dose." How about that? Unbelievable!


I also reiterated that there was no risk at starting lower.

She capitulated and said she would get the 60mg capsules.

Well she certainly made you work on behalf of your boy and took great care to try to make you feel like a heel for being right before acquiescing. She's the heel here and shame, shame on her!

I had found them locally at a few other vet offices. They said they would sell to me as long as my vet sent a script to them.
My vet said she absolutely would not do that; that it was illegal and unethical. I didn't push that part.

But that means he won't go on the meds until sometime next week.
My poor boy. :(

Chances are that your boy could have overdosed on 120mg so don't feel sorry for Brick because you love him enough to ask questions and protect him. He's certainly not a poor boy, he's a darn lucky boy to have you as his dad.

I just hope my actions haven't ruined the relationship with the vet & her office.

I really do trust & like her & everyone at the office.

Every arrogant, patronizing response you received from your vet was a reason for you not to trust her to act in Brick's best interest. She just put her ego above Brick's best interest with every one of her responses. In my opinion, she just ruined the relationship, not you. If Brick were mine, I'd be hard pressed to let her touch my dog again and would be looking for another vet who appreciates an educated pet owner and who is willing to be part of a team in your boy's treatment.



We don't abide by vet bashing here so please don't interpret my comments as such. We aren't here to assuage vets' egos either at the expense of our members and their precious cushdogs. There is nothing about the exchange with your vet that you just shared that convinces me in any way, shape or form that your vet is acting in Brick's best interest and I don't want you to buy into her accusatory and detracting comments to you. You are standing on solid ground with solid support from the manufacturer so how dare she try to make you feel small for expressing a very legitimate concern. It makes me angry for you, Mark, because she was totally out of line. I'm proud of you for standing strong for Brick. Both you and Brick deserve a lot better from her.

Glynda

[camval1]

Thank you, Squirt's Mom, Sharlene, and Glynda for your support.
I appreciate it.

[molly muffin]

We have all walked on your path. It isn't easy but it is so worth it to have a safe experience with these drugs.

Hugs. You're doing great

[flynnandian]

mark, you are doing great indeed!
the safety of your dog comes first.

[Renee]

Wow, just wow. Unbelievable that your vet would be so disrespectful to you. Good for you for not giving in or letting her bully you into taking an unnecessary risk.

I suggest you start looking for a new vet, as soon as possible.

And, many of us get our meds from online pharmacies. Once you get a stabilized dose for Brick, you may look into that option.

Please do not lose hope. You are doing amazing and you have a lot of support here!

[Dixie'sMom]

Good job Mark! It's easy to forget sometimes that we have a voice with regard to our own medical treatment and those of our pets. We have been trained not to question the "experts". Good for you for standing up and being a voice for Brick.

A couple of things stood out to me as far as your vet is concerned. If it's true and she consulted other colleagues and a specialist for recommendations on dosage, then she likely has not treated many Cush pups or she wouldn't have had to seek them out. Also, as Renee said, when you get Brick to the proper dosage, getting his meds from a compounding pharmacy is a much more cost effective option. If she wouldn't even call another vet's office for you to pick up the 60 mg tabs, she may not be willing to call his prescription in to a compounding pharmacy. She is being very controlling which, as someone else noted, is in her best interest - not that of Bricks. Hopefully she will decide to cooperate and work as a team, but if she doesn't don't hesitate to shop around for a new vet who is a better fit.

You are doing a great job! Brick thanks you and all future cushpup parents thank you for helping to educate the vet community.

[camval1]

Meds are in.
I'll pick them up in just a little bit.

I'm guessing they won't want me to start him on them until Friday due to the test that has to be run 10 days from starting.
Can't have day 10 fall on a Friday, Saturday, or Sunday. Can't do testing or receive results on those days.


I have more questions, but I'll post those later from home.

[Renee]

10-14 days is the recommended, but you have some wiggle room on that. My vet actually tested 7 days later, rather than waiting 2 weeks.

I am glad you got the meds and have a plan for starting.

[molly muffin]

I think I went with day 12 as it was right in the middle between 10 - 14 days. So yea, like Renee said you have some wiggle room.

[camval1]

I start him on Friday and we test on Monday the 15th.

Questions:
- I'm working from home on Friday in order to monitor him. And of course I'll be able to monitor him over the weekend. How many days should I do this? I have a job which I really can't be away from.

- If he were to react badly after getting the meds, how many hours after getting it might I expect a negative reaction?

- How many days before I can be confident there will be no negative side-effects?

- Is Frontline Plus compatible with trilostane? I know the Frontline is topical, but just want to make sure they're OK together.

- What are the symptoms of excessive trilostane? I know vomiting, diarrhea, lethargy. What else?

- If he has a bad reaction, I know to give him the prednisone and then call the vet. I assume I'd have to get him to the vet. How long do I have to get him there before any serious negative effects happen? This one concerns me because I'll be at work and my mother will be watching him (after the first few days). If he runs into issues, she'll have to call me at work. It'll take me 25-30 minutes to get home, then anywhere from 15-25 minutes to get him to the vet or ER.

- If I give him the medicine at around 6 AM on workdays, should I be getting up early on weekends and days off to give it to him at the same time? Or is it OK to give a little later (around 7:30 AM) when I have the day off?


I think this is all for now. I'm sure I'll have more questions as Friday gets closer.

Thanks for all the support.

[camval1]

Another question:

- If the meds have to be adjusted, by what increments should they be adjusted? 10mg, 20mg, 30mg, some other increment?

[LauraA]

It would really depend on the stim test and what the numbers show for the cortisol. If there hasn't been a big change then they will do a bigger increase than what they would if the cortisol levels have dropped a lot.

[labblab]

Hi Mark! I surely understand how nervous and worried you are about starting out on treatment. But truly, the odds are that everything will go just fine and I'll bet that by this same time next week, you'll be feeling a WHOLE lot more comfortable and relaxed. I've gone ahead and given you my own answers to your questions, written out in red below.


I start him on Friday and we test on Monday the 15th.

Questions:
- I'm working from home on Friday in order to monitor him. And of course I'll be able to monitor him over the weekend. How many days should I do this? I have a job which I really can't be away from.

I wouldn't expect that you will need to take any more time off from work at all. You are starting off at a very reasonable dose, and especially since your mom will also be at home, I shouldn't think you'd need to alter your work schedule next week.

- If he were to react badly after getting the meds, how many hours after getting it might I expect a negative reaction?

According to the manufacturer's literature, Vetoryl reaches its maximal effect by about 1.5 hours after administering the med (meaning the cortisol is at its lowerst point). So, theoretically, that's the beginning of the window of time during which side effects from low cortisol would most likely manifest.

- How many days before I can be confident there will be no negative side-effects?

Unfortunately, there is no set time frame for this one. Side effects can appear at any time during treatment. There is one exception, and that relates to something called "cortisol withdrawal syndrome." This occurs early in treatment, and what it refers to is the fact that dogs can feel pretty yucky when their cortisol levels are abruptly lowered. The withdrawal symptoms can mimic the symptoms associated with truly abnormally low cortisol levels. The only way to know the difference for certain is by blood-testing the cortisol level. One reason why we encourage folks to start with lower dosages of the drug is because withdrawal symptoms are less likely to occur when cortisol levels are lowered more gradually.

- Is Frontline Plus compatible with trilostane? I know the Frontline is topical, but just want to make sure they're OK together.

As far as I know, there is no problem with combining the drugs. I would probably hold off giving the Frontline at the very same time that you are starting the trilostane, however. I would wait a few days. It is better not to start anything else right at the same moment that you start the trilo, because if there does turn out to be an ill effect of some sort, you cannot be sure as to the cause.

- What are the symptoms of excessive trilostane? I know vomiting, diarrhea, lethargy. What else?

Those are the biggies. Loss of appetite is another.

- If he has a bad reaction, I know to give him the prednisone and then call the vet. I assume I'd have to get him to the vet. How long do I have to get him there before any serious negative effects happen? This one concerns me because I'll be at work and my mother will be watching him (after the first few days). If he runs into issues, she'll have to call me at work. It'll take me 25-30 minutes to get home, then anywhere from 15-25 minutes to get him to the vet or ER.

It is really uncommon for a reaction to be so severe as to constitute an emergency situation. Depending upon what is actually happening (for instance, just seeming "off" and not wanting to eat vs. acute vomiting or diarrhea), you may want to call the vet before giving prednisone. The reason for this is that accurate readings of cortisol levels cannot be made within 24 hours of giving prednisone, so that diagnostic tool is rendered unusable for at least a day after prednisone is given. Unless a dog is really acutely unwell or is experiencing problems during hours that the regular vet is not available, it's probably best to first call the vet and alert him/her as to what is happening or else just take the dog directly in to be seen.

- If I give him the medicine at around 6 AM on workdays, should I be getting up early on weekends and days off to give it to him at the same time? Or is it OK to give a little later (around 7:30 AM) when I have the day off?

Of course the ideal is to give the drug at about the same time every day. But waiting until 7:30 on your "off" days should not be that big of a deal. If you are taking him for an ACTH test on a Monday, however, you may want to bite the bullet on the day before and get up earlier so as to be dosing him at the same time for both of the two doses prior to the test.

And just as Laura has said above, the size of any subsequent dosing changes will totally depend upon the test results as well as symptom resolution.


I think this is all for now. I'm sure I'll have more questions as Friday gets closer.

Thanks for all the support.

[camval1]

Thanks to all for the answers. It really helps. I appreciate your time & knowledge.

Tomorrow is the big day.
He starts on his meds.

I'm nervous, anxious, and excited all at the same time.

I keep telling Brick that tomorrow is the first day of the rest of his life.:)

[camval1]

First dose is on board.

Hope everything goes OK today.

If no issues, then I'll check in at the end of the day.

Thanks for all the prayers, good thoughts, good vibes, and Airezen. We appreciate it.

[labblab]

Good luck, and we'll be very anxious to hear the report. I'll bet Brick will do just fine! :)

Marianne

[LauraA]

Hope Brick does as well as my girl did at the start :) Hardest part is being patient while we wait for the cortisol to come down lol. I know after the 1st stim test after starting the Vetoryl I felt such a huge relief to know exactly how she was doing :) And I could stop stalking her every move which I think she greatly appreciated hehe.

[camval1]

So no issues yesterday.
He seemed to tolerate the medicine well.

[labblab]

YAY!!! Thanks for the update.

[doxiesrock912]

Awesome news Mark!

[Harley PoMMom]

Hi Mark,

I scanned a few posts but couldn't find one that says what dose of Vetoryl that Brick is actually taking, is it 60mg?

Hugs, Lori

[camval1]

Hi Lori,
He is on the 60mg capsules, once per day.

Today is day 4. He's already received his dose for today.
So far, I haven't noticed any negative consequences.

[Squirt's Mom]

That's good news, Mark!

[TotesLove]

YES. You are correct about the 1mg per kg starting dosage.
That’s what we did, even after our vet wanted to just follow the box instructions and start us out at 60mg.
She has Pituitary-Dependent Cushings
Our vet argued with us, but we stood our ground and boy am I glad that we did because my mother-in-law didn't really know to question her vet and they started her dog off on a high dosage and he died of an overdose. This was years ago before I knew anything about this whole thing.
Sometimes vets are well-meaning, but ill-informed.

Studies have been showing that the larger the dog, the LESS it needs per kg of body weight.
The starting dosage of Trilostane can be really low - 1m per kg of weight and it might even end up being lower in the end.
This is what we started our dogter on (in May of 2013) and every follow-up blood work test shows that 1mg per kg of weight (or 20mg per day) is sufficient

She weighs 45 lbs, which is appx 20kg
So at 1mg per kg, she gets 20mg per day
We give her 20mg per day
ONE 10mg cap with bfast + ONE 10mg cap with bfast
ALWAYS GIVE WITH FOOD !!

Dr. Peterson is a wonderful vet expert and he has a great practice and an informative blog that has all kinds of information about all of this w/ links to scholarly journal articles.

HERE IS THE WEBSITE (endocrine dot vet dot blogspot dot com):
http://endocrinevet.blogspot.com/search?q=Trilostane

[camval1]

Brick goes in for his 10 day check-up on Monday.

The vet says no food after 6PM the day before, but water is fine.

They said to bring his medication with him and they'll give him the dose after testing.
Does this sound right?

I could have sworn that the vet had previously told me to feed him & dose him as normal the day of the test, but to tell her exactly when I dose him so they can run the test 4-6 hours later.


I'm confused.

[My sweet Ginger]

Is that the same vet 'cus the first one was correct.

[labblab]

Brick goes in for his 10 day check-up on Monday.

The vet says no food after 6PM the day before, but water is fine.

They said to bring his medication with him and they'll give him the dose after testing.
Does this sound right?

I could have sworn that the vet had previously told me to feed him & dose him as normal the day of the test, but to tell her exactly when I dose him so they can run the test 4-6 hours later.

No, no, no the instructions to fast him and to hold his medication are absolutely wrong!!!! As Song has said, the instructions to feed and dose normally are the correct ones.

If you fast him and hold the medication, the test results will be useless. Just as Song has asked, are these two different vets talking? Here is a link that explains why it is so important to administer the trilostane along with breakfast as you normally do prior to testing:


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.

http://endocrinevet.blogspot.com/2011/03/whats-best-protocol-for-acth.html

Marianne

[camval1]

Thanks guys.
That's what I thought.

I'll stop at the vet on the way home to confirm.


(His regular vet originally said to feed & dose as normal before the test. I'm assuming his regular vet also came up with this new plan (I'm pretty sure the girl that answered phone said his regular doc)).

[Renee]

Just stopping in to say what a great job you are doing Mark. It's so important to check everything along the way!

[camval1]

So I called them back and asked for clarification, seeing as I received two different answers.
This time I told the girl that the vet had told me feed & dose normally before the ACTH stim test.

She went back & checked and said, "oh, you're right. We were thinking of another drug. Good thing you called back".

[Harley PoMMom]

She went back & checked and said, "oh, you're right. We were thinking of another drug. Good thing you called back".

Unfortunately that does happen, that is why it is so very important for us as pet parents to have an active role in our pet's health care with the vet.

You are doing an excellent job being Brick's advocate!

Hugs, Lori

[Dixie'sMom]

I agree with the others... You're doing a great job, Mark! And you are staying on top of things beautifully! Brick has a great Papa! :)

[camval1]

Brick had his 1st ACTH Stim test today.
I should have results on Wednesday.

Woo dogie, was that expensive!

In addition to the Stim test, there was the Cortosyn, and the full blood panel/CBC.

And then we repeat again in 3 weeks.

Good thing I have a decent job. Don't know what I'd do if I didn't.

[Renee]

Oh yes, Mark. That cortrosyn is like liquid gold. Unbelievable how expensive it is.

The test itself is $110 for me, but add in the cost of the cortrosyn, and it's up to $260 per test. :(

Hopefully your vet knows not to inject the entire amount into Brick and is diluting it down. My vet gets about 5 stim tests out of one acth.

Also, maybe some will not agree with me... but, I do not do bloodwork with every single stim test.

[molly muffin]

I know, I always say I work for the dog. :)

Crossing fingers for a good report. I think it will be. :)

[molly muffin]

I'll just add that I don't do full blood work every ACTH test either. I do them periodically but it takes awhile for the liver enzymes to come down so, no point in constantly checking them. If everything else is okay.

[camval1]

Hi all,
It's 4:22 AM here.
Brick just threw up about 5 minutes ago.

Should I give him one of the prednisone pills?

Not really sure why he vomited. So far, it just the one time.
He hasn't eaten anything since yesterday at about 5:45 PM.
This was his meal from yesterday.

Might this be a side effect of the ACTH Stim test from yesterday?

What do I do now?

[camval1]

Just called the ER vet. She said they'd be hesitant to give the pred if the only symptom is one vomit.
She said I could bring him in to the ER now, or if he doesn't display any other symtoms, to wait until my vet opens at 8.
I did NOT give him any pred so far.

[camval1]

Also, I figured that he gets no trilostane or food this morning, correct?

[LauraA]

If it was me I wouldn't give him the trilostane in the morning. Won't hurt for him to miss a day or two. It may just be a one off hopefully. Just see how he does for the rest of the day, if he wants to eat and do his normal things, no diarrhea etc. Hopefully you will get the results of your Stim test soon and this will let you know if he is low or just having an off day.

[camval1]

I can't speak for other symptoms thus far. No diarrhea; can't tell for lethargy as we were sleeping before and we went back to bed after.

Here's the rundown of the events:
Everyone was sleeping; he got up and hopped off the bed and waited at the bedroom door; I got up and we walked to the back door; I hooked him on his lead and let him out; he walked down the stairs; walked around the yard a bit; had a pee; walked around some more; pooped (looked normal); walked around some more; pooped again (looked normal); walked up the stairs; came in; drank some water; vomited about a minute later (only the one vomit); put him back out; he didn't go back in the yard, just sat on the stoop; brought him back in; we went back to bed.

[molly muffin]

The ACTH test dumps any cortisol in the adrenal glands into the body. With my dog I call it the ACTH spaz as she runs around like a nut. It can affect each dog differently. I wouldn't give pred I would give breakfast and yes no big deal to skip trilostane today. As Laura said it doesn't matter if you skip a day or stop start.
Poops were good. Not lethargic.

[camval1]

Poops were good. I don't think there's any lethargy

I gated him off in another room when I fed Zeke.
Brick hopped off the bed as soon as he heard the scoop going thru the food, stood at the gate, tail wagging, and barking.

I let him out after Zeke finished.
Brick licked Zeke's empty food bowl, licked his own empty food bowl, drank water, and then was "snorfeling" the floor eating anything that resembled food to him.

I'm eating breakfast now and he's lying down next to me.

[camval1]

Other than the 1 vomit, I don't see any other out-of-the-ordinary signs.
I just went downstairs to get my shoes. He came down with me. Then he saw his leash and tried to get it. And then he saw Zeke's leash and DID get his leash.
He tried to hump Zeke. He tried to hump my leg.

I just called my vet. The tech said she'd get me some guidance from the vet. Hope they call back soon.

[camval1]

Vet said to feed him some chicken and rice and then give him a prednisone.
No trilostane until we get the blood work results back.

[Squirt's Mom]

You've done good, Mark! Keep up the good work, Dad!

[Harley PoMMom]

He tried to hump Zeke. He tried to hump my leg.



I really got a chuckle from that statement :D


Vet said to feed him some chicken and rice and then give him a prednisone.
No trilostane until we get the blood work results back.

This plan from your vet sounds really good to me. Once in a while my non-cush boy, Sampson, would drink a bunch of water at one sitting and then if would run around this would cause him to vomit some of the water back up.

With Brick having a appetite, that is an encouraging sign that he is feeling favorably.
And I totally agree with Leslie, you are doing a wonderful job with Brick!

Hugs, Lori

[labblab]

Hi Mark, I totally agree with everybody else that you are doing a marvelous job!!!!!!

I do think your vet is exercising an abundance of caution by giving the prednisone after only the single vomiting episode and given the fact that Brick otherwise seems totally normal. Most often, prednisone is reserved for instances when a dog seems truly unwell and this episode honestly doesn't seem very serious at this point. But this is coming from a mom of Labrador retrievers for whom upchucking is a pretty normal activity after having consumed any manner of grass, twigs, and other wayward "junk" they can scrounge up wherever they are walking and sniffing (rabbit poop is a particular delicacy...:eek:).

The pred won't hurt Brick, though, although the combination of pred with no trilostane may end up triggering all those typical Cushing's symptoms again for a couple of days. Anyway, we'll be anxious to hear those ACTH results right along with you.

Marianne

[Renee]

I have to agree with Marianne here - I'm not sure that one isolated episode of vomiting, given his normal behavior since, would warrant giving pred at this point ... but, caution is never a bad thing. I think you'll know much more when you get the acth results and can see what is really going on.

[camval1]

So it looks like he did OK today.
He had more chicken & rice for dinner tonight.


It seems like he's peeing a bit longer tonight. Could the effects of the trilo wear off that fast? I'm sure the pred is contributing to it, as well


He's lying next to me right now chewing on a bone. <3　


Nervous and excited about his results tomorrow.

So what can I expect? What kind of questions should I be asking?
If we have to make a change in dosage, how much should we move by?

Is there a good explanation about the results of a Stim test, what they mean, what the vet looks for, and how the results are interpreted?

[Renee]

The vetoryl starts to wane after just a few hours, and can safely be assumed to be out of the body within about 12-16 hours. Given that he has not had any today, and adding in the pred -- yes, I would expect some cushings symptoms to re-appear.

If the results come back as anything other than too low, then you stay the course another 2 weeks, retest again, and use that cumulative information to decide about increasing or keeping current dosage. It is never recommended to increase a dose for the first time after only 2 weeks. Now, if the results are too low, then you may consider decreasing. Vetoryl causes the cortisol to drift down in the first 30 days, meaning that even if you don't change the dosage, it is very likely that in two weeks when you run another stim test, his cortisol may be lower.

Very excited to see what his results are.

I always increased in 10mg increments, but not everyone does that.

[labblab]

Mark, here's a link to Dechra's Treatment and Monitoring Flowchart that will give you a good idea as to the significance/ramifications of monitoring ACTH results. One tip is to print out the flowchart because I think it is much easier to read on paper!

http://www.dechra-us.com/files//dechraUSA/downloads/Client%20Literature/47902_VETORYL_10mg_Treatment_and_Monitoring_Brochu re_Update_3_2_ps.pdf

Marianne

[molly muffin]

The ACTH can make them have full cushing symptoms for around 48 hours (from what I have noticed) as it dumps cortisol into their body from the adrenal glands. Then no trilostane, and adding in prednison I would fully expect to have cushing symptoms for a good 48 - 72 hours and a bit higher activity level, I mentioned my dog spaz's after an ACTH test.

I think you'll be just fine though and this doesn't actually appear to be an incident of anything other than a water puke which the cortisol could have caused even, or just regular ole, going to throw up this water vomit.

I think you're doing an excellent job. Right now, anything will make you a bundle of nerves. With time, you'll know what is normal for Brick with the trilostane meds and what isn't. For now though, it's all a learn as you go experience. Pretty much the same for all of us. :)

[camval1]

Haven't got the results yet.

Which numbers specifically should I be asking for?

[Renee]

You'll get a 'pre' or baseline number, then a post number.

[labblab]

As far as the "electrolytes" or blood chemistries, the two values that are of particular interest are the potassium (K) and the sodium (Na). In addition to lowering cortisol, trilostane also has the potential to lower aldosterone which is the adrenal hormone that regulates the balance of those two chemicals. When dogs are overdosed, the potassium can elevate to levels that are too high, and this can have negative consequences on heart and kidney function, etc.

Marianne

[camval1]

Results are in.
Not what I was hoping for.

His electrolytes were good.
Kidney levels were good.

Liver enzymes elevated:
ALP = 1051
ALT = 252
GGT = 27

Not the best news for the ACTH results:
Pre ACTH = 10.7
Post ACTH = 11.2

Would have been nice to know what the ACTH Stim numbers were before starting meds but we didn't run the test.

I really thought we were moving the ball in the right direction. We saw some improvements since starting. Small, but improvements none the less.

She wants me to give him the 120mg capsules now. It scares me, but then I see his stim results and can understand why we should go up. They're so far out.
The PRE stim wasn't even in spec, for cripes sake! And his ALP went UP!?!

This is so disheartening. I'm pretty dejected right now.

[flynnandian]

brick is only on vetoryl for 2 weeks, so his cortisol levels can drop for weeks on the same dosage.
just give it some time.
so will the levels of his liver enzymes. most dogs with cushing's do have those higher liver values.
they will come down once the cortisol level drops.
as long as symptoms are improving, you are on the right track.

[labblab]

Mark, HOLD ON HERE!!!!

Since you did not perform an ACTH prior to starting treatment, you have no idea how large a decrease this may represent. My own boy's pretreatment post-ACTH was nearly 40, for instance, so a drop down to 11 after only 10 days (not even two full weeks) would have been an enormous reduction.

Take another look at that flowchart of Dechra's that I listed for you earlier. The only dosing change they recommend making within the first 30 days is a decrease in the event that cortisol has dropped too low, or the smallest possible increase if absolutely no improvement has been seen at all and the cortisol is hanging at a high level. Otherwise, you need to stay the course because cortisol levels will continue to drop further during the first month even when the dose is left unchanged. Even now, after this short time, you are not very far at all from the acceptable upper limit of approx. 9 (in the event symptoms are resolved at that level). There is no way on earth that I would double Brick's dose to 120 mg. this early into therapy.

Did you print out that monitoring flowchart? If not, please do so. And if you need to, you can also share it with your vet. What she is suggesting does not conform with the current dosing protocol accepted by the majority of researchers and specialists. And this is exactly how dogs get into trouble by overdosing.

Take a deep, deep breath. You and Brick are doing great at this very early stage of treatment!

Marianne

[Renee]

Mark!

Deep breath. Calm down. These are NOT terrible numbers.

Do not up him to 120mg!

His numbers are not that far out of range. When treating with vetoryl, you can safely have cortisol up to 9 ug/dl if symptoms are controlled. Since he is currently at 11.2, he is getting close to range, and after only 2 weeks on the meds, I would say that is very good.

You absolutely do not want to drop his cortisol all at once. Allowing him to drift down on the meds over a month or two is much safer for him. Keep in mind, his numbers will continue to come down over the next 2 weeks as well, because vetoryl brings those numbers down for the first 30 days. I encourage you to read my thread (and others) too follow how the dosing should work and how the numbers correspond.

My suggestion is to stay the course with 60mg for the next two weeks - retest, then based on those results, consider increasing.

Don't sweat the liver values. Those can take months, or even years, to come down with treatment. My girl has been on vetoryl for a year and her numbers are still slightly elevated, although she never had numbers as high as a lot of cush dogs.

[molly muffin]

I completely agree. I kept my dog at the same dose of trilostane for a month and each test her cortisol continues to come down. I have made no changes.
Also, as noted. With control, post number can be up to 9.0ug really, you are close to that.

Hang in there and don't panic and don't get dejected. You Are on the right track!

[camval1]

Is there any correlation between the LDDS cortisol numbers and the ACTH Stim cortisol numbers?

[My sweet Ginger]

Mark, I don't have anything else to add to what's already been said by other members.
Your vet scared me when she wanted to start Brick on 120mg on a 58(?) lbs. pup but she's terrifying me now with wanting to double Brick's dosage.:eek::eek::eek:
I want you to calm down and listen very carefully what everybody is trying to tell you because it is VERY important that YOU understand how Vetoryl works. Yes, Vetoryl work for 30 days and for that reason you do not increase before 30day mark. You can decrease the dose if there's any adverse reaction and the reason you test the pup at 10-14 day mark is to check how cortisol level is trending so you can decrease the dose but not to increase.
With that being said, I think you should be very happy that Brick's cortisol level is nicely trending downward after only say 10 or 14 days? Keep going the way it has been his cortisol will probably be where it should be by 30day mark and who knows you may even need to decrease a little by then. You just never know.
So, please DO NOT DOUBLE his dosage, please.
Looks like you have to educate your vet on Cushings because she seems to be lacking knowledge on Cushings a big time. I know you like her a lot but unfortunately it really doesn't matter how much we like our vets. Some of us have learned it the hard way.
You increase a little by a little after an ACTH each time if it turns out an increase is necessary. You don't double the dose the very next time.:eek::eek::eek:
The safest route seems to be low and slow.
Please, do not increase at this point and wait until 30 day mark and another ACTH test.
BTW, just so you know I don't have any hands on experience with Vetoryl but for over one year I have read way too many incidents our innocent pups go into Addison's crisis and suffer unnecessary consequences at the hands of inexperienced vets. And we, the parents have to go through the unbearable heart wrenching moments for days. I just can't let you and Brick to be the next.

[Renee]

Is there any correlation between the LDDS cortisol numbers and the ACTH Stim cortisol numbers?

Not in any useful way for vetoryl treatment. Had you done a stim test before starting vetoryl, you would have been able to use it as a baseline, so to speak, in measuring how cortisol is responding, but in the long run, it does not matter, because the goal is to get into the proper range and control symptoms, regardless of what the number may have been before starting treatment.

[camval1]

With that being said, I think you should be very happy that Brick's cortisol level is nicely trending downward after only say 10 or 14 days?

That's the thing, I don't know if it's trending down.
No stim test was performed before treatment started. And I don't know if there is any direct correlation between the LDDS cortisol numbers and the stim cortisol numbers.

[labblab]

Is there any correlation between the LDDS cortisol numbers and the ACTH Stim cortisol numbers?
No. They are measuring two entirely different processes -- one is a suppression test and the other is a stimulation test. This is why, for instance, a dog can even test "negative" for Cushing's on one test and "positive" on the other.

Marianne

[camval1]

.....but in the long run, it does not matter, because the goal is to get into the proper range and control symptoms, regardless of what the number may have been before starting treatment.

But wouldn't the baseline have been helpful in understanding if he was trending downwards? Without that baseline, we don't know if the trilo did anything. And if it did, how effective was it?
And without that data, how do we make a move on dosage?

[labblab]

That's the thing, I don't know if it's trending down.
At this point, the only safe assumption is that it is indeed trending down. The alternative -- that you need to double the dose because Brick is not yet in target range -- is a dangerous assumption. In three weeks when you test again, you will finally have a frame of reference upon which to base a revised dosing decision, and you will have a reasonable sense re: the direction and magnitude of any change that needs to be made. But right now, you would be operating blindly with the dosing increase. And from everything you've written thus far, Brick's safety is your paramount concern.

[Renee]

I think you can safely assume it has trended down, at least to some degree. It's highly unlikely that his post stimulated cortisol before treatment was below 11. Don't let the frustration of not having that before treatment number cloud your judgement now. It's frustrating to not have it... but, has no real bearing on the treatment plan now. Regardless of how far it has dropped, absolutely nothing you have told us would warrant a jump from 60 to 120mg in less than 2 weeks.

[labblab]

But wouldn't the baseline have been helpful in understanding if he was trending downwards? Without that baseline, we don't know if the trilo did anything. And if it did, how effective was it?
And without that data, how do we make a move on dosage?
Yes, a baseline would have been helpful. But for whatever reason, your vet did not recommend it. So at this point, in a sense, this first monitoring ACTH is your baseline. When you see what the next test result turns out to be, you will then have a basis for deciding the direction and magnitude of any dosing change.

[molly muffin]

Yes a baseline would have been helpful, but not all vets do an ACTH is an LDDS has shown no or little suppression.

You base a judgement on your knowledge of how the medication works and how your dog is reacting to it.

Dechra guidelines now are suggestive that cortisol will continue to lower for up to at least 30 days on the same dose. Most vets will not do an adjustment now at the 2 week mark because of that continued lowering. This was not true even last year when often at 2 weeks vets would adjust upwards.

If it were my dog I would not adjust at this point. I would see where the cortisol level is at a month and then you'll know how much it came down in the last 2 weeks and you will have a guide.

You can of course call Dechra too if you want. They were helpful last time. But go up to 120mg?! Nope, wouldn't do it personally.

[LauraA]

If I was in your position Mark I would carry on with the current dose and do another stim test in 3-4 weeks and then make a decision as to whether or not to increase the dose. I know at the 2 month mark my girls cortisol was still dropping without any change in dose. In 3-4 weeks then you can do a proper comparison between between the results instead of trying to guess how much he has dropped.

[My sweet Ginger]

I truly believe it is trending downward. Please do not increase any amount right now. Wait another two weeks and we will know better then but still watch him very closely for any adverse reaction.

[camval1]

If I stay with the 60mg and retest in 3 weeks, does it matter he was off the meds yesterday & today?

And if my vet gets upset with me again and I have to find a new one, how do I do that? Because I'd want one in my area, one that was EXTREMELY knowledgeable with Cushing's, and one that was willing to let me make the decisions.

[molly muffin]

No I don't think it will matter that he was off for a couple days.
You just say what you think, if you want to stay with 60mg, then you say, something like, call me nervous but I'd rather stay at 60mg for the moment and see what the results are when we retest and do a comparison. That is what I'd say anyway and a decent vet will go along with that, because in the end, it is your dog and you are the responsible person for his care. We all are with our furbabies. It all comes down to us. What you want is your vet to be a team player in the treatment of Brick and to know that you to are part of the team.

[labblab]

I truly would print out that Dechra flowchart and arm yourself with the published information when you go in. The recommendations are written out very specifically, including the recommendation that any increase made at the 10-14 mark should only be in the event that symptoms remain marked and that the increase be made in the smallest increment possible -- in other words, no greater than 10 mg. None of us are just making this stuff up -- you have professional literature to back up your request. If she persists in pushing to double the dose, I would politely ask her to explain why her position differs from that of Dechra since it seems confusing that their recommendation differs so greatly from hers. There is nothing to be lost by increasing the dosage slowly other than your own money for additional tweaking and testing -- which she will be pocketing! Why should she have a beef with that??

Do you live in an area that lacks many vets? Do you really feel as though you have few alternatives?

Marianne

[Renee]

I am always amazed and appalled by how many prideful vets there are. You should just be completely honest and up front with her about your decision and the reason.

Having a very knowledgeable vet is nearly priceless.. but, even more priceless than that is having an educated owner that can advocate and be proactive in the decision making process, regardless of the vets experience. I have a vet that has almost zero experience treating cushings, and in fact has never used vetoryl before. We've had really good treatment success, with minimal side effects. Because I am active and informed in decision making.

[My sweet Ginger]

I was in your shoe a little more than a year ago, no knowledge on Cushings what so ever, had blind faith in our vet and totally confused between our vet's instructions and the advice coming from the members on this forum who are not vets but have hands on experience on Cushings. What really opened my eyes wide was one sentence that was said by one of the members on here which I still go by that wisdom and that is not giving Lysodren (in this case staying on the same dose) outweighs overdosing this potent drug. How true.
You have to remember that you are the one and only advocate for your Brick's safety. Not your vet no matter sweet she is or anyone else for that matter. Once I realized those two things, I was no longer afraid to speak up for my Ginger with any type of professional.:rolleyes:
Try to talk with her first, maybe she is a bigger person than you'd think. Also call Dechra yourself and get their guidance before you talk with her and ask her to do the same so you will all be on the same page as it's paramount that you approach this disease as a team, you being the most important part. I think it will work out fine once everything is said and done and soon you will be a Cushings savvy.
You can do it Mark and you will do it for your Brick.;)

[camval1]

I gave him a 60mg dose this morning.

I guess I can expect a fight later today. <sigh>

[My sweet Ginger]

That's all right, fight if you have to if that's the only way that will keep Brick safe but don't be afraid. You make the final decision. She is a hired help when it comes down to it and you have other options if things don't work out with her. No huge loss tho the way she come across so far.
You need professional back up so I urge you to call Dechra and also print out the flow hart Marianne provided for you before you see her, please. I know it's not easy but it's something you must do.:o

[camval1]

I printed out that flow chart (11x17, to see it well).

Look at page 2 of the PDF (which is the first page of the flow chart). You'll see the first small block right in the middle of the page. It says "Post-ACTH serum cortisol >1.45 ug/dl (>40nmol/L) and clinically well*"
That kind of fits Brick except that his clinical signs are still present.

That asterisk at the end of the statement leads you to the third page of the PDF (2nd page of the flow chart). It says "If the post-ACTH cortisol is >9.1 ug/dl (>250 nmol/L) and the clinical signs of HAC are marked then you should consider a dose increase at this stage. Increase dose by smallest increment possible."
This statement fits Brick. His levels are above 9.1 and he still has clinical symptoms. Slightly better than before treatment, but certainly evident.

And if you look at page 4 of the PDF, Table 1 says that he should be at 120mg (I don't buy that). And table 2 supports an increase in dosage at this time.


In my mind, all of this means he needs a dosage increase.
Certainly not double like my vet wants, but maybe a 10-20mg uppage.

Unless I'm reading this wrong.

Thoughts?

[labblab]

Look at page 2 of the PDF (which is the first page of the flow chart). You'll see the first small block right in the middle of the page. It says "Post-ACTH serum cortisol >1.45 ug/dl (>40nmol/L) and clinically well*"
That kind of fits Brick except that his clinical signs are still present.

That asterisk at the end of the statement leads you to the third page of the PDF (2nd page of the flow chart). It says "If the post-ACTH cortisol is >9.1 ug/dl (>250 nmol/L) and the clinical signs of HAC are marked then you should consider a dose increase at this stage. Increase dose by smallest increment possible."
This statement fits Brick. His levels are above 9.1 and he still has clinical symptoms. Slightly better than before treatment, but certainly evident.
Yes, the printed flowchart offers the opportunity for a judgement call between leaving the dose alone for the first 30 days vs. adding in the smallest increase possible (which would be no more than 10 mg. since that is the smallest capsule available in the U.S.). In more extensive written commentary elsewhere, the recommendation is made that as long as some degree of improvement is seen and the post-ACTH level is not still hanging up extremely high (a great deal higher than 9.1), the most advisable course is to leave the dose alone until the 30-day result can be evaluated. And just from a practical and financial standpoint, it is a lot easier to stick with the 60 mg. for three more weeks than it is to buy an additional box of 10 mg. capsules to add in at this point.

However, if the current extent of Brick's symptoms are of a magnitude that is still causing you a great deal of distress, then increasing by 10 mg. is an option that the monitoring guidelines offer. Just be aware that a dosing increase also offers a greater opportunity for his cortisol to drop too low during the next three weeks. As anxious as you felt over the isolated episode of vomiting, you need to consider whether or not the pressure you are apparently feeling to eradicate all symptoms as quickly as possible offsets increasing your anxiety over a possible overdose and the risk of him becoming truly unwell. Bear in mind that even though not all symptoms have yet been resolved on the 60 mg. dose, that doesn't mean that you won't continue to see additional sumptom improvement during the coming weeks even if the dose remains unchanged. This is because, as we have said, his cortisol level is expected to continue to drift downward even on the 60 mg. alone.

As far as the 120 mg. dose in the attached chart, those are the dosing guidelines that have been revised and replaced by Dechra's directive issued in July. Their new protocol advises a starting dose not to exceed 1 mg. per pound. The literature is already being reprinted in the U.K., and we can hardly wait until the changes are reflected in the U.S. dosing charts as well.

http://www.vetsonline.com/news/product-news/140722-new-lower-starting-dose-for-vetoryl.html

[My sweet Ginger]

As long as his symptoms are not worsening, I'd leave his dose @ 60mg until next ACTH stim test.
Remember low and slow has been proven the saftest way again and again.

[Renee]

Mark, in the nicest way possible.... I must say, I think you are being rather hard-headed here. Cushings does not happen overnight, nor should it be controlled overnight. You want the cortisol to drift down safely, over time, and the fact that you are expecting resolution of symptoms within just a few weeks means that you are risking Brick's health with your impatience. If he was showing some improvement (maybe not significant yet), then he is on the right path. Let his cortisol continue to come down and the symptoms resolve over time.

Even after I got my pug into the correct range, it still took weeks and months for the symptoms to completely resolve. I am battling CC with my girl, which is probably one of the very worst cushings symptoms, and I still took it safely and slowly, knowing that it would take a few months to get into the proper range and see results in a significant way.

You really do not know how significantly his cortisol has dropped over the last two weeks, due to not have a prelim stim test done, so even adding just 10mg, you have no idea how that may affect his cortisol and to what extent he may continue to drop. By all means, get a stim test in another two weeks, then increase if needed. At least you will have a full 30 days at the same dose in order to be sure you know how it will affect him in an appropriate amount of time.

[labblab]

Mark, I know it must feel as though we are really piling on, but I do want to add this last cautionary note. We are now set to enter a two-week holiday period when most regular vet practices will be closed half the time. You definitely do not want to be facing an emergency situation on a holiday eve, a holiday proper, or an intervening weekend. So in all seriousness, if you and your vet do decide to increase Brick's dose significantly right now, be sure and find out in advance from your vet how you can contact her in a back-channel manner if he should fall ill during a time when the office is closed. Otherwise, you'll be at the mercy and excessive cost of an ER vet if something should go wrong.

Aside from all the other considerations, if it was me and my dog was doing well after only ten days on trilostane, I would stay the course until we had safely navigated our way through the holidays...

Marianne

[camval1]

So Cornell is not able to provide me with any recommendations for Cushing's experienced vets in my area.
Not that there aren't any, but it's not something they do.

I called my vet back and discussed the flow chart.
She said she is familiar with the manufacturer's recommendations but her experience has shown her otherwise; that the manufacturer recommendations are optimistic at best; and that small dosage changes don't do anything. She also says that she rarely has to decrease dosages; mostly has to increase them.

I mentioned how we didn't do any baseline testing so how could we make such a drastic change. She said the LDDS at 0 hour is essentially the baseline. That's the amount of cortisol in the blood before any drugs/stimulants/suppressants are added. His LDDS 0 hour was 7.9. His pre-ACTH is the amount of cortisol in the blood before any stimulants/suppressants are added. The pre-ACTH was 10.2. His cortisol levels went up. Even with treatment.

But what I also did was to make an appointment with a specialist/internist at another office. This is an internist that was found via the link that is on this site (this link: http://www.acvim.org/AnimalOwners/FindaSpecialist.aspx)
I need a second opinion from an experienced specialist.

In the meantime, I'll keep him on the 60mg dose.

Please don't give up on me. This is a lot for me to process in a short amount of time.

[Dixie'sMom]

Oh Mark. NO one is giving up on you. :) You are being cautious and that is the correct thing to do. I agree with the others in that another stim test should be done at 30 days and then any adjustment in dosage should be in small increments, such as 10 mg at a time, and then only after waiting another 30 days.

I hope the IMS in your area is someone who will be willing to work with you. Hopefully your own vet will understand your position if you remain firm in not jumping from 60 mg to 120. You both want the same thing which is for Brick's Cushings to be controlled, you just differ in the method of getting there. Your position as Brick's owner trumps her speedy method because you are paying the bills. :) Hang in there and take a big deep breath. You are doing fine.

[Squirt's Mom]

No one here will ever give up on you, Mark. We may come after you with a wet noodle if you're really screwing up but that's about all. :p And you ain't no where near screwing up so don't worry 'bout the noodle either. ;)

Keep talking, keep asking questions, keep reading and you will be a pro in no time...then you get your own wet noodle to wield if needed! :D

[labblab]

Mark, of course we won't give up on you!!!!!!!! It is really impressive that you are devoting this much time and concern to trying to sort out info coming at you from so many different directions. It is clear how important Brick is to you, and that you are only trying to figure out the best path forward.

I have to say, though, that I am delighted you will be getting a second opinion. The fact that your current vet is trying to justify doubling Brick's dose on the basis that the resting cortisol on the day of his ACTH is higher than his resting cortisol on the day of the LDDS is....I am searching for the right word...NUTS~!!! Resting cortisol levels fluctuate dramatically from day-to-day, even hour-to-hour in all dogs -- even those without Cushing's. Simple stress alone can dramatically elevate a resting cortisol. That is why resting cortisols are useless when it comes to diagnosing Cushing's -- there is too much overlap between dogs with and without the disease.

Researchers have been trying to find a way to correlate resting cortisol levels with trilostane monitoring because it would be so much cheaper for the owner. But the research I have seen to date all concludes that you cannot safely increase trilostane dosing solely on the status or comparison of resting cortisol levels (although resting cortisols can have value in identifying dogs at risk of cortisol levels that may be dropping too low). So I truly do think your vet is in error on this one. And I am very relieved to think you will be getting a second opinion!

Marianne

[molly muffin]

I think you can safely use the resting cortisol to make sure that you aren't going to low, but not to base a dosage increase on.
That is just my opinion, but vets in Europe who couldn't get the stimulating agent for a long time, used the baseline along with electrolyte testing to make sure the dogs weren't going to low.

I just personally don't like big jumps in dosages as it worries me that it can cause an Addison's crash. I personally always would rather error on the side of caution than not.

I think you're doing a great job with Brick's care and in the end you are the voice that counts.

[My sweet Ginger]

As far as where Cushings is concerned the more she talks the scarier she gets it seems. Even going by her theory you just don't double the dosage at anytime while on Vetoryl.
Give up on you? Well, she's scaring us so much that you'd better come on here everyday and check with us on everything she does with Brick.
Again, I think you and Brick are on the right path so far and I wouldn't do anything that will jeopardize his safety for the next two weeks.

[camval1]

I just got off the phone with Dechra.
Had a nice conversation with a Jill Stohs (she's a vet with them).

They can't recommend specific treatment as they don't have all the dog's records. Understandable.

She seemed a little intrigued that my vet essentially discounted the instructions, and that she wanted to double the dose (and so soon), but said that vets base treatments off of their own experiences all the time.

Said that Dechra's procedures are based on their trials and those results and FDA approval procedures, but that every dog responds differently.

We went thru the process of the Stim tests and what the results mean.

We talked about my vet's remark about the LDDS t=0 result being the baseline. She said no, it doesn't work that way. There is no correlation between the LDDS t=o and the pre-ACTH. Plus the resting cortisol varies hour-to-hour. Vet shouldn't have said that.
What would have been better is to have an ACTH test before treatment and compare the post-ACTH of that to the post-ACTH of the 10-14 day point.

She asked me about his numbers. She commented that 11.2 (post-ACTH) is close, and pretty good for 11 days. She also said that she'd keep him on the current dose & retest at the 30 day mark. Actually surprised she gave me that advice.

I asked if she could tell me how to find a vet that's really experienced in Cushing's in my area. They really don't have that ability, but she did give me the name & number of a board certified internist that specializes in endocrinology. He's not in my area but I may call him to see if he knows of any experts where I live. She said he does phone consults?

So that's where we are today.
He seems pretty lively tonight. He was playing with his boomerang tonight and he & Zeke were playing, too.

[My sweet Ginger]

I'm so glad you called Dechra.

[labblab]

That's great that you talked to Dechra, Mark. Good job, and I'm glad to hear that Brick is doing well tonight! ;) :)

[doxiesrock912]

Mark,
Your vet is wrong on so many levels.
Thank God you called Dechra and many IMS specialists will work in conjunction with your local vet. Personally, I don't get the impression that your vet would be willing to do so and I would definitely explore other options.

Cushings progresses slowly, so there is plenty of time to get this right!
Never ever increase like that!!! The thought of doing so scares me to death!

The fact that Brick is playing shows that you're not too far off as things are right now.
Please be patient. Hugs

[camval1]

Brick has licked a hot-spot into his LF leg.
He's done things like this his whole life, so I don't think it's a symptom of the Cushing's or a side effect of the meds.

I've given him Benadryl in the past when he's done that, but of course he wasn't a Cushpup then on trilostane.

Is it OK to give him some Benadryl while on trilostane?

[labblab]

Benadryl should be fine. I feel your pain -- my nonCushpup Peg has bad winter allergies and has a favorite spot on her paw that she often licks raw. I've been taping a sock over her paw and the old sore is almost healed, but about 15 minutes ago I heard slurping and I see that she's licked another sore right above the top of the sock. :o :(

Sometimes it is so hard to keep ahead of them! And unfortunately Benadryl has never nelped us, although I wish it would.

Marianne

[camval1]

Yeah, Brick has always done stuff like this.

He gets obsessed about stuff and can't let it go.
I have to keep 2 cones handy to stop him from licking too much.

I put some bacitracin with a pain reliever on the area and it seems like it's helping. He settling down now.

[Renee]

Hey Mark, my Tobey was like that too. Obsessive air licking. Funny thing... when her cortisol came down into proper range, the severity stopped. I suspect she has always had mildly elevated cortisol her entire life. I don't think it's a specific cushings symptom, per se, but it's funny how that activity lessened in severity once her cortisol was brought down.

[camval1]

How does everyone deal with a begging cush pup?

Last night and tonight, Brick has been just relentless about begging for food.
He's lying by me doing this quiet, airy, whining thing. He might start barking if I pay any attention to him.
If I ask him what he wants, he runs to the food bin and starts barking until I give him some food.

That seems to make him content for a short while, then he starts all over again.

My mother says he doesn't do this when I'm gone. She thinks he does it because I give in to him.

It's frustrating as heck.

Any advice?

[Spencersmom]

Lol.....oh my!!! Story of my life! My Spencer is all that and more! I look forward to seeing the responses you get, cause we have been total fail in that area!! I can totally relate to your situation!

We cook Spencers food and make his jerky treats! He gets a little processed dog food, but it's not the majority. He LOVES his homemade jerky treats, and I had to lay the law down tonight with hubs, cause he is a sucker for the whine, whimper, pitifull eye contact!! Hubs would give him a snack constantly if he could, and Spencer would certainly be happy to eat them all up!

[Harley PoMMom]

Hi Mark, As you can see I've merged your last post into Brick's original thread so all information regarding Brick is in one place which makes it easier for us to reflect back on his history.

Oh, that Cushing's appetite!! How about trying carrots or frozen green beans to help curb those hunger pangs.

[molly muffin]

I'm keeping a bag of cooked green beans in the fridge lately. It's a never ending battle it seems. Funny, my dog didn't have this symptom until her cortisol started to come down. And it's not her food she wants it's treats. I also have her joint med as a treat, her liver med as a treat, so those are two she gets each day that she'd have to have anyway but I can convince her that it's a treat and she is okay with that.

blueberries are good too, some dogs like them, others don't. My Molly will have a bit of banana loves that. But only a bite.

In the end though I think that what we all have to do is limit the "treat" option, because they will train themselves to keep asking and the more we give in the more they beg for it. I put myself right square in there with way too often falling for the oh poor woe is me look, you're killing me, starving me, depriving me, such a bad mommy look. Sigh.

The more we can find that is low carb, low cal, low fat for a treat option the better we'll be.

[doxiesrock912]

Carrots are high in sugar. Opt for green beans, even freeze them for a tasty treat.
Ignore the begging. Never give into that, not even once.

[camval1]

I think one of two things are happening:

1) the trilo is wearing off by the evening and he is feeling hungry
or
2) he is playing me


When he acts like this, I give him a half cup of his weight management food.

[Squirt's Mom]

Carrots are fine! Unless diabetes is a factor, then you don't want to give many but for a cush pup, carrots are just fine. Most fruits and veggies are good for our babies. You can google and learn what to avoid. ;)

Since Brick does this only with you according to your folks, in my view he is playing you because he knows you will give in. When he starts that walk away, move out of his sight. And do not give a bite. Offer treats when you want, not when Brick wants. ;)

[molly muffin]

Quite often this is why people end up going to a split dosage, where instead of 60mg once a day, you'd do 30 mg in morning and 30mg in the evening to keep the levels, well level.

[camval1]

Quite often this is why people end up going to a split dosage, where instead of 60mg once a day, you'd do 30 mg in morning and 30mg in the evening to keep the levels, well level.

This is what I was thinking.
I will mention this to the internist when I see her on Monday.


I ended up giving him a Benadryl at 4:45 PM. He was starting to act up.
I also gave him a few carrots and he settled pretty quickly.

He's been pretty quiet tonight but the boys had a busy day today.

Up at 6 AM, in the car at 8 AM for an hour ride to Zeke's groomer. Then Brick & I waited in the truck for 2 hours while Zeke was getting spiffed up (too far to drive back & forth). Done at 11 AM. Then drive an hour directly to Petco for Brick's bath. He was there from 12-3 PM.
Finally home around 3:30 PM.

Heck, I'm tired. :)

[molly muffin]

Heck, I'm tired.

Me too and all I did was read about!

[camval1]

Brick is so funny.

He was really good about his begging/whining during the afternoon yesterday.
But later in the evening, he started up again. I couldn't get him to stop.

One thing I've noticed, if I go into the finished basement to watch TV, he seems to whine more.

But last night, when we went to bed, he didn't come in the room with me. Typically, he leads us into the bedroom at bed time, but not last night.

He laid down in the dining room next to the food bin and stayed right there until about 1 AM when he finally came in the bedroom.
I don't know what he was thinking. Was he guarding it? Did he think it would open up by itself? Did he think the food would just pour out of it somehow?

Silly dog.

[Renee]

My Tobey is crazy about food too, and for a while during treatment, she was waking me up at all hours of the night to eat. She's doing it right now too. I do split her dose between morning and evening, but that hunger still hits.

A big part of it is from giving in too. I was giving her treats in the middle of the night if she would wake me to up go out and pee (rather than just peeing in the house). It became a very likeable habit for her... me, not so much.

I just had to stop with the treats and she eventually learned I was not getting up all night to give her food. I also bought the very tiny training treats, so she wasn't getting too many calories at night.

Just work through this part, I am sure it will resolve.

[molly muffin]

Must say Brick has high hopes. :) Determination in that boy. LOL

[camval1]

Do only certain cush pups get to have a split dosage or can a split dose be used for any pup?

Brick does so much better when the meds are at max strength.

He's settled, no panting, no begging, no water gulping.

I really want to pursue a split dose for him.

[doxiesrock912]

Mark, the split dose was recommended to me because cortisol naturally rises and falls throughout the day and Daisy's IMS felt that this was the best was to keep cortisol levels as even as possible 24/7.

Have you asked the specialist yet?
Given that Brick seems to be hungrier at night, I would think that this would be a good thing to try with him.

[labblab]

A split dosage can be given to any dog. Some clinicians prefer to dose all their patients that way in order to maintain a consistently lower level of cortisol. Other clinicians (as well as Dechra) recommend starting with one dose daily, and only switching to twice daily dosing if cortisol levels have fallen within the desired therapeutic range on a once daily dose but symptoms still seem to be rebounding at night.

There really is a great deal of variability in the manner in which individual dogs metabolize and respond to the drug. Many dogs seem to do just fine on a once daily dose after cortisol levels have been sufficiently reduced. Therefore, for ease of administration (it's not always convenient for owners to dose along with food at 12-hour intervals), the once daily regimen may remain preferable for many patients. Twice daily dosing may also end up being a more expensive alternative because two capsules of a lower dose may end up costing more than one capsule of a higher dose. That all depends.

In Brick's case, if a twice daily regimen is not inconvenient for you, then you certainly can talk to vet about switching at any time. However, just bear in mind that as of his last ACTH, his cortisol still had not been lowered sufficiently on a once daily dose. So it remains possible that his symptoms will end up being well-controlled throughout a 24-hour time period once he reaches therapeutic level on the once daily dose. However, there is nothing to stop you from discussing the switch with your vet. From a practical standpoint, you may want to wait until after the next monitoring ACTH test, however, so you'll have an apples-to-apples comparison to the first test upon which to base any subsequent dosing change.

One other point to note is that we have been warned that dogs who are dosed twice daily may run a greater risk for dropping their cortisol levels too low. Perhaps this is because levels never rebound as greatly at any time during a daily cycle? I dunno and am only speculating about that.

Also, even though Brick is not diabetic, for the benefit of our other readers, twice daily dosing is virtually always recommended for diabetic dogs so that insulin and cortisol levels can be maintained as consistently as possible throughout a 24-hour time period.

Marianne

[camval1]

We see the specialist tomorrow morning at 9 AM (EST).

Any particular questions I should ask?

[molly muffin]

I don't know that there is anything necessarily specific. Talk about how many Cush dogs he has treated. The dosage you are on. (Making sure that he is on the same page as you and dechra). About doing the split dose. About wanting a team for brick of which you and the doctor would both be members. You know so much more already than you did when first diagnosed. You have been a very proactive doggy dad and that is wonderful. You are looking for a vet who can be a part of the team. You don't need to worry about an argument over every thing on this journey. I wouldn't even go down that road of my bet wants this. I want that. Just have an easy going chat about brick. Treatment. What to expect for long term planning to manage this. Etc.

[camval1]

Just got back.

Liked this doc very much.

She is younger than his regular vet, so it seemed that she was more open to new research. But that might be because she is an internist and has to stay on top of the latest & greatest procedures & info.

She found no fault with all the diagnostic work his regular vet did (I never did, either).

She agreed with the opening dose of 60 mg. I told her I had to fight for it and she seemed a little surprised. She asked what dose his vet wanted and I said 120. She said, "well, he might have been OK at that dose".

She was pretty happy with the 1st stim test results. Didn't really feel the need to up the dose at this time, but she gave me the option if I wanted to.
Actually, she gave me a few options: up the dose now, do another stim test now, and do another stim test in a few weeks. None of those choices would be wrong.

When it comes to increases, she said that the Vetoryl capsules are available in 10 and 30 mg capsules, so we can tweak the dosage carefully. It was clear that she believes in the low & slow methodology.
She wants to see a post stim of 2-6. Ideally, she'd like to see a pre stim of 3 and a post stim of 5. But, more than anything else, the relieving of the symptoms is the most important factor. She said even if the numbers are not perfect, but the dog has no symptoms, then that's the best indicator that we got the dose right.

Split dosages: Typically it's done for dogs that are constantly getting up in the night to pee. Brick's not doing that. But we can pursue that if I like, but it typically comes after we get the symptoms under control with once-a-day dosing. One thing that I didn't see anywhere else is that we don't have to split equally. We may give 60mg in the morning and 30mg in the evening.

She said that we don't always have to do the full blown testing at every stim test. If he's doing well with no symptoms, then we can do more limited testing.

She hooked me up with www.allivet.com for his meds. They're half of what his regular vet charges.

She's open to holistic approaches as well. Some owners want to go only that route while others like to mix it in with traditional treatments. She told me to pick up some melatonin and start him on that at night, but only 1 pill to start to see how he reacts.

She said she loves internal medicine, including endocrinology. That, along with only a few other disciplines, is all she focuses on.
She's treated a lot of cushnoid dogs, all with positive results. She said she's never had one go Addisonian.

Oh, and they have Saturday hours for the stim tests, so I won't have to take time off from work. That's a big plus.
And she gave me her e-mail addresses and told me I could e-mail her any time. His regular vet doesn't even have e-mail.

Overall, I'm very pleased with today's meeting.
I've set up his next stim test for 1/17/15.
I'm sure we'll make a change to his dosage then, but I'm relieved that it will be a small increase and not doubled.

[Dixie'sMom]

Wow... that sounds like a very productive trip and she sounds great! I'm happy you have someone you can trust. It makes all the difference in the world to your peace of mind. It sounds like Brick will be in good hands. (((HighFive)))

[molly muffin]

I do think that this vet sounds more like what one wants with Cushing's. Sp maybe she can manage the Cushing aspects for you from now on. Great they will do the ACTH on a Saturday. I know how hard to keep having to take off work is.

[addy]

Sounds like a good find, especially email and Saturday hours and sounds open to you thoughts.

Great job funding a decent vet with experience.

[camval1]

So maybe she can manage the Cushing aspects for you from now on.

That's just what we'll do.
The internist will manage the Cushing's and his regular vet will take care of the everyday stuff, wellness, vaccines, etc.

[Renee]

That's just what we'll do.
The internist will manage the Cushing's and his regular vet will take care of the everyday stuff, wellness, vaccines, etc.

Many people do this Mark. I think this is a great plan for you, and maybe along the way your regular vet can learn a thing or two!

[camval1]

Does Cushing's and/or trilostane cause gas?

Brick has had some pretty lethal gas the past week or so.
Usually in the evenings.

His diet hasn't changed.

[Harley PoMMom]

Both of the medications used for Cushing's have the potential to cause gastric upset, I would ask the vet about trying Gas-X.

Hugs, Lori

[camval1]

Brick had his second ACTH Stim test today; his first with his internist.

I gave him his trilostane at 6:18 AM with his breakfast.
He went in at 11:00 AM, they took the first draw at 11:35 AM, gave the Cortosyn right after, and the second draw at 12:35 PM.

I picked him up at 1:00 PM.

Should have results on Tuesday.

The Saturday hours are really convenient.

I was charged $225. I don't think we're doing the full blood work or electrolyte testing this time.

[flynnandian]

hoping for good numbers.
how is brick doing? no more gas?

[Harley PoMMom]

Brick had his second ACTH Stim test today; his first with his internist.

I gave him his trilostane at 6:18 AM with his breakfast.
He went in at 11:00 AM, they took the first draw at 11:35 AM, gave the Cortosyn right after, and the second draw at 12:35 PM.



According to Dechra, the post draw needs to be performed within 4-6 hours after the Trilostane is given, so that second/post draw was done a bit over that 6 hour window which will need to be taken in account when evaluating those ACTH stim results.

Please do post those ACTH stim results when you get them...thanks!

Hugs, Lori

[Renee]

$225 sounds reasonable. You may be able to cut that cost if you purchase an entire bottle of cortrosyn on your own and then have them dilute it. This is what my vet does.

Lori is right about the draw being just a touch over, but I don't think it's enough to invalidate the testing. I dose at 630 and then get Tobey to the vet at 10.

[camval1]

hoping for good numbers.
how is brick doing? no more gas?

I think he's doing pretty well.

Water consumption is down.
I have a spreadsheet that I'm tracking it on. I'd post it but I don't know how to post an Office document in a forum.

I'm not sure if the frequency of his urination has decreased, but I've seen a definite reduction in the time of each urination. He was going for 30-35 seconds before. Now he's down to 8-12 seconds.

Panting doesn't seem as prevalent.

He's not begging as much.

The gas hasn't been nearly as evident the past week or so.

I think I'm OK with the test timing. He always seems to be his best at the T + 5.5-7.0 hour mark.


There's still room for improvement, but I think we're heading in the right direction.

[flynnandian]

this doesn't sound bad at all.
maybe you have to increase the vetoryl dosage a little, but i am glad his health has improved!

"'I think I'm OK with the test timing. He always seems to be his best at the T + 5.5-7.0 hour mark."'

every individual dog is different. if he is at his best at this hour mark, then no worries!
those few extra minutes don't make the test worthless.
glad brick is doing better.

[camval1]

Just got the call from the vet.
Brick's stim results are in.

Drumroll please...
.
.
.
.
.
.
.
Pre Stim = 2.8
Post Stim = 4.9
:D :D :D :D :D

Can't believe how good his numbers are.
So pumped! I can't stop smiling.

Doc said she wishes she could get all Cushing's patients to these numbers.

I asked if it's normal to take upwards of 45 days to see good results. She said it's not uncommon.
I then asked about the logic of increasing dosage after the first stim test (10-14 days after starting medicine) and she said that 1st test should just be used to insure that the dog isn't overmedicated. It shouldn't be used as a gauge to increase meds. 10-14 days in is too soon to increase. Takes time to take effect.

So now I just keep him on his 60mg per day. Watch to see if symptoms get worse and of course continue to watch for signs of crashing. Otherwise, we're looking great.
She would want to see him again no sooner than 4 weeks and no later than 8 weeks. I imagine we'd check his electrolytes & full blood panel at his next test.

I just want to thank all of you here for the knowledge & support, If it wasn't for you, I hate to think where Brick & I would be right now. You guys got me thru this. Thank you.

[Dixie'sMom]

WHOOOOOOOOOOO HOOOOOOOOOOO!

Awesome news! You and Brick have done a great job! Now you can cruise along, watchful, but not worried! :D:D:D:p

[Renee]

WOOP WOOP! Way to go! Those are excellent numbers. :D

[labblab]

Oh Mark, this is great news!!! :) :)

And it looks as though the 1 mg. per pound formula has really come through for Brick since he has started out so well on the 60 mg. I'm SOOOOO glad you adjusted him down from the 120 mg. that your other vet was first recommending! ;)

Marianne

[Harley PoMMom]

Oh Mark, those are excellent numbers!! Congrats!!!!! Great job!!!

[My sweet Ginger]

Yay!! Those two numbers look awesome. I'm very happy for both of you. :)

[flynnandian]

great numbers, glad you didn't give him 120 mg!

[Squirt's Mom]

Way to go, Brick and Dad! :cool::cool::cool:

[camval1]

When do you guys think I should have him checked again? Barring any major changes, of course.

[Harley PoMMom]

If Brick continues to do well, I would recommend another ACTH stimulation test along with having the electrolytes checked in 30 days.

[camval1]

Found a way to convert Brick's water consumption Excel graph into a jpeg.

Here it is:

http://i295.photobucket.com/albums/mm153/HuJass/misc/waterconsumption_zps4072b1ba.jpg


I don't know what his consumption was before we started the meds.


Keep in mind this is for BOTH dogs. I don't have a way to separate them.

[Harley PoMMom]

Sorry but the link for water consumption is not showing up in your post.

[labblab]

I am seeing the graph, and it's pretty impressive! :)

Marianne

[Harley PoMMom]

I'm on the computer at work, I wonder if that is why I can not see his link? :confused:

[camval1]

Hi all.
Long time no hear.

Brick had a follow-up ACTH Stim test this past Saturday (2/21/15) and I just received his results back.

pre-Stim = 2.0
post Stim = 3.3

We also looked at electrolytes and a complete blood work-up.
Some results (the ones in red are ones that are outside of the range):

Glucose = 74 (range is 63 - 114 mg/dL)
BUN = 18 (range is 9 - 31 mg/dL)
Creatinine = 0.8 (range is 0.5 - 1.5 mg/dL)
BUN / Creatinine Ratio = 22.5
Phosphorus = 5.2 (range is 2.5 - 6.1 mg/dL)
Calcium = 10.8 (range is 8.8 - 11.2 mg/dL)
Sodium = 144 (range is 142 - 152 mmol/L)
Potassium = 5.2 (range is 4.0 - 5.4 mmol/L)
Na / K Ratio = 28 (range is 28 - 37)
Chloride = 104 (range is 108 - 119 mmol/L) L
TCO2 (Bicarbonate) = 23 (range is 13 - 27 mmol/L)
Anion Gap = 22 (range is 11 - 26 mmol/L)
Total Protein = 7.9 (range is 5.5 - 7.5 g/dL) H
Albumin = 4.2 (range is 2.7 - 3.9 g/dL) H
Globulin = 3.7 (range is 2.4 - 4.0 g/dL)
Alb / Glob Ratio = 1.1 (range is 0.7 - 1.5)
ALT = 198 (range is 18 - 121 U/L) H
AST = 19 (range is 16 - 55 U/L)
ALP = 1,107 (range is 5 - 160 U/L) H
GGT = 10 (range is 0 - 13 U/L)
Bilirubin - Total = 0.1 (range is 0.0 - 0.3 mg/dL)
Bilirubin - Unconjugated = 0.1 (range is 0.0 - 0.2 mg/dL)
Bilirubin - Conjugated = 0.0 (range is 0.0 - 0.1 mg/dL)
Cholesterol = 329 (range is 131 - 345 mg/dL)
Amylase = 753 (range is 337 - 1,469 U/L)
Lipase = 583 (range is 138 - 755 U/L)
Creatine Kinase = 48 (range is 10 - 200 U/L)

She didn't seem to be too concerned over the values that were out of spec.
At this point, we just continue what we're doing and recheck in 3 months unless I see a change.


I told her how he seems to be drinking a little bit more and scrounging a bit more in the evening compared to during the day. She suggested that we could give him a small dose in the evening to bump the trilostane level in his blood up a bit for the evening. She suggested 30 mg but left it up to me if I wanted to try this.
So he would still get his 60 mg in the morning (approx. 6 AM) and then a 30 mg boost about 4 PM.
I was thinking this is what he was needing before he was rechecked, but I'd like to get your thoughts on this approach.

Otherwise he seems to be doing well. Water uptake is pretty flat. Nothing really to report. I guess that's a good thing.

[labblab]

Brick had a follow-up ACTH Stim test this past Saturday (2/21/15) and I just received his results back.

pre-Stim = 2.0
post Stim = 3.3

Well, you are asking for opinions so I won't be shy in offering mine. :o

With this ACTH stim result, no, I absolutely would not increase Brick's daily total dose at all, and certainly not by 50%. If you do, I fear you are risking driving his cortisol way too low. When the monitoring ACTH indicates that cortisol is being maintained within the desired therapeutic range but symptoms are rebounding at night, the recommended protocol is simply to divide the daily total -- not to increase it. Here's a quote from Dechra's U.S. Product Insert for Vetoryl:


Once daily administration is recommended. However, if clinical signs are not controlled for the full day, twice daily dosing may be needed.
To switch from a once daily dose to a twice daily dose, the total daily dose should be divided into 2 portions given 12 hours apart. It is not necessary for the portions to be equal. If applicable, the larger dose should be administered in the morning and the smaller dose in the evening.

In Brick's case, it would be easy to divide his daily total exactly in half by giving 30 mg. both morning and evening. But no, I would not increase his daily total. On the basis of clinical experience and also research studies, we are being told by specialists that dogs dosed twice daily may actually end up needing a lower overall daily total than dogs dosed only once daily.

Marianne

[Renee]

Ha, I was just thinking about you the other day and wondering when you were going to check in!

Here, here to Marianne's opinion. I fully agree. He is in excellent range now, so it's a good time to try splitting the dose into twice daily dosing and re-run a stim test to see how he reacts. Please, do not increase the dose. Calling it a 'boost' is misleading. It's an increase and a big one. He could drop quickly. I am a little surprised by your vet even suggesting an increase.

I have always done twice daily dosing from the start, but that was a decision I made given that Tobey's symptoms seem to peak in the late afternoon and evening. We do an even 20mg in the morning and 20mg in the evening.

[Harley PoMMom]

Yep, I agree too, split his dose and give 30 am & 30 pm. :)

[molly muffin]

I agree too, no upping the dosage or you risk a crisis, as he is already in a perfect range. Divide if you want, but don't increase.

That is my personal opinion based on the manufacturer and what we have seen on the board here.

[camval1]

Hi everyone.
Haven't been here in a little while.
Hope everyone is well and their furbabies are getting along as best as possible

Just a quick update on Brick.

He seems to be doing fine. I never increased his dosage or split it. I want to see where he lands with his next Stim test, which isn't till May 30th.
His cortisol levels have dropped each time we measured. So I didn't want to upset the apple cart just yet.
It would be nice to see where he settles out before making a move.


Brick had his first Airecut of the year.
His first since last October and his first since he was diagnosed with Cushing's.

Here's some pics:

http://i295.photobucket.com/albums/mm153/HuJass/dogs/DSC_1047a_zpshn82ejae.jpg

http://i295.photobucket.com/albums/mm153/HuJass/dogs/DSC_1046a_zpsm84k7zee.jpg

http://i295.photobucket.com/albums/mm153/HuJass/dogs/DSC_1045a_zpsbnqoywrx.jpg

http://i295.photobucket.com/albums/mm153/HuJass/dogs/DSC_1042a_zpsxmzhtjbh.jpg


His fur looks great. I was a little nervous because it was looking a little sparse back in late November, early December, but it seems to have filled back in nicely.

And this was a new groomer. His previous one eliminated her Saturday hours so we were forced to find a new one.
Which stunk because the previous groomer is an Airedale breeder and she knows how to groom them.

The new girl did a pretty good job. His legs and body are great but she was off in the face. I fixed him a bit when I got him home.
But I think I'll stick with her because they are literally only 2.5 minutes from home. Can't beat that.

[camval1]

deleted repetitive post

[Squirt's Mom]

MODERATOR NOTE: I have merged your post about Brick's haircut into his 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!

[camval1]

Hi all,
Just checking in.

Brick is well.


Question about flea/tick preventatives:

I'm thinking of switching Brick from Comfortis oral flea preventative to NexGard oral flea AND tick preventative.
It's a newer product and I have no experience with it.

I was wondering if there were any negative interactions between this drug and trilostane.
Then I wondered if there were any potential negative outcomes in giving NexGard to a Cushing's pup.

I called the makers of each drug and they said there is no known negative interaction between the 2.

I also called Brick's internist and left a message asking the same thing. Haven't heard back yet.


Anyone have any input on the topic?




BTW, he goes in for his next Stim test on 5/30.

[judymaggie]

Hi, Mark! Good to hear that Brick is doing well! I switched Abbie to Nexgard about 7 months ago. I had been using Frontline Plus before that time and was concerned that I would find fleas on her before the end of the 30 day re-application time. My vet had experienced the same thing with his dogs and decided to use the three of them as informal test subjects with Nexgard prior to offering it in the clinic. His dogs had no side effects and he saw no fleas at any point. That was good testimony as far as I was concerned. However, the Nexgard at the clinic was extremely expensive so I purchase it on-line at a much better price and it has been very effective. Abbie has had no side effects and she loves the taste! Abbie is on Lysodren so can't speak to any interaction with trilostane.

I hope Brick's stim test numbers are right where they should be!

[camval1]

Thanks for the feedback Judy.
I appreciate it. :)

[molly muffin]

Interesting I haven't heard if Nexgard. I wonder if we have it in canada. Right now I am using revolution.

Great to hear that Brick is doing so well

[camval1]

Hi all,
Brick wasn't really interested in his food tonight. He ate some of it (maybe half). And it wasn't all at once. Probably over a half hour period.
He ate his breakfast fine.
He wasn't really interested in treats, either.
Should I be concerned with this? I haven't seen this behavior before.
How long do I wait to see his vet if this behavior continues?
Otherwise, he seems to be acting pretty normally.
It was kinda hot in the house today (around 85), but I gave him access to the basement which is cooler. Plus I gave him a couple Benadryl's around 2:30 PM because there was a chance of storms today. There were a few rumbles of thunder today. He's scared of thunder. I fed him at about 6:45 PM.


I gave him a NexGard anti-flea/tick med last Wed. They say a side effect is lack of appetite, but I find it hard to believe that it would take almost a week to show up.

Thoughts?

[camval1]

He ate ALL his breakfast this morning like normal.
He was even pushing his bowl around after eating and looking for food in Zeke's bowl.
All normal behavior.


He never stopped drinking, no vomiting, no diarrhea, no other abnormal behavior.

[molly muffin]

My guess is it was the couple of benzapril that made him uninterested I. Dinner last night. Since he is fine this morning that is my guess. Just pay attention on days you give him something to calm before storms if his appetite isn't so good. I give Molly melatonin before storms. She seldom wants much other than treats when she has that. If I don't give her melatonin the storms freak her so much that she wouldn't eat a treat never mind trying for dinner or a meal.

[Squirt's Mom]

So glad Brick was acting more like his old self this morning! My heart always skips a beat when I read one of our babies isn't eating well. ;)

[camval1]

I didn't give him his Cushing's med yesterday.
I called the vet yesterday morning and she called me back a little later.

She said if he eats his dinner (yesterday) and eats his breakfast (today), then to start him back on his trilostane.

He ate his dinner great yesterday. And he had some carrots at night. And a little bit more food.
He then went out for pees and poops, which all looked normal.

He ate his breakfast AND dinner just fine today.
I gave him his trilostane this morning.

The vet said it's hard to determine just what causes a dog to not eat one meal. Could have been the heat, could have been the Benadryl, could have been the thunder. Or a combination of those things.

[molly muffin]

Great to hear that he is back to himself fully.

[camval1]

Hi all,
Just checking in.

Brick had another Stim test this past Saturday (June 27th).

Before I get to the results, I'll post his schedule from test day:

- breakfast at 6:20 AM
- 60mg trilostane at 6:20 AM
- 1st blood draw at 11:20 AM
- Cortosyn administered at 11:20 AM
- 2nd blood draw at 12:20 PM

Results:
- pre-Stim: 1.1
- post-Stim: 1.5

So yeah, he's right on the edge, maybe even a bit low.

His intern suggested we reduce his dosage.
And also to stop the meds until the new dosage arrives.

She's suggesting either 30mg once a day or 30mg twice a day if symptoms aren't well controlled with the 30mg/once per day dosage.

I think it makes safe sense to go with the 30mg once per day & see how he does. We can always increase a bit if need be.

Thoughts on the new pathway?


I'm waiting for the remainder of his results (liver levels, electrolytes, etc.) to be emailed to me. I'll post them when I receive them.

[labblab]

Hello again! It's very interesting that Brick's cortisol has continued to decrease over these last few months, even while remaining on the same 60 mg. dose of trilostane. Your experience is further evidence that it is indeed very important to continue the ongoing monitoring testing for as long as a dog is taking the medication.

As usual, for the most apart, I agree with your vet. I think Brick's test result definitely calls for at least a temporary break from the medication followed by a lower dose. How has he been doing behaviorally? I know you had written a little while back that he was being picky about eating -- has that continued, or was that just a temporary issue? Anything else "off" for him? If not, and if he has been behaving normally, then probably just the temporary break and the lower dose will be the proper solution. If his results were any lower, or if he has been behaving abnormally, then I think you'd want to wait until you have concrete proof that his adrenal function has rebounded before starting back with the meds. The proof would be a return of overt symptoms and/or an ACTH that is once again climbing.

However, whenever Brick resumes treatment, I am concerned about your vet's dosing recommendation.


She's suggesting either 30mg once a day or 30mg twice a day if symptoms aren't well controlled with the 30mg/once per day dosage.

I understand the 30 mg. once a day, since you are wanting to decrease his daily total. Cutting the daily total fully in half may turn out to be a bit too much of a decrease to keep his cortisol well controlled, but you will find that out over time. However, the part that makes no sense is the alternative of dosing 30 mg. twice daily. That would be returning to the 60 mg. daily total that has already proven to be too high a dose. Combining this advice with a dosing recomendation that your vet made earlier makes me fear that she is unaware of changes in dosing recommendations that have occurred since trilostane was first introduced. A decade ago, twice daily dosing meant doubling the once daily dose. Subsequent to intervening years of research and experience, twice daily dosing NOW means giving portions of the overall daily dose at 12-hour intervals. So if 30 mg. once daily proves to the best dose in terms of ACTH monitoring results, but symptoms rebound later in the day, you would split the 30 mg. into two portions to be given in 12-hour intervals. You would not double the dose. Here's the most current recommendation from Dechra re: twice daily dosing.


Once daily administration is recommended. However, if clinical signs are not controlled for the full day, twice daily dosing may be needed.

To switch from a once daily dose to a twice daily dose, the total daily dose should be divided into 2 portions given 12 hours apart. It is not
necessary for the portions to be equal. If applicable, the larger dose should be administered in the morning and the smaller dose in the evening.

For example, a dog receiving 90 mg would receive 60 mg in the morning, and 30 mg in evening.

So for the ease of dosing, I think it's fine to first start with the 30 mg. once daily and see where that takes you in terms of ACTH results. If Brick's cortisol runs too high on the 30 mg., you will need to increase again incrementally. Once his ACTH is back where you want it on the once daily dosing, if his symptoms are still rebounding later in the day, you can then visit the plan of switching to a twice daily dose. But once again, that means dividing the morning total into portions, not doubling it!

Marianne

[camval1]

Hi Marianne,
Thanks for the feedback.

There was only that one meal where Brick wasn't interested.
Fine before that and fine after that.


He's been doing great, otherwise.
He hasn't had any accidents in the house since I started him on the trilostane back in the beginning of December 2014.
His water consumption is down & is continually going down (should post his latest graph).
It isn't as low as it was before he develped Cushing's. Back then, he was like a camel. I would have to change his water every 3 or 4 days because dust & fur would settle on it. He would NEVER empty his bowl, even in that timeframe.
But it's much better than what it was before he started the meds.

His appetite is good. He begs for food at night but I think a lot of that is behavior and not disease related, as the other dog starts barking for food, too.

Fur looks great.

No vomiting.

No lethargy.

Length of pees are shorter. Something like 30 seconds per episode before meds to about 12-16 seconds nowadays.

His back legs shake occasionally, but it seems like he can control that.

He's popped a bunch of those wart-like adenomas since diagnosis, but that might be just age (he's just past 11).

He has a bit of lenticular sclerosis (denseifying of lens in eyes), but that it common in older dogs.

He seems to stink a little more than normal. We're not sure if that is his age, disease, or maybe even his fish oil. I'm trying a different brand fish oil with supposedly less odor.
Might try a benzoyl peroxide shampoo if the different fish oil doesn't help.


In terms of dosing, his intern is trying to find a dosage that's easy to give and easy on my wallet. It'll get expensive real quick if I have to buy all sorts of different dosages to get the exact one we want.
We're trying to avoid that if we can. If not, then we'll go that route.


What was funny was that she made a little quip about how his regular vet wanted to give him 120mg.
She also said that he seems sensitive to the drug (I interpret that as, he gets bigger returns than other dogs on the same dosages).

[labblab]

Mark, I definitely appreciate her wanting to help you as much as possible with the cost. But if you do need to increase incrementally, a less expensive route would be to switch to a compounded version of trilostane. I personally have some reservations about compounded products, but they can be a life-saver if doses are required that cannot be easily obtained in brandname Vetoryl, or if the cost is exorbitant. As I say, I do worry that dropping clear down to 30 mg. may not offer enough cortisol control for Brick. But if so, based on these test results, you will need to arrive at a daily total that is less than 60 mg. In that event, you may want to consider a compounded alternative.

I truly don't understand why she'd recommend a return to 60 mg. daily total under any condition. You've already found that it is too much for Brick when given once daily. And research has shown that dogs being dosed twice daily frequently need even a lower overall daily total than if they are dosed only once daily. So to me, that recommendation to double the dose is simply not safe and could cost a great deal of money if an Addisonian crash were to result. Plus, if you were going to try adding an evening dose in addition to the 30 mg. in the morning, a 10 mg. capsule would be cheaper than another 30 mg. capsule, anyway. So why would you not first start there, for cost as well as safety?

For reasons that are not yet understood, it also seems that larger dogs may need lower doses per pound than do smaller dogs. I can confirm that we have witnessed very large dogs here who end up requiring even smaller doses than much smaller dogs. So that may be part of your vet's experience.

[camval1]

Hi Marianne,
Much like you, his intern has reservations about compounded trilostane, as well.

I wasn't really thinking in terms of the twice daily dosing at this point. I'm more interested in formulating a good single daily dosage that works well for Brick.

[camval1]

So since Brick's last stim test (6/27), we reduced his dosage from 60mg once a day to 30mg once a day.
He had another Stim test yesterday to test the effectiveness of the new dosage.
Got the results today.
Pre-Stim = 1.9
Post-Stim = 2.3

So we're going to reduce his dosage again.
This time, we'll go to 10 mg once a day.

Keep in mind that his numbers have been decreasing since he started trilostane back in the beginning of December 2014.

I suspect his numbers to pop up a little bit after switching to the 10 mg dose.

Remember, his last post stim on 60mg was 1.5. And it only rose to 2.3 on 30mg.
So if it goes up to 3-3.5 on the 10mg dose, that'll put him right in the sweet spot of post stim numbers.

He'll start the 10 mg in a few days and then we'll retest in 4 weeks.

If it keeps decreasing, we'll take him off the med altogether.
The good news is that he seems to be doing well. No real Cushing's symptoms, no overmedication symptoms.
I'm pleased with his progress and care.

[molly muffin]

I'm glad to hear he is doing well, but yes he does appear to be one of the sensitive ones. I agree if 10mg would put him in the 3. - 4. range, that would be good.

[camval1]

Have you guys ever seen or heard of a dog that was on 1/6 mg per pound of body weight?
But hey, if it's what he needs & it works, then yee haa!!

[lulusmom]

Hi Mark,

Studies have shown that a number of dogs being treated with Trilostane have gone into spontaneous remission. It is believed that these dogs have some level of adrenal necrosis, much like dogs who are treated with Mitotane. Brick is not an anomaly as it is well known that dogs stabilized on the same dose for years can all of sudden have scary low cortisol levels and if not caught by acth stim test, can have an addisonian crisis at any time. The fact that Brick's post cortisol rose less than one point on half the dose, could be an indication that he may not need treatment at all.

Glynda

[camval1]

Hi Mark,

Studies have shown that a number of dogs being treated with Trilostane have gone into spontaneous remission. It is believed that these dogs have some level of adrenal necrosis, much like dogs who are treated with Mitotane. Brick is not an anomaly as it is well known that dogs stabilized on the same dose for years can all of sudden have scary low cortisol levels and if not caught by acth stim test, can have an addisonian crisis at any time. The fact that Brick's post cortisol rose less than one point on half the dose, could be an indication that he may not need treatment at all.

Glynda

Hi Glynda,
Thanks for the feedback.

Would adrenal necrosis show on an ultrasound?




What's weird is that he went thru about a 2 month period back in 2011 or 2012 where his drinking & urination increased markedly.
Bunch of tests were run (no Cushing's tests, though) but nothing definitive was found.
As inexplicably as that came on, it ended.
I wonder if he went Cushnoid for a little bit back then.

And if we end up taking him off meds in the near future, I wonder if he'll be going in & out of Cushing's for the rest of his life.

[Squirt's Mom]

Remember two key points - 1) those signs are not exclusive to Cushing's but are in fact seen in many, many conditions other than Cushing's and 2) most if not all of those other conditions can cause false positives on the Cushing's tests. That old adage "if it looks like a duck and quacks like a duck then it's a duck" doesn't really apply to canine Cushing's. ;)

[camval1]

Remember two key points - 1) those signs are not exclusive to Cushing's but are in fact seen in many, many conditions other than Cushing's and 2) most if not all of those other conditions can cause false positives on the Cushing's tests. That old adage "if it looks like a duck and quacks like a duck then it's a duck" doesn't really apply to canine Cushing's. ;)

Agreed.
We attributed those symptoms (including elevated liver numbers) back in '11 or '12 with him potentially chewing/eating black walnut shells.
Black walnut shells are toxic to dogs. They have tannins in them that can harm a dog.

The symptoms fit the action of ingesting black walnut shells and I found chewed up black walnut shells on the back porch. So that's why we settled on black walnut shell ingestion.

It wasn't until he was officially diagnosed late last year did we begin to wonder if he dipped a toe into the Cushing's pool back in '11 or '12.

I guess we'll never know.

[camval1]

Brick's latest stim test results came back today.
Remember, he is on 10mg of trilostane, once a day.

He stimmed at 2.7 post.

So he'll stay on the 10mg dosage and we'll retest in 3 months.

[My sweet Ginger]

What was his pre number?

[molly muffin]

At least he isn't dropping again. Good question from Song (My Sweet Ginger) do you know what the pre number was?

[Renee]

Honestly, with numbers so low over the past few months, and the continuous drop in his dosage - have you thought about just stopping the vetoryl altogether for a while?

When he was on 30mg, his post was 2.3. Dropping down to 10mg only brought him up to 2.7. Those really are perfect numbers, but I wonder if he even needs the medication anymore?

[camval1]

Hi all,
Just an update on Brick.

He had a stim test back in November of 2015. He edged up a bit from his August 2015 results, so we bumped him to 20 mg once a day.

Fast forward to now, he had another stim test last Friday. Just got the results yesterday.
Pre = 1.0; Post = 1.3.

So the vet said to cut him back to 10 mg once a day.

She's very happy that we're able to control his Cushing's with such a small dose (for a dog his size).

[Renee]

With numbers that low and blunted, you may want to back off altogether for a week (or longer), and then start back up. I had the same numbers with my girl and we stopped the vetoryl completely for 10 days. She rebounded nicely, then started back up at a lower dose.

I believe Dechra recommends the same approach in their treatment flowchart.

[labblab]

Yes, I want to chime in here alongside Renee: with numbers that low, the general recommendation is to entirely hold off on giving any trilostane at all for at least a week, before resuming at a lowered dose. This is assuming the dog is outwardly looking well. If the dog seems ill with a cortisol level that low, then additional testing is needed prior to resuming dosing in order to make sure that the adrenal function is rebounding properly. Take a look at the "Treatment and Monitoring of Hyperadrenocorticism" chart that appears midway through this official Dechra publication:

http://www.dechrace.com/pdfs/vetoryl/VETORYLTechnicalBrochure.pdf

Marianne

[molly muffin]

It certainly shouldn't hurt to hold off for a bit and then start back in at the lower dose.

[camval1]

I had Brick retested last Friday.
His appetite seems to be a little off.
He used to go after his food with gusto but not so much anymore. He'll eat it all, but it takes tempting and a few tries. He might eat his dinner over a span of about 2 hours. A little at a time.

His results came in Monday.
Now mind you, we think the lab transposed the pre & the post numbers.

pre = 2.9
post = 1.4

Like I said, these are most likely reversed, so that the:
pre = 1.4
post = 2.9

He was on 10mg since the last time he was tested back in mid April.

What do you think of these numbers?

His internist wants to take him off completely for a few days to see if his appetite rebounds.
We'll then make a decision about keeping him at 10mg per day or dropping him to 5mg per day.

In the meantime, he's had a complete blood panel run with nothing remarkable to post. And they took another sample of blood for a GI panel, to ensure his GI system (incl pancreas) is working properly. Should have those results back tomorrow.

There's some concern as he's lost almost 4 lbs since March, he looks & feels kinda bony, and his appetite isn't as strong as it used to be.

It could be all age related. He's 12.25 years.

Thoughts on all this?

[lulusmom]

Hi Mark and thanks for updating us.

I totally agree with withholding the Vetoryl until Brick's appetite is completely normal again. The results you posted are most likely correct. My own cushdog had those results a few times but the post stimulated cortisol was higher than Brick's so her IMS was not concerned. When a dog is injected with the stimulating agent, that agent is asking the adrenal glands to dump cortisol into the blood stream. If cushing's is not well controlled, the adrenal glands will dump too much in which case you would see an unacceptably high post stimulated cortisol. If the Vetoryl dose is controlling the disease too much, the adrenal glands don't have enough cortisol in reserve to respond to the stimulating agent, which would yield the non stimulatory result you are seeing. Once you restart dosing after Brick's appetitite normalizes, should he become picky with his food again, that would be a pretty good indication that the dose may need to be adjusted downward. Please keep us posted.

Glynda

[Renee]

Hey Mark,

So glad to see you here.

I wouldn't be so quick to think the values are backwards. If you went through Tobey's thread, you would see that she consistently had a lower post than baseline for close to a year. My vet contacted Dr B about it and he said he wasn't as rare as it used to be.

Brick has been trending downward for months and months, even with his dose being lowered. I've suggested in the past that you discontinue the meds and I think he's at the point where he most definitely needs to.

I agree with your IMS that you should go ahead and discontinue the vetoryl altogether, although my opinion is to wait on starting it back up. Let his adrenals get good and rebounded before starting again. I've talked with Dechra a few times about this type of situation. It doesn't happen often, but some dogs eventually just stop needing the drug. It may be that Brick is one of them. My own pup needed an extended break from her vetoryl, based on her numbers. We eventually started her back up on a lower dose. Although, she may be due for an increase (a whole other story!).

You are doing good!

[molly muffin]

My dog had a higher pre than a post. She was shivering and shaking all the time and we decreased her dose, had her off for a few days for the appetite to come back and now she is in a good range again on the lower dose. It does happen from what I've been told.

It doesn't hurt to have him off to see if his appetite comes back.

[camval1]

Yup.
He's off the trilostane for now.
Hoping his appetite gets stronger. He needs to gain weight.
Might there be something else wrong with him? I know that diabetes can go hand in hand with Cushing's. If he had diabetes, what other symptoms would I see?
And wouldn't it show up on a regular blood panel?

It doesn't help that the Advanced Dasuquin I put in his dinner smells (& probably tastes) terrible.
That's part of the reason he's getting finicky about his dinner. It's not all of it but it's part. I know because I left it out once and he only ate just a little faster.
Trying to get the soft chewy version of the supplement. Proving kind of difficult.


This is the 1st time the numbers have been reversed.
I guess we'd have to wait for another test to see if it's a trend.

If it happens once, then I would believe that to be an error. If more than once, then I would lean towards something with the dog.

[camval1]

For those that stopped the drug for a while, how did you know when to put them back on it? Hopefully there's some kind of sign before they start peeing everywhere.

I'm at work all day with no one home.
I'd hate to come home to find puddles all over the house.


I do monitor his water uptake with a spreadsheet. I think I've posted it before.
And I time the duration of each pee.

[lulusmom]

We have had a number of dogs on this site who lost weight for no apparent reason while treating with Vetoryl (trilostane). I've researched extensively and have been unable to find any mention of weight loss as being a stand alone unexplained side effect. Most studies include it in a list of symptoms you would expect as a result of low cortisol crises.

A dog with diabetes presents with many of the same symptoms associated with cushing's, primarily excessive drinking and peeing, increased appetite and even hind end weakness. Lab abnormalities caused by diabetes on blood chemistry also overlap with many of those associated with cushings so if your vet ran a full blood chemistry, blood glucose and several other abnormalities would have been noted. It sounds like Brick had no abnormalities at all so that's a good thing but it doesn't explain the weight loss, especially if his appetite had been normal up until now.

Brick should be off of Vetoryl for no less than two weeks and in that time I hope you can find a way to make his food more palatable to get him eating normal again. I actually agree with Renee and think it might be a good idea to not restart dosing until Brick becomes symptomatic again. We have seen more than a few dogs who have, for some reason, gone into remission of various durations. This phenomenon has been recorded in many studies so it happens more than you think. As I recall there have been a few dogs who never needed treatment again. Wouldn't that be nice? I definitely think you should discuss this possibility with your vet.

Glynda

[camval1]

Most studies include it in a list of symptoms you would expect as a result of low cortisol crises.
So, with his numbers being low, we can say that he has low cortisol levels. And you've found research that suggests low cortisol levels contribute to weight loss. Do I have that correct?


A dog with diabetes presents with many of the same symptoms associated with cushing's, primarily excessive drinking and peeing, increased appetite and even hind end weakness.
No excessive drinking or peeing. Certainly no increased appetite. But he does have some hind end weakness. He has suffered from muscle loss. It's pretty evident.


get him eating normal again.
He's pretty much eating the same amount of food, he just doesn't gobble it all up like he used to. He'll eat some of it, then come back in a half hour to an hour to eat more, then come back in another half hour to hour to finish it.


I actually agree with Renee and think it might be a good idea to not restart dosing until Brick becomes symptomatic again.
I just worry he'll have an accident in the house without me there.


As I recall there have been a few dogs who never needed treatment again. Wouldn't that be nice? I definitely think you should discuss this possibility with your vet.
I will.

[lulusmom]

I apologize for not making myself clear about Vetoryl and weight loss. The studies I've read lists weight loss in a group of symptoms, such as vomiting, diarrhea and weakness, all of which are experienced as a result of cortisol that is low enough to throw a dog into a full blown Addisonian crisis. These dogs can lose weight because they are severely ill. What I have never been able to find is anything that would suggest that there is something in the makeup or genetics of a minority of dogs who experience unexplained weight loss caused by Vetoryl. When you discuss things with your vet, why not ask him to contact Dechra to discuss Brick's case? They can explain why Brick's last stim test would appear to be a lab error and they may also be able to tell you why Brick continues to lose weight despite eating the same amount of food and perfect labs. I've included a link below to the contact info for Dechra Technical Support. You could actually call them yourself if you are comfortable with that.

http://www.dechra-us.com/contact/technical-support

[Harley PoMMom]

Is Brick pooping normally, are they an organey or gray color and is it soft or well formed. I realize these questions seem odd :eek::) but sometimes information about their health can be gained from their stool.

Hugs, Lori

[camval1]

Is Brick pooping normally, are they an organey or gray color and is it soft or well formed. I realize these questions seem odd :eek::) but sometimes information about their health can be gained from their stool.

Hugs, Lori

His poop looks very much normal.
His frequency is normal, too.

His poop only gets orange bits in it when I feed him a lot of carrots.
He loves carrots. I figure it's a good snack for him.

[camval1]

Results of the GI panel are back.

He has a touch of pancreatitis, what looks like the early beginnings of IBD (his good & bad flora balance is off a bit), and his B12 is off a bit.

So we'll start him on Cerenia (an anti-nausea med that is believed to have an analgesic effect on the GI tract); chicken & rice for a bunch of days, and 2 tablespoons of plain yogurt with active cultures (for the pro-biotic) per day.

Since his appetite/eating habits haven't changed since taking him off the trilostane, she said I could put him back on it at any time.

This morning, I put 8 cups of water in his bowl at about 5 AM. By 7 AM, half of it was gone. Now, Zeke might have drank some out of Brick's bowl, but I didn't see that. Zeke doesn't tend to drink out of Brick's bowl.
I'm hoping that Zeke drank a big part of that. I don't want to come home to puddles this afternoon.

If there's no "surprises" when I get home today, I'll keep him off the trilostane for the rest of the weekend to see if his appetite comes back at all.
If not, I'll put him back on it on Monday.

[camval1]

So I got home about 4:45 PM this evening and didn't find any puddles. Whew.
The water bowls looked to be at about the same level I left them in the morning.
So now I'm more sure that Zeke was drinking out of Brick's bowl this morning.


I'm now feeding him chicken & rice for a while.

He ate it pretty well except when he encountered those damned supplements. He ate around them.
I had to doctor up the food a bit to get him to finish.

[kanga]

Welcome to the forum mark, so sorry to hear about what happen to your baby hope you find some helpful information here. Prayers for your baby hope the treatment will be succeed.

[camval1]

Welcome to the forum mark, so sorry to hear about what happen to your baby hope you find some helpful information here. Prayers for your baby hope the treatment will be succeed.

Thank you for the welcome, Kanga.

Brick and I have been on the forum since he was diagnosed back in November 2014.
So far, his treatment has went very well. He only needs a small dosage (less than a 1/4 mg per pound) to keep his Cushing's in check.

I suspect his other issues are due to old age, hard as that is for me to accept.

[molly muffin]

They are smart about pills in their food aren't they.

Well the pancreatis answers some questions on what is going on.

How is he doing now?

[camval1]

They are smart about pills in their food aren't they.

Well the pancreatis answers some questions on what is going on.

How is he doing now?

He's eating his chicken & rice pretty well. Would like him to eat his dinner with more enthusiasm but the Dasuquin is really turning him off. He will, though, eventually eat all of it and ask for more later in the evening.

He hasn't pooped yet since putting him on the chicken & rice. I called the vet about this. She asked if he was straining to go. I said no, because he hasn't even attempted to go.
She's not worried then.
She said chicken & rice is highly digestible so there's not much left as waste, plus it's not nearly as bulky as dog food. So it may take awhile before I see poop.

But he eats his breakfast well (nothing in it but the food) and he does eat his dinner (slowly, due to the disgusting supplement).
Drinking seems about normal as does his peeing.

[DoxieMama]

Hi Mark,

I'm glad you've got some answers now. I hope he's feeling better soon.

I have noticed a decrease in waste from my pup, who is also on a bland diet right now (rice and cottage cheese in his case). My vet said essentially the same thing when I asked him about it last week. He's not pooping near as often, nor with as much bulk now.

Any chance you can put the supplement in something really yummy, apart from his dinner? I'd worry that he'd stop eating his food because that's in there, which might cause more issues. I've been giving my guy his meds on a tablespoon with meat baby food which he is licking right up - before he gets his meal so he's hungry. Just an idea, unless of course you find the chewable. :)

Shana

[camval1]

Hi Shana,
I've put the supplement in peanut butter, cheese, & pill pockets.
He sniffs it right out & turns his nose.

But with the diagnosis of pancreatitis, I'm not sure what I can use to tempt him with.
He'll probably be on strict, low-fat, low fiber, bland diet from now on. Not sure how treats fit into that.

[molly muffin]

My dog isn't haven't as many or as much poops right now either as she has been eating bland plain protein and ignoring her kidney food. So chicken, turkey, etc.

Right now I have to put mollys pills wrapped really well in ham, i'm using shaved ham, that I have them cut for me (as don't want a lot of sodium) and plain piece first, then a pill wrapped, with lot of "do you want this, you want this", raised high pitch voice for excitement and then followed swiftly by a piece with nothing in it again. Sigh it is a challenge for sure.

[judymaggie]

Mark--like Sharlene, I have to be creative with Abbie's pills. I roll her pills in a teeny piece of cheese (just enough to cover them- the cheese softens as I work it so easy to form a ball). Then I fold the cheese ball in a very thinly sliced piece of chicken (fortunately, my grocery store sells this in a package). Abbie will no longer take the ball on her own so I have to stick it down her throat and keep her mouth closed until she swallows. Since I have another piece of chicken right in front of her nose, she swallows pretty quickly! This is the morning and evening routine with her Vetoryl and other meds. Her mid day meds she takes rolled inside her canned food--I think the difference is that those pills are not cut and have no odor.

One other thought--when Abbie was really balking about taking her meds, I wrapped them in a tiny bit of canned cat food (something recommended by my vet's office).

[Harley PoMMom]

Yep, a low fat diet is recommended for dogs with pancreatitis which can make it difficult in finding treats/food to hide pills in. Low fat hot dogs (chicken, turkey or beef) could be an option.

Hugs, Lori

[camval1]

Hi all,
Just checking in.
Brick had a stim test yesterday.
If you remember, he's been on a small dose most of his treatment. He's been on 10 mg for the longest time.
Anyways, he stimmed at 1.4 pre and 1.8 post.

So his intern wants to stop his meds for awhile. If symptoms don't return, he'll stay off of them. If they come back, then we'll restart him at 5 mg.

Otherwise, he's hanging in there. He's almost 12.75 years old now.
He's lost a lot of weight over the last 8-9 months (from about 63 lbs to about 48 lbs) and muscle tone in his back end.
He's back up to almost 50 lbs now.
So far we haven't been able to determine what caused the weight loss.
He's gotten pickier with his food. He doesn't like the special GI foods. I can get him to eat better by putting something tasty in his food.

He still likes to run in the yard, albeit slower nowadays. Still likes to go for walks. Still likes to go for car rides.

[Harley PoMMom]

I think the vet`s decision to stop the Vetoryl is appropriate and maybe an added benefit is that his appetite will pick up.

Hugs, Lori

[camval1]

I think the vet`s decision to stop the Vetoryl is appropriate and maybe an added benefit is that his appetite will pick up.

Hugs, Lori

That's exactly what she is thinking.

[molly muffin]

I hope that helps with his appetite. It is really hard when they become picky eaters.

I think we all slow down as we get older. :)

[camval1]

So his appetite never really got much better. Maybe just a little bit.

Anyways, he had an accident while I was at work today. Poor guy.
I'm going to start him back up on the Vetoryl tomorrow morning, but at 5 mg per day. That's down from the 10 mg per day he was on.

He made it a month off the meds without an accident.

[Harley PoMMom]

The pee accident could be due to an UTI instead of an increase in the cortisol level and the only way to know if his cortisol is high is to perform an ACTH stimulation test.

[lulusmom]

It sounds as though you are starting treatment again solely because your boy had an accident. My concern is that his accident may not be due to high cortisol. Is Brick drinking a lot of water again and could you tell if his pee was concentrated, meaning it had an odor and was yellow? If the accident was caused by cushing's, Brick's urine would be diluted so if there is an odor and color, it is highly unlikely that cushing's is the cause. This is very important to know given that he is still not eating well and unless you know for a fact that his adrenals have recovered and are again hyperactive, giving him any dose could make matters worse. I agree with Lori that you might consider an acth stimulation test to make absolutely certain that there is a need to restart treatment.

Glynda

[camval1]

The pee accident could be due to an UTI instead of an increase in the cortisol level and the only way to know if his cortisol is high is to perform an ACTH stimulation test.


It sounds as though you are starting treatment again solely because your boy had an accident. My concern is that his accident may not be due to high cortisol. Is Brick drinking a lot of water again and could you tell if his pee was concentrated, meaning it had an odor and was yellow? If the accident was caused by cushing's, Brick's urine would be diluted so if there is an odor and color, it is highly unlikely that cushing's is the cause. This is very important to know given that he is still not eating well and unless you know for a fact that his adrenals have recovered and are again hyperactive, giving him any dose could make matters worse. I agree with Lori that you might consider an acth stimulation test to make absolutely certain that there is a need to restart treatment.

Glynda


I'm sorry. I should have put more info in my last post.

His water consumption had gone up considerably; from 2-3 cups per day to about 7-9 cups per day.
The number of times he asked to go out went up, and the length of each pee went from about 8 seconds to about 16 seconds.

These were some of his same symptoms when he was first diagnosed.