Julie

[Julie's Mom]

Hi, I'm Julie's Mom. Julie is my Silky Terrier who will turn 14 in February, 2015. During routine blood work to undergo teeth cleaning, her liver readings were elevated. A subsequent ultrasound showed an enlarged liver and adrenal glands, but no tumors. I have spoken to two vets how both are reasonably certain we are looking at Cushing's. Further blood work is being recommended for confirmation, but I have started my research.

Julie currently is not showing any symptoms associated with Cushings: weight gain, change in eating or urinary habits, lack of energy, changes in behavior. So while I agree with the vets that this is likely Cushing's, I'm not anxious to begin a drug therapy that could have bad side effects. The vet thinks the drug he would use would be 30 mg of Trilostane. (Julie weighs 13 pounds)

My questions to the group are:

1. Should I begin drug therapy now or wait?
2. What are the benefits and disadvantages of now versus waiting?
3. What has your experience been with Trilostane?
4. How many follow up blood work visits did it take to determine the right dosage and drug therapy?
5. How expensive can this get?
6. What if I do nothing to treat the Cushing?

I know that every dog and case is different, I'm just looking for your story so I can be as informed as possible. Since Julie is currently showing no signs or symptoms, I feel I have a little bit of time to do my research and would greatly appreciate any information.

Thanks

[labblab]

Welcome to you and Julie! I am going to take a stab at giving you my answers to your questions (my comments will be in red). ;)


1. Should I begin drug therapy now or wait?

In the absence of any corroborative observable symptoms, especially in a senior dog, I would not begin therapy at this time. Virtually all experts agree that the history and symptom profile are the two most important features in making a Cushing's diagnosis. It is one of the most difficult diseases to acccurately diagnose because there is no single definitive test and because other unrelated conditions can cause the same laboratory and imaging changes. Also, unless a dog is suffering from an adrenal tumor that can be surgically removed, Cushing's is not a disease that can be cured -- the goal is instead to manage the symptoms. So if a dog is not exhibiting any symptoms, what is the point of initiating what can be an expensive and rigorous treatment regimen? In the case of a younger dog, the argument can be made that by treating sooner rather than later, you are helping to stave off future systemic damage that chronic elevated cortisol can cause over the course of time (for instance, damage resulting from high blood pressure, vulnerability to infections and ligament damage, etc.). But for an older dog, I believe that current quality of life really trumps possible future issues. So if the dog is not suffering from observable symptoms, I probably would not choose to treat.


2. What are the benefits and disadvantages of now versus waiting?

For a dog of Julie's age, I really don't see a disadvantage to waiting until/if the time arrives when uncomfortable symptoms emerge. One other issue with geriatric dogs is that lowering cortisol levels can actually aggravate arthritic issues. So if a dog is already known to suffer from arthritic discomfort, Cushing's treatment may necessitate alternative anti-inflammatory and pain management strategies.

3. What has your experience been with Trilostane?

Probably the majority of the dogs on this forum are now being treated with trilostane. Their experiences are as variable as you would expect with any group of patients being treated for the same disorder. Some sail through with no problems at all, some have major glitches along the way. Most fall somewhere in between. The key is affiliating yourself with a vet who is knowledgeable about the disease and also with the most current treatment protocol associated with using this medication.

4. How many follow up blood work visits did it take to determine the right dosage and drug therapy?

This totally depends. With trilostane, at a minimum, you will conduct blood testing at the two-week mark, at the month mark, and then every three months thereafter. Many dogs must be tested more frequently, however, especially during the early phase of treatment when dosage changes are required based upon symptom resolution and monitoring test results.

5. How expensive can this get?

Cushing's is not an inexpensive illness to treat. The costs are highest at the beginning when you combine both diagnostic testing and initial monitoring testing.

6. What if I do nothing to treat the Cushing?

It all depends. In the short run, in the absence of confirmatory symptoms, there is really no reason to think that anything will change. Because without symptoms, there is not any way to know with confidence that Julie even has the disease. If troublesome symptoms do emerge later on, you can always proceed with further testing at that time.


One last comment: if you do proceed with testing and decide to start treating with trilostane, 30 mg. is much too high a starting dose for a 13 pound dog. In earlier years, recommended doses were much higher. But intervening research has really altered dosing protocols, and the current dose recommended by the manufacturer of the brandname trilostane product (Vetoryl) is a formula not to exceed 1 mg. per pound. This formula is now widely accepted among researchers and specialists worldwide.

Marianne

[labblab]

Here is the most recently revised directive re: initial dosing amounts issued by the manufacturer of Vetoryl just last summer. The referenced dosing formula of 2 mg. per kg. translates into 1 mg. per pound. Whether or not you proceed with testing for Julie, it would be helpful if you bring this publication to the attention of your vet so that he will start revising his initial trilostane dosing downward for all his Cushing's patients.

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