Milo our 10 year old Boston Terrier

[leahdan]

First off let me say what a wonderful and informative site! Our Boston was diagnosed with Cushings yesterday and to be honest we just feel relieved. I know we have a bit of a road ahead of us, but to know that it is treatable and to have an explanation for his weird symptoms that were always nagging me at the back of my mind is positive.

We suspected Cushings when we brought him in for testing yesterday, and his regular bloodwork came back all within the normal range, so they did the cortisol testing and after stimulation, his levels were too high for their machine to read but definitely Cushings. I didn't think to ask for copies of the results so I don't have any values.

I am a little worried about the dosing our vet gave us - Milo is 25lbs (3 lbs heavier than normal with his weight gain over the last few months) and has been prescribed 60mg/day of Vetoryl. Reading here - it seems very high but then that is the recommended dose on the package insert? I did question this with our vet - but he wanted to try this dose and would readjust in 2 weeks. What side effects should I be looking for if it is too much? I work from home so he is monitored closely.

Milo does have a liver condition (hepatic micro-vascular dysplasia) which means his liver takes longer to break down medication (Vetoryl is processed in the liver) so I am always concerned with overdosing. The vet doesn't
think this will be a problem with this medication - any thoughts would be appreciated? Does this increase his risk of overdosing?

Looking back I think Milo has been developing Cushings for the last few years - with the first real symptoms starting about 6 months ago with new symptoms every few months. They include in order of appearance:
-loss of hair on chest
-chest area getting chubby
-increased thirst and urination
-eating all the time (which is not normal for Milo)
-less energy
-pot bellied and weight increase
-waking up at night and whining
-hotter than normal (not sleeping under blankets, etc)
-loss of hair on rest of belly, sides, back of legs

I feel bad that I didn't follow my gut that something was wrong until now - they just all seemed so minor when looked at individually.

I think I may take some pics of him now so we can actually see the changes as we get this disease under control :)

Thanks :)
Leah

[leahdan]

I have a follow up question as well - if 60mg/day is too high, could I take the Vetoryl to a local compounding pharmacy to split into 30mg pills?

[Renee]

I don't have a lot of time for a long post, but do have some quick questions.

First - PLEASE DO NOT GIVE HIM 60MG!! That is much, much too high.

Can you call and get those ACTH results and post them here? I am especially interested to know how their machine could not read the cortisol level. I do hope they weren't just going on his resting baseline?

[pansywags]

Leah, please don't feel bad. So many of the Cushing's signs can be attributed to normal aging so it's very easy to let them all go on for quite some time before connecting the dots. Many of us have done the same.

Can you contact your vet to get a copy of the tests and post the values here?

Welcome to you and Milo - I just love Bostons!

[leahdan]

I got his results emailed just now - his ACTH Stim result was >30ug/dl.

[Renee]

I got his results emailed just now - his ACTH Stim result was >30ug/dl.

There should be two figures on the ACTH; a pre/baseline and a post figure. Can you look at the report and update these numbers?

[Dixie'sMom]

Welcome Aboard! I'm glad you found us. I think you will find that this is a great place to get support and knowledge and the folks here are excellent with regard to Cushings symptoms, treatment, testing, etc. It helps so much to have others to chat with that have first hand experience with owning a Cushing's pup.

Aside from welcoming you to our family, I wanted to also 2nd the DO NOT GIVE THE 60 MG. Dechra, the manufacturer of Vetoryl is now recommending a starting dose of 2 mg/kg or 1 mg/lb. They have not updated their product inserts, but here is a link to this information which you may want to share with your vet.

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

It is recommended that the capsules NOT be split. It would be difficult to distinguish the medication from the filler, so the dosing could be inconsistent from day to day and it's very important to the success of treating Cushing's that all of the information is accurate. I would trade the 60 mg package for 10 mg and start at 2 per day for a starting dose of 20 mg. You could also exchange for the 30 mg capsules (1 per day) which wouldn't be too much over the 1mg/lb starting dose recommended. Let's see what the experts think. I'm sure more folks will be stopping by soon to welcome you and Milo and to chime in with their thoughts.

I look forward to getting to know you and your sweet boy. Please do post those pictures. My favorite part of this forum is looking at all the sweet pups. :D :D

[leahdan]

There should be two figures on the ACTH; a pre/baseline and a post figure. Can you look at the report and update these numbers?

That's all they sent so I've asked for all the results from yesterday so I should have the rest of his results shortly.

[Renee]

That's all they sent so I've asked for all the results from yesterday so I should have the rest of his results shortly.

Here is what concerns me - a lot of vet clinics can run a resting/baseline cortisol in house. These in-house labs are usually limited on how high they can read. For example: at my pet er clinic, they can test resting cortisol, but cannot read it for anything greater than 10. It is not common for a vet clinic to be able to run a post cortisol sample in house. That is why the ACTH stim tests are sent out to labs. My vet sends the stim tests to a Phoenix lab, as an example.

All of this is to say - if your vet is diagnosing cushings by relying on a resting/baseline cortisol, then I am very, very scared for you because resting cortisol levels have no bearing on cushings. That figure can fluctuate wildly and be impacted by a number of things, in healthy or otherwise dogs. It may turn out indeed that your baby has cushings, but either way - you'd be best to find another vet, and quickly, if my fear is correct.

Let's wait and see what they send though. Hopefully I am just over-reacting!

[Harley PoMMom]

Hi and welcome to you and Milo!

I see that Suzie did post a link to Dechra's most recent published literature regarding their revised starting dose which is 2 mg per kg, that calculates to 1 mg per pound of a dog's weight. So for Milo's weight of 25 lbs, we would advise a starting dose of Vetoryl at 20 mg.

How was Milo's liver condition diagnosed? Dechra does recommend that Vetoryl not be used in dogs with primary hepatic disease, so I do suggest having a liver panel performed more often to keep an eye on those liver values. Vetoryl does have a short-half life and does leave a dog's system rather quickly which is a plus if a dog is showing symptoms of their cortisol dropping too low. However with Milo having a liver problem, this means that the Vetoryl will stay in his system for more of a period of time than it usually does and therefore if he would show signs of being unwell it will take longer for him to bounce back, so this would be another reason to start on a lower dose.

Here's a link to Dechra's product insert: http://www.dechra-us.com/files/dechraUSA/downloads/Product%20inserts/Vetoryl.pdf

I do believe a compounding pharmacy may be able to repackage those 60 mg capsules of Vetoryl into 10 mg or 20 mg capsules. Does your vet know of a reputable compounding pharmacy? Many members here use Diamondback drugs: http://www.diamondbackdrugs.com/

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

[leahdan]

Am I correct in assuming that when you say resting cortisol - that would be without any stimulants?

So without knowing the specifics of the testing until they send me the rest of the results, what I do know is that they ran a full chem/cbc/electrolyte panel which was all in the normal range. They also ran a resting cortisol at the same time - I don't know what that showed if anything. After they ruled out diabetes, etc, they gave him the stimulator (I have no idea what this is actually called) shot and waited 4 hours (I believe that's how long it was) and ran the ATCH stim test with the results I posted. I should have included that the anything over 22 ug/dl with this test shows the possibility of Cushings. It was an in-house test, but I have also been surprised by their in-house testing capabilities before.

As for running away from this vet - I think that is a little premature. We dealt with a lot of vets and specialists when Milo's MVD was diagnosed and there is a lot to be said for a vet that is willing to work with you and open to your concerns and suggestions. I have call into him now to investigate a lower dose - now that I have info to back up my initial gut reaction ;)

[leahdan]

Hi and welcome to you and Milo!


How was Milo's liver condition diagnosed? Dechra does recommend that Vetoryl not be used in dogs with primary hepatic disease, so I do suggest having a liver panel performed more often to keep an eye on those liver values. Vetoryl does have a short-half life and does leave a dog's system rather quickly which is a plus if a dog is showing symptoms of their cortisol dropping too low. However with Milo having a liver problem, this means that the Vetoryl will stay in his system for more of a period of time than it usually does and therefore if he would show signs of being unwell it will take longer for him to bounce back, so this would be another reason to start on a lower dose.


Hugs, Lori

Thanks Lori!

His liver problems only showed with a bile acid test - a liver panel showed absolutely nothing - even at it's worst (seizures, etc) and a Doppler ultrasound ruled out a shunt. At the time we decided not to do a liver biopsy. It's controlled with diet and he's had relatively few issues once we got it diagnosed (besides sedation and some meds). We are going to start him on a liver support of some sort (probably start with milk thistle again) because of the Vetoryl.

We have a local compounding pharmacy that I was hoping could spit up the meds I have - our vet is about an hour away and after 2 trips yesterday I cringe at the thought of packing the kids back in the car to pick up new ones.

I appreciate all the feedback and info from everyone- although we are relieved by the diagnosis (I know there is a lot worse things out there!) It is still quite a big learning curve! I was totally on the ball with keeping his records and results and knowing as much as possible when he was diagnosed with mvd, but I realize I've gotten lazy and should have researched more before taking him in and had copies of everything when we left the vet's yesterday.

[labblab]

I got his results emailed just now - his ACTH Stim result was >30ug/dl.
Hello, and welcome from me, too! Yes, I do agree with you that this result is likely a stimulated or "post" ACTH result since I have never seen a resting/baseline cortisol level that approached being this high. So yes, if so, this result is consistent with a Cushing's diagnosis.

I also agree with the other folks here who are encouraging a lower starting dose. That is not to say that your dog will not end up needing an increase down the road. That is entirely possible since every dog metabolizes the drug individually. But our experience here mirrors the experience of Dechra upon which they've revised their initial dosing recommendations: dogs tend to experience fewer unwanted side effects when cortisol levels are lowered more gradually rather than rapidly via a higher dose.

I will depart a bit from the others and say that if this were my dog, I would probably lobby for a starting dose of 30 mg. This is just a touch above the 1 mg. per pound formula, but from a practical perspective, it will be easier and probably less expensive to give a single 30 mg. capsule rather than two 10's. If you opt to make a dosing change, it will probably be better to just start out fresh with the correct dose rather than compounding the 60 mg. capsules at this stage. I would just hold on to them for the time being. Who knows, you may end up advancing upward to that dose down that road.

Marianne

[leahdan]

dogs tend to experience fewer unwanted side effects when cortisol levels are lowered more gradually rather than rapidly via a higher dose.


That makes a lot of sense and is convincing me further that a trip to the vet tomorrow for a lower dose is needed!

[Renee]

Didn't outright mean to suggest you leave you vet. I readily said that my fears may be incorrect, but that if they were diagnosing cushings based solely on a baseline, then that could be cause to leave. Sorry, online forums it is hard to pickup tone and nuance.

How wonderful for you if your vet clinic is able to run a stim test and get the results in-house. I would love that!

[leahdan]

No offence taken - we have left vets running as fast as we could before :) from past experience i've learned to really appreciate a vet that wants to work with us as opposed being very rigid in their views and who doesn't listen. We are lucky about the clinic's capabilities but it's a big trade off with the distance to get there!

[leahdan]

So I spoke with our vet and laid out my concerns regarding the high dose. He researched further for me and after conferring with an Internalist, agreed on a lower initial dose. We are going to go with 30mg/day, which is higher than the optimal 20-25mg/day to start but is still so much closer than 60mg/day! I am comfortable with this and we will make the trek back tomorrow afternoon to pick up the new pills, so Milo will officially start Vetoryl on Friday! I am still pretty excited to see the improvements - even if they come slower by starting out on a lower dose. Mainly I really want him to start sleeping well at night as he's been living in luxury on our bed for the past few weeks and I am tired of waking up to bony BT legs poking me and a dog bum in my face ;)

[labblab]

YAY!!! I think we will all be a lot more comfortable with that 30 mg. dose. ;) :)

Good job, mom! I'm sorry you have to make the trek back to pick up the med, but I truly think it is the safer way to go.

Marianne

[leahdan]

Thanks!! I feel so much better about it too :)

[Harley PoMMom]

... i've learned to really appreciate a vet that wants to work with us as opposed being very rigid in their views and who doesn't listen.

That is so very true, a vet has to be a team player when it comes to our furbaby's health. My vet wasn't real knowledgeable regarding Cushing's, and neither was I when my boy, Harley, was diagnosed.

The wonderful and supportive people here guided me and shared their vast knowledge and experiences with me. I also read everything I could get my hands on that was canine Cushing's related.

I took in all that information so I could make educated choices for my Harley, as I was his only voice and advocate. Harley's vet was very willing to hear me out and listen to everything I had to say, WE, meaning Harley's vet and I as a team, made decisions together regarding my boy's treatment.

So I totally understand and completely agree that a vet/IMS that is willing to work with you and a team player is very important.

Sorry for that novel :o

Now, there are some important protocols to follow with the Vetoryl: it has to be given with food to be properly absorbed; the ACTH stimulation monitoring tests need to be performed 4-6 hours after the dose of Vetoryl is given; 10-14 days after treatment starts a monitoring ACTH stimulation test should be done and another one at the 30 day mark. After any dosage adjustment an ACTH stimulation test needs to be performed within that 10-14 day window and after an optimal dose has been achieved the ACTH stimulation test are done in 90 days and every 3 months thereafter.

Since a dog's cortisol can continue to drift downward during the first 30 days of treatment, a dose adjustment is not recommended at that 10-14 day window. Also, treatment is not a cure for Cushing's the goal of therapy is to control those bothersome symptoms, so when deciding on a dosage increase, the control of the dog's symptoms along with how the dog is feeling are just as important as those ACTH stimulation test numbers.

Here's a handy link to info regarding Trilostane/Vetoryl: http://www.k9cushings.com/forum/showthread.php?t=185

Please feel free to print anything out, and do not hesitate to ask all the questions you want.

Hugs, Lori

[Dixie'sMom]

Excellent news! The 30 mg will be much safer to start with. I'm so glad you have a vet who is willing to listen to your concerns and work with you. When is Milo getting his first dose?

[leahdan]

We picked up the 30mg box today so he will get his first dose tomorrow morning!

I also got copies of all his blood work while I was there - which will be helpful if we have to go to a local vet for an emergency too!

His ACTH Pre-stim was 9.3 ug/dl and post-stim was >30.0 ug/dl

The rest was as follows with ranges in brackets:
ALB = 2.8g/dl (2.2-3.9)
ALKP = 302 (23-212) - high but the vet said this was common with cushings
ALT = 62 u/l (10-100)
AMYL = 609 u/l (500-1500)
BUN/UREA = 15mg/dl (7-27)
Ca = 9.0 mg/dl (7.9-12.0)
Chloride = 111mmol/l (109-122)
CHOL = 203 mg/dl (110-320)
CREA = 0.9 mg/dl (0.5-1.8)
GGT = 6 u/l (0-7)
GLU = 120 mg/dl (70-143)
LIPA = 1067 u/l (200-1800)
OSM calc = 314 mmol/kg
PHOS = 5.6 mg/dl (2.5-6.8)
Potassium = 4.6 mmol/l (3.5-5.8)
Sodium = 158 mmol/l (144-160)
TBIL = 0.1 mg/dl (0.0-0.9)
TP = 5.7 g/dl (5.2-5.8)
Glob = 2.9 g/dl (2.5-4.5)
ALB/GLOB = 1.0
BUN/CREA = 17
Na/K = 34

[Renee]

Excellent. I see your vet did run the stim test. And those figures are in line with a cushings diagnosis. I am so jealous your vet can run and get the results of a stim in-house!

Good call on lowering to the 30mg.

Make sure you are scheduled for your follow up stim test in 10-14 days from starting the vetoryl. And, make sure to dose with a full meal.

:)

[leahdan]

I have scheduled a follow up stim test in 2 weeks but I have a question about dosing with food...

How do I make sure he eats his breakfast when I give him his meds? It's not really a big issue with the cushings appetite but before, he would be very intermittent with his morning meal. We feed him 3 times a day, but a lot of times, it would sit until mid-afternoon. I'm just wondering how to deal with this when his insane appetite resolves.

[molly muffin]

i dress molly's with a bit of her can food, but she doesn't eat all her meal at the same time either and will leave it sitting. This way I at least know she has some food in her stomach so the meds can work.

[Harley PoMMom]

Sometimes getting a dog to eat is through their nose!! Making their meal smell "stinky" might perk up the appetite, using such things as tuna water, tripe, sardine juice (water packed), grated parmesan cheese, or add a bit of warm meat broth (no onions/powder) to the food.

[Renee]

When I contacted Dechra with this exact question, their answer was that the medicine needs to be given with a full meal, not a snack. I know that's difficult for some dogs that don't have a big appetite. Hopefully, his morning appetite is strong, and you don't have to worry about the rest of the day? I think most people give the breakfast, then dose directly after with something very exciting like peanut butter, cream cheese, or lunch meat. My pugs eat so fast, I never have to hide pills. Just drop the pill in her food and down it goes, lol.

You could try feeding earlier in the evening, so he wakes up hungrier in the morning?

[pansywags]

For a long time I was able to get Pansy to eat a meal using a smelly topper on her kibble like warmed up wet food. Her appetite was really suppressed near the end and the only thing she never turned her nose up at was chicken and brown rice (which I always kept servings of in the freezer in case of illness) or Stella and Chewy's freeze dried lamb patties (expensive but she needed to eat).

Looks like Milo's headed for some spoiling :)

[leahdan]

His diet is still somewhat restricted because of his liver issue, but broth may be the answer! Honestly I will be excited to get to that point :)

[Squirt's Mom]

Unless there is a medical reason to feed a full meal 3x day, I would start today cutting back the noon meal a great deal so it is more of a snack and cut the supper meal down just a tad so he will be hungry in the morning. Then hold breakfast time back an hour or so tomorrow to give his tummy time to wake up and perhaps settle. Let him smell good smells meantime, like your breakfast cooking or give him a whiff of something but no bite to stimulate the digestive system and start the hunger process. Maybe things like this will help his appetite in the mornings.

[leahdan]

Thanks for all of the suggestions! Milo gets 3 meals a day because of his underlying liver condition and has been on this schedule for so long that all of our pets have adopted it.

Eating breakfast is not a problem right now - a little parmesan had him begging for seconds this morning. I was just wondering about tips for if/when his appetite goes back to normal and he's not so food obsessed - anything to take a little stress out of getting us all out of the house on time in the mornings, plus medicating now 2 of our senior pets, is helpful :)

Just an update: Milo had his first dose of 30mg this morning and wow so much less stressful (for me) than when I gave him that one dose of 60mg a few days ago. So glad for the experience of all of you to recommend going back to the vet to look at a lower dose :)

[molly muffin]

Checking in to see how Milo is doing on the 30mg?

Is he eating okay his breakfast?

[leahdan]

So Milo is doing great this far! It took a little more when than normal to get him to eat his breakfast which i take as a good sign and we are going to move his last meal earlier once his appetite slows down a bit. We found him under a blanket for the first time this winter - it's early but it's all hopeful :) I know 3 days is too early to really expect any symptom improvement - should we be concerned about adverse reactions and his cortisol going down too much if we start seeing symptoms getting better already?

[Squirt's Mom]

With Cushing's, the concern of the cortisol going too low is a constant - we can never let our guards down but must be ever diligent for signs the cortisol has dropped too low. It can happen the first day or it can happen the 1001 day. But Milo has a good mom and a whole family here beside him and I am sure you will do just fine and so will he.

[leahdan]

We had Milo's 2 weeks follow up stim test today and his levels came back at 7ug/ml. The vet was very happy and he's staying on the 30th vetoryl dose. We've noticed a significant decrease in his thirst, eating and urination (getting much closer to normal anyway). He's sleeping so much better and is brighter and playing normal again.

My question is that if it can take a month for the cortisol to drop to a normal level, would a decrease of this much indicate that his dose is still to high? With his liver condition and how well hes doing I'm so happy we didn't go with the 60mg dose😊

[labblab]

Oh, this is such good news that Milo is doing so much better! :) :)

Yes, that is indeed a big drop in two weeks. His cortisol will likely come down even a bit more on this same dose, but there is no way to tell exactly how much. You will want to keep on watching him carefully, which I know you would be doing anyway. If you see any negative changes -- loss of appetite, vomiting, diarrhea, significant lethargy -- then you will want to run a repeat of the ACTH even sooner than the one-month mark. But we will keep our fingers crossed that this works out to be the perfect dose for him!

Marianne

[molly muffin]

That is a big decrease, but very glad he is doing so well. I'd make sure to keep an eye out and test in 2 weeks. Hopefully you have found is perfect dose right out of the gate. :)

[leahdan]

As we approach another scheduled stim test for Milo, I am wondering about the need for continued testing. I know the protocol is to test 2 weeks after starting treatment and then at 30 days and then every 6 months or so, but have been wondering if it's necessary? Bare with me - I'm asking because we did years of testing with his liver problem, only to realize that we were able to catch symptoms way faster than a 6 month blood test would. Here is my question - if his cortisol levels did change, am I likely to see the symptoms before detected on a blood test or would the increases be so slow, that it would be best detected at the 6 month checks?

I know that Cushings is a different disease than his liver MVD, but the concept of symptom management holds true to both and it got me thinking about the necessity of continual testing or if we should try what's worked for his liver problem and test based on symptoms?

I'm not against testing (although the money savings is nice)- I'm just wondering what the opinions are out there.

For an update - Milo is doing great. He's got some yellow scales on his belly which seem to be increasing but most other symptoms are improving and he's happy, active and seems to be handling the trilostane very well :)

[Harley PoMMom]

When a dog becomes stabilized with their Vetoryl/Trilostane dose, Dechra, the makers of Vetoryl, recommend having an ACTH stim test performed every 3 months along with a chemistry blood panel. Here's an excerpt from Dechra's product insert:
Once an optimum dose of VETORYL Capsules has been reached, re-examine the dog at 30 days, 90 days and every 3 months thereafter. At a minimum, this monitoring should include:
• A thorough history and physical examination.
• An ACTH stimulation test (conducted 4-6 hours after VETORYL Capsule administration) - a post-ACTH stimulation test resulting in a cortisol of
< 1.45 g/dL (< 40 nmol/L), with or without electrolyte abnormalities, may precede the development of clinical signs of hypoadrenocorticism.
• Serum biochemical tests (with particular attention to electrolytes, renal and hepatic function).

I believe having frequent ACTH stim tests are needed because symptoms of cortisol dropping too low may not be noticed until the situation becomes dire, Dechra also states in their product insert that:
Hypoadrenocorticism can develop at any dose of VETORYL Capsules. In some cases, it may take months for adrenal function to return and some dogs never regain adequate adrenal function.

Dechra's U.S. Product Insert (http://www.dechra-us.com/files/dechraUSA/downloads/Product%20inserts/Vetoryl.pdf)

[molly muffin]

I'd definitely do the 30 day test and then take it from there and work out a schedule with your vet that is acceptable to the possible risks for monitoring.

Lets see where the levels are at now and then you'll know more about how he is reacting to the drug

[leahdan]

Thanks all! I appreciate the feedback. I may be a bit late getting his 30 day test done but it's booked and I'll post results when we get them :) We cross the border for our vet and my daughter's passport expired without me realizing it (shaking head). Thankfully I realized before we got turned away at the border lol.

[molly muffin]

Eeek, yea that wouldn't be a good thing to have to turn around and come home from the border. Glad you caught that.