When to start treating with vetoryl

[kramer451]

I have a 7 yr old spayed (spaying done at 4 years) female Scottish Terrier. She has had low thyroid and was on 1/2 tab 0.1 mg soloxine with thyroid levels at 1.7. We were told to increase her thyroid meds to 1 tablet daily and retest thyroid levels in 2 months. At the time of retest, we were asked if we wanted to have blood drawn for a study being done looking at increased alt levels independent of cushings disease in Scottish terriers. We allowed the blood to be drawn. The thyroid levels were 1.5 and her alt levels were 252u/l. her alkp was also elevated but I do not have that number. My vet has been a scottie breeder for years and very up on the medical care of Scotties. So she suggested we do an acth stimulation test to determine if our dog had cushings. Below are the results of it and the cbc/chem screen. Keep in mind the dog has no clinical symptoms of cushings. She is 19.2 lbs, eats 3/4 cup Iams mini chunks daily, urinates 2 to 3 times daily, drinks 1.25 to 1.5 cups water daily (she has water down at all times) and is very active. Her coat is not the thickest of all the Scotties we have owned but it has not changed in the last 3 years since we have had her. The only area her coat is thinner than the rest is the base of her tail. It is also flaky in the winter but that improves when the humidity is not so dry. The thinning is not noticeable but I groom her. Like I said, it has been this way since we got her. If not for the participation in the study we never would have run the acth stimulation test. That said here are the results. Anything not mentioned is within normal ranges. I did include some of the cbc that were inside normal range because I know that these results can be impacted by cushings.

baseline cortisol 2.4 ug/dl
post injection cortisol 18.4 ug/dl ref. 18-22ug/dl cushings possible. > 22 ug\dl in presence of supporting clinical signs results are consistent with Cushing's.
BUN 6mg/dl ref 7-27
ALB 4.1 g/dl ref 2.3-4.0
AlT 227 u/L ref 10-125
ALKP 516 U/L ref 23-212
AMYL 442 U/L ref 500-1500
RCB 9.14 M/ul ref 5.65-8.87
HCT 58.1% ref 37.3-61.7
NEU 4.43k/ul ref 2.95-11.64
MONO 0.25 K/ul ref 0.16- 1.12
LYM 1.73k/ul ref 1.05- 5.10
EOS 0.15K/ul ref 0.06-1.23

Vet wants to start her on 30mg vetoryl daily and retest in 2 weeks. Interested in what everyone thinks of starting her on meds or waiting until she has clinical symptoms? Thinking of asking for a UA to check for protein. Anyone had any luck with herbal treatments? I have my concerns about the vetoryl including sending her into hypoadrenocortism esp. since her cortisol levels do not seem to be that high. Would be good with the meds if she had clinical symptoms but seems the risk benefit is just not there. Happy to hear what anyone has to say and thank you!

[Harley PoMMom]

Hi and welcome to you and your girl,

So glad you found us and we will help in any way we can. Could you edit your post with those values and add the reference ranges...thanks. Different labs have different reference ranges so that is why we need to see them.

The common clinical symptoms seen in dogs with Cushing's are: excessive drinking and peeing, I mean peeing rivers and drinking buckets upon buckets of water; voracious appetite, they are like little hoover vacuum cleaners looking for any crumb they can find; panting; loss or thinning of coat; skin issues; muscle wasting; muscle weakness, especially in the hind quarters; exercise intolerant; difficulty or unable to go up steps or jump on furniture. Dog's with Cushing's have a low Urine Specific Gravity(USG). Was an urinalysis done and does your girl have diluted urine with a low USG?

I really don't think her post cortisol number is that high and since she is showing no symptoms of Cushing's I would not start treatment.

How was her hypothyroidism diagnosed? Thyroid medication is generally given twice a day. I'm including an article from Dr. Mark Peterson's blog regarding canine hypothyroidism: http://animalendocrine.blogspot.com/2011/02/how-do-we-treat-dogs-with.html Dr. Mark Peterson is a renown Cushing's expert and is also a contributor to Dechra's continuing education site.

If you have any questions please do not hesitate to ask them ;)

Hugs, Lori

[kramer451]

Thanks. I posted the references for the lab results. The hypothyroid was from blood work (not sure what exactly (T4, t3, TSH) as I do not have a copy of the results). I was told reference for that was 1.0-4.0 normal. I have been giving the soloxine with food but am stopping that when she gets her pill today. They were not interested in increasing her thyroid dosage-not sure why-seemed to be more interested in the borderline cushings and if that was impacting the thyroid values.

I need to have a UA done. As of right now, me vet thinks I am giving the vetoryl and am to go back for 2 week testing on april 24th. But after coming home and being told to read about the drug, I had more questions and an uneasy feeling. I am trying to get all my facts and information straight before I call the vet.

I can not seem to find any research stating what a safe level of cortisol is to start vetoryl treatment at. I would assume there is lower threshold. I sent an email to the manufacturer asking them for this information. I did not see anything in the contraindications.

Thanks

[molly muffin]

If you were going to start medication I wouldn't start at the 30mg. I wouldn't start at over 20mg and would probably do lower since she is borderline.

I too was given 30mg and instead of starting it I went back and said, I wanted an ultrasound done before deciding to start medication. I had an ultrasound, nothing abnormal and when we did start medication finally to get the cortisol level down, we started much lower and worked up slowly. My dog never had the classic symptoms of cushings. We finally started the medication because the high cortisol was contributing to other issues. Scotties are tricky with their ALKP results from what I remember as we have seen some high ones that didn't end up having anything to do with cushings.

So that is probably what I would do, UA and ultrasound, then go from there.

[Harley PoMMom]

I can not seem to find any research stating what a safe level of cortisol is to start vetoryl treatment at. I would assume there is lower threshold.
Thanks

I'm not sure of your question, are you asking what the cortisol level should be when restarting the Vetoryl/Trilostane when a dog has had an Addison's crisis from medication?

Ok, I just saw that you did include the reference ranges for that ACTH stimulation test, so you are probably asking about how high that post has to be in order to start medication, right?

Strong obvious symptoms play a huge part in the diagnosis for Cushing's. The drugs used for Cushing's do not cure the disease, they control the symptoms. With no symptoms, how do you know if they are effective? Since her post is only a bit over those reference ranges and she shows no symptoms of Cushing's I would not start treatment.

Here's a quote from Dr. Peterson's blog regarding Working Up the Asymptomatic Dog for Cushing's Disease (http://animalendocrine.blogspot.com/2013/09/working-up-asymptomatic-dog-for.html):
I certainly wouldn't start treatment immediately since your dog is not showing any clinical signs. None of the medical treatments we use for Cushing's disease, including trilostane (Vetoryl) or mitotane (Lysodren) actually cure the dog — these drugs only act to lower the cortisol values and control the clinical signs (1)

Lori

[labblab]

baseline cortisol 2.4 ug/dl
post injection cortisol 18.4 ug/dl ref. 18-22ug/dl cushings possible
To further pursue Lori's question...if you are asking whether it is OK to start Vetoryl treatment when the post ACTH result is not high enough to confirm a Cushing's diagnosis, I would be hesitant to begin the medication without a bit more testing. I would recommend performing a second diagnostic blood test, the LDDS (low dose dexamethasone suppression test). It tests the body's adrenal response in a different way, and is less likely to give a falsely "negative" result for a dog who truly does have Cushing's.

Given the lack of overt symptoms in conjunction with the marginal ACTH results, I do not believe I would start treating without greater diagnostic evidence that Cushing's is actually present.

Marianne

[kramer451]

when we did start medication finally to get the cortisol level down, we started much lower and worked up slowly. My dog never had the classic symptoms of cushings. We finally started the medication because the high cortisol was contributing to other issues.

Thanks. At what level were the cortisol before you started treating and what contributing issues? Also, how did you monitor her to decide when to treat?

I am trying to decide which tests to ask the vet to run and how often so we can keep an eye on her cortisol levels to decide when to treat.

[kramer451]

Yes, what I was looking for was for the manufacturer to have listed cortisol level to be at least XX before you start treatment on this drug. Especially since it is a competitive enzyme inhibitor.

But I spoke with them this am. They do not have a hard and fast number. But they DO NOT recommend starting a dog on Vetoryl who is NOT exhibiting clinical symptoms. They say numbers alone are not meant to prescribe the meds. The owner needs to be able to see improvements of clinical symptoms to determine if the drug is working. They recommend keeping a journal detailing things like water consumption, urination frequency, panting, fur loss, skin changes so that you have something to show your vet.

They also recommend starting dose at 1mg/lb and work your way up as needed. Even if that means giving her 2 10mg pills instead of 1 30 mg pill. As far as testing to monitor cortisol levels PRIOR to starting Vetoryl they recommend LDDS (I did read UC has recommended the same and are only using ACTH stimulation in a few instances).

As of right now, I am still not giving her the Vetoryl. But now I need a "monitoring" plan besides just clinical symptoms. Any thoughts on which tests and how often in lieu of clinical symptoms? Once I notice any clinical symptoms (and we are now on high alert for those), we will be back to the vet for a LDDS. But I want to keep an eye on those cortisol levels as we go along. Since she is just 7 yrs old, I want to know what is "silently" going on inside.

When she goes this month for annual vaccinations, I will get the UA.

When I do start the Vetoryl, I want to start at 20mg total.

Anyone know of any herbal, diet, etc things that we can try to keep those cortisol numbers down?

I still need to call the vet and let her know I am not giving the meds. But I want to have some ideas of the path to move forward before I talk to her and get her input. Not sure if to keep the Vetoryl they gave me when I got her ACTH stim. test done or see if they will take them back.

Thanks for all the help.

[molly muffin]

I'm in Canada first off, so my results are in nmol, rather than ug, but I have done a conversion. This was molly's ACTH prior to starting vetroyl:

Oct 2014
ACTH
pre 74nmol = 2.68ug
post 1hr 858nmol = 31.09ug
post 2 hr over 1000nmol = 36.24ug

Contributing issues was that in 3 months time, she developed high BP, protein loss via kidneys and retinal bleeds in her eyes causing focal point loss of sight.
She never did anything different, just my vet during boarding, said, molly's eyes look like they have aged 2 years in 3 months. At her prior checkup, her BP was normal, her eyesight was clear and good and we'd been checking UPC for protein loss and didn't get consistant high results. She never showed the normal signs of cushings. Just everything went bad very quickly. So we decided to start vetroyl and started at 8mg once a day. We are now going to be moving up to 15mg once a day and her post cortisol number is around 378nmol = 13.76ug

We had all agreed prior to these contributing factors, to not start any medicating as she wasn't showing symptoms.

Take what I tell about Molly with a grain of salt, because she is no text book cushings case and has in fact stumped most of us here for years. This includes my specialists.

[Harley PoMMom]

Letting those clinical symptoms guide you into when to start the tests to diagnose Cushing's, and thus treatment, is really the best way to go. The only test that measures cortisol production is the ACTH stimulation test. To me, having a full stim test performed without any Cushing's symptoms being displayed is a waste of money, and a baseline reading is of no use because cortisol fluctuates throughout the day.

As far as holistic medications, unfortunately I don't know of any truly effective alternatives to Rx medication when one wants to lower cortisol levels significantly. Cushing's does move at a snail's pace and it takes a while before that very elevated cortisol starts to do any serious damage internally.

Truly, having bi-annual CBC/chemistry blood panels done along with an urinalysis, I believe is the best way to monitor your girl, and maybe having an ultrasound done once a year, I think, would be sufficient...now that's just my 2 cents worth ;)

Hugs, Lori

[kramer451]

Thanks for everything. I called the vet's office to cancel the follow up ACTH stimulation test since we are not giving the meds. But I will call and talk to the vet nexti week and will post how that conversation transpires. I need a mental break from reading scholars papers, clinical trials, and rehashing all my biochem text books !!!!!!

As an fyi- my vet's treatment plan was based on the theory that since the dogs cortisol levels were borderline, and she had no clinical symptoms or other blood work issues, starting her on vetoryl would keep cortisol levels and therefore their impact on her health at a minimum. While I like the theory a lot, the meds are not benign. They come with a host of issues and , for me, it comes to risk vs benefit. If the drugs were milder , with less side effecs and chance of od, I would give her the meds. But that is not the case. I will treat her when her cortisol numbers begin to impact her health. I will
Post my game plan next week after talking to the vet. For now, someone is insistent that I throw a stuffed lovely! Terriers!!!!

[molly muffin]

Better to be throwing a stuffed toy than reading all those papers anyway. :)

If the cortisol if very high, then I think there are vets who are of the opinion that it is better to get it down than wait too long for any problems that might or might not occur. That is probably what your vet is thinking.

[kramer451]

I agree. But her levels are .4 above normal and in the consider Cushing's range. If her cortisol numbers had been over 22ug\dl ( that is the low end of positive from our lab) , I think I would have started the meds.

[molly muffin]

It doesn't hurt to monitor and see if they go up and then make a decision on medication based on that.

[kramer451]

Sharlene,

Would you treat her now or monitor her levels and treat when they go up and\or when she had clinical symptoms?

How has molly done on the meds? I agree about starting her on a lower dose, like 20 mg per drug companies recommendations.

[molly muffin]

I would and did wait. You are barely borderline into the "might be" zone and not a definite diagnosis. Scotties too are one of those breeds where things can be higher than normal and still be normal for them, or caused by something else.
With no symptoms at all and a low maybe, I'd personally wait.

Molly is doing fine on her meds. We are going to be doing a dose increase, I've raised her gradually to try and get her where we want her to be and she is fine. She had about a month of the afternoon tremors, but not sure if that was blood pressure or kidneys, maybe the trilostane, but those have since disappeared and while she's had days that might be more off than others, she basically is still her same, playful self. Grabs a toy when she wants, loves her walks, etc.

That is of course my opinion but I base it on my own dog and a multitude of dogs who have come through here with cushings and maybe cushings and other problems, that turned out to not be cushings.

[kramer451]

Just wanted to post an update. Since my Scottie dog shows no clinical symptoms and her numbers are borderline, we decided not to start treatment. I spoke to her vet today about how to proceed. I told her I had implemented a monitoring program for clinical signs. I have a journal where I record all information. Mon-wed-fri, i measure her water intact, number of times and duration of each urination (I count the seconds she pees for to have some quantitative idea of the volume). Her food is always measured. Fridays, I also weigh her, measure the girth of her abdomen, check her skin for flakes , infections, and bumps, check her coat for thin spots, and check her eyes for cloudness. Daily we are mindful of panting and activity levels. I told the vet if any of the items being monitored were outside her norm, I would call. My baby is seen 3 times yearly by the same vet-vaccination schedule and dental- so the vet will have her eyes on her then. We will check her urine for protein in the fall. We are watching for clinical symptoms and will repeat blood work as needed. The vet was very happy with my monitoring schedule and what I was monitoring. I will start meds when either her cortisol numbers increase significantly and\or she develops clinical symptoms. Risk vs benefit and right now making g a healthy acting dog sick if we did not get the meds dosage right is not a benefit. She did confirm Cushing's is not an emergency and that everyone needs to research the disease and meds, ask questions, and be comfortable with whatever decision they make. It is very personal since no two dogs are the same. When we do start meds we will start at a low dose and she did confirm she has had a few dogs, that for unknown reasons, have only had to be on vetroyl for a short time and the cortisol numbers sent and stayed within normal even when they were no longer on the drug.

Sorry this is so long, but maybe it will be useful to someone in my same boat. Will keep everyone updated. Thank you.

[kmwilliams6113]

One thing you should also keep a close eye out for is UTIs. I know cushings dogs are more prone to them, and cushings dogs also have a harder time fighting off infections. We spent months throwing darts, trying to pin down a problem with our Greta, when she had every cushings symptom except the heavy water consumption--potbelly, hunger, high liver enzymes, desire to go out and pee more often than her brother, seemed to get sick more often, losing hair, etc. When we finally got a cushings diagnosis and could begin treating the cushings, after waiting a month for a collapsed disk in her neck to heal, she had a raging UTI. We're now on our third set of antibiotics for this UTI that was first diagnosed April 2. If we would have caught and started treating the cushings earlier, perhaps she wouldn't have such trouble getting rid of this now antibiotic resistant UTI.

All that to say, your monitoring plan sounds very wise and exactly what I'd do, but just keep an eye out for the pesky UTI or other infections that can not only have symptoms masked by cushings, but be a real pain to get rid of with cushings.

[Harley PoMMom]

Thanks so much for the update, we really do appreciate you taking the time to let us know what is going on with your sweet girl. I think your plan sounds excellent, and I'm glad your vet is willing to work with you, that is so very important to have a vet like that. You are doing an exceptional job with your girl, and you are an amazing advocate for her too.

Hugs, Lori

[kramer451]

Thanks so much definitely will be alert for infections!!!!

[kmwilliams6113]

Sounds like you're definitely on top of it, and that makes your pup one lucky pup!

[molly muffin]

Good plan. If I could add in the other things I'd want to monitor, high blood pressure and protein in the urine, both can be signs of the high cortisol causing damage, even if they clinically are not presenting as cushings. My dog never had the huge appetite and the drinking/peeing/accidents in the house. It was the blood pressure and kidneys that had us initiating treatment. It can turn so fast too. We went from fine to 3 months later, all kinds of problems.
I didn't necessarily realize I should be checking those things before, but now I tend to add it on to the things to monitor.

[kramer451]

Thanks. She goes back in August, will be sure to have her vet check those things. And when she goes back in Oct. I know you can do a dipstick check of urine for protein and wanted to get some test strips. Does anyone have a source? Than I can check her weekly. Can you use the ones for humans? Those I can get but I could not find literature stating if they were OK.

[molly muffin]

I don't know if you can use the human ones or not. Not a clue. I usually take molly in, or even drop off a urine sample and they run a UPC/urinalysis on it. But she has known issues with the protein loss, so for us that makes sense. Until then, I would just take it in every so often to get checked.