Hypoadrenocorticism secondary to Vetoryl

[SRuppelt]

Just joined the group and I can already tell this is going to be an amazing support system!
I have a 15yo dachshund Kolbe who was diagnosed with Cushings in February. His initial ACTH numbers were 13.4 pre and 32.7 post. He did not have the classic symptoms but an abnormal ALP caused suspicion. Our vet wanted to treat because Kolbe had been suffering from corneal ulcers that would not heal. He thought the inability to heal may have been related to the Cushings.
Kolbe weighed about 15 pounds and 30mg of Vetoryl was started 2/21. ACTH on 3/6 was 2.1 pre and 6.2 post and on 3/21 was 2.5 pre and 6.5 post. Vet was happy with these results and the 30mg dose was continued.
On 4/9 Kolbe had a keratotomy to treat a stubborn corneal ulcer in his left eye. Within a day or two, he was shaking, shivering and just not himself. I assumed it was secondary to the procedure and continued the eye drops prescribed by the ophthalmologist. He deteriorated over the weekend; took him to our vet 4/13 to have electrolytes checked. I was concerned the keratotomy stressed him out and the Cushings was out of control. No ACTH test was done at this point; all labs came back normal.
He continued to deteriorate; shaking, shivering, loss of appetite, diarrhea, lack of coordination... He spent the night at a hospital 4/14. Neurological exam was normal, X-rays showed some disc narrowing (he has IVDD; ruptured 2 discs when he was 2yo, but no issues since), abdominal ultrasound normal. $2000 later we really didn't have any answers and they felt his symptoms were disc related. Sent us home with tramadol and crate rest.
No signs of improvement over the next few days and I actually started researching in home euthanasia options. I just couldn't see this poor dog suffer any longer. Kolbe was due for another ACTH test which I told my husband was the last thing I would put Kolbe through. We'd spent so much money and put him through so much poking and prodding I felt enough was enough. ACTH test 4/20 was 1 pre and 0.9 post. Looks like he's been suffering from hypoadrenocorticism and no one picked it up. So frustrating! We stopped the Vetoryl yesterday and he does seem a bit better. He ate a little bit and seems to be more comfortable. How long should we hold the drug for and at what dose should we restart (he's down to 12 pounds). Should another ACTH test be done prior to restarting?

[labblab]

Hello and welcome to you and Kolbe. Gosh, sounds like the poor little guy has been through the wringer!

I'm afraid I don't have time for as lengthy a reply as I'd wish, but the bottom line is that I do not believe it is safe to restart the Vetoryl at any dose until you have solid evidence that Kolbe's adrenal function and cortisol level have rebounded back to a range requiring control. This would definitely require another ACTH test. Plus, in the absence of any outward symptoms of Cushing's other than the original eye infection, I think it is doubly important that the Vetoryl not be restarted without monitoring what happens to Kolbe's cortisol level now that the corrective surgery is over.

Kolbe's crash highlights the importance that vets check both cortisol levels as well as blood chemistries when dogs being treated for Cushing's are unwell. Abnormalities in either area can cause Addisonian problems, even while other readings may appear to be normal.

If Kolbe does not not rapidly show more improvement, he may very well need supplemental prednisone to replace the cortisol he is lacking. The typical formula for "rescue" dosing of prednisone is .25 mg. per kg. (and 1 kg. equals 2.2 pounds). We will certainly hope that Kolbe's adrenal function soon normalizes on its own. But some dogs remain Addisonian for extended periods of time -- some even permanently -- so you will definitely want to watch him closely and start supplemental treatment if his behavior remains abnormal.

Good luck and keep us updated!
Marianne

[SRuppelt]

Thanks Marianne. I took Kolbe in today and had blood drawn to check his electrolytes again and picked up some prednisone. Will have the results of the electrolytes in the morning. He's not progressing as quickly as we hoped being off the Vetoryl, so hopefully the prednisone will speed things along.
I called Dechra today and got some advice about the Vetoryl. They suggested a dose reduction of 50% if and when we restart. Will do another ACTH prior to restarting when he returns to normal functioning.
Thanks again for the information!

[SRuppelt]

I tried searching older posts, but couldn't find anything related to the prednisone rescue dose of 0.25mg/kg. Can you direct me to the source of that information? Would like to read more about it.

[labblab]

I will try to find a citation for the specific amount of .25 mg. per kg. since that is the "rescue" dose that has been discussed here on the forum for many years (thank you for asking about it because it will be good to formalize the source). In the meantime, though, here is a link to an endocrinology blog authored by noted Cushing's/Addison's specialist, Dr. Mark Peterson. You'll see that he discusses a dosing range of .10 - .20 mg. per kg. for ongoing daily replacement therapy in a dog that is permanently Addisonian. If dogs are given amounts significantly greater than that, the steroid is exceeding their daily physiological need and you risk inducing an unwanted Cushing's response from the supplemental prednisone.

Of course, this is referring to the use of prednisone solely for this one particular purpose. Much higher doses of prednisone may be given to treat other types of conditions.

http://animalendocrine.blogspot.com/2013/08/how-to-adjust-glucocorticoid-dose-in.html

I surely hope the prednisone will be helpful for Kolbe.

Marianne

[molly muffin]

Yes I'm actually surprised they didn't immediately give him some prednisone to get him to feeling better faster. It can take quite a bit of time for adrenal function to come back, if it does, you never know if it will or not. It is more likely to with vetroyl, but still we've seen it take anywhere from weeks to months to one case, I think was a year. Every dog is different. The starting dose for vetroyl is 1mg/1lb and can continue to drop for over 30 days on the same dose. So, it isn't unheard of and is why they changed the recommended starting dose.

Right now, no way would I start back until I had a cortisol reading (ACTH) that suggested he was coming up greatly again and symptoms return.

Hopefully his electrolytes are okay.

[kufan0001]

Wishing you the best of luck with Kolbe! I have a 15.5 year old dachshund, Dumbo, who will be 16 on July 1. He has Cushings as well, and we decided to treat Vetoryl also. He had a bad reaction and his electrolytes went way to loo low, so we stopped treatment. We are going to play it safe and not ever put him back on the medication. It was enough to scare me thinking he was much better without treating.

Every dog is so different and I wish you the best. The best advice I would give after learning about all of this is to monitor, monitor, monitor! Make sure to have your dogs checked up when on this medication for sure! With proper monitoring - the treatment remains much safer!

Good luck! Best wishes to you!

[LtlBtyRam]

monitor, monitor, monitor! Make sure to have your dogs checked up when on this medication for sure! With proper monitoring - the treatment remains much safer!

This is the key definitely. My pup is now 15 we have been at this for over two years and without this medication (and all of the supportive therapy we get for her) we would not have her. Every dog, case, and family is different. We can only do what works best for each of us and support each other.

[SRuppelt]

Kolbe's electrolytes came back normal and we've been on the rescue dose of prednisone for a week. I cannot believe how much better he's doing! He's eating and drinking again, walking with much more stability and actually starting to act like his old self again; I'm so relieved! Any suggestions at what point we should consider another ACTH test? I would like to know where we are at, but not sure I want to spend the money if it's too early (which my gut tells me it is).

Thanks for all the advice and info!

Sara

[Harley PoMMom]

Hi Sara,

It's great that Kolbe is feeling much better!!! It can take a while before his adrenal glands start producing enough cortisol, so he may be on the prednisone for some time. The one important thing with taking prednisone over a period of time is that it has to be tapered down slowly to give those adrenal glands the time they need to resume their normal function. When done in this way you will be able to see if the gradual tapering is agreeing with Kolbe, and even when the prednisone is no longer being given I wouldn't have an ACTH stimulation test performed until he would start to show the symptoms of Cushing's.

Hugs, Lori

[molly muffin]

Hi Sarah, checking in to see how Kobe is doing. Is he still on the prednisone?

[SRuppelt]

Hi Sharlene,

Yes, Kolbe is still on the prednisone (1.25mg) daily; it's been almost 4 weeks. Not sure where we go from here and would love some advice.

Kolbe is definitely better than he was since stopping the Vetoryl, but I don't know how long we should continue the prednisone. I've read to continue until he shows signs of Cushing's again, but he never really initially showed any signs when he was diagnosed. We only treated him with the Vetoryl because of the results of his ACTH test and the fact that his corneal ulcers wouldn't heal.

He's starting to develop some patches along his spine where he's loosing his fur. I've done some research and looked at images online and it seems to be calcinosis cutis. What should we do about the skin issues now? Have we pushed him back to a Cushing's state? Do I stop the prednisone and does it have to be tapered? When do we repeat an ACTH test? I'm assuming the ACTH test should be done once he's been tapered off the prednisone for some time? I appreciate any advice from the group; the vet we use does not have much experience treating Cushing's and this group seems to be so knowledgable!

Thanks,
Sara

[molly muffin]

You don't just take th off the prednisone. It is usually tapered down under a vets supervision.
How long Kobe will be on it depends on how he is doing and if his adrenal glands are producing
Cortisol again.
Have you discussed tapering down with your bet and then doing a retest ACTH? Of not do so. Or even have an ACTH and see where you are at on the prednisone. But get a plan in place you are comfortable with.

[Harley PoMMom]

Sharlene is right, you have to slowly taper down the prednisone. It is recommended that a dog have no prednisone for 24 hours when an ACTH stimulation test is performed because prednisone can cross-react in the cortisol assay to falsely increase the measured serum cortisol values. Dexamethasone could be an option instead of the prednisone as dexamethasone will not cross-react in the ACTH stimulation test.

How much does Kolbe weigh? There are a couple articles regarding Addison's disease on Dr Peterson's blog which I will provide links to. An excerpt from his blog:
I dose prednisone or prednisolone at 0.1-0.2 mg/kg/day. If the dog develops polyuria and polydipsia (PU/PD) or any other signs of iatrogenic Cushing's syndrome, I would lower the dose as needed.

http://www.endocrinevet.info/2011/02/q-whats-ideal-prednisone-dose-for-dogs.html

http://www.endocrinevet.info/2013/11/trilostane-prednisone-and-acth.html

http://www.animalendocrine.info/2011/04/treating-dogs-with-hypoadrenocorticism.html

Hugs, Lori

[SRuppelt]

Talked to our vet today and we're going to dose the prednisone every other day for a bit and then stop. He's on such a low dose (1.25mg daily) and has only been on it for 4 weeks that she doesn't think it will take too long to taper. She wants to repeat the ACTH test in a few weeks to see if Kolbe's adrenal glands have recovered from the Vetoryl dosing.

I'm worried about the calcinosis cutis. If Kolbe is still in an Addison's state without the prednisone, what are our options for treatment if we can't use steroids?

It's been such a roller coaster! We went from Cushing's to wiping out his adrenal glands with the Vetoryl and just when we thought things looked better with the prednisone, he develops the calcinosis cutis. I feel like we're in a bit of a catch 22 and I don't know what options we have left.

[molly muffin]

He is probably producing cortisol or the steroids are causing the cc which is caused by either high cortisol or steroid.

It might be that once the prednisone is stopped if his cortisol isn't over producing again that the skin will clear up.

You want to keep the areas clean and dry. Use an antibiotic spray or shampoo. To keep bacterial and yeast infection away.

http://www.amazon.com/TrizCHLOR-Spray-Chlorhexidine-oz/dp/B0035176N0

[labblab]

Hi, just wanted to add that the skin issue may not actually be calcinosis cutis. Unfortunately, it takes an actual skin biopsy to make a definitive diagnosis of cc. But I am in the midst of treating a skin infection in one of my non-Cushpups, and have come to learn that there are several types of infection that can cause hair loss and skin oddities. Not that you wouldn't be concerned about a skin infection, regardless, but it may turn out to be something that can be adequately treated with topical and/or oral antibiotics/antifungals. Has your vet seen the spots yet?

Marianne

[SRuppelt]

I took Kolbe to the vet today; his skin is getting worse. The sores seem to pop up suddenly and are starting to ooze. The vet prescribed a 7 day course of Clavamox. Also scheduled another ACTH test for next Tuesday to see how his adrenal glands are working. Anxious to have those results and hopefully a plan on how to proceed!

Thanks to all!

[Harley PoMMom]

We do have members that are experiencing success with their dog's treatment for calcinosis cutis. Improvement with calcinosis cutis is slow, and the treatment that works for one dog might not work for another dog.

I am providing you with links to other members threads that are dealing with CC:

http://www.k9cushings.com/forum/showthread.php?t=5850

http://www.k9cushings.com/forum/showthread.php?t=5908

Renee is our resident CC expert, and in her photo album she has pics of her sweet Tobey with varying stages of CC, could you take a look and see if this is what Kolbe's bumps look like, here's a link to Renee's album: http://www.k9cushings.com/forum/album.php?albumid=805

[SRuppelt]

Thanks for the links! I looked at the pictures and they look like Kolbe's lesions. For now, they are limited to just along his spine and they don't seem to bother him, so I hope it stays that way!

I did order some of the Tricolor Spray from Amazon this afternoon, so will start using that on the weekend. I'm just hoping that getting him off the prednisone will help clear up the skin issues, but I understand it can take quite a bit of time for everything to heal. This will be a test of my patience, I guess! :-)

[molly muffin]

Even if it is not cc, the tricolor spray should help, along with the round of antibiotics if there is any infection. With cc, they start as hard little bumps of calcium that push up through the skin, causing sores, around with the hair is lost and they tend to become a bit angry/red looking. Often they don't seem to bother the dog so much, but it is easy for them to become infected. If they actually clear up, and go away with the antibiotics then is is probably not cc but something else. Antibiotics don't make calcium deposits go away.

I'm hoping that it clears up and isn't cc.

[SRuppelt]

Hi everyone,

Just wanted to post an update on Kolbe. His calcinosis cutis is SLOWLY healing, but we're moving in the right direction. He's off the prednisone and his last ACTH test showed Cushing's again. We started 10mg of Vetoryl Saturday (weighs 13 pounds); last time he was started on 30mg and we got into trouble, so we're starting much lower this time around.

In the meantime, my other dachshund Sadie, has also been diagnosed with Cushing's; I know what are the chances of having two unrelated dogs diagnosed!? She's been on Vetoryl 10mg for about 2 weeks (weighs 9 pounds) and her post cortisol this week was 16. Our vet wants to continue the 10mg for another 2 weeks and recheck. If it's still around 16 in a few weeks, we'll talk about increasing the dose.

It's been a rough time having both dogs diagnosed, but we're taking it day by day. It's so hard not to think that there was something environmental I did over the years that caused this. Just hoping they both tolerate the lower dose okay and we can avoid what happened with Kolbe a few months ago!

Sara

[molly muffin]

Great to hear that Kolbe's cc is getting better. That is a slow and steady wins the day issue to deal with.

Oh my goodness. 2 of them. Well it isn't unheard of unfortunately. Based on the number of dogs we see with Cushing's I think it must me very prevalent in the canine world than we all originally thought and vets Re much more inclined to diagnose it these days it seems.

There has never been any reason found for a definitive cause of Cushing's. Lots of theory's but no proof.

Your vet is right you don't want to up the dosage till after 30 days. My Molly is always lower at day 30 than day 14. Only go up by slow increments too.

Sadie doesn't also have cc does she?

Sending a big hug your way. One can be nerve wrecking. Two. Lol. Can't imagine.

[Squirt's Mom]

ah HA! The chip situation! Some folk can't have just ONE cush baby, they are like potato chips, ya know! :p The Doxie's seem to be very well presented in this disease sadly - lots and lots of Doxie's with Cushing's. They are just one of the breeds prone to this disease.

I am glad the CC is clearing! That takes lots and lots of time but it can clear up once all the calcium has left the skin - which leaves those horrible sores but keeping the cortisol in range will do wonders....along with your TLC, which I am sure there is LOTS of.

Feel free to start a new thread for Sadie. That will help keep feeble old minds like mine from getting confused as to which baby we are talking about if they were both in the same thread. :p

[SRuppelt]

Love the potato chip analogy! :)

Wanted to ask about twice daily dosing of Vetoryl. Our vet mentioned it as an option if Sadie's results are still high in another 2 weeks. Is it used primarily in dogs who continue to have symptoms later in the day or are there other advantages to dosing the drug in the morning and evening?

Thanks,
Sara

[molly muffin]

Twice daily dosing primarily keeps their cortisol at a more even level throughout the entire day. Done dogs get a spike in the evenings it seems on once a day dosing. Not all but some. If there are other medical issues like diabetes for instance twice a day is absolutely needed.
It really depends on you and Sadie and what works best for her.

[SRuppelt]

I need some advice! So, we restarted Kolbe on Vetoryl 10mg daily 7/11/15 after his post-cortisol was 24. Recall he'd been off Vetoryl 30mg for a bit and on prednisone because of hypoadrenocorticism. We had another ACTH done yesterday and his pre-cortisol was 2.2 and post 2.1 and this is after being on only 10mg for about 2 weeks. He weighs 11 pounds.

Our vet is not sure where to go with him. I'm assuming we should hold the Vetoryl for a few days, but then what? I have a feeling his cortisol levels will rise again; do we then start an even lower dose of say 5mg? Any advice would be much appreciated!

Thanks,
Sara

[molly muffin]

Yes I would wait a bit, minimum of 2 -4 weeks, retest and if his levels are coming back up then I'd start 5mg and retest after 2 weeks.

That would be my plan of actions based on how quickly he dropped on the 10mg even. Some dogs are more sensitive than others and don't require as much, others are stubborn and need higher doses.

So, that is my thoughts on the levels, dosage and shown reaction.

[SRuppelt]

Thanks Sharlene.

Just got off the phone with our vet and we're going to stop the 10mg and treat based on clinical signs. Apparently, Decha is now making a 5mg capsule; has anyone been able to get this? Our vet said her distributor doesn't carry it yet.

[molly muffin]

Yes dechra is making a 5 mg now. I know in the UK the vet can get it directly from dechra. Maybe your vet can call dechra in the US and see if it is available here or not. If not and it turns out you need it prior to availability then you could use compounded trilostane until the 5 mg is available.

[SRuppelt]

Does anyone have experience dosing Vetoryl every other day? Kolbe was on 10mg daily and his post cortisol was 2.1. I understand a 5mg capsule will be available the fall, but wondered if 10mg every other day would be an option in the meantime.

Sara

[Harley PoMMom]

Hi Sara,

I've merged your new post into your original thread about Kolbe. This way, Kolbe's entire health and treatment history are all in one place.

Every-other-day dosing is generally not a good option. Since the medication remains active in the body for no longer than 24 hours, skipping a day only sets up a roller-coaster of higher cortisol one day, lower cortisol the next.

This is especially troublesome in terms of trying to interpret the results of an ACTH stimulation test. If the test is performed on an "off" day, the results will be higher; if the test is done on a day with the med, the cortisol level might even be lower.

Many members have their dog's Trilostane compounded, would this be feasible for you to do?