New dose required

[MichelleNZ]

Hi I am new to this forum and would love some feedback. My standard schnauzer Millie (now 18 years old) was diagnosed with Cushings 2.5 years ago and we started her on Vetoryl 30mg per day. She has been controlled on that for some time. In the last several months there have been some behaviour changes which we put down to old age and also missing our other standard schnauzer who we sadly lost 5 months ago. She was pacing a lot a night so I (without checking with my vet) switched her Vetoryl to night time rather than morning. The pacing stopped. However, a few weeks ago she started circling (not all the time, tight circles - which she does break out of herself) and had hind leg weakness. We rechecked her Cushings levels and found she was not being controlled on the 30mg once a day. She's now on 30mg twice a day and her hind legs have improved hugely. However, she's still circling a bit. My vet doesn't think this is a Cushings issue but online a lot of people talk about circling in Cushings dogs. He also doesn't think her pituitary tumour is expanding because she only circles in one direction. She has no other obvious brain tumour symptoms. She's been on her new dose of Vetoryl for only 5.5 days. Do you think it might help the circling - has anyone had any experience of this? Otherwise, she's eating and has all normal functions working just fine. Thanks in advance, Michelle

[mytil]

Hi and welcome to our site.

When you get the chance post the results of the most recent ACTH test so we can see the circulating cortisol levels and let us know if this was before the dosage change or after.

Circling can be mean a number of things. One can be attributed to her age (developing dementia) or vestibular disease or an inner ear infection.

What direction is she circling (left or right)?

Keep us posted
Terry

[Squirt's Mom]

Hi and welcome to you and Millie! :)

18 years old! What a blessing to share such a long life with your baby!

Now for the news that won't be easy to hear. What you are describing does sound as if the tumor could be growing on the pituitary. The circling in one direction is classic. Studies have found that Vetoryl helps these tumors grow if they are so inclined, and logic says Lysodren would do the same. Another possibility that won't be quite so harsh is doggy dementia, CCD or CCS. My old girl, Squirt developed it and a product called Novifit worked wonders for her. It does not require a prescription and is a stable SAMe product - and no, other SAMes do not work the same way. Something about a stable molecule they use - I've asked and they answered but this old brain sorta checked out after the 10th 3" long word! :D Anipryl (Selegiline) is a prescription med used to treat CCD. So I would talk to the vet about both these possibilities...and from what you have said, I suggest you do some in depth research on macroadenomas and doggy Alzheimer's before to talk to him since they seem to be the type that is set in their ways and not apt to be keeping up with current veterinary advances on their own - they don't recognize classic signs. ;) Many, many of us here have had to educate our beloved vets on several things so join the club! :)

Here is a link to a thread we have here on macros - it was started by a mom to a cush pup who developed a macro and others who dealt with them have added their experiences. It may help you see things you haven't before that will help determine if this is a possibility for your baby. http://www.k9cushings.com/forum/showthread.php?t=3567&highlight=macroadenoma

I'm glad you found us and look forward to getting to know you and Millie!
Hugs,
Leslie and the gang

[labblab]

Hello and welcome from me, too. Terry and Leslie have already shared some great thoughts and questions, so I will cut to the chase and focus on just one concern of mine: what was the timing of this last ACTH upon which you based this Vetoryl increase? If Millie was given her Vetoryl the night before the test was run the next day, the test results were likely much higher than they would have been had the test been properly run 4-6 hours after dosing. Trilostane has a very short active life in the body, and by 12 hours after dosing, the cortisol level for most dogs has rebounded back up to a level that is significantly higher than during the initial hours when the drug is first ingested. Especially if your vet was unaware that you had switched to night-time dosing, he may be mistakenly concluding that Millie needs a dosing increase when that really is not the case. And since you have now fully doubled her dose, I am doubly worried that you may now be significantly overdosing her. :( :(

As awkward as it may feel, you have to let your vet know that you changed the Vetoryl dosing schedule before that last test so that he can take that info into account when evaluating this dosing increase.

Marianne

[MichelleNZ]

Hi everyone and thanks so much for your replies. I was really happy to see them when I woke up this morning (I live in NZ so I think maybe we're on opposite sides of the world!). Yes, 18 years old! She's been a pretty robust dog, had some health issues over the years but seems to bounce back. She's always been a bit of a grouch but she's mellowed in the last couple of years.

I told my vet at the consult that I switched her Vetoryl from day to night but he didn't say anything about it and still went ahead and did the test. He's a Vet Specialist but I guess that doesn't always mean anything. I really struggle with vets (have had a lot of experience) and am often disappointed with their advice.

Here are the results of her latest test (I'm sorry this is all I got sent so I hope it helps):

Pre-Millie Cora 210 N/MOL/L
Post Millie Cora 785 N/MOL/L

I have no idea what this means other than the lab said her post ACTH result is "exaggerated above what I would expect to see in a normal dog". They also commented that she had similar results in 2013 (this is when she was first diagnosed) and also an abnormal LDDST.

I guess I have never paid much attention to the data because we went on the recommended meds back then and she's been good for 2.5 years.

I looked up the overdose symptoms and she doesn't seem to have any - not lethargic, no vomiting or diarreaha. Is there something else I should watch out for?

She always circles left. Just so you know for about 2 months she had nasal discharge from her left nostril (our normal vet was no help) - no blood though, just morning discharge (and not overly yellow or pus-like). Suddenly about 3 weeks ago it stopped. Wondered if it could be related the left circling? No ear issues.

She doesn't head press so I did consider vestibular syndrome - because she did seem dizzy and was leaning against furniture and cupboards. She's not dizzy any more, just the circling still going on. Also had none of the eye movements associated with that (that I noticed). The circles are quite tight and sometimes get tighter until she's spinning. I just pick her up and put her in her bed and she goes straight to sleep. She spins maybe twice a day but circles a bit more often but then will also break out and walk to her food and water bowl. I will investigate those meds you recommended, thanks - I'm not sure what we can get over here but I will find out!

Sorry I have gone a bit wider than Cushings here but you all seem very knowledgeable and I value your input.

We lost our other standard (Mollie) to a horrible brain tumour this year. We tried very hard to save her and moved 200 miles to get radiation treatment for 6 weeks - but sadly we couldn't save her in the end. She was the baby of the family at only 15 and a half years and was completely healthy in all other ways. So, as you can imagine I really worry about Millie at 18 now. The radiation and other vets kept telling me Mollie was an 'old girl', but my reference point is Millie, so Mollie always felt like the young one.

Many thanks again, Michelle and Millie

[molly muffin]

Yes, it's true you are on the off time for most of us in North America. We do have another gal from New Zealand, but she isn't on as much right now. Her dog though had a pheo adrenal tumor.

I would think that rather than go to a night time dose and make your ACTH tests pretty much invalid, the thing to do is to split the dose. Instead of 30mg, you would give 15mg in the morning and 15 mg in the evening. You can get this through a compounding pharmacy by perscription from your vet, or use a combination of vetroyl and trilostane compound.
This would have the benefit of keeping her cortisol more level throughout the entire day.

Welcome to the forum.

[MichelleNZ]

Hello there
I wanted to give an update and also ask for some advice. Millie has been on her new Vetoryl dose now for more than a month - it was first doubled from 30mg to 60mg per day. Another test showed she still wasn't controlled so the dose was increased to 30mg in the morning and 40mg at night. We are very lucky - no side effects and her hind leg strength has improved hugely. She seems a lot more settled. However, she still circles (day time), gets stuck in corners, seems confused etc. - we believe it is Canine Cognitive Dysfunction. I have read about a drug called Anipryl and am keen to try it BUT I see that Anipryl is also used for cushings. Has anyone here ever used Vetoryl and Anipryl together? Thanks in advance, Michelle

[Harley PoMMom]

Has anyone here ever used Vetoryl and Anipryl together? Thanks in advance, Michelle

On the forum I don't recall if they have been used together, but my memory is feeble :eek:

Dr. Mark E. Peterson, who is a world-renowned veterinarian specializing in endocrinology, has a blog and a veterinarian asked about using Anipryl along with the Trilostane. Dr Peterson stated that:
For cognitive dysfunction, some owners have reported marked improvement changes in their geriatric dog's behavior after starting Anipryl, while other dogs may not respond at all. Because of the drug's low incidence of side effects, however, it's certainly worth a try in dogs with suspected cognitive dysfunction.

That blog can be found here: http://www.endocrinevet.info/2011/04/q-pacing-and-circling-in-cushings-dog.html

Novifit is another medication that can be used to help support cognitive function in dogs, some members have reported success with Novifit.

Hugs, Lori

[MJI]

Hi - sorry I had to reset my username and password (having trouble with the old one). I posted a while ago about my 18 year old standard schnauzer. She was diagnosed with Cushings around 2 and a half years ago and started on Vetoryl 30mg once a day. No side effects back then. She was re-tested over the years and then again a couple of months ago. The vet said she's not controlled and asked me to increase her dose from 30mg once a day to 40mg at night and 30mg in the morning (BUT he did not do the test 4-6 hours after Vetoryl - was more like 15 hours). She was retested some weeks later (at the right time) and he then asked me to increase her dose to 40mg morning and 40mg night. So in two months she's gone from 30mg to 80mg. Since she started on the extra dosing she has had very bad ataxia off and on - no other side effects but when that extra 10mg was added last week, within a day she could barely stand - falling over all the time. Eating etc. is still ok. Last night after reading some posts I gave her a lower dose of 30mg and this morning I gave her 10mg. This afternoon she seems marginally better - a bit more steady on her legs. I am seriously thinking of stopping this drug altogether - she's 18 and falling over constantly is not an option. Just so you know ALSO when the vet suggested we test her for Cushings 2.5 years ago she did not (and has never) had any symptoms - no pot belly, no excessive drinking/eating, no hair loss etc. Not one symptom. I didn't question it at the time because back then I knew nothing about it and she had another unrelated issue we were treating - so I just took his advice. I have no idea why he thought she might have Cushings. Should I just stop this drug and see what happens? It can't be worse for an 18 years old dog than falling over all the time.
Would love your advice. Many thanks M

[mytil]

In my opinion I would certainly stop giving the Vetoryl given the symptoms she has now. I would also take her and have an ACTH test run to see if the cortisol levels have fallen too low as well as have her electrolytes checked. Her stumbling around is not a good sign and historically means the cortisol levels are too low.

When you get the chance, let me know the title of your previous thread so I can merge this one with the others so we can see the history. We can talk further about a misdiagnosis a bit later but this can be an emergency situation for your girl.


Terry

[labblab]

I agree with Terry 100%. At your dog's age, the only reason why I would consider treating her for Cushing's is if the Cushing's symptoms were severely compromising her immediate quality of life. Since that is not the case and the opposite seems to be true -- the medication seems to be making her feel worse -- I would not be treating her even if I felt certain she did have the disease. So I would hold off on giving any more in the hope she'll normalize once again.

Marianne

[My sweet Ginger]

Yes, please stop the Vetoryl and get an ACTH test done ASAP as she may even need rescue dose of prednisone. Electrolytes should be checked also.

[labblab]

OK Michelle, I just now retrieved your message from the forum's gmailbox so I was able to find your original username and thread. Both threads are now merged together. For what it is worth, I was able to successfully log in just now using your original username and the replacement password you had been sent. So perhaps you were somehow mis-typing that new password. But at any rate, we are back in business now. ;)

From reading your earlier posts, it seems as though your main concern at that time was her neurological function: pacing, circling, confusion, etc. Did you ever end up trying the Anipryl? I am now wondering whether her stumbling is part of the same issue as are these other problems. So perhaps the trilostane, perhaps not. Regardless, I would still try withholding it to see whether there is any improvement.

Marianne

[Squirt's Mom]

How is Millie today? You did stop the Vetoryl, right?

[MichelleNZ]

Hi Terry
Thanks for your post and sorry I haven't replied before now - I have been very stressed and worried about Millie. I contacted my vet and he said to take her off the vetoryl for 24 hours and then re-start at the dose she was on before (30mg twice per day). She seemed to do ok on that and her hind legs were pretty good considering her age. After reading your post I had actually already taken her off it - so have just started back again the lower dose this morning. He agrees her cortisol levels got too low but she didn't have any of the other emergency symptoms (vomiting etc.). I guess this is a very sensitive drug and obviously the extra 10mg added in during the day pushed her over the edge. She's a standard schnauzer but only weighs 11.5 kg - she's always been small and now at 18 her weight is down from what it once was. Thanks again, this forum is really reassuring.
Kindest regards, Michelle

[MichelleNZ]

Sorry I have only just seen all of your other replies - so thank you so much all of you. I feel like I have been going crazy with all of this. In my gut I feel that she doesn't need the Vetoryl but after 24 hours + off it her legs were still so bad and seemed worse and this is my biggest worry. It is very stressful seeing your once very athletic dog falling over constantly. I will try the lower dose (which she seemed to tolerate ok) and then re-evaluate. I'm still confused about why she had no symptoms but her tests showed she had Cushings. I do think there are some neurological issues as well. I did try Anipryl (we can get it her as Selegeline) but she started this the same time her day time dose was increased and then had the hind leg problems, so I panicked and stopped it. If she can remain stable for a bit then I may try it again. Other than her legs, she is very very healthy and has normal bloods, good heart, liver, kidneys etc.
Thanks again everyone

[mytil]

Hey again Michelle,

I will say I am confounded as to why your vet mentions yes, the cortisol levels most probably have fallen too low and yet did not perform an ACTH test to confirm this --- it is the numbers that will most certainly tell you the exact levels of the cortisol and if too low --- stop the Vetoryl for more than just a couple of days ---- usually it is for a couple of weeks or until the levels raise. Any vet knows it is not wise to change a dose without doing an ACTH test before.

When you get the chance, post the results of the tests your vet performed to diagnose Cushing's. If he did not perform any tests, using only visual observations (which is impossible to confirm as you stated there were no symptoms) and still prescribed this powerful medicine I would seek another vet.

Keep us posted
Terry