newly diagnosed with cushings

[scottyjt]

Hi everybody,

I am new to this site. My 14 year old jack russell cross was diagnosed with Cushings Disease about 5 weeks ago. He has been on Trilostane, once a day since diagnosis and all the symptoms seemed to disappear overnight. His fluid intake, his urination inside, his panting, his constant desire for food. It all disappeared which was a great relief. Until a few nights ago. He has started to urinate inside again. I should add this only happens of a night time. He is completely house trained and I have a dog door so he has always been able to go in and out of the house as he pleases. I took him to the vet and they did some follow up tests and they said his blood levels etc were perfect and that the trilostane dosage does not need to be changed. I'm very confused as to why he would all of a sudden start to urinate inside again of a night time only. The vet reckons it is not happening due to the cushings as she feels that it is under control. Has anybody else ever had this happen where their dog has been doing really well on the medication and the disease is under control but the problem of urinating inside of a night time reappears? If anybody can help me with this it would be greatly appreciated.

Kind Regards,
Scott

[labblab]

Hello Scott, and welcome!

There are two initial thoughts that come to my mind upon reading your post. The first is that I am wondering whether your dog's cortisol level is truly within the desired therapeutic dosing range. It is not uncommon for vets to mistakenly believe that as long as the cortisol has been lowered to a level that is "normal" for a dog without Cushing's, then the treatment is sufficient. But this is not the case. The cortisol for a dog taking trilostane should be lower than the generally posted norms. Can you please tell us your dog's weight, the size of the dose, and also the exact numbers for any Cushing's related tests -- especially this most recent monitoring test (it should have been an ACTH stimulation test with two numbers).

My second thought is that even if the cortisol was in the desired range at the time of testing 4-6 hours after taking the medicine, the therapeutic effect may be wearing off by evening. Trilostane has a very short active life in the body, and for some dogs, symptoms start rebounding again after only twelve hours or so. In that event, the remedy is to give half the total dosage in the morning and the other half twelve hours later. To be clear, this means dividing the daily total as opposed to doubling it.

So once again, if you can provide us with your dog's weight, the dose, and the test results, it will help us a great deal. And also once again, welcome!

Marianne

[scottyjt]

Hi Marianne,

Thank you for getting back to me so quickly. I'm unsure of the exact test results as such. The vet rang me this morning and told me all the tests came back fine. I can visit my vet tomorrow and get the exact details. Regarding the other details you were after, my dog, Hugo, is 7.4kgs and the dosage is 60mg once a day.

Kind Regards,
Scott

[My sweet Ginger]

Scott,
At 7.4 kg, that will be 16.28 lbs. The recent recommendation for a starting dose on trilostane is 1mg/lb or 2mg/kg.
At 60 mg Hugo's dosage is 3.7 mg/lb, way too much for him for a starting dose. He may be being overdosed with dire consequences. Get those two numbers and post them for us ASAP. Thank you. Song

[labblab]

Yes, Scott, I am also very worried about the 60 mg. starting dose. To reinforce what Song has written, please read this post:

http://www.k9cushings.com/forum/showthread.php?p=1251#post1251

It is possible that Hugo may be a dog who can tolerate that high a dose, but for his safety, he should not have been started out at that level. Aside from the nighttime urination, is Hugo otherwise behaving normally? I would be very worried that his cortisol may continue to drop lower on such a high dose, leading to problems caused by oversuppression of his adrenal glands. How recently was his monitoring testing performed?

[Squirt's Mom]

Oh my! That starting dose is quite scary! If I were you, I would stop it now and get with the vet to put him on the correct starting dose - 1mg/lb or 2mg/kg. Tell them to call Dechra, the manufacturer, if they need "official" verification. ;)

Here is a link to the Dechra website. In the second section titled "Dechra Veterinary Products" you will see a drop box. Chose your county then when that page opens you can use the "contact us" at the bottom of the page to get the phone # for your area. I can't find any location for you so I am going to assume you are in the US. IF so, here is the contact info for Dechra (if you are in some other country, use the second section to find your contact info ;)) -

For USA -

Dechra Veterinary Products
7015 College Blvd., Suite 525,
Overland Park, KS 66211

Tel: + 913-327-0015
Fax: + 913-327-0016

Let us hear from you when you can!
Hugs,
Leslie and the gang

[scottyjt]

Hi All,

His behaviour (apart from the urination inside) is normal. He is eating fine. Has energy. When I take him for walks he is fine. I went and double checked the bottle of trilostane and it says 60mg tablets. So I am assuming that is the dosage he is taking. Anyway, I am now extremely concerned. I have rang the after hours vet and they said not to stop the medication due to his latest results coming back good (the latest test was done yesterday). I will give my vet a visit first thing in the morning and discuss it with them further and I will just clarify the dosage etc. I should also add that his urinating inside only occurs of a night time. When he is home by himself of a day time when I am at work, he goes outside and urinates. It baffles me why it is only of a night time.
Thank you everybody for replying. I will keep you updated.
Also, just to let you all know, I am in Sydney, Australia.
Kind Regards,
Scott

[LauraA]

Hi Scott. I am in Perth Australia. My girl is 7kg and she is on 30mg. 60mg is quite a high starting dose so I would keep a close eye on him for any side effects of dropping too low in cortisol.

[scottyjt]

Hi Laura,

How long has your dog been on the trilostane? Has the medication worked? I'm getting really stressed about this. I have to believe that my dogs cushings is under control as the vet said the results were fine. But I don't understand why has started to urinate inside of a night time again (considering he stopped doing that as soon as he started the medication). He is 14.5 years old so unless a bit of dementia is setting in. My dog means the world to me so I am finding this cushings disease really stressful and upsetting. So I imagine it must be much worse for my poor dog. :(

Kind Regards,
Scott

[labblab]

Hi again, Scott. In re-reading what I wrote to you earlier, I want to clarify a couple of my thoughts. If Hugo's monitoring test results from yesterday are truly within the desired therapeutic range after five weeks on the trilostane, then it may indeed be the case that the 60 mg. total daily dose is appropriate for him and I would not suggest that you lower the dose right now. But for the benefit of our other readers, we want people to know that current recommendations are to first begin dogs at much lower doses until enough time has passed to be able to evaluate whether larger doses are needed. Dogs do metabolize the drug differently, and all subsequent dosage changes are based upon behavior, lab results, and monitoring ACTH testing. So if Hugo is essentially doing well on all three of those fronts, it is an indication that he is a dog who actually does require a higher dose of medication for good control. Having said all that, I do think it is possible that his cortisol may continue to drift downward over time, especially on a dose that high. That's why you will want to watch him closely for signs of overdose (which obviously you are already doing, because it's clear that you are taking such very good care of him!).

However, going back to his night-time urination, I still believe it is possible that the medication's effect may just be wearing off too quickly for him. If you are using brandname Vetoryl, this should not present too big a problem, however, because you could switch him to taking one 30 mg. capsule in the morning and one 30 mg. capsule in the evening. If you are using a compounded form of trilostane, it really should not be a problem, because custom doses can be made up in almost any amount.

So when you do talk to the vet, in addition to getting the test results, I would ask him about the possibility of switching to twice-daily dosing as an experiment to see if that helps things.

Marianne

[scottyjt]

Hi Marianne,

Thanks so much to you and everbody who has replied. I will be going to the vet shortly to get a copy of the full results and speak to them about Hugo's medication. One other thing I have noticed is Hugo has a slight dragging on his back legs when he walks. Sometimes the left one drags a little and sometimes the right. He can run fine though. Anyway, i will give you an update when I return from the vet.

Kind Regards,
Scott

[molly muffin]

Hi Scott, I just want to say welcome.

I too would have concerns about starting a 16lb dog on 60mg of trilostane. The manufactuer just lowered the recommended range of the starting dose, to 1mg/1lb due to the higher starting doses causing problems in Some dogs. So that is why our concern.

It depends a lot on what the ACTH results actually are, as we've had vets read those wrong too.

So, we are definitely looking forward to seeing what the actual test results show.

[scottyjt]

Hi Everybody,

I have just come back from the vet and they have printed out the results of the tests prior to going on the Trilostane and the results of his latest test which was done 3 days ago. There is so much information on these results that I am unsure of which to mention so I will do them all. (I apologise in advance for this very long message). Also, the vet said to give him half a tablet in the AM and half in the PM and see how he goes on that. And his dosage is definitely 60mg a day.

Anyway, results for prior to going on Trilostane are:

ENDOCRINOLOGY:
*cortisol resting 83 nmol/L 15 - 170
*cortisol 1st post 70nmol/L

*cortisol 2nd post 86 nmol/L
*1st dose post time 4
*2nd dose post time 8

Results from 3 days ago:

ENDOCRINOLOGY:
*CORTISOL RESTING 45 nmol/L 15 - 170
*CORTISOL 1ST POST 68 nmol/L
*1st POST DOSE TIME 1

Normal dog:
Post-ACTH cortisol 170 - 470 nmol/L

Hyperadrenocorticism (hyperA):
Post-ACTH cortisol >600
nmol/L consistent with hyperA

Post-ACTH cortisol 470 - 600 nmol/L
equivocal


There is a lot more information on the printouts but I think what I have mentioned above is what you were asking for. I do not understand any of this so if anybody can help me out and give me some guidance I would be very appreciative. I'd also like to mention that they discovered Hugo has a heart murmur. They discovered this on Friday. They do not want to do anything about that but they said they will check it again in 3 months. And there is one other thing I'd like to mention (and this is something that is not bothering me but wanted to mention it). My dog has started snoring (loudly) since starting the Trilostane. Anyway, I look forward to hearing back from you all. I'm sure you have been told this before, but I am so glad I have found this site.

Kind Regards
Scott

[labblab]

Scott, thanks so much for providing this info so promptly. I am just now heading to bed on my side of the world, so only have time for a short note right now. I'll try to come back and elaborate tomorrow. But the short answer is that your first test was a diagnostic LDDS test, and the results are consistent with Cushing's. This particular pattern could be associated with either the pituitary or adrenal form of the disease -- you would need additional testing to try to determine which form he suffers from if this is something you would want to know.

The second test was a monitoring ACTH stimulation test. Hugo's result was indeed within the desired therapeutic range for a dog treated with trilostane for a period of five weeks, although you would not want his cortisol to be dropping much lower. So I do think you will want to keep a watchful eye out for ill effects in the future, and retest his cortisol level should any appear.

Since his trilostane is in tablet form, it appears as though it is OK to split them in half (capsules should not be opened and split). It will be really interesting to see whether this helps to control the night-time urination. As I say, I will write in more detail tomorrow and give you some reference links.

Marianne

[scottyjt]

Thank you so much Marianne. I really really appreciate all the information and help you have given so far.

Look forward to hearing from you tomorrow.

Regards,
Scott

[Squirt's Mom]

A GREAT relief, and a tad bit of surprise, at that ACTH result. He is within normal range thankfully but do keep a very close eye on him just in case - tho I know you already do that.

[labblab]

OK Scott, I'm back again with a few more comments. :)

First, here's a link to a thread on our Resources forum that offers a lot of helpful info about trilostane treatment and monitoring. There are several publications you can click on for in-depth explanations about the use of this medication.

http://www.k9cushings.com/forum/showthread.php?t=185

Next, here are conversions of Hugo's test numbers into units with which we are more familiar in the U.S.

Diagnostic LDDS

Resting cortisol: 3.0 ug/dL
4-hour cortisol: 2.5 ug/dL
8-hour cortisol: 3.1 ug/dL

Monitoring ACTH test

Resting cortisol: 1.6 ug/dL
Post-ACTH: 2.5 ug/dL

So what does this all mean? As I wrote earlier, the results of the LDDS are consistent with Cushing's, and could be the result of either form of the disease. Trilostane can be used to treat both, but if a dog is a candidate for surgery, adrenal Cushing's can be totally cured. It is a risky and very expensive surgery, however, so it is not an option for all dogs and owners. If you are wanting to know what type of Cushing's Hugo suffers from, however, you would need to perform additional testing such as an abdominal ultrasound or special blood testing (which may already have been done?).

Turning to the ACTH test, you will see from publications on that resource thread that Dechra (manufacturer of brandname Vetoryl) considers post-ACTH values between 1.45 and 5.4 ug/dL to be ideal. So coming in at 2.5 after five weeks of treatment, Hugo is in the midst of that range. Both of his test values are higher than 1.45 and he is not exhibiting symptoms of low cortisol, so I believe Dechra would be satisfied with this result. Some clinicians instead prefer that the post-ACTH number not drop below 2.0, but Hugo still meets that criteria. But as I say, you do not want his cortisol to drop much lower.

So bottom line: right now Hugo seems to be doing fine except for the rebounding urination, and hopefully the split dose will help with that. How soon does the vet intend to recheck Hugo's ACTH after making this dosing change? Even if he is outwardly doing well, I probably would not want to wait longer than another thirty days because we have been told that shifting to twice daily dosing may result in lower cortisol levels even when the daily total remains unchanged. And if he were to start acting unwell, you will want to retest even sooner.

[LauraA]

Hi Scott
My girl has been on trilostane for a couple of years now. The drug has worked out great in her case and really given her a good quality of life back. In her case it probably took about 4 months for all her symptoms to become controlled and even longer for her skin issues to improve. She had absolutely no control over her bladder at all initially but as her cortisol became controlled she finally was able to get that control back.

Also when your dog is going in for the important ACTH Stim tests it is really important that the test is done around 4 hours after your dog has had his Trilostane tablet (always with food) to get an accurate result on the test.

Hopefully the split dose will do the trick :)
Laura

[scottyjt]

Hi Marianne,

Thank you very much for the link and all your help so far.

I spoke with the vet again today and she would like me to bring Hugo back in a month just to check everything again. However she said if I notice any negative changes in him to bring him back earlier.

Today is the first day whereby I am changing Hugo to half a tablet in the morning and half a tablet in the evening. So fingers crossed there will be no urinating inside tonight. The vet wants me to get back to them in about 10 days to let them know whether he has stopped weeing inside.

I will check back with you all again tomorrow to let you know how our first night.

Kind REgards
Scott

[molly muffin]

Hopefully splitting the dosage between morning and evening will help control the symptoms throughout the entire day.

Let us know how things are going.

[scottyjt]

Hi everybody,

Well this is day 3 of splitting the tablets by taking half the daily dose in the morning and the other half at night. the first 2 days/nights went well. but tonight Hugo has been a bit restless and has urinated inside. I will give it a week to gauge how regular it is and to see if indeed splitting the tablet has worked but if it doesn't work, I really don't know what else to do...... I have noticed that his water intake has lessened again which is a good thing but I am still unsure why he would urinate inside. Especially considering he did it quite near the back door and the door was open. Anyway, if anybody has any thoughts on why he could be doing this considering his cushings is under control since being on the trilostane, I would be very grateful for some feedback. Also, the vet has advised that he definitely does not have diabetes.

[scottyjt]

So just further to this, Hugo just went to his water bowl and had a drink (I was very quiet and followed him and watched him ensuring he could not see me). He had a drink and straight away did a wee beside his water bowl. The water bowl is situated right at the back door next to the doggy door so he could have easily went outside to urinate. This has me very very confused and I am now more anxious about this than ever. Please, if anybody can help me understand what is going on i would be very appreciative.

kind regards,
Scott

[Squirt's Mom]

One thought comes to mine - DI, or diabetes insipidus. It is a rare form of diabetes that has nothing to do with blood sugar but rather with how the body regulates and processes water. Excess drinking and peeing are signs for DI as well as Cushing's (and many other conditions as well ;) ) so it is worth talking to the vet about. The test for DI is risky, a water deprivation test, so most vets simply start treatment and if it helps, there is the diagnosis. We see DI here more than most vets see it during their entire practice....but it is often misdiagnosed as Cushing's. ;)

[scottyjt]

Thank you Squirts Mum. I will contact my vet today and ask them about it. Really really appreciate your help.

Regards
Scott