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View Full Version : Concerned about Appetite and Vetroyl Side Effects



puppro
11-03-2015, 10:44 AM
Hi there. I have a Cavalier King Charles Spaniel named Lady C (aka Charlie). She was diagnosed with pituitary Cushings July 2014. She had a pre-dental screening blood test show elevated liver enzymes and that lead to all the tests for Cushing's way back then (at Oregon State University in Corvallis...she had every test available). Charlie is 10 years old now. She also has mitral heart valve disease. It is fairly mild and no need for meds yet for mvd.

Charlie has been on trilostane (Vetroyl) since diagnosis. We started her at lowest dose and very slowly increased it over several months. We diligently tested with ACTH stim tests. She has been tested about a dozen times since July 2014. We wanted to slowly increase dosages to give her adjusting time and reduce side effects. Her numbers were not satisfactory to internist, who used the guidelines from the Vetroyl manufacturer. The numbers were not low enough per guidelines, even with dosage increases. From August 2014 to June 2015, the meds were eventually increased to 60 mgs a day for 20 lb dog. 30 morning and night, always with food. I was concerned about such a high dose.
Her numbers were about 7 pretest and about 13 post test when that dosage increase was made at end of June. Looking back, her symptoms (besides panting) were pretty controlled even with those numbers. They wanted numbers under 5.

Her symptoms, in the past, included increased thirst, panting, rearend muscle wasting, and great hunger. She had no hair loss. Some mild skin thinning on tummy.

With trilostane, the thirst was completely controlled. Her appetite was healthy. I had her on Honest Kitchen and many homemade 'super foods' to help her immune system and general health. Besides an internist treating her, I consulted with integretive vet for diet needs besides Honest Kitchen.

Up until that last dosage increase, things went pretty well. Still lots of energy and short walks 3-4 times a day. She also took Denamarine for liver health and omega 3s.

About a month after dosage increase, she started loosing hair very rapidly. Her thirst increased. I thought it was the Cushing's of course, though hair loss a new symptom. By Sept, she lost her appetite. She had an earlier than usual ACTH test and her numbers were way too low, under 1. She refused her Denamarine and all her super foods and HK. I had to entice her with lean ground beef, fresh cod and eventually canned Evangers salmon. Internist stopped meds for 4 days. Then wanted her on 10 a day, increasing eventually to 10 twice a day. For the past two months, her appetite has been inconsistent, though much better than when she was on high dose. On the 10 mg a day, she improved and I could get her to eat with spoon feeding and the new foods. I added powdered vitamins. Her walks were still good. Still happy, though a bit more tired. Going to 20 mgs for just 2 days, her appetite wained again and she stopped eating. She sleeped all day. So she is off the meds again to regain appetite. It has only been a day. I do not mind the sleeping, but eating is imperative! I think she will eat again off meds. ( It is 3 am while writing this and just got her to eat some more hamburger). The appetite thing is definitely related to meds.

She never had vomiting or diarrhea with vetroyl.

Amazing, once the high dose of meds stopped, her severe hair loss (for those 2 months) has decreased significantly. I see small amount growing back. Her breath is really bad, from the stomach not dental. Pepcid has not helped. Still bad now.

My concerns are about not having enough meds so she will keep her appetite. She no longer will take Denamarine. She scratches a lot now. She wears a cone so she does not scratch her eye.

Anyone had this type of experience? Also, the Cushing's caused her to loose weight. Not just the initial muscle wasting, but beyond that. I fed her about 5 times a day to MAINTAIN weight. She cannot go more than a day without eating. It affects her a lot. She is hovering at 17-18 lbs. I pray she eats in the morning.

Her most recent chem panel results, which was taken with last ACTH test, were pretty good. One liver enzyme elevated again.

molly muffin
11-03-2015, 09:48 PM
Hello and welcome to the forum.

Okay first my concern is that she is still too low. Was an ACTH test done after she dropped so low? The reason I ask is that normally trilostane would not be resumed after an Addison crisis which is what we call it when they go that low until 1) symptoms return that show her cortisol is rising and her adrenal glands are working again and 2) this is verified by an ACTH test.
We have seen dogs whose cortisol doesn't come back for weeks and sometimes months. A couple never. So starting back on even a low dose of trilostane might not have been the best option for her.

The cortisol can be up to 9 ug if symptoms are controlled. It is only if the symptoms aren't controlled or if there is another reason that they wanted her at below 5 ug.

From what you have said though. She isn't eating. Hair. Energy levels are all better when she was off medication or even a lower dose. So I would have an ACTH done immediately if you haven't and I definitely would give her 20 mg when she is reacting so badly to it. It seems she is still low to me.

That is my initial thought of what might be going in and what it sounds like.

The manufacturer guidelines for following an ACTH showing low cortisol is the protocol I mentioned above.

I hope she eats in the morning too but low cortisol can cause loss of appetite and the lethargy.

Squirt's Mom
11-04-2015, 08:06 AM
I'm with Sharlene and concerned the cortisol is still not back up to an acceptable level. On such a massive dose for that weight it wouldn't surprise me to learn she still needs prednisone and maybe some electrolyte support....but I would want those tests asap - ACTH and electrolyte check.

How is she this morning?

puppro
11-04-2015, 08:09 AM
Thank you for your response.

She ate yesterday (Tues) with coaching, three meals. Very happy with that. She had no meds since 10 mg Monday morning, so definitely medicine related as I thought.

The internist wants her off meds for 3 days, back on 10 mg for 7 days and then acth test again. I am concerned about the 10 mg now.

She took 2 walks yesterday. Not as tired.

Her last acth, which showed low numbers, was Sept 21st. So yes, I agree she should get another now. I will call her internist and see about testing without resuming meds.

Is the 9 number pre or post injection?

My sweet Ginger
11-04-2015, 09:48 AM
Please no Vetoryl resuming at any dose before an ACTH test and insist on doing it if you have to. I think her safety very much hangs on this test. She may need more time than 3 days.
The #9 is post, after an injection.

puppro
11-05-2015, 08:24 AM
Today, things changed a bit. She ate nothing and became more lethargic. Appears to be an addison crisis. She woke up in pretty bad shape. She had no weight to loose to begin with. She was a little shakey too, which was new.

By 2 pm, she was given 1 mg of prednisone. The internist wanted to start it right away. Imho, she should have never been put back on trilostane after her low numbers on Sept 21st. I wonder if the past month+ of 10 mg hurt her adrenal glands permanently. She did well on the trilostane for over a year, with small dosage increases, but the last one was obviously too much.

Anyway, after the 1 mg at 2 pm, she finally gained appetite by about 7:30 pm. So it appears the prednisone will work.

She prescribed 1 mg BID for three days and then 1 mg once a day for 7 more days. She states her acth cannot be tested while on pred. It will make the test inaccurate.

Should her electrolytes be tested? I was surprised internist did not suggest it, and I was too upset to remember to ask. I bought some unflavored pedialyte, but not sure if ok or how much to give. Or if I insist on electrolyte check, will giving her pedialyte throw the test off?

My main question now is can I give only 1 mg a day of pred instead of 2, if one mg is working?

Will she be in Addison's permanently or on pred permanently and off Trilostane? I assume it will be dependent on a valid acth test? How long after 10 days of pred can she accurately be tested? What should I expect in terms of pred side effects or what happens when the ten days end? Can I give it for only two days, if it works so well and her appetite is back?
I would hate to make her Cushing's part worse by the prednisone, or is that irrelevant at this point? If she starts to have panting and extreme thirst on prednisone, does that mean the Cushing's has returned or just a side effect of prednisone? Will it exasperate the,Cushing's?


Please share your knowledge in this area.

labblab
11-05-2015, 08:49 AM
Hello and welcome from me, too. Can you tell us how much your dog weighs? I am guessing around ten pounds, and if so, I would follow the prednisone dosing schedule just as your vet has given it to you. That low dose of pred (2 mg. total for a couple more days and 1mg. thereafter) should only make your dog feel better and not trigger any extreme Cushing's symptoms.

Yes, it probably would have been good to have the electrolytes checked now, but if she normalizes again after taking the pred, you can probably safely assume that she is not in need of electrolyte supplementation as well. And no, I do not believe you should give any pedialyte at all, regardless of how she is doing. If the pred doesn't straighten her out, then you need to notify the vet so that her electrolytes can be tested and her exact potassium/sodium needs addressed based on the testing outcome.

An ACTH should be accurate by 36-48 hours after her ten days of pred are completed. So you shouldn't have to wait long to test.

Please keep us updated!
Marianne

My sweet Ginger
11-05-2015, 09:31 AM
Well, the need for an ACTH test just went out the window as she needs prednisone to survive. How long Charlie will be on pred will totally dependent on her. We can only hope her adrenals are not permanently damaged and start regenerating after a break from Vetoryl. Please focus on getting Charlie back to health again for now. In my opinion too often people are anxious to resume back to Vetoryl too early at your pup's expense. Please take your time.
Under dosing:rolleyes: heavily outweighs the side effects of overdosing with potent drugs such as Vetoryl.
1mg BID sounds just about right to me for Charlie's weight (17-18lbs) going with the recommendation of 0.25mg/kg rescue dose of pred and try to taper it off slowly. I will follow your internist's instruction on that. PU/PD maybe expected on pred.
I'd like Charlie off pred about 48hrs before an ACTH test for an accurate reading of her cortisol level if she's doing ok without pred.
If she wanes again during off days, you know her cortisol is still too low.

puppro
11-05-2015, 01:38 PM
Helpful info. Thx! Yes, she was not doing well very quickly and pred became the priority over acth.

She walked ok to go potty this morning which is an improvement over her wobbly walk yesterday.

She went back to sleep right after without asking for brekkie. About ready to wake her again and see how it goes this morning.

puppro
11-05-2015, 02:04 PM
Helpful info. Thx! Yes, she was not doing well very quickly and pred became the priority over acth.

She walked ok to go potty this morning which is an improvement over her wobbly walk yesterday.

She went back to sleep right after without asking for brekkie. Woke her up and she ate hamburger only, fed with baby spoon. But at least she ate something. I mixed in her daily powdered vitamins, so she has nutrients. She also received her 1 mg of pred, so hopefully that will kick in for another meal in a couple hours. She is back to sleep. Her eyes look much better than yesterday too, but not 100%. Relieved we are going in the right direction at least.

molly muffin
11-08-2015, 01:59 PM
I think that you are going to want to see exactly where the cortisol levels are even with the pred, to make sure that it is enough in her body.
I'd also have a complete bood workup to check her electrolytes, she might need a Dex injection and iv for electrolytes if they are not within range.

How is she doing now?