Leo - Cavalier diagnosed January 2016

[LeoLove]

Hi,

I'm so glad I found this group -- what an amazing resource.

After several months of unnecessary tests, my super sweet 7 1/2 year old dog Leo was diagnosed with Cushing's.

In October he started exhibiting excessive thirst and hunger. It seemed relatively sudden, although looking back I think he had started begging for food more often in the preceding months. And he went through a period of occasional panting about a year earlier, but it had stopped.

Anyway, this past fall he all of a sudden wanted to drink non-stop and was constantly hungry -- and of course peeing a lot too. He rarely has accidents -- but occasionally because of all the drinking he'll have some leakage while he sleeps. I started waking him up in the middle of the night to relieve his bladder.

He also lost strength in his legs very rapidly, and now can no longer get up on anything even a low chair or couch. He even sometime stumbles just walking or going up on a curb.

He also developed a little pot belly over the past 6 weeks, but is basically skin on bones everywhere else. His face is very gaunt and his eyes seem to be almost popping out since there's no more padding on his face. (He's still extremely adorable -- will put up some photos, pre and post cushing's.) It seemed this happened in the span of a couple months -- all while the original vet was telling me repeatedly he didn't have Cushing's and we were testing for everything but. I wasted a couple thousand dollars I could have used to treat him for what he actually has!

Finally I switched vets and got a Cushing's diagnosis.

Here are the results of his ACTH STIMULATION:

PRE-ACTH CORTISOL 12.8 ug/dL

POST-ACTH CORTISOL 47.8 ug/dL

He also had an abdominal ultrasound which showed an enlarged left adrenal gland "with a focal hyperechoic region suggestive of hyperplasia or mass; this is more suggestive of ADH, but can not completely rule out PDH."

He started on Vetoryl (trilostane) 8 days ago.
DOSE: 5mg, 2x per day. (he weighs 14.5 pounds)

Already I've noticed some slight improvement in his excessive thirst and hunger, and overall he seems a little more upbeat and is looking less sickly. He's also only getting up once a night usually.

I have a couple questions (for starters)...

1. Should I consider having surgery? The vet suggested a surgeon consultation.

2. His nose is EXTREMELY dry, and has a sort of sour cheese like odor. Has anyone had this with Cushing's? I need a solution!

3. Can I wait until a month before I get a follow up ACTH Stim? Since he seems to be doing fine?

Thanks everyone!

Mikaela

[Harley PoMMom]

Hi Mikaela,

Welcome to you and Leo! I am sorry for the reasons that brought you to us but so glad you found your way here.

Thanks for posting those ACTH stimulation results and along with Leo's clinical symptoms it does seem that a diagnosis of Cushing's is likely. However, there are other non-adrenal illnesses that do share some of the same symptoms of Cushing's, such as diabetes and any thyroid issue, have these been ruled out? Did Leo have a CBC/chemistry blood panel done recently, and if so, could you get copies of those tests and post those levels that are abnormal along with their reference ranges and units of measurement....thanks!

Adrenalectomy can be a cure for a dog with the adrenal type of Cushing's, however this is very serious, very expensive surgery and should only be done by a seasoned surgeon. One of our members, Trish, has had a successful adrenalectomy performed on her furbaby, Flynn. I'm including a list of questions she prepared for others debating adrenalectomies for their dog:
Part I - Questions to ask when considering if surgery is an option for your dog’s adrenal tumour:
1. What type of tumour do you suspect, ?functional, ?non-functional, pheochromocytoma, benign, metastatic
2. Expected life span for my dog in a normal situation. If your dog is close to, at or past his expected lifespan for his breed is surgery going to be of any benefit?
3. Prognosis for my dog if we treated medically i.e. with Cushings medications. AND if we do not proceed with surgery how long do you think it would be before the tumour started adversely affecting his quality of life?
4. If he is miserable now, does the benefit of potentially risky surgery outweigh his current quality of life?
5. Are there any other health problems that could impact on a positive surgical outcome, for example: if your dog is overweight or has heart, BP, liver, kidney or lung conditions
6. Is there any sign of tumour spread – imaging should be done, including ultrasound and on advice of specialists either CT or MRI to check whether there is local invasion around the tumour, into blood vessels including vena cava or spread further away in the body to lungs etc
7. Surgeon recommendations – would he/she do it for their own dog?
8. Psychological impact for the owner: It is important to understand this is risky surgery, sadly current guidelines indicate 1:5 dogs do not make it, and some recommendations are not even that high. Can you accept it if your dogs dies during or in the postoperative recovery period surgery? This is where it is important to weigh up whether the benefit of your dog being fully cured is worth the risk of possibly losing him.
9. Financially – can you afford it? Find out estimate of costs.
10. Hopefully this will not happen, but if your dog collapses, e.g his heart stops either during his surgery or afterwards what emergency measures should be undertaken, do you want your dog to have CPR, how far are you (the owner) willing to go for your dog to be saved in such circumstances

Part II - Surgery has been recommended as treatment for your dogs adrenal tumour, here are a few suggestions on what questions you should ask your surgeon:
1. Are you board certified? How many operations of this type have you done? What complications have you experienced? What were the outcomes?
2. Please explain to me how you will do the surgery, which part would likely give you the most trouble? Will you be doing the actual surgery or a resident in a teaching situation? If so, is their close supervision?
3. Will there be a specialist anaesthetist available for the surgery?
4. If it hasn’t been done, do we need a CT/MRI scan to look at the tumour more closely to check for vena cava involvement or any other tumour spread?
5. What are the risks associated with this surgery, including
• Bleeding (including trauma to blood vessels or other organs during surgery)
• clots
• Blood pressure or heart problems such as arrhythmias
• pancreatitis
• pneumonia
• kidney failure
• infection
• wound problems
• bowel problems
• anaesthetic risks
• adrenal insufficiency or electrolyte abnormalities
• death (sorry but you have to ask that risk too)
6. If we proceed with surgery does my dog need preoperative treatment with Cushing’s meds, antihypertensive if high blood pressure is a problem – phenoxybenzamine recommended preoperatively for dogs with pheochromocytoma, anticoagulants or anything else?
7. How will you treat to prevent clots postoperatively?
8. What would you do if you found anything else during the surgery i.e. nodules in other organs e.g. spleen, opposite adrenal, liver, kidney. Would you remove them and what are the risks associated when doing additional abdominal surgery together with adrenalectomy
9. How long will it take and when will you contact me so I know all is OK, when can I visit after surgery?
10. How will the postoperative period go, how long would you anticipate he would need to stay in hospital? How will we manage pain?
11. What monitoring would be needed, e.g. heart monitoring, oxygen levels in the postoperative period
12. If your dog has an adrenocortical tumour affecting cortisol production will he need to be on steroids following surgery and for how long?
13. If there are problems when I take him home, who do I contact? Hopefully the surgical team until all is stable.

Now, for that dry nose, that can be a sign of high blood pressure which is commonly found in cushdogs so I would have his vet check his BP. When my Harley had a dry nose I used Vitamin E and/or vaseline which helped.

So Leo is getting 5 mg of Vetoryl being given twice a day for a total of 10 mg, right? Is this is so than his dosage of Vetoryl is even lower than the guidelines that Dechra recommends, which is 1mg per pound of a dog's weight. Since Leo weighs 14.5 pounds, the recommended starting dose would be 14 mg, so that 10 mg is really, really good dose to start off with!

Dechra does state in their product insert that an ACTH stimulation test should be performed 10-14 days following the onset of treatment. On the forum we are seeing that some vets do wait until that 30 day mark to perform that first monitoring ACTH stimulation test as long as the dog is doing well and is not showing any adverse signs.

Well I think I have written you a novel here :eek::o:) If you have any questions at all please do not hesitate to ask them ;)

Hugs, Lori

[judymaggie]

Hi and welcome to you and Leo! Lori has covered all the bases so mainly just wanted to say "hi".

With regard to the dry nose, I have used Bag Balm on my Abbie's dry paw pads and it works immediately without any greasy residue and it can be used on a dry nose as well. A couple of other products are out there -- both with silly names, Nose Butter and Snout Soother (both available on Amazon)!

A dry nose could be related to allergies, in particular an allergy to plastic --- if you are using plastic water and/or food bowls, you could dry switching to metal or ceramic.

[LeoLove]

Thanks so much for the detailed response!

Below are Leo's relevant blood results comparing November and December results:


ALT (SGPT) - (Ref. Range 12-118) (Units U/L)
Nov- 204 (HIGH)
Dec- 270 (HIGH)

Alk Phosphatase - (Ref. Range 5-131)(Units U/L)
Nov- 233 (HIGH)
Dec- 387 (HIGH)

GGTP - (Ref. Range 1-12) (Units U/L)
Nov- 12 (NORMAL)
Dec- 42 (HIGH)

Creatinine - (Ref. Range 0.5-1.6) (Units mg/dL)
Nov- 0.6 (NORMAL)
Dec- 0.3 (LOW)

BUN/Creatinine - (Ref. Range 4-27) (Ratio)
Nov- 17 (NORMAL)
Dec- 50 (HIGH)

Phosphorus - (Ref. Range 2.5-6.0) (Units mg/dL)
Nov- 6.2 (HIGH)
Dec- 5.7 (NORMAL)

Cholesterol - (Ref. range 92-324) (Units mg/dL)
Nov- 368 (HIGH)
Dec- 343 (HIGH)

Amylase - (Ref. Range 290-1125) (Units U/L)
Nov- 272 (LOW)
Dec- 271 (LOW)

PrecisionPSL - (Ref. Range 24-140) (Units U/L)
Nov- 236 (HIGH)
Dec- 252 (HIGH)

Monocytes - (Ref. Range 0-840) (Unites uL)
Nov- 273 (NORMAL)
Dec- 957 (HIGH)

Any thoughts on those results?

Regarding his nose, it's definitely something beyond just being dry. It smells maybe a little yeasty... I may have to take him back to the vet for that, as I'm concerned it might be a fungal infection.

[My sweet Ginger]

A welcome from me too.
Is Leo's dry nose also badly cracked and got bigger due to opened up cracks?
You will see on my Ginger's photo album what her nose looked like.
I used Bag Balm on her nose too but it only softened the surface but didn't really bring down the size of the cracks. What finally brought them down was Amlodipine. Her nose still gets dry but it's not big like when she had all those big cracks so now her nose looks normal just dry. So I'd definitely check her BP.
And she also had that stinky odor and still does but not as bad.

[molly muffin]

One of the first thing that jumped at me is the high monocytes, as that is often indicative of an infection somewhere in the body.

ALT (SGPT) - (Ref. Range 12-118) (Units U/L)
Nov- 204 (HIGH)
Dec- 270 (HIGH)
This increase usually shows the liver is being affected by something, cushings is one of the things that can affect the liver.

Alk Phosphatase - (Ref. Range 5-131)(Units U/L)
Nov- 233 (HIGH)
Dec- 387 (HIGH)
A high ALKP, also liver related is often elevated with cushings.

GGTP - (Ref. Range 1-12) (Units U/L)
Nov- 12 (NORMAL)
Dec- 42 (HIGH)
Again liver related

Creatinine - (Ref. Range 0.5-1.6) (Units mg/dL)
Nov- 0.6 (NORMAL)
Dec- 0.3 (LOW)
Vets don’t usually talk about low Creatinine so much as high creatinine which can be worrisome

BUN/Creatinine - (Ref. Range 4-27) (Ratio)
Nov- 17 (NORMAL)
Dec- 50 (HIGH)
Was a plan BUN result shown that might be a reason for this to be high? As the creatinine was low, I’m thinking the BUN might have been elevated, which can be caused by many things and sometimes is a day type event, not a chronic event.

Phosphorus - (Ref. Range 2.5-6.0) (Units mg/dL)
Nov- 6.2 (HIGH)
Dec- 5.7 (NORMAL)
Good this is normal

Cholesterol - (Ref. range 92-324) (Units mg/dL)
Nov- 368 (HIGH)
Dec- 343 (HIGH)
Not too much out of range, was she fasted before the testing?

Amylase - (Ref. Range 290-1125) (Units U/L)
Nov- 272 (LOW)
Dec- 271 (LOW)
the only health reason I can think of for low amylase is cortisol or steroid

PrecisionPSL - (Ref. Range 24-140) (Units U/L)
Nov- 236 (HIGH)
Dec- 252 (HIGH)
Not sure what this is, one of the others might be familiar with it

Monocytes - (Ref. Range 0-840) (Unites uL)
Nov- 273 (NORMAL)
Dec- 957 (HIGH)
This indicates an infection normally

Definitely check the BP as the other have mentioned.

Has a thorough urinalysis been done to check for an infection? Not dismissing the adrenal at all, just wondering if an infection could be the reason for some of these other values to be off.

and Welcome to the forum

[judymaggie]

Hi--just wanted to address what the PrecisionPSL test is. It is short for "Precision Pancreatic Sensitive Lipase" and is a new test from Antech Diagnostics. It replaces the previously used lipase test and is basically a screening test for pancreatitis. That said, with Leo's high levels two months in a row might well indicate some pancreatic inflammation. This might be the infection Sharlene is considering.

[molly muffin]

Thank you Judy. Always learning on here. :)

[LeoLove]

Wow, thanks again for the thorough and informative responses.

RE: LIVER LEVELS & POSSIBLE INFECTION
Regarding his high levels of ALT, Alk Phosphatase, and GGTP... It's possible a gallbladder issue was causing those levels suggesting liver involvement. Because the ultrasound he had this month indicated some thickening in the gallbladder. The vet said the bile -- which is supposed to be sort of like pulpy orange juice was too thick and likely the result of infection -- she said it appeared to be cholangitis or verging on cholangitis, which she said could explain the high liver values.

He's almost done with a 14 day round of antibiotics (Baytril) to treat it.

He's was on multiple antibiotics in November and December, because of some of the levels which indicated infection. (They were minocycline, Zeniquin, Metronidazole, and Clavamox) But Urine cultures haven't shown any infection. Just had urine test 2 weeks ago.

RE: BUN...

BUN/Creatinine - (Ref. Range 4-27) (Ratio)
Nov- 17 (NORMAL)
Dec- 50 (HIGH)
Was a plan BUN result shown that might be a reason for this to be high? As the creatinine was low, I’m thinking the BUN might have been elevated, which can be caused by many things and sometimes is a day type event, not a chronic event. >>>I'm not sure what you mean, but there was not a plain BUN result, just the BUN/Creatine. But the vet suggested I start Leo on famotidine (antacid) for his elevated BUN. Does that make sense?

RE: BLOOD PRESSURE...
I'm pretty sure it's been fine. It was checked when I took him to the cardiologist a month ago. I'll have to go back and find the results, but I don't recall it being an issue.

RE: DRY STINKY NOSE...
The vet just prescribed Quadritop and Dermoscent to help with hyperkeratosis. Anyone have any experience with that.

I also wonder if all the antibiotics have killed the healthy stuff. I've been giving him probiotics which I'm hoping will help.

(BTW he does drink out of ceramic bowls)

[LeoLove]

Does anyone know how important is it to give trilostane with food?

Can it be with a snack or should it be with a full meal?

Also, how long does it usually take to see significant improvements?

[Budsters Mom]

Pasted from PET MD....

"Dosage and Administration

Always follow the dosage instructions from your veterinarian. Trilostane (Vetoryl) should be administered with food unless otherwise directed by your veterinarian."


Trilostane needs food in order to be properly absorbed. A full meal is not needed. Some soft canned food or a substantial favorite snack works well. Trilostane can be hard on sensitive tummies. That's another reason for dosing it with food. I always dosed it with a full meal. That's what worked best for my boy because his stomach was extra touchy.

Kathy

[labblab]

Through the years, we've gone back-and-forth as to our understanding as to how much food is necessary. However, Dechra's most recent literature references giving the med with the morning "meal," and the implication now seems to be that a full meal is best if possible. For dogs who are dosed twice daily, as large a meal in the evening may not be part of the dog's daily regimen. But even then, it sounds as though something more substantial than a snack would be preferred, if that is possible. However, as Kathy says, a substantial snack is better than nothing. A totally empty stomach absolutely needs to be avoided.


Give VETORYL Capsules with a meal in the morning so they can be effectively absorbed. Administration in the morning is critical so your veterinarian can perform the monitoring test at the appropriate time after dosing...

...Don't give on an empty stomach. Food is critical to ensure the optimum absorption of Vetoryl capsules.


http://www.dechrace.com/pdfs/vetoryl/VetorylClientBrochure5mg.pdf

Marianne

[Renee]

I contacted Dechra directly with this question. Their response was that the medication needed to be administered with "a full meal" (exact words).

[Joan2517]

I give Lena hers after she eats her breakfast with an extra spoonful of canned food. Then watch to make sure she doesn't spit it out somewhere!

Joan

[LeoLove]

Thanks for the replies everyone!

I guess the issue is that Leo takes 2 doses... which are supposed to be 12 hours apart but he eats around 8am and 6pm... So I'm wondering if it's better to do the 12 hours and have his second dose 2 hours after his dinner, or with the meals even if if means NOT 12 hours between doses...

[Renee]

Thanks for the replies everyone!

I guess the issue is that Leo takes 2 doses... which are supposed to be 12 hours apart but he eats around 8am and 6pm... So I'm wondering if it's better to do the 12 hours and have his second dose 2 hours after his dinner, or with the meals even if if means NOT 12 hours between doses...

I dose twice a day, and have been since Dec 2013. My dosing is not exactly 12 hours apart, but I'm close. 6am breakfast, and between 530-630 for dinner. I think as long as you keep it in range, it's more important to dose with a full meal, as instructed by Dechra.

[labblab]

If it was me, I believe I'd go ahead and give the second dose with dinner. I think that's probably the better option. He'll be getting it a little early, but this way you know it will be metabolized properly and I think that is really more important.

Marianne

[LeoLove]

One more question on dosing...

is it advised to be given with meal to avoid stomach upset? Or does it have to do with absorption -- in other words might it be more effective if given with food?

[Harley PoMMom]

Food is needed for the Trilostane to be absorbed properly. If not given with food than when the ACTH stim test is performed those results can be skewed. Pepcid AC is recommended for the gastric upset.

[LeoLove]

NEED DOSAGE ADVICE!

Hi --
Leo just had his second ACTH Stim after 3 weeks on 10 mg/day of Trilostane, and based on his results the vet is recommending doubling his dosage to 20mg (10mg 2x per day).

NEW results 2/12:
PRE-ACTH CORTISOL 8.9 ug/dL (ref range 2 - 6 )
POST-ACTH CORTISOL 15.2 1 ug/dL (ref range 6 - 18)

Old results from 1/20:
PRE-ACTH CORTISOL 12.8 ug/dL
POST-ACTH CORTISOL 47.8 ug/dL

Doubling seems a little extreme considering how much his levels came down... and isn't his post ACTH cortisol in the reference range? He has definitely improved... but some symtoms are still present... still drinks too much and pees a lot, and occasionally when he's asleep he'll leak a little. Other than that I've seen improvement, and his muscles are starting to come back. he doesn't fall as much as before...

Thoughts on double the dosage? I'm more inclined to give him 15mg (10mg in the morning and 5mg at night). As opposed to doubling it.

He weighs 13.5 lbs...

[Harley PoMMom]

His stim numbers have dropped considerably so I would definitely not raise his dosage at all right now because while on the same dose of Vetoryl a dog's cortisol can drift downward during the first 30 days of treatment.

Hugs, Lori

[judymaggie]

Hi! I wanted to provide you with Dechra's technical brochure -- page 11 has a great flow chart which shows you the options to change dose as well as the hoped for ranges.

http://www.dechrace.com/pdfs/vetoryl/VETORYLTechnicalBrochure.pdf

The post cortisol range that you are indicating (6-18) is, on the lab results that I have, the appropriate range for a normal reading on an untreated dog. Per the Dechra flow chart you want post cortisol to be below 9.1 as long as symptoms are controlled and lower than that if symptoms still persist. Accompanying arthritis or high blood pressure or proteinuria will be taken into consideration in order to find ideal post-cortisol level.

Also, wanted to ask you if Leo's nose is still the same?

[My sweet Ginger]

Since increasing dosage is not recommended before 30days and Leo only has 1 more week to go until 30day mark I'd stay on 10mg for 2 more weeks and test his cortisol. Only then increase his dosage if need to be. Keep in mind with this drug slow and low wins the race.
Also since his level has been coming down nicely on 10mg I wouldn't double his dosage next time even if an increase is warranted after an ACTH test. Just my 2 cents.

[LeoLove]

Hmm.... the vet definitely seems to really think I should double the dosage. I emailed her and asked about only going up to 15mg/day and this was her response:


The desired number is actually between 1-5 when on Trilostane (it says that on the bottom in the list of reference ranges). So I would start giving him 2 (5mg) capsules twice a day and we are still within the reference dose range for trilostane with this. I just don't know if you are going to see a major difference in his clinical signs with the 15 mg/day dosing. But if you feel more comfortable starting with 10 mg in the morning and 5 mg at night, we can go that way.

Frustrating... not sure what to do.

And by the way, I met another Cushing's dog at the park in my neighborhood who goes to the same veterinary clinic (different doctor) who said her dog was doing really well but then ended up having too much trilostane and veering into Addison's territory so they had to reduce dosage.

As far as Leo's nose, I treated him with dermascent this week.

And the vet prescribed Quadritop. It's anti-fungal and antibiotic and STEROID combined. His nose seems to have improved a bit after using that and some of the dried up skin fell off, revealing healthier nose skin underneath... the cheesy odor has improved as well, but is still present. Do I need to worry that it contains a steroid???

Another note -- the vet said his ears were infected as well. I had noticed there was some debris in them, but he didn't seem bothered at all so I hadn't been worried about it. She cleaned and treated them.

[My sweet Ginger]

I'd definitely feel more comfortable with 15mg, let the 15mg do it's work for 14 days (possibly 30days) and then ACTH. At 30day mark, a small increase if needed. With his weight of 13.5 I wouldn't go up to 20mg just yet. That way you will have a better chance of avoiding an overdose, maybe a little slower getting where he needs to get but safer in my opinion.

[Harley PoMMom]

Dechra states in their product insert that the therapeutic ranges for a dog being treated with Trilostane are 1.5 ug/dl - 5.4 ug/dl and the post can go as high as 9.1 ug/dl if clinical symptoms are controlled. That 1 - 5 range that the vet stated is for a dog being treated with Lysodren which is a completely different medication to treat Cushing's.

If your raising the dose by 5 mg I'd be more inclined to give it with the 10 mg unless it seems that his symptoms start to rebound towards the evening...just my 2 cents worth ;) If Leo's dosage is increased an ACTH stimulation test will be needed in two weeks.

Hugs, Lori

[Budsters Mom]

I am going to play the unpopular card here.:o

Here goes.... If Leo where my dog, I would not raise the Trilo dosage at all at this point. My Buddy is a perfect example of cortisol continuing to drop beyond (and up to)The 30 day mark. When he received his ATCH at the two week mark, his cortisol level dropped some, but still remained high. We did not up his Trilo dosage. After another 30 days, he was tested again. His levels had dropped into normal range without any increase. He then stayed with his initial dosage.

So again, it does happen quite often. If cortisol stays high, it's inconvenient and expensive, but not life-threatening. More testing, more dose tweaking, etc. If it drops too low, you risk an Addison's crisis. I would personally rather go do baby steps with the dosages, then risk a crash. Just my two cents worth.

In response to your question about the steroid containing nose cream. Yes, steroids in any form, can raise the cortisol. in fact, prednisone is generally used to raise the cortisol when it dips too low. Have you asked the vet about this?

Kathy

[Renee]

I'm a bit confused why your vet waited 3 weeks before testing? Standard protocol is to retest in 10-14 days, then again at the 30 day mark. You're somewhat stuck in the middle now, not quite at 30 days, but a bit past the 2 week period to judge how fast the cortisol is dropping.

Be that as it may, given Leo's drastic drop in cortisol in just a 3 week period, I would definitely agree with Kathy and not increase the dosing quite yet.

My opinion is to run a stim test again in another 2 weeks and reassess. I would not make any judgements about efficacy of the dosing in such a short time. The symptoms take time to resolve, even when they are properly dosed.

[My sweet Ginger]

That was my exact thinking in my post #23.

[molly muffin]

Some vets are opting to not test at the 14 day mark now and to test at 3 weeks or even the 30 days. Much more likely if starting at under the 1mg/1lb dosage.
Every dog is different and you did have a quick large drop so no I wouldn't double. Some dogs, most will drop for 30 days. There is usually less of a drop in the last 2 weeks than in the first two weeks. Just from tracking I have done with my dog.

[labblab]

I've thought and thought as to what I'd do if Leo were mine, and I'm going to be contrary to what others here are thinking, but I believe I'd go ahead and add in the additional 5 mg. with the breakdown as you are suggesting. Since he's already being dosed twice daily, I'd give him 10 mg. in the morning and 5 mg. in the evening. Most definitely, I would not double his dose.

This is my thinking...it's true that you are a week away from the 30-day mark and the cortisol may still drift downward a bit even if you leave the dose unchanged. I would have been happier to have waited until 30 days to make a dosing change, too. But I would expect that you've already witnessed the far larger drop within these first three weeks. I just don't expect to see Leo continue to drop enough on this dose in one more week to put him in therapeutic range, and far less likely for him to plunge down to a level of oversuppression (<1.5). He still seems pretty capable of cranking out the cortisol -- even his pre result is awfully high (8.9). Not that weight is a consideration right now since test results and clinical signs are the monitoring tools once treatment has started, but by adding in 5 mg., he would be getting 15 mg. in total for a dog weighing approx. 14 pounds. That's actually the place where many folks might have started dosing.

I know you watch him like a hawk, so I feel comfortable that you will catch any outward signs of overdosing. So I think I'd add the 5 mg. now and retest in another 2-3 weeks.

Marianne

[Harley PoMMom]

NEED DOSAGE ADVICE!
Leo just had his second ACTH Stim after 3 weeks on 10 mg/day of Trilostane, and based on his results the vet is recommending doubling his dosage to 20mg (10mg 2x per day).




Can you clarify Leo's Vetoryl dose for me? According to the post above Leo is being dosed once a day. However the initial post does state that Leo was getting his Vetoryl twice a day. :confused:...thanks!

[labblab]

Lori, I think Leo is currently getting 5 mg. twice daily for a total of 10 mg. each day.


He started on Vetoryl (trilostane) 8 days ago.
DOSE: 5mg, 2x per day. (he weighs 14.5 pounds)


I guess the issue is that Leo takes 2 doses... which are supposed to be 12 hours apart but he eats around 8am and 6pm... So I'm wondering if it's better to do the 12 hours and have his second dose 2 hours after his dinner, or with the meals even if if means NOT 12 hours between doses...

Marianne

[LeoLove]

Thanks so much to everyone for the input. This is such a great resource and I'm amazed how much time people take to weigh in, because Cushing's really can be difficult and confusing to manage.

I just noticed that in my initial post I said Leo's weight was 14.5 lbs, and in my more recent post (following his last vet visit) I said 13.5 lbs... but I think the 13.5 was a bad weigh -- because I'm pretty sure he's filled out. Before going on trilostane he was losing weight rapidly and was skin and bones (even though he was eating a normal amount).

To clarify in case it wasn't clear, Leo has been getting 5mg of trilostane TWICE a day.

Since starting the cream for his nose, which contains a steroid, I think I've noticed his symptoms return slightly... not sure what to do about that.

But I'm thinking of increasing trilostane to 15mg/day.

The breakdown would be 10mg in the morning and 5mg in the evening.

His symptoms are definitely still present and yes, I am very much in tune with what's going on with him, so hopefully I would notice if anything was wrong.

That brings me to another question... is an "addison's crisis" permanent? I know it can easily be life threatening, but it can be reversed, correct?

[molly muffin]

I look at an Addisons crisis as being just that a crisis, which can be recovered from. In that you go low, but you aren't going to be permanent Addisions.
That being said, the difference between a crisis and going permanent, may not be too far apart, so that is why you have to be so vigilant. You never want to get to the point where electrolytes are affected by being too low in cortisol as that can be life threatening. This isn't said to scare you but to let you know what you have to be on the watch for, diarrhea, vomiting, wobbly can't stand, refusing to eat, not drinking, those things or a combination of those can be warning signs.

That also being said, as Marianne mentioned at 3 weeks into dosage, you've Probably seen the largest drop already but may have a bit more too.

I am not a fan of doubling, but at 15.2 you still need it to go down more. If you decide to raise I'd only do the 5mg, that is my preference though.

[labblab]

Here are my thoughts about Addisonian issues ;). Dogs who are being treated with medication for Cushing's can experience either temporary or permanent adrenal oversuppression. An initial "crisis" can look the same, either way. The question is whether or not the adrenal glands recover sufficient function to rebound.

The mechanism by which Lysodren erodes adrenal tissue is well understood, and if too much of the adrenal cortex is eroded, this results in a permanent Addisonian condition. Some vets in some countries purposely use Lysodren in this way, in the belief that Addison's is easier to manage than Cushing's. Here in the U.S., vets do not typically aim to erode the adrenals to that extent -- only enough to reduce adrenal oversuppression while leaving general function intact. But this is why dogs who are treated with Lysodren must be monitored very closely, especially during the initial loading phase, to make sure the drug is dosed in an appropriate manner. Dogs treated with Lysodren can also experience just a temporary Addisonian state if too much tissue has been eroded but the adrenals still retain the capacity to rejuvenate. You never know at the outset of an Addisonian event, though, whether the rejuvenation will occur. You just have to wait and see.

Basically, the same is true of trilostane. If an Addisonian condition occurs as a result of overdosing, you have to wait and see whether or not the adrenal glands recover their function. There are differences from Lysodren, however. One is "positive" in my mind: worldwide clinical experience indicates that permanent oversuppression occurs less often with trilostane. The more typical scenario is that adrenal function rebounds after the drug is simply discontinued for a period of time and redosing begins at a lower dose. However, the other difference is not so positive to me: when permanent adrenal oversuppression does occur with trilostane, it appears to be the result of adrenal necrosis due to a mechanism that has not yet been explained. So there are question marks as to what it is that has happened in that situation, and why.

For these reasons, we tell folks that overdosing has to be closely monitored no matter which medication is being used. For both, Addisonian episodes are more likely to be temporary and reversible. But for both, the adrenal changes can turn out to be permanent, and in the event a dog is overdosed, only time will tell whether or not that is the case.

Marianne

[LeoLove]

Thanks for the info on addisons crisis.

As I said I plan to increase his dose from 10mg/day to 15mg/day... instead of doubling it as the vet suggested.

I'm a little concerned because he started having accidents the past week and a half or so. It seems to correlate with starting him on the cream that contains steriod...

[LeoLove]

So frustrated!

Leo's seemed to be improving after 3 weeks on 10mg/day of trilostane.

But he started drinking again constantly and now has to pee every 2-3 hours. On advice from the vet, I upped the dose to 15mg/day but nothing has changed.

I was sure he had a UTI but a urine culture came back negative...

Does anyone have any insight as to why this might be happening?? The peeing seems worse now, not better.

[Harley PoMMom]

Has diabetes been ruled out? It's not uncommon for a cushdog to suddenly become diabetic.

[LeoLove]

His tests from November and December showed no indication of diabetes... I don't think that's it, but could have him tested again if it can come on that suddenly.

Any other thoughts?

[Harley PoMMom]

Is the increased drinking/urinating all day or does it seem that they rebound in the evening?

[molly muffin]

I would also have a complete kidney profile work up as that too can change in a matter of months. Bun, Creatinine values, etc. Just make sure that is still okay and yes diabetes can come on suddenly.

[LeoLove]

There seems to be a new problem... within the past 2 weeks or so Leo appears to have developed calcinosis cutis. Nothing is erupted... but there are hard white bumps all along his spine. They don't seem to bother him at all, and his hair doesn't appear to be falling out there, but I'm worried they might erupt and then I'll have a very bad situation on my hands.

I've made an appointment with Dr. Bruyette who I've heard is an expert... but not for another week and a half. I'm concerned it might even get worse between now and then.

I've read through some threads on calcinosis cutis, but not really sure if it's curable. Anyone?

I've also read that Lysodren is better for dogs with calcinosis cutis, but he's been on trilostane for almost 2 months... it's not like I can just switch easily, right?

So frustrated!

[molly muffin]

Well if it is cc (calcinosis cutis) then they usually do come up and out. They are hard calcium deposits and yes, once cortisol is controlled and the skin and hair follicles go through their cycles (this can take months) then as long as the cortisol is kept low enough, hopefully no new ones or very few will develop.

We have seen on here that to get rid of and prevent new formations, a post cortisol of under 5.0ug is normally best.

Yes, Dr. Bruyette is considered one of the experts in cushings. We often recommend people who are in his area to go to him.

[LeoLove]

It's definitely calcinosis cutis.

It started with the hard bumps under Leo's skin.

Now some of it has turned black and scabbed over in some places... it's hard to see because it's all under his fur, but when I dig through I can see the scabs separating form the skin. Does this mean it might be healing? It hasn't bled or oozed, and doesn't seem to bother him (although he's a bit lethargic, so I'm guessing he's not feeling great).

My main question -- is the scabbing over indicative that the cc might be going through the heeling process? I'm not picking at them at all... just letting them be. I suspect he'll lose hair when they fall off... but not sure.

I've looked through the posts on cc and found useful info, but again, not sure if the scabbing means it's worsened, or if it's healing.


Any insight?