Lowering Trilostane Dose

[BuzzyToes]

Haley will be 13 next month, diagnosed with Cushing's close to two years ago. She has been on a steady dose of 60 mg of Trilostane every morning and has been doing fine until recently. She has been losing great gobs of hair so I thought maybe it would be time to check her levels again today. She had her test this morning, four hours after her dose, and her steroid level was less than .05mc/g (I didn't get the exact number, but the vet said basically it was unmeasurable because it was so low). We are lowering her dose to 30 mg and rechecking in two weeks, with the stim test. Just wondering how common it is to LOWER the dose of meds in Cushings dogs? I had a Chem 10 done as well and all of those numbers were normal. At her age, I am just worried that this is a bad sign and not a good one.

[judymaggie]

Hi and welcome to you and Haley! First, congrats on successfully treating Haley. I wanted to respond to your concern about the need for a lower dose for Haley. This is not uncommon. I am going to provide you below the link to Dechra's (manufacturer of Vetoryl) technical brochure. On page 10 you will see their reference to this issue:

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

However, Dechra does recommend that all Vetoryl be stopped for seven days after a post-ACTH of less than 1.45 ug/dL occurs. Then the lower dose would be started. Even though you reported that the chem panel results didn't show any issues with potassium or sodium levels (which can happen with cortisol levels that have dropped too low), I would be more comfortable if you gave Haley a break before restarting. I am sure our Admin Staffers will be along and they may have additional insights into this practice.

It will help us to guide you if you could provide us with some more details about Haley's situation. Is this the first time she has lost her coat? (It is actually not unusual for this to happen with our Cush pups -- often the new coat that comes in is of a different consistency). How often have you been testing her cortisol via ACTHs since you first started treatment? Does she have any other health conditions and, if so, is she on any other medications?

Looking forward to learning more about Haley!

[BuzzyToes]

Thank you for that info!! I feel completely comfortable with my vet, but will be sure to call Monday asking about stopping completely and restarting.

I try to get her in once per quarter to have her blood done, but in reality it's probably between 3-6 months. She was diagnosed around July 2014 and I think this is the fourth or fifth time we have tested. Always with normal numbers, but this is the first time I had heard about the four hour window, so now I wonder how accurate her other results were. This is the first major amount of hairloss. She sheds a normal amount, has fine hair that sticks to you, but this is different. She will get up from laying down and a small clump of hair will be left behind. I vaccum one day, and two days later there will be ten small clumps of hair around. I can actually feel her skin now when I comb her, instead of just fur. No bald spots yet though. She is a pound puppy, but a Cocker mix of some sort. Her DNA test came back Aussie and Cocker.

[judymaggie]

Hi--my experience has been that my vet is much more receptive when I bring up things from experts in the field or companies like Dechra rather than info learned from an internet group. You know your vet best so decide how to approach him/her.

What ACTH testing protocol has your vet been following?

Also, for your info, your vet can call Dechra directly and discuss their recommendations. You can call them also but they seem to prefer discussing technical issues with vets.

[glfprncs]

Just an FYI...when my boy, TC (50 pounds), was on Vetoryl, he started on 60 mg/day, we went to twice/day dosing when symptoms didn't decrease, and eventually his cortisol dropped so much that we went to 20 mg/day. His cortisol kept dropping, dropping, dropping, even on the lower dose, but his Cushing's symptoms kept increasing. We were stumped.

I've read somewhere (don't know if it was in this group or in another group I'm in), that SOMETIMES, Vetoryl can increase the 2ndary hormones secreted by the adrenals (atypical cushing's) which can mimic those of pituitary and adrenal type cushing's disease. This was the case with my boy. We switched him to lysodren and it was smooth sailing for almost 2 years.

[Harley PoMMom]

She had her test this morning, four hours after her dose, and her steroid level was less than .05mc/g (I didn't get the exact number, but the vet said basically it was unmeasurable because it was so low).

Could you clarify her post stimulated number for me, I'm thinking that it is .5 ug/dl? If her cortisol is that low Haley is in an Addison's crisis, which can be life threatening, and it is vital that she have a supplemental steriod such as prednisone because her adrenal glands are not producing enough cortisol for her body to function properly. I am very worried about your girl please keep us updated.

Hugs, Lori

[BuzzyToes]

Could you clarify her post stimulated number for me, I'm thinking that it is .5 ug/dl? If her cortisol is that low Haley is in an Addison's crisis, which can be life threatening, and it is vital that she have a supplemental steriod such as prednisone because her adrenal glands are not producing enough cortisol for her body to function properly. I am very worried about your girl please keep us updated.

Hugs, Lori

Ugh I just had a long response typed out and hit refresh on accident. At any rate, I gave Haley her morning meds, and they did the test four hours later. It is just listed as a "cortisol" test, and my understanding is the stim test takes eight hours? At any rate, other than the hair loss, there are no other symptoms or anything out of whack. Same appetite, drinking, peeing, pooping, etc. She has gone stone deaf but I imagine that is just a product of of her old age. :) I am a worrier so I tend to take them to the vet over the slightest thing, and I have noticed no change in her at all.

[Harley PoMMom]

Ugh I just had a long response typed out and hit refresh on accident.
I've lost long posts in that way too, so now I type them into wordpad first and then just copy and paste. ;)



It is just listed as a "cortisol" test, and my understanding is the stim test takes eight hours? At any rate, other than the hair loss, there are no other symptoms or anything out of whack. Same appetite, drinking, peeing, pooping, etc. She has gone stone deaf but I imagine that is just a product of of her old age. :) I am a worrier so I tend to take them to the vet over the slightest thing, and I have noticed no change in her at all.

Generally an ACTH stimulation test takes no more than an hour to perform. I am glad and relieved to hear that she is acting normally.

Hugs, Lori

[labblab]

Hmmmm...it is making me wonder whether they only performed a baseline cortisol as opposed to a full ACTH stimulation test. If that's the case, you really cannot draw any firm conclusions from the results.

It will be really, really helpful to us if you can get the actual numerical results for any monitoring cortisol tests that have been performed to date. I know it's a pain, but the info will help us a great deal!

Marianne

[Dawn Anderson]

I agree with Marianne, need to have a proper stim test performed, I am also concerned with the fur loss, I would have them do a biopsy on the area AFTER and only AFTER the stim test has been performed to see if your pup has started to develop what is called calcinoisiscutis what we call CC. Please post her results as soon as you get them so that we as a team can help you and your baby

Dawn
Buttercups momma

[molly muffin]

The LDDS test is the one that takes 8 hours and that isn't used once treatment starts. The ACTH usually has a pre and a post, the pre is done when they first get there to check resting cortisol, then an hour later, they draw the post, after the stimulating agent is given that causes them to dump whatever is in their adrenal glands.
If that is a post ACTH, then definitely you should stop and wait for symptoms to start to come back and then restest. Electrolytes should also be tested. If that is just the pre, without a post being done, then it doesn't really signify what the adrenal glands are doing, other than that her body did not have hardly any cortisol in it when the pre was taken. (that is usually not great either and is especially concerning and could be life threatening, if the post is also low, but with just one number it is impossible for us to really tell what is going on)

Let me know if that doesn't make any sense when you read it.

I do have concerns that she is very low both pre and post, with the hair globs coming out like that and yes, if that is the case, completely stop medication, wait, retest, start at a lower dose, is the protocol.

The brochure link that Judy posted, will help to explain it and you can even print that out, take it to your vet and discuss.

What did the vet say today?

[labblab]

Ugh I just had a long response typed out and hit refresh on accident.

Just wanted to direct you to this thread because it may help prevent typing losses like you experienced earlier. Believe me, we've all been there and done that, and it makes us all crazy when it happens! :rolleyes:

http://www.k9cushings.com/forum/showthread.php?t=1329

Marianne

[molly muffin]

Checking in to see how Haley is doing?