My Annie - need advice

[kellyjade]

Annie is a 14 year old lab/pit ix, about 50 pounds. Late last year, we noticed a marked increase in her water uptake, raiding the trash can, and having accidents - all new behaviors. After many rounds at the vet, we finally got a cushings diagnosis (Pituitary Dependent) based on low and high dose suppression testing and ultrasound.

In the past month and a half, we have tried unsuccessfully to get the right dosage of medicine. vet started her on 60 mg of vetoryl, which caused her resting and stim cortisol to drop below 1. We cut back to 30 mg of trilostane (pharmacy compounded in drops so it could be given 15 mg twice a day). Resting level still below 1, though stim was above 1. Cut back to 15 mg total, divided 7.5 and 7.5 in the morning and afternoon. Her test a week after this dosage was good, 1.3 and 2, respectively, and she was definitely drinking less and seemed to be perkier. Vet wanted to test after 10 days again, and called this weekend to say her resting level had dropped below 1 again and to stop.

We are trying to figure out what to do - we're almost to the point where dropping it would mean such a teeny dose. At the same time, even having her off it for a few days now, I am noticing an uptick in the water drinking. The vet said some dogs are just super-sensitive to trilostane. At this point in time, given her age, im wondering if we should just not medicate her, as im worried about doing more harm than good.

I would love to hear any thoughts, this is all new to me. She has never had any health problems before, and even as an older dog has always had lots of energy. it is breaking my heart to seeing her slowing down, although I knew this would eventually happen. I just want to do what is best for her quality of life.

To that end, I have switched her to Instinct Wet food because I read a wet, grain-free diet might be good for Cushings - any thoughts on that? Also, any tips as to how to handle the accidents, which make life hard for all of us? my husband and I both work, we have taken to leaving the back door open so she can go out during the day, although that is not an ideal situation.

thanks so much!

[Whiskey's Mom]

Hi! I really understand what you're going through, especially your last 2 paragraphs. My dog Whiskey was always healthy(never had any vet visits other than yearly checkups until the past year), and he has so much energy for an older dog too.
I'm new to the forum so I cant give advice, just support. It's all so overwhelming. Whiskey doesn't have accidents in the house anymore and he doesn't drink huge amounts of water, but it was a problem in the beginning. We got the generic absorbent pads with the blue plastic backing used for people, they were cheaper than the dog ones. They didn't always solve the problem, sometimes we would duct tape them to his favorite spots but often he would pick a different place to lay anyway. We went through LOTS of paper towels, and tried to stay calm so we wouldn't upset the poor dog. We never tried doggie diapers, I doubt he would have kept them on anyway.
As far as feeding, We are having some issues too so like you I'm hoping for advice. Hopefully you will get Annie's dose adjusted soon so you all can get some relief. By the way, my name is Annie also!:o

[Harley PoMMom]

Hi and welcome to you and Annie!

I've only got a moment to post (I'm at work:eek:) so I'm sorry this post will be so short.

You did the correct thing in stopping Annie's Trilostane when her cortisol has dropped too low and then restarting her at a lower dose. So I'm in agreement with the vet that Annie might just be sensitive to the Trilostane and she needs yet a smaller dose, we have seen this happen before.

For the accidents, some members use doggy diapers and lots of pee pads.

As for the diet, a high quality protein, moderate fiber and low fat is what is recommended, however the diet should be tailored to that individual dog's health needs.

I'll try to get back later on, hang in there.

Hugs, Lori

[labblab]

Hello and welcome from me, too. I'm really sorry you're having such a tough time getting your girl regulated, and I do understand why you are rethinking the whole concept of treating at all.

If Annie were mine, before throwing in the towel, I believe this is what I would want to try. First, I would shift to giving the trilostane only once in the morning with breakfast. Some clinicians do prefer twice daily dosing, but the maker of Vetoryl still recommends once daily as the starting point unless owners see symptom rebound later in the afternoon/evening even when mid-day cortisol levels seem to be optimal. For some dogs, the drug's effect wears off quickly enough to allow cortisol to increase again more quickly.

But not all dogs metabolize the drug that quickly, and at least one noted endocrinologist, Dr. David Bruyette, has warned us that dogs dosed twice daily run a greater risk of having their cortisol levels drop too low, I presume because their cortisol is never allowed to really rebound at any time within a 24-hour time period. So given Annie's experience whereby she consistently drops too low, I'd want to try once daily dosing. FYI, here's a quote from a reply that Dr. Bruyette posted here some time ago for our benefit:


Both good questions. With regards to once vs twice a day dosing if we look at all the studies throughout the world you will see that about 80% of dogs do well with once daily dosing. One huge advantage of once daily dosing is owner compliance which goes up substantially when owners only have to dose once a day. While twice a day dosing may result in a lower amount of trilostane being used per day it will require closer monitoring as the ACTH stimulation tests tend to be lower so we have to look for both hypocortisolemia and electrolyte abnormalities.

Dave Bruyette DVM DACVIM

Secondly, given Annie's history and since this may be your final try, I believe I'd restart her on 10 mg. Vetoryl capsules instead of the liquid compound. There is nothing scientific or researched about what I'm going to say next, but it just seems to me that members here who have used liquid preparations more often complain of dosing and testing inconsistencies. Whether it might be that the liquids have shorter shelf lives or the medication is more difficult to distribute evenly throughout the suspension, I do not know. But if it were me and this was my last try with Annie, I'd want to revert to the brand capsule where I had greater confidence that she was getting the exact dose in a researched form. And since the 15 mg. daily total was too much for her, I'd start first with one 10 mg. capsule in the morning.

I am not a vet, so this is just my personal opinion. But this is what I'd discuss with my vet if Annie was mine.

Marianne

[molly muffin]

Hi, I just want to say hello and welcome to the forum.

I can't add anything to what Marianne said as I think she has some very good thoughts on where to go with Annie, if her cortisol comes back up. Once a day and do pills rather than liquid and see how she does.

How is she doing now?

[kellyjade]

thank you all!

I did speak with the vet again - we are going to try her on the once a day dosing, the vet actually wants to start her back on only 6 mg. I'm going to give it one more try and test again in two weeks, see where she is.

The vet also mentioned that some of the problems i'm seeing with accidents - when she wakes up in the morning, her bed is usually wet, and sometimes there is a small amount of "leakage" on the floor where she lays - could be general incontinence seen in older female spayed dogs. She is recommending we try Incurin to see if that helps - any thoughts?

thanks so much for all the insight and support!

[Whiskey's Mom]

Actually, Whiskey has the "leakage" you speak of at times also, but its definitely much much less since he hasn't been drinking so much, and his bed hasn't been wet in the morning for a long time. My vet also said it's mild older age incontinence, I see a few drops where he's sleeping or if he gets up really quickly a few drops come out. We are not medicating him for it at this time, its not that bad and we'd rather not add another pill to his day.

[judymaggie]

Hi! I was not familiar with Incurin -- I had treated my last beagle with Proin and then "Leaks No More", the latter working great! I looked up Incurin and the Merck Manual mentions:


Incurin is contraindicated in dogs showing polyuria secondary to polydipsia, or in pregnant dogs.

It also says that Incurin can have a side effect of excessive water drinking. I fully expect your vet having looked up all of this but this medication would not be my first choice with a Cushing's pup.