Twigs - Newbie on Vetoryl

[rossanav]

Hi, I have an 8 year old, 5 lb. Chihuahua/Yorkie mix who was just diagnosed with Cushing's last week. They have ordered compounded Trilostane for her that should arrive tomorrow and we were going to start then. Unfortunately she developed vomiting and lethargy a couple days ago that seems worse today. I just got back from vets office. They gave her fluids and a shot for the vomiting and pills and special food for vomiting. They told me to hold off on starting the Trilostane until she is not vomiting and seems more energetic (she's very lethargic today.) He said it would probably be a week before we start.The did a test for pancreatitis and it was negative.

I am a bit nervous about the Trilostane because of all the negative things I have read but I want to do what is best for her and am hoping that it will go well so she can have a good quality of life and be with us longer. I wanted to join this board and tap all the wisdom of experience here with regard to Cushing's and also what to look for to tell me she is not doing well with the medicine and if it needs to be stopped or she needs to see the doctor ASAP. Afraid I will miss something and she will have a crisis and not survive. Twigs (her name) seems better since we got home and hopefully she is on the mend from whatever is causing this.

Would love feedback from folks who have been on Trilostane and know what a bad reaction looks like. Fortunately I am retired and home a lot as are other family members so she will not be alone too much. We want to really be on top of things so she won't get into trouble. The vet scared me a little bit about the medicine and the negative potentials. Happy I found this board!

[DoxieMama]

Welcome to you and Twigs! I'm sorry I only have a moment to post, but I wanted to let you know you've found a great source of information and support. :)

Can you tell us a little more about Twigs, especially what symptoms brought you or your vet to test for Cushing's, what tests were done to diagnose and the results of those? The more information you can provide, the better we can help you support Twigs.

I look forward to learning more about her!

Shana

[kanga]

Welcome to the both of you! Sorry to hear about what happen to your baby don't have any experience about that, but there's a lot of member here that will help you and give you some advice. Hope you find the answer soon. You are always in my thoughts I pray for her.

[rossanav]

Hi Shana,
Twigs started looking skinny and bony in spite of good appetite. She also seemed to have thinning hair. Tummy got large and bloated looking. Drinking excessively and peeing everywhere which was very unusual for her. Took her in for testing and found her to be hypothyroid and vet was suspicious that she might have Cushings. First did a urine test for Cushing's that was positive, then did th ACTH test which was also positive. She started vomiting about 3 days ago but none since yesterday when vet gave her fluids and a shot for vomiting. She was sent home with Cerenia pills for vomiting and the ID Prescription food. I am expecting the Trilostane to arrive in the mail today from the pharmacy but vet said to hold off for about a week until we are sure she is no longer vomiting. He tested for pancreatitis yesterday and it was negative. She has been on thyroid medicine and thyroid levels are normal now.

[rossanav]

Thank you Kanga, we appreciate the prayers.

[judymaggie]

Hi and welcome to you and Twigs! We appreciate your adding more details to Twigs' history. In order to offer our best guidance to you, it would be very helpful if you could give us the actual test results. If you don't have hard copies of those, please ask your vet for them. Aside from providing us with info, it is a good idea to keep a file of test results to help you see patterns and, should Twigs ever need to see a specialist or need to go to a 24 hour emergency hospital (hopefully, never!), you would have all that info in one spot.

With regard to blood tests, you need only type the test information for levels that are marked "H" for high or "L" for low along with the test name and range. For example: ALK Phosphatase 1020 (H) (range 5-131).

Urine tests will also show highs and lows or for "protein" will indicate a number, i.e., 3+ (High).

Specific Cushing's tests may have 2 numbers for the ACTH, a "pre" and a "post". The initial urine test that Twigs had was probably a UCCR (urine cortisol creatinine ratio test) and results may have three numbers (first is the cortisol, second is the creatinine and third is the ratio).

Since cortisol levels are very sensitive to whatever else is going on, results can be skewed by, for example, untreated hypothyroidism or an infection. How long was Twigs on thyroid medication before the Cushing's tests were completed? Also, how soon after the tests, did Twigs' start vomiting?

What is the dose of trilostane that your vet has ordered? The current recommended dosing for trilostane is 1 mg./1 lb. Since Twigs weighs 5 lbs. and a 5 mg. Vetoryl tablet is available, I am curious why your vet is having you give Twigs compounded trilostane. It may be that your vet is trying to save you some money as compounded trilostane can be less expensive that brand name Vetoryl.

Your vet's guidance to not start trilostane until all signs of illness are gone is exactly the correct thing to do and am so glad that pancreatitis was ruled out. Is Twigs' eating her regular food now? Since Trilostane/Vetoryl needs to be given after a full meal, it would be best to wait to start until her appetite is back to normal. Has your vet talked with you yet about monitoring tests? Here is a link to a pamphlet from Dechra, the manufacturer of Vetoryl -- page 11 has a great flow chart which shows the timing of follow-up tests as well as what to do depending on the results:

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

Below is a link to Dechra's Client Brochure. Page 6 has a listing of possible side effects:

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

Has your vet given you any prednisone to have on hand should Twigs have a negative reaction to the trilostane? This is good to have should this happen when your vet's office is closed.

Sorry for the long post -- others will be along to catch anything I missed. Hang in there -- we are all here to support you and Twigs!

[lulusmom]

Hi and welcome to you and Twigs.

Many of the physical and clinical symptoms of hypothyrodism overlap with cushing's and both cause the boney appearance and distended abdomen you mention. Poor Twigs has a double whammy. :(

Since a urine cortisol creatinine ratio nor an acth stimulation test tells you whether the dog has adrenal or pituitary dependent disease, did your vet do an abdominal ultrasound or other differentiating test to make that determination? The majority of dogs have pituitary based disease so the law of averages says that's what Twigs has; however, if she were to have an adrenal tumor, her prognosis could be much different. Some pet owners opt out of differentiating testing because surgery, which is the first line of treatment for an adrenal tumor, is not feasible. The good news is that Vetoryl is very effective in treating both.

When was Twigs diagnosed with hypothyroidism and placed on supplementation? Did your vet run a full thyroid panel or did he base the diagnosis on the T4 hormone only? I ask because if the low thyroid and cushing's diagnosis were both confirmed in a relatively close period of time and a full thyroid panel was not done to rule out sick euthyroid, cushing's could be the reason for the low T4. A lot of vets are very comfortable with diagnosing low thyroid based on T4 and putting a dog on trial supplementation to see if symptoms resolve. That is a very common practice but that is probably also why it is one of the only canine disease that is more misdiagnosed than cushing's. I am bringing this up with you because if that were to be the case for Twigs, once her cortisol is reduced with treatment, the thyroid supplementation could throw her into hyperthyroidism. Symptoms of hyperthyroidism are excessive drinking and peeing which can muddy the waters when trying to get cushing's under control. I've seen it happen many times. My first cushdog had both conditions but the diagnoses were confirmed almost two years apart.

It would be very helpful if you would please get copies of all testing that was done to diagnose Twigs and share the results with us. With respect to the blood chemistry and complete blood count (CBC), we need only see the highs and lows and please include the normal reference ranges.

Twigs has been through a really rough time of it and I hope she is feeling much better. I love her name and I'm dying to know how she got it.

Glynda

P.S. I see that Judy posted while I was trying to get my post typed in between interruptions at work so I apologize for any duplication.

[rossanav]

Thanks so much for the information. Luckily my vet owns the local 24 hour emergency. It is him and his 2 partners office during the day and then at 6:00pm and on weekends the 3 rotate who covers it. I have seen all 3 of them many times over the last few years so I am comfortable. Twigs was on thyroid for a month before the urine test and the ACTH. The thyroid was picked up a little over a month ago on the "senior panel" we did on her before scheduling a dental cleaning. Haven't done that dental yet! Assuming that can wait until she is stable. After finding hypothyroid and some unusual liver values and her symptoms, it made him suspect Cushing's. He put her on thyroid and said we would retest everything a month. Her thyroid was perfect at the one month retest but still peeing and drinking like crazy and liver values were still off. Kidney values were normal so he didn't think it was a renal issue and suggested urine test for Cushing's as a starting point. When that came back positive he ordered ACTH which was also positive. I don't know the values but I will ask for copies of the test results.

He said treating was a choice I would have to make and he is not a huge advocate of treating since other than peeing too much she doesn't seem to be bothered by it at this point. His partners, both young vets in their early 30's (he's probably mid-40's) think I should give the medicine a shot. I do like them both very much too, Especially the female vet who saved my little toy poodle about a year ago when he almost died from severe diarrhea.

I am anxious about the treatment but also anxious about doing nothing too. Would like to prevent the bad complications of Cushing's if possible. A 5mg starting dose was ordered and we did talk about the retesting in 2 weeks and then I think in 1 month if Ok and then 3 month etc. We also talked about having prednisone on hand in case of problems and that dosing of Trilostane could have to be adjusted at anytime as things change. He also said we could stop treating if we changed our mind or things didn't go well. Not sure why it is being compounded, maybe for economic reasons as you said. We ordered the smallest amount which is a 30 day supply and it is $30.00 plus $7.00 shipping from New Jersey. I am in Southern California.

As far as Twigs today, she seems to be back to herself. She has always eaten just about anything that wasn't nailed down and even when she was vomiting she still gobbled down the food. There has been no more vomiting since the injection he gave her yesterday and she is enthusiastically eating the prescription ID food he put her on. The Trilostane should arrive in the mail today and I will hold off for another week like he suggested to make sure she is well from whatever was causing the vomiting. Can I put the Trilostane in her food when we start it? She will definitely gobble it down that way.

I will post her test results when I get them from the vet. Thanks so much for your help. I am hoping I am making the right decision to treat her. As the vet said, if it works well you will be thrilled, it's when the problems arise that it can be scary.

[rossanav]

I know the vet ordered a Free T4 after the initial thyroid test showed it was low. I was wondering about the Thyroid too and if the Cushing's caused the thyroid or if she was hypothyroid independently. Seems like maybe we should do another urine for thyroid after she is stable on the Trilostane and see if she still needs. As far as Twigs name, she came with it and we liked it so much we kept it. We have 4 toy breed rescue dogs and Twigs came to us when she was 8 months old and was found as a stray out in the rain. She's a Chihuahua/Yorkie mix (Chorkie according to the vet) and has long hair that sticks out all over and looks like twigs. The rescue named her and we thought it fit so we kept it. I have been trying to figure out how to post a photo but so far haven't managed it.

[molly muffin]

Not starting the trilostane until she is not vomiting or having any other issues is a good plan. Never give triostane to an ill dog who is already vomiting as that is one of the symptoms of over dose, so you do want to be sure.

I agree that after being on trilostane, it would be a good idea to recheck that thyroid and make sure it wasn't low due to the cushings and it is possible the thyroid meds won't be needed going forward.

Liver values like ALKP being high are one of the common things we see with cushings, but you do want to keep track of all test results so you can refer back to them and see what progress is being made or where something may not be reacting as you would expect. Many of us keep our own file once cushings is diagnosed as we refer to them quite often. The ACTH is another one you want to know and be able to refer to and see how she is responding to the trilstane.

How much does Twigs weigh? (love that name btw) I'm guessing just over 5lbs, as the starting dose is 1mg/1lb with trilostane.

[rossanav]

Twigs was 4.8lbs. yesterday. She used to have a weight problem for most of her life but about a year ago started losing weight. Still haven't figured that one out completely, Cushing's perhaps? The hypothyroid should have made her gain weight but it didn't. We have been feeding her more but can't seem to get her to put on weight.

[molly muffin]

My dog too has lost weight over the past year. I think mine though is due to kidney issues. Sometimes though it is hard to keep everything balanced. Like a high wire walk on a very narrow rope.

[Harley PoMMom]

Hi and a belated welcome to you and Twigs!

I have a couple thoughts ;)



A 5mg starting dose was ordered and we did talk about the retesting in 2 weeks and then I think in 1 month if Ok and then 3 month etc. We also talked about having prednisone on hand in case of problems and that dosing of Trilostane could have to be adjusted at anytime as things change. He also said we could stop treating if we changed our mind or things didn't go well. Not sure why it is being compounded, maybe for economic reasons as you said. We ordered the smallest amount which is a 30 day supply and it is $30.00 plus $7.00 shipping from New Jersey. I am in Southern California.

Dechra, the manufactures of Vetoryl in which the active ingredient is Trilostane, produce 5 mg capsules, so this strength can not be compounded. Is the compounding pharmacy using Vetoryl as it's base for the capsules, or has the brand-name Vetoryl been ordered?


Can I put the Trilostane in her food when we start it? She will definitely gobble it down that way.



Yes, you can put the capsule in her food, but you want to be completely sure Twigs is getting the capsule in her system because Trilostane has to be given with a meal to be properly absorbed.

Carbs can help with weight gain, such as pasta, potatoes, etc..

Hugs, Lori

[rossanav]

Trilostane came in the mail today and they are pills, not capsules like I thought. They are 5 mg. and are scored so I can divide them and give half in morning and half at night which the vet says can sometimes be better. Twigs has recovered from whatever was causing her vomiting and vet wants me to start on Tuesday morning so she has a week of no vomiting before we start. Thanks for your help. I am going to try mixing more carbs into her food to see if she can gain the 1 lb. back that she has lost over the last year. Vet wants me to keep her on the prescription food for awhile after we start the medication to hopefully help keep her stomach settled. She tends to be a "barfy" kind of dog but I want to be able to monitor it carefully once the medicine has begun for signs of trouble.

[rossanav]

Glad to hear Twigs is not the only one with the mysterious weight loss. I can see this is going to be a balancing act.

[molly muffin]

That is good that they are scored and you can divide them, with capsules you can't. I rather wish I could sometimes :)

Just watch fat content with carbs, as you don't want to risk pancreatis which our cushing dogs are prone to.
Moderate fat, good protein, in whatever form is usually what you will eventually want, once the prescription is through with.

[judymaggie]

Hi! Since Twigs tends to lean toward vomiting, I would suggest you ask your vet about giving her Pepcid AC (original) about 20 minutes before each meal after which she will be getting the trilostane. This will help her digest the medication. I get generic Pepcid in a big box store very cheaply. Since Twigs is so tiny, I do not know what the appropriate dose would be -- your vet can guide you in this regard. My Abbie weighs 24 lbs. and she gets 5 mg. twice a day.

[rossanav]

Thank you for the good advice!

[rossanav]

I have an 9 year old chihuahua/yorkie mix that is finally stable on medication after months of dose adjusting. Taking 20 mg Vetoryl once a day which I understand from my vet is a large dose for a tiny dog. She is also hypothyroid and on levothyroxin twice a day. I am having a hard time keeping weight on her. She started out at 6 lbs. but over the last year is down to 4.5. She eats voraciously so that is not a problem. Has anyone had any success with the high calorie supplements that are on the market? I have been feeding her large amounts of food and adding more calories where I can but still not enough. Any suggestions would be welcome.

[Squirt's Mom]

I have merged your post about high calorie supplements into Twigs' original thread. We like to keep all info about each dog in one thread. That way it is easier for us and you to look back thru the history if needed. I also took the liberty of changing the title to include Twigs' name and treatment. Thanks!

[rossanav]

Thanks, I am not so great at figuring out how the forum works. A bit internet challenged!

[molly muffin]

Hi again.

What was her last acth test results and has she had any blood work and urinalysis done? It might be something else causing the weight loss.

You can add innthings like pasta to her food. Carbohydrates and see if that will help.