Stanley the Dachshund

[AHall123112]

Hello! I'm Ashley and my 12 year old dachshund Stanley was diagnosed with Cushings in December. He's shown symptoms since we adopted him in May 2014, but his blood work always came back okay until Dec 2015. Since then we have had to adjust his dose multiple times, but we've always had to decrease it instead of increase it like most Cushings dogs. Just a little about his dosages for those of you who are familiar with Cortisol levels and dosages and curious about the rollercoaster that Cushings can cause.

Symptoms throughout 2015- unmanageable hypothyroidism, elevated liver values (ALT got to over 400 so he was started on Denamarin and Ursodiol after negative ultrasound and ACTH Stim test to check for Cushings), waking multiple times throughout the night to pee, excessive drinking, aggression especially around mealtime, pot belly, and skin issues (we shaved his belly for the ultrasound in March 2015 and his hair had still not grown back by December 2015)

December 2015
ACTH Stim test again
Cortisol level 6.8- diagnosis of Cushings
Started 10mg Trilostane every morning
Dscontinued Ursodiol after liver values improved significantly after starting Trilostane
Maintained blood levels through January, but symptoms started getting worse again (waking up multiple times throughout the night to drink and pee) so we switched to 5mg morning and night.
Discontinued Denamarin

Blood levels maintained through end of February 2016
At this time he began acting very lethargic, was peeing all the time and would drop urine. He acted like he felt awful, and this went on for 2 days.
Rechecked cortisol and he was at 0.8 (normal level is 2-4) so basically he was in adrenal crisis. He also had a severe urinary tract infection which he did not have a month prior.
We discontinued Trilostane for a week and he cortisol rebounded to 5.2
Restarted Trilostane at 2.5mg (now liquid dosage) morning and night
Urinary tract infection was very resistant and took 3 different antibiotics to clear
Cortisol levels maintained from end of March 2016 to end of June 2016

June 2016
Seemed to be acting a little more lethargic so I took him in as soon as I noticed
Cortisol dropped to 1.46 (again range is 2-4)
Reduced Trilostane to 1.5mg morning and night
We will recheck this next Wednesday so fingers crossed!

It's also worth mentioning that before his cortisol dropped both times he had received acupuncture (which he gets quarterly for his back) less than a week prior. I am still trying to figure out if that is just a coincidence or if it is a trend.

Sorry for the long post, but this is such a weird disease and I am trying to figure it out as best I can so I can take care of my boy. I hope others might benefit from what I've provided as well!

[DoxieMama]

Ashley, hi and welcome to you and Stanley. You and your husband are angels for adopting a senior dog!

We had somewhat similar issues with our dachshund when we started treating him with Trilostane, having to reduce the dose to find the right one. Are the results you've provided for cortisol the Post ACTH numbers?

Your thoughts regarding the acupuncture sound feasible to me, though I'm far from an expert. It seems if Stanley is experiencing pain from his back, that would raise his cortisol levels... then if the acupuncture alleviates that pain, his natural cortisol would be reduced.

Don't worry about the length of your post. We appreciate having as many details as we can!

Shana

[AHall123112]

Thank you for the warm welcome! I'm so glad to know I'm not the only person who has had to decrease doses. I was prepared to increase over time as the disease progresses, but it's been quite strange to me to have him stable on one dose for a while and then have to decrease it.

As far as the acupuncture, that's definitely a view I hadn't considered in regards to pain relief lowering his levels! He hasn't had any back problems since early 2015, but he does have a touch of arthritis in his front legs. We do quarterly acupuncture with him and two of our other dachshunds for maintenance.

The only ACTH test we did was the initial one if I remember correctly, though we might have done a follow up one after his levels stabilized the first time. The rest have been resting cortisol levels. They are relatively cheap so I don't hesitate to get him checked out if I have even the slightest feeling something is off. I'm a nurse so I tend to notice little changes pretty easily!

How long has your baby been on the Trilostane?

[Renee]

The only ACTH test we did was the initial one if I remember correctly, though we might have done a follow up one after his levels stabilized the first time. The rest have been resting cortisol levels.


Sorry, hold the phone -- your vet has been dosing with vetoryl and not running an monitoring ACTH?!

Yikes. Huge, huge, and very dangerous break with protocol. In no way, shape, or form can the efficacy and safely of vetoryl / trilostane be monitored by using resting cortisol values.

I have concerns for Stanley and for you. It is imperative that your vet either smarten up, or you find a new vet that knows how to treat cushings disease, if in fact Stanley even has cushings.

[DoxieMama]

Hi again Ashley. As Renee said, you really need to have a full ACTH test done per the manufacturer's recommendations to determine just what impact the Trilostane is having on Stanley. The resting cortisol doesn't do it. I know it's cheaper, but it is not a replacement. You also want to have electrolytes tested at the same time (which is pretty inexpensive in comparison).

[AHall123112]

We have been regularly monitoring his cortisol levels, but not with the full blown ACTH Stim test which uses the injection to stimulate cortisol production. We did the ACTH Stim test for his diagnosis, as well as the two times we have changed his medication dose to ensure it was stable (I didn't think we had done it that many times, but in looking back through my paperwork I can see that we did check it after each side change). My clinic has 4 veterinarians who all consult on cases, and we also see his acupuncturist who is at a different clinic in town and they all seem to agree with the testing methods we are using. The serum cortisol is measured 4.5 hours after his morning medication at least every 4 weeks- sooner if I feel he is not acting himself. I definitely appreciate your input though and I will speak with my veterinarian to ensure we are using the appropriate testing methods! My main concern is making sure he is taken care of. He's been doing great on the medication with the exception of the minor hiccups to keep his levels within range. Thank you for your feedback!

[AHall123112]

Out of curiosity, how often do you all have your dog's cortisol levels checked using the ACTH Stim test?

We check his electrolytes regularly as well and they have always been great (knock on wood) even when his cortisol was very low.

[Harley PoMMom]

Hi and welcome to you and Stanely from me as well!

As the others have mentioned it is critical to have the full ACTH stimulation test performed when monitoring cortisol levels while a dog is being treated for Cushing's.

The resting cortisol is really of no value because it will fluctuate during the day.

According to this published study:
RESULTS:

Baseline cortisol concentrations had considerable overlap between excessively, adequately, and inadequately controlled dogs. Only baseline cortisol >4.4 μg/dL (in 12% of tests) was a reliable diagnosis of inadequate control. Endogenous ACTH concentrations did not differ between groups. The overlap of the cortisol/ACTH ratio between groups was large. Correct classification was only possible if the cortisol/ACTH ratio was >15, which occurred in 4% of tests.

CONCLUSIONS AND CLINICAL IMPORTANCE:
To monitor trilostane treatment the ACTH stimulation test cannot be replaced by baseline cortisol, ACTH concentration, or the cortisol/ACTH ratio.

http://www.ncbi.nlm.nih.gov/pubmed/23701195

Regarding how often an ACTH stim test should be performed, I'm providing this excerpt from Dechra's product insert, Dechra is the manufacturer of Vetoryl (Trilostane):
4. Long term monitoring
Once an optimum dose of VETORYL Capsules has been reached, re-examine the dog at 30 days, 90 days and every 3 months thereafter.

At a minimum, this monitoring should include:
• A thorough history and physical examination.
• An ACTH stimulation test (conducted 4-6 hours after VETORYL Capsule administration) - a post-ACTH stimulation test resulting in a cortisol of
< 1.45 g/dL (< 40 nmol/L), with or without electrolyte abnormalities, may precede the development of clinical signs of hypoadrenocorticism.
• Serum biochemical tests (with particular attention to electrolytes, and renal and hepatic function).
Good control is indicated by favorable clinical signs as well as post-ACTH serum cortisol of 1.45-9.1 g/dL (40-250 nmol/L).
If the ACTH stimulation test is < 1.45 μg/dL (< 40 nmol/L) and/or if electrolyte imbalances characteristic of hypoadrenocorticism
(hyperkalemia and hyponatremia) are found, VETORYL Capsules should be temporarily discontinued until recurrence of clinical signs
consistent with hyperadrenocorticism and ACTH stimulation test results return to normal (1.45-9.1 μg/dL or 40-250 nmol/L).
VETORYL Capsules may then be re-introduced at a lower dose.

Here's a link to Dechra's product insert:Dechra's U.S. Product Insert (http://www.dechra-us.com/Admin/Public/Download.aspx?file=Files%2fFiles%2fProductDownload s%2fus%2fvetoryl-5mg-pack-insert.pdf)

Those ACTH stim tests are expensive because of the stimulating agent. Cortrosyn is generally the stim agent used and another cost savings would be for the vet to reconstitute the Cortrosyn. Dr Peterson, who is a renown canine Cushing's expert, states on his blog on how this can be done, here's an excerpt from his blog:
Cortrosyn is expensive. And once reconstituted, it has a limited shelf-life.

However, by following the protocol outlined below, you can easily dilute, aliquot and store Cortrosyn after reconstitution for up to 6 months. This makes each ACTH stimulation test much less expensive, because each vial of Cortrosyn can be used to perform as many as five ACTH stimulation tests. http://endocrinevet.blogspot.com/2011/03/how-to-extend-your-supply-of-cortrosyn.html

I am sorry for the reasons that brought you here but so glad you found us and we will help in any way we can.

Hugs, Lori

[AHall123112]

Thank you for this information Lori! I will definitely speak with my vet about it. We have always drawn the serum cortisol at exactly 4 hours and 30 minutes after his morning medication dose, and we always use the same laboratory (Texas A&M Veterinary and Medical Diagnostic Lab) to keep as much as we can consistent. It is also the same lab that has processed his ACTH Stim test values. I worked for this vet for many years a while back and I remember what a hassle Cortrosyn was to deal with! I will pass along the article you included with the information regarding the reconstitution. My vet is wonderful and she is the type to contact more experienced veterinarians if she is having an issue or would like to learn more about something so I know she will appreciate this information! And if this is something new to her then it will be shared with the other 3 veterinarians she works with which will help even more animals!

Thank you again!
Ashley

[AHall123112]

Something else I just found in his paperwork is that we used the Dexamethasone suppression test after his initial ACTH Stim test showed inconclusive results.


Forgive me for being scatterbrained, but I have 8 dogs and 2 cats almost all of which are seniors and require medical monitoring so it gets a little much when I'm trying to remember who had what! I'm in the process of documenting their testing and results in an Excel spreadsheet to keep better track, but I have to go back a couple of years!

[Harley PoMMom]

You're not scattered brained at all, I know how hard it is to keep the records straight for my 1 dog and cat, and you have 8 dogs and 2 cats!!! OMGoodness :eek:

Just post those LDDS test results when you get time.;)

Hugs, Lori

[AHall123112]

I have an appointment tomorrow to meet with my veterinarian as well as the practice manager for the clinic to discuss the concerns about using a serum cortisol 4.5 hours post-prandial/medication instead of always doing an ACTH Stim test. I will also be getting the results for each of his tests, and my sweet sweet husband is currently making an Excel spreadsheet so I can log everything more easily!

TBC... thanks for the input!

[kanga]

Don't have any information to give! Hope you find some helpful information soon good luck!

[DoxieMama]

EIGHT dogs AND two cats?!! :eek: I bet your house is fun. :D

I use an Excel (type) spreadsheet to keep track of things, too. And I only have one dog with medications and tests to keep track of!

Please do keep us updated on how Stanley is doing. :)

[molly muffin]

Okay so it does sound like you did a full ACTH both times you changed dosages from what you said right?

The thing about resting cortisol is that it goes up and down throughout the day and so Dechra doesn't pay that much attention to the resting or pre ACTH result, with the important number being the post number, as that determines how much cortisol is in the adrenal glands and in storage so to speak. The stimulated post result is when the adrenal gland like a sponge dumps the cortisol into the body and they can then determine how much is actually being made and store by the glands. That is what dosage adjustments are based upon.

Hopefully that helps explain it a bit as to why we all go a bit haywire when we think dosages are being determined on solely baseline results.

Once your dog is on a stable dose, you don't have to have acth done as often unless you notice a change in your dogs behavior. Our next test will be 8 weeks after the last one. We've gone 3 months at the longest.

[Renee]

Checking in :)