Blue diagnosed last week/ just started trilostane

[aintnuthinbutahounddog]

Hi everyone! My 13 year old mixed breed (hound/lab/heinz57 variety) aka "Blue" was recently diagnosed with Cushing's. I don't yet have his diagnostic info but can tell you that his ALP enzymes were high (his last senior panel was 6 months ago and all levels were normal) which prompted the Dr to do a LDDS. His baseline corstiol was 10 and at 8 hours it was 4 (unfortunately I don't remember his 4 hour #). His urine was also diluted. His regular vet confirmed the diagnosis as positive (which to be honest, was not a major surprise as I already suspected Cushing's) and recommended we start him on trilostane at 120mg -- he weighs 60lbs. Before starting treating, we went and saw an internist who specializes in Cushing's after the diagnosis. He said that based on the results and Blue's appearance he is "the poster child" of Cushing's. I had no reason to think Blue was misdiagnosed, but he is a nervous dog who lives in a somewhat agitated state and was stressed during his LDDS so I was concerned that his cortisol levels wouldn't have been accurate. Both vets assured me that because he suppressed at the 8 hour range, this was a definitive case of Cushing's - more specifically PDH. The internist agreed with the method of treatment prescribed by our regular vet so I started the trilostane at 120mg once daily yesterday and we will go back for ACTH in 10 days. So far, so good in terms of no noticeable side effects but I guess my question is -- and I know every dog is different -- but what should I be on the lookout for (besides diarrhea, vomiting, lethargy, appetite loss) and how long does it typically take to see results? My understanding is that the excessive thirst and urinating go away in a few weeks, but what about the panting and restlessness? As I mentioned, Blue has always been anxiety prone, but aside from the other symptoms he seems pretty spry for a dog his age. He loves walks, races me down the driveway, can still jump up in the car and on the couch and has normal energy levels -- but he no longer wants to be petted (except for a head pat) or cuddle and is pretty vocal about that.

One other thing I wanted to mention -- like other Cushing's dogs, Blue has gotten into the trash on several occasions in the last few months. He's always had a voracious appetite, but he seemed extra defiant in his quest to sniff out anything to eat. At the same time, he stopped eating his regular food (Honest Kitchen Grain free) which he used to love. I started giving him a mix of kibble (Instinct Raw Boost) and the Honest Kitchen (powder mix that you add water to) and he started eating happily again. Why would a dog who is constantly hungry go on a hunger strike like this? It seemed as though he just didn't like his regular food anymore bc he would eat anything else I gave him. He also has gained about 5 lbs since we started the kibble mix so I'm going to decrease his amount a bit. I actually started to notice most of his symptoms around the time we switched his food, so I thought perhaps it had something to do with the change. Another strange thing that happened the night before I took him to the vet to get his blood tested -- he was drooling profusely out of one side of his mouth. His bed was wet and his entire right side of his mouth was soaked and water was dripping as if he had a faucet inside. The vet checked and there was nothing lodged inside his mouth to prompt the drooling -- and neither vet knew what would cause it. It stopped a few hours later but seemed very odd at the time.

Thanks for reading this long post. Any advice on what to expect, what to be on the lookout for, and any thoughts on diet and drooling are much appreciated. It's hell watching them get old but I'm glad to know there's treatment and a community of folks with lots of info to help keep our dog's comfortable in their golden years.

[DoxieMama]

Hello and welcome to you and Blue! I'm so happy to read that you have consulted with an internist, though I am still a little concerned about the starting dose recommended. The current recommendation of the manufacturer of Vetoryl (Dechra) is to start at 1mg per pound (technically, FDA approval was at 1-3mg per pound, starting at the lowest possible dose within the range... ) so I'm curious why they chose to start at 2mg per pound with Blue.

You are giving the dose in the morning immediately following his meal, right? Be sure to do so, especially on the day of the ACTH (hopefully they mentioned that to you).

The side effects you noted are what I've learned to watch for as well. I think the cortisol levels are the lowest anywhere from 2 to 6 hours after you give the morning dose... my own dog was a bit lethargic approximately 2 hours after his breakfast when we started, but that resolved after a few days. His thirst and urination decreased within the first week or 10 days. I can't speak to panting or restlessness as he didn't have those symptoms.

I'm sure others will be along to provide their feedback - and maybe more questions for you.

Again, welcome, and I look forward to getting to know Blue. He sounds like a great dog. :)

Shana

[aintnuthinbutahounddog]

Thanks Shana. I originally read that the dosage was 1-3mg per lb but have now seen in other posts on this forum about the 1mg per lb recommendation, so was curious about that myself. One of the reasons I went to see the internist is bc I wanted to see if he was also ok with that dosage. The internist is Dr. B and he has written quite a bit of the research that's available today about Cushing's so I feel as though he would be up to speed on the latest dosage guidelines for Vetoryl. Nevertheless, it's a good question and I'll inquire with him about that.

Today is Blue's second day taking Vetoryl. He was a little late wandering over his food bowl for dinner yesterday but still finished all of his food. Otherwise, I haven't noticed any side effects. Do side effects generally show themselves in the first few days or after a few weeks? One thing neither dr. mentioned is the need to have prednisone on hand, but his regular vet is 10 min away and open 24 hours so maybe that's why...?

[judymaggie]

Welcome to you and Blue! I am going to be a little bit stronger than Shana was in her concern -- I am extremely concerned that Blue will be starting on a dose twice that recommended. Even though I am not surprised when vets are not aware of the change as not all vets are up to date on the latest treatment of Cushing's but I am very, very surprised that Dr. Bruyette is still dosing at that level.

Here is a link to several articles regarding treatment with Vetoryl (trilostane) -- please take some time to read them, in particular those in the second post which discuss the downward dosing:

http://www.k9cushings.com/forum/showthread.php?t=185

There is actually an article from a discussion with Dr. Bruyette where he recommends starting all dogs at 1 mg./lb. The article is from 2013 and that dosing level is more widely recommended now. After reading the articles, there is absolutely nothing wrong with you contacting Dr. Bruyette and asking him why he is recommending the 120 mg/day for Blue. There is also nothing wrong with telling him that, based on the reading you have done, you would feel much more comfortable if you changed Blue's dose to 60 mg./day.

It may very well be that Blue would eventually be on a higher dose than 60 mg/day but, one of the advantages of using trilostane to treat Cushing's is that you can move the dose up slowly (if follow up tests warrant it) in order to avoid any side effects.

On the same page cited above, there is an excellent flow chart from Dechra which will help you understand the dosing and testing:

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

I am not able to address the drooling -- will have to do a little research on that. Hopefully, others will come along who can offer some suggestions in that regard.

With regard to your question about when side effects can occur, they can occur at any time -- you just need to be vigilant.

[aintnuthinbutahounddog]

Thanks for those links. I emailed Dr. B and will keep you posted on his response.

[aintnuthinbutahounddog]

Dr. B said he's good with the dose of 120mg once daily so I'm going to stick with that. So far Blue is doing well so we will see. I'm not the kind of person who puts blind trust in my dr's, but I also respect that their education and experience make them far more qualified to make decisions about medicating my dog than my 1 hour of googling and research does. I feel very fortunate to have such good dr's looking out for Blue's health and appreciate your concern, but I'm going to go with the experts on this one. Thank you kindly for your support.

[DoxieMama]

I won't argue with that. Just please be absolutely diligent in watching for signs of overdose (as I'm sure you are already).

Also, please keep us updated on how Blue is doing! :)

[judymaggie]

Hi! Dr. B is absolutely an expert in the field of endocrinology. I would still be curious why he is going with that dose ... anyhoo, glad that Blue is doing well.

[Harley PoMMom]

Dr Bruyette's recommendation of 120 mg for a 60 lb dogs is very confusing to me especially since his most recent peer reviewed article, which was published April/May 2016, states that:
Trilostane is well tolerated in most dogs. Adverse effects are usually mild and self-limiting, and include diarrhea, vomiting, and lethargy in up to 63% of treated dogs.8,9 However, the percentage of dogs that develop adverse events is much lower when they are treated with current recommended (lower) starting doses. Current recommendations for trilostane use specify administration of an initial dose of 1 to 2 mg/kg Q 12 to 24 H. :confused:

This article (Part 3: Current & Investigative
Options for Therapy) can be found here: http://www.k9cushings.com/forum/showthread.php?p=189827#post189827

Hugs, Lori

[Renee]

Sorry to highjack your thread here ..

But, I must confess my great disappointment in Dr B recommending a higher starting dose like that. :( I have tried reaching out to him lately about my own cush-dog to little avail. I can only assume he is incredibly busy with his research and whatnot.

I hope Blue tolerates this higher dose. You are scheduled to check his levels in 10 days?

[molly muffin]

hmm, I find it strange also.
That being said, just watch for the signs mentioned above, diarrhea, lethargy, not wanting to eat, vomiting and have a stim (ACTH) done at around the 12 - 14 day mark. Sooner if you have any concerns and see where his cortisol is at. What ever it is, you wouldn't raise the dose until after 30 days as you can expect it to continue to drop for at least 30 days on the same dose.

You are looking for a post result between 1 - 5ug and up to 9.ug if symptoms are controlled.

[aintnuthinbutahounddog]

I'm sorry but I don't understand why you guys would be disappointed in my vet. He's a great dr. who has written a lot of the research that has served you all in understanding your dog's diseases. Obviously there is no magic dosing guideline and it takes some calibrating and finessing on the parts of trained veterinarians based on lab results and feedback from their owners. It seems very odd to me that you would want to malign my vet for using his expertise and judgment in choosing a starting dose and insinuate that he doesn't have my dog's best interests at heart. I honestly regret mentioning his name on this board as I would never want to paint him in a negative light, neither privately nor publicly.

I came here looking for information and support on what to expect now that my dog has been given his diagnosis, but based on what I've read and the responses I've received by some -- there does seem to be a tendency to be mistrustful of our veterinarian caregivers to the extent that some of you think you know what's best for a dog you've never examined, whose lab results and medical history you have knowledge of, and without, I presume, a degree in veterinary medicine.

While I am grateful for your feedback and concern as I realize it most likely comes from your own personal experiences and desire to be helpful, it is highly unlikely that I will be posting here again, and if someone could kindly point me in the direction as to how I can both delete this thread as well my account, I would be most grateful.

[Renee]

Please don't go away. I can probably speak for everyone on this board when I say that not a one of us is intending to personally attack you or Dr B at all. I realize this disease is very, very stressful, and I am sorry you are getting the brunt of what is a lot of head scratching on our part in regards to Dr B's dosing recommendation.

Dr B is HIGHLY respected by all of us on this forum. Many of us have reached out to him about our own dogs and we often use his peer reviewed articles to educate pet parents that are new to the disease. Even though he has personally not been too helpful with my own cush-pup, I still rely on much of his work and am excited by the research he is doing. I have read almost every article he has written about this disease and I would never malign or insinuate anything negative about the work he has done or continues to do.

One of our biggest education points is helping people begin the treatment process as conservatively and safely as possible. This means a starting dose of no more than 1mg/1lb. This overwhelmingly decreases the risk of adverse affects. We rely on Dr B's own peer reviewed statements in regards to the safest starting dose for vetoryl. When he personally contradicts it in one of his patients, it surely does cause a lot of confusion on our part. None of this is meant to attack you. I suppose we are all just very surprised by this turn of events.

[DoxieMama]

I don't think any of us are disappointed, rather just confused at the starting dose recommended for Blue. I just went back and reread all the comments here in your thread and I don't see anything that is painting him in a negative light at all. As Renee said, Dr B is highly respected here, and his recommendation for Blue doesn't change that.

As for the tendency to be mistrustful, my own personal opinion is to be cautious, recognizing that though they may have a degree and even experience with Cushing's dogs directly... they are still human. They can and have made mistakes. Having a second (or twelve) other sets of eyes to check and triple check things is not a bad thing, unless it interferes with our own decision making ability.

Blue is your dog, and you are the only one who can truly make decisions for him. Not Dr. B, not me or anyone else here... You. We will support you in whatever decision you make. And as you said, we're just interested in sharing our own experiences and knowledge, providing what support we can.

I sure hope you change your mind about withdrawing from the forum, but if that is your decision, I wish you ... and Blue ... well.

Shana

[molly muffin]

I've consulted with Dr. B concerning my own dog and followed his recommendations. No one here has ever maligned Dr. B, nor would we. We refer members to him and to Dr. Peterson all the time.

No we aren't vets and we are not making a treatment recommendation, other than to stat what the manufacturer of the drug, Dechra, recommends and is stated in their most recent published literature.

I think our over abundance of caution comes not only from personal experiences but from having hundreds of members who have gone through the same things and not all of them have had successful outcomes, although many many do, so here at least, we always let members know what the manufacturer recommends and what to watch for in the case that a dog has a bad reaction, sometimes this is caused by starting too high of a dose. There is no way to predict how a dog will or will not react to any medication, so being aware of the warning signs is a simple precaution.

What you or anyone else does as far as treatment or no treatment, is their decision. The key is to be an informed pet owner so that you are able to make decisions and have discussions with your vet. That is what we help people do, gain knowledge.

[Harley PoMMom]

I totally agree with what the others have said and if I, in any way, made you feel that I am bashing Dr. Bruyette or made you feel uncomfortable in posting here I am truly very sorry...please do not leave us, we are here for both you and Blue and are here to help in any way we can.

Again I am so sorry.

Hugs, Lori