New member Brodie - Questions about treatment

[catgerry1]

I am so touched by your message. It's pretty much exactly where I'm at, with Brodie's new diagnosis and my feelings. We've done all the
testing and vet visits and although we weren't sure what we should do about treatment, we gave him the first day's dosage and he had a strong reaction to it. He became much more lethargic, even stumbling when he tried to stand. I felt he was going too far down, if that makes sense, was up most of the night, trying to decide whether or not to take him to an emergency clinic. It's three days later and we're doing alot of researching, including this wonderful resource, and I still can't decide whether or not to restart. I hope anyone who reads this and can give some advice, will be willing to share. All I want is to be able to make the right decision for my dog. He's such a good and loving boy. God bless you and your dog in this scary journey.

[labblab]

Hello and welcome to you and Brodie! You'll see that I've moved your reply so as to begin a thread that is yours alone. This way, it'll be much easier for our members to reply to you directly. ;)

Can you please tell us more about Brodie's overall health history, as well as the symptoms and test results that led to the Cushing's diagnosis? Also, how much does he weigh, and what dose of medication has he been prescribed? Sorry for so many questions, but the more specific you can be, the easier it will be for us to offer our guidance.

Once again, welcome to you both!
Marianne

[Harley PoMMom]

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

Marianne has covered the questions that I would ask and those answers will allow us to provide more meaningful feedback.

Since Brodie had such a bad reaction to the Cushing's medication (I'm assuming this was Vetoryl/Trilostane?) it could be that his dosage was too high or that he is sensitive to the drug. Stopping the medication was definitely the right move and because he seems to be feeling better off the medication I bet one of the two options that I mentioned above was the reason for the adverse effects you observed.

If this were me I would continue to withhold his medication until you have a chance to talk to the vet about this and if the dosage strength was too high you can always restart it at a lower dose. With Vetoryl/Trilostane the recommended starting dose is 1 mg per pound of a dog's weight so if you can provide that information we can than see if the dose prescribed was proportional to what Dechra, the manufacturer of Vetoryl, has stated in their guidelines.

We have a wealth of information regarding Cushing's; the medications used, and treatment protocols, which can be found in our Resource thread and it also includes articles written by some of the most renown veterinarians that specialize in endocrinology such as David Bruyette, Mark Peterson, and Edward Feldman. So please utilize it to educate yourself and if you have any questions do not hesitate to ask them. We all eventually figured out that safe and effective treatment is much easier facilitated if the vet is experienced and the pet owner is educated. Here's a link to our Resource thread: Helpful Resources for Owners of Cushing's Dogs (http://www.k9cushings.com/forum/forumdisplay.php?f=10)

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

[catgerry1]

Hello and welcome to you and Brodie! You'll see that I've moved your reply so as to begin a thread that is yours alone. This way, it'll be much easier for our members to reply to you directly. ;)

Can you please tell us more about Brodie's overall health history, as well as the symptoms and test results that led to the Cushing's diagnosis? Also, how much does he weigh, and what dose of medication has he been prescribed? Sorry for so many questions, but the more specific you can be, the easier it will be for us to offer our guidance.

Once again, welcome to you both!
Marianne

Brodie is ten. He needed a home and came to us at a year old. weighs 89 lbs, down from a healthy weight of ll4. Had cancer on shoulder soon after we got him. Was excised, malignant, but didn't have to have chemo or radiation. Well until two weeks ago, when I noticed lots of panting, drinking and peeing and lethargy. Took him to vet. I'll note the things he had flagged. If you need the others, I can
list them too:
ALT-l59.0
bilrubin-.87
BUN-10.6
cholesteral-373
ALK PHOS-558
glucose-142
anion gap-18.4

NEU%79.6
EOS%0.2

Urine creatinine 27.0
urine cortisol - 4.7

urine
urine cortisol/creatinine ratio

cortisol resting15.90
cortisol post ACTH - 25.00

He then had an ultrsound which showed a mass on his spleen and spots on his liver . Dr. later bipsied it and said it was not malignant and was probably caused by Cushings.
Next visit was given Trilostane, 60mg, 2x a day and a serum biochemistry panel was taken.

He was ok after the first pill and the second really floored him. He was extremely letharic, wobbly legged, panting even more and generally
looked very ill. I stayed up all night with him, trying to decide whether or not to take him to the vet ER. When we finally started out, he got somewhat excited, jumping up a bit, and we decided he wasn't as ill as we'd first thought. I haven't given another pilll yet, hoping to glean more information to help make up my mind. I'm I need to feel he'll not have a repeat of his strong reaction. Vet has said to give one pill a day, skip two days (we've skipped three at this point), the medicate eo day.

I'm very uncomfortable and need most to know how he'll react now and later, if it will be worth taking the chance, what the odds are that e can be better for it, at least for awhile. Any information about the meds and what it will do for him, please.

[tank&kat]

I am sorry Brodie isn't doing well on the medication. For an 89 pound dog, 120 mg sounds like too much for him. There are studies that show larger dogs weighing more than 25 kg (55 pounds) need lower doses on a per kilogram basis to control clinical signs. It makes a lot of sense that he didn't start to feel bad until you gave the second dose.

I would talk to the vet about starting restarting only when symptoms return or if an ACTH can confirm his cortisol levels are within normal/high range. Did the vet mention any abnormalities with the adrenal glands on the ultrasound? Normally, dogs with pituitary Cushing's have one gland that is larger than the other. If you have those results, it would helpful if you could post them here as well.

I know you would be hesitant to start him on this drug again but I genuinely believe the dose was too high. Does Brodie have arthritis or any other medical issues? I would also be interested in hearing about his symptoms that led you to believe he had Cushing's.

~Kat

[Harley PoMMom]

Thanks so much for additional information about Brodie. I know this is a pain but could you edit your post and add the reference ranges for those lab values...thanks!

Every-other-day dosing is generally not a good option. Since the medication remains active in the body for no longer than 24 hours, skipping a day only sets up a roller-coaster of higher cortisol one day, lower cortisol the next.

This is especially troublesome in terms of trying to interpret the results of an ACTH stimulation test. If the test is performed on an "off" day, the results will be higher; if the test is done on a day with the med, the cortisol level might even be lower.

60 mg of Vetoryl twice a day is quite high for a dog weighing 89 lbs. Dechra recommends a starting dose of 1 mg per pound so for Brodie's weight of 89 his dose should not have exceeded 89 mg. As Kat has mentioned, larger dogs may require lower doses than small dogs so you may want to drop that dose down considerably, say around 20 mg. The one down side in starting out so low is there may be some extra tweaking needed to get his cortisol down to the therapeutic ranges, but the consequences of overdosing can become life threatening so I always err on the safe side.

I want you to know that Cushing's is not a death sentence and with proper treatment, a dog can have a great quality of life and there is every reason to believe they will live out their normal life expectancy.

Safe and effective treatment requires an experienced vet and an educated pet owner and it is when one or both is missing that dogs get into trouble.

Vetoryl/Trilostane is a strong drug, and yes, it does have some pretty scary side effects, however, adverse effects are minimized when the proper treatment protocols are followed. We have many members that are treating their cushdog with Vetoryl/Trilostane and are experiencing success.

We certainly understand that you may have some apprehensions in restarting treatment but you are not alone and we will walk this journey with you. If you have any questions please do not hesitate to ask them.

Hugs, Lori

[dsbailey]

catgerry1,

Just as a reference my girl was 57 lbs and was started on 60 mg once per day, that was too high and her cortisol levels dropped way low within one week. After a week off the meds we restarted her on 30 mg once a day and have been working in the 30 mg to 35 mg range to get things right. As stated by others 120 mg was too high of a starting dose. I think I would start at 30 and work my way up from there if necessary. All dogs are different.

Good Luck - Darrell and Lolita

[labblab]

Hello and welcome from me, too! I'm also sorry about Brodie's bad reaction and totally agree with the others about a concern that his trilostane dosage was simply too high. When cortisol levels are lowered rapidly, dogs can suffer from a reaction known as "corticosteroid withdrawal." This does not necessarily mean that they cannot tolerate the drug at all, but instead that their bodies must be given time to lower the the cortisol level more gradually.

Since you already have the 60 mg. capsules on hand, I am going to depart from the recommendations of the others and say that, if Brodie was my dog, I'd be inclined to go ahead and start back with a single 60 mg. capsule once daily in the morning. If I am understanding your vet's instructions properly, this is the pattern he intended for you to follow after an initial "trial" period of one 60 mg. capsule followed by a couple of days off. I have to assume this is in order to see how Brodie does, in fact, respond to the 60 mg. dose before continuing with daily dosing.

There is certainly nothing wrong with starting back with even a lower dose as the others have suggested. But 60 mg. does not seem like an unreasonable starting dose for a 90 pound dog. If Brodie again exhibits ill effects similar to before, however, I'd again stop the drug immediately and consider even a lower dose as the others have said. The saving grace is that is sounds as though Brodie did start bouncing back from the higher dose within a few hours. This is what is generally expected since the drug does exit the body for most dogs within 12 hours of dosing.

Marianne

[Squirt's Mom]

Hi and welcome to you and Brodie!

Like the others, I think that starting dose was probably too high, BUT my concern is the diagnosis itself. Since we already know a malignancy is in play it is entirely possible that has reared its ugly head again and has caused false-positives on any and all testing for Cushing's. Elevated cortisol is one of the body's natural responses to stress, internal or external, and cancer is most certainly a stressor. If I were you, especially in light of the response to one pill, I would first concentrate on the possibility that the cancer has returned. I pray that is not the case but I would not feel right recommending that you continue treatment for Cushing's at any dose without making this suggestion. My own cush pup came to this journey with positives on all tests - but it turned out she had a tumor on her spleen and once that was taken care of, her cortisol returned to normal. So I KNOW without question it is very possible that non-adrenal conditions can and do lead to incorrect diagnoses of canine Cushing's. ;)

I'm glad you found us and look forward to hearing from you again soon. One thing to keep in mind - you and Brodie are now part of our little family here at K9C and we will walk every step with you from here on.

Hugs,
Leslie and the gang