Elli Belly Vetoryl dosage Question

[puhmuckel]

Thank You for allowing me to join this forum. I have already learned a lot. I have a Bichon and her name is Elli. She is approximately 13.5 years old and has had a really busy year. She has multiple benign growth and an benign anal tumor removed, had a dental that resulted in a oro nasal fistula with partial repair (no drainage). She did well until she became very sick and after many tests was diagnosed with pyelonephritis and acute kidney failure. She was hospitalized in for fluid therapy and was on Baytril for 60 days.

At that time , she has an AbD U/S that showed enlarged liver and adrenals as well. She also had a heart murmur grade 1-2. After she stabilized we saw an increase in liver enzymes, along with incontinece and drinking a lot (has been for a while). She was tested for cushings using the 8 hour test with results below. Endogenous ACTH shows Pituitary origin.

Meds : She is on Enalapril 2.5 mg bid, Amlodipine 2 mg qd

MD started her on Vetoryl 5 mg twice a day and she is 14 pounds. My concern is that when the 14 day ACTH will be done will be results be off because she is only receiving 5 mg on that morning and the blood will be drawn 5 hours later. With the short half life of the drug would more precise results not be achieved if she received 10 in the am and then the test results be more accurate. Please help.

Thank You

Dex Suppression test pre 3.1 4 hours 2.3 8 hours 2.3

Chemistry Results
Glu 107
BUN 52
Crea 1.3
Phos 5.3
Ca 11.3
TP 7.2
ALB 3.6
Glob 3.7
ALT 539
ALKP 312
GGT 39
Cool 273
AMY 857
LIPA 1364
NA 150
K 4
CL 112
Ohm CALC 312

CBC ABNORMALITIES ONLY POSTED
LYM .89
PLT 666
MPV 7.3
PDW 7.7
PCT 0.49

[Harley PoMMom]

Hi and welcome to you and Elli!

I have manually approved your membership so now all your posts will be seen right away. Also, please just disregard the validation email that was sent to you from k9cushings. ;)

I am so sorry you and your dear girl have been through so much and how is she doing now?


Dex Suppression test pre 3.1 4 hours 2.3 8 hours 2.3

I'm at work so I only have a moment to post :( I am quite concerned with your precious girl's diagnosis for Cushing's. Those results you posted are from a low-dose dexamethasone suppression (LDDS) and it is considered the "gold standard" test for Cushing's, however, any non-adrenal illness can create a false positive result so was Elli completely well before the LDDS test was performed? As far as the adrenals being enlarged other underlying illnesses can cause that too.

Increases in drinking/urination are hallmark symptoms of kidney problems, are her kidneys functioning properly now?

Also, could you edit your post and include the normal reference ranges for the those values listed? Thanks!

The ACTH stimulation monitoring test is performed 4-6 hours after the Vetoryl is given with a meal with the mornings being preferred, even when dosing with Vetoryl twice a day.

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

Hugs, Lori

[puhmuckel]

Thank you for your Response...yes Elli has been completely well when those tests were taken. She also had the endogenous test that pointed towards pituitary origin.

Elli has a pot belly , a rat tail and sparse hair on her trunk. Her Creatine has returned to normal, only BUN is elevated. Only her liver enzymes are now elevated.

I am afraid the giving the half dosage that the morning dosage is only 5 mg so the test will give a false low reading. Not sure....

She has been on the med for 3 days and is going very well thus far. Thanks again for responding to my long post.

[labblab]

Hello and welcome from me, too! I just want to reassure you that testing after giving the usual 5 mg. in the morning is the correct thing to do. You are wanting to know what the cortisol reading would typically be at that time on every normal day, and the only way to find that out is to follow the same regimen on testing day that you follow every other day. You are not wanting to falsely skew the test reading, and by suddenly shifting to 10 mg. on the morning of the test, you'd be doing exactly that. You'd be risking lowering the cortisol more at testing time than is normally the case, and thereby perhaps falsely concluding that the total daily dose needs to be altered. Since every dog metabolizes the drug on their own time table, you want to know exactly how your girl's current dosing schedule is affecting her cortisol level during the time period that each 5mg. dose is having its maximal effect (4-6 hours after each 5mg. dosing).

Hope this reassures you re: the testing schedule.

Marianne

[puhmuckel]

Yes that answers the question well. Thank you

[puhmuckel]

Thank You all for this group that has helped me learn so much about the cause of action to take with my little Elli. She was kept in a closet when I rescued her 9 years ago. She is a one person dog and the ruler of two other bichons and deserves the best I can provide. I wished there was a group like this when my Winki died suddenly of a pheo tumor. I had to put him down at UC Davis 3 days after diagnosis.

Little Elli has been on Vetoryl 5 mg twice a day and she is 14 pounds. She is 13 and a half years old and since treatment she has stopped drinking loads of water and has stopped peeing in the bed or leaking in the house. She eats slowly and is more picky. Somehow she still seems very frail and has some hind weakness that has not really improved. She is more alert and more there wanting attention then before. We have our first test scheduled on Wednesday. I know she only gets a mini dose but I wonder if they look at the lab results for control or control of some symptoms in titrating dosage. I am somewhat concerned at how frail and small she looks but at almost 14 years old this may be just old age.

[Harley PoMMom]

I have taken the liberty and merged your latest post with your original thread so as to keep all of Elli's history in one place. ;)

How the dog is feeling, acting, and the symptoms should always be taken in account when a dosage adjustment is being considered.

What has me a bit concerned is her eating, has she always had a picky appetite or is this something that started with treatment?

Hugs, Lori

[puhmuckel]

Thanks for responding......she was not a picky eater before but perhaps so in the last 3 month or so along with weight loss of 3 pounds. I am worried that there may be another issue.

[Harley PoMMom]

If the appetite change coincided with the start of treatment than I think that the Vetoryl dose may need to be reduced....JMO ;)

[molly muffin]

It might also be worth it to do retest of the BUN and Creatinine which had been elevated to see if they are staying in a normal range (especially the creatinine) as that can affect appetite too.
It is also true as lori said that the vetroyl dose might need to be adjusted.

[puhmuckel]

Thanks, she is going for her first test on Wednesday at 2 PM. She is actually getting a baby dosage of 10 mg for a 14 pounds dog. She is holding steady on her weight , still drinks more than the others but stopped leaking and having accidents at night. Thanks al.

[puhmuckel]

Today , Elli has been on her medication for 2 weeks. We went for our first ACTH Test today and we were charged $375. No electrolytes were checked such as Sodium or K. Over the 2 weeks they never checked in with us on how things were going. I am not feeling good about this and I am sure that Elli's dosage will be too low. She is on only 5 mg twice a day and she is 14.5 pounds.

We are seeing an Internist in Berkeley, CA and I am wondering if I should go back to my regular Vet wit the help of this board....

I am also wondering about the price of these tests..

[dsbailey]

Hello,

All pups are different, my girl is 52 lbs and is currently taking 15 mg daily. That must be a super baby dosage. Clinical Signs, ACTH Test Results, and eventually a gut feeling will be how you dose. I just wanted to make that point to clear your mind a bit. "Baby Dosage Tunnel Vision :D"

In Florida our IMS charges $275 for an ACTH Test. My vet charges $210 because he splits the Cortrosyn (ACTH Stimulating Agent) into two doses for my girl, freezing one for the next test. Even for California $375 seems expensive. One question to ask is if they are using Cortrosyn or ACTH Stimulating Gel. The gel is the least expensive, compounded, possibly less accurate, and not a favorite of the group members here.

I may be forgiving about not checking in after two weeks because they started low and seem to know protocol by testing on day 14. The next step to see if they really know what they're doing is for them to not make a dosage increase until the 30 day test. Only if the ACTH test comes back really high and speaking with some of the real experts of this group should a small dosage increase be considered before 30 days. The cortisol tends to drift downward during the first 30 days.

If by chance the results are low according to the report specifying the range for dogs being treated with Trilostane / Vetoryl. Note: It's a different range than for dogs not being treated and also another for dogs being treated with Lysodren. If the results are below the bottom of the range, get an electrolyte test and temporarily stop the Vetoryl.

For future reference whenever in doubt (Diarrhea, Throwing Up, No appetite, or just acting off) stop the Vetoryl until your figure it out. No Harm or major setbacks will occur taking the time to figure things out.

When in doubt ask here or call Dechra they're very helpful and will set up a case file that both you and the vet can refer to.

Sorry for the long post and answering things you didn't ask but there seemed to be a few things not mentioned that may help down the road.

Darrell and Lolita

[Harley PoMMom]

I would definitely call them and request the results of that monitoring ACTH stim test.

You can save money on those ACTH stimulation tests if your vet is open to cooperating. There is no reason why s/he shouldn't so make sure you talk to him/her about splitting the vial of cortrosyn, which is the stimulating agent used in the ACTH stim test. It is the cost of this agent that makes the stim test so darned expensive. Those members with small dogs can capitalize on this savings. You and your vet can read about this on Dr. Mark Peterson's blog for veterinarians, found here: http://endocrinevet.blogspot.com/2011/03/how-to-extend-your-supply-of-cortrosyn.html You can also get the Trilostane compounded which will save money too.

One of the ways that helped me with the expense was applying for Care Credit. It's a revolving credit line that allows you to pay large bills same as cash for a year. This information and other financial resources can be found here: http://www.k9cushings.com/forum/showthread.php?t=212

Hugs, Lori

[puhmuckel]

Oh , thank you all so much for your detailed advice on how to cope with this. The time you take with your response is greatly appreciated and i have read so much and already learned a lot here.

A Vet Tech called me this morning (not the Vet). She gave me the results and it is :

Pre 3.1
Post 8.1 (1-7)

So, she is only mildly elevated and the noted stated that she is very pleased thus far. No dosage increase for 2 weeks and then I am supposed to come back for another test and a senior panel.

This is not the place that would be probably be advocating splitting a dosage. It is an Emergency and Specialty Hospital in Berkley , so you know it will cost. I can afford it , but it is still shocking. I am also afraid that my regular Vet may make a mistake in handling the samples for that test and that during induction I should that there until she is stabilized....thank you again.

Elli is looking pretty good apart from the thin sparse hair on her trunk.
She is more alert and even walks better. Go Elli!!
Looks like that Baby dosage works...

[puhmuckel]

I was anxious for someone to advise me if an
post ATCH of 8.1 should be adequate for meds need to be adjusted to be in the normal range. Can a dog stay on a lower dose if the owner is o.k with current deceased Cushings symptoms or will it cause too much organ damage?

[Squirt's Mom]

Since Elli is in her first 30 days on treatment no dose change is recommended. If after the next ACTH her post # is still out of range and all her signs are not well controlled, then an increase may be in order. But for now, her cortisol can continue to drop for at least 30 days after first starting treatment so I would leave her just where she is for now.

How are her signs? Are the all gone?

[labblab]

Yes, a post-ACTH value less than 9.1 ug/dL is considered to be therapeutic long-term as long as adequate symptom-relief is provided. Elli's cortisol may continue to drift downward even more during the next couple of weeks. But even if not, this current level will be acceptable as long as you are satisfied with her improvement.

It's great that Elli is doing well right now :). And given her age of 13 1/2, I honestly would be more focused on immediate quality of life than slowly progressing organ damage. If she seems to be happier, more energetic, and overtly symptom-free with her cortisol at this level, I wouldn't see a need to press to lower her cortisol any further.

Marianne

[puhmuckel]

Thank You, this is exactly what I was thinking as well. I just needed confirmation on that. I am satisfied with her quality of life; she is no longer drinking all of the time, peeing has decreased and she is bossing the other two dogs around like she is the BOSS. She had a couple of incidents of leaking a bit in the bed at night , but I now put a towel down and most of the days it is dry. So , I will not make an adjustment if she maintains like this. Thank You.

[molly muffin]

It sounds like she is doing very well on this dosage. That's great news and an 8.1ug isn't bad with symptom control at all. Yay!

[puhmuckel]

Thank You all for easing my mind about little Elli.

[puhmuckel]

Last night , Elli vomited mostly bile. This morning she is is slightly shaking but ate all her food. I will be holding her morning dose and go to work. Slightly concerned about this now.

[Harley PoMMom]

A dog vomiting is concerning and withholding the Vetoryl is the right think to do, let us know how Elli is doing.

Hugs, Lori

[puhmuckel]

I held her dosage yesterday but gave the evening dosage and at 6 am, she was wrenching but no vomit. She ate and I gave her the meds and went to work. I have the 30 day follow up labs to be done next week and I am wondering if I should get them done on Friday or Thursday one week early? I just am not sure which way to turn right now or just wait until next Wednesday.

[Harley PoMMom]

If she is still wrenching than most likely her tummy is still upset, is she eating normally? Vetoryl is known to cause gastric upset so giving pepcid AC 20-30 minutes before her Vetoryl dose could help, I'd ask the vet about this.

Are her bowel movements normal?

[labblab]

Yes, if Elli isn't back to normal this evening, I'd call your vet and ask him/her what they'd like you to do, both in terms of dosing and also testing. Since her post-ACTH one week ago was 8.1, it seems unlikely that her cortisol has suddenly dropped so low as to be causing her problems. So as Lori says, it may just be a reaction to the med itself, or it may even be something totally unrelated. The tricky thing is that if you withhold the medication for more than 24 hours prior to testing, then you won't know the true effect of this specific dosing amount. So it becomes a bit of a judgement call in terms of whether to test right away or whether to wait until her stomach settles and she's back on the normal dosing schedule again. So that's something I'd want to discuss directly with the vet.

Marianne

[puhmuckel]

Thanks the vet is an Internist and she is off today and does not work on Fridays. I do not think that her cortisol level has dropped and so maybe I should continue the med and as long as she eats and wait until Wednesday. I will get the chemistry done early at the regular Vet.

[puhmuckel]

Thanks the vet is an Internist and she is off today and does not work on Fridays. I do not think that her cortisol level has dropped and so maybe I should continue the med and as long as she eats and wait until Wednesday. I will get the chemistry done early at the regular Vet.

[molly muffin]

What about giving her a small amount of food in the evening before bed. In case it is gastric, that could help.

How is she doing over all, minus the trying to vomit?

[puhmuckel]

She is fine overall but was shaking the last two mornings, but is acting fine. I just scheduled her 30 day tests for Friday instead of next Wednesday cause I will be in Hawaii for 4 nights. So better safe than sorry and I will be here to deal with things. Thanks she will be fine...

[molly muffin]

Oh good, that is best, especially with you being away for a few days.

Just going to say it, super jealous as I love Hawaii. :) :)

When did you last have a full blood work up and kidney tests done? Just to ease your mind that might be worth chatting with your internist about too.

[puhmuckel]

Thanks , yes I am getting a full senior profile run all at the same time. I actually forgot all about Hawaii....I bought a lot there and have to check it out. The dogs will be with a live in pet sitter. Hopefully no bad news , but I am prepared if it is not great.

[puhmuckel]

I gave Elli 5 mg of Pepcid last night and she has been fine, no vomiting. She cried to get down from the bed and in the morning there was a leakage spot on the bed. I slept for 8 hours. I changed her appointment back to the 23 rd . The office told me that they would go into emergency mode and I would not get the results of any tests until the next Monday, but I now think this is just bull and I will get the results one way or the other. I will have to speak to them about theses issues. I am a nurse , and while my dog is getting much better care than most people in this world , it is us who have to bend over backward for the families.

[molly muffin]

I think the reason they are saying there would be a delay in receiving the results is perhaps because of the holiday next week. That would be my guess any how and that they expect labs to working with holiday staffing and likely closed on the Thursday.

[puhmuckel]

She peed in the bed again last night. Now she is drinking lots and lots of water and going out a lot again. I am just not happy with these developments, she is on 0.7 mg per pound and most likely a dosage too low. I am having levels done on Tuesday and they will most likely be low as symptoms are not controlled at all again. Poor Ell .

[labblab]

Please try not to feel too discouraged (although I know that's not easy :o). Given the combination of the rebounding symptoms and the previous post-ACTH of 8.1, it's very likely that Eli will indeed benefit from a dosage increase. But the benefit of giving her the 30 days on this initial dose is that now you will have solid information upon which to gauge the appropriate increase to make. There's still every reason to believe her symptoms will resolve once that therapeutic level is determined. So try to hang in there!

Marianne

[puhmuckel]

last night she had to get down 3 times to drink all the water and pee. She left the cat food. Her Urine is more dilute. This morning she does not want to eat. I added some cat food to the food and she is eating very very slowly. Rebound effect...? or something else

also her urine is very very dilute

[puhmuckel]

Elli did not eat this morning, we are at the Vet for a full work up.
Not feeling good about all of this...exhausted.

[puhmuckel]

Kidney failure...3.4 and 92 all other values pretty normal.

[Joan2517]

I'm sorry...

[puhmuckel]

Vetoryl has been stopped and an ATCH, labs and urinalysis with culture has been done. We came home with Baytril and I cooked her some chicken and rice. Elli ate and has been sleeping and peed a couple of times. Last night she wanted to go out every hour. She must have a complicated UTI and the Vet will call me tomorrow about the cortisol levels. I would lik to restart the Vetoeyl at the small dosage as it did help her a lot. Her k went from 4 to 5.8 and her ratio was 28 , so I guess an increase would not be prudent. Not sure if she even wants me to restart the meds....

Hopefully we will sleep better tonight ...

Glad Elli is resting

[labblab]

I'm so sorry about these problems, and I surely hope you all did sleep better. I am guessing you will not be restarting the Vetoryl, however, until you can get the kidney issues figured out and her renal values normalize again. There is a specific warning against giving Vetoryl when renal function is compromised. I think this is because the drug will not be properly excreted from the body and can accumulate in an unsafe way. So the first step will be controlling the infection, which in and of itself will hopefully improve the issues with excessive thirst and urination.

Definitely do keep us updated.
Marianne

[puhmuckel]

She is already better ate everything and only out once during the night. I am. Going to give her subs fluids and have renal values checked next Wednesday.

[labblab]

That's great that she's improved so much! :)

Fingers crossed that it will continue. ;)

Marianne

[puhmuckel]

Thank You.

[Squirt's Mom]

Good news! I hope the trend continues today and she is back to her old self very soon!

[molly muffin]

I too am crossing my fingers that the sub-q fluids will help with the kidney values. There is a difference between a crisis and a complete failure, just like with any organ it can be either and will depend on whether her values can rebound. This could take some time, so don't be discouraged.
That is is eating again is excellent news.
She may not even need fluids after awhile, it just all depends.

Do let us know how things are going.

[puhmuckel]

Little Elli had her kidney values rechecked and her creatine is normal again but BUN is 80. Internist said likely due to high protein diet. I will be out of town until next Friday and she recommended to restart the Vetoryl at 5 mg per day if at all. I do feel like I want to restart the med, but not sure if the 5 mg will do her any good.

I really do think that she would benefit from the Vetroyl but her increase in kidney values is still a mystery.

She is doing pretty good right now, but I have noted less mobility since I stopped the med. Much more limping and slower moving girl.

[Harley PoMMom]

So glad that her creatinine has come down within the normal ranges, that is very good news!! Regarding the Vetoryl, if she is not displaying symptoms I would be hesitate to restart it because Dechra advises not to use Vetoryl in a dog with renal problems.

Again, I am so happy that Elli Belly is doing much better!!!!

Hugs, Lori

[molly muffin]

This is wonderful news! So glad the creatinine is down I don't worry near as much about BUN if the creatinine is doing okay.
But as Lori said I wouldn't restart any trilostane just yet if it where me. See how things go first.

[puhmuckel]

Well, she is eating a lot better but looks like she has more weakness in her hind quarters. She is not wetting the house or having accidents at night. I was thinking to restart as I have now wasted close to $2000 on cortisol test overall. Perhaps it is better not to restart and this is just an expensive lessons learned . I will wait at least 1 month and to see if there is any other reason why her CR jumped up.

She is almost 14 years old and every day is special now. I realize this and will not have her hospitalized every again nor have any invasive procedures performed on her.

Right now she is happy , lets wait and see.

[Joan2517]

Happy is good...I'm glad she is feeling better.

[puhmuckel]

I am writing an update on Elli and her spirit to fight.

I have restarted Elli on 5 mg Vetoryl for the last week or so. She is doing well and has had no adverse reactions or symptoms. She has become extremely picky with her food and will often not finish the bowel unless it is something very yummy like chicken.

This Thursday she will go and have her Chemistry drawn. If her CR is elevated again , then I will take her off the meds and she will have to wear a diaper at night. If her CR is good, I will get her Cortisol checked in another week or two. She was on 5 mg BID before and now on 5 mg QD.

She is hanging in there and loving life .......

[Harley PoMMom]

Thanks so much for the update and we will be hoping her creatinine level is still normal.

Hugs, Lori

[Gracie123]

Hi!

I just noticed you posted that your dog has kidney disease. My beagle had a BUN of 65 and creatinine of 1.6 before Vetoryl. The vets at that time didn't think it was kidney disease because the creatinine was normal. My 19 pound Gracie went into an Addisonian crisis after being on Vetoryl 10mg daily for a little over 1 month. The crisis now has put her in stage 2-3 kidney failure.

Now the vets think she may have had early kidney disease this entire time because her symptoms of frequent drinking and urination never improved on Vetoryl.

Betty

[puhmuckel]

Hello all,

Elli is doing well clinically on her 5 mg Vetoryl and her BP meds. She has been on this reduced dosage for about 10 days.

Her repeat lab profile shows a normal Creatinine of 1.5 and slightly elevated BUN of 55 (was 80). Her Potassium is elevated at 5.9 (normal range is 3.5-5.8) with normal Sodium.

Not sure if that should worry me or if or stay the course.

any input is appreciated.

[puhmuckel]

Na/K ratio of 26

looks like I should not continue the med

[Gracie123]

Na/k of 26.....looks like you're headed towards Addison's.

[puhmuckel]

Yes, I am very discourage by this development. We have not had a good run with the medications and now I think it is not worth risking an Adrenal crisis or kidney failure. She seems so well and so alert and is even moving well. All of this at only 5 mg of Vetoryl. I think it best to let her live the rest of her life without the medication. I thought I could increase the quality of Elli's life but it has not been the case. This has been an expensive journey to say the least and we are were we started from now.

I do not think it is fair to Elli to continue down this road when it is obvious that this drug is not well tolerated by her.

[labblab]

For what it's worth, I would consult with the internist before deciding to discontinue the 5 mg. since apparently it otherwise is making Elli feel more comfortable. Trilostane is known to have the potential to elevate BUN and potassium a bit in all dogs, and if she remains only slightly out of range in both BUN and potassium, then she may be able to squeak by. It is possible that those values will not worsen any more than they have already. I would definitely repeat the blood chemistries in another 1-2 weeks in order to check for further elevations, but this may be as high as those values increase. Just a thought, although I realize it would be a gamble that you may not want to risk.

Marianne

[Harley PoMMom]

I see that Elli Belly is on a BP medication. Is this for high BP? Some BP medications can cause elevations in potassium, what BP med is she taking?

[DoxieMama]

I'm so sorry you are feeling discouraged but completely understand, as my boy did well clinically but his electrolytes were similarly out of range. High potassium, normal sodium, low ratio (<26). We stopped the meds, then restarted at a lower dose a couple times, which brought those numbers in range. He had other issues come up before long though so I can't say if that would have continued to work for him or not. Regardless, I second Marianne's suggestion to discuss things with the specialist. Perhaps a compounded lower dose would work for Elli?

[puhmuckel]

Thank You for all the support. Three weeks ago , I spoke to the Internist after Elli's CR had increased and she vomited 2 times. At that time she was on a "mini dosage of 5 mg twice a day. During the conversation she said that we should discontinue the Vetoryl altogether.
Elli is on Enalapril 2.5 and Amlodopine 2.5 mg for her blood pressure. She is also on Aluminum Hydroxide.
During that conversation I eluded to the fact that I wanted to try one more time with the med and she said that we should try 5 mg per day and she is now 14 pounds. Elli is drinking and peeing a lot, but she is also alert and following me everywhere. From what I am seeing is that every time, there is something and another issue.
I have an appointment with the regular Vet today just to get back on track. I will discuss with her if they know how to draw Cortisol stem tests , but who knows maybe it is best to stop the meds and observe Elli for a while. I will talk to her in about an hour.