My Oreo was just diagnosed and we hit our first bump in the road

[Kathi]

Hello,
I am thrilled to have discovered this forum as my 14.5 year old Shih Tzu, Oreo, was just diagnosed with Cushings. I brought him to our Vet because he was drinking inordinate amounts of water and seemed to have a constant hunger but was losing weight. He has actually dropped from 12lbs to barely 10lbs in this past year despite an increase in food consumption. Because Oreo does not present with a pot belly, the Vet was not sure whether he had Cushings or something else so she referred us to an Internist who performed both and ultrasound and the low dose dex suppresion test. We got the diagnosis of Cushings on Wednesday and the Internist said Oreo's "levels are high" so she feels he has had Cushings for quite a while. I have not yet picked up a copy of those test results but will do so in the next few days.

The Vet prescribed 5mg of Veteryl once per day as she said it is best to go low and slow. Oreo took the first dose on Wednesday morning and I thought he seemed perkier throughout the day, although it could have been in my imagination. He took his second 5mg dose yesterday (Thanksgiving) and by last evening he had no interest in eating. Other than that, he seemed ok. Last night, he woke up to pee and drink (not typical but this has happened a few times in the past few weeks) and when we went back to bed, it was clear that something was not right. Oreo could not settle into a comfortable position and when he finally did, he was trembling. After 30 minutes, he needed to go out again, but this time he vomited the small amount he had for dinner while simultaneously having an immense bowel movement. It was such a sad sight as you can imagine! He is so skinny and frail so vomiting is the last thing he needs. I honestly cannot remember the last time Oreo vomited so it is clear that the Veteryl must have been the cause.

This morning, Oreo was listless, shaking and food averse. I withheld the Veteryl and called the Vet who was not in the office due to the Thanksgiving weekend. The Vet's office told me they would have another doctor call me (it is a huge vet medical hospital) so I spoke to another doctor a few hours later. By this time, Oreo was willing to take small amounts of food and was beginning to perk up a bit. The on-call Vet suggested I hold off on the Veteryl until I speak with Oreo's Internist on Monday. In her opinion, she thinks maybe 5mg two days in a row was too much for him, despite the fact that this is a very low dosage. She suggested that the Internist may tell me to try giving Oreo the Veteryl only every second or third day until his body begins to adapt.

I have been doing non stop research and have not come across this "every few days" protocol with Veteryl anywhere. I know that other Cushings meds are used in this way but not Trilostane (Veteryl). I am wondering if anyone else has had a similar situation with the Cushings dog.

The good news is that Oreo seems to be getting better this afternoon and there have been no further incidents of vomiting. His appetite is coming back and he is no longer shaking. I have to admit that if the Internist does recommend trying the Veteryl again on a less frequent schedule, I will be nervous to do so because I hate to put Oreo through the terrible ordeal of being so ill. I suppose the only other alternative, however, would be to let him live out his life without treatment, and that is a difficult decision as well. Any insights other Cushings pet owners might have would be so appreciated!
Thank you!
Kathi

[dsbailey]

Hey Kathi,

Welcome to the group. It seems most of the regulars are off enjoying the holiday. Sorry to hear that Oreo ran into a bump in the road but the road ahead is full of bumps and you just have to work through them. I'm not going to get into the treating or not treating conversation with you there are others much better at that then myself.

Before I go further being that it's a holiday weekend and it's hard to get test done and talk to who you need to talk to etc... Don't give Oreo any more Vetoryl until you get him to the vet and sort things out. This is where the "slow" part comes in, it's not a race and stopping medication for a few days or weeks is not a setback just a reset and the safest choice when in doubt. All dogs are different and 5 mg might be just to much for his system. The only option that Dechra can offer is 5 mg capsules so I can see where they may have a protocol to dose every other day or whatever. I don't like how that roller coaster ride sounds. Trilostane which is the active ingredient in Vetoryl can be compounded into any dosage that you need.

There's a slight chance that Vetoryl just doesn't agree with him which I've read about but is not usually the problem, it's usually the dosage. My girl was 57 lbs when she was diagnosed and started on 60 mg SID (once a day). After 7 days she seemed a bit off and I had her ACTH Stim tested and her numbers came back very low, we stopped for a week and restarted on 30 mg SID, then another month, test and low again down to 25 mg (low again) and now after six months and all of the dose changes she's on 15 mg SID and going for another ACTH Test Monday. She weighs 52 lbs now.

If it were me and I was to decide to restart Oreo I'd wait at least a week and if he's feeling the same as before the first try. I'd talk to the vet about starting him on compounded Trilostane at 2.5 mg SID on a Monday (not a holiday week). A lot of us here use Diamondback Drugs in Arizona and it usually takes less time getting compounded Trilostane made and is cheaper than Vetoryl from online pharmacies. They work a bit different at Diamondback and have a minimum charge by batch, it cost the same for 60 30 mg capsules as 30 15 mg capsules. You can call them for a price quote yourself. 60 15mg capsules cost me around 40$ with shipping.

I didn't see you mention if you gave the Vetoryl with a full meal, if not then that's important to do. Also it upsets some dogs tummies and I know that people here use pepcid (I'm not sure which variety but I know one is good and one shouldn't be used, someone will answer this).

I hope I've helped relieve some of your anxiety which is highly understandable. There will be some other people stopping in to help guide you and answer any questions.

Please post any abnormalities in the blood work, Ultrasound Findings, and LDDS results when you get them. Start a folder with all of the test results now and in the future, if an emergency happens that can help the emeregcy vets unfamiliar with Oreo tremendously.

Darrell and Lolita

[molly muffin]

Hello and welcome to the forum.

I agree, do not give Oreo any further vetroyl at this time.

Did Oreo have a CBC blood panel? A urinaysis with culture, kidney profile, liver, etc. ?

I am wondering if any other values were off on the blood work, either high or low.

It is not unheard of to have a false positive on an LDDS if something else is going on and normally, losing weight is not the issue with cushings, putting weight on is. However, other things could be a factor, so that is why I asked about the blood test. If it is something Other than cushings, then cushing meds could have an adverse affect.

No, every other day is not a normal protocol with vetroyl, however that doesn't mean we haven't seen vets suggest it. Usually when there is an adverse reaction.

I think if it where me, that first I'd want to get to the bottom of anything going on with Oreo, and make sure that you are on the right track with him, rather than switching to the every other day dosing regime, which might not address any other issues that are going on.

We'll be able to give you better feed back once we know more about anything that might be off in his bloodwork. (high/low with range would be helpful).

How is he doing now? Is he eating okay? Any more vomiting or diarrhea?

[Kathi]

Thank you so much for your swift and informative replies. You really filled in several blanks for me, especially the idea that the drug can be compounded to the correct dosage for Oreo's needs. I did not realize that but it definitely seems more sensible than giving him 5mg every few days.

Yes, I did give Oreo the Veteryl with a full meal each of the two days that I gave it to him. He seemed fine until late the second day when he refused dinner. Although he refused all food this morning, he did begin eating small amounts by afternoon and ultimately ended the day eating about 2/3 of his normal amount. Although he is eating, he is being picky, which is something that he has not been doing since he began showing Cushings symptoms a few weeks back. I am just relieved that he is eating so I am willing to put up with a finicky eater!

Oreo has not had any vomiting or diarrhea since 4:30am this morning and that was a single (but dramatic!) incident. I am definitely not going to give him any more Vetoryl until I speak with the Vet on Monday and we devise a new plan. I appreciate your advice to wait until Oreo is back to his pre-Veteryl self before trying again. And beginning on a Monday as opposed to the Wednesday before a holiday weekend is very smart as well. I was anxious to get started with the meds as I want to do everything possible to improve Oreo's quality of life, but I realize now the importance of moving slowly and cautiously.

Below are the "out of range" results of Oreo's blood and urine panel:

Oreo - Reference range
ALKP 1781 - 5-131
ALT 830 - 12-118
AST 108 - 15-66
BUN 36 - 6-31
GGT 70 - 1-12
GLU 63 - 70-138
Mg 1.4 - 1.5-2.5

Hematology
Absolute N 11152 - 2060-10600
Absolute M 952 - 0-840

Once again, thank you for your suggestions and for all of the vital information you shared with me. I am hopeful that Oreo will recover to the way he was before the meds. Right now, he is looking better although he seems less steady on his feet than a few days ago. I will keep you posted once I reach out to the Vet on Monday.

I am so appreciative of your help!!

Kathi

[labblab]

Hello and welcome from me, too! I am sorry, though, that Oreo is doing so poorly and I must admit that I am surprised that he would have such an extreme reaction to only two doses of what is a rather low amount of trilostane given his weight. Coupled with his poor appetite and weight loss (weight gain is the norm with Cushpups), it makes me wonder whether something else, or something in addition, may be going on with him.

Another red flag for me is the fact that all his liver markers are high quite, across the board (ALKP, ALT, AST, GGT). Cushpups often exhibit highly elevated ALKP along with mild to moderate elevation in some of the other markers. But Oreo's levels for the markers other than ALKP are all very high -- higher than we typically see -- causing me to worry that there may be a primary liver condition and actual liver damage at play here which could be responsible for Oreo's symptoms of excessive thirst, urination and weight loss. As Sharlene said above, the LDDS is vulnerable to giving "false positives" when other underlying illnesses or conditions are present. You mention that the specialist did perform an ultrasound. When you talk to her on Monday, I'd press her further as to the status of Oreo's liver as seen on the imaging and also as reflected the in these lab results. It may be the case that a liver biopsy might be advisable.

Regardless, I agree with the others that I would not restart the Vetoryl just yet, especially until the liver issues are sorted out. The company that makes Vetoryl specifically cautions that the drug must be used carefully in dogs who suffer from liver damage because the drug will not be metabolized properly.

Marianne

[Squirt's Mom]

I'm with Marianne - those liver values are alarming to me and I would want that organ thoroughly checked out. The reaction your baby has had to the Vetoryl could me a few things, two of which are - 1) she has been misdiagnosed and does not need Vetoryl at all (liver disease is one of the many conditions that can cause false positives and some of the same signs), or 2) she is one of those pups who simply cannot tolerate Vetoryl and needs to try Lysodren IF IF IF she actually has Cushing's (with those liver values I am wondering....).

I think it's time for deeper investigation beyond the Cushing's. ;)

Hugs,
Leslie and the gang

[Kathi]

Good Afternoon,

As a mentioned in previous posts, Oreo, my 10lb, fourteen and a half year old Shih Tzu was recently diagnosed with Cushings. This diagnosis was made by an IMS after a blood work and liver panel, an ultra sound and a low dose dex suppression test. Oreo does exhibit many of the symptoms of Cushings, including extreme thirst with frequent urination, stiffness of his back legs, which seems to be escalating rapidly, and increased appetite. He does not, however, have a pot belly and over the past year has lost a few pounds rather than gaining.

Oreo's IMS prescribed 5mg Vetoryl once per day which made him ill with vomiting, tremors and weakness after the second dose. I stopped giving him the Vetoryl (he only had it for 2 days) and spoke with the Vet on Monday. I described to her Oreo's symptoms which included loss of appetite, weakness, and lethargy which lasted about 3 days. Based on the advice given by several knowledgeable members on this site, I also asked whether she might review Oreo's various test results with a focus on possible liver disease, based on the fact that all of his liver numbers are so highly elevated.

She said based on Oreo's ultrasound, which showed enlarged adrenals and an enlarged liver and coupled with the other data from his liver chemistry and the low dex suppression test, she does not think he has liver disease but that he likely has had Cushings for quite some time. She said that the fact that his albumin levels were normal (and some other thing was normal which I cannot recall) she feels the results do not point to liver failure.

The doctor recommends that I wait for at least 4 or 5 more days to make sure Oreo is back to his pre-Vetoryl level before moving to the next step. She then recommends that I give him 5mg every other day to see how well he tolerates that. Although I am surely no expert, that does not make much sense to me so I asked her about having the drug compounded to a lower dosage to use daily. She replied that she has had issues with compounding pharmacies and does not like to prescribe Trilostane that way. She said she has had better results using the every other day approach with Veteroyl. I asked when we would do the acth stim test if Oreo is on an every other day regimen and she said she would still do it after 10-14 days to see where his levels are. She said then she may consider using a compounded dosage based on the results of the test. She sounded a bit vague as to whether she would go the compounding route.

I have been doing research and I do not see the every other day protocol being used very frequently. I did see some case studies where they did use that approach in the U.K. at one point but it does not seem very common. I am betwixt and between as to what I should do. I did tell the Vet that if I do try the every other day trial and Oreo becomes ill again, that will be it for the Vetoryl. He is so thin and frail that I don't believe he can endure another episode of vomiting and anorexia.

I also asked the Vet if she ever prescribes Anipryl. I know it is no longer considered very useful in the treatment of Cushings but I thought it might be worth trying as it is now sometimes prescribed for Canine dementia, which Oreo has in a mild form. She said she would have no problem prescribing it for Oreo but that I would not see a diminishing of the drinking and urinating. She did say it is generally well tolerated and it may give Oreo a boost of energy but the major symptoms of Cushings would remain unchanged. Again, I am not sure if this is a better route to take.

The IMS came highly recommended and is part of a large and well-respected Veterinary Hospital in my area so I want to put my faith in her knowledge in treating Cushings. She has been practicing for about 15yrs and has a great reputation. My concern is that prescribing a medication which lowers Cortisol every other day makes no sense to me at all. I am a retired English teacher and profess a very weak knowledge in all things science but that does not seem logical to me. Perhaps she is just trying to see if Oreo's system can gradually adjust to the medication so she feels a day on and a day off will help this to happen? I guess in my gut something seems off.

Right now, Oreo is doing okay without any Cushings meds and has regained most of his appetite, although he has taken a dislike to eating breakfast. We try to make up for that throughout the day. Ironically, Oreo has been on a raw food diet for 3 years, and that is one of the recommended diets for treating Cushings. Since the 2 doses of Vetoryl, however, he will not take as much as a bite of his raw food and will only eat kibble. It is so odd. He has not had a bite of kibble in years yet this (and people food) is all he wants to eat. That is fine for now as I am hopeful that he will regain his appetite for raw.

If anyone can point me to any research regarding the day on/day off protocol for Vetoryl, I would be so appreciative. And any other advice or recommendations would be welcome as well!!

Thank you,
Kathi

[dsbailey]

I'd convince the IMS into writing me a 2.5 mg script of Trilostane and use the highly recommended Diamondback Drugs to compound it. It's your dog and a safer logical dosage.

[labblab]

I agree with Darryl that in the long run, I'd prefer that my own dog be dosed once daily with whatever is deemed to be a therapeutic amount of medication. In Oreo's case and in the short run, however, I suppose I'd be willing to try the 5 mg. of Vetoryl every other day in order to see whether or not you get the same response as you did before. My actual worry is whether or not he can tolerate the medication at all, as opposed to a dosing issue. For a dog weighing 10 pounds, it would be surprising to think that only three daily doses of 5 mg. would lower his cortisol so significantly as to cause ill effects. So it makes me worry that it is the medication itself to which he may be reacting, as opposed to the dose. If it ends up that he reacts more favorably to the every other day dosing, though, that is the point at which I would discuss a switch to the compounded 2.5 mg. daily instead, since it would imply that it was indeed the dose that was the culprit -- that his cortisol was consistently bring driven too low on the 5 mg. daily dose. Dunno whether what I've just written makes sense :o, but it may be kind of what your vet is thinking, too.

If Oreo reacts just as badly to the Vetoryl once again, then I'd think the Anipryl would be worth a try. It is true that only a small percentage of dogs see resolution of Cushing's symptoms as a result of this med, but you might end up being one of the lucky ones with Oreo. I'd also normally suggest Lysodren as an alternative for dogs who cannot tolerate Vetoryl, but given Oreo's frailty and appetite issues, I don't think it would be a great choice.

In terms of his appetite, I see you've mentioned reading that a raw diet is recommended for Cushing's patients. Several new folks have mentioned this recently, and I'm curious about the source because it is not something about which I've seen any concrete research and our experience here throughout the years has been that treatment success does not seem to correlate with any particular diet. We have had dogs who have done well and also poorly eating the entire range of food types: raw, dry, wet, home-cooked. Regardless of type, the real key seems to be good quality ingredients. So if it were me, I would not stress about getting Oreo to return to the raw food if it does not seem to be appetizing to him. For instance, I think that many raw or higher protein foods seem to have a fairly high fat content, as well, and that may not be appealing to him right now if he is having digestive issues.

Anyway, please let us know what you decide about the Vetoryl, and good luck!

Marianne

[molly muffin]

Hi i just wanted to check in and see how Oreo is doing today. Hopefully better.

[Kathi]

Hi Sharlene, Marianne and Darryl,

I am happy to report Oreo is doing better. He weighed 10.1lbs on Oct 31 and today weighs 11.4. At least his ribs are no longer obvious and he definitely is stronger. The goal is to get his weight up another pound or two. He went on strike and will not touch a drop of dog food but he is absolutely savoring the meals I have been cooking for him. And I am thrilled to see him clean his bowl every day!

I did not re-start Oreo on Vetoryl as my gut tells me that 5mg every other day does not seem optimum. He took 5mg Vetoryl for 2 days a few weeks back and I do not want to revisit the vomiting that occurred after the second dose. As I had mentioned in my last post, my IM vet does not feel comfortable with compounding pharmacies. Marianne, I think you are exactly right in that my Vet most likely recommended 5mg every other day in order to see if Oreo could tolerate the drug at all. I believe she would be willing to have a lower dose compounded if the every other day protocol showed some success.

I decided to give Anipryl a try and picked up that script this evening so Oreo will start with a 5mg daily dose beginning tomorrow. The Vet (and my research) claims that most dogs are able to tolerate Anipryl pretty well. Because it is prescribed for the Pituitary type of Cushings as well as for canine dementia, I am hoping to see some improvement in both of those areas. The Vet believes it will provide Oreo with some energy but she is not confident that it will minimize the excessive drinking/urinating. I guess I will find out within the next month.

Overall, I see improvement in Oreo's symptoms. He has been taking flaxseed lignans and melatonin for about a month now and perhaps that is helping. He is able to sleep through the night for 7-7.5 hours without having to urinate, which is not bad. He seems to be drinking less than a few months ago and definitely is stronger and more alert. His biggest challenge is that his back legs are quite stiff, which makes it hard for him to scooch down into a comfy position.

I am hopeful that Oreo will continue to gain weight and that the Anipryl will help to give him energy. Perhaps I will revisit the Vetoryl discussion with the Vet after Oreo puts on a few more pounds. For now, I am grateful that he is alert, more energetic, hungry and a little "rounder" than a month ago. Baby steps!

Thank you all for your knowledge, input and advice. I will keep you posted as to how Oreo fares on Anipryl.

Thanks so much,
Kathi

[molly muffin]

Great to here Oreo is doing better.

See how he does on the Anypril. Hopefully it works for him. The melatonin and lignans seem like they are helping too.

Keep us updated!

[dsbailey]

Kathi,

I'm glad Oreo is feeling better now and put on a bit of weight. The older we get the stiffer we get too. :rolleyes:

Darrell and Lolita

[Kathi]

Hello Friends,

I wanted to give an update about Oreo's status. As you may recall, he was diagnosed with Cushings in November (chem panel, ultrasound and low dose dex suppression test) and as per the results of his low dose suppresion, his Cortisol levels are very high. The internal medicine vet prescribed 5 mg Vetoryl once a day on the theory of going low and slow. (At the time he weighed just over 10lbs after losing 2lbs over the course of a year. He is 14.5yr old SHih Tzu.)
Back in November, after 2 doses of Vetoryl, Oreo vomited and stopped eating. He laid in his bed and had no energy to move. This occurred at Thanksgiving time so the vet was not in the office but another doctor at the practice told me to cease the Vetoryl until speaking with our vet the following Monday.

The internal medicine vet suggested that I give Oreo a chance to recover his appetite and then try Vetoryl every other day until he gets accustomed to the drug. She said she is not comfortable with using compounding pharmacies so unless I changed vets, I was stuck with the 5mg dosage.

It took Oreo a week to get his appetite back and I worked to get some weight on him. He now weighs 11.8lbs which is much closer to his usual weight. He no longer looks boney or starved, which is great. In early December, I asked the vet if we could try Anipryl as it typically is better tolerated. She gave me a script but she was doubtful that it would eliminate the Cushings symptoms. She thought it might give him some zip but that is about it.

Oreo tolerated the Anipryl great and continued to have a decent appetite. He still drank in excess but he had more energy and seemed more aware of the world while taking that drug. His back leg stiffness did not improve and he still urinated a lot but in the month he was on it, Oreo seemed to be enjoying a slightly improved quality of life.

The Anipryl script ran out last week so I decided to see if Oreo could better tolerate Vetoryl now that he is more robust. I gave him the first dosage on Friday morning, skipped Saturday as per the recommendation of the vet and then gave him a dose on Sunday, Monday and today. I only skipped one day because he seemed to be tolerating it and did not vomit like the last time. Skipping days just seems wrong based on the research I have done. Over the past 2 days, Oreo's appetite has diminshed and he is only eating a small amount. Today he had no energy and definitely has lost his zip. Oddly, last night he had to urinate at 4am which is a first as he has always been able to get through the night. Also, he is laying on my lap right now and his body feels very warm. I am beginning to think Oreo just does not tolerate Vetoryl and I am contemplating stopping the medication.

My question is do the side effects from Vetoryl eventually go away? I don't think I could stand to watch him waste away from inappetance. Would his appetite eventually come back if he remained on the drug? Will his energy return? I so want to do the right thing for my little guy but I just don't know whether to stick it out with the Vetoryl for another week or stop the drug now.

As I sit here looking at my little sad sack and thinking of how he looked a week ago, I am realizing that the Anipryl really was helping somewhat. And perhaps we would see even greater improvements after a second month on it. I am thinking that even though it will likely never eliminate the basic Cushings symptoms, it might be the best route for Oreo.

Any insights would be greatly appreciated.

Thank you so much,
Kathi

[judymaggie]

Hi, Kathi! A couple of thoughts -- has Oreo had any follow-up ACTH tests since his initial diagnosis in November? Were his electrolytes checked when he was having a negative reaction to the Vetoryl? You might consider having an ACTH done now along with a chem panel to get some more information on his current cortisol levels and to make sure that his electrolytes have not dropped too low.

Also, it is not a good idea to give Vetoryl if the dog is not feeling well. I would be inclined to stop the Vetoryl and run some tests.

I am also going to throw out another option -- the other commonly used medication for Cushing's is Lysodren. It is possible that Oreo might have a better response with that. That said, I think the most important thing right now is to get a better grasp of his levels.

[molly muffin]

I too am curious as to whether a follow up ACTH was done when Oreo was having a bad time with the vetroyl or even this time?

What about going back on anypril?

How is he now?