Question about Vetoryl

[pech58]

From what I've read, a dose of Vetoryl peaks around the 3-8 hour mark and is generally out the system in 12 hours. Assuming the once a day dose is in the morning, will a dog experience rising cortisol levels at night? Why wouldn't they do a twice a day dosing?

[judymaggie]

Hi and welcome to the forum!

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Many others will be along with lots of questions so we can become familiar with your pup and offer relevant guidance. For now, with regard to your question about twice-daily dosing, here is a quote from Marianne, one of our administrators:


I realize that, everything being equal, some clinicians do prefer to give trilostane in two daily doses. There are thought to be possible benefits to maintaining cortisol levels more consistently low throughout an entire 24-hour time period. However, experience worldwide is that many dogs still experience positive symptom resolution when dosed only once daily in the morning, and that remains Dechra's starting recommendation. If symptoms rebound later in the day even when cortisol levels seem to be optimal 4-6 hours after dosing, then Dechra recommends shifting to the twice daily regimen.

Dechra is the manufacturer/distributor of Vetoryl. Twice daily dosing is usually recommended for dogs who have concurrent high blood pressure and/or diabetes. Also, speaking from personal experience as my dog is dosed twice a day, compliance can be difficult. Doses need to be given 12 hours a part and this can be problematic for those who are working out of the home and/or those who go out in the evenings.

[pech58]

When my dog first started on Vetoryl, our vet insisted that it was best to start at a higher dose and titrate down from there. My dog was 70ilbs and he was started on 120mg daily. After 30 days, he was retested and his dosage was lowered to 60mg.

I've read in the forum here that the manufacturer revised their starting dosage recommendations. Where can I find that change to show my vet so other dogs are treated with the correct starting dosage? I'm sure if he did the research he would find it but feels his way is the best way.

[LauraA]

It was changed back in 2014 to a lower dose but a lot of vets don't seem to know even know that it was decreased.

https://www.vettimes.co.uk/news/new-lower-starting-dose-for-vetoryl/

[labblab]

Laura has given you an excellent citation. Here's an additional link to a post here that will give you some additional info and context for the revised, lower dosing recommendations.

http://www.k9cushings.com/forum/showthread.php?p=1251#post1251

Also, hello and welcome from me, too! You'll see that I've combined your two questions into this single thread. We prefer to consolidate all questions written by a member into one thread in order to avoid repetition of info and confusion about overlapping replies.

We'd love to learn more about your dog's overall diagnostic and treatment history. What symptoms and testing led to the determination that he has Cushing's, and how's he doing now? Actual numerical results for the diagnostic and monitoring tests would be especially helpful for us.

We're really glad you've found us, and we look forward to reading much more about your Cushing's journey.

Marianne

[pech58]

Will Pepcid interact with the Vetoryl?

Chip is a 10 year basset hound. He was diagnosed back in September after I had voiced concerns to the vet about excessive drinking, pot belly, dry skin. Blood work and urinalysis was done which necessitated the ACTH Stim test. That confirmed Cushings. The vet decided not to do an ultrasound as he felt that wouldn't add anything to the diagnoses and his treatment plan.

Started on 120 mg for a 70lb dog. As I mentioned in an earlier post, thought this was high based on what I researched but the vet thought start high and titrate low if warranted. Repeated 30 day Stim test which prompted him to lower the dose to 60mg. He did fine for several months on the 60mg dose. Symptoms were well controlled. Over time however, appetite started to decrease, noticed his gut making loud sounds at times and certain days he didn't want to eat. Took him in, complete blood work and x-rays. Everything normal. Repeated Stim Test and his level was 3.5 on the Vetoryl

We started him on Pepcid which seems to help a bit. Than he started with a little diarrhea so also added in Metronidazole. Things improved but when we stopped the metronidazole his appetite decreased again with just some very minor vomiting over one night. Decided to stop the Vetoryl for a few days and that seemed to make a difference. He seemed excited to eat again. I'm still giving him Pepcid and metronidazole. Afraid to stop. I need to call the vet to update him and see if it makes sense to go to an even lower dose maybe 30mg of the Vetoryl to see if that makes a difference without affecting his Cushings symptoms.

[Harley PoMMom]

Hi and welcome from me too!

I know of no contraindications between pepcid ac and Vetoryl, many of our members (including me) have used them together with no ill effects. One thing with the pepcid ac it should be the ‎original strength and not the maximum. Also is should be given 20-30 minutes before the Vetoryl is administered.

I'm relieved to see that you are withholding the Vetoryl because diarrhea, vomiting along with inappetence are symptoms of cortisol going too low. Seeing that he improved after forgoing the Vetoryl it is very likely that his cortisol did drop too low, therefore I do agree with you that the Vetoryl dosage strength should be decreased.

Hugs, Lori

[pech58]

Talked to our vet and he is suggesting we keep him off the Vetoryl for one week but than restart him at 60mg again. Not sure I agree with this approach. He seems to be thinking IBD instead which if it is the case, I would assume is difficult to treat since steroids are a typical treatment for IBD. How would a cushings dog be treated for IBD besides diet modifications?

[WeLoveAthena]

Interesting..Just posted about something similar and our Vet wanting to move our girl to twice a day dosing....
Please see Athena's thread. She actually (vet) consulted and we may be moving our girl to 30mgs twice a day.

[labblab]

Talked to our vet and he is suggesting we keep him off the Vetoryl for one week but than restart him at 60mg again. Not sure I agree with this approach. He seems to be thinking IBD instead which if it is the case, I would assume is difficult to treat since steroids are a typical treatment for IBD. How would a cushings dog be treated for IBD besides diet modifications?
You know, I'm with you as far as considering lowering the Vetoryl dose when you resume. You say that Chip's last monitoring ACTH result was 3.5 (I'm assuming that was the "post" result). As long as a dog's Cushing's symptoms are controlled, a result as high as approx. 9 is considered acceptable. So you really have a fair amount of upward mobility in terms of Chip's cortisol level, and I believe I'd take advantage of that by lowering the dose and monitoring the consequences.

Since Vetoryl also comes in 5 and 10 mg. capsules, you can always continue to incrementally add in a higher dose if it seems warranted. But you're right, it may involve a bit of a balancing act to arrive at the dose that is optimal in terms of controlling the Cushing's symptoms at the same time that you avoid unmasking other issues. We have had other dogs here who also suffer from IBD, as well, and it can take some tweaking to arrive at that sweet spot in terms of cortisol level. Also, Chip may benefit from GI "soothers" longterm such as the Pepcid and also adding in some daily probiotics to encourage healthy gut flora. There are a number of veterinary probiotics available, and you can ask your vet to recommend one. There is also an herbal supplement named "slippery elm" that several members here use to advantage. But I agree with you 100% -- an additional step I'd take would be to lower the Vetoryl dose when you start back. As long as you are willing to assume the responsibility of careful monitoring of symptoms, I don't see why your vet should object to that approach. By the way, here's some info about slippery elm:

http://umm.edu/health/medical/altmed/herb/slippery-elm

http://www.littlebigcat.com/health/slippery-elm/

Marianne

[pech58]

Chip had an ultrasound today due to the ongoing gastro issues and as suspected it supported a diagnosis of IBD. For now the plan is to keep him on Metronidazole at a full dose for 2 weeks and than being to taper getting him to a maintenance dose or maybe off completely. We will only know once we being to taper and see if any problems return. The vet wants to restart the Vetoryl at 60mg again. I'm hesitant as I feel what was stated in the previous post is correct - that a post of 3.1 we likely have some room to maybe go down to 30mg. I have a bunch of 60mg capsules so my plan is to open the capsules, split the dose in half and dissolve in broth to put in his food. I'm assuming of course that doing this will not effect the potency of the Vetoryl. Of course I will have him tested again in a month or two.

I got copies of the 3 Stim tests he has had done to post.

8/24/16 Pre 2.5 Post 20.3 (started on 120mg of Vetoryl)

10/5/16 Pre <1.0 Post 2.2 (Dosage reduced to 60mg)

1/20/17 Pre 1.6 Post 3.1 (Dosage unchanged)

[Squirt's Mom]

... so my plan is to open the capsules, split the dose in half and dissolve in broth to put in his food. I'm assuming of course that doing this will not effect the potency of the Vetoryl.

This is not a good plan and goes against expressed directions from Dechra, the manufacturer who states to never open the capsules. There are several reasons for this - 1) the powder inside is not all the active ingredient but also contains fillers so it is impossible to be sure that each portion of powder contains the same amount of Trilostane, the active ingredient in Vetoryl; 2) the coatings on pills and the capsule container are designed to break down at specific places in the digestive tract, some in the stomach, some in small intestines, some in the colon, etc. so by removing that capsule you are forcing the drug to start working in the mouth, throat, etc. and by the time it reaches the place it was intended to start working it may be completely broken down and useless. These are just two of the reasons it is never a good idea to open capsules....in addition to the direction from the manufacturer. ;) So, no, please don't do this.

Tell your vet, who works for you, that you want a 'script for 30 mg and go from there. This is the best and safest way to give this drug....but I would not even think about restarting until everything else is settled as much as possible.

Hugs,
Leslie and the gang

[pech58]

Update = Chip had been doing well. We've been tapering off on the metronidazole and he was down to 250 mg. Restarted the Vetoryl about 10 days ago. Seemed to fine than yesterday had vomiting. Took in him they gave him anti nausea meds to stop the vomiting. The vet checked his electrolytes and sodium levels as he said those would be out of range if the Vetoryl was the source of the problem. Any thoughts on this? The results were normal by the way.

[labblab]

Electrolytes are only half of the equation when Vetoryl overdosing is suspected. Cortisol can drop too low even when the electrolytes remain within normal range (and vice versa). Please see this quote from Dechra's U.S. Product Insert for Vetoryl:


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.

http://www.dechra-us.com/Admin/Public/Download.aspx?file=Files%2fFiles%2fProductDownload s%2fus%2fvetoryl-5mg-pack-insert.pdf

Whenever a dog taking trilostane is unwell with vomiting or diarrhea, low cortisol has to be one of the possibilities that is considered. I personally believe it is unsafe to resume dosing until the dog normalizes or blood testing establishes that there is no problem with either cortisol or the electrolytes. So unfortunately, I don't think your vet's assessment of the situation is correct. Chip's cortisol level may be fine, but I don't believe you can make that assumption based solely on blood chemistry levels.

Marianne

[liltara]

These are common side effect issues that I've seen countless times here in the forum - my dog had similar issues. Primarily inappetence after a period of time ... and vomiting in some cases as well.

He's since been diagnosed with a macroadenoma that seems to be the cause of the inappetence and vomiting. The vet at Dechra feels his tumor swells when cortisol is beginning to be controlled and it affects the appetite and vomit area of the brain which is adjacent to the pituitary where the tumor is.

This is my personal experience, of course, but it is worth talking to your vet about.

[pech58]

Are there any dangers with repeated stopping and starting Vetoryl? I just started him up 10 days ago and now have stopped again because of the vomiting. We restart soon as all seems good again.

[Squirt's Mom]

No, that is one of the good things about Vetoryl - it can be stopped and restarted easily. Please stop giving him this drug while he is sick and tell your vet to do an ACTH immediately to check the cortisol. This is crucial. ;)

[pech58]

It's been a bit since I last posted about Chip. We seem to go through a cycle where he's on the Vetoryl for 60-90 day and he develops GI upset and we have to take him off for a couple of weeks. During the time he's off the Vetoryl, appetite improves and he starts eating like he use to. Start the Vetoryl, appetite decreases and he starts getting sick again. Wondering at this point if we are betting off not treating.

[Harley PoMMom]

Has he had any ACTH stimulation tests done recently to see where his cortisol levels are at?

[molly muffin]

As Lori mentioned it is important to know where his cortisol levels are doing these episodes that he gets sick.

I would look into decreasing the vetroyl dosage personally and see if that doesn't allow him to be treated for cushings, without getting sick