Vetoryl dosage concern

[Arlenes]

I had the low dex test done on Paches my 13 year old boston terrier but haven't received my order yet. I am a little concerned in that he weighs 20 pounds and the vet has him starting on 60 mg. From my own research on dosage I thought this was high. I did kinda say wow 60mg to vet tech and she said that was vets recommended dose. Should I question
this more before i start giving that to him ? Also some additional medical info. He has pituitary tumor we had radiation last year. He was doing quite well up till 1-2 months now with dronking,peeing, pooing, skin rash, hair loss. No weight gain but weight loss. No over eating, eating less.

[labblab]

Hello and welcome to you and Paches, and yes, I definitely believe you are correct to question that dosage! While it is true that the written U.S. product insert for Vetoryl still carries a general initial dosing range of 1-3 mg. per pound, the very next sentence says this: "Start with the lowest possible dose based on body weight and available combinations of capsule sizes." Since Paches weighs 20 pounds and Vetoryl is available in 10 mg. capsules, 20 mg. would be the lowest and therefore most desirable dose.

That dosing range, itself, has been modified in recent years by clinicians and researchers worldwide who don't believe a starting dose should ever exceed 1 mg. per pound. In other publications, Dechra themselves have revised their own written recommendation so as to recommend no more than 1 mg. per pound. Here's a link to a post on our Resources forum that discusses these revised dosing recommendations in greater detail.

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

You may want to print out the post along with some of the referenced resources to make available to your vet. But under no circumstances would I feel comfortable starting Paches on 60 mg. We can certainly talk with you more about this after you've looked over the info.

In the meantime, we'd love to find out more about Paches' overall health history, as well as the symptoms and complete diagnostic testing that led to the Cushing's diagnosis. Actual numbers for the LDDS would be most helpful.

So once again, welcome, and we look forward to learning much more about Paches!

Marianne

[labblab]

Also some additional medical info. He has pituitary tumor we had radiation last year. He was doing quite well up till 1-2 months now with dronking,peeing, pooing, skin rash, hair loss. No weight gain but weight loss. No over eating, eating less.

I see you added this additional info while I was typing out my own reply. Was Paches taking Vetoryl prior to the radiation treatment? Did he have some of these same symptoms prior to the radiation, and are you now seeing them rebound once again? Or are these instead new problems?

Marianne

[DoxieMama]

Welcome to you and Paches! As Marianne said, I would absolutely question that starting dosage. Sometimes the techs misunderstand, and sometimes the vet doesn't know about the lowered recommendation.

In my case, I had to be very insistent to start at lower than the vet said, even arguing with the vet tech. I finally just told them that I was more comfortable starting low as I wanted to make sure that he tolerated it well. And in the end, even the 1mg per pound dosage we started on was too high for my boy!

I look forward to learning more about Paches. Please do keep us updated!

[Arlenes]

Paches had been doing extremely well until the beginning of last year. Every year he had labs and I was told great every time November 2015 perfect I have copy. I then started noticing he seemed to hang his head, started stumbling, seemed wobbly, then started standing in front of things just like numb. He then started circling. Eyes started deteriorating. Some things I thought could be age related. It took me 6 months of vet visits to finally convince the vet that I did not believe it was his teeth and at least 3 told me it could be his teeth since he had mild-moderate tartar. (I personally had a spinal cord tumor removed from my neck in 2013 and I do know a little bit about Neurological symptoms) Labs were done by a 2nd opinion vet we saw in April 2016 labs showed a borderline ALP at 153, A High ALT 143 (they said teeth).

Before the last vet visit I had scheduled a Neurology vet visit. 1 of the Vets where I was going finally said she thought Neuro. I took him home and he collapsed and was knocked out in front of my husband and I that afternoon and I decided I was not waiting. I googled The Hope Center in Rockville, Maryland and Bush Neurology and was able to get him in the next day a Saturday. The MRI showed a Pituitary tumor. They recommended we go to The Oncology Center in Leesburg, Virginia. We scheduled with them and had treatment for 18 days in July 2016. (I did meet another very special lady, Pam and her dog Madison who had a pituitary tumor getting treated as well. I wish I had thought about this more when Pam asked if my Vet had also checked for Cushing in that sometimes Pituitary Tumors and Cushing's can go hand in hand which is what her Vet had said, but I didn't and I feel guilty for not looking into that further) We go back for regular checkups to the Oncoloy Center and the Doctor had been very pleased with his progress. He did quite well. Many symptoms subsided as his body came off the radiation and his body came back to somewhat normal (eyes, he was a little wobbly at times and slow but still had age in mind). He started barking again, getting up on the couch, playing some and more. Then gradually the end of the year started drinking alot, peeing alot, wobbly, spitting up at times, losing weight and not eating alot (but activity very low also) and pooing in the house. In this past month and 1/2 started getting skin ulcers and hair loss which initially Vet said staph. Gradually got worse even after 2 weeks antibiotics and thats when I started researching Cushing's more. Vet did labs and said we should do low dex test because his labs 1/20/2017 were elevated: His pH 8.0 and specific gravity 1.008 not unusual for peeing alot and drinking alot. His A/G ratio 2.2 ALT 122 Alk Phos 174 BUN(creatinine) 30, Calcium 12.1, Magnesium 2.7 and the very worst which blew my mind Triglycerides 1282 otherwise all else good. I took him to another Vet closer to home for the testing but did not see the actual results. The Vet and Tech said his levels stayed high for each lab test and said Cushings and prescribed 60mg. I already ordered it but I really was concerned sat the dosage. I really want to get him started before more damage is done but I don't want him over dosed either.

[Arlenes]

Also he rescued me from the animal shelter when he was 5 months old in 2004 and I will do whatever it takes to get him the help he deserves. He has been the best and I know God brought him in my life because he knew I needed him. He really is a happy go lucky boy and does not show some of the common Cushing's symptoms but like his Momma we try not to show things and even though we are not normal. :D

[DoxieMama]

Thanks for all the additional info. Do you have the results from the LDDS (the actual numbers)?

[Arlenes]

Not yet but I will get them tomorrow from the Vet.

[Harley PoMMom]

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



and the very worst which blew my mind Triglycerides 1282 otherwise all else good.

Yes I agree, Paches' Triglycerides are extremely high, what did the vet say about that? And was hypothyroidism ruled out? An underactive thyroid can cause those elevations in Triglycerides.

Lori

[Arlenes]

No Vet just said to check for Cushing's since triglycerides were elevated nothing else.

[molly muffin]

Hmmm... first welcome to the forum.

Second, I wouldn't go with a cushings diagnosis at this point based on high triglycerides.

Cushings is caused by either a tumor of the pituitary or adrenal glands. Last year you had a pituitary tumor treated with radiation, I'm assuming based on the neurogological symptoms that this was a macro tumor and symptoms subsided.

What we are now dealing with is Hyperlipidemia it sounds like, which is high triglycerides. That can be caused by several things but we haven't established that it is caused by cushings (pituitary or adrenal tumor) yet.

https://www.vetary.com/dog/condition/high-cholesterol

So I personally wouldn't start vetroyl yet based on this information, and never would I personally start at more than 1mg/1lb once cushings is confirmed.

A positive LDDS can be a false positive if other things are determined to be underlying, so I'd want to eliminate any other possibilities first.

One question is was his blood tested after fasting or was he fed before?

Was he given medication to lower the triglycerides.

Thyroid, diabetes, (was glucose elevated at all?) need to be ruled out.

I think if I was in this position, I'd take the test results to the specialists who did the radiation treatments and see what they think. Do they think the tumor has come back? Is there now an adrenal tumor (ultrasound can rule this in or out)
The LDDS test might also be able to point to either pituitary or adrenal, but really what I'd want is all the information possible to know what the next move should be and I'd want it to be discussed between myself and a specialist.

So what I've laid out and my concerns are the steps that I would take personally. This might be areas that you have already covered, in which case, if everything has been ruled out and pituitary or adrenal confirmed, then talk about next steps.

The pituitary tumor coming back would be a top concern. Also that skin issue that they said was staph, did they do a biopsy to confirm that? If not I would want a biopsy to know if it is staph or if it is possible calicinois cutis (calcium deposits caused by high cortisol levels) That would also point to cushings and make it important to know more about that pituitary tumor status.

So I'm throwing all of these thoughts out for you to consider and discuss with vet/specialist as you see fit. It's just what I got out of what you've told us so far.

[labblab]

Hello again from me. From everything you are describing, it does seem quite possible to me that Paches' pituitary tumor is enlarging once again, and that could very well be the cause of many of the symptoms you are describing. However, before starting the Vetoryl at any dose, I agree with Sharlene that I think it would be important to consult with the oncologist once again. If the tumor is again enlarging, then lowering Paches' cortisol may not be the best move overall. Even though excessive cortisol can indeed cause certain problems, it can act as an anti-inflammatory agent that eases other problems such as the swelling and inflammation of the brain that may accompany a re-enlarging pituitary tumor.

Hearing about Paches' loss of appetite makes me feel especially concerned about starting up with Vetoryl right now. You don't want to curb his appetite any further, which might be the case with the Vetoryl. All in all, given Paches' known pituitary history, I really think you should consult again with the specialistics who handled the treatment of his tumor before moving forward with the Vetoryl at any dose.

Marianne