A month into using Vetoryl

[JessMiller]

Hi there,

I've read through quite a few posts on this forum and am happy to have found you. Our 9 yo cattle dog mix was diagnosed with cushings a little over a month ago after ruling out just about everything else. We had the ACTH test done and she was at a 41. She's on the smaller side and our vet started her on the 30mg. After 3 weeks, we tested her again and she was at 17. We put her on the 60mg and are on day 11 of that. Her pacing at night, water consumption, urination and bulging eyes have all gone down in intensity but are still present. She is still pretty frantic at night and has no desire to be pet or cuddle up to us. She is a totally different dog and I'm sure that has to do with the fact she is clearly uncomfortable. Maybe it's a side affect of the medicine? I'm not asking for vet advice, we love our vet! We're just not sure if she is too experienced with this disease so we want to be sure we have realistic expectations.

I guess our question is if your dogs have gone back to their normal personalities after figuring out the proper dosage of meds? We miss our pup :(

Thanks in advance for anyone who can offer some insight!

-The Millers

[labblab]

Hello, and welcome to you all, although I'm sorry for the problems that have brought you to us. I apologize in advance, but I'm going to ask you a few questions before launching into a more thorough discussion of things.

Can you tell us more about your dog's overall health history, and also the specific tests that were run in addition to the ACTH? Cushpups typically exhibit certain other abnormalities on standard blood and urine panels, so the overall lab profile can help make Cushing's seem more or less likely. It is certainly true that 41 is quite highly elevated on an ACTH, but it will help us to know whether there have been other ongoing issues, as well.

Leaping forward, it may be the case that Jess might see more successful symptom resolution if her daily dose of trilostane was divided in half and given at 12-hour intervals. The medication has a relatively short effective life in the body, and as a result, some dogs experience rebounding symptoms within a 24-hour time period. So, for instance, 30 mg. given twice daily might make her more comfortable than 60 mg. once daily.

However, I'm putting the cart ahead of the horse right now ;). As I say, let's learn a bit more about the path that brought you to us, and then we'll be better prepared to move forward.

Marianne

[DoxieMama]

Hello and welcome to you and your girl. We like to have all the history that we can, so I apologize in advance for all the questions headed your way. But can you tell us more about what led you and your vet to test for Cushing's? What symptoms did she have, what tests were done for diagnosis and what were the results of those tests? How much does your girl weigh?

[Carole Alexander]

Hello and welcome,

I am certain that others will post who can discuss the finer points of your dog's diagnosis (What's her name?) and Drecha's direction regarding dosage. However, it is apparent to me that something is terribly wrong, likely caused by [B]doubling [B] the dosage to 60 mg. How much does she weigh? At most she should only be receiving 1 to 2 mg of Vetoryl per pound of body weight. Her first Stim test of 17 was good progress but this dosage is clearly too much and your dog is at risk of an Addison's crisis. Can you call your vet and have another Stim test today? Drecha and vet researchers recommend retesting 10 to 14 days after each dose change. Otherwise I would consider withholding the Vetoryl until she is retested.
Regarding her behavioral changes, I will share my experience. My dog Skippy was diagnosed in late November and has been dosed with Vetoryl since early December. We are still trying to get the dosage at the correct level; his Stim test yesterday was post 16 and he has been up and down since beginning treatment. Before Cushing's he was very loving and affectionate, a be by ya boy. At the beginning of treatment, he became a totally different dog to use your phase - distant, unresponsive, seemingly depressed, lethargic, didn't want to be petted or respond to requests, in addition to all the classic symptoms. Only in the last few weeks has he begun to return to his old self although he is still very different, e.g., he sleeps mostly on the wood floor, still doesn't much want to cuddle, won't walk much distance, won't come on command, often trembles when I put him in the car and is fearful and anxious. I am hoping I will see further improvement if we can get is cortisol under control.
You have begun a long and difficult journey but your dog is only nine and with proper treatment I am optimistic that she will dramatically improve. But, please have her tested asap. Best regards,

[labblab]

Just wanted to come back and add a P.S. Carole's point is well taken in that I don't think you will want to wait much longer than another week to retest since you doubled the dose. However, I am not as concerned about immediate retesting or the fear that overdosing is occurring right now. A post-ACTH level of 17 is still quite high, so you have quite a lot of downward mobility yet to go.

We will indeed be anxious to learn your dog's weight. However, the 1 mg./lb formula really only relates to the very first starting dose. All subsequent dosing changes depend solely upon monitoring test results and clinical improvement rather than weight. Since each dog may metabolize the medication differently, some dogs may end up stabilizing on much less than 1 mg./lb; some dogs may need much more than that.

Therefore, given your dog's 3-week ACTH result, I am not shocked by the dosing increase. But fully doubling the dose is indeed a hefty jump, and you will definitely want to retest soon. Of course, if you see actual symptoms of overdose such as vomiting, diarrhea, or lethargy, you will indeed want to discontinue the medication and test immediately, as Carole suggests.

Marianne

[Squirt's Mom]

Hi and welcome from me as well! One thing caught my eye - you say your baby has "bulging eyes". That is a sign often seen with hyPERthyroidism. Has a full thyroid test been done to rule out any conditions with that system?

[labblab]

Super good catch, Leslie! Especially since hyperthyroidism also causes excessive thirst, urination and restlessness, too. Hmmmmm...

[JessMiller]

Thank you all for the quick responses!

I dont have any copies of the tests to provide more detailed info but was planning on asking for them this coming Tuesday when she has her next test (I read in other threads that that was a common request :))

Prior to the ACTH test, she had blood work and urine tests to rule out a UTI and kidney issues. I'm not sure what exact tests were done but everything came back great. The only thing they noticed was abnormal liver levels. After looking up her symptoms on google, we were concerned she had hypERthyroidism but it came back she did not. Our vet put her on liver support and actually suggested she may have extreme anxiety due to our first baby on the way (we're due April 2nd!). We knew it had to be something more so we asked if we could do some xrays to get a better look at her stomach since she was so bloated. Our vet did full body xrays and sent them in to a radiologist. They came back normal other than an inflamed liver. But I believe the radiologist suggested a cushings test. Our vet ordered one in, and based on the results and her symptoms, she was diagnosed and we started her on the vetoryl.

Barkly weighs about 35lbs. Our vet initially told us that her test results indicated she should be on a 60mg dosage but she suggested we should start with the 30mg if we were willing. She said it would be easier on Barkly and she wanted to be extra cautious cause of her weight. I think she gave us the option of starting with the 60 because of cost of treatment and was maybe thinking that if it worked, we’d have to do 1 less test. We of course took her advice and started with the 30. The diagnosis and treatment costs are definitely adding up (as I am sure you all know too well!) but we will do what we can, and currently we can keep testing.

We are pleased with the results so far and were shocked at how quickly the water & food consumption slowed down. I think after 3 days on the 30mg, she only needed to go out once a night and her pacing at night (tip tapping on the hardwood floors all night and up and down the stairs) finally slowed down. She is still quite restless and just not the same dog. I know this is completely different, but I cannot help but compare her to a grandmother I had with Dementia…she’s just not there. We were happy to finally receive a diagnosis (especially one with treatment) but we are curious if she will be back to normal?

After getting levels down to normal, did your pups got back to their typical selves?

I am still figuring out this forum, and it looks like I reply to each of you individually? I’ll try that next, but if I missed any questions, please let me know!

THANK YOU!

[JessMiller]

Hi Leslie,

Yes, we did check for hyperthyroidism. After initially googling her symptoms, thats what we figured she had! Her crazy eyes have gone down after we started treatment for cushings...I wonder if thats a symptom as well?

Thanks,
Jessica

[JessMiller]

Hi Shana,

I think I covered your questions in my recent post, but Barkly weighs 35lbs. I'm not sure what all of the tests done were officially called, but she had the ACTH test to confirm cushings.

Prior to that, she had blood & urine tests, and a full body xray.

I should have more details to provide on Tuesday if that helps with anything.

thanks!

[JessMiller]

Hi Carole,

Thank you for your feedback! Barkly weighs about 35lbs…though she should probably weigh about 30 :/

I’ve seen so many different suggestions of the recommended dosage of Vetoryl, anywhere from 1-3mg per lb. I was definitely more comfortable with the 1mg as you are suggesting. She is scheduled to be tested again on Tuesday but I think I might request Monday if possible. Unfortunately, that is the quickest she can get in as our vets office is closed. Not that I do not appreciate your concern, but she has not exhibited any signs of overdose or addisons crisis so I am less inclined to rush her to an emergency vet for the test.

It’s good to hear you have been using Vetoryl for some time now and are seeing good results. I have so much to learn about this process that I need to review with our vet! But I am quickly becoming aware that there appear to be many different dosages and interpretations of what the treatment plan should be for Vetoryl! I’m curious what you have been doing dosage-wise? For instance, you said doubling the dosage was extreme…did you get yours compounded? I thought it only came in 30, 60 and 120mg? How are you experimenting with different dosages? Are you skipping days? I’ve seen a few people who’ve had success doing 2 days on, 1 day off… are you doing something like that?

Thanks for telling me more about Skippy’s experience. He sounds a lot like Barklys current state and behavior. I don’t understand the sleeping on the hardwood floor…I never thought I would have to coax her ON to the couch ;-) Good luck with everything and any other insight/tips you can provide is greatly appreciated!

[JessMiller]

Hi Marianne!

Thank you for all your feedback - you seem to really know your stuff. I am working on getting more info about what tests were done but i did also post more details in an earlier post this morning.

I am really curious about the 30mg dosage twice a day and plan on speaking with my vet about that on Tuesday. Thank you so much for the suggestion!

I'm also curious if you can tell me what your understanding is of the testing. I don't think i asked my vet enough questions about this. It seemed to me that if Barkly went from a 41 to 17 in 3 weeks, that the 30mg was working! But maybe the meds go into effect more quickly than that and she as at a 17 only a fews days in then just maintaining that level? does that make any sense? I guess I want to know how quickly the vetoryl will "max out" and how we know what the final dosage we should use is?

thank you again!!!

[labblab]

Hello again, Jess, and thanks so much for all this additional info. You are doing a great job of navigating the forum and addressing all of our questions! You can continue to post separate replies to answer us individually, or if it's easier, you can just consolidate the things you want to say in a single reply. We all read through every reply whether it's addressed to us, anyway, so either way we'll see what you write. It's totally just what you prefer.

To answer a couple more of your questions, brandname Vetoryl also comes in 5 and 10 mg. capsules. So you can actually have a great deal of flexibility in arriving at dosing combinations. Clinical experience indicates that when treatment begins, cortisol levels tend to decrease most rapidly within the first 10-14 days, with some continuing downward drift throughout the first month or so even when the dose remains unchanged. Since Barkly was tested after three weeks on the 30 mg. dose, it is possible that her cortisol level may still have dropped a bit more on that same dose, but the biggest decrease -- to the 17 ug/dL -- had likely already occurred. That level is still much too high for therapeutic control of Cushing's, so an increase was not unreasonable. The question will be whether fully doubling the dose will end up being the right amount or not. If not, more incremental dosing changes either up or down can be made by using smaller capsules, or by going the compounding route. Even if her cortisol level seems just right this second time around, you will want to test yet again after another month, just to make sure that her cortisol level has truly stabilized at that level.

Following correct ACTH testing protocol is very important, though. Many vets are unaware that on the morning of the test, dogs should take their Vetoryl along with a full breakfast, just like every other day. They should not be fasted for the test, or else the Vetoryl will not be metabolized properly and the ACTH results will come back at a higher level than is normally the case. This can lead to the false assumption that the dose should be increased. So I am hoping that Barkly was tested after having eaten, and also within that 4-6 hour timeframe after dosing that Dechra recommends.

We will all be interested in the results of the test next week. As far as shifting to twice daily dosing, you can certainly go ahead and discuss the possibility with your vet, but you may want to hold off on considering the change until you see how Barkly is feeling once her ACTH results drop at least below 9 ug/dL on a once daily dose. As of the last testing, her cortisol level was still too high to expect complete symptom resolution. So once it is down lower, you may find that all her behavior throughout the day may be much closer to normal.

Marianne

[Carole Alexander]

Jessica,
My apology if I overreacted about my concern that Barkly is getting too much Vetoryl. And, of course, the first and critical question is - is it Cushing's? Skippy has been seen by three vets, two Internal Medicine Specialists and his local vet. Mostly they are adamant about low and slow in respect to dosage, but even after three months he is nowhere near a therapeutic level of cortisol. And, if it is not Cushing's the question of dose is moot.
In respect to your comment that Barkly is "just not there", I have sometimes had the same question about dementia and one of the IMS vets raised the question of a macro pituitary tumor, but then said that "Skippy doesn't look like a dog with a macro tumor". (Whatever that means!) And, just to give you an idea of how confusing Cushing's sometimes is: none of these vets has ventured an opinion as to why Skippy's cortisol levels are continuing to bounce and/or creep up even with small incremental increases in dosage. (He is 28lbs and is on 20mg morning and night.) Finally, I read on this forum that the stimulating agent, Cortrosyn, comes in a vial and only a small amount of the product is used to perform the test. Seemingly, the remaining Cortrosyn can be refrigerated and used for subsequent testing as it is very expensive. I haven’t asked the teaching hospital about this as the place is large and the idea seemed unlikely. But Skippy just had his fourth Stim test in 3 months because of dose changes and the cost of diagnostics, stim testing and Vetoryl is astronomical and seemingly without end for the foreseeable future. I truly hope for you all that the problem is Barkly’s thyroid and not Cushing’s.

Jessica, just saw your last post and I agree with Marianne's comments completely. One time Skippy was tested almost completely without food because the vet tech insisted that he be fasted! Also, I think she addressed your questions about dosing in large part. I am nearly certain that Vetoryl should not be administered on an every other day dose; it only stays in their system for 8 to 10 hours. You can look up the research on this forum for more detail on these dosing questions and the research findings. BTW, Skippy is being medicated with the Vetoryl capsules and they come now in 5, 10, 30 and 60 I think. (Of course the cost goes up when you start tinkering with the incremental doses, e.g., 5ml costs nearly as much as 10ml.) Buying the Vetoryl on line, or in my case at the teaching hospital, is cheaper that your local vet. I have had no experience with compounding but others seem to have had good results. That's all for now and we look forward to learning what you learn. :)

[Carole Alexander]

Final thing - all of the vets keep telling me that they are looking at "clinical signs" far more than Skippy's cortisol numbers. I sometimes think they mean the drinking and peeing primarily as they give me a blank stare when I talk about all of the other behavioral issues. Last week, the local vet did prescribe Xanax and an NSAID which I'm now giving Skippy morning and night. Also, I give him Melatonin and flax lignans at night as I suspect that his sex steroids are also out of whack. Ever so slowly...

[molly muffin]

Hello and welcome from me too

I agree, that if the cortisol went down to 17 after 10 days on the same dose from 41, then I'm not sure why the increase in dosage. yes you want to get down to around 5 or just under with symptom control but you can expect cortisol to continnue to drop for up to at least 30 days on the same dose so doubling it might be too much.

Watch out for any signs of over dose, like won't eat, vomiting, diarrhea, wobbly (can't stand, etc)

[Carole Alexander]

Hi Jess,
You don't have to respond to me personally but I just wanted to ask you how Barkly is doing? I can't remember when you were going to test his cortisol again.
Has his behavior/personality returned more toward normal? Is he still pacing, lethargic and aloof? If you read through my thread toward the end you will see that Skippy is still struggling with many of the same symptoms as Barkly along with an episode of severe trembling when we increased the dose to to 30/30. He has been back on 20/20 since Monday and so far is tolerating the drug but without significant improvement. Skippy will see another specialist in two weeks. At any rate, I hope Barkly is greatly improved and you all are doing well.

[Carole Alexander]

You probably know by now that Vetoryl comes in 5, 10, 30, and 60 mg. It also can be compounded to any dose as trilostane. Many people speak highly of Diamondback Pharmacy as a cheaper alternative.