On Trilostane, still symptomatic

[Cem]

Hi all. I have a 9 year old golden retriever named Izzy who was diagnosed with cushings last September. She is on 50 mg of triolostane, twice a day, also takes thyroid meds twice a day and also blood pressure meds once a day. She has had all the 'tests' you normally do for cushings and an ultrasound. Vet feels she is stable on the meds at this point. We have one more quarterly stim test to do and then she feels comfortable going to those twice a year rather than 4 times. Izzy is tolerating all her meds very well, we still walk every single day (at a good clip), she has lots of energy and is acting like 'her' except for a few symptoms that have not gone away. She was drinking about 35 cups of water a day before she was diagnosed, after med control down to about 20. I have managed to get her to 14-16 a day by total control over her water. She gets a specific amount throughout the day, I do not leave water in her bowl because she will drink it till it is gone. She goes outside to pee 'normal' and has never wet in the house. She is also still very hungry but always has been fixated on food. Also some excess panting but not all day. The biggest issue is the water. I cannot be gone from the house for long periods of time and trying to figure out how to have a vacation while friends dog sit is a challenge. They all have dogs so restricting water throughout the day with multiple dogs is not fair to their dogs. Any tips or anything you have found that helps with the water issue? My vet is happy with her dosage and does not want to increase it. She started at 30 mg a day and is now at 100 total. Some of the water issue is 'golden behavior'! Thanks!

[labblab]

Hello and welcome to you and Izzy! I am very glad you've joined us, but sorry that you are still having problems.

I'm afraid you won't be happy to hear my first piece of advice, but usually it is very risky to withhold water from an animal who craves it. There can be various causes, including uncontrolled Cushing's. But for most all causes, there are physiological reasons why withholding water can result in dehydration and/or even worsening problems. If Izzy is still drinking excessively, it is really important to continue to search for the underlying reason, and probably important to make as much water available to her as she is seeking.

In terms of her Cushing's, can you find out the actual numerical results and dates for her monitoring ACTH tests? We've been surprised that a number of vets assume that adequate control is bring achieved just so long as cortisol levels have returned to the normal range for dogs who don't have Cushing's at all. But this is not the case -- the desired therapeutic cortisol range for dogs being treated with trilostane is lower than the normal range for a dog without the disease.

There can be many causes of excessive thirst/urination, including liver and kidney problems. But from what you are describing, Izzy is still suffering from multiple symptoms that can be consistent with uncontrolled Cushing's: excessive hunger and panting in addition to the thirst and urination. So let's start off by finding out exactly where Izzy's cortisol levels have been maintained since starting the trilostane.

Marianne

[Harley PoMMom]

Hi and welcome from me as well!

I see that Izzy is on thyroid meds, has her thyroid level been checked recently because if it is too high this can cause a dog to drink and urinate more. Another medical reason for PU/PD is an UTI, has this been ruled out via an urine culture?

Lori

[LaurieS]

Hi and welcome,

I'm sorry about Izzy's diagnosis but you are in the right place! I recently lost my boxer, Charlotte, and I know I couldn't have gotten through it without all these wonderful folks! I have learned so much and although I hope I never have to deal with cushings again in any of my pups I will be much better prepared if I do.

Marianne and Lori covered most of the questions I was going to ask you but I did want to know if Izzy has pituitary cushings or adrenal cushings. I believe you said they did an ultrasound so I assume they ruled out adrenal?

Laurie

[Cem]

Sorry, this will be brief. Having trouble posting, have tried 4 times! Thank you all for your responses! Laurie, I am so sorry about the loss of Charlotte. They are our 'heart' and this disease is tough.

Izzy has pituitary cushings. She started at 31 and after meds and multiple stim tests was at 6.17 and then 5.9. Is now on trilostaine, compounded 50 mg twice a day. Started on Vetroyl 30 mg, then 40, then 45 compounded. Her last stim test was 4/9. Sample #1 was 4 and sample #2 was 7.6. Has had recent tests for thyroid, liver, kidneys, uti, all good.

[Cem]

Wanted to make sure the first one posted! Vet consulted with specialists about monitoring her water. Was concerned about kidney stress. She gets 2 cups of water with each meal. then about 30 min later another cup. She gets water about every other hour when I am home and also a couple of cups after we have our walk, spread out a bit after she has rested. Water before bed with her bp meds. if it is a hot day, she drinks more than the 14 cups I have been trying to limit her to. when I am gone from the house she gets 3-4 cups to drink till I get home. I can't be gone all day, or I come home mid day to check on her. She does not have excess urination, surprisingly. Goes out like a normal dog throughout the day. She holds it all night, usually 8-9 hours and has never had an accident.

[DoxieMama]

Hello and welcome to you and Izzy! I don't have anything more to add, but glad you've found us.

[labblab]

Izzy has pituitary cushings. She started at 31 and after meds and multiple stim tests was at 6.17 and then 5.9. Is now on trilostaine, compounded 50 mg twice a day. Started on Vetroyl 30 mg, then 40, then 45 compounded. Her last stim test was 4/9. Sample #1 was 4 and sample #2 was 7.6. Has had recent tests for thyroid, liver, kidneys, uti, all good.
Thanks so much for this additional information!

As much tinkering as you've done with trilostane dosing so far, you're probably not going to like hearing this...but if Cushing's symptoms such as excessive thirst/hunger/panting remain unresolved, a post-ACTH result of 7.6 is probably too high for Izzy and yet another dosing increase is probably in order :o.

I will give you the link to Dechra's U.S. Product Insert for Vetoryl, wherein you'll find these dosing recommendations:

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


Post-ACTH 1.45 to 5.4 ug/dL:
Continue on same dose.

Post-ACTH >5.4 to 9.1 ug/dL:
EITHER: Continue on current dose if clinical signs are well controlled
OR: Increase dose if clinical signs of hyperadrenocorticism are still evident*

So in other words, if Izzy's symptoms were all well controlled, her most recent result of 7.6 would be fine. But it doesn't appear as though her post-ACTH reading has ever been below 5.4 on any dose, nor have her symptoms ever showed complete resolution. So she may be a dog who simply needs her cortisol level to be maintained at a lower level.

Has your vet ever discussed the optimal ACTH results that he/she is targeting for Izzy? Is there a specific reason why you all have been wanting them to run a bit higher than Dechra recommends for a symptomatic dog?

Marianne

[molly muffin]

Hello and welcome from me too.

We have a lot of members whose dogs drink and eat like crazy until their cortisol comes down into what is considered a good control area 2.0 - 5.0ug (post on the ACTH test)

I think the worry with not letting them drink when they want to is that they drink because their kidneys are working overtime due to the cortisol so they need water or they will become dehydrated.
It isn't that they urinate more because they drink more water, it's the other way around actually. So, good kidney health suggest that they need to drink more.

I'd try to get that cortisol down a bit more, not too much, just a bit

[Cem]

Thank you all so much! I will be talking to the vet about her results and whether we should adjust her meds again to get more control over her symptoms.