Confused about subtlety of food changes with Vetoryl?

[Big Fish]

Hi All,
Welcome some clarity here.
My dog was started on a 1/2 dose (30mg)of vetoryl last Sunday. We're due to start this Sunday with a full dose(30mg-2x@day). Here's my problem. He is a finicky eater to begin with. His 'normal' before starting trislostane, was to stop eating partway through his food and stare at me. I have to 'spice it up' by adding in some ' doggy crack' (freeze dried liver, or chicken,or lamb, etc) by crumbling it on top, then he'll go back to eating. He does his routine 2-4 each meal, then he finishes it. The internist told me danger sign would be 'when a crappy eater becomes an even crappier eater." Does that mean he won't eat AT ALL? Walk away from his bowl? Or does that mean he'll stop twice as many times, so l have to add crack 6-8 times to get him to finish? Wondering how others with picky eaters gauge medicine effacy by their dog's food consumption?
P.S. can not use a decrease in PU/PD as a signal, as he'd currently being medicated for that. BTW, he is a 10 yr old, 83# coonhound. THank you in advance for your help!

[labblab]

Hello, and welcome to you and your boy! You'll see I've moved your thread to our main discussion forum -- this way, more of our members are likely to stop by.

Before addressing your own questions, I'm afraid I have a few of my own. Can you tell us more about the symptoms and testing that led to the Cushing's diagnosis? When you say your boy is already being treated for PU/PD, what exactly does that mean?

Excessive hunger, thirst and urination are three of the most common and troublesome overt symptoms of Cushing's, so if your boy no longer exhibits any of these common symptoms, it will help us to know exactly what has prompted the diagnosis and the desire to treat Cushing's.

Thanks so much for any additional background info you care to share!
Marianne

[Big Fish]

Thank you for helping me navigate the board!

I recognized sub-clinical symptoms in my dog about 2 yrs ago. Started doing tests, more tests, more tests. At first, everything came back mildly elevated, marginal etc. Over the past 2 years we've done: ACTH stims, numerous chem + CBCs, thyroid screens, tick titers, complete UAs, UCCRs, UPCRs, 2 abdominal ultrasounds, full body x-rays, 2 full adrenal panels sent to U of TN and LDDST. I might be leaving some out, trust me, if there was a test we did it.

He was suspected of having CDI after we R/O any other cause for his PU/PD, so started him on desmopressin acetate last January. He responded wonderfully, went from an SG of 1.004-1.011 to 1.038-1.045. He had/has recurring skin infections (which responded unsuccessfully to oral antibiotics) which I 'manage' with topical treatments, was diagnosed with PLN, and had an acute crisis of pancreatitis + aspirated pneumonia that required 2 back-to back 4 day stays in the ICU. I recently included an internist into his treatment team, who positively gave the DX of Cushing's, pituitary dependent type. There's still some question whether it's micro or macro. At this point I'm electing NOT to do an MRI or cyberknife surgery if indicated. Plan will be once he's stabilized on trilostane (as the internist said "when his numbers look pretty after 2 weeks on full dose") we'll ween him off the DDVAP and later the benazepril for the PLN. Hope that answers your questions! Thanks!!

[labblab]

Thanks so much for this additional info! I'm afraid I still have some remaining questions, however. I must first warn you that I am not a vet myself, so I am not intending to challenge your new internist's treatment plan. But your dog's clinical presentation does not fit the more typical Cushing's profile, and in order to give you our best advice, it will help us to know more.

This request relates directly to the question you've come here to ask us: how to judge medication efficacy in a dog with a poor appetite. The dilemma for us is that the norm for Cushpups is a ravenous appetite. We are always concerned when trilostane is prescribed for a dog who is not eating properly, because inappetance is not usually associated with the disease itself except in the presence of an enlarging pituitary macrotumor.

I am still wondering about the basis for this current Cushing's diagnosis. It sounds as though you had a ton of tests done previously, but I'm assuming that none of them confirmed Cushing's. Can you tell us what test results have led your new internist to make the definitive diagnosis now?

Part of what puzzles me is the expectation that your dog will no longer need the DI medication once the trilostane dose is stabilized. If your dog truly has DI -- which is apparently the case since he has responded well to that medication -- then as far as I know the trilostane would have no bearing on resolving that condition. DI can indeed be associated with pituitary tumors, but as far as I know, direct treatment for the DI must continue regardless of trilostane treatment.

It seems as though your other concerns have included recurrent infections and the protein-losing nephropathy. It's true that both those vulnerabilities can be caused by Cushing's, but neither would definitively diagnose the disease in the absence of positive results on tests that are specific to the disease.

The reason why I am going to such lengths to determine the basis for the diagnosis is because lack of appetite is a major red flag/issue for a dog being treated with trilostane. As you're already aware, loss of appetite is one of the markers for a cortisol level that has dropped too low. So it's worrisome if your dog is already picky from the get-go. Is the picky appetite due to a different underlying condition altogether? Is it due to an enlarging pituitary tumor? If that's the case, you may not want to even institute trilostane treatment at all, because decreasing the circulating cortisol may increase inflammation and swelling of the tumor and surrounding brain tissue.

Last but not least, there's a concrete reason why trilostane treatment is problematic for a picky eater -- to be metabolized properly, the drug must be given along with a full meal. So if you're planning to dose twice daily, that means two meals must also be consumed alongside the trilostane.

So returning full circle, I'm afraid I don't have an answer for the question that brought you to us :o. Lack of appetite is not typical of an uncontrolled Cushpup, and therefore I can't give you guidelines as to how to judge whether even worsening appetite is cause for worry or not. To be honest, I'd be worried about even starting trilostane with a dog who doesn't want to eat.

Marianne

[Big Fish]

Internist thinks DDVAP might be masking what is really Cushing's. Both can be caused by a pituitary tumor as you stated. While he's a 'picky' eater, he does eat full meals, eventually, and so ls administered vetoryl with a full meal (administered at the very end, while he's eating last portion.) Internist made a positive DX due to cortisol levels from results on the 2 full adrenal panels, ab. ultrasounds + LDDST +other labs + physical presentations. He does not have many of the 'classic signs' (no pot belly, no symmetrical hair loss, no voracious appetite) and is not a typical Cushing's dog, i.e. being a large, male. He may also have some GI/pancreatic enzymatic insufficiency due to his pancreatitis episode that caused scarring that we may address later but are controlling right now with a LF diet, digestive enzymes and tylan powder. He's a complicated case, hence why my vet involved a specialist to read through all the info, examine my dog and offer his expert opinion. He's not your typical case for sure...it's why I dragged my feet, did so many tests and re-tests, sought more insight. I appreciate your time to consider all this. He's complicated for sure. U of TN suggested starting him on a maintenance dose of lysdodren. The internist feels trilostane has less adverse effects. Just interested on what those with less aggressive eaters look for. Thanks again for your thoughts + time.

[labblab]

If UTenn recommended a maintenance dose of Lysodren, that suggests to me that on their adrenal panels, your dog fit the pattern for what they label "Atypical Cushing's." This is the situation where a dog's cortisol falls within the normal range, but some or all of the other tested adrenal hormones are elevated. If a dog exhibits elevated cortisol on their panels, they instead usually recommend either trilostane or full Lysodren loading. So their treatment recommendation leaves me wondering about your dog's cortisol level.

By any chance, do you have the actual numerical results for the Tennessee testing as well as the LDDS results? As we all proceed with your dog's treatment, it will help us a great deal if we have a better understanding re: the actual status of his adrenal hormone levels. That way, we can be more helpful with suggestions as to judging whether the trilostane is having a helpful or not-so-helpful effect.

Marianne

[Big Fish]

not sure how to upload pdf?

[labblab]

Unfortunately, members can't upload attachments to the website. One option is to take a digital photo of paper results, and upload the picture to a personal photo album that you can create here. Or you can just go ahead and type the results into your reply. For the LDDS, it will just be three numbers (baseline cortisol, 4-hour result, 8-hour result). For the UTenn panels, it's a bit more laborious, unfortunately. But you can still type out the baseline result and the post-ACTH result for each of the hormones.

Or, last but not least, you can embed URL links into your replies. So if you have the test results posted elsewhere in some other form or using a web data manager, you can give us the link.

Marianne

[molly muffin]

Hi from me too. I was one with a picky eater. It was a real bugger to get her to eat a meal all at one time. I ended up having to use toppers to get her to eat enough to be considered a meal to go with the trilostane. She did have high cortisol but not a big appetite. She was a grazer, so would just munch off and on at her bowl till it was done. Not easy to deal with when meds are involved.

I made up for this by doing frequent testing for cortisol levels. Every couple weeks to start with just so I would know what was going on and how she was responding and I used other things like, was she lethargic, did she show the same levels of activity and engagement. No voimiting or diarrhea.

An ACTH would have a pre and a post level so you could just post like this:

ACTH
pre 10.
post 35

LDDS
base
4 hr
8 hr

And any high or low levels on cbc (don't post the normal levels)
that is what I use to do and I'd update the test results each time I got them back. I always got a copy and kept my own file to refer back to.

Also for pdf convert to jpg, you can also do that online. I'd upload to a pdf converter, have the website convert to jpg and then save that to my computer and load it in an album here on the forum. But for the most part I just typed in cushing results and cbc and urinalysis results by hand.

Welcome to the forum.

[Big Fish]

Thank you Sharlene!!! I'm grateful to know of others with 'food issues' happen and can be treated with vetoryl. The internist didn't seem concerned nor surprised but I'm brand new to Cushing's so worry more. My hound has been an anomaly, such an odd duck, through this all (why there are several veterinarians monitoring + directing his treatment). He too eats all his food after after I add on extra goody bits! Appreciate the posting tips for labs as well, will try to get to those later. Thanks again!

[Big Fish]

ACTH
Baseline: 2.4
Post: 25.8

1. LDDST: pre 3.1, 4hr- 1.6, 8hr 2.8

[Big Fish]

Here are results:



3/17/17
LDDST: pre 3.1, 4hr- 1.6, 8hr 2.8


4/7/2017
ACTH: Baseline: 2.4, Post: 25.8

[Big Fish]

and
4/8/ 2016
ACTH: Baseline: 2.5, Post: 22.7

[molly muffin]

He is now on the full dose of vetroyl? 30mg twice a day?

You want a post ACTH of 5.0ug at least, but can go up to 9.0ug post if symptoms are controlled, so you have a was to go. Once you are on the full dose, allow for at least 30 days before making a change, as cortisol can continue to drop for that long.

Make sure you are giving with food and enough of that topper to get him to eat all his meal. ;) then the ACTH was done 4 - 6 hours after given the pill with meal on the morning of the test ?

[Big Fish]

We started first week on 30 mg 1x@day, for 7 days.
He's been on 30mg, 2x@day for 4 days now.
All's good so far, knock wood.
Have an appt. for ATCH recheck on 7/19 (11 days in).

Sharlene he eats ALL his food each meal, eventually...within 5 min with added toppings.
I'm feeding him 3X@day, he gets the vetoryl at 2 meals.
His meals are good sized, approx.one cup of home cooked, 2/3 cup of commercial at each meal X 3 each day.

Thank you for your input!

[Big Fish]

Hi All, So did his test results relate something different than what I wrote previously before? What are your suggestions, monitoring ttrilostane based on appetitie alone with a finicky eater? Thx!

[labblab]

Hi again, and thanks so much for posting those test results. The recent results do indeed appear to be consistent with conventional Cushing's. In terms of distinguishing between adrenal and pituitary forms of the disease, the LDDS results are borderline, in that neither the 4-hour nor 8-hour result is less than 50% of baseline (the 4-hour being just a hair above 50%). But you've told us that your boy has also had two abdominal ultrasounds performed, and an adrenal tumor should have been noted if one was present. So that would lead us to the diagnosis of pituitary Cushing's, as you described earlier.

Just to clarify, though, you've mentioned that both of the ACTH tests were part of full adrenal panels performed at Tennessee? If so, there would have been results given for multiple other hormones in addition to cortisol. When cortisol is elevated, it is not surprising to see elevations in other hormones, as well. I am wondering, though, at what time UTK gave the recommendation for the maintenance Lysodren. Perhaps it was in conjunction with last year's test, when the cortisol was a bit lower. At any rate, that is all water under the bridge now as we move forward with the Vetoryl.

I'm so glad that Sharlene is giving you helpful tips based on her experience with her Molly. I am guessing the main thing in your situation will be watching for any negative signs of overdose such as vomiting, diarrhea, or lethargy. As long as your boy is behaving in a manner that is normal for him, then we'll be assuming that he is adjusting well to the medication.

Marianne

[Big Fish]

Scheduled an ACTH Stim for 7/19. He will have been on full dose of vetoryl for 11 days then. Curious to see his numbers. He's such a stoic dog, plays his cards close to his chest. Looking for his numbers to 'be pretty' as internist said. Wishing for good results. Seems the next ACTH check is again 2 weeks after that? at a month long's time on the drug.
Thanks.

[molly muffin]

The two week test on the full dose is to see how he is tolerating it and then the 30 day test will show you where he is probably going to level at on that dosage.
You'll know if you need to increase or not at that point.

As Marianne said, with a finicky eater, even though he does eat all his meals eventually, you have to monitor more the things that would be abnormal like any vomiting, diarrhea, lethargy that is unnatureal to him specifically.

That is excellent that he is doing so well right now and we will take that as a good sign. Coming down slowly is really the best way even though it does usually involve more of the follow up testing.

[Big Fish]

I'm all about going slow. Rather be safe than sorry. If it costs a bit more here and there, it's worth it to me to have a healthier, happier dog. My dogs probably get better health care than me, LOL, sad but true. Firm believer in setting up a medical protocol that compliments your animal's best needs. I'm looking forward to knowing his test results next week. So far, so good. Thanks again.

[molly muffin]

I'm positive my molly had more doctors than I ever had. hahahhahaa she had two GP vets, IMS, ophthalmologist, neurologist
If she needed it she got it and I don't regret that one bit, ever.
We just do what we have to do for them. :)
You're doing great and we'll see what the numbers are next test

[Big Fish]

Hi Group! Just finished giving my dog his 2x @week medicated bath with Malaket. Wondering from those of you who also have Cushing's dogs with continual skin infections, do they EVER resolve? If so, how many weeks, months, on vetoryl does it take to see some improvement? My dog and I are both looking forward to that day. :-) Thanks! Deb

[labblab]

Hi again, Deb! You'll see I've merged your newest question into your original thread. I understand why you were hoping to target your specific question about skin infection, but we've found that it's best to keep all conversations about a member's dog consolidated in one single thread. That way, we have the entire history to refer to. ;)

As far as resolution of skin infections, I'm afraid that can take some time since it may depend upon an overall strengthening of the dog's immune system. Systemic effects of Cushing's such as hair loss, pot belly, muscle wasting, vulnerability to infection, etc., do take time to improve or resolve. But it sounds as though you are doing a very good job in terms of supportive therapy such as the frequent medicated baths. And, generally, research shows that the topical treatments really can help in terms of skin infection control.

I have a non Cushing's Lab who suffered from recurrent staph infections of unknown origin for several months. Hers did respond to oral antibiotics, but always recurred as soon as the med cycle ended. I hated for her to live on antibiotics, so did some reading and started frequently bathing her with chlorhexidine shampoo, treating lesions with antiseptic spray, and giving her daily oral omega oil capsules. In her case, we suspected food allergy might possibly be a trigger, so we also switched to a food based on a novel protein source and more limited ingredients. It took 4-6 months, but ultimately her skin infection totally resolved. Again, since we don't know the cause, it's hard to know exactly what to credit. But I do believe the topical treatment can be very helpful, so I encourage you to stick with it -- even though bathing our big dogs 2-3 times a week can get to be pretty tedious...:o

Marianne

[Big Fish]

Thanks for adjusting location of post. Unfortunately we have to avoid any of the oils (Omega3s, coconut) which used to be part of his diet pre-pancreatitis episode. Internist was 'thumbs down' on adding those back right now. I tried several topicals, without much success: diluted Bentedyne rinse, TrizChorHCL spray (the smell of which is nauseating to me) neosporin, etc w/o improvement. So we're sticking to the bi-weekly baths. Thank goodness so far he's been a good sport them because trying to get an unwilling 85# dog in a tub would be no easy feat.:-)