Trudy, newly diagnosed - Trudy has passed

[Trudymom]

Hi everyone...I'm new to the forum. I'm glad I found this. My name is Sarah :-) Let me give some background on Trudy.

Trudy is a 15 year old (soon to be 16), female spayed, 30# beagle. Last year, she was diagnosed with bladder inflammation. Further testing (CADET BRAF) has shown she has TCC cancer of the bladder. The GOOD news is there is no evidence of mass/tumor so it's caught early. At this time, we are not focusing on the cancer. We began an NSAID in December 2017 for the inflammation. Starting in January, Trudy began to have elevated BUN. We retested in April and she continued to have an elevated BUN and for the first time, we saw an elevated ALP. In early April, Trudy had steroid injections with hydraulic acid in her knees due to a torn ACL in her left hind leg. We discontinued the NSAID (piroxicam) in mid April.

Towards the end of April, we began to notice Trudys thirst increase. She was also panting and seemed anxious. Looking back, I felt she was drinking a little bit more water, but it drastically increased to where she was constantly seeking out water sources. She also had an increase in urination, also accidents in the house. We tested for a UTI through urine culture and it was positive. We began treatment right away.

Fast forward to early May. We decided to do the ACTH test to see if Trudy had Cushings. It appeared normal or inconclusive? We went to see an internist for a few reasons: elevated BUN, elevated Liver enzyme, TCC cancer. The internist was not convinced that Trudy did not have cushings so she asked our vet to run the LDDS test. Two weeks ago we received word that her results are consistent with Cushings.

Trudy's cushing symptoms: Increase thirst, increased urination, panting (no changes in hair, pot belly, or ravenous appetite; THOUGH she did appear to beg more)

Trudy has a few things stacked against her. Here are some results. Let me know if you need to see more:

May 4, 2018:

05/04/18 Urine Specific Gravity 1.015 Below Normal 1.016 - 1.080
05/05/18 SDMA 21 ug/dL Above Normal 0.000 - 14.000 ug/dL
05/03/18 Alkaline Phosphatase (ALKP) 115.000 U/L Normal 23.000 - 212.000 U/L Ellicott City
05/03/18 ALT/SGPT (ALT) 214.000 U/L Above Normal 10.000 - 100.000 U/L Ellicott City
05/03/18 Amylase (AMYL) 477.000 U/L Below Normal 500.000 - 1500.000 U/L


May 22/23, 2018:

ACTH:

Cortisol Sample 1 6.9ug/dl (normal range 1.000-5.000 ug/dl)
Cortisol Sample 2 18.4 ug/dl (normal range 8.000-17.000 ug/dl)

05/22/18 ALT/SGPT (ALT) 343.000 U/L Above Normal 10.000 - 100.000 U/L
05/22/18 Amylase (AMYL) 570.000 U/L Normal 500.000 - 1500.000 U/L
05/22/18 BUN (Blood Urea Nitrogen) 58.000 mg/dL Above Normal 7.000 - 27.000 mg/dL
05/22/18 Urine Specific Gravity 1.018 Normal 1.016 - 1.080 Ellicott City


June 2018 Internist Ultrasound/bloodwork:

6/8/2018 ALB = 3.3 g/dL 2.2 - 3.9
6/8/2018 ALKP = 366 U/L (H) 23 - 212
6/8/2018 ALT = 267 U/L (H) 10 - 125
6/8/2018 AMYL = 531 U/L 500 - 1500
6/8/2018 BUN/UREA = 48 mg/dL (H) 7 - 27
6/8/2018 Ca = 10.5 mg/dL 7.9 - 12.0
6/8/2018 Chloride = 114 mmol/L 109 - 122
6/8/2018 CHOL = 362 mg/dL (H) 110 - 320
6/8/2018 CREA = 1.1 mg/dL 0.5 - 1.8
6/8/2018 GGT = 28 U/L (H) 0 - 11
6/8/2018 GLU = 109 mg/dL 70 - 143
6/8/2018 LIPA = 650 U/L 200 - 1800
6/8/2018 PHOS = 5.3 mg/dL 2.5 - 6.8
6/8/2018 Potassium = 4.0 mmol/L 3.5 - 5.8
6/8/2018 Sodium = 153 mmol/L 144 - 160
6/8/2018 TBIL = 0.3 mg/dL 0.0 - 0.9
6/8/2018 TP = 7.2 g/dL 5.2 - 8.2
6/8/2018 GLOB = 3.9 g/dL 2.5 - 4.5
6/8/2018 ALB/GLOB = 0.8
6/8/2018 BUN/CREA = 44
6/8/2018 Na/K = 38
6/8/2018 OSM calc = 315 mmol/kg

History:
suspect TCC, lower urinary tract signs
Body Area/Views:
Recheck abdominal ultrasound, compared with a previous study from 12/2017.
Findings:
The urethra measures and appears normal. The bladder is small and normal. The ureteral jets are
normal. The medial iliac lymph nodes are normal. The liver echotexture is somewhat coarse, which is
static. There is gallbladder sludge. The left kidney is somewhat irregular and smaller than previously.
The right kidney has mild renal pelvis dilation at 3.6mm. Both kidneys have somewhat poor internal
architecture. The left adrenal gland caudal pole measures 6.7mm and the right adrenal gland is normal.
Interpretation:
Bilateral kidney changes that suggest chronic disease. The single adrenal gland plumpness is of
unknown significance. The liver changes are static and nonspecific. The abdomen is otherwise
unremarkable, with no lower urinary tract changes to suggest neoplasia.

Fast forward to 7/7/18 (LDDS test):

Cortisol Sample 1 6.0 ug/dl Evaluation: Above Normal Lab Range: 1.0-5.0 ug/dl
Cortisol Sample 2 DEX 4.9 ug/dl Evaluation: Above Normal Lab Range: 0.00-1.4 ug/dl
Cortisol Sample 3 DEX 5.0 ug/dL Evaluation: Above Normal Lab Range: 0.000-1.400 ug/dl


Hope all this is not overwhelming because it sure is to me LOL!

She started Vetoryl 13 days ago. 10 mg twice a day. She goes tomorrow for her ACTH test. Some concerns I have is her appetite is changing. She is supposed to be on a kidney diet and now she's refusing to eat the prescription food. I'm having to dress up her food in order to convince her to eat. She seems a little lethargic too. Less energy. Odd thing is she begged for food before. She still seems to beg (arrooo/bark) for it but when you put something in front of her, she's not excited (unless it's people food)

I'll share all this tomorrow, but I would love any thoughts. I'm getting her to eat, but it is a little struggle for a beagle who has never refused food before in her life. Thanks :-)

[labblab]

Hello Sarah, and welcome to you and Trudy! I wish I could write a more complete reply to you right now, but we’ve had kind of a flurry of new memberships and I want to make sure I have the chance to carefully review what folks have written prior to posting.

However, in advance of Trudy’s monitoring ACTH tomorrow, I want to make sure you’ve received the instructions given by Dechra, the maker of Vetoryl. Trudy should be given her Vetoryl along with a normal breakfast (she should NOT be fasted), and the test performed 4-6 hours after dosing. Some clinicians do prefer to test a bit soon after dosing — like within 2-3 hours. However, being dosed along with food is most important, regardless of timing. In order to be metabolized properly, trilostane must be administered along with food. Otherwise, it won’t lower the cortisol level as effectively, and a vet may mistakenly believe that a dosing increase is in order. Actually, Dechra generally counsels against increasing a Vetoryl dose at the 14-day mark, regardless, since cortisol levels often continue to drift downward throughout the first month of treatment, even though the dose has remained unchanged.

Good luck with your test tomorrow, and I’ll look forward to talking with you much more about Trudy’s situation.

Marianne

[Trudymom]

Thank you for your response. Timing should be good. She eats at 6am and will be dropped off around 9am. I was instructed to feed her normally and give vetoryl with her meal. She gets it with breakfast and dinner each time too. It will take a day or two to get the results. I'll be sure to post here. Thanks again!

[Harley PoMMom]

Hi and welcome to you and Trudy!

Gosh I am sorry sweet Trudy has so much going on right now, and the loss of appetite is worrisome. I know when one of my boys didn't want to eat how frantic I felt and how frustrating it was trying to find something that would entice them. Sometimes heating their food helps.

Did the piroxicam put the TCC in remission? And if not, how does this affect Trudy's demeanor? I ask this because, unfortunately, with the LDDS test any non-adrenal illness can yield a false positive result, so I do have some reservations regarding her Cushing's diagnosis. Also, was her urine cultured again after the antibiotics were finished to make sure it was completely gone?

Please know we will help in any way we can, and if you have any questions don't hesitate to ask them.

Lori

[Trudymom]

Hi Lori....so with regards to the TCC, there is a test called the CADET BRAF test. It picks up this cancer really early. Most people don't run it until they have symptoms. We did an US on her back in December and found bladder inflammation/thickening. Well, Trudys' sister had bladder cancer 3 years ago. The recommendation was to do a biopsy on Trudy, but since I knew about this test, we decided to run it instead. There can be false negatives, but very rarely do you see a false positive because you SEE TCC cells in the bladder. In Trudys' case, she does not have any signs of the cancer. In fact, her inflammation has gone away. We did another US a few weeks ago, no signs. We saw the oncologist two weeks ago and have decided to focus on the Cushings right now.

She did have urine culture again to verify the UTI was gone. We actually ran another one last week because she is still peeing and having accidents so we will find out today whether it's positive or not.

Here's what I am wondering. It almost seems like a poor appetite can be expected in cushings dogs while they begin medication? I'm trying to gauge that because our vet mentioned holding the vetoryl for a couple of days if her appetite continues to go down. She is eating though. Is this all par for the course being on Vetoryl for some dogs?

[Harley PoMMom]

During the first 10 days of treatment a small percentage of dogs can go through cortisol withdrawal syndrome and a loss of appetite is one of those symptoms. However, it always makes me nervous when a dog has inappetence, especially beagles as they are known for their passion for food!

Trudy's ACTH stimulation test is today, right? And if so, than I would give her the morning dose of Vetoryl (as long as she is eating it with a meal) and proceed with the ACTH test. Afterwards if her appetite is still waning than I would discontinue the Vetoryl until the ACTH stimulation test results are known. They are going to be checking her electrolytes too, right? If they didn't plan on checking them I would recommend it.

Lori

[Trudymom]

Oops...no they did not check her electrolytes. Can I ask why you would recommend that?

She ate breakfast at 6am with her Vetoryl (ate really well) and they drew her first sample at 9:15. We will get results tomorrow. She ate really well last night too, but ate maybe half this morning. I gave her some wellness topper and she ate it right up. This is the first time Trudy hasn't been a good beagle eater. The doctor said as long as she continues to eat. We are dealing with the kidney stuff too so need to watch that.

We did find out she has a UTI which makes me feel better. I feel like the panting is a lot improved. The drinking is improved about 50% or so but the urination wasn't. She had 3 types of bacteria :-( We gave her the first dose of antibiotics last night.

[Harley PoMMom]

Trilostane (which is the active ingredient in Vetoryl) can lower aldosterone. Aldosterone helps maintain electrolyte levels so even if the cortisol is within therapeutic ranges there could be an imbalance in the electrolytes. Dechra, the makers of Vetoryl state in their product insert that the electrolytes should be checked along with every ACTH stimulation test:
...After approximately 10-14 days at this dose, re-examine the dog and conduct a 4-6 hour post-dosing ACTH stimulation test and serum biochemical tests (with particular attention to electrolytes, and renal and hepatic function).

3. Individual dose adjustments and close monitoring are essential

Re-examine and conduct an ACTH stimulation test and serum biochemical tests (with particular attention to electrolytes, and renal and hepatic function) 10-14 days after every dose alteration. Care must be taken during dose increases to monitor the dog’s clinical signs...

4. Long term monitoring

Once an optimum dose of VETORYL Capsules has been reached, re-examine the dog at 30 days, 90 days and every 3 months thereafter. At a minimum, this monitoring should include:

• A thorough history and physical examination.
• An ACTH stimulation test (conducted 4-6 hours after VETORYL Capsule administration) - a post-ACTH stimulation test resulting in a cortisol of < 1.45 g/dL (< 40 nmol/L), with or without electrolyte abnormalities, may precede the development of clinical signs of hypoadrenocorticism.
• Serum biochemical tests (with particular attention to electrolytes, and renal and hepatic function).
Good control is indicated by favorable clinical signs as well as post-ACTH serum cortisol of 1.45-9.1 g/dL (40-250 nmol/L).

Dechra's U.S. Product Insert (http://www.dechra-us.com/Admin/Public/Download.aspx?file=Files%2fFiles%2fProductDownload s%2fus%2fvetoryl-5mg-pack-insert.pdf)***

Glad to hear that her eating has picked up but so sorry about that UTI, they can be difficult to get rid of so hopefully those antibiotics will kick that UTI's butt.

Lori

[Eve]

My dog had appetite loss when he started Vetoryl. I'd say he got back to normal after 6 days.

Eve

[Trudymom]

It's been two weeks. She didn't eat as well yesterday but did all her breakfast this morning. It's going to be a balancing act.

[Trudymom]

Hi there...So Trudy had her first ACTH results (day 14). She's on 10 mg, twice a day.

Her results:

Lab Result Evaluation Range

08/01/18 Cortisol Sample 1 4.3 ug/dL - 1.000 - 5.000 ug/dL
08/01/18 Cortisol Sample 2 6.5 ug/dL Below Normal 8.000 - 17.000 ug/dL


I heard it was a good spot. She will continue and be retested on day 30.

Question for you. I am in a facebook cushings group. I am learning a lot there too! I'm curious if you guys compound your Trilostane? I was told it was a lot cheaper to do it, but in order for it to be compounded it, it cannot be a dose that is already made. (Vetroyl has 5, 10, 30, 60 mg). So what some members do is take a 10 mg dose and instead compound it to 11 mg and it ends up being much cheaper for tablets...a lot cheaper!

I'm curious if folks here in this group do that.

[LauraA]

Hi Trudy. Yes Trilostane is so much cheaper than the named brand Vetoryl. I am not sure where you are from but in the US you do have to get a dose that Dechra does not make. However I am in Australia and we can get any dose we want in the compounded trilostane. If you are in the US then Diamondback drugs is the most trust worth and cheapest place to get it. I would wait till your 30 day test and then you can see what combination of dose will be most effective as the cortisol will continue to come down a bit more at this stage. The 6.5 is a good place to be at this stage but if you notice any signs of cortisol going too low then you can do the stim test a bit earlier :)

[Trudymom]

Cool! Thanks Laura! I think I hesitated just a bit because my vet consulted with our internist who did not recommend compounding the trilostane. I was surprised. As for waiting 30 days, yes, we are doing that. Since we are testing on day 30 and her vetoryl runs out on that day, we are getting another box. Here in the US you can't compound any dose that is already available so it would have to be 11mg instead of 10 mg. It's more than twice as cheap. I'm glad my regular vet is willing to do it as she knows we are juggling other diagnosis' as well. Thanks again Laura!

[labblab]

I’m very glad that Laura was able to give you the info about compounded trilostane availability here in the U.S. She’s exactly right in what she’s written. One note that I’ll add is that the reason why some vets are cautious about recommending compounded trilostane, however, is because a research study has shown that some versions are more variable than is brandname Vetoryl in terms of dosing accuracy and drug effectiveness. The study did not name the pharmacies that made the versions they tested, so it’s impossible to know from the research which pharmacies are ones to use and which are to be avoided. As a result, we must rely on our trust in using pharmacies that have established a good reputation among our members. As Laura has written, Diamondback is one that is at the forefront.

Given these general concerns about compounding, however, I also strongly agree with Laura that I would wait until my dog was stabilized on a given Vetoryl dose to make a change to a compounded product. Once you’ve established where the cortisol level is holding on Vetoryl, you’ll have a better idea as to whether or not the compounded version is maintaining the same level of control and consistency. I do agree that your first ACTH result for Trudy is in a good area, and hope you guys will see continued improvement!

Marianne

[Trudymom]

That is our plan to have her stabilized first.

Trudy seems to be struggling. She is more lethargic. Doesn’t want to do anything. We are still struggling with appetite. She eats but I have to add beef, chicken, broth, stew. The dr suggested maybe trying once a day to see if it helps.

I’m not sure what to do. Someon suggested we stop the meds for now. This would mean symptoms return too ��. What would our options be if she can’t hsve this med?

[Squirt's Mom]

Lack of appetite is a sign the cortisol has gone too low which can be life threatening. Personally I would stop the med and have an ACTH done to see where the cortisol is today. That's me tho. ;) Others will probably disagree. LOL

[Harley PoMMom]

The inappetence could be due to the antibiotic she is on for the UTI.

Another thought is that her electrolytes may be unbalanced and/or since she has kidney issues the phosphorus may be elevated which can cause a dog to lose it's appetite.

[Trudymom]

she began the inappetence very soon after starting the vetoryl. Her kidney disease is in early stages. Her creatinine and phosphorus were all normal two days before she began taking the vetoryl. She started taking the antibiotic on day 14 when her ACTH was done and was in the good range and she was already have appetite issues.

I feel like it's the vetoryl unless it's something else we don't see. I have a consult with her doctor today and I'll have the urine culture results today. Her last antibiotic was last night too. I believe we will stop the meds, at least for a few days to see if that's the definite cause.

[Harley PoMMom]

Has her urination/drinking normalized since being on the antibiotic? And are they going to do a repeat urine culture to make sure that the UTI is completely gone?

I think discontinuing the Vetoryl to see if her appetite picks up is a great idea.

[Trudymom]

After I posted I heard from the doctor. Her UTI seems to be resolved but they will redo a urine culture in one week to be sure. Not sure if I said this or not but she started the antibiotics two weeks after starting vetoryl. Her panting improves quite a bit and her drinking was getting better. As for urinTiin, not quite on par so I asked for a urine culture. It was positive. I have seen improvement on the antibiotics.

I would say the drinking is more than 75% improved and panting 100%. BUT now she’s lethargic and appetite is worse. Sometimes she begs for something human though so go figure.

[Trudymom]

I wanted to share that we let Trudy go today. We are almost certain she had cancer. We stopped the Vetoryl a week ago to see if there was improvement. Her appetite improved just a little bit, but she still didn't have much energy. I'm not sure if I mentioned it or not but she had a fast growing mass on her neck that was found less than two weeks ago. We tried to aspirate it and it was "inconclusive". We believe now it was cancer. We decided to let her go because we love her.

Thank you for your support. I will continue to pray for all the babies with cushings disease.

[Joan2517]

I am so, so sorry for your loss....

[labblab]

I, too, am so deeply sorry. You’ve made the decision that is the most merciful for Trudy, but we know how much you must be hurting, yourself. We hope it may give you some comfort to know that Trudy has now joined our other angel babies on our memorial thread of honor:

http://www.k9cushings.com/forum/showthread.php?8846-Remembering-All-Who-Have-Left-Us-(2018)

We will always remember Trudy, and we’ll always remain here to offer our support to you in the days ahead. Please know that we’ll welcome you back at any time should you wish to talk, to share memories, or just to let us know how you’re doing. Trudy was a sweet brave girl, and we’re honored that she will remain a member of our family, always.

Marianne

[joalgopa]

I'm so sorry for your loss. I'm new to this forum too but in the last few weeks I've found a lot of support and learned a lot here, thanks for sharing your experience with us.

[Squirt's Mom]

Dear Sarah,

I am so sorry to hear about your precious baby girl. What you feel today is a pain I, and many others here, know only too well. Some people think we are weird or nuts because we grieve so deeply for an "animal". What they don't realize is those "animals" are our family, our children in many cases, and we hurt deep in our Souls because we love them just as we would family. When they have to leave this life the hole left behind in our Souls is vast. Every tear we shed is in honor of that love shared with our babies. So grieve as long as you need, in any way that you need to honor your baby girl, Trudy. And know you are not alone, ever. We are here any time you wish to talk, cry, vent, scream, whatever - we DO understand.

My deepest sympathy,
Leslie


May I Go Now?

May I go now?
Do you think the time is right?
May I say goodbye to pain filled days
and endless lonely nights?
I've lived my life and done my best,
an example tried to be.
So can I take that step beyond
and set my spirit free?

I didn't want to go at first,
I fought with all my might.
But something seems to draw me now
to a warm and loving light.
I want to go
I really do.
It's difficult to stay.

But I will try as best I can
to live just one more day.
To give you time to care for me
and share your love and fears.
I know you're sad and afraid,
because I see your tears.

I'll not be far,
I promise that, and hope you'll always know
that my spirit will be close to you
wherever you may go.
Thank you so for loving me.
You know I love you too,
that's why it's hard to say goodbye
and end this life with you.

So hold me now just one more time
and let me hear you say,
because you care so much for me,
you'll let me go today.

- Written for a beloved pet & friend, by Susan A. Jackson

[Harley PoMMom]

Dear Sarah,

I am so sorry for the loss of your precious girl and my heart goes out to you and your family. Making the decision to set them free is most difficult but it is made from the deep love that we have for them. Please know we are here for you and do understand the pain you are feeling so if you should need to talk, vent, or want to share anything just come here and we will listen.

With Heartfelt Sympathy, Lori