Dosage feedback a

[Kit]

My dog a 43/44 lb beagle was just diagnosed with Cushing diesease jointly by vet and vet university about 4-5 weeks after completing a CHOP protocol for stage 4 lymphoma of which enlarged lymph was detected by his dad and we ask our vet to test. We had dog at an emergency center 2 days prior and 1 month before for prostatic cyst and skin condition. Emergency center agreed lymph node felt large but did not suggest anything further. Fast forward to the present and dog is in remission but now Cushings can be added to the list of items this baby has to deal with. He also is taking medicine for seizures and a thyroid condition. Heart slightly enlarged since birth. As mentioned he also has a prostatic cyst which vet and us both agreed the risk to surgically treat is greater right now than the benefit. For cushings, vet prescribed 60mg of Vetoryl but agreed to start with a 40mg dosage after I express concernsbeginning with a dosage exceeding the 1mg recommended on insert. Also vet recommended we continue with enalapril, while university had told us to stop. Only gave dog 2 doses of that medicine before stopping. Vet explained the 60mg is a low dose for a dog his size; not consulted with resident at university. A concern is that dog was not fasted for the low dex testing; I had asked prior and told not necessary.

Dog is losing protein in urine (range 3+) and university ruled out infection or blood in urine as possible cause. ACTH level was at 200 when blood work first completed and 500 7 days later (results are from CBC panel/specific results from low dex testing not shared). Results of low dose dex testing is what made vets diagnose Cushing. The ACTH simulation test results were inclusive...in a gray area. Dog is drinking and urinating excessively. Energy level is lower in evenings and tires easily when playing with our other dog, a 11 yr old. I would like feedback on whether we should start with 40mg instead of the 60mg and increase if blood work in 10 days support or could we be causing more harm by doing so

[labblab]

Hello, and welcome to you and your beagle boy! We’re really glad you’ve joined us, and we will do our best to be of help. Having said that, I’m afraid it will be tomorrow before I can return and write in more depth. Your sweet boy certainly has had a lot going on, and before adding some thoughts, I do want to have the chance to take some time to really think through all this excellent information that you’ve shared with us.

So for right now, I’m afraid that I must head away again for the evening. But I will be back soon, and in the meantime, once again we welcome you both!

Marianne

[labblab]

OK, here I am back again ;-). First of all, if you do proceed with giving the Vetoryl, I strongly agree that I would begin with a dose no greater than 40 mg. I’m afraid your vet may be unaware that initial dosing recommendations have been lowered in recent years, and 60 mg. is higher than would generally be recommended at this time.

However, even beyond the dosing, I have a few other concerns that I want to discuss. First, the LDDS is a test that is vulnerable to returning “false positives” in the presence of bodily stress or illness other than Cushing’s. In other words, an elevated cortisol reading on that test does not necessarily mean that Cushing’s is the culprit. The ACTH can also return “false positives,” but is less likely to do so then is the LDDS. Given your dog’s known lymphoma and recent treatment, it does make me pause a bit upon seeing that his ACTH was normal — it makes me wonder whether that abnormal LDDS is truly indicative of Cushing’s. I would really be interested to see his actual results on that test.

Secondly, I’m assuming the “P” of the CHOP protocol was prednisone. I don’t know how high a dose of prednisone your dog was taking or for how long, but prednisone can cause Cushing’s symptoms, all on its own, and it can also skew testing. I’m assuming the university vet school was aware of the prednisone and felt that a month without prednisone was sufficient time “off” to allow for valid Cushing’s testing, but I did want to mention the fact that it can muddy the water when it comes to Cushing’s. Was your dog drinking and urinating excessively prior to the prednisone treatment, or did that begin afterwards?

I see that there are also other symptoms consistent with Cushing’s, however. Untreated Cushpups often exhibit lowered thyroid readings, and the urinary protein loss can also be secondary to kidney changes prompted by Cushing’s. So the diagnosis may well be accurate. And if so, the question comes down to treatment. As noted above, I would not begin with a dose greater than 40 mg., and likely would not increase the dose during the first month of treatment. This is because cortisol levels often continue to drift downward during the first month, even when the dose remains unchanged.

As far as the enalapril, there are cautions about giving Vetoryl and enalapril together because they are both medications that can negatively affect potassium levels. However, enalapril is used to treat protein loss in the urine, and we’ve had dogs on the forum with protein loss who have successfully taken both drugs at the same time. You do need to be especially vigilant about monitoring blood chemistries, however. So you may want to clarify with the vet university as to whether they view the enalapril as a greater danger than a benefit. Did they suggest any other medication other than enalapril to help treat the proteinuria?

In closing, I’m going to give you a link to a thread on our Resources forum that explains in greater detail the newer, lower initial dosing recommendations. You may even want to print off a copy to give your vet. Once again, we’re so glad you’ve found us, and please feel free to return with any additional questions or concerns.

http://www.k9cushings.com/forum/showthread.php?185-Trilostane-Vetoryl-Information-and-Resources&p=1251#post1251

Marianne

[Kit]

Thank you for informative response. I am not completely convinced it’s cushings and hesitant to start meds but condition seems to be progressing as dog has gotten-up earlier in morning to drink and urinate yesterday and today. He rests in the morning without issues and symptoms are much worse in the evening probably because that is when he’s most active. Also while it seems crazy there seems to certain things that seem to trigger the symptoms - food and feral cats. University did rule out the prednisone because it was stopped earlier in the protocol so it has been more than 5 weeks since last dose. When on prednisone dog did drink and urinate excessively and returned to normal after he did not take for 2 weeks and was fine until about 7 - 8 weeks ago. Started noticing a change towards the end of the CHOP protocol and shared concerns with Oncology. Current symptoms are similar to when he was on prednisone except that he is not waking up multiple times during the night and having accidents in mid-morning. I will try to obtain results of ldds test to post. Found your comment about dogs with Cushing tend to have a low thyroid reading interesting. Dog is now 8 yrs old and was diagnosed with the thyroid condition about 3 years ago. Dog always drank and peed more than my other two dogs which vet contributed to him being intact but when diagnosed with thyroid condition he was drinking even more than usual. And continued to do so until thyroid level was at optimal level. After starting thyroid treatment vet insisted all was well but I pushed and vet then consulted with an internist who advised dosage should be increased and test performed 6 hours after it’s administered. After making adjustment to thyroid med, dog drink and urinating level was more normal but again was more than the other dogs. About two weeks before lymphona diagnosis I started noticing an increase again which is a sympton of lymphona. Once in remission, normal drinking & urination until about 5 weeks ago

[Kit]

I made the difficult decision on Sunday Nov 4 to begin treatment, starting with 40mg of vetoryl. So far I have not noticed a decrease in urination and drinking. Vet said it is too soon and also consider that we started with a dose lower than what was recommended and suggested we increase dosage this Mon, Nov 12 if no change. From reading the posts and Dechra matketing material, it seems like we should have started noticing a positive change if a cushings dog. Dog though seems to be tolerating Vetoryl with no issues..maybe more quiet but not significant and has more stiffness in joints. I would be interested to hear from other members on how quickly they had seen a change after starting Vetoryl and whether they think it is too soon as well based on their experience. Lymphona had spread to liver and spleen but oncologist believes it to be in remission due to lymph nodes are fine. Saw on one of the posts that a dog with a tumor in the spleen had symptons similar to Cushing. Had asked the university internal med and local vet to complete an ultrasound to check spleen and liver as well as to help confirm the Cushing diagnosis and both said not necessary. University did not make any recommendations on how to treat protein loss detected in urine. Local vet said will follow-up with them to understand why they requested enalapril be stopped. Oncologist agreed to perform ultrasound at his next check-up on Nov 20 if we want. However they feel the risk of sedation and discomfort to dog outweighs the benefit.

[labblab]

I truly don’t understand why your vet keeps insisting that 40 mg. is a “low” dose for a 40 pound dog, and it concerns me that he does so. Given the uncertainty about the accuracy of the Cushing’s diagnosis in the first place, if your dog were mine, I would not feel at all comfortable with increasing the dose any further prior to a month of treatment. Excessive thirst and urination are typically among the first Cushing’s symptoms to respond to effective treatment, but it still may take a few weeks, rather than a few days, to see a noticeable difference. Having said that, one key piece of information will be the 10-day cortisol testing. I’m assuming your vet is planning to carry that out prior to making a decision about a dosing change? If not, I absolutely would not increase the dose, no matter what. Increasing the dose without knowing the effect of the current dose on your dog’s cortisol level simply isn’t safe.

Please let us know how he continues to do throughout this week.
Marianne

[Joan2517]

My boy Gable was almost 80 lbs. at beginning of treatment in May. I told my vet we would start him at 40mg. I knew that they probably had 90mg or more in mind. He has done very well on this low dose. It did take a few weeks for his thirst and hunger to slow down, but his health and my peace of mind were worth the wait. And no way would I have let them increase it before the 30 day mark (we haven't had to raise it yet).

My first cushpup Lena was only 5lbs and they started her on 10mg, increased it to 20mg, then to 30mg all within about six weeks. I didn't know any better at that time, but I do now.

[Squirt's Mom]

What Marianne said!