Newbie needs help

[jem69]

Hello everyone. I am needing some help and advice as my vet has been a nightmare and I'm in a state of despair. My 4 year old Bolognese, Teddy was diagnosed with Cushings beginning of August. He is on 30mg of vetoryl once a day and currently weighs 10.6kg. Very over weight and its just going up and up. I have cut food right down and have done nothing different for his weight to rise. He had his 30 day ACTH test yesterday (2nd attempt as my vet did it wrong last week so it had to be repeated!) but his symptons remain the same. Drinking excessively, hungry all the time, panting, won't play and sometimes won't go out for walks. My vet said yesterday that they may have to up his meds. Is that right? I think the dose is high? I can't post attachments by the looks of it so can't put his last results on here but from what I can see when he was tested first his pre ACTH was 466 nmol/L and post ACTH was 599 nmol/L. At 14 day test it came down to pre ACTH 111 and post 64. Has this come down too quick? A note from the lab recommends pre to be less than 200 and post to be greater than 50. They say his dosage is currently perfect. Be interesting to see what the 30 day test results are. If this is the case, why am I not seeing any improvements in Teddy? I am very worried about increasing the dosage on such a small dog.

[Harley PoMMom]

Hi and welcome to you and Teddy!

I am so sorry for the reasons that brought you to us but glad you found your way here. Was your sweet boy's Cushing's diagnosis based with that first ACTH stimulation test? Was an ultrasound or low dose dexamethasone suppression (LDDS) test performed? Also, it is vital that Vetoryl be given with a meal to be properly absorbed and those monitoring ACTH stim test have to be performed 4-6 hours after the Vetoryl is given, have these protocols been followed? Since cushdogs are prone to UTI's and this type of infection will make a dog drink/urinate more, has an urine culture been done to make sure that Teddy doesn't have an UTI? Was a CBC/chemistry blood panel done and if so, could you post any values that are marked abnormal with their reference ranges and units of measurement; as an example: ALT 150 U/L (5-50)...thanks!

Teddy's most recent ACTH stim results (which I have converted to the units we are used to seeing) pre - 4.02 ug/dl ~ post - 2.31 ug/dl, are indeed within the therapeutic ranges, however cortisol can continue to drop for the first 30 days of treatment so please keep a watch out for symptoms of too low cortisol which are: lethargy, loss of appetite, diarrhea, vomiting, or Teddy not just acting right, if any one of these symptoms are noticed than stopping the Vetoryl is advised. When is his next ACTH test scheduled?

I am sorry for all those questions I asked but the more we know about your precious boy the better our feedback will be, and know, we will help in any way we can.

Lori

[jem69]

Hi. Many thanks for your reply. His diagnosis came about with a full biochemstry when endocrinology test was pre ACTH was 466 nmol/L and post ACTH was 599. No ultrasound or LDDS (not sure what that is - is it a separate test?) in which case the answer would be no. The 14 day test yes protocol for 4-6hrs was done. The 30 day test last week wasn't - so was void. Had to be repeated 5 days later (arghhhh). I am waiting for those results. I did take a urine sample in last week and all came back clear - whatever that means. I asked to see the paperwork for it and they can't produce it (again argghhh). Needless to say I have changed my vet and see him on Monday.
The only blood chemistry done was at 14 days. I refused to take my dog back the day after 30 day ACTH test on Monday for this. he was too stressed and to be honest would not let the vet anywhere near him again. It can be done with the new vet next week.
Alerts as follows on 14 day test:
Haematology:
HCT 0.687 High (normal range 0.383-0.565) 1/L units
MCV 84.3 High (normal range 59.0-76.0) fL units
MCHC 27.2 Low (normal range 32.6-39.2) g/dL units
Absolute retic count 120.6 High (normal range 32.6-39.2)
Lymphocytes (absolujte) 0.94 Low (normal range 1.06-4.95)
Monocytes (absolute) 0.07 Low (normal range 0.13-1.15)
Biochemistry:
Total protein 83.5 High
Albumin 45.3 High
Alk Phosphatase 1785 High (reference range less =130.0) units U/L
Cholesterol 7.05 High (ref range 3.20-6.20)
Clacium 2.95 High (ref range 2.36-2.84) mmol/L
and of course his enocrinology as above
I hope you can understand all these results.

[Harley PoMMom]

The LDDS (low dose dexamethasone suppression) is a test that takes 8 hours to perform and is considered the "gold standard" test used to diagnose Cushing's, it also has the capability to differentiate between the adrenal or pituitary form of Cushing's.

Some of Teddy's blood panel anomalies can be associated to Cushing's such as the elevated ALP and cholesterol but generally a dog with Cushing's syndrome have what is called a "stress leukogram," which refers to a specific white blood cell distribution in the blood. This includes a high total white blood cell count with increased numbers of neutrophils and monocytes and a decreased numbers of lymphocytes and eosinophils and Teddy's CBC shows that only the lymphocytes are low.

Exactly what protocols weren't followed with his 30 day ACTH stim test? Glad to hear that you've changed vets and hopefully this one will work out, many of us have had to do the same thing...great job being a excellent advocate for your Teddy! Please keep us updated!

Lori

[jem69]

My boy is on Vetroyl. Does anyone know if it's OK to give Bravecto and Milbemax worming and flea treatments?

[Squirt's Mom]

I have merged your latest post concerning parasite medication usage with Vetoryl in to Teddy's original thread. We like to keep all posts about each pup in one thread. That way it is easier for us all to keep up with the history....plus this thread will serve as a sort of diary of Teddy's cush journey for you.

Since I am not familiar with those medications I did a bit of research and found nothing on either one that says not to use in conjunction with the treatment drugs for Cushing's. I would contact the companies that make these drugs and ask just to be sure tho....however I am a HUGE twitcher and tend to worry about every little thing. :D:rolleyes::D I did find some stories about Bravecto that scared me a bit concerning side effects other dogs have experienced but can be true of just about any powerful medicine like heart worm preventatives. The one I have used with all my dogs, Advantage Multi, has scary stories but I have never had any issues with any dog that used it.

[jem69]

Bit of a stupid question but is the 30 day ACTH test 30 days after the 14 day ACTH test or 30 days from start of medication (i.e. 16 days after the 14 day test)?

[labblab]

Hello from me to you and Teddy! The 30 day test is generally performed one month after the start of medication. We’ve seen some vets vary the exact timing somewhat based on variables that are specific to an individual patient such as starting dose, symptom resolution, adverse effects, etc. But in general, the test is recommended 30 days after starting treatment.

Given Teddy’s continuing problems and significant cortisol drop after the first two weeks on a somewhat high starting dose of medication, I’d definitely advocate for testing earlier rather than later in his case. How are things currently going for your little guy?

Marianne

[jem69]

He’s doing so much better since stopping all meds. We start again after a 10 day break next week on 20mg. He’s booked in for ACTH 14 days after starting and then I’ll book him for another one 16 days after that for the 30 day test. My new vet seems more clued up so hopefully he won’t be over dosed this time. Thanks so much for your advice.

[jem69]

When giving Vetoryl is it ok to give directly before eating breakfast or is it best directly after?

[Squirt's Mom]

If you are absolutely positively sure the food will be eaten, before is ok. It is better to wait and give after the meal or at least half way thru the meal to make sure the tummy has fats onboard so the drug will be absorbed.

[jem69]

I may be having a senior moment here but I am confused with compounded trilostone (I am in the UK). Teddy is currently on 10mg vetroyl once a day. We saw the specialist vet a couple of weeks ago who wants to keep him on 10mg but go to 5mg twice a day. We cant get 5ml vetoryl in the UK so I have picked up compounded liquid from my regular vets this morning. I've got home and it says 10ml on the bottle. Is this right? I don't know why but I expected it to be 5ml. Am I just being thick? Also do I have to leave 12hrs between each dosage? I usually feed at 9am, 12 and 4pm (3 small meals as he has been on a diet). If I understand correctly I would have to give last feed at 9pm? That would be terrible because his appetite has never diminished and he's hungry ALL the time. I've finally got his weight down by 1kg and do not want him putting on any more weight through over feeding. Help!!!

[Squirt's Mom]

Liquid med doses can easily be confusing so don't feel bad. ;) The bottle should say something like 50mg/ml or 10mg/ml or 20mg/ml. Then it will tell you how many ml to give. So if you are using one that says 20mg/ml and you are told to give 0.5ml you would be giving 10mg with each dose (20 x .5 = 10). So the mg per ml (mg/ml) is what you need to know.

As for the timing, it is best to give the med as close to 12 hours apart as possible. So you might start breakfast at least an hour earlier and the feed supper at least an hour later so the med is closer to 12 hours apart. I used Lysodren to treat so someone who used Vetoryl may think differently and I am sure you will hear from one of those users soon....I just know that Vetoryl needs to be given as close to 12 hours apart as possible when dosing twice a day.

How is Teddy doing? Do you know what the results were of his most recent ACTHs? Especially the latest one? Are his signs improving?

Good to hear from you again! Don't panic over the liquid...as soon as you get used to the dosing I think you will find this is a great way to treat because the liquid makes it very very easy to adjust doses as needed. And often makes it easier to give the medication period as those capsules can often be an issue with the pup. ;)

Hugs,
Leslie

[labblab]

Welcome back to you and Teddy! You’ll see that I’ve merged your new post into your original thread about Teddy. This way, we’ll be able to keep track of his entire treatment history ;-).

Switching to liquid trilostane can definitely be a bit confusing to begin with. This is because the dosing instructions have to be given in terms of a *liquid* measurement (like ml.) as opposed to a measurement of weight or *mass* (like mg.). So in terms of liquid dosing, the key issue is how many mg. of medication have been dissolved in how many ml. of fluid. And then, in turn, how many ml. of fluid do you give to make up a dose. The label on the bottle should tell you that, and I’m assuming the concentration of the liquid on Teddy’s bottle means that 10 ml. of fluid will contain 5 mg. of trilostane. But if you’ll tell us exactly what the label on the bottle says, we can help make sure that’s true.

As far as the timing of the dose, I don’t think it has to be exactly 12 hours apart. But it would probably be better if you could stretch it out further then just 7 hours apart. Maybe break his overall total into four meals rather than three, and give the last one at 7:00? Or move breakfast up to 8:00 and shift dinner to 6:00? I think it would be good to try to get at least ten hours in between. But the bottom line is probably just to check back with the specialist. Who knows, he may not care that much about the actual timing just as long as there is some degree of separation with the doses.

Overall, how is Teddy doing these days? It’s great to hear back from you, and we’ll look forward to more updates if you’re able to write again.

Marianne

[jem69]

Hi Leslie. Thanks for your reply on both sites: Teddy has been back and forth to a specialist vet for CT and ultrasound scans as his drinking, panting and still ravenous appetite were back and his liver enzymes hit 3000. Adrenals and liver enlarged and although scans didn't show it the vet has said his cushings is pituitary. Nothing else untoward. He didn't want to increase the dose of 10mg - he weighs 9.2kg but wants to try splitting in to 2 doses a day. He'll have another ACTH in 10 days after starting new regime. So sort of back to square one but I'm hoping with the compounded trilostone we can get a better handle on dosage. He was overdosed on vetoryl by another vet when we first started out on this journey and he nearly went in to Addisons so hence I want to double check before administering anything now. Thanks for your help x

[jem69]

hi Marianne
Im not sure how to attach a photo but all it says on the bottle is 10mg/ml in 50ml bottle. The label from my vet says to give 0.5mls twice daily.

[labblab]

hi Marianne
Im not sure how to attach a photo but all it says on the bottle is 10mg/ml in 50ml bottle. The label from my vet says to give 0.5mls twice daily.
That’s great — that’s what we needed to know. This means that every ml. of liquid contains 10 mg. of trilostane. So in order to give Teddy a 5 mg. dose of trilostane, you’ll be giving him 1/2 a ml. of liquid.

I’m assuming they gave you a syringe or a measuring spoon of some type?

[jem69]

Thank you so much for clarifying Marianne. I can now start him tomorrow instead of waiting to talk to the vet on Monday. Yes thankfully I got 2 syringes.

[jem69]

Hi everyone. My pup has been on compounded trilostane for about a year. Still cant get the dosage right but it's pretty close. Ever since coming off the vetoryl tablets he's had nothing but skin problems especially sores on his feet and now a bacteria eye infection where there is black scaly skin peeling off around his eyes as well as his nose also. Nothing else on his actual body. Has anyone experienced this? I want to take him off the compounded for a month and re start on the veteryl tablets. Is this a reasonable thing to do?

[labblab]

Hello again and welcome back, although I’m sorry Teddy is having these problems. You’ll see that I’ve merged your new question into your original thread about Teddy. This way, we can keep all his information consolidated in one place. And, in looking back through your earlier posts, I see that you made the shift from Vetoryl to compounded trilostane because that was the only way you could arrive at the twice daily dosing schedule that your vet wanted. Has Teddy’s dosing regimen changed so that you could now go back to Vetoryl? If so, I’d see no reason why you couldn’t give that a try. I honestly don’t know that it would make any difference since the type of skin problem that Teddy is suffering from is not one that we commonly see around here. But I don’t think you have anything to lose by giving it a try, either.

Aside from the skin problems, how is Teddy doing in terms of Cushing’s symptoms?

Marianne