Cushing’s diagnosos 14+ yr old Vizsla - Vetoryl start dose?

[cken]

Hello, We have a 14 1/2 yr old Vizsla (Rumor) . Her appetite, water guzzling, weight , urination, panting, all increased rapidly over 4-8 wks so we took her into the vet for lab work. She was a lean 36 lbs but jumped to 42 very noticeably and she has been very unsettled in comparison. We just found out yesterday as suspected a Cushing’s diagnosis (pituitary dependent). She had been other wise healthy active and well for a dog of advanced years and still liked her long walks and runs so if he can help her comfortably in her twilight years

We’ve read up a bit about Vetoryl dose and the followup testing. The vet isn’t in today but the tech said she wanted to start with a 60 mg dose. This surprised me since she said she would start low yesterday. Based what I’ve read this seems a good bit higher than the 1 mg/lb. Does 60 mg seem right or high for a starting dose for a 36-43 lb ? Is it better to start low and adjust up or vice versa if necessary? Does it depend on her numbers. Baseline precort=8 vs 4hrs=3.4, 8hrs=4.7

TIA and glad we found this site.

[labblab]

We’ve read up a bit about Vetoryl dose and the followup testing. The vet isn’t in today but the tech said she wanted to start with a 60 mg dose. This surprised me since she said she would start low yesterday. Based what I’ve read this seems a good bit higher than the 1 mg/lb. Does 60 mg seem right or high for a starting dose for a 36-43 lb ? Is it better to start low and adjust up or vice versa if necessary? Does it depend on her numbers. Baseline precort=8 vs 4hrs=3.4, 8hrs=4.7

Hello, and welcome! To cut to the bottom line, I would not feel comfortable starting a dog of your girl’s weight on a 60 mg. dose. Your reading is exactly correct. The currently accepted formula is to start at a dose that does not exceed 1 mg. per pound. In order to lessen the risk of overdose or unwanted side effects caused by significantly lowering cortisol levels quite rapidly, it is indeed much better to start low and work upward rather than vice versa.

There’s also a practical reason as to why it’s better to start with smaller dosage capsules rather than larger dosages. This is because you can always combine smaller capsules if dosing increases are warranted. But you cannot open and divide a larger capsule if the dose needs to be decreased. Especially given her age and the fact that you’re hoping to keep your girl as comfortable as possible through this process, I’d honestly advocate for starting at a dose of 30 mg. As I say, you can always combine additional 10 or 30 mg. capsules should an increase be warranted. Two boxes of 30 mg. capsules will indeed cost more than one box of 60 mg. capsules. But you’ll have greater confidence that all the 30 mg. capsules can be put to use over time as you arrive at a stable, longterm dose.

And lastly, no, the diagnostic test result numbers do not influence the recommended starting dose. That decision is based on weight alone. Since dogs respond very individually to the medication, all subsequent decisions are then based on monitoring blood testing in combination with observed symptom resolution. Some small dogs may end up needing larger doses than big dogs, based on their individual physiological response. But in starting off, you’re looking at weight alone.

Once again, welcome to you both!
Marianne

[cken]

This makes sense to me. I’m more concerned with quality of life for her and getting this started than drug costs at this point in her twilight years. 30+10 makes sense for now and once we are started we can find the better price.

Thanks much.

[cken]

We are just starting the dosing on our dog Rumor and didn’t want to delay starting so we went with the Vet clinic drug stock for now and the drug cost were almost triple what it can be purchased for elsewhwere. I understand clinics charge more but almost triple? ... Since changing hands their drug costs are crazy high but we will get the Vetrosyn elsewhere next time.

But I also suspect this Vet clinics labs are way higher too...?

The recommended testing at 10-14 days is the ACTH pre and post cortrosyn stim ($377)
Electrolyte ($40)
Chem17 panel ($105)
Total $522.

I haven't yet broached the pre Vetrosyn cortisol test alternative with them. It this still not done in the US routinely? Communication with this new vet in these COVID times is tough right now, but I will be calling around for alternatives if these costs seem out of line for Central Florida. The former vet was excellent.

Thanks for any thoughts or advice on this testing plan and costs of they seem out of line.

Ken

[Harley PoMMom]

Hi and a belated welcome to you and Rumor!

It would seem to me that the Chem 17 panel would have the electrolytes included, so you wouldn't need to have the electrolytes done separately which would save $40. Now, if you have had a Chem 17 panel done recently I would only have the electrolytes done along with the ACTH stimulation test.

I also want to include a link from our Resource forum that has cost saving ideas for parents with cushdogs: https://www.k9cushings.com/forum/showthread.php?9066-Cost-Savings-for-Owners-of-Cushingoid-Dogs&p=211096#post211096

If this were me, I would start Rumor at a Vetoryl dose of no higher than 30 mg, because there is a published study that has found that larger dogs require less of the recommended dose of Trilostane (active ingredient in Vetoryl) to control cortisol, here's a link to that study:https://onlinelibrary.wiley.com/doi/full/10.1111/j.1939-1676.2012.00956.x

Welcome to our family and please do not hesitate to ask all the questions you have, and know we will help in any way we can.

Lori

[cken]

Thanks Lori, I did see the info earlier on cost saving ideas and one is the “pre-Vetoryl cortisol monitoring as an alternative to the ACTH test, which is why I referenced this above. Simpler, and less expensive. The argument for this approach (cost aside) also seems to make sense.

https://www.dechra.co.uk/therapy-areas/companion-animal/endocrinology/canine-hyperadrenocorticism/vetoryl-monitoring-1?utm_source=directmailing&utm_medium=link&utm_campaign=PreVetorylCortisolSuperPage (https://www.dechra.co.uk/therapy-areas/companion-animal/endocrinology/canine-hyperadrenocorticism/vetoryl-monitoring-1?utm_source=directmailing&utm_medium=link&utm_campaign=PreVetorylCortisolSuperPage)

https://www.dechra.co.uk/therapy-areas/companion-animal/endocrinology/canine-hyperadrenocorticism/vetoryl-monitoring-1 .

Apparently more accepted in the UK. But is anyone here in the US doing this routinely.

[labblab]

It would seem to me that the Chem 17 panel would have the electrolytes included, so you wouldn't need to have the electrolytes done separately which would save $40. Now, if you have had a Chem 17 panel done recently I would only have the electrolytes done along with the ACTH stimulation test.
I wanted to first start off in total agreement with what Lori suggested above. The two electrolytes that you’re most concerned about in relation to Vetoryl are postassium and sodium. Those values ought to be included on a comprehensive blood chemistry panel, anyway, so it would be duplicating the testing to run both panels simultaneously.

As far as how commonplace the pre-pill testing has become in the U.S., I’m afraid I really can’t say. We’ve had a few members who have introduced the procedure to their vets, and are continuing to use it subsequently as an available option as long as everything is looking stable. But we probably haven’t yet had anybody come here whose vet has suggested it first, on their own.

By the way, what dose of Vetoryl did you settle on using?

Marianne

[cken]

By the way, what dose of Vetoryl did you settle on using?

Marianne

Thanks for the responses Lori and Marianne,

We started Rumor on 40mg just under 1 mg/lb. We reconnected with Rumor’s breeder who is also a veterinarian and very experienced and focused on this breed and she thought it was a conservative place to start. So far Rumor is handling the dose OK after a few days. Not getting us up a few times a night now which the biggest improvement, not throwing up, still loose stool even on a rice chicken, whole fat cottage cheese diet. A bit less anxiety and definitely less panting, breathing less noisy..., still has an increased appetite and water guzzling though and still more sensitive to the Florida heat. Its only been a few days. Should we drop the 10mg down to just 30mg or stay the course?

BTW, These were her elevated liver enzymes. ALT: 608 ALP: 1618. GGT: 43. Everything else was in range. How concerning is that?

Thanks,

Ken

[labblab]

Hi again, Ken. From the reaction you’re describing, I think it’s fine to stick with the 40 mg. until Rumor is tested. And I just want to make sure you’ve been advised to give Rumor her Vetoryl alongside a full breakfast. Vetoryl must be given with food to be metabolized properly. Also, the same holds true on the day of her monitoring ACTH test. She should *not* be fasted, or else you run the risk of a cortisol reading that is falsely skewed upward (because the Vetoryl was not metabolized efficiently that morning). Because she needs to be fasted for the ACTH, your vet may choose to hold off a broad chemistry panel until another day since some of those values, such as glucose and cholesterol, do require fasting to be accurate. If only the basic eletrolytes (e.g., potassium and sodium) are to be checked, however, I don’t think they’d be affected by food. That’s something you can check on.

As far as Rumor’s liver elevations, yes, we do commonly see increases in those enzymes. ALP can be dramatically elevated, even higher than this. You’ve not given the normal range for the ALT or GGT, but I’m assuming these are more moderate elevations. These elevations do not necessarily signal functional liver damage, but rather just the effect the steroid (cortisol) is having on her liver. Effective Cushing’s treatment can lower these elevations, but sometimes Cushpups never do completely resolve back to baseline. But that’s typically not cause for significant worry.

Marianne

[cken]

Thanks much for the advice Marianne. I think I misunderstood the starting at 30mg and after discussion with with Rumor breeder/vet who thought 1mg/kg to start for a Viszla (not large) . One 30mg would certainly be better and cheaper if she responds but here we are on 40mg and doing OK and better. She had a more normal-ish poop today this morning finally. We are certainly giving the drug with a full breakfast and adding some whole milk cottage cheese for a bit of fat and know we don’t want to change that for the 10-14 day test.

I will ask about the Chem17 separately with fasting. I will also ask about the pre-Vetoryl cortisol level in what we hope is a maintenance mode.

Here are those liver numbers with ranges. I wish I could figure out how to attach images here.

ALT: 608 Normal Range 10-125
ALP: 1618 Normal Range 23-212
GGT: 43 Normal Range 0-11

Thanks much again.

Ken

[vavinya]

Hi. My Viszula is also 14.5 & recently diagnosed. I’m at a loss at this point. I’ll find her labs & post
Thanks.

__________________________________________________ ____________________________________
Administrative Note: I’ve made a copy of this reply and started a new thread for this member so that we’ll have a specific place to discuss the lab results and any further related questions. Here’s Vavinya’s new thread:

https://www.k9cushings.com/forum/showthread.php?9383-New-member-14-y-o-Vizsla

[cken]

Our old lady Vizsla Rumor is mostly responding so far on Vetoryl 40mg with reduced symptoms and will get her first ACTH followup in a couple days. Less anxiety, not panting, not guzzling water or asking to go out as much like she was at night. She is still eating well but not as ravenous and not looking for stuff to eat in the yard. Still has the potbelly and still gets heated up sooner on the walks in this hot weather, and not running like she was 2 months ago so we go short and easy. If the vet thinks we could/should raise the dose level, I may want to do twice daily to spread out the pharmacodynamics. We have another 14 yr old Vizsla who still runs and a 3 yr old “pup”.

[labblab]

Basically this sounds like an encouraging report to me :-). I hope Rumor’s monitoring testing goes very smoothly. Just another reminder: she needs to take her Vetoryl dose along with a normal breakfast on the morning of her ACTH. Also, the recommendation of Dechra (manufacturer of Vetoryl) and experienced clinicians is to hold off on dosing increases until the first month of treatment has been reached. Even if Rumor’s cortisol is still running higher than you’d like it to be at this first testing, it may continue to lower somewhat during this first month, even if her dose is unchanged. So if you can remain patient for a couple more weeks, you’ll actually have a more accurate sense as to the true effect of this initial once-daily 40 mg. dosing regimen. That will allow you to make subsequent dosing changes with greater confidence as to optimal timing and amount.

Marianne

[cken]

Thanks Marianne, The new vet we are trying wasn't so adamant about the 10-14 day first ACTH because he thinks it is often too early to see a drop in Cortisol, as long as symptoms are improving and there no Addisonian symptoms. He thought 3-4 weeks.. But we are doing 14 days. I will talk to him about the pre-Vetoryl test as well going forward... I hope he will work with is on that.

It does seem like Rumor starts paw licking more again in the evening, probably as the Vetoryl effects wane. But she still isn't asking to go out nearly as much and sleeps all night. Before the drug’s effects 3-4 hrs after breakfast dosing, she is a bit less settled and asking to go out more. In maintenance mode I am wondering if BID dosing would be better.

Does the potbelly eventually go away if we watch the diet? She has always been so lean and the added weight on her belly effects her getting up and squatting (arthritis more noticeable) and breathing in the heat or laying down sometimes. She’d be more comfortable without that belly...

[labblab]

I’m kind of an outlier here in that I don’t really disagree with your new vet’s theory about waiting a bit longer for that first monitoring test, as long as there are no indications of overdose. There are other clinicians who follow that approach, as well. However, from a safety standpoint, you can never go wrong by testing at that 10-14 day mark. In other words, you can never have *too much* information to go by. And yes, hopefully you’ll see improvement in the pot belly over time. But it does take time for the musculature to rebound.

Marianne

[cken]

Just got Rumor’s 14 day post Vetoryl ACTH stim results this evening. Haven’t spoken to the vet yet but based on what I’ve read, these numbers look OK so far.

Cortisol Pre ACTH 2.8 ug/dL
Cortisol Post ACTH 5.0 ug/dL

Most importantly, as mentioned above, for the most part the Cush symptoms have reduced markedly. She has had a couple intermittent days of diarrhea and vomiting and lethargy. The vet is thinking more gastroenteritis than Vetoryl AE and did prescribe Cerenia and metronidazole and it seemed to work well. She had a really good day today. More active after getting going this morning with less rear foot dragging. We are encouraged so far but am wondering if a lower dose than the current 40mg (she’s 43 lbs) could be tried now (30mg) given these numbers? Also BID vs QD? I don’t have an endocrinology background but do have a research and antibiotic pharmacology background so always in pursuit of lowest effective dose and timing.

I also found this nice summary writeup on Trilostane treatment and monitoring: Trilostane Treatment and Monitoring: Is the ACTH Stimulation Test Gone for Good? by Jon M. Fletcher, DVM, DACVIM.

https://www.isvma.org/wp-content/uploads/2019/10/TrilostaneTreatmentan-MonitoringIstheACTHStimulationTestGoneForGood.pdf

Thanks for the help and thoughts. Ken

[cken]

Spoke to the vet today. He also was thinking we could try the lower 30 mg dose (drop the 10) given Rumor’s response so far within 14 days. He also thinks the pre Vetoryl cortisol level testing is a good way to go going forward. Another good day for Rumor.

[labblab]

So glad to get this good report on Rumor! Those initial testing results are certainly excellent. If you want to try dropping the dose, you can do so in an experiment to see whether she continues to maintain adequate symptom control while taking less of the medication. But these first results are very good.

Thanks very much for the link to the article. As the authors discuss, there are reasons why BID dosing may hold advantages. Without any doubt, a dog who exhibits symptom rebound at the tail-end of a 24-hour dosing period may do better when dosed every 12 hours instead. And BID dosing is generally always recommended for diabetic dogs in order to keep insulin and trilostane efficacy as consistent as possible over time. However, after sharing in so many treatment journeys here over the years, I’m inclined to think that if a dog is doing well on once-daily dosing, there may not be a big benefit to shifting. Since trilostane should always be given alongside a meal, timing of the evening dose may become a bit of an issue. Plus, some dogs may actually feel better if their cortisol level is allowed to increase a bit through the course of a day as opposed to remaining consistently more flattened. From a practical standpoint, it can be more expensive to dose twice daily. For instance, if you continue to give brandname Vetoryl, it will likely cost less to give one 30 mg. capsule in the morning as opposed to giving the combination of 10 mg. and 5 mg. capsules both morning and evening.

So, yes, without a doubt there are research studies that have found certain benefits to twice-daily dosing. However, we’ve had many dogs here who’ve done fine with dosing just once in the morning. If I were to have another Cushpup, that’s probably how I’d choose to start off, myself. Whatever you decide, though, I’m so glad to hear that things are going well thus far!

Marianne

[cken]

I and the vet agree with everything you say in the 2nd paragraph. We are trying 30mg QD now and if she’s doing OK so far with QD stick with it. Its certainly easier. She seems to be doing a little better strength wise every day and the potbelly actually seems to be just a bit less prominent.. also, less and less symptom rebounding later at the tail end of the dose. So encouraged. She’s much more herself. Who knows we may have to go down in dose later. The vet said maybe check in 30 days if symptoms are still reduced and she’s still doing well.

Thanks, Ken

[cken]

For our 40 lb dog. How much food minimum do we have to have her injest for her once daily 30mg Vetoryl dose and does it have to have fat or protein content for proper absorption and distribution?

[labblab]

For our 40 lb dog. How much food minimum do we have to have her injest for her once daily 30mg Vetoryl dose and does it have to have fat or protein content for proper absorption and distribution?

Welcome back! You’ll see I’ve merged your question into your original thread about Rumor — we’ve found that keeping all questions and replies about a dog in a single thread makes it much easier for us to give fully informed answers ;-).

Historically, Dechra has always advised us that dosing with a normal full meal is optimal. If a full meal is not possible, then try to give as substantive a snack as you can. In terms of metabolizing the medication, it’s my understanding that including some fat is the key factor, as trilostane is a fat-soluble chemical.

If you’re having issues with feeding, though, tell us more and maybe we can help with some suggestions.

Marianne