Pre pill cortisol test

[Hannah1108]

Hi, I was wondering if anyone knows whether the pre pill cortisol test can be done before 28 days or should it be the acth stimulation test done? My dog is booked in for a 14 day pre pill test but wasn’t sure if it’s too soon/not the right sort of test for that time frame? Hoping someone may be able to just confirm it’s the right test as I’m worrying about an incorrect result coming back due to the wrong test being done!

Thanks so much.

[Squirt's Mom]

If your baby is booked at 14 days after starting treatment with Vetoryl then the test will be, or SHOULD be, the ACTH and not the PVC. I would call the vet to make sure which test is being used so you know what you are supposed to do in preparation. The instructions for you will be different depending on the test used. If you are in the UK the odds are it will be the PVC but some vets in the US are starting to use this newer test. So I would call just to be safe. Be sure to get the info from the vet and not the tech or individual who answers the phone. ;) Sadly all too often the incorrect info is given if the vet isn't involved.

Hugs,
Leslie

[labblab]

Hello from me, too! In checking back, I see that you posted to our group back in 2017 when your dog at that time was diagnosed with a pheochromocytoma and you were considering surgery. Here’s a link to your earlier thread:

https://www.k9cushings.com/forum/showthread.php?8428-Pheochromocytoma-and-Cushings-operation-advice

Is the dog that you’re asking about today the same dog, or do you now have another Cushing’s baby that you’re caring for? If it’s the same dog, we’d love to get an update as to what’s been happening for you two during this intervening time. If it’s instead a different baby, we’d love to get a bit more info about his/her history and diagnosis.

Having said that, in answer to your question, I’m going to offer some differing thoughts. I must first warn you that I’ve had no personal experience with pre-pill monitoring myself, and we’ve not had a lot of dogs on the forum who have been monitored in this fashion. So our experience here has been limited. I know that Leslie has been busily helping with some other internet Cushing’s groups in addition to ours, so she may have been exposed to some different recommendations that she can share with us.

But from the recommendations I’ve seen thus far that come directly from Dechra (maker of brandname Vetoryl), they say pre-pill monitoring can be used at any time in place of the ACTH, with one important qualification: the dog must appear to be well. If the dog seems ill — and especially if oversuppression of the adrenal glands is suspected — a full ACTH should be performed. So if your dog is looking well and behaving normally, then I think Dechra would say that pre-pill testing at the 14-day mark would be fine. Here’s quite a long publication from Dechra that contains this information:


The Vetoryl dose should be titrated according to individual response as determined by monitoring of clinical signs and laboratory test results.
Assessment should be performed pre-treatment and then at 10 days, 4 weeks, and thereafter every 3 months, following initial diagnosis and after each dose adjustment.
A positive response to Vetoryl therapy is regarded as an improvement in clinical signs and a Pre-Vetoryl Cortisol concentration of between 40 and 138 nmol/l.

https://www.dechra.pt/Files/Images/dechra-website/Superpages/Vetoryl/UK/Product-support-piece.pdf

So if your vet is familiar with the pre-pill protocol and has used it with success, I think you should be fine. But we all can definitely discuss this further, and as I say, we’d love to learn more about your Cushpup.

Marianne

[Hannah1108]

Thanks Leslie. I am in the U.K. she’s booked in for a test 14 days after starting vetoryl and it’s the pre pill cortisol test. Do you happen to know if the pre pill test gives an accurate result if carried out at this 14 day period? I don’t want to end up with a false high/low result.

[labblab]

Hi again — I think we were typing at the same time. I just want to make sure that you have a chance to see the Dechra quote that I included in my reply above. I believe they’d say it’s fine to perform the pre-pill testing at the 14 day mark.

Marianne

[Squirt's Mom]

Here is a flowchart for the PVC using the mnol units seen most often in the UK:

https://drive.google.com/file/d/1gqUchP2gvFIyG8udZgNS1bWfppWW6fin/view?fbclid=IwAR2TDEnFt5570_b1CeC6XBSf3wHHzSSLzW4I UpSlGWUxYE37t8WPWNZMHcA

This is what I based my comments on above and how we typically see this test performed - at the 28 day mark with an exam and discussion of history to date around the 10 day mark. I don't think there would be any harm in doing the PVC at 14 days at all. :) What Marianne said about which dogs are best suited to this test is important.

I will do some questioning about the timing and get back to you. Heaven knows there is always more to learn about this disease and its treatments! :D

Hugs,
Leslie

[Squirt's Mom]

I questioned those who understand the PVC better than I and here is the response:

"I have wondered why it's okay to skip testing at 10 to 14 days when using the PVC test but it's necessary for the ACTH stim test. To answer your question, according to PCV protocol which you can find in the comments in our pinned post, no test is necessary until day 28 after starting dosing." The "pinned post" is the PVC flow chart I posted above.

So this may be yet another gray area we don't have clear answers to just yet.

Hugs,
Leslie

[Squirt's Mom]

And this is the take on the quote from Dechra...the "assessment" is referring to the examination and discussion of history to date, not the actual blood work....but again, this is new territory for us all and we are still learning. Since you are in the UK your vet can call Dechra and get clarification, to find out if it really does matter whether they test at 14 days VS 28 days. In the US Decra can't share anything with vets about the PVC because our FDA hasn't yet approved this test. If your vet does make this call it would be wonderful if you could share what Dechra tells them about this timing! ;)

Hugs,
Leslie

[labblab]

Thanks so much for your added thoughts and clarification, Leslie. In honesty, even in terms of the ACTH, I think there has always been somewhat of a gray area in terms of the advisability of testing at the 10-14 day mark vs. waiting until the end of the first month of treatment. Dechra’s published guidelines have always recommended the earlier ACTH testing, but a certain number of experienced clinicians have ended up permitting their patients to wait for a month — so long as the dogs do not appear to be unwell. I may be wrong, but I think Dr. Ramsey may have been one of those clinicians. I need to try to search our archives about that. But especially if so, it really doesn’t surprise me that the monitoring guidelines for the pre-Vetoryl protocol omit a mid-month testing since Dr. Ramsey has been instrumental in establishing that guidance.

Whether or not my recollection about Dr. Ramsey is correct, I believe the chief goal of the earlier mid-month ACTH testing has always been one of safety: to make sure a dog’s cortisol production is not being oversuppressed. Dechra warns that doses should rarely be increased mid-month due to the likelihood that cortisol will drop further during the month even when the dose is unchanged. So the only medication change that the mid-month testing should prompt would be a decrease if oversuppression is feared. To that extent, it seems to me that a pre-pill test or a full ACTH would be serving the same purpose in that regard. Neither may actually be necessary as long as a dog seems to be well. But either could help supply reassurance that the cortisol level hasn’t dropped too low. So that’s a very long way of saying that the current pre-pill protocol may not require mid-month testing, but I wouldn’t see any harm in performing the test and it may provide added reassurance that you’re on the right dosing track.

For sure, though, as Leslie says we’d love to hear any direct clarification from Dechra regarding the pre-pill protocol!

Marianne

[labblab]

Aha, here’s a quote from a summary paper on trilostane treatment that Dr. Ramsey published clear back in 2010. As you’ll see, he was rather dismissive of the early mid-month ACTH testing clear back then. So as I say, it doesn’t surprise me that his newer pre-pill protocol would omit it now unless a dog appears to be unwell. But still, if your vet prefers to get a reading on your dog’s cortisol level at the mid-month mark, I would simply view it as added information going forward.


In the 6 studies listed in Table 1 the frequency of monitoring is one of the most consistent features. However the basis for this frequency is not clear. The caution of the early studies may not be appropriate now that more is known about the response to trilostane. In particular the clinical signs and cortisol concentrations continue to improve in most dogs in the first month [18, 20]. Performing an ACTH stimulation test 10 to 14 days after starting therapy is likely not to be so useful as changing the dose at this stage would risk increasing the dose of trilostane too early. Very few cases indeed develop trilostane overdosage in the first 2 weeks of therapy. A review consultation should be adequate and an ACTH stimulation test only performed if adverse effects have been noted. Monthly monitoring for the first 3 months followed by 3 monthly monitoring for the first year followed by 4 to 6 monthly monitoring thereafter may well be adequate.


http://eprints.gla.ac.uk/30479/1/30479.pdf

[Squirt's Mom]

At one time Dechra had a very good video of Dr. Ramsey discussing his findings but the link to that is broken indicating Dechra has removed it. Several are now searching for it and I will share it here if it's found again. Thanks for posting that from the paper on the study of the PVC, Marianne!

[labblab]

I’ve been looking unsuccessfully for that video link, too! I’m fearing that Dechra may have removed a lot of their Vetoryl treatment and monitoring info from public view. If so, that’s *really* maddening! I guess I shouldn’t make premature accusations, but I’m suddenly finding a lot of broken links to stuff that was previously available to us :-((((...

I’ll keep looking, too!

Edited to add: OK, I’m back from searching Dechra’s website, and it looks as though Dr. Ramsey’s video — as well as other in-depth info — is now only available to “Veterinary Professionals” who register and log in. Only a limited number of brochures are still publicly available to “Owners.” How annoying!!!!! I believe I’ll be giving Dechra a call to convey my surprise and displeasure. Good grief. :mad:

https://www.dechra.co.uk/therapy-areas/companion-animal/endocrinology/cushings-disease

[Hannah1108]

Thank you so much for all of your replies and sorry for the delay in responding. I did read them at the time but just didn’t have the time to properly reply. We had another diagnosis of a mast cell tumour and possible lymphoma, investigations are still ongoing.

Our other dog, shyla, who had the diagnosis back a few years ago is still with us. She is still monitored regularly to make sure she’s doing ok but in herself she is generally well. She remains on cerenia and phenoxybenzamine. Recently she has been having some weakness in her back leg and she had protein and blood in her urine a few days ago which she’s been put on antibiotics for. Waiting to see now if the antibiotics clear it up or not though. I wonder whether anyone has had any experience of this being related to the Cushings?

[Squirt's Mom]

Urinary infections, and hind leg weakness, are common in cush pups so I hope the ABs solve the issue. How is she doing?

[Hannah1108]

She is doing ok thank you. She’s just had some test results back which show that the mast cell tumour she was diagnosed with hasn’t spread and that the lymphoma is indolent which is all relatively good news. They have mentioned the possibility of starting chemo though which is worrying me a little bit with her Cushings meds. They are possibly going to start her on prednisone but I’m not sure how this will impact the vetoryl? Or the best way to juggle it if it’s a case of needing to choose just one. At the moment the Cushings is quite well controlled with the vetoryl. I have read that vetoryl can actually make the cancer grow quicker. They have been monitoring the growth of the abdominal nodes and until her most recent scan, growth had been slow but the most recent scan shows more significant changes in size.

Thank you for anyone who reads this, your comments are always so helpful on this group

[labblab]

Welcome back to us! We’re glad to hear about the relatively good news, but sorry to hear that you’re still facing some challenges. Am I correct that the prednisone is being considered for treatment of the lymphoma (and is that what you mean in terms of the abdominal nodes)? In the past, we’ve had a few dogs who were diagnosed with both Cushing’s and lymphoma, and I need to go back and try to track down the treatment decisions that were made. I *believe* that sometimes both prednisone and Vetoryl were given. On the face of it, that sounds paradoxical since prednisone increases circulating steroids and Vetoryl lowers them. However, I think there may be a rationale for keeping the natural cortisol production under control so that the supplemental prednisone can be given in a predictable and consistent dose. Take those comments with a grain of salt, though, until I can track down those threads and add some links here.

Also, if I’m confusing things and the abdominal nodes are related to something other than the lymphoma, then it’ll help us if you can tell us more about those nodes. So we’ll await some further info from you, and I’ll start looking for those threads about Cushing’s/Lymphoma treatment. In the meantime, once again, we’re so glad to have you back.

Marianne

[labblab]

OK, I’m quickly back with one link to add. The thread dates clear back to 2014, but it involved conversation with two of our members who had dealt with both lymphoma and Cushing’s. Unfortunately, neither of those members have been active here for many years, but perhaps the info they discuss may be helpful to you. Of course, this is assuming that lymphoma is indeed the cause for the talk about chemo for your dog. On the face of it, I don’t see them talking about a Vetoryl/prednisone combo, so I may be dreaming that up in relation to lymphoma. You’ll see that one of the members does discuss discontinuing Lysodren (an alternative Cushing’s med) in lieu of prednisone in order to allow the natural cortisol production to increase. However, as I say, this is now dated info, and perhaps the treatment protocols have changed,

If you’re a Facebooker, one of the most helpful bits in this thread may be a link to a Facebook group that is dedicated to canine lymphoma. They may actually be able to help you more than we can in terms of current treatment goals. Anyway, here’s a link to our forum thread here:

https://www.k9cushings.com/forum/showthread.php?6384-cushings-and-lymphoma

And here’s a link to that Facebook group:

https://www.facebook.com/groups/LymphomaHeartDogs/

Hope this may help.

[Hannah1108]

Thank you that is all really helpful. That’s correct re the nodes and chemo being related to The lymphoma diagnosis. I’m going to have a look on the Facebook groups. I appreciate the time taken to find that thread from
2014 though! That was our thoughts with regards to one mrs lowering and one med increasing the cortisol. It’s very confusing!

[labblab]

Yes, the Cushing’s/Lymphoma combo surely does seem to make things more of a jumble. Perhaps just lowering the Vetoryl dose a bit to allow the natural cortisol to rise might be an alternative to prednisone, at least as a trial. That would duplicate Bettina’s lowering of the Lysodren for her dog. But her Nico was also taking some other chemo drug as well. Anyway, I do hope the Facebook group will be a good resource for you. Over the years, we’ve heard very good things about that group, so I hope folks are still actively posting there.

And I’ll keep nosing around in our archives over the next few days, and I’ll post additional links here if I come across any more that seem helpful.

Marianne

[Hannah1108]

Thanks again marianne