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Thread: clinical symptoms combined with ACTH results - Sammi is now in heaven

  1. #11
    Join Date
    Jun 2012
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    Canada
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    16,150

    Default Re: clinical symptoms combined with ACTH results-please ANY suggestions/feedback welc

    Hello and welcome from me too. I could be a stronger batch in the last prescription of trilostane, it could be both drugs together aren't working for her (Simplicef and trilostane) but I would venture to guess that not feeling good with a bout of pancreatis and her cortisol being lower than it is normal is making her feel awful. This could contribute to a panic type of breathing (my thoughts only)
    So what I'd do is no trilostane until the pancreas is normal, she is eating fine and no diarrhea. Then start back at 10/5 or 5/5 dosage to see how she does and then retest after starting at the normal protocol.

    To have a firm diagnosis of protein loss via urine, you want to have 3 consistent UPC test, taking about 2 weeks apart. I prefer first urine of the day, as that is easiest and you can do a drop off at your close vet and have them run the test. If all 3 consistently test high, then you can look into a food with lower protein in it and see how that works. (they should have a dietician at the VCA)

    She might be hanging her head due to the pancrease as quite often you will see a sort of hunch with that, from the pain and hurting.
    Sharlene and the late great diva - Molly muffin (always missed and never forgotten)

  2. #12
    Join Date
    Mar 2017
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    122

    Default Re: clinical symptoms combined with ACTH results-please ANY suggestions/feedback welc

    SAMMI WAS DOING GREAT ALL DAY AND NOW SHE'S BREATHING REALLY FAST WHILE SHE'S SLEEPING. HER MOUTH IS CLOSED AND SOMETIMES ITS NOISY (A LITTLE LIKE SNORTING) AND THEN SOMETIMES IT'S JUST THE FAST BREATHING.

    ITS REALLY SCARING ME. SHE HAD 10MG Trilostane this morning and 5mg last night and 5mg yesterday morning.

    The fast breathing will stop for a little and then start again, but all while she's sleeping.

    We were seeing Dr. Bisignano (internist) at the VCA and then we started seeing Dr. Kaplan (general) only because he did Sammi's teeth and a month later (just the other day) is when she was tested again (ACTH) and we just stayed with him. But I think we're going to stick with the internist there (Dr. Bisignano)

    Dr. David Bruyette is not with the VCA anymore as far as practicing but ironically, when I was panicking on Sunday and Monday I was researching who are the best Cushing vets and Dr. Bruyettes name came up.

    On a fluke, I emailed him and he called us back and we've been emailing back and forth ever since. He really helped us get through the day on Monday. My husband and I offered to take him to dinner and drinks because we couldn't get over how much time he took in answering our questions.

    He looked at her blood work and her past blood work and mentioned a few things about her BUN/creatinine and it could be from a few things but he believed muscle wasting.

    I don't want to wear out our welcome by asking him so many questions and he's definitely answered them all but I was wondering what the opinions were as far as Sammi taking 10mg 1x/day vs 5mg. 2x/day. she was taking the 10mg Trilostane 2x/day and now the general prac. recommended lowering the Trilostane to half of what she was taking (which I agree with) but he said just do the once a day dosing.

    I don't know why that's bothering me because I thought it was better to do 2x/day and just make it 5mg. It's still only 10mg/day but more equal dosages.

    I don't really understand about the pituitary tumor. I understand the difference between the adrenal type and pituitary type but is he saying that this tumor could be growing and that's whats causing her symptoms and how would coming off of Trilostane help it.

    (I copy and pasted below what Dr Kaplan said)
    __________________________________________________ ______________
    "No….changing the formulation could change absorption and throw another variable in there you do not need. I would just decrease to 10 mg once daily and see how she does……patients with Cushings secondary to pituitary tumors sometimes do better with higher cortisol levels for the reason previously discussed—ie sometimes it is better to deal with symptoms of Cushings if it decreases symptoms from the pituitary tumor."

    "I would not get caught up in trying to normalize Sammi’s blood values because I do not believe that would make her feel any better--- and that is what this is all about. I believe that her weight loss, lethargy, etc is due to a pituitary tumor pressing on her hypothalamus. The definitive treatment would be radiation to shrink it. If that is not in the cards, then we might find it advantageous to totally take her off the trilostane if cutting the dose in ˝ did not reverse her current malaise. By taking her off the trilostane, we may further increase her cortisol levels which might decrease swelling of the pituitary tumor—assuming she actually has one."

  3. #13
    Join Date
    Apr 2009
    Location
    Georgia
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    15,292

    Default Re: clinical symptoms combined with ACTH results-please ANY suggestions/feedback welc

    I'm so glad you got the chance to correspond with Dr. Bruyette. He is really amazingly generous with his time! A few years ago, he joined our forum here as a member and for a short time answered questions on the forum. He no longer does that, but he still makes himself available to us via email, too. I sometimes contact him with questions, myself, that are stumping us. I believe he's still the Medical Director at VCA, right? But I guess he no longer has the time to see patients directly. That's too bad!

    Anyway, on to your questions. I think it would be fine to try shifting to the once daily dosing. There are reasons why some clinicians generally prefer once daily dosing and others generally prefer twice daily dosing. But once daily dosing isn't harmful, and remains the recommended dosing pattern of Dechra, the maker of brandname Vetory, unless it appears as though the drug is wearing off too quickly within a 24-hour time period.

    In Sammi's case, yes, I think the vet is suggesting that her pituitary tumor may be growing and thereby placing pressure on the areas of her brain that control hunger, alertness, etc. So for her, there may actually be an advantage to allowing her cortisol level to increase a bit overall, and also specifically within the course of a 24-hour time period. The increase in cortisol may help control swelling of the tumor and ease inflammation of the surrounding brain tissue -- as he says, IF the tumor is indeed actually expanding. That may not be the case at all, but this would be an approach to try if it is.

    Did you happen to ask Dr. Bruyette his opinion re: the dosing switch? You might do so, but based on an actual answer that he posted here on the forum back in 2009, I'm betting he'd be fine with it.

    With regards to once vs twice a day dosing if we look at all the studies throughout the world you will see that about 80% of dogs do well with once daily dosing. One huge advantage of once daily dosing is owner compliance which goes up substantially when owners only have to dose once a day. While twice a day dosing may result in a lower amount of trilostane being used pre day it will require closer monitoring as the ACTH stimulation tests tend to be lower so we have to look for both hypocortisolemia and electrolyte abnormalities.
    Marianne

  4. #14
    Join Date
    Mar 2017
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    Default Re: clinical symptoms combined with ACTH results-please ANY suggestions/feedback welc

    Thank you for explaining that!

    One of my other concerns is the compounding pharmacy Trilostane. We use Valley drug but we'd be willing to switch pharmacies or even switch to Vetoryl if anyone had any suggestions on that.

    I did read where Dr. Bruyette wrote about compounding but I don't know if things have changed since he wrote that.

  5. #15
    Join Date
    Apr 2009
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    Georgia
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    Default Re: clinical symptoms combined with ACTH results-please ANY suggestions/feedback welc

    We are familiar here with an internet pharmacy, valleyvet.com, that sells Vetoryl. However, I don't believe they provide compounded trilostane. So perhaps your Valley Drugs is a local pharmacy there in your neighborhood?

    Overall, I think the same general questions remain re: compounded trilostane -- it may be the case that there is variability in the effectiveness or consistency of some compounded meds. That's why it's important to use a reputable pharmacy. If VCA recommended your compounding pharmacy, though, they ought to be reliable. As an alternative, a lot of our members get compounded trilostane from an internet pharmacy, Diamondback Drugs in AZ.

    If you're considering making a switch, though, you could indeed always try a month or two of brandname Vetoryl, just to see whether that makes a difference in Sammi's monitoring results or behavior. There are several reputable online pharmacies that sell Vetoryl at prices less than what many vets charge.

    Marianne

  6. #16
    Join Date
    Mar 2017
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    122

    Default Re: clinical symptoms combined with ACTH results-please ANY suggestions/feedback welc

    Sammi has another bladder infection confirmed by a urinalysis. The vet is prescribing something for her and hopefully we can start that antibiotic asap.

    This is now day 5 of her taking the 10mg Trilostane, once a day, in the morning (instead of 10mg 2x/day that she was taking for the past year).

    Every evening she has a breathing episode (with the exception of one night - which was last night). She is also breathing very fast in addition to her holding her mouth open with her tongue sticking out, breathing hard. She isn't making the snorting sound as much but I also don't believe it's panting. Just as I said this the heavy breathing in with the snorting sound started.

    She is able to to drink during these episodes and if you distract her for a moment the hard breathing will sometimes stop. It's killing me every time this happens because I can't stand if she's in any sort of discomfort.

    We gave her 12.5 mg. of Trazadone (this is the second time since last Thursday) and it does seem to help, but I don't know if it's the Trazadone OR the breathing episode is just stopping on it's own.

    I have also noticed a little bit of lip licking, sometimes followed by a little burp, and an odd smell when these episodes happen. It's not her teeth because she just had nine extractions and her teeth cleaned 7 weeks ago.

    I'm wondering if it could be acid reflux OR post nasal drip. I'm just trying to figure anything else it could be so I can try to fix it!.

    Does anyone have any clue what these breathing episodes could be and is it possible that part of it is acid reflux or post nasal drip (or anxiety?).

    I'm trying to figure out if there's any correlation to the Trilostane in the morning and then 12+ hours later, the breathing episodes start. But, she also had these episodes while on 2x/day Trilostane.

    This is so upsetting, but right now, I think the 12.5 mg Trazadone is helping her relax because she looks like she's sleeping and snoring peacefully.

  7. #17
    Join Date
    Apr 2009
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    York, PA.
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    11,037

    Default Re: clinical symptoms combined with ACTH results-please ANY suggestions/feedback welc

    These breathing episodes have been noticed by other members in their dogs while on Trilostane and respiratory signs (coughing, congestion) are listed as a side effect in Dechra's product insert: Dechra's U.S. Product Insert

    The lip licking and that odd smell is more than likely due to nausea and/or the reflux as you mentioned, medication for gastric relief, such as Pepcid AC, is generally recommended by veterinarians. I also found this statement in an article:
    Brachycephalic breeds, which are those with a very short, flat muzzle and a wide head, are predisposed to developing gastrointestinal gas, primarily because they swallow excess air while eating due to the unusual shape of their skull.

    These breeds include the Boston Terrier, Boxer, Bulldog, French Bulldog, King Charles Cavalier Spaniel, Pekingese and Pug, among others
    http://www.petwave.com/Dogs/Health/Gas/Symptoms.aspx

    Hugs, Lori

  8. #18
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    Mar 2017
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    Smile Re: clinical symptoms combined with ACTH results-please ANY suggestions/feedback welc

    We're having some of the same issues with our 14.5 yr old doxie. I wanted to share some of our symptoms and findings in case it may help your situation. For your little one, I think the breathing is a stress related symptom. I think as they age stress affects them more.

    Our Petey has been on lysodren for 3 yrs and has done great with it, only 1/4 a pill per day. UNTIL, he had surgery 4 weeks ago to take off some infected wart/mole-y areas and a dental that stemmed 3 teeth to be pulled. He has had several surgeries in his life but he has never been in so much pain. Appears that the stress of the surgery upset his cortisol levels and the lysodren dose is too much for him. At first we thought it was back pain with the hunch back look. The more research I did looked like pancreatitis. After more research it looks like lysodren toxicity. Research said Pancreatitis can be a symptom of lysodren toxicity. He had all symptoms but vomiting.

    When he was first checked it showed glucose in his urine so they tested him all day and it showed normal, the vet said glucose could spill over in his urine from the stress. He was rechecked the next week after I asked the vet if he could have pancreatitis. Tests showed he did, they gave him IV fluids and meds this past tue&wed. I had skipped his lysodren 3 days before that. He appeared to be getting better and she asked that I start him back on the lysodren so we could do the stem test after he was on his normal dose for 2 weeks. He's had 4 days of being back on the lysodren and his stool is totally runny and he's got a bit of hunch back starting again.

    I feel that maybe his stress level is not back to normal yet so his normal lysodren dose may be too much for him right now. Before surgery you would never had known he was 14, he was as spry as a pup. I feel I should hold his lysodren again, I'm calling the vet in the morning.

    I pray that they figure out how to help your baby get back to normal. I'll be looking for your updates.

  9. #19
    Join Date
    Mar 2009
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    rural central ARK
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    Default Re: clinical symptoms combined with ACTH results-please ANY suggestions/feedback welc

    Hi Petey's Mom,

    One thing I wanted to let you know about stress - it can actually RAISE the cortisol making the need for the med stronger, not less. This is one reason this is such a difficult disease to correctly diagnose - a pup who gets stressed simply going to the vet can skew the test results causing false-positive. I am concerned however that his cortisol level may be too low since your vet did not do an ACTH. I would as that that be done asap.

    I also invite you to start a thread for Petey. That way we can talk to you about him there without confusing things. We like to keep all info about each pup in their own thread making it easier on both members and parents. But PLEASE do continue posting to other members!

    Hugs,
    Leslie and the gang
    "May you know that absence is full of tender presence and that nothing is ever lost or forgotten." John O'Donahue, "Eternal Echoes"

    Death is not a changing of worlds as most imagine, as much as the walls of this world infinitely expanding.

  10. #20
    Join Date
    Mar 2017
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    2

    Default Re: clinical symptoms combined with ACTH results-please ANY suggestions/feedback welc

    I am sorry for the delayed response. Thank you so much for the info and for this forum Leslie. I'm not sure how to start a new thread but I'm fixing to look.

    Hugs to all the pet moms,
    PeteysMom, Tara

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