GSD with Cushing's - Kaiser has passed

[Junebugs]

Were his electrolytes checked? If not, I would want to verify that those electrolyte levels (mainly sodium and potassium) are normal because Vetoryl has the ability to lower aldosterone, the adrenal hormone that controls the balance of sodium and potassium.

I believe it is important to have an ACTH stimulation test performed before restarting the Vetoryl to confirm that the adrenal glands are producing enough cortisol. Has he been drinking and urinating more? How is his appetite, any diarrhea episodes?

I will have to ask if they tested electrolytes this time, as they did not send me that result. They did during the August test, and levels were good. He may have had one episode of diarrhea last week, as I had found his back end a bit messy one day, but seemed to be an isolated incident. In general, his stools have been slightly on the drier side. He is starting to drink more water now, and getting up in the night to do so, which he had not been doing for quite some time. I think the insomnia is starting to kick back in, too. Appetite is good, and he is returning to looking for scraps after dinner again. I find him searching under the bird cages for any seeds he can find...

[Harley PoMMom]

It makes me a bit uneasy when I see a dog's post cortisol level drop below 2 ug/dl and according to Dr. Peterson's blog, he feels the same way too:

Dosage adjustments — lowering the dose

In this report (13), trilostane treatment was continued in dogs with a post-ACTH cortisol concentration less than 1.5 μg/dl, as long as no adverse clinical signs were reported. I disagree with that regime.

When using trilostane, it has become increasing clear that we do not want the cortisol values to drop too low, because that may indicate early or mild adrenal necrosis (1,11,12). In contrast to the protocol used in this reported study, I recommend stopping the drug in all dogs that develop a ACTH-stimulated cortisol values less than 2.0 μg/dl, and repeating the ACTH stimulation test in 1- to 2-weeks in those dogs. Some of these dogs will require that the drug be restarted at a lower dosage, but others will maintain low to normal serum cortisol concentrations for prolonged periods of time. And a subset of these dogs, presumably because of mild adrenal necrosis, will never need any further trilostane treatment to control the signs of Cushing's syndrome.

https://endocrinevet.blogspot.com/20...rilostane.html

When a dog's post cortisol level is < 2.0 ug/dl those adrenal glands may not be able to produce enough cortisol and/or an imbalance in the electrolytes could occur which can cause a dog to drink/urinate more.

[molly muffin]

I too like a post of over 2.0ug. Remember that going too low can cause the same symtoms as high cortisol (drinking, insomnia, etc) so want to watch that and I'd lower the dosage if it were me I think to bring that post up a bit.

[Junebugs]

It makes me a bit uneasy when I see a dog's post cortisol level drop below 2 ug/dl and according to Dr. Peterson's blog, he feels the same way too: https://endocrinevet.blogspot.com/20...rilostane.html

When a dog's post cortisol level is < 2.0 ug/dl those adrenal glands may not be able to produce enough cortisol and/or an imbalance in the electrolytes could occur which can cause a dog to drink/urinate more.

Thank you so much for this info. It has made me realize that I need to be super careful right now. The vet did mention that there would be a chance of necrosis if the levels go too low. Now I see why another stim test before restarting at even the lower dose is so important.

[Junebugs]

I too like a post of over 2.0ug. Remember that going too low can cause the same symtoms as high cortisol (drinking, insomnia, etc) so want to watch that and I'd lower the dosage if it were me I think to bring that post up a bit.

Thank you Sharlene! I did not realize that symptoms could be the same in either direction. Good to know, and not assume that his cortisol has risen, which is what I was doing.

[Junebugs]

I spoke to the vet today, and scheduled another ACTH test for Wednesday to see where Kaiser's cortisol is now that he has been off the Vetoryl for a couple of weeks. I also asked to have an electrolyte panel done as well. I will post the results once they are in, then make a decision on his treatment going forward, rather than just start him up again now at the lower dose. Thanks everyone for helping me navigate this!!

[Harley PoMMom]

I spoke to the vet today, and scheduled another ACTH test for Wednesday to see where Kaiser's cortisol is now that he has been off the Vetoryl for a couple of weeks. I also asked to have an electrolyte panel done as well. I will post the results once they are in, then make a decision on his treatment going forward, rather than just start him up again now at the lower dose. Thanks everyone for helping me navigate this!!

Crossing fingers for those electrolytes to be normal and that his cortisol has come up a bit....You're doing a great job, Theresa!!!

[Junebugs]

Kaiser's lab results are in. Just to re-cap, we temporarily stopped his Vetoryl 30mg daily due to his previous ACTH numbers. The specialist at Dechra recommended a brief holiday from dosing, with the plan to restart @ 20mg daily, with split dosing 10mg am and again in the evening.

1/25/18
Pre ACTH 4.8 ug/dL
Post ACTH 10.1 ug/dL

It's my understanding that normal ranges while off therapy are Pre 2-6 and Post 6-18. The vet and Dechra specialist think we should leave him off treatment until the clinical signs become bothersome, and then start the lower, twice daily dosing. Does this sound like a good plan for now? He has a little insomnia creeping back, along with a little panting, but not really bothersome yet. He is doing really well with being able to get around and walk longer distances since he has been off treatment, so maybe a short holiday is a good thing? I certainly don't want to wait for the balding and skin issues to come back, though.
His last numbers while on 30mg each morning were 12/23/17 Pre 0.6 and Post 1.5
We did a full blood panel, and electrolytes are normal. Glucose, which was a tiny bit high previously is now normal. IDEXX SDMA is normal @ 11 (reference value is 0-14). ALP is still way up there @ 6,896.
Theresa

[Harley PoMMom]

I'm happy to see that his cortisol has come back up, and FWIW, I agree with the plan of withholding the Trilostane until clinical symptoms reappear.

[Junebugs]

I'm happy to see that his cortisol has come back up, and FWIW, I agree with the plan of withholding the Trilostane until clinical symptoms reappear.

Thank you! I feel much better now knowing this is all going well. We go for Kaiser's chiro adjustment and acupuncture tomorrow. His doctor will be pleased, I'm sure. Maybe this weekend I can try taking him out on a short trail walk again!