Is it cushings or not with our blue - Blue has passed

[Larinda]

Blues acth came back 3.5 pre and 3.5 post. (At the bottom of the results the lab stated an extra lavender tube was submitted and would be held for 48 hours). So I'm hoping they did the tests right. Ever see it perfect like that? The same? Last month prior to vetroyl it was 3.0 pre and 28 post. Doctor said keep him on 120mg daily and unless anything changes with him they would test again in 6 months. He weighed in at 95lbs. Last month he was 106lbs. T4 is 1.7 . I asked the doctor about the dosage and how the guidelines from drug maker may have changed to lesser mg per lb recommendations but the doctor stated he was on correct dosage. I also told him I was new to cushings and I am trying to educate myself and I thought I had read where testing should be 30 days rather than 6 months? He felt if blue is doing well then keep doing what we are doing. If he loses weight or gets sick like vomiting diarrhea let them know. I admit I should be jumping for joy I suppose but I also feel this nervous speculation. I guess I'll take one day at a time and hope for the best. Blue is doing better with his symptoms somewhat. Certainly no worse. His skin is looking better and they gave him 3 more weeks of antibiotic and still prescribing thyroid pill as well.

[molly muffin]

Blue is on 120mg and went from 28 post cortisol to 3.5 pre and post? in 30 days on 120. And blue weighs 95lbs, so my concern here is that the dosage is too much, that is alot very quickly. 3.5 pre and post means that no additional cortisol was released from the adrenal gland after the ACTH injection.

So, here is what I would do if in your shoes. Based on a the way testing is now being done in Europe and which is actually considered to be a more accurate method of determining how a dog is reacting on the medication. They are testing cortisol levels, with a simple blood draw prior to the trilostane being given to see what the level is. It cost less and is accurate.

This was posted to another member

Just within the last couple of weeks, those of us in the U.S. have learned that many vets in the U.K. and Europe have shifted away from using ACTH stimulation tests to monitor trilostane treatment unless there is a worry that a dog’s cortisol may have dropped too low. Instead, they are simply measuring resting cortisol right before the next dose of trilostane is due to be given. New research supports the notion that this actually gives better guidance re: the need for dosing increases, and it’s certainly a heck of a lot cheaper. Take a look at this link and the monitoring flowchart that’s included. Your vet may be very interested in this info, as well, and might be willing to investigate it further on your behalf.

http://www.k9cushings.com/forum/show...=1252#post1252

So I'd print that out, take it to the vet and say just to ease my mind, can we please just check the cortisol before she gets her med one day in a week or two.

[labblab]

In reading back, I see that Blue started taking the Trilo on 3-25, so he dropped clear from 28 to 3.5 in only two weeks. That is a big, big drop in a short time, and it sounds as though your vet is unaware that cortisol typically continues to drop even further clear through the 30 day mark when treatment is initiated. I agree with Sharlene 100%. I would insist that testing of one sort or the other take place at that time — either a full ACTH or a pre-pill cortisol level. If Blue’s cortisol does remain stable and the dose is unchanged, then I would insist on retesting at the three month mark. Your vet is not following the testing protocol recommended by the drug manufacturer, researchers, and clinicians alike. I do not know why. But as Blue’s advocate, I think you need to insist on the proper monitoring yourself.

Marianne

[Larinda]

I had a random question...its 3 weeks today Blue is on Trilostane 120mg daily. He seems to be doing ok. he does look like he's lost some more weight but its hard to weigh him at home. he went from 106lbs march 15th to 95lbs - on april 6. i should probably try to get him weighed again somehow. He had a couple good days this weekend. his eyes looked good. (last weekend his eyes looked dilated or something- it seemed kind of weird). But...I do notice sometimes he breathes kind of different when he's sitting in his chair, and it seems like his heart is beating right out of his chest sometimes. my friend noticed it also this past weekend when he was sitting beside him. why is that? should I be worried or is it just some random thing. I thought I'd see if you've ever encountered anything like that. In the meantime, I did email my vet(she was out on vacation when blue had his last ACTH test april 6) to ask her to review the last ACTH test, as it seemed so "perfect" and I also asked about a 30 day testing rather than 6 months as her associate vet told us. perhaps she will enlighten me more when she returns from vacation. thanks for any insight.

[Harley PoMMom]

Like Marianne and Sharlene mentioned, there was a huge drop in Blue's cortisol in only 2 weeks so an Addison's crisis could be a possibility. When the cortisol drops too low and/or an imbalance in the electrolytes has occurred many symptoms will present themselves, one of them being a change in breathing and heart-rate so having his cortisol tested is what I recommend.

[Larinda]

We spoke with blue's vet today and we are doing another month of 120mg trilostane. (he started this medication a month ago) She then wants to go to 60mg and schedule acth test 10-14 days after the change in dosage. We'll see how he does. So far so good. His skin is looking much better too, and his antibiotics are almost finished. (6 weeks worth). Thanks to all of you who are helping me to better educate myself on this crazy cushings. I know what to be looking for. One day at a time I suppose.

[labblab]

If he is doing well on 120 mg., why would she want to cut the dose in half a month down the road? Has she scheduled another monitoring ACTH test now that a full month has passed? If not, I’m doubly baffled by her dosing plan. If she doesn’t know how the 120 mg. has effected his cortisol level at this point, how does she know it’s safe to continue for a full month as is? And if it is indeed a safe and therapeutic dose, why would she then want to arbitrarily cut the dose in half. I am totally baffled. Can you share her rationale with us?

Marianne

[Larinda]

she said....and here goes....
" In regards to the ACTH stim testing: equivocal results pre and post within the reference range are excellent. It means the adrenal glands cannot be stimulated excessively and are producing adequate levels of cortison.
If symptoms are well controlled that easily I usually back off testing for a while as well. Nevertheless I do agree that with the weight loss and the additional research coming out of UC Davis, it is a good idea to try a lower dose of Trilostane.

Let’s go with 60 mg after your next box is finished and monitor his response. If his symptoms return, we will increase his dosage to 90 mg. If he is stable, happy and healthy with no excessive drinking and urinating, normal appetite and energy levels, I still want a repeat ACTH stim test after about 10 days to be able to compare apples to apples.

There are different opinions out about doing resting cortisol levels only, as there can be unexpected fluctuation present on a daily and circadian basis, which in return may lead to us switching his Trilostane dose erratically. The most important factor for us is his quality of life and control of symptoms.
he is currently doing well, tolerating his medicine well and improving. My goal is to see if the lower dose will suffice to help him just as much. I don’t anticipate him having negative effects from staying on 120 mg for 4 more weeks and then switching. So go ahead and finish that box of 120 mg and follow up with 60 mg, thus setting his next ACTH stim test in 6 weeks."

so...I guess that's good news then?

[labblab]

Hi again, Larinda. Thanks for supplying us with your vet’s email. Unfortunately, I still have remaining concerns about your vet’s dosing/monitoring recommendations. Here are my worries.

she said....and here goes....
" In regards to the ACTH stim testing: equivocal results pre and post within the reference range are excellent. It means the adrenal glands cannot be stimulated excessively and are producing adequate levels of cortison.
If symptoms are well controlled that easily I usually back off testing for a while as well.

Your vet hasn’t offered any explanation as to why she thinks it’s OK to back off from testing other than the fact that Blue’s symptoms are well controlled. The problem is that we can expect that Blue’s cortisol level continued to drop even lower after that first two-week testing mark. Outwardly, he may still be looking OK, but inwardly, he may be verging on a cortisol level that may end up being unhealthy for him. Virtually all specialized clinicians recommend that cortisol testing be done at the 30-day mark after beginning treatment. Here’s what Dechra, the manufacturer of Vetoryl has to say: “Given that there is so much emphasis placed on using the control of the clinical signs to monitor Vetoryl, why bother with Cortisol testing? This sounds like a good idea but there is no way of detecting too little cortisol in an otherwise well dog until it becomes unwell – and hypocortisolism can be dangerous.”

Nevertheless I do agree that with the weight loss and the additional research coming out of UC Davis, it is a good idea to try a lower dose of Trilostane.

Let’s go with 60 mg after your next box is finished and monitor his response. If his symptoms return, we will increase his dosage to 90 mg. If he is stable, happy and healthy with no excessive drinking and urinating, normal appetite and energy levels, I still want a repeat ACTH stim test after about 10 days to be able to compare apples to apples.

Again, if Blue’s symptoms are well-controlled and his cortisol level does remain within the desired therapeutic range on the 120 mg., I don’t understand why your vet would arbitrarily cut the dose in half. Broken record here, I would want to know where his cortisol level has stabilized after a month on the 120 mg. before continuing for another full month on that dose, or before making any dosing change.

There are different opinions out about doing resting cortisol levels only, as there can be unexpected fluctuation present on a daily and circadian basis, which in return may lead to us switching his Trilostane dose erratically. The most important factor for us is his quality of life and control of symptoms.
he is currently doing well, tolerating his medicine well and improving. My goal is to see if the lower dose will suffice to help him just as much. I don’t anticipate him having negative effects from staying on 120 mg for 4 more weeks and then switching. So go ahead and finish that box of 120 mg and follow up with 60 mg, thus setting his next ACTH stim test in 6 weeks."

In regards to testing resting cortisol levels alone, your vet is correct that some research done several years ago on testing baseline cortisol several hours after giving trilostane yielded equivocal results. However, she may not be aware of very recent research that has revolutionized trilostane monitoring in the UK and Europe. It utilizes baseline cortisol testing right before the daily dose of trilostane is given (“Pre-Pill” testing). This is now the monitoring testing protocol that is formally recommended by Dechra in the U.K. and Europe. I would give your vet this link so that she can read about the newest monitoring advances. After doing so, I’m hoping she will rethink her decision to delay retesting Blue, whether via ACTH testing or pre-pill resting cortisol level.

https://www.dechra.co.uk/therapy-are...tisolSuperPage

As owners who know our dogs best, we are always responsible for watching them closely and reporting any observable changes to our vets. Unfortunately, though, your vet is placing an extra burden on you personally. By neglecting to test Blue’s cortisol before continuing with the 120 mg., the first warning that you would have of low cortisol is him actually becoming sick, and overdosing can be life-threatening. So you will need to make note of any changes at all that you see, and report them immediately. I have to trust that your vet will know how to respond appropriately by testing cortisol level and if called for, stopping the Vetoryl and giving supplemental steroids as needed.

Marianne

[Larinda]

ok good to know thank you so much. I'm a nervous wreck but I watch him closely. i'll keep you posted. thanks for all your advice.