Pituitary Cushings Diagnosis- Trilostane side effects, any other medications?

[Belle's Mom]

My dog has a pituitary tumor and surgery is not an option due to her age and other medical issues. We had her on Trilostane and it reduced her Cushings symptoms but she had diarrhea, stagger (hard to walk, legs giving out, front paws turning over when walking) dizzy, lethergy, would not eat and this lasted for three days before we stopped it. Now she is just on her Denamarin, Ursodial, and a new med: Telmisartan. She has proteinuria. She was on the Trilostane and Benzopril together when she was having all of the symptoms above. Her Cushings symptoms subsided when she was on the Trilostane but the 'side effects' were unbearable after a few weeks of treatment. Once we stopped the Trilostane, her Cushings symptoms came back. I am wondering if anyone has tried any of the other medications besides Trilostane and had success? I have been doing research and it looks like Ketoconazole has been used as well as Mitotane or Lysodren (afraid of this because of Addisonian reaction). Has anyone had the same symptoms from Trilostane and tried something else?

[Harley PoMMom]

Hi and welcome to you and your girl! I have only a moment to post but have a few questions. What dose of Trilostane was she started on? How much does she weigh? What test/s were performed that diagnosed the Cushing's and could you post those results? Could you also post her monitoring ACTH stimulation test results?

You definitely did the right thing in stopping the Trilostane and I'm glad she is feeling better.

I'll try to get back later and I hope in the meantime others will be by soon. I'm sure sorry for the reasons that brought you here but glad you found us and we will help in any way we can.

Lori

[Belle's Mom]

She was taking 30mg of Trilostane daily and she is 11 lbs. Tests for Cushings she has had is ACT sim test. First one was 19.9 and then it went up on second one- can't remember the value. She has had multiple physical exams- has all of the symptoms of Cushings. Had a ultrasound and has a mass/tumor on adrenal gland which they feel is the cause of her Cushings. All of her Cushings symptoms went away when she was on the Trilostane but after 2 weeks of medication- she was also on Benzapril at the time (don't know which one was causing this) she started staggering/diarrhea/would not eat/ folding her paws over when trying to walk etc.

Because she is not a good candidate for surgery, as the adrenal surgery only has a 50/50 chance of success- I have the very tough decision to either restart the Trilostane (and hope it was the Benzapril) or try Lysodren instead or do something else. It is a hard decision because when she got sick and would not eat and was staggering around I thought my heart would break. She is my baby and I cannot watch her go through that again. I would like to make the right choice to restart meds to try to get her Cushings under control so that we can have some more time together.

[Squirt's Mom]

Hi and welcome to you and Bella!

What were the results of the 2 week ACTH? She should have had one 2 weeks after starting the Trilostane. Her starting dose is VERY high so that first test would be critical. The starting dose is 1mg per pound so at 11 lbs, 30 mg is more than 2x the recommended starting dose. If she has not had an ACTH she needs on ASAP...she also needs her electrolytes checked. This is to see where her cortisol is...she is exhibiting signs that it has dropped too low which is a life-threatening situation.

Also, Benzopril is an ACE inhibitor and the manufacturer of Vetoryl (Trilostane) says to use caution when combining the two drugs. Is her vet aware of this caution and have they been taking steps to make sure she is doing well on both drugs? From the Vetoryl brochure:

Angiotensin converting enzyme (ACE) inhibitors should be used with caution with Vetoryl Capsules, as both drugs have aldosterone-lowering effects which may be additive, impairing the patient's ability to maintain normal electrolytes, blood volume and renal perfusion.

For your education, here is the link where the above quote came from. You will find much important and valuable information there. Sadly, the success of our babies with Cushing's depends a GREAT deal upon our own knowledge because all too often we have vets who know little to nothing about the disease or the drugs used to treat it. So read up on the drug your baby has been given - https://www.drugs.com/pro/vetoryl.html

You can learn a lot on the disease, treatment options, and many other things in our Helpful Resource section found here - http://www.k9cushings.com/forum/foru...Cushing-s-Dogs

I'm glad you found us and look forward to learn much more as time passes! I am also looking forward to seeing all those test results Lori asked for.
Hugs,
Leslie

[Belle's Mom]

She had her first ACTH test before starting the trilostane in February and it was PRE 2.6 and POST 19.9. Then she took the trilostane until May when she got sick and could not eat/stagger/ etc. and brought her back then she had another ACTH test which was PRE 3.6 POST 30.0. Between the first test and the test in May she had multiple tests for BUN CREATININE as it was also high 57 and 2.7 in Feb. She is having sub Q fluids 150ml every other day and (protein loss in urine) and also renal failure- her ALP was 1360 with a reference range of 13-289.

Thanks for the information on Bezopril and trilostane. I did not know that- not sure if my vet did or not. Hopefully that did not make her renal values worse. Now she is on Tomasartin and vet wants to start back up on the trilostane but I am worried as she had that episode last time. But maybe it was due to the combo of benzopril and Tomasartin?

[labblab]

Hello and welcome to you and little Belle. I'm surely sorry about all the problems she's having, and it sounds as though there are quite a few question marks as to exactly what is going on. I know that makes things twice as tough!

One of my first questions, though, is whether the vet thinks that Belle has a pituitary tumor in addition to the adrenal tumor that was viewed on the ultrasound. You've introduced Belle to us as having pituitary Cushing's, but it sounds as though it's actually an adrenal tumor that has been diagnosed instead? This can make a big difference in terms of treatment options and prognosis. Most pituitary tumors are benign, but adrenal tumors have a greater risk of being cancerous. Also, adrenal tumors can end up spreading and/or invading important blood vessels, which can be a serious problem as well. So depending upon the presence and nature of an adrenal tumor, it seems possible that some of Belle's problems could be explained by the growth of the tumor or the invasion of vessels or other organs.

The exact nature of Belle's kidney problem is also an issue. Dogs with Cushing's can indeed suffer from proteinuria (abnormal levels of protein being excreted into the urine). Benazepril is a medication which can help reduce proteinuria, but as Leslie has already noted, it can sometimes present a danger when it is combined with trilostane. Both of those medications have a tendency to increase potassium levels in the blood, and this type of chemical imbalance can present a danger. However, we have had members who have been able to give their dogs both drugs, just as long as potassium levels are routinely checked. It sounds as though Belle has had regular blood draws since starting the trilostane, so the combination of the two drugs may not have actually been a problem from that standpoint.

But it sounds as though Belle's kidney problem is more involved than just proteinuria. If her creatinine and BUN have been elevated and she's still requiring Sub-Q fluids, I'm assuming that her kidneys are not functioning normally right now. If so, this would be a big reason NOT to resume the trilostane. The manufacturers of Vetoryl (brandname trilostane) include specific warnings against using this medication in dogs who are suffering from impaired kidney or liver function. If the kidneys are not working properly, the chemical in the medication may not be metabolized and excreted properly from the body.

I am sorry to bring up so many new questions at a time when you are already worried enough. And it may be the case that there remains a safe path forward for Belle in terms of effective Cushing's treatment. But right now, it'll help us if we can gather some more information about the whole big picture. It is really, really strange for a dog of her size to have such a massive increase in cortisol level while taking such a large dose of trilostane. This makes me wonder even more about the state of that adrenal tumor -- whether it may be pumping out huge amounts of cortisol, or otherwise placing enormous stress on her body. So any new information you can add about the presence or status of either/both a pituitary and adrenal tumor will be helpful, as well as any specific diagnostics that have been done re: her kidney failure.

Thanks so much in advance!
Marianne

[Belle's Mom]

I am sorry, I do see that I said pituitary tumor and that is not the case. It is an adrenal tumor. I did not get the specific records on size but I did get some records and this is what it says: RIGHT adrenal gland enlarged and irregular: suspect tumor and strongly suspect that pet has hyperadrenocorticism due to this, given the ACTH simulation test results and clinical signs.

This is from when she went in in February:
DIAGNOSTICS & THERAPEUTICS
Chest Radiographs: Heart appears normal in size. Trachea not displaced dorsally. No pulmonary edema, no pleural
effusion.
CHEM 8: Hemoconcentration, azotemia, hyperglycemia
PCV Canine: 58
Serum: clear
Total Protein: 8
BUN Canine: 51
Glucose Canine: 374
Creatinine Canine: 2.6
Sodium Canine: 142
Potassium Canine: 3.6
Chloride Canine: 104
TCO2 Canine: 23
Ionized Calcium Canine: 1.34
Anion Gap Canine: 19
Hematocrit Canine: 56
Hemoglobin Canine: 19

Blood Pressure - 179 Systolic 179
Diastolic: 150
MAP:164
Blood Pressure - 114 Systolic 114
Diastolic: 73
MAP:80
Glucose w/Glucometer Canine: 89

-Is on N-R at 35 ml/hr, BG q 4hr, seizure watch and give 2.5 mg diazepam IV if seizes, vitals q 4
-Reduced fluids to 20 ml/hr
-Ordered UPC: 5.1
-BUN and creatinine at 1:30PM: BUN 24 mg/dL, creatinine 1.1 mg/dL
-Three view thoracic radiographs (remaining lateral view added to last night's 2): some lower airway mineralization.
Abdominal Ultrasound Exam:
Liver: normal size and overall normal echotexture. Many small (0.2-0.55 cm) ill-defined hypoechoic nodules present
in all lobes. No abnormal vasculature detected.
Gallbladder: normal size, about 50% filled with somewhat moveable echogenic bile. No evidence of biel duct
obstruction/enlargement.
Spleen: normal size and echotexture. A few sharply defined, smooth, hyperechoic nodules present. The largest in
0.80 X 1.48 cm in diameter. None interrupts cortex of the spleen.
LK: moderately reduced corticomedullary definition, with hyperechoic cortex. Scattered tiny calcifications in
medulla. Very mild pyelectasia (consistent with fluid therapy). Length of kidney= 3.80 cm.

RK: moderately reduced corticomedullary definition, with hyperechoic cortex. Scattered tiny calcifications in
medulla. Very mild pyelectasia (consistent with fluid therapy).Length of kidney= 3.60 cm.
Urinary bladder: normal except very tiny amount of apparent soft tissue within trigone. Very hard to discern well but
looks smooth and rounded.
Adrenal glands: the left is small, the right larger and regular in shape. The left measures 0.87 X 0.34 and 0.30 cm at
the cranial and caudal pole respectively. The right is 1.84 X 0.39 and 0.70 cm. The caudal pole is bulbous in
comparison to the normal cranial pole.
GI: normal stomach and intestines seen.
Other: no pancreatic lesions seen, nor lymphadenopathy. No free fluid seen.

This is from the ultrasound report and it says left adrenal gland is small and right lareger and regular in shape. But the doctor said she has a tumor in adrenal gland and it says in the assessment that the left adreanal is enlarged and irregular...?

Now I am questioning this as something is wrong with this record.

[Harley PoMMom]

I see that Belle is also diabetic, was this diagnosed at the same time as the Cushng's? Was her blood sugar hard to get under control?

Could you do us a favor and add the reference ranges for those values you listed? Thanks!!

PS ~ Our sister site k9diabetes.com can help with any questions you may have concerning canine diabetes, here's their link: http://www.k9diabetes.com/forum/
They are a wonderful and knowledgeable group of people so I do urge you to join there too!