Kiki - Treatment questions

[BarryB]

Hi:

First post. Our German Shepherd mix, Kiki, about 11 years old and 55/60 pounds, is being treated for Cushings – back in the late summer we noticed excessive panting, drinking and urinating. We worked with our regular vet for a while to make the determiniation that Kiki had Cushings but switched in the fall to an internal specialist.

At this point we are at 60 mgs of Vetoryl twice a day. The heavy panting has stopped. We thought we were still experiencing issues with the drinking and urinating. This last weekend at our vet’s suggestion we monitored Kiki’s water consumption for 24 hours which came out to about 72 ounces. The vet felt that this was not an excessive amount based on the dog’s weight. We still are having urination issues – she will wake us in the middle of the night to go out and will still on occasion urinate in the house.

Our vet’s comments based on the most recent ACTH test are below. I am inclined at this point not to increase her dosage – if she is not drinking excessive amounts of water perhaps the urinating issues are not Cushing related at this point? I would appreciate any comments and or questions – I’m sure I left some information out.

“Kiki's ACTH stimulation results remain on the high side, with a post-cortisol of 7.1. I feel comfortable aiming for a post result of 3-5, but if Kiki's water intake has really decreased significantly then I could go either way on increasing her dose again. If you feel that she remains poorly controlled at home, we could increase her to 120 mg twice per day and recheck a stim in 10-14 days. We could also wait and see how she does over the next few weeks on her current dose and plan to recheck an ACTH stimulation in about a month since her water intake is technically normaly. Please let me know how you're leaning.”

Thanks,
Barry

[Squirt's Mom]

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[lulusmom]

Hi Barry,

I'm sorry for the reasons that brought you here but am glad that you found us. Before I start asking questions and making comments, I wanted to let you know that I have manually validated your membership so everyone can now see your thread. You can ignore our email asking you to validate.

Now for the questions. Did your vet do a urinalysis with culture to rule out a urinary tract infection? Can you tell if Kiki's urine is dilute, meaning clear and usually odor free? This would be the norm for a dog with uncontrolled cushing's; however, studies by Dechra, the manufacturer of Vetoryl, as well as UC Davis studies show that a small percentage of dogs never had a resolution of pu/pd (excessive drinking and peeing). It is true that a post stimulated cortisol of 7.1 would be acceptable but only if all symptoms have resolved. Without ruling out a UTI and knowing if Kiki's urine specific gravity is low, there is no way to determine if her problem is directly related to cushing's.

As for your vet's option to double Kiki's current dose of 60mg BID to 120mg BID is absolutely unacceptable so please, please do not even go there. That would be very dangerous for Kiki. Was this your vet or the internal medicine specialist that presented this option to you? I would be shocked if it was the internal medicine specialist. Firstly, I think it's premature to increase the dose before addressing the issues above and secondly, if an increase in dose is truly necessary, I would suggest that you consider purchasing 10mg Vetoryl capsules and add 10mg morning and evening. With a post stim of 7.1ug/dl, you don't have a lot of wiggle room so low and slow is best.

Others will be chiming in shortly to share their experience and knowledge. We've all walked in your shoes, some of us more than once so stay tuned.

Glynda

[BarryB]

Lulusmom:

OK - my first mistake - Kiki is actually presently on 90 mgs twice daily not 60 - do you think this is excesive - she has been bumped up twice sofar and yes it was the internal specialist who made the comments I quoted.

I do not know if the urine is presently dilute but when she first began being diagnosed this was noticed. She has had a urinalysis done both by our regular vet at the beginning of her symptoms and more recently by the specialist.

Thanks

[molly muffin]

Hello and welcome to the forum.

Glynda has made an excellent point about a urinalysis.
I was actually coming on to say the same thing of no way, you don't double the dose when your post is already lowered to 7.1.
Glynda is right on with a 10mg addition is an excellent way to raise the dose slowly if needed. That way you only go up a bit and not tons, which would likely send Kiki into a crisis.

Sharlene and Molly Muffin

[molly muffin]

I think you posted at the same time I did. :) If urine culture are clear and you still want to get better control of the urinating to see if that will decrease at around post 5.0, then I would still raise it slowly and not go from 90 twice a day to 120 twice a day. I'd to go 100mg twice a day and see how that works.
Every dog is different and metabolizes differently, so the starting dose is a general rule, where any dog will end up is very much specific to that dog. We've had big dogs on small doses and small dogs on big doses.

Do you give the vetroyl with food? That is necessary so that it processes correctly. Also, when you do the ACTH test, vetroyl should be given with food on the morning on the test and then the test completed within 4-5 hours of the dosage.

If all of that is being met, then you are within a bit of wiggle room if you want to try a slight increase and see if that helps

Sharlene and molly muffin

[Renee]

Coming to add my opinion - I'm not sure if you know the difference between a urinalysis and a urine culture, but the urinalysis is basically useless. It can be notorious for missing infections and tells you nothing about the infection. The urine culture will identify the exact bacteria so you know which abx will be effective.

If water intake has decreased, but she still continues to have accidents / need to pee often, I would suspect an infection. Especially since cushings dogs are more prone to infections. I myself wish I had known that 2 years ago when my pug had chronic UTI's.

[goldengirl88]

Welcome to the forum. I caught bits and pieces but when I saw where you wanted to double the dose I had to jump in on my favorite subject. Please, please listen To Glynda and Sharlene. Just 10mg is the very most I would raise it too. I have a lot of experience with many different doses and I can tell you from my experience with this go low and slow the cortisol had already come down and you don't want Addisons. These are powerful medicines and you most proceed with caution to make sure you dog can adjust to the dosage. Better safe than sorry. Blessings
Patti

[BarryB]

Thanks for your responses.

I checked our records and she did have a urine culture on December 12th which came back negative.

Sharlene: Thanks for mentioning giving the med with food. This is something we haven't been doing. We have pretty hectic schedules at home and I take care of the meds and my wife and daughter the feeding.

Is a handful of kibble enough to give with the meds?

At this point we are probably going to stay the course for a bit before changing her dosage.

Thanks again.

[Renee]

Yay for getting the urine culture! Good job. It really bothers me when vets don't help pet parent's understand the drawbacks to just relying on urinalysis, when they can be so inaccurate.

As for the giving vetoryl w/ food - I had this question as well, and I contacted Dechra directly. Their response was to give the vetoryl with a full meal. Not a snack, or a treat, but a full meal. I was worried about getting the dosing at exact 12 hour intervals, but I am allowing myself some wiggle room, to ensure she gets the meds with her breakfast / dinner.

[molly muffin]

Dechra says to give with a meal, so I'd think, more than a hand full of kibble would be needed. The food is needed to for the medicine to be properly absorbed into the body. Renee actually just called Dechra and spoke with them about this very issue.
This might make a difference giving properly with food in how well it is being used by her system. So, even if you have a meal prepared the night before, to give her in the morning with her meds that would help.

Sharlene and Molly Muffin

[lulusmom]

Hi again,

I am very disappointed that the vet did not instruct you to always give Vetoryl with a meal, especially on the day of an acth stimulation test. If you did not give Kiki her dose with a meal before the last acth stim test, it is highly probable that the post stimulated cortisol is higher than it would have been. It's even possible that the results would have been within the range your specialist is now suggesting. It is also very important that you get Kiki to the vet within 3 to 5 hours of her morning dose. Have you been doing that? It may well be that if you start dosing her with a meal that cortisol will drop as the drug will be more readily absorbed into the bloodstream.

I'm glad your vet did a culture and thank you for letting us know. Can you check with the vet to see if he also has the results of the urine specific gravity from the last urinalysis done in December? Please post the result here. If the USG is within the normal range, it is highly unlikely that cushing's is causing the excessive peeing and drinking.

I think your plan of action in staying the course is a good one, especially now that you know to dose with a meal. Just keep an eye on her for signs of low cortisol. Those signs would be extreme lethargy, vomiting, diarrhea, refusing food, tremors, difficulty walking. You may only see one or two of those signs but you would still need to immediately stop dosing and call your vet. If symptoms become severe, know where to take Kiki after hours in case of emergency.

Glynda

[BarryB]

Glynda:

We have been doing the ACTH test within the required time frame but not with a meal. In the past we have fed her once a day so we are going to split her meals now to accomodate her medicine times - in a few weeks we will have the test done again.

I may have the results of the urine test at home - I'll check later today.

Thanks

[Harley PoMMom]

I agree with Glynda, giving Trilostane with food and the timeline of the ACTH stimulation test is vital when monitoring treatment. Dr. Mark Peterson, a renown expert in Cushing's, has a excellent article on his blog regarding Trilostane and ACTH stimulation testing, here's a link: Protocol for ACTH Stimulation Testing to Monitor Dogs on Trilostane Therapy: Timing, Feeding, and ACTH Preparation All Matter (http://endocrinevet.blogspot.com/2013/11/protocol-for-acth-stimulation-testing.html) An excerpt from his article:
First, trilostane should always be given together with food. It has been shown that feeding immediately after the administration of the drug significantly increases its absorption (1,2).

[BarryB]

Hi:

Sorry for not getting back on here sooner. We have been feeding Kiki twice daily with her meds for over a week now and are still having urination problems.

Glynda:

You had mentioned finding out the USG number from December - it was 1.014 but this was while she was still on 60 mgs twicw a day not 90.

Appreciate your thoughts. The Dr still feels we have room to increase the dosage if we choose.

Thanks

[Harley PoMMom]

Since Kiki is now getting her Trilostane with food, if this were me, I would not increase the Trilostane dose untill a more recent ACTH stimulation test is done so that the results would reflect the dosage being given with food.

Hugs, Lori