Buddy, The Mighty Lizard Hunter - Suspected Pituitary Macro Tumor

Buddy, My 10-year-old large Yorkie has recently been diagnosed with Pituitary dependent Cushing's. After $1600 in tests and vet bills, this Diagnosis was confirmed. His illness came on very suddenly, although he's probably had Cushings for several years, Although I didn't know it. A few weeks ago he had a restless night and then woke up vomiting the next day. He also was so weak he was practically unable to stand. His back legs were wobbly and would not hold him up. After taking him to the vet and having numerous tests including blood work and x-rays, we were referred to the emergency hospital for a ultrasound. His liver was so large that they thought he had a tumor. It was difficult to see his other organs. Buddy was stabilized and set home. He was able to eat a meal normally in the hospital and kept it down. Cushing's was suspected by both hospitals. We left with the referral to specialty hospital for a neurology consultation. Due to the extreme weakness in his hind limbs, a consultation was needed to see if Buddy was even a candidate for Cushings treatment. In the meantime Buddy became Stronger and was able to move easier, but still very wobbly. The neurologist gave Buddy clearance to go ahead and have Cushing's testing. He was given the low dose eight hour test a few days later at his regular vet. That is when pituitary dependent Cushing's was confirmed. Five days ago trilostane treatment was started. Buddy weighs 16 pounds and is on 20 mg once per day. He is not fat, just a large Yorky. He has been having many stomach upsets since treatment started. He has had a gassy, sour stomach but hasn't vomited and has eaten normally. Right now it's 4:24 AM and he's been up with an upset stomach all night And hasn't been able to settle. I'm going to call the vet in the morning. Have any of you tried giving your Cushing dogs Pepto-Bismol? Do your dogs get upset stomachs with trilostane? Does it eventually go away once they adjust to the medication? I have to take Buddy back for another blood test to check his levels 7 to 10 days after starting the medication. Can anybody give me any help or insight in the meantime? It would greatly be appreciated. Thank you.

MODERATOR NOTE: Your post has been manually approved so that members can start responding to you. Please check your email for a message from k9cushings. You will need to reply to that email so that your post go directly to the board and are not delayed waiting for approval. If you have already received and responded to the confirmatory email, please be patient. Your registration will be finalized shortly. Thanks and welcome!

Hi Mom and welcome to you and Buddy! :)

Something many of us use to help with tummy upsets is Pepcid AC - be sure it is the AC form only - not time released, fast acting, etc, just plain Pepcid AC. Tagamet is another one used. Generic Pepcid AC is Famotidine; generic Tagamet is Cimetidine. Most stores have their own brands under the generic names that will save a few pennies. Do call your vet tho and let them know how the Trilostane (Vetoryl) is affecting sweet Buddy.

If you don't have them, get copies of the actual tests results so far and post them here in Buddy's thread. That will help us, help you. ;)

We are a Lysodren (MItotane) house so I will let our Trilo parents talk to you about that. But I will tell you that any time the diagnostic tests for Cushing's are given while another illness is present, it makes the diagnosis suspect because so many things can cause the tests to give false-positives and share the same signs as Cushing's. Also, Cushing's does not come on suddenly....it is a very slowly progressing condition. So seeing all those tests done before starting treatment will be beneficial. Also, the more detail you can tell us about Buddy the better. We LOVE details! ;):D See all the questions that follow? :p

Is he having any issues with his vision?

Is he neutered?

Does he have any other health issues that you are aware of?

Is he on any other meds, supplements, herbs, etc? If so, what?

How is his appetite?

Any loose stools or diarrhea since starting the Trilo?

What signs were you seeing before the diagnosis and have they lessened, gotten stronger or are they about the same since starting treatment?

Here is a link to our Helpful Resources section that will give you a lot of info on Trilostane (Vetoryl) - http://www.k9cushings.com/forum/showthread.php?t=185

I'm glad you found us and want you to know it is always safe to cry, or talk, share your fears and hopes, even scream here. You and Buddy have a new family now and we will be with you every step of the way. Keep your chin up and keep reading and talking to us. I'm very glad you and Buddy are here!

Hugs,
Leslie and the gang

Quote:

---

His illness came on very suddenly, although he's probably had Cushings for several years, Although I didn't know it. A few weeks ago he had a restless night and then woke up vomiting the next day. He also was so weak he was practically unable to stand. His back legs were wobbly and would not hold him up. After taking him to the vet and having numerous tests including blood work and x-rays, we were referred to the emergency hospital for a ultrasound. His liver was so large that they thought he had a tumor. It was difficult to see his other organs.

---

Hi and Welcome,

Yes, Trilostane/Vetoryl can cause an upset stomachFDA report of a study when first approving the drug"

[QUOTE]Adverse Reactions: Adverse reactions are reported here using the entire enrolled population of 75 dogs. Five dogs were withdrawn because of adverse reactions including lethargy, anorexia/inappetence, not drinking, vomiting, diarrhea, and muscle tremors.

Quote:

---

The most common adverse reactions were vomiting (17.3 %), lethargy (17.3%), diarrhea/loose stools (14.7%), and anorexia (6.7%). Other adverse reactions were: nocturia, upset stomach, corneal ulcer, cough, persistent estrus, vaginal discharge and vulvar swelling in a spayed female, hypoadrenocorticism, electrolyte imbalance (elevated potassium with or without decreased sodium), collapse and seizure, shaking, constipation, scratching, weight gain, and weight loss.

Conclusions: Trilostane was effective in lowering post-ACTH stimulation cortisol levels and improving clinical signs in dogs with pituitary- and adrenal-dependent hyperadrenocorticism. The most comment adverse reactions were vomiting, lethargy, diarrhea, and anorexia.

---

But I am concerned. I know it is hard to write down everything and/or remember but could you round up copies of any blood work done and post abnormal findings? Cushings does not come on suddenly and should not he used in dogs with primary liver disease. Are the vets saying Cushings is the cause of the enlarged liver? Did the neurologist say the leg problems are soley due to muscle wasting from Cushings? It just feels like a part of the puzzle is missing.

Glad you found us

Hi and welcome to you and Buddy, take some deep breaths, we are here for you..Those tummy issues can be hard to deal with, the cush parents here have some great ideas..My Simba has tummy issues too, I feed him more small meals then 2 bigger ones, seems to help with him...also when he has flare ups, I make an egg for him, seems to settle things down...He eats turkey foods, seems to be better for him...its sometimes a guessing game to see what works for our cush pups, just keeping asking and you will get lots of info from this site, and a hand to hold along the way! Sending hugs!

I have been trying to post an update to answer some of the questions that were asked of me and post test information. I am new to this site as of early this morning. I checked my email like I was supposed to and connected to login properly. My post still is not showing up. I am obviously doing something wrong. Please bear with me if it ends up being posted a couple of times. As I'm going to try to do it again. Thank you for understanding.


Hello again. My name is Kathy. Thank you for being willing to help us and for your outpouring of love and support. Before Buddy was diagnosed with Cushings, I had never heard of it before. This is my very first forum I found you out of desperation. But he is not only the light of my life, he is also my best friend. The thought of not being able to help him weighs heavily on my mind and heart. You asked for details, so here goes!

First, I'd like to answer some of your questions. Buddy is neutered he was neutered at six months. He has always had many allergies. They have shown in various skin issues ,allergies to food and environmental sneezing, runnynose and wheezing allergies. They have practically been nonexistent the last couple of years. They returned in full force after starting Trilo. Could this be due to a drop in his cortisol levels? Other then these issues, he has been basically healthy. His allergies have been controlled by an occasional dose of Benadryl.

About a year ago I noticed that he was slowing down. He was no longer able to jump up on the cedar chest to see out. I made an ADA approved ramp For him to use instead. He needs to be able to get to the window for his job, which is guard duty. He takes it very seriously. Lizard hunting is another important job. About six months ago but he started having trouble getting up the ramp. One he made it up there, he would have a hard time getting down and would freeze. He would stay there until someone came to help him down. I finally had to end up taking down the ramp. Right around that same time I noticed that but he could no longer get through his doggie door Or go up one small step to get back into the house. His beautiful hair started thinning about a year ago. I wasn't overly concerned because he always had so much of it. It now takes a long time for his hair to grow back in after grooming and I have to be very careful when I groom him. The doctor said that Buddy skin was thin? That was something that I hadn't noticed. Although he was showing mobility issues, I Thought these concerns were due to normal aging. Buddy up until becoming really ill, was always happy an active, happy, little guy. He started drinking more water the last few years. In fact, lots of it. He would drain most of a bowl and then Be drinking again a few minutes later. When he urinates, It's as if a dam has burst. I don't know where he puts it all! So far, there hasn't been any accidents in the house. Buddy's appetite is normal. No matter how upset his stomach is or how bad his allergies are, he always eats!
There has been no more vomiting, diarrhea or loose stools since starting Trilo. His stomach is very's upset most of the time now And allergies remain a problem, specifically wheezing , sneezing and runny nose. I don't have copies of all of his recent tests. I will ask for them when I return to the vet in a few days. Attached is what I have:

March 4, 2013. Pet emergency and specialty center

Medical record for Buddy 1:00 PM
Clinical history-
Betty presented for multiple episodes of vomiting and ataxia. Ate well Saturday p.m. Sunday a.m. Vomited, then vomited water when offered. Vomited a total of 8 to 10 times during Sunday. Owner gave Benadryl 12.5 mg, to try to help with nausea. No vomiting since 11 PM. Drink small amounts this a.m. and have kept it down. Yesterday at time of vomiting became ataxic. owner feels it is improved today. Urinated today a.m. Normal stool yesterday. No c/s.

pmh Of allergic run to vax, Only gets rabies now. On blue Buffalo salmon.

At rdvm today: hct 49.5, neu 11.48 bands suspect, wbc 13.81, plt 305 bun 41, alkp >2000, ggt 10, chol 392, na 143, rest wnl

rads at rdvm: Good and detail, Large liver extending the last rib, enlarged spleen. Large bladder, Feces in colon. Soft tissue density dorsal to stomach on lateral view (r/o Stomach pushed by liver vs mass effect vs other). Thoracic view diffuse interstitial pattern.

Referred here for ultrasound

Physical examination
BP 120, Temperature 102.9, Pulse 150, Respiration 60, Weight 7.273 kg, 16.00 lb, 0.38 m2

1. GEN APPR:BAR, Appears hydrated
2. EENT:MM Pink and moist CRT< 2 sec PERL
3. CARDIOVASC: NSR, GRADE 1-2/6 murmur ausculted, ausculted, Good pulse quality, no pulse deficits.
4. RESPIRATORY: Panting, lung sounds clear
5. ABDOMEN: Tens on palpation, hepatomegaly Palpable, difficult to palpate deeply. Rectal formed stool.
6. MUSC.SKEL: Ambulatory times 4.BCS. 7/9. Walks with stiff gate, primarily appears to be due to right hind limb. No obvious instability. No reaction to back palpation.
7. NERVOUS: PLR intact. CP deficits both hind limbs. Hyper reflexive reflexes in hindlimbs. Intact anal and tall tone.
8. GENITAL/URIN: Normal
9. INTEGUMENT: Normal
10. LYMPH NODES: Normal

PROBLEMS IDENTIFIED
-Mild hypothermia r/o stress, Infection, inflammation, Neoplasia, other
-Vomiting multiple times r/o Metabolic, endocrine, pancreatitis, Neoplasia , Fb obstruction, toxin, other
-Ataxic gait/CP Deficit/hyper reflexes r/o 13 – 13 Myelopathy ( ivdd, neoplasia, fxr, luxation), toxin, discospondylitis, discospondylosis , other
-Distended abdomen r/o hepatomegaly,Cushings, asites, Neoplasia, other
-bun r/o pre renal, renal, post renal, other
-elevated alkp, ggt, hepatomegaly, r/o endocrine hepatopathy, vacuolar hepatopathy, inflammatory hepatopathy,neoplasia, other
-Increased soft tissue density dorsal to stomach r/o mass effect, secondary to hepatomegaly, ingesta, other

DIAGNOSTIC TREATMENT PLAN
Met with Mrs. J and examined buddy. Discussed PE and rad/bloodwork concerns. Discussed ataxia appears to be more a Peripheral neuropathy rather than central. (As good mentation, alert, cn intact). Recommend USG to evaluate azotemia. BP to evaluate again for possible hypertension. It was normal the first time at 120. AUS Ideal to evaluate liver and abnormal appearance of stomach on rads. Would recommend spinal rads or advanced imaging to better evaluate spine. At this time plan to Ward OBS while awaiting AUS and will use this to help make decision in case mass etc. is found. She understands will not be done until late this afternoon plan approved.

CLINICIANS PROGRESS NOTES
BP 120
Neg. glucose, small bilirubin, neg blood, ph 6, protein 100

4:30 PM
Back from AUS. Initially vocalizing and appears stressed in cage but quiets down. CP deficits remain but is able to emulate on hind limbs. Still no evidence of back pain. Offered z/d diet- Ate very eagerly.

Telecom with Mrs. J, updated on urine, BP and AUS, overall fairly good results as no obvious masses and hepatomegaly is suspected secondary to endocrinopathy. Would recommend follow-up with rdvm For testings for Cushings At a future date.ataxia and increased reflexes are still concerns – possibly could have thrown a clot, could relate to Cushing's this way but otherwise may be a separate problem. (13-13 myelopathy, neoplasia, other). Can do pain meds and activity restriction trial, next diagnostic step would be spinal rads but discuss limitations of rads. Discuss signs can progress, worsen, it occurs would recommend more advanced imaging, consider sx or neuro consult if this occur. Mrs. J. approves final rads, will monitor at home follow up with our RDVM. Discussed activity restriction.

Two views spinal rads: No obvious bony lesion. Subjective disk space narrowing T 10-11-12

Tgh Tramadol ( Elect to hold off on NSAIDs given high suspicion of Cushing/other hepatopathy )

CLINICIANS PROGRESS NOTES 2:37 PM
ABDOMINAL ULTRASOUND
-Liver-diffusely hyperechoic ( same eghogenicity as spleen) With mild Mottling and ill defined hypoechoic regions. Subjectively plump based on degree of overhang over midline gastric axis, recommend rads to delineate hepatic margins, prominent hepatic vasculature, no
discrete masses or nodules.
-Gallbladder- Gallbladder filled with significant amount of moderate eghogenic debris with possible early organization, bile duct WN L
-Stomach- Normal rugal folds, multiple Pinpoint hyperechoic foci in muscularis; small intestinal segments evaluated have normal architectural layer definition, multiple full pinpoint hyperechoic foci in muscular is, all segments(0.35cm).
-Pancreas-Homogeneous texture and smooth capsule in sections evaluated; R pancreas 0.56
-Spleen-Homogeneous echotexture, normal echogenicity, focal hypoechoic nodule within Parenchyma.
-Kidneys- right:4.25 cm- ragged corticomedullary Definition, hypoechoic cortical, cyst containing a pinpoint hyperechoic density that shadows (ie:mineral); left: 4.8 cm, attenuated corticomedullary definition; No pelvic dilation, mineralization of diverticuli bilat
-Adrenal glands-right 0.52 cm, left 0.69cm (Normal average cat 0.43 cm, normal canine <0.75 cm);
-Urinary bladder-Unremarkable
-Prostate – WN L
-Lymph nodes:meds enteric and sublumbar LN WNL
-No asites
FINDINGS
>hepatopathy And liver changes – r/o : endocrine hepatopathy , vacuolar hepatopathy, inflammatory hepatopathy, less likely Infiltrative dz
>hepatic vessels midly prominent – R/O: R sided Heart failure, fluid overload
> Multiple pinpoint hyperechoic foci in muscularis of stomach and intestines – consistent with Mildly dilated lymphatics r/o: Transient Gastrointestinitis or inflammatory bowel disease "these are most likely", Infiltrative DZ, other
> Mild soft tissue mineralization and kidneys

TENTATIVE DIAGNOSIS
Open for ataxia
Enlarged liver

DIET- Normal diet
RECOMMENDATIONS
Summary:
Buddy presented for ultrasound evaluation after his liver looked large on x-rays at your family veterinarian after multiple episodes about vomiting. Ultrasound evaluations of his liver was most consistent with changes secondary to An endocrine disease such as Cushing's as well as G.I. changes most likely secondary to Gastrointestinitis. He has eaten well in the hospital with no further vomiting.

He does have a wobbly gait in his hindlimbs and abnormal reflexes which are most consistent with the spinal issues such as a disc or blood clot among other causes. Spinal x-rays did not show any obvious bony lesions. We are sending him home with pain medication and recommend activity restriction as we discussed if these signs persist or worsen, advanced imaging and even surgery may be recommended.

Please keep buddy confined to a crate or small room. No running, jumping or playing. He should go outside on a leash for bathroom purposes only.

Please monitor buddy for any progressive difficulty using his hindlimbs, vomiting, in appetence, diarrhea, coughing or any other abnormalities. If these occur please recheck immediately with your family veterinarian or the PESC if after hours.

Everybody is doing well with no further vomiting and eating and walking please recheck with your veterinarian in two days. Recheck sooner if problems occur.

END OF MEDICAL RECORD

I don't have copies of the low dose eight hour Cushings test that determined Pituitary Dependent Cushings, as of yet.
Below are the test results I do have.

CATALYST DX (March 4, 2013)
Below are the items that fell beyond the normal range
BUN 41mg. 7-27 HIGH
ALKP greater than 2000 UL 23-212 HIGH
GGT 10 U/L 0-7 HIGH
CHOL 392 mg. 110-130 HIGH
NA 143 mmol/L 144-160 LOW

PROCYTE DX (MARCH 4, 2013)
items out of normal range
NEU 11.48 K 2.95-11.64 HIGH
BAND - Suspect Presence
MONO 1.13K 0.16-1.12 HIGH


This is all I have for now. The doctor called me this evening to check on Buddy. She said to continue the Trilo, giving Buddy time to adjust to it. Upset stomach's are common when initializing treatment. Watch for vomiting and diarrhea. Let her know if he stops eating. As for Buddy's allergy symptoms recurring, that means Cortisol levels are dropping, which is what we want. Treat the runny nose, sneezing, wheezing etc. with Benadryl 3 times per day. Once Buddy is breathing better, he may be able to rest. Benadryl causes drowiness, which is good also. We go in Wed. or Thurs. for a blood test to see if Buddy's Cortisol levels are coming down. That is 7-10 days after initializing treatment. Adjustments may need to be made at that time.

Thank you for reading this....Kathy and Buddy

Hi Kathy,

I only have a moment to post but I wanted to welcome you back and I will let the Administrators know that you need approval so please be patient with us...Thanks so much.

Love and hugs,
Lori

so perhaps Buddy had a transient gastric episode along with an acute clot or disk problem with his back legs which is why he suddenly seemed ill, subsequently they found Cushings while checking everything out? That would seem to fill in the puzzle. At least that was how I read it but I am by no means an expert so hopefully after the holiday, one of our administrators will come along and read through it all.

Dropping Buddy's cortsiol will make his allergies flare up, he was self medicating with the higher cortisol, keeping them in check. It is not unusual for them to feel under the weather while their cortisol drops if they have other issues the higher cortisol was helping them with.

Quote:

---

Recommend USG to evaluate azotemia

---

I am hoping someone else can dechiper what they are saying about the kidneys and their thought on the protein in the urine. I am not clear on that.

Hello again,
For those of you who are not independently wealthy, how do you pay for it all? I am terribly frustrated! Buddy is having an ACTH test on Wednesday To determine if the trilostane is reducing his cortisol levels. They do the first one 7 to 10 days after initializing treatment. This leaves me with a bill of approximately $2000 since the beginning of March. I work in a local public school district. This is my 21st year with the district. I love what I do, but I don't bring home anywhere near two grand in an entire month! I only work nine months out of the year! The $2000 does not include the cost of His meds. It only includes tests and vet bills. These tests have to be done regularly. I am feeling very stressed!

Update:
During the neurology consultation, I found out that buddy did not appear to have a disc problem in his back, causing his hind leg weakness. It could've been caused by a stroke. A $3000 MRI would determine if he had had a stroke. Even if he did have a stroke, there is nothing I can do about that anyway. The doctor said to go ahead and test for Cushing's, that Buddy was stable enough. She said that his hind leg weakness could be due to Cushings Deterioration. She also said that he didn't appear to be in any pain. So yes, Cushing's was tested and found And treatment with Trilo was started. Buddy's stomach has finally began to settle. His allergies,however are going haywire! I know baby steps. Several people including family members has suggested that I put buddy down. That is not something that I'm willing to do even though the bills are continuing to pile up. He has given me 10 years of unconditional love. Illness is not a time to abandon him and I won't do that! Thank you for giving me a safe place to vent.

By the way, When I called the vet to get a quote for Wednesday's test, I also asked for copies of all of Buddy's tests. I'll pick them up on Wednesday.
Hugs, Kathy and Buddy

The initial cost expense is during the diagnostic phase and when a dog becomes stabilized on treatment the cost does go down considerably.

Here is a post from one of Administrators, Glynda, where she details another cost saving method:

Quote:

---

Originally Posted by lulusmom

Hi Kelly

The reason why the acth stim test is so expensive is because the stimulating agent, cortrosyn, is ridiculously expensive. There is good news for those with smaller dogs because studies show that while instructions on the .25 mg (250 mcg) vial is to inject the entire vial, only 5 mcg per kg of weight is necessary for an accurate result. While Java isn't small, her weight is still low enough to get two stim tests out of one vial. If you do the math, she'd need a bit over 113 mcg so your vet could just split the vial exactly in half.

I have provided the url to instructions on how to split, reconsititute and store for future use. This info is brought to us by a highly published and well respected endocrine specialist, Dr. Mark Peterson. Either give the url to your vet or print out the article for him and ask for a revised quote.

http://endocrinevet.blogspot.com/201...cortrosyn.html

Glynda

---

Having the Trilostane compounded is a money saver too.

Hello and welcome from me too.

It is Very over whelming when the testing first begins that is for sure. Check out the ACTH frezing option that Lori posted above. Call the vet and ask if they will do this for you and give you a new quote. It helps. It is a doozy though to get through in the beginning. The hind leg weakness is definitely one of the possible signs of cushings, it causes muscle wastage in the hind legs usually. This sometimes will improve once treatment is under way. The pot belly also will hopefully go down some too and the drinking/peeing should get better as cortisol lowers to a better level.
Now on the other hand, allergies and arthritic sysmptoms may show up more since the cortisol is no longer covering it up. So that is something to keep in mind and be prepared for. Just see how he does. Hopefully no more vomiting episodes.
Hang in there. We know this isn't easy. Feel free to vent whenever you want. We've all done it more than once. :)

Sharlene and Molly Muffin

Buddy is scheduled to have ACTH stimulation testing on Wednesday. I have been reading lots of information from your site to learn as much as I can about Cushings. I found out a few things and am very distressed about it. Buddy was started on trilostane a week ago Tuesday. 7 to 10 days after initiation of treatment he is due for for a ACTH stimulation test. I have discovered a few real problems With Buddy's treatment. First of all As per RX ,Buddy has been taking his trilostane on an empty stomach one hour before breakfast. He has not been taking it with food as Dr. Mark E Peterson advises . That's the first problem! The second problem is, I was told that Buddy needs to be fasted before taking his AC TH stimulation test on Wednesday. I was to give him his pill and then bring him in for his testing 4-6 hours later. Dr. Peterson article says that fasting will cause The test to be invalidated and even can cause harm. What should I do now? I haven't been giving Buddy his pill with food. If I go ahead with the ACTH test on Wednesday it wouldn't be accurate Even if I gave him his pill with food before the test. Would you suggest that I wait another week before having the test done and start giving him his pill with food tomorrow? Should he be having his pill with his regular breakfast or Just be given his pill with a small amount of food, then fed breakfast later? The more Information I read, the more it conflicts with my vet's instructions. I'm confused. Please advise!

Thank you, Kathy and Buddy

I would ask to share Dr. Peterson's suggestions via email. My vet was unaware that the dosages recommended by the company were too high. Trilostane must be given with food and the ACTH tested is to be completed 4 - 6 hours after the morning dose of Trilostane.

Also ask if they partial out the Cortisyn because doing so lowers the cost of testing. If you have an IMS (small animal internal medicine) vet in the area, a visit to one is a good idea. Having an ultrasound is very helpful in determining how miuch Cushing's has been present. Our dog Daisy, has had it for at least a year prior to outward signs.

Ladies, I'm sure that you'll correct me if I've gotten any of this wrong :)

Good morning and good luck :)

You can go ahead an start giving the medicine with the food and just make sure you give it with the food 4 - 6 hours before the test. Even if you have not being do so until now, as long as you start to do it and continue the morning of the test, the result will be valid.

Print out what Dr. Peterson says about giving it with food and take that in to your vet. We have found that many vets do not actually Know the protocols for giving the medicine. That is okay as long as they are willing to learn.

The food allows the medicine to be absorbed into the body more efficiently. Without it, the medicine doesn't absorb correctly from what I understand.

How is Buddy doing?

Sharlene and Molly Muffin

Hello to you and Buddy,

I agree with Valerie -- I encourage you to talk with your vet about your concern that you've been told to give Buddy his trilostane on an empty stomach. In addition to Dr. Peterson's article, you can also cite these "Treatment Tips" published by Dechra, the manufacturer of brandname Vetoryl:

http://www.dechra-us.com/files//dech...UT_2_0_dis.pdf

When contacted directly, Dechra has told me and other members that the trilostane also needs to be given with a meal on the morning of the ACTH testing. If your vet has any questions about this, I know the technical representatives at Dechra will be happy to discuss this either by phone or by email.

I do not know why your vet is telling you to wait one hour after dosing before you feed Buddy his breakfast. Perhaps there is some reason of which we're unaware. But I would definitely want to discuss this before proceeding with an ACTH test. I agree with you, I'd want to dose Buddy properly (giving his trilostane along with his regular breakfast) for approx. a week before moving forward with the testing.

Marianne

Oops I was thinking that the test was Next Wed. I agree that you'd want Buddy to have been taking the medicine with food for a bit prior to the ACTH test.

Sharlene and Molly Muffin

Good morning,
I forwarded the information I learned on your site on to the vet last night. Below is her response. I copied and pasted it from the email I received.

Many studies have shown that there is no difference in absorption whether trilostane is given with or without food. This is even stated in the main veterinary drug resource book. However, the gastrointestinal side effects are reduced if given on an empty stomach and this has been the standard since this drug came to America about 7 years ago. You are welcome to do it however you wish.

If you want to have the test done giving it with food I am happy to do that. However, most labs recommend fasting anytime cortisol is read as the results are actually more accurate with the method they use to test. So it's basically up to the lab. But with that said, our lab doesn't care either way. :-

Thank you for your feedback so quickly! I'm going to reply and let them know that I will be bringing him in next week for his ACTH test.
I also conversed with them already about fractioning the drug used in the ACTH test. They already do it.

Hugs, Kathy and Buddy

Hi Kathy,

Since your vet seems to be aware of studies that conflict with what we have been told by the manufacturer and the studies we are aware of, would you mind asking her to supply you with supporting information for the studies she mentions? It is always possible there is info out there we are not aware of and having a full arsenal of information is always nice! ;)

Hope things are going better for you and Buddy!
Hugs,
Leslie and the gang

Kathy, I hate to "pile on" re: questioning your vet. But I am really puzzled by what she has told you. The clinical trials and studies in the custody of Dechra (the brandname drug manufacturer) are the basis for FDA approval of Vetoryl in this country, and it is the manufacturer's prescribing information that is likely to be contained in any official drug compendium. The link I gave you earlier was to a Dechra publication directed to pet owners. But here is a link to the official U.S. Product Insert for Vetoryl (this is the FDA approved prescribing information):

http://www.dechra-us.com/files/dechr...ts/Vetoryl.pdf

And here is a direct quote from the Product Insert:

Quote:

---

CLINICAL PHARMACOLOGY:
Trilostane absorption is enhanced by administration with food. In healthy dogs, maximal plasma levels of trilostane occur within 1.5 hours, returning to baseline levels within twelve hours, although large inter-dog variation occurs. There is no accumulation of trilostane or its metabolites over time.

---

The recommendation to administer Vetoryl (trilostane) with food is not a new one. I started treating my dog with trilostane in 2003, and at that time the drug had to be imported from the U.K. because it had not yet received FDA approval for sale in the U.S. But even at that time, the recommendation was to give trilostane along with breakfast. At that time, "Arnolds" was the manufacturer of Vetoryl (Arnolds has since been incorporated into Dechra). Here's a link to an archived version of Arnolds' 2002 prescribing recommendations (click on "Vetoryl FAQs" on the main index page):

http://web.archive.org/web/200308012...Page/index.htm

And here's the relevant quote:

Quote:

---

6. Should Vetoryl®be given with food?
Yes, Vetoryl® is best given with food.

---

In the absence of supporting documentation, I do feel concerned if your vet persists in advocating for giving trilostane on an empty stomach. I realize it may feel awkward to press her to provide research citations and you may not wish to do so. Like Leslie, I would surely be interested in that info. But whether you ask her or not, I do encourage you to really read through that Product Insert carefully yourself. That way you'll be familiar with all the manufacturer's recommendations if/when you discuss other aspects of Buddy's care with your vet.

Marianne

Marianne,
I forwarded your entire message onto Buddy's vet giving her a chance to respond with documentation if she would like. I did tell her that was her choice. Having open communication with one's vet is vital to the well-being of our beloved four-legged family members. I don't want to upset that balance or close the door to communication. I'll forward on any response I get.

Kathy

Kathy,

you are correct. I voiced my opinion of mutual cooperation with Dr. Morgan at Cornell and she was in full agreement.
I won't even take that crap from my own doctors regardless of how "good" they are.

She's an internal small animal specialist and her recommendations were to give Trilostane with food for proper absorption and to be sure that Daisy has it 4 - 6 hours before her ACTH testing.

It is possible that your vets information is out of date.
Dr. Peterson is well known for his research of endocrun disorders.

Hello Kathy and welcome to you and the Budster! I saw your heading and it brought back such memories...this is a great site, keep on your Vet or try to find a new one, I did and am very happy with him and his humbleness in taking advice - he even wanted me to thank the group after a bit of letting go of some ego....

I am no expert, there are many on here who are way more knowledgable and experienced so I will leave the advice giving for them. Please know that I will be praying for you and Budster (Buddy).
I was an EA as well years ago...now disabled, I will also pray you will have the funds to help buddy's quality of life.

Peace and Blessings Abound,

Sharon, Norman (cushings Doxie) and Millie (yorkie-pooh)

Hi Kathy, I too would be very interested in any documentation or studies that your vet could supply us with that suggests that it is better to give food later than earlier, especially for gastrointestinal upset.

My main reason and you are welcome to supply this to your vet is that we are a forum, almost solely devoted to cushings (of course that goes along with so many other things it seems kidneys, diabetes, pancreatis, etc) and we have members from all over the world that come here looking for help, advice, etc. What we tell members is based upon, our own experiences, and also based upon documented studies, papers. So if there is something out there, that we are unaware of (and we do have administrators who read every published paper they can get their hands on for the sole purpose of staying up to date on new studies), then anything she could provide us with would of benefit to people and their cushings dogs all over the world. We never turn down or turn our noses up at new information, but we do need it to be up to date info and we welcome input from veterinarians for the purpose of helping our members.

Sharlene and Molly Muffin

Hi Kathy,

Many of us are voracious researchers and I for one would be very interested in more information from your vet on the many studies she's seen that show there is no difference in absorption whether trilostane is given with or without food. Everything I've read and based on my own experience with two cushdogs, says differently.
Information submitted to the FDA by Dechra, the manufacturer of Vetoryl (trilostane) for approval of the drug very specifically says that VETORYL Capsules should be administered with food. Route of administration repeatedly says; "Oral, given with food".

http://www.fda.gov/AnimalVeterinary/.../ucm049823.htm

I do understand that some labs specifically ask that a dog be fasted for an acth stim test; however, I believe that only applies if the test is being done for purposes of diagnosing addison's or cushing's. Protocol is completely different for purposes of monitoring treatment with Vetoryl or Lysodren. Dr. Mark Peterson, a world renown endocrine expert, mentions this in his March 16, 2011 blog entitled "What's the Best protocol for ACTH Stimulation Testing in Dogs and Cats".

http://endocrinevet.blogspot.com/201...-for-acth.html

Quote:

---

Remember that the ACTH stimulation test is the most useful test for monitoring dogs being treated with trilostane (Vetoryl) or mitotane (Lysodren) see my blog entitled, Diagnosing Cushing's disease: Should the ACTH stimulation test ever be used? Both medications are fat-soluble drugs and must be given at time of meals, or the drugs will not be well absorbed.

With trilostane, it’s extremely important to give the morning medication with food, and then start the ACTH stimulation test 3 to 4 hours later.

Fasting these dogs on the morning in which the ACTH stimulation test is scheduled should be avoided since it invalidates the test results.

When a dog ‘s food is withheld, the absorption of trilostane from the gastrointestinal tract is decreased. This leads to low circulating levels of trilostane, resulting in little to no inhibition of adrenocortical synthesis. Therefore, serum cortisol values will higher when the drug is given in a fasted state than when it is given with food.

---

Like Marianne, I was treating my dogs with Trilostane before Vetoryl was approved by the FDA in 2008 and the route of administration has never changed in the last seven years. To be quite honest, I hope your vet will consider calling Dechra to confirm what we've told you. We're just laypeople so I don't expect her to take our word for it which is why we've provided citations for her. Getting it from the horse's mouth is much perferred to telling pet owners to do what they want. Vetoryl (trilostane) is a serious drug and she needs to direct treatment according to proper protocol. I will also say that if the lab involved knows that the test is being used to monitor Trilostane treatment, they need to educate themselves too and understand that a dog must receive their dose WITH FOOD no more than 4 to 6 hours before the acth stimulation test; otherwise, you might as well flush your hard earned money down the toilet.

Glynda

Oh gosh, I just realize a bunch of us posted on the same thing. I hope we haven't totally overwhelmed you!!
We are the forum of worry warts you know. :) It's like having a dozen mother hens running around after you. :) :) :)

Sharlene and Molly Muffin

It's fine. I am a big girl. I can handle it. :) It all is a little overwhelming. Particularly since I hadn't even heard of Cushings until Buddy became ill and it was discovered.

My biggest stress is finances right now. How I'm going to be able to afford to pay for Buddy's needs. I know in my heart that it will all work out, but in the meantime it's stressful. Thank you for all of your help. I found your forum out of desperation. I was looking for someone to explain some of it (any of it) to me. I kept hearing the words Cushings and seeing $$$$. Tests, tests, and more tests! Buddy's regular Vet, Emergency hospital for an ultrasound and A neuro exam and consultation, at yet a third hospital. It was a hole that I kept falling into deeper and deeper without a clue as to what was happening. Vets kept telling me that they need to do this and that. I didn't know what any of it meant or what they were searching for. All the while the $$$$ became bigger and brighter with no end in sight. These professionals spit out fees as if they were gum balls in an endless sea of pennies. They don't see them as thousands of dollars.

Update: I gave Buddy his Trilo dose with Breakfast for the first time this morning. Up until then, hes been getting it one hour before breakfast. His stomach has been fine all day. The resurfacing of his allergies continues to be a challenge for Buddy, but Benadryl is helping somewhat. Sometimes Buddy will sneeze 20 times in a row, while his nose runs continuously. Now with the Benadryl, he's a least able to breathe easier and sleep most of the night. It is a blessing that I am on Spring Break right now. It gives me the opportunity to monitor him more closely as he adjusts to his meds.

I haven't heard back from the vet since this morning. I forwarded her your questions. It is up to her whether she chooses to respond. If she does, I'll forward that on.

Kathy and the Budster

Kathy,
that's great news! Benadryl can make Buddy sleepy so it's good that he takes it at night. Sleep is so important in the healing process for humans and furbabies.

If your vet doesn't respond or makes your comments sound unfounded, honestly I would find another vet.

Cushing's is difficult to treat and so many other issues can go right along with the disease. Properly treated and our guys can live out their full life span or close to it comfortably and happy.

Well, here goes....I received a response from Buddy's vet this morning. It is cut and pasted below. :D

Kathy, I don't know what to tell you on this. The forums on VIN, the database for UC Davis, cannot be cut/pasted and accessed without a passoword. All of the doctors here have been asked and we all agree is doesn't matter. This drug was given fasted for many many years with excellent treatment successs.

So that it! :eek:
Kathy and Buddy

WOW,

I have resisted chiming in. Me thinks she has a resentment building because she was sure not paying attention to the links.:rolleyes:

Solution: Why dont you call Dechra directly and simply ask them. They will give you a case number and she can then access Dechra through your case number.;);)

I did that and it really ticked off my IMS and embarrrassed her:):)
But, a girl has to do what a girl has to do to protect her pup.:):)

((((((((hugs)))))))))))))

Great idea Addy, especially since my IMS at Cornell suggests twice a day! Cornell is a well known teaching vet hospital so I expect their knowledge to be current.

Good luck!

Quote:

---

Originally Posted by Budster's Mom

Well, here goes....I received a response from Buddy's vet this morning. It is cut and pasted below. :D

Kathy, I don't know what to tell you on this. The forums on VIN, the database for UC Davis, cannot be cut/pasted and accessed without a passoword. All of the doctors here have been asked and we all agree is doesn't matter. This drug was given fasted for many many years with excellent treatment successs.

So that it! :eek:
Kathy and Buddy

---

Well. Your vet is not giving us much help here, is she. :o

Being the obsessive person I am, I have been busy Googling my iPad to death ever since we started this conversation. All I find are repeated instructions, through the years, to administer trilostane with food. This ranges from the citations we've already supplied to treatment directives published by IDEXX Laboratories to the most recent study results published by UC Davis in which the researchers specifically note that dogs were given trilostane along with food in advance of all ACTH tests. Out of all these searches, I did find one author around 2008-2009 who stated (without any supporting citation) that it had not been proven that food improved trilostane absorption -- but even that author still noted that the prescribing recommendation is to give the drug with food. Bottom line: I have found no reference anywhere by anybody, at any time, that recommends dosing trilostane on an empty stomach. Will some of the drug still be absorbed, regardless? Yes, I suppose so. So if this is the way your vet has been dosing all her dogs, presumably they would still be getting some benefit from the drug. But I would suspect they would likely be requiring a higher dose (and hence, at greater expense) than would otherwise be the case if the drug was being absorbed maximally.

For your own peace of mind, you can certainly contact Dechra. As to whether or not this will make a difference to your vet, I do not know since she seems to be totally disregarding Dechra's published directives. I don't know whether she'd respond differently to a verbal conversation. But at her request, maybe they could supply her with some actual research data. I know at least one such study exists, although I have not been able to access the full text yet ("It has been shown that feeding immediately after the administration of trilostane increases its absorption"). But Dechra may have custody of this or other studies that could be provided to your vet:

Johnston L, Chohan A, Chapman E. Absorption of Trilostane in the Fasted and Non- Fasted Healthy Dog. Proceedings 15th ECVIM Congress, 2005; p223 (abstract).

But at this point, we've pretty much beaten this particular issue into the ground. So the big question seems to be, where do you go from here? I guess your reaction to your vet's response will be tempered by your overall relationship with her. Is this a vet whom you've used for a long period of time and generally with positive results? Do you otherwise feel comfortable with the care your dog has received? Aside from this instance, does she generally address your questions in a satisfactory manner? Do you feel as though you have other options? Right now, she is not winning me over in terms of either her receptiveness to new information or her expertise in using trilostane. But you are the far better judge as to your overall comfort level with her care.

Marianne

Good morning,
It appears obvious that my vets do not have the information regarding Cushings that you have.:rolleyes::eek:

As a recap...I rescheduled Buddy's ACTH test for next week. I hadn't been giving him his Trilo with food per doctor's orders. :mad: I was instructed to fast him before his ACTH test. :mad:I started giving him Trilo with breakfast a few days ago. I wanted to dose him according to protocol for at least a week before his ACTH test.

Buddy is taking Benadryl three times a day (every 8 hours)to control the onslaught of allergies. I don't like giving it to him that often particularly since it makes feel drugged and sleepy. If I don't, he literally cannot breathe well. He sneezes continuously with a runny nose and wheezes without relief. So, drugging him is the lesser of two evils for now.

Here's my question… Is it okay to give Buddy Benadryl on the morning of his ACTH test? If not, he is going to feel really miserable. I'm going to have to take that day off, which looks pretty bad after being off on break for two weeks. That is the only way that I know he will get his test completed in the required the 4-6 hour time window.
If I drop him off there on the way to work and pick him up after, I will have no idea when they actually started or completed the test. I've been giving Buddy his dose of Benadryl when he gets up in the morning. Then I've been giving him his trilostane a half an hour or so later with breakfast. Would it be okay if I did that the morning of the test?:confused:

Thanks for your help in advance,
Kathy and Buddy:):D

I've never read or been told that antihistamines interfere with the ACTH, but this is another thing that you could double-check with Dechra if you'd like. Here's contact information for their U.S. office in Kansas:

http://www.dechra-us.com/Default.aspx?ID=365

THey have vets and vet techs on staff who are available to field questions via phone or email. They used to be very responsive to talking directly with pet owners, but seem to have become more selective as to what they prefer to discuss only with vets. But I would think that a question like this would be something that they'd be fine with answering for you.

For what it's worth in the future, you may want to experiment with switching Buddy to one of the newer, non-drowsy antihistamines. One of my non-Cushpups has terrible seasonal allergies, but she also has to take phenobarb for a seizure disorder. The combination of phenobarb and sedating antihistamines is not a good one, so my vet has switched her to Claritin. In honesty, neither Benadryl nor the Claritin have seemed to help her very much. But you can keep experimenting with different antihistamines to see if one provides a better response for Buddy. I'm sure you can Google a list of acceptable antihistamines/dosages for doggies, or maybe one of our other members can supply one.

Hi Marianne,:)
I posted my last post before I read your email. Thank you for all of your hard work and for trying to search these things out for me as we'll as for others.

I have used that vet's office since Buddy was a puppy (10 years). I was referred there by others who are very happy with them. I have been very satisfied and comfortable with them handling Buddy's care up to this point. My regular vet was out on vacation when I ended up taking Buddy in so ill. That's how I ended up with this other doctor. I was very impressed with her, I must admit. She was the first one to suspect Cushing's. She referred us to an emergency hospital for an ultrasound, because she said we needed a specialist. She said that they could do it there, but Buddy had so many problems going on she thought he needed specialist. I appreciate her telling me that, instead of moving forth without proper testing. She referred us to a Specialty Hospital and to a specific doctor for his neural consultation.
She called ahead and talked with the neurologist, making sure they had everything they needed before my appointment. I believed everything she told me regarding Cushing's treatment until I found your forum. This form is like a very addicting drug. I couldn't get enough of it!;). The more I read, the more confused I got. :rolleyes:
I am not distressed by the fact that she didn't know. No one knows it all! What bothers me is the fact that I forwarded numerous citations from this forum and her opinion has remained the same. It also disturbs me that she said that everyone in your office felt exactly the same way about Dosing Trilo with or without food. That it makes no difference either way. If that is really true, then going back to my regular vet wouldn't help, would it? I have been really happy with my regular vet. He treats his pet parents as if he has all the time in the world to answer all of their questions. He even brought out a bin of bones once to show me how Buddy's knee worked when I didn't understand what he was telling me. I really like him, but I am afraid that office doesn't know enough about Cushings. So yes, I could find another vet. I live in a populated area where there are many. Hence my dilemma!

Marianne,
THANK YOU!!!!! I followed your device and called Dechra. They were very helpful. Not only were my all of my questions answered, they were also explained. They told me that Vetroyl was fairly new in the United States and a lot of vets are not familiar with it's protocol.

1. Trilostane must be administered with food for proper absorption.
2. ATCH testing - No fast- Meal with medication - a smaller meal is warranted if the animal tends to get carsick. Test must be
started within a 4-6 hours, but doesn't have to be completed by
then.
Vets often want to do several tests at once therefore requiring a
Fast. In that case it is advisable to do the ACTH test at a different time.
3. Benadryl - Benadryl shouldn't in any way affect the ACTH test results.

So there is your verification once more! I wish my vet would call!
There are other Cush parents who are going to be getting the same instructions that I was given and won't know enough to look further.:(

Kathy and Buddy:)

Oh Kathy, I'm so glad you called Dechra and that they were able to answer all your questions. And thank you so much for passing their information on to us. :)

I am really sorry that this conflict has come up regarding your vet's instructions. From what you've described, it does sound as though she acted very kindly and responsibly during Buddy's crisis. And the last thing we want to do here is to undermine a member's relationship with his/her vet. But I agree with you whole-heartedly that the more disturbing thing to me is not that your vet may have been originally misinformed (of course that happens), but instead that she doesn't seem to be responsive to the information that you've supplied to her now. It can be hard to have a conversation about this via email, though. Will you have the opportunity to talk face-to-face when you take Buddy in for his test? Especially now that you have had the chance to personally talk to Dechra, I'm thinking that could be the basis for your conversation with your vet. And I'm hoping that you'll get a different response from her when you have the chance to relay exactly what you've been told by Dechra, and I'm surely hoping that she will be motivated to seek further clarification herself if she remains unconvinced.

Marianne

Kathy, did they give you a case number? If so, you can give the case number to your vet and tell her what Dechra told you and that she can call, refering to the case number to verify the information you received directly from the drug's manufacturer.;)

No they just talked to me and answered all my questions. They were very helpful and didn't seem to mind that I wasn't a vet. I didn't think to ask for a case number.
I'll call ahead and get my vet's schedule for next week so that I can hopefully talk to her when I take Buddy in for his ACTH Test. We'll see how it goes. That would give her a few days to research anything that she might like to, or calm down enough to hopefully listen to what I have to say. I don't want to come across as a threat or make her feel intimidated. I just want her to be open-minded enough so we can continue to learn together. We'll see,

Kathy and the Budster ;)

I know, it is balancing act. Sometimes face to face is better than email. The written word sometimes is misunderstood; there are no facial expressions or voice tones to use as cues.

I am so glad you called Dechra.

I'm really glad that you called Dechra and they answered your questions. Now if your vet will take their responses into consideration, maybe it will all work out. It's really hard when you have been with the same vet for a long time and have had a good experience usually with them.
Hang in there, you are doing great!

hugs,
Sharlene and Molly Muffin