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Addy:
It could be she has to adjust to the low cortisol. Tipper went thru that, acting really strange for a while just something was not right. Now she does it if her cortisol goes too high as she got used to it being low. You know best if something is just not right with Zoe. I am sure you will put your finger on it in the upcoming days. Blessings
Patti
Hi Addy,
Boy, what a puzzle. But I totally "get it" that you are aware that something has shifted for Zoe.
You know, to this day I don't really know what to think about stim results when the "pre" is the higher of the two. Our beloved Dr. Allen didn't seem to be concerned about it just so long as both results are higher than 1.45. He told me that it could just be stress that was affecting the first draw. But still, doesn't that mean that there is less cortisol in reserve than you might like? It doesn't seem as though there is a clear answer in that regard. Some clinicians prefer a higher "post," and others don't seem to care.
I think Zoe has often had higher "pre's" than "posts." But her overall result is significantly lower than in August. And since you are noticing a change in Zoe, I wonder whether she *would* be better off if her cortisol is allowed to increase a little bit? You are currently doing 30/20 right? Maybe it would be worth backing off to 20/20 for a little while? (Although that means more expense if you stick with Vetoryl :o). I don't know. Just musing. But if she were mine, I think I might give that a try for just a little while...
Marianne
Hi Addy,
Trixie is on a total 28mg a day divided into 14mg am/pm. I'm using 10mg Vetoryl and 4mg Trilostane.
Hope that helps.
Barbara
This is significantly low for Zoe, her pre is always elevated. Of course it is wonderful so many things are now normal on her tests and her hair and tummy are great but it seems there has to be a balance some how. Dechra kept telling us to watch her as she may drift too low. To me, this is quite a drop in 3 months, especially when her pills were melting for who knows how long?
Her alkp was never greatly increased, 800 something like that was the top mark for her and then came down, so it is not like it was super high and now normal.
I don't think I can swing another $60 (plus or minus) a month for her meds. I told her vet I would have to switch to compounded if I did 20/20. That evening dose has always seemed to bother her which is why I thought maybe I could try cutting back at that first. She has always seemed to struggle with her nightly dose.
I cant even believe I am saying this, that I am thinking of taking her off twice day dosing after all this time and energy. I was preparing for really bad news as we always seem to get that every six months or so. Here comes another crisis, me waiting for the shoe to drop.
Dang, I hate this. I have to think about it all.
Addy, if anyone can figure this out, it is you. But I think you've done enough figurin' for a minute. Take the rest of the day and tonight and, to borrow one of your own phrases, "put this in the drawer" for a little while.
Spend some time doing something relaxing, distracting, and fun. Talk hubby into taking you out for supper; meet a girlfriend for drinks after work; cook your favorite meal; something out of the routine and worry for a short while. Enjoy, try not to analyze but enjoy, Zoe and Koko for a bit - have fun.
When you do come back to this, use fresh eyes - look around outside the Cushing's box as well as inside. You may find that something you have looked at 50 times suddenly has new meaning. ;)
Just don't forget that Mom needs attention from time to time, too. ;)
Hugs,
Leslie and the gang
Quote:
Adjusting the trilostane dose when ACTH-stimulated cortisol values fall too low
Even even if the prednisone isn't having any effect on cortisol measurements, a post-ACTH stimulated cortisol value of 2.0 µg/dL is too low for me (1,2). I'd recommend that you decrease the trilostane (Vetoryl) dose down to 30 mg once a day, and repeat the ACTH stimulation test again in 2-4 weeks. If the post-ACTH serum cortisol value remains less than 2-2.5 µg/dl on the lowered Vetoryl dosage, I'd even stop the drug completely for 2 weeks to see if the cortisol concentrations will go back up (generally to above 10 µg/dL), as an untreated dog with Cushing's disease should do within a few hours to days.
In many dogs that I treat with Vetoryl, the dose can be decreased over time. In some of these dogs, the dose can even be permanently stopped, and their cortisol secretion remains "normal" and never goes up high enough again to cause signs of Cushing's disease (3,4). The aldosterone secretion is not affected in these dogs, and they never develop any serum electrolyte changes associated with hypoadrenocorticism. This "cure" presumably is the result of mild adrenal necrosis, but we don't know for certain. In any case, when it does happen it certainly is not a bad thing, and the owners are generally thrilled!
Permanent adrenal necrosis, however, can result in life-threatening adrenal crisis (undetectably cortisol values with hyperkalemia and hyponatremia) if the dog is not properly monitored and the dose of the drug lowered or stopped as needed.
found here
http://endocrinevet.blogspot.com/
in this case the dog's appetite was off but he isn't even discussing symptoms when he says he does not want them lower than 2 ug/dl.
You'll get it all figured out.;) I hope your dinner is a little better tonight. xxxxx
Addy.. I know what you are going thru. It felt like I was never going to get the right dose for Boriss. Some days he is still off. I am just relying on the fact that most days he is good. What if you do a 30/10mg split? I was doing that with Boriss for awhile. It was going good until he started getting more hungry at night & having accidents. That is when we went up to 30/30.
Oh Amy, I thank you so much for posting as I have been racking my brains trying to remember who did 30/10. I thought it might be you.
She is just not right. I hate to give up all the good things that have happened to her but this is starting to concern me a lot, the way she was when I got home tonight. i am not even giving her an evening dose tonight.
The thing is, she has been on Vetoryl now for 2.5 years and to have such a drop on the same dose and now see these strange things I never saw before, I can really appreciate what Dr. Peterson is saying.
If she had not been on this drug for so long I may not be in such a panic.
So thank you, thank you, thank you for stopping by Amy:):):):)
Addy, we know that it is possible that after dogs have been on vetroyl for awhile, that they will no longer need as large of a dose, so I don't see where dropping the dosage would do any harm and may not even change the good things that have happened. It could though prevent any further drops which would Not be good.
Remember before the test was doing, we were talking and suspected that her cortisol might be going low by the way she was acting.
I think a change of a decrease would actually be a good thing and Dr. Peterson mentions the possibility of lower dosage after awhile too.
I think you are on the right track. I'm just sort of talking it out with you, as I think you already know what you'll feel most comfortable with.
hugs,
Sharlene and Molly Muffin
Thank you Sharlene,
It helps to talk it out. It was the week of October 15th, I cut her down to 30/10 for five days, after what I thought was a mini seizure, I still have no idea what it was, but she sure looked like she was going there again tonight.
When in doubt, withhold the pill and if was something else bothering her, i guess no harm done.
Absolutely no harm to withhold and better to be safe anyway.
So, do you remember how she did on the 30/10 previously, when you she had that episode?
Wouldn't hurt to go there again.
hugs,
Sharlene and Molly Muffin
I'm sorry I can't be helpful, but I'm right here by your side....or on your shoulder.:)
Love,
Sus
i just got her blood work emailed to me everything is normal except her cholesteral, which was 417 high normal 300. Even her GGT is normal, everything listed is N ALKP is NORMAL she has a stinking mass on her liver and it is all normal?
NORMAL:confused::confused::confused:
I feel like I am in the twilight zone:eek::eek: Is it me? The vet thinks I am nuts.
No I don't think it is is you at all. I think you know Zoe and you have always known when something is wrong, even before there was medical confirmation of it.
So, in this case, if her cortisol is low and it is bothering her, or if it is something else, you can tell by the way she acts. Sometimes, diagnostic issues actually show up later, after you feel bad and then you think to yourself, oh okay, so this Is why I felt like crap all that time.
I just think that you feel it and know it because you know her so well. I think that is the case with all of us really.
Hang in there. Take a step back and look at her, see her, feel her, do you still feel something is off? If so, then proceed with that instinct.
hugs,
Sharlene and Molly Muffin
You are not nuts Addy. I am a little nuts, but you are not nuts!:D if you say that something is not right with Zoe, that is a fact that cannot be disputed. You just don't happen to know what it is yet, so the investigation continues. You'll find it. I am sure of it.;) xxxxx
whatever was bothering her last night, she is better this morning.
I wanted to make a birthday card for hubby last night from an old photo of the Paris rooftops and Eiffel tower we took years ago.
Took me longer than I thought it would as I wanted special dreamy effects on it. Took my mind of my girl for a bit.
I swear between Zoe and my Mom- I sure get to be investigative caregiver:rolleyes: T:rolleyes:hank goodness they dont do it at the exact same time;)
Addy:
Sometime when you are least likely to be thinking about it you will get an epiphany and the light will come on. Just like Tipper and I with the lentils. I am very confident you will solve this mystery you are noticing with Zoe. It is a shame there are so many things involved with this disease. Sometimes you think you are going to go crazy trying to figure it all out. I will say a special prayer that you solve whatever is off with your baby. Blessings
Patti
Thank you Patti, I know you have had to do a lot of solving as well:)
Patti- when Tipper's pre was too low what were her pre and post and her dose and where is she now as far as dose and stim numbers?
Addy:
When Tipper went low she was on 30mg one time a day her numbers on 8/8/13 were pre-0.7 post-3.0 her last ACTH on 10/17/13 she was on 25mg- 20 Vetoryl morning 5 trilo evening her pre number was 1.5 and the post jumped to 8.3. She is now on 20ma vetoryl morning and 7mg trilo evening. I somehow feel her number is not right as she is drinking a lot and moving about the bed at nite. I am not sure if it is the new diet and she is hungry or the cortisol. I plan to test her in mid to late December as she has hasd way too many ACTH's and it is wearing on her nerves. Unless she continue to exhibit uncontrolled symptoms then it will be sooner. Hope some or any of this helps. Blessings
Patti
Just letting you know I'm thinking about you.... if it makes you feel any better, I still haven't figured Keesh out. Just today after so many weeks of not drinking much, he's drank a lake within the last 18hrs or so. I'm chalking it up to the meds for the ACTH test. He's such a mystery, hope you have better luck reading Zoe then I do Keesh.
Boriss did really good on the 30/10 split for awhile. Then he needed more. When he first got regulated on the 30/30 split I was worried. I thought he was acting strange & couldn't handle the added dose even though his numbers were good. He just didn't seem like himself.
But, I went ahead & gave it a couple of months & he seemed to adjust to the lower number.
But, if Zoe's numbers keep dropping on the same dose I would be worried too. Hang in there.. You know how it goes. I bet you will find what works best for Zoe soon. ;)
I wish it were easier to figure out & not so expensive. :(
Sweet Addy,
Your great anxiety over Zoe saddens me, and gosh I know what an awful place to be in. Not really knowing which way to go. Ugh! Hey I understand all babies are different, but since you are so concerned over her cortisol dropping even lower, have you entertained the idea of stopping the Vetoryl altogether? Yup, perhaps a trilo break for the Zoe, and see how far that takes her? Obviously, based on my own experience with my Princess, and her extended trilo vacations, I just needed to throw it out out there for you to consider. But I do understand your fears in making a drastic switch in dosing. In my case with my girl, it was a no brainier, and I welcomed those nice breaks when they came. I certainly wish that were the case with Zoe.
Things will fall into place somehow dear Addy. For now, take Leslie's great advice and let go and let God.
Prayers for strength and guidance.
I love ya. Xo Jeanette
Ps: Is today your hubby's bday? If it is, then he and the Princess share a very special day together. I'll be darned.
The birthday card sounds wonderful and "dreamy" :) Love that. So glad that Zoe seems better this morning too. Hope that continues through tonight.
Are you guys going out for a special dinner or something to celebrate hubby's birthday? I hope so. It's just so stressful for you lately that some romance and fun sounds like just what the doctor would order for you both. (Dr. Sharlene that is hahahaha )
hugs,
Sharlene and Molly Muffin
I will take the prescription Dr. Sharlene:D:D We are going out Saturday night but having family over tonight.;)
Jeanette- I think we will stay the course but cut back for a week and see how she does. It is supposed to be about quality of life so- I will see how she does for the next five days on 30/10.
I just keep thinking about that post by Dr. Peterson, cant get it out of my mind.
Everyone thank you for your insight and support. Amy- is good to know how Boris reacted, Tipper as well.
I have to go with my gut as always.
I have no suggestions on the dosing...just saying hi and I know how you feel!! This disease is so difficult and complicated. It stinks!! :mad::mad:
Definitely go with your gut, your instincts can be counted on!
Barbara
Addy:
I hope you get some answers soon as I know what it is like to have something gnawing at you and you just can't put your finger on it. I am hoping you are able to enjoy a nice evening out for you hubby's birthday. I know when something is not right with Tipper I get it stuck inside my head and I will not let go of it until I get it figured out. That is not always a good thing! Like I have said several times on here, this disease has aged me 10 years. Praying for all to be resolved. Blessings
Patti
Thank you Barabra, I know you are worried about Trixie too and Patti, you are not alone in aging from this- I cant believe I how look compared to 2 years ago:rolleyes::rolleyes:
I did 30/10 last night and I will continue that for a week to assess how she is. I keep thinking about Dr. Peterson's statements about a dog at 2ug/dl that has been on the drug for a long time. Then I think about some member's vets talking about the adrenal glands and why they felt once day dosing was better. I need to find those threads to reread. Sharon and Norman was one and there was another study as well and a discussion about it.
Since I am seeing what I will assume are side effects from the drug as is sound like some of our other pups are having some of these issues unless she has a macro causing neuro problems my main goal is to keep Zoe with a quality of life, which has always been my goal.
Zoe has had a good quality of life all and all even through the dark days after her surgery when everything went to heck even though her numbers were 4 ug/dl. I gave up chasing numbers as her GP always advised me. I miss him, he was such a good sounding board when I would get overwhelmed. He trained at U.C. Davis and worked with Feldman too. Now I have no GP at all and two specialists with totally different approaches.
I have brought my baby this far and I pray I can keep making the right decisions for her.
Sorry, did not mean to get so serious, I have headache, too much Chinese food last night:rolleyes::rolleyes::rolleyes:
Addy:
Are you saying that there was some evidence that once a day dosing is better for Adrenal tumors? If so please forward that to me when you find it as I am curious about that also as Tiper did do much better on the once a day dose, but it was the 30mg. I am sure I could do the 20+ 7 trilo together in the morning , I would just skip the 7mg trilo the nite before. It controlled her hunger so much better with one dose in the morning. I am fighting hunger issues now. Blessings
Patti
Patti, I dont think it was as it relates to adrenal tumors, I need to go back and find the study.
day two of 30/10 after skipping one evening dose- she investigated the closet (has not happened in more than a month, mini trot to the dining table ( has not happened in a month) for two days she was drinking water like crazy and panting- not today and hubby did not have to help her up off her bed today.
I wonder if I should keep the test going for a week before I try to put her back to 30/20.
Oh and she finished all her food without leaving some in the bowl and taking forever to eat it and spitting it out all over.
Now the worry is will her cortisol go too high?
October 15th, I cut her back to 30/10 for five days and it was not until 11/8 she got worse again with the head tremors and falling over.
Then she just kept getting slower and slower. I guess only time will tell but my spirited girl seems to have rebounded and her large personality is back:):) Not sure for how long but tonight I will take it.
Hi Addy,Quote:
Originally Posted by addy
Saying the "M" word is taboo!:eek::eek: We don't want to even think about going there!! Yes, it's about quality of life.
I hope you mom has settled and is doing okay for now. xxxxx
Hi Addy
I so hope the tweaking does the trick, it is such a fine line between the good and bad. Her Mom knows her best though! Must do your heart good to see her more perky! I wish I knew more about the intricacies of dosing but I do not, but I am thinking if you are seeing improvement you are doing something right so trust your gut, I have learnt to do that and it is usually right :)
Thank you for being there for me through this last traumatic week, you are a great friend to have Addy and I always feel you have our backs and for that I am very thankful I have met you xxxxxxxxxxxxxxx
Hi Addy... you know I can't help or give advice on anything, but wanted you to know Zoe and you are constantly on my mind.
With the gamut I've been through for months, I totally agree with you in regard to quality of life. That's all I can do right now for Keesh.
Each day they are feeling great to me is a blessing.. a day at a time.
Glad Zoe is enjoying each day.
Addy, re: the studies comparing once vs. twice-daily dosing, here's some of the info you may be looking for. This is a 2012 retrospective comparison of the results of trilostane testing during 2001-2002 performed at the Royal Vet College in conjunction with the original licensing of Vetoryl in the U.K. by Arnolds (the company that ended up being bought by Dechra). The first study involved once daily dosing. The subsequent study involved twice daily dosing, and although it's always been known the twice-daily study was done, to my knowledge this is the first time the results have ever been published.
When we started Barkis on trilostane in 2003, there was some other preliminary research that suggested twice daily dosing might be preferable. I was so anxious to find out any recommendations from the U.K. study that I even tried to contact Dr. Neiger myself (but with no luck). At my urging, our IMS was willing to go ahead anyway and we dosed Barkis twice daily, although in retrospect I wish we had not, since the general thought at that time was to double the once daily dose rather than halve it. Anyway, after all these years, finally we see the original study results. And it seems to confirm what I'd eventually ended up suspecting -- that those original researchers did not find a significant advantage to dosing twice daily. And I presume that's why Arnolds/Dechra did not originally publish the data or alter their recommendation to begin with dosing only once daily.
I haven't had time to read through the article in any detail, but it does seem as though there are some interesting tidbits that mirror the results of other studies. For instance, dogs dosed twice daily seemed to achieve faster and more effective control than those dosed with the same amount once daily. However, in a departure from what Dr. Feldman has anticipated, dogs who were able to remain on once daily dosing (some dropped out of the study) did not exhibit any more unwanted ill effects than those dosed twice daily. But you need to read through the whole discussion to understand the various study limitations, and I do have remaining questions. For instance, I don't understand why Dechra recommends increasing the total daily dose when switching from once to twice-daily dosing, since that seems to run counter to the study results. But anyway, here's the bottom line:
Here's a link to the German veterinary journal in which the article is published (note that you can download the full study for free):Quote:
Objective: This retrospective study describes the use of trilostane given once versus twice daily in dogs with hyperadrenocorticism (SID vs. BID group)in separate clinical trials. Material and methods: The groups were compared over a six month period using laboratory findings, dose required to suppress post-ACTH cortisol, and clinical scores from owner and clinician questionnaires. Results: Ninety-three dogs enrolled the trials but for analysis of the final visit results only 56 dogs filled the inclusion criteria: 30 dogs in the SID-group and 26 dogs in the BID group. Both treatment groups showed an improvement in clinical scores with time and no significant difference between them. In the BID-group post-ACTH cortisol concentrations went below 250 nmol/l sooner and in a higher proportion of dogs than in the SID-group. Twice-daily administration of trilostane also achieved a faster and more effective control for comparable daily doses. A higher individual tolerability (based on clinical scores) was found in the SID-group but there were no supporting laboratory findings. No dogs developed serious side-effects. Conclusion: This study reveals only small practical differences between once and twice daily trilostane administrations in treating hyperadrenocorticism. And the overall benefits of twice daily dosing have to be considered against the effect on the owners and their compliance with treatment.
http://tpk.schattauer.de/en/contents...ipt/19145.html
And then, for comparison purposes, here's the link to Dr. Feldman's 2012 twice-daily dosing study and the summary of the results and conclusions drawn by the Davis team:
http://www.k9cushings.com/forum/showthread.php?t=4442
And here's one more new comparison study that I just now located:
http://onlinelibrary.wiley.com/doi/1...12207/abstract
Marianne
Thanks guys, there were a couple evenings last week when she was laying down, she tried to lift her head and could not, she just dropped it back down.:eek::eek:
and the food thing was like her mouth did not work right
this morning her bark is strong, she is active and curious, she seems more like she was in August and September. Even the hard panting has eased up.
I wont jump to any conclusions yet, I know each day can change and bring something new but she this morning she seems so much better and is walking so much better.
I would rather have her bald and walking then how she was. Last week we would go out for her chicken walk and she would just stand there and not walk, she would just take a few steps and stop and theat head thing and falling over freaks me out.
sorry guys, I am getting emotional now and starting to cry.
Have a great Saturday we are off to find a turkey
Addy, it looks like we were posting at the same time. I just want to make sure you see those links re: the dosing studies I think you were wanting to revisit. ;)
Addy:
My heart just breaks reading your post. I hope you get some resolution to this soon as I know how you are feeling, and it is not good to be under so much stress, I know that all too well. It is a shame how this disease can make your life so unbearable at times. Blessings
Patti
What a life saver you are Marianne, thank you so much for finding the studies for me.
I have been printing and googling my heart out this week so thank you so much.:):):):)
Hubby has flashing lights in his eyes now so we have to find a opthalmologist and watch to make sure he does not develop signs of a retina tear.:eek::eek:
He is usually pretty patient about me bouncing things off him but right now he is worried about his eye so I need to bounce things off on my thread right now:):)
I did recheck pricing for 20/20 and hubby finally caved in if we decide that route. I just am not sure that is the right way to go yet.:confused:
oh my gosh, your poor hubby, first the shoulder now his eyes. Well, I hope you can find a good ophamalogist and get him in today to get it checked out. Mine is currently at a physio appt for his shoulder. I swear if he doesn't get this shoulder thing fixed it is going to drive us both nuts.
I hope it isn't anything too serious causing the flashing lights. :(
Do you keep a journal on how Zoe reacted for each medication change? I'm wondering where she feels best at. I know you've made a few changes over the years, but I agree, it is heart breaking when she won't do the chicken walk, you know she doesn't feel good or right. The falling over would scare the bejeebes out of me too, so whatever it takes to get rid of that, would be worth it. I'm with you rather a balder zoe, but a happy zoe.
Now what is the thinking of going 20/20 vs 30/10? More evenly spread out? Do you notice the bad issues after the first dose of 30 rather than in the evening on the 10?
hugs,
Sharlene and Molly Muffin