Reggie, an 8-ish pit mix who may have Cushing's and/or other issues

A little late on posting this but after two weeks of 40mg trilostane/day, he was slightly less ravenous and not getting up in the middle of the night to pee, but still drinking a lot and acting pretty hungry. Energy levels seem somewhat better and his skin and fur seem less dry. Post-trilostane ACTH stimulation test two weeks in came back 2.8 ug/dL pre, 8.6 post, while the internist said her targets for a dog being treated for Cushings were 1.5-3 pre, 4-6 post, so still a little high. We decided to up it to 60 mg/day, no signs whatsoever of cortisol dropping too low since then, maybe a minor further improvement in the eating and peeing but still not where I'd like it to be.

We're doing a pre-trilostane resting cortisol test two weeks out from the dosage change, so toward the end of this week. I'm thinking we may want to split the dosage and go twice a day. His drinking and appetite seem worst first thing in the morning.

Thanks for the update! Glad you're seeing some improvements, however I'm a bit worried that the dosage was increased because it is recommended that no increase should be done until after the dog has been on Vetoryl for 30 days, the reason for this is that cortisol can continue to drift downward during the first 30 days of treatment.
Please do keep us updated and I do highly recommend that a full cortisol test be done since the dosage was increased.

Lori

Reggie's pre-trilostane resting cortisol was 2.8 ug/dL. He's been drinking and peeing a bit more lately (though less than before we started treatment) especially overnight and first thing in the morning, but otherwise seems to be progressing pretty well, still a little hungrier than I'd like but his energy and demeanor are notably better, his skin and coat are much less dry, and I think I'm already seeing the coat filling back in some (his fur is short enough that even a little fuzz makes a real difference).We're continuing 60mg once per day of vetoryl until the inital package runs out at the end of the month, then trying 30 mg twice a day.

Overall, I think this is a very good report. And I understand the notion of shifting to 30 mg. twice daily after you’ve finished the 60 mg, capsules. Twice daily dosing may be just the “tweak” you need to see sustained improvement. Thanks so much for continuing to update us, and we’ll definitely be interested in finding out whether the dosing change leads to even greater symptom resolution.

Marianne

So, I have a call in to my internist and will try to get ahold of my regular vet during working hours but:

Reggie (~50lbs) has been on 30mg Vetoryl twice a day for a few weeks now, "down" from 60mg once a day. Drinking and peeing seem better controlled, and appetite somewhat better controlled as well -- still generally quite hungry but has been letting me "sleep in" a bit more before breakfast -- shifting from ~4am to ~5am (versus he used to sleep until ~7am).

The evening of Tuesday 8/15 during our walk he found something on the sidewalk he ate before I could identify it. I suspect this is the cause of his subsequent digestive issues (see below) but I realize they are also consistent with the symptoms of overly suppressed cortisol. But would you expect to see that happen overnight several weeks in to a constant dosage regime?

Tuesday 8/15 his appetite was very fuil.

Around midnight the transition to Wednesday 8/16, he went out to poop (looked normal). Then he went out to poop again about an hour later (still normal, a little soft). And again multiple times the rest of the night, with very little coming out but still sniffing and squatting. At his usual breakfast time he wanted no food, but over the next couple hours he started accepting treats, then canned food, then kibble. We took a normal walk in the morning and he had a small but decently formed poop. He ate more kibble mid-day. Then around 4pm he threw up. Then he ate some canned food but refused kibble, took a good walk with some good poops, and seemed generally fine (but still not interested in kibble) until he threw up again at 9:30. He didn't seem to drink as much as usual in the morning, but drank at his recent normal level the rest of the day.

Around 3:30am Thursday 8/17, he threw up a very small amount, then went out and had a normal poop. As of 7am he ate a tiny treat and a spoonfull of canned food (all I offered him of that) with enthusiasm, but has no interest in kibble. Drinking normally.

So, I will follow my internist's advice, but as i wait to hear back...any thoughts on whether that the sudden onset of these symptoms is consistent with over-suppression, especially given the dietary indiscretion the night before?

I’m so sorry Reggie is feeling poorly and totally agree with checking in with your vet. However, on the face of what you’re describing, like you, I’m guessing it’s the dietary indiscretion that’s to blame as opposed to low cortisol. Having lived with and loved three Labs, I’m sadly quite familiar with the acute upsets associated with “garbage gut.” It’s truly amazing how quickly some of our dogs can spot and scarf up the nastiest of tidbits :-(.

However, it’s definitely good to consult with the vet. And if the acute symptoms continue or worsen, I’m guessing a cortisol check may still be recommended, just to be on the safe side. But hopefully you’ll be seeing improvement from this point on.

Marianne

Yes, thanks, that makes sense. I'm still waiting back to hear from the internist (and unfortunately she only works half days Thursday and not on Fridays or weekends, so it might be a while) but I was able to see my regular vet. She did some in-house bloodwork and based on his sodium-potassium ratio and a few other things does not think it's likely to be low cortisol. Unfortunately his ALP is even higher than the last time we checked, and for the first time his glucose is slightly above the reference range as well -- though she said that could be a response to stress.

Also, between when I posted the first message and when I saw my vet, he suddenly had blood in his urine. So we could be looking at a UTI as well, we sent out for urinalysis/culture but won't have results for that until tomorrow.

Edit to add: Heard back from the internist. She agrees this is unlikely to have anything to do with his cortisol being too low. However, she said it might be worth pausing the vetoryl until he felt better anyway, since this is the sort of event that should lead to elevated cortisol normally.

Quick update: Reggie's digestive upset had nothing to do with the trilostane, as we all suspected. He had a minor UTI that seems to have cleared up after some antibiotics. Progress on Cushing's treatment has not been great. His drinking and peeing are still abnormally high but tolerable and definitely better than pre-treatment. His appetite remains through the roof, he's continuing to put on a little weight, and he's remaining pretty lazy and recently lost some fur from his tail. This has been on 30 mg vetoryl twice a day. We just did a pre-trilostane blood draw yesterday, 4.0 ug/dL which is not super high, but higher than it was last time (2.8 both July 13 and June 27) or even his baseline in his LDDS test before we started treatment. So we're upping the vetoryl to 40 mg twice a day -- at his new weight of ~51 lbs that doesn't seem overly high.

Thanks so much for this update. I’m glad you’re seeing a bit of improvement with Reggie, but realize you still have a ways to go in terms of symptom relief. Coupled with the results of his cortisol test, I understand why you’re making the move to increase his dose. I really hope this will be a bigger step in the right direction. As always, good luck to you both, and please keep the updates coming.

Marianne

Thanks. If the 40mg dosage does seem to do the trick, I'm wondering what the latest group wisdom is on compounded trilostane versus branded Vetoryl. The internist I'm working with doesn't have strong feelings either way. Reggie has insurance, which helps quite a bit but doesn't fully cover the costs, so I do find myself wondering if spending around 4x as much for 30+10 mg of Vetoryl versus 40 mg compounded trilostane really makes sense in the long term.