Skippy has passed; 12 y/o Yorkie with likely pituitary tumor (Trilostane)

Unfortunately a small number of our members have had their dog`s system be resistant to the effects of Vetoryl, but I really don't think you're at that point right now.

Increasing the dose to 20 in the morning/20 in the evening sounds reasonable to me. Having Skippy's cortisol checked in 2 weeks is a great idea and that falls within Dechra`s guidelines.

I know this journey has been so frustrating for you so I'm sending some huge comforting hugs.....keep your chin up! ;)

Hugs, Lori

Thanks Lori,
I will stop whining - now. I know Skippy and I are very fortunate and the situation could be much worse. I appreciate your kind words.

I made a mistake regarding Judy's Abbie being resistant to Vetoryl when actually Abbie started out with Lysodren and when that became ineffective in controlling her cortisol Abbie was switched to Vetoryl, (Thank you Judy for correcting me). I am so sorry for that inaccurate statement. :o:o

Please do not ever feel that you are whining, our hope is that this forum is a place where our members are comfortable enough to share whatever is troubling them, ok? ;)

Hugs, Lori

Hmm, so it's still elevated enough that if you wanted to increase the dosage you could. You could even do a 20/15.

Pffft whine away. (I just call it good old fashion worry and concern) :) still if not here then where else could you get it all out and know those reading understand, exactly, what you mean. :)

HUGS

Lori and Sharlene,
Thank you for your support. My comment about stopping whining was simply to say, perhaps to myself, buck-up and remember how fortunate both you and Skippy are at this point in time. Many dogs and their owners on this forum have lost the battle or are suffering grievously. Skippy does not appear to be in pain, he is tolerating the dose increase to 20/20 that we began on Saturday and while there is no observable improvement in clinical/behavioral signs, he is no worse. My fear is that I am missing something and that Skippy is dying by inches. But ultimately we all die by inches; I understand that and just want to make sure I am doing all that I can to ensure that he lives his remaining inches with the best quality of life possible. Never one to simply accept and endure, I'm going to secure a new blood panel when he has the next stim test in tenish days (he hasn't had one since he was diagnosed in November), an orthopedic evaluation and hydrotherapy (since he won't or can't walk), if it is available at Purdue. Maybe I'm simply reinforcing my own denial but to do nothing and watch him slip gently into the night is completely unacceptable until I have exhausted the possible remedies. If there are other things that I should pursue, I would be grateful for your thoughts or ideas. Thank you again.

I think you are doing an exceptional job advocating for Skippy and you are looking into and doing every possible course of action in order to help your sweet boy.

Regarding his dose of Trilostane, Dr Peterson replied to one person on his blog that

Quote:

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smaller dogs tend to require larger amounts of the drug.

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So it is entirely possible that Skippy's dose just needs more tweaking in order to get his cortisol controlled and see improvements in his remaining symptoms.

We certainly understand how worried you are about your precious boy, so just to reinforce...You are doing an excellent job!!! ;)

Hugs, Lori

Link to Dr. Peterson's quote: http://www.endocrinevet.info/2012/12...rilostane.html You'll need to scroll down to May 7, 2015 at 11:29 PM for his response.

Just a brief update on Skippy:

Skippy had his fourth Stim Test in three months on Thursday. We have now increased the dosage five times, mostly by increments of five since beginning this saga in December. On his current dose of 20/20 (29lbs) his cortisol increased to pre 5.6 and post 13.1. (His last post was 10.) Clearly, Skippy is going in the wrong direction. While his clinical signs continue to improve slightly, many of the behavioral issues remain, e.g., trembling a lot, often trots home after poops instead of going for a walk, is fearful, ravenous and sometimes anxious, sleeps a lot on the wood floor, no interest in play and little interest in being petted or cuddled. Local vet added Xanax and an NSAID to his pill repertoire a week ago. Purdue wants to wait a week on current dose and see if there is improvement in clinical symptoms. If not, they will then retest and run a blood chemistry panel. They kept emphasizing that it's not the numbers but the clinical signs. In Skippy's world, neither are great. The adenoma on his butt is not growing but now the new Purdue vet thinks I should have a biopsy. (The prior vet said leave it alone until cortisol is under control.) My question is whether others have had experience with cortisol levels going up with treatment? Does this suggest that Skippy has a macro tumor? (This vet mentioned the possibility but thought that Skip did't "look like" he had one.) Thanks in advance for any input as I am at a loss.

I just reread some threads and read a few others related to dosing with Vetoryl and I am still uncertain. Two days ago, I sent the local vet a lengthy email summarizing Skippy's history of dosing and Stim tests and ask to see her. She responded that she didn't need to see him but wants me to increase the Vetoryl dose to 30/30 and Stim again in two weeks. I picked up the 30mg. box last night and gave him the first dose this morning. But, I am very worried that this is too big of an increase. Here's the history:
12/6 79.2 (Began dosing 2 BID with Vetoryl 10ml)

12/20 Pre - 2.2 (Marked Lipemia) Post – 10.8 (Moderate Lipemia, Slight Hemolysis)

1/23 Pre – 6.3 Post – 16
Purdue increased dosage to 15/10 BID

1/30 Consultation with local vet and that day we increased the dose to 15/15 BID

2/10 Pre – 6.8 Post – 12.0
Purdue increased dosage to 20/20 BID

2/23 Pre – 5.6 Post – 13.1
Purdue kept dose the same 20/20 and wants to Stim again in a week.

3/1 Local vet increased dose to 30/30 and I gave one dose this morning.

Is this too big of an increase? I would feel more comfortable going 30/20 but I know the local vet believes that Skippy (29 lbs.) is being seriously underdosed in light of his continuing clinical signs and symptoms. Finally, I emailed Dr. Feldman and he suggested that I discuss switching to Lysodren with the vets.

Good morning and I hope someone can please help. I increased 29lb Skippy's vetoryl two days ago to 30/30 as directed by his local vet; the IMS said leave to old dose, 20/20 alone and Stim again in a week or ten days. He has been very restless in general at night but was far worse last night. He is trembling, even while sleeping and last night for an hour or so, he was trembling so hard that I thought he was having a seizure. I have watched him all night and he is now sleeping but trembling slightly. Also, he is reluctant to eat and his perianal adenoma has started bleeding but perhaps the bleeding is coincidental. Should I withhold the Vetoryl; the local vet is off today. I could call Purdue and see if they could Stim him again today. Am I overreacting; I am so afraid of overdosing him on this drug. Thanks so much for any help.

Hi Carole,

It seems curious to me that you are getting recommendations from both Purdue and your local vet.. and possibly another vet via email. I would personally choose one vet's recommendations to follow, or at the very least, have them consult with each other and all agree on what to do. As it is now, you've got one telling you to increase, one to stay the same and another to possibly switch meds entirely. I'd be completely confused and uncertain what to do!

If it were me, at this point I think I'd call Purdue and schedule the test they asked for... tell them about the increase and then follow their recommendations.

Dear Carole,

I'm so sorry for you both that Skippy is having these worsening problems. Given his pattern of ACTH results, I actually can't argue with your local vet's recommendation re: the dosage increase and it would seem surprising to me for his cortisol to plummet to a level that is too low within only two days time. But having said that, no matter what the reason, clearly Skippy is not in a good place right now. Whenever a dog won't eat and/or appears unwell, our general advice around here is to temporarily withhold trilostane dosing until things improve. If Skippy was my own dog, that's probably what I would do right now -- hold the trilostane altogether for the moment and see what effect that has. I don't know that an ACTH is urgently necessary because, as I say, it's hard for me to imagine that his cortisol is really too low. But if he doesn't bounce back to his previous baseline behavior by Monday, you'll need to consult with your vet as to next steps.

Honestly, I cannot disagree with Dr. Feldman' recommendation to switch to Lysodren in this situation. The trilostane has not been as effective for Skippy as is typically the case, and he may be suffering medication side effects in addition. Has Lysodren been mentioned as a possibility by any of your vets? If not, I would definitely discuss that option next week. If you did indeed make the switch, Skippy would need to be off the trilostane for around a month, anyway. So giving him a medication break this weekend wouldn't interfere with that game plan.

If Skippy worsens even more today, then certainly you'll want to consult with Purdue before the weekend sets in. But I'm hoping maybe he'll rebound a bit on his own today. Definitely keep us updated, OK?

Marianne

Hi Shana,
Thanks so much for your feedback and suggestion. I know it may seem like I am vet "shopping" but I was referred to Purdue by my local vet and they are supposed to be collaborating. (I am not so sure that is happening as I think they may disagree philosophically about dosing.) The problem is further complicated by the fact that Skippy's Stim tests keep going up in spite of increasing the dosage. Neither Purdue or the local vet seem to have a clue as to why that is happening. My question to the online expert was to try to answer the "why" of Vetoryl failing to reduce his cortisol and symptoms. But now I perhaps have a new problem and I will call and see if they will Stim him today.
Thank you again so much for your thoughts and recommendations. I have been up all night watching Skippy and am pretty stretched out with this. (He is sleeping and slightly trembling.)

I see that you, Shana, and I were all typing at around the same time, so I'll add this additional P.S. to what I wrote above. If it is not a problem for you to take Skippy in today for the ACTH and Purdue thinks it's a good idea, then yes, you can certainly do that. I would also have them check his electrolytes, as well. And then we can all go from there.

Marianne and Shana,
Thank you again so much for your counsel. I am especially grateful that you think it is unlikely that his cortisol has gone too low. He is up, quiet but all of his parts seem to be working okay and he is not begging for food. Checking his electrolytes is a great idea and I will call now and see what is possible regarding testing. Thank you again, you guys are incredibly knowledgeable and caring and I am so grateful.

I forgot to mention that yes, Purdue raised lysodren as a possibility early on after the adenoma appeared on his butt. They prefer trilostane and I have been reluctant to change until we exhaust vetoryl treatment and I have been plain scared of lysodren. I will begin reading as soon as I get thru today!

Update: I spoke with Skippy's local vet since she had prescribed the increased dose. She said to stop the Vetoryl for the weekend. She didn't think his cortisol was too low given how high it had been last week and the increase in Vetoryl was for only two days. She also didn't think that tremors were suggestive of low cortisol. (I told her that Drecha mentions tremors as one of the symptoms of low cortisol in their monitoring guidelines.) She did not think it was necessary to Stim Skippy today. She speculated that perhaps Skippy has been misdiagnosed and may have an adrenal or macro pituitary tumor (He's had two adrenal US's.) She also mentioned switching him to lysodren. I asked about checking electrolytes and she said that lethargy was the usual symptom, not tremors. (I reminded her that he was lethargic.) In the meantime, Skippy continues to lightly tremor, is very lethargic and will barely eat anything this morning. If Skippy appears to be getting worse, I will call her or Purdue and try to secure a Stim test. Again, thank you so much for your support and advice.

Carole, thanks for these updates. As I had written initially, I doubt that Skippy's cortisol is too low, either. But whether his blood chemistries may be off, I do not know. If he doesn't rally, that would actually be the blood testing I would be more anxious to perform, rather than an ACTH. In addition to his sodium and potassium levels (electrolytes), I would want to check his kidney, liver, and blood glucose values. All of those will be on a standard panel of blood chemistries. The importance of the blood glucose check is because dogs with consistently elevated cortisol levels are vulnerable to developing diabetes, and the onset can be quite rapid.

From what you are describing behaviorally, unfortunately I do think an enlarging pituitary macrotumor may be a possibility. Imaging of the head to evaluate the size of a pituitary tumor is something I'm certain that Purdue can do, but the downside is that a CT or MRI of the head is usually quite expensive. So if it hasn't been done recently, I do think the first place I'd look right now is a basic blood panel including both chemistries and also complete cell counts ("CBC").

Marianne

How is Skippy doing off the vetroyl this weekend? Has the tremors stopped?

Hmm, seems to be that Shana's furbaby Visuddha had his cortisol be within normal range but his electrolytes still became elevated so it is possible for electrolytes to be out of whack even if the cortisol is high or in range.

Yes all of Visuddha's ACTH results were within range (5.2, 3.4 and 4.3) but his Potassium was elevated (high normal to high) and Na/K ratio was low, so his dosage was repeatedly lowered.

How's Skippy doing today?

First, Skippy did rally on Friday after sleeping deeply but tremoring slightly for half of the day; he has done extremely well all weekend after stopping the Vetoryl on Thursday. He is eating and drinking normally for him - peeing and requests to go out are no more or less than on the Vetoryl regardless of dose. No tremors whatsoever; no sudden jumping around at night and inability to settle; no picking at the butt adenoma. Skip was willing to take three long walks on Friday, Saturday and Sunday afternoon, but he’s still doing that weird thing in the morning where he poops and refuses to walk further. He is still lethargic but was a little more interactive than earlier in the week.
Here’s the update on the medical front:
• Two calls from Purdue student, Jessica: On Saturday morning she called to check in on Skippy. I filled her in on the dose increase, severe tremors and withholding Vetoryl. After speaking with the resident IMS, Jessica called me back and said to put Skippy back on a dose of 20/20 for at least three or four weeks; she said that there are research studies that document that some dogs need a much longer time on Vetoryl in order to lower their cortisol to a therapeutic range. I asked her to email the studies and she said she would. She would not speculate on the cause of the tremors but said that perhaps the increased dose was too much. I asked about securing a blood panel and CBC but she said they don’t think that further testing is warranted at this time. They also think that getting cortisol under control is top priority versus addressing the adenoma.
• Local vet (whose vet training was at Purdue) called this morning as promised. She does not think Skippy has a macro tumor either but she’s never seen a dog react with severe tremors and lethargy when his cortisol is too high. She speculated that perhaps Skippy cannot tolerate Vetoryl and raised the idea of switching him to Lidoderm but stated that she had not used it “in years”. She thought because Skippy’s cortisol is down to 13, we could induct him beginning in a week or so, which I questioned. Regardless, I said I wasn’t ready yet to go that route and we finally agreed to start him back on 20/20. I inquired about diabetes or other sick conditions that might be affecting his behavior or cortisol. She responded that Skippy would be unwell, not eating, vomiting, lethargy, etc. She did agree to review the December bloodwork from Purdue. Perhaps best of all, she agreed to call the head of Purdue’s vet clinic, Dr. Scott-Moncrieff who has done extensive endocrine and Cushing’s research, to discuss and perhaps review Skippy’s medical history. Dr. Scott-Moncrieff supervised this local vet during clinical training and although there is a potentially awkward situation of going over the heads of other vets there, she is willing to do it.
• In the meantime, I spent my weekend digging through your archives and learned a tremendous amount and felt incredible sadness, awe and respect for all of you and your dogs who have struggled bravely and are still struggling with this vile disease. I learned, among other things:
A number of other dogs here have had severe tremors and lethargy. Can I call it The I Want My Dog Back Syndrome? I didn’t find anything about the cortisol too high after three months on Vetoryl.
That Carprofen is Rimadyl by another name; I threw the bottle away.
That Drecha had (has) a vet who sometimes will consult on dog’s responses to this drug.
I am considering insisting that someone run blood tests and CBC.
After medicating Skippy this morning, he is a little jumpy but no tremoring. Also, local vet office just called back to say that Scott-Moncrieff is not in “Clinic” this week and normally doesn’t do telephone consultations. But they will send his file to her and request a consultation. Sorry this is so long and my thanks, you are the best!

Just received a call from Purdue: Dr. Scott-Moncrieff, the head of Purdue's clinic and an endocrine researcher-practitioner will see Skippy on March 21st! My local vet made this happen! I am in disbelief but very grateful.

I'm glad to hear the local vet was able to arrange that office visit with Dr. Scott-Moncrieff! And will be waiting, anxiously, for his/her opinion. You're doing a really great job and I pray that you will find the answers that will help sweet Skippy.

Hugs, Lori

Lori, Dr. Scott-Moncrief is a female. Her full name is J. Catharine Scott-Moncrieff and she is a super star who wrote the entire chapter on the Thyroid Gland in my Fourth Edition Canine & Feline Endocrinology textbook. Congrats, Carole, for having a vet with connections. I'll be very interested in hearing all about your consult.

Glynda

This is awesome news!!!! Hopefully some answers will be forth coming now with this specialist.

Very impressive credentials

Carole i just read through your whole thread and i feel you pain and frustration. But its great news that Skippy is now scheduled to see this specialist who sounds awesome so i look forward to hearing what she has to say. Ill be sending positive thoughts and prayers your way!

Laurie

Laurie,
Thanks for your kind words of support. I am trying not to approach the future with raised expectations of anyone. I know now there there are no miracles but I'm determined to give Skippy the best shot that I can afford to give him, as you are doing with Charlotte. This disease is all consuming.
Glynda and Sharlene, thanks for your endorsement of Dr. Scott-Moncrieff; the appointment has risen to the level of notice of the IMS who saw Skippy last week. He called last night very concerned that Skippy is now Addison's and when I told him of the appointment on the 21st, he was adamant that Skippy couldn't wait until then. He asked me to bring him in at noon today for a look and a baseline blood draw. Then he said he wanted to do another Stim. I agreed in the vain of caution I guess. Skippy is the same but not willing to eat unless food is richly doctored. Thanks everyone...

Oh gads, I hope he isn't Addisons. When do you get the results?

Hi Everyone,
Skippy spent his afternoon at Purdue yesterday. They called today:
- Stim post test: 10.2 No Addisons! The Stim was after 4 days back on Vetoryl.
- They found swollen glands in Skippy's shoulders; no lymphoma but they want to check further for underlying disease especially they want to look for melanoma in his lumps and especially in his mouth!
- Blood panel and CBC okay except that his liver enzymes were a little more elevated than in December.
- The IMS who saw Skippy consulted with Dr. Scott-Moncrieff who will review Skippy's tests, ultra sound and history before she sees him. She (Scott-Moncrieff) said if the trilostane wasn't working then stop the drug and they will evaluate further.
- THEN TODAY - Skippy has taken three long walks without resistance or turning around; tonight he actually ran for a ball, jumped around at length for a chew treat and has significant glimmers of the Skippy of old. I have taken him off all meds except the Vetoryl but will keep him on it for the next two weeks (they didn't change the dose from 20/20). He is reluctant to eat without significant enrichment of his food, but only in the morning and has lost a couple of pounds. (Good if no malignancies)
Is it possible that the Vetoryl is working after all this time??? I have a glimmer of hope at least for a moment. I will get copies of his tests and post shortly. Thanks,

Tremoring has subsided except in bath and car to Purdue, but not on return. Tiny tremors sometimes during the day.

Awesome news! So happy to hear no Addisons! Its also great to hear his tremoring is subsiding. I think thats what bothers me most about Charlotte, sometimes the tremoring is so bad and she looks so pathetic. But it sounds like overall he is feeling much better and that is so great!

Laurie

Live in hope, die in despair or whatever one does. Skippy's engagement in life was brief to say the least. Now we are back to sleeping, little appetite, starts to walk and then heads for home, more staring, lethargy, no playing and little interaction. He is tolerating the Vetoryl and has no tremors. I've read all that I can find on here about macrotumors, including Kathy and Laurie's threads. I am now considering an MRI or CT scan if I can swing the cost. I found cost estimates on the University of Illinois website and they estimated an MRI with contrast at $1,200. Do you all know if that is a lowball estimate? If it is a macro, I don't know if I could afford or he would be a candidate for radiation. But right now we are in limbo with little prospect for future improvement. I would appreciate your thoughts or feedback. Thank you

Also, continuing to test Skip for various diseases, i.e., lymphoma, melanoma, changing medication, taking him off Vetoryl, etc., is feeling like a magical mystery tour through the process of elimination. Patience is truly a virtue but doing the same thing over and over and expecting a different outcome is contributing to my insanity! :)

Before I went to the expense of looking for a macro, I would make sure I was willing and able to pursue treatment should one be found or should something else be found. Otherwise it is a waste of money and unnecessary stress for Skipper. ;) So for me, that is always the first thing I have to decide when faced with testing of any kind...will I and can I do anything about what is found? Next is - are there any options available that I can afford and would ask of my baby?

Well drat. yes $1200 is about on target for an MRI or CT scan. Leslie makes a good point of if it would change your current path or not based on what is found.

Did they take biopsies to test for any kind of lymphoma? What do they recommend doing (Purdue)

Leslie and Sharlene,
In response to your questions and comments: My thinking about an MRI is this: if Skippy has a macro tumor (and he has many of the symptoms) we need to know whether or not it is too large to treat. Yes, I would potentially treat but he may be beyond that. Re: lymphoma, no biopsies but they did extract fluid or tissue from each gland (I know there is a medical term for this) and saw no evidence of lymphoma. I'm not sure where the melanoma question came from except that he has three or four lumps on various parts of his body in addition to the adenoma on his butt. (He had a number of lumps removed last May but I don't think they were biopsied.) Scott-Moncrieff was reviewing Skippy's history and said, via the IMS, to stop the Vetoryl if it's not working; Skippy will see her on the 21st. I have continued the Vetoryl with the hope of lowering the cortisol.
However, this morning we are back to mild tremoring and diarrhea and he has been reluctant to eat and only eating small portions the past few days. So we are taking a Vetoryl break and I'll see how he does for a few days. I guess I need to see what Dr. Scott-Moncrieff recommends next week before making any decisions about an MRI. Finally, I called the local vet last week about securing a biopsy with sedation of the adenoma tomorrow, so as to rule out a malignancy before next week's appointment. Meanwhile, Skippy is pretty miserable. Thank you for your feedback.

I feel for you Carole, it sounds exactly what we have been going through with Charlotte, good days can turn to bad days very quickly. My husband has even used the insanity quote. Unfortunately we can't afford a CT scan or MRI (UC Davis quoted us $1600-$2000 for the CT and said it would be over $2000 for the MRI) and like Leslie said, if we can't follow through on the treatment once the diagnosis has been made then it really is just wasted money and unnecessary stress to the dog. But I sure do wish we knew for sure what we are dealing with!

The quote you got from the University of Illinois sounds good and if you would be able to treat, if he is a candidate, then it would be so helpful for you to know what is going on with him. I wish you and Skippy all the best, whatever you decide!

Laurie

Thanks Laurie and I posted a note on your thread regarding Charlotte's great and I hope long lasting progress.

Skippy took himself off Vetoryl yesterday as he stopped eating. And, he was supposed to have a biopsy of his tumor on his butt this morning, but I cancelled as he has diarrhea and seems weak. He continues to sleep this morning and I am still trying to figure out what to do next. If he is drinking, the answer is likely nothing.

Hi, Hoping things turn around for poor Skippy and it's just a bad day. I'm in a sad place right now with our boy, so I really do feel for you.
Annie and Whiskey

I'm so sorry Carole, poor little Skippy. Is he doing any better today?

Laurie