Down the Cushings Road Again -- Abbie, 15 year old beagle is now at peace

Hi, all! The vet and I spoke for a while this evening. Due to Abbie's continued increased drinking/peeing as well as the increased worm obsession (really the only marker for an increase in hunger) and continued high ACTH post number, we have decided to tweak her Lysodren dose by adding another 125 mg. One week she will get 500 mg. with the next week at 625. As has been her pattern, Abbie starts maintenance doing well but then slides back. If her symptoms abate, we will do another ACTH a month after improvements.

I do have a question about what would be considered a controlled drinking level. Would the amount be the same even after treatment has started? I have been going by what Dr. Feldman references in his loading protocol, i.e., below 60 mg/kl/day of water, which for Abbie would be 22 oz./day. My vet says less than 26 oz.-- not sure how he figures that amount.

Abbie has started to demonstrate a couple of concerning neurological symptoms---her right back foot occasionally knuckles under and twice I have seen her back legs cross over each other. The crossing happened this morning when we were leaving the chiropractor. The vet manually crossed her legs and Abbie was slow in straightening them, indicating slowed reflexes. The acupuncturist had previously noted that her pulses are not as strong in the right leg. I mentioned all this to the vet tonight--we agreed that I needed to keep a close eye on these things with a neurology consult a possibility.

Generally, a dog normally drinks at least one ounce of water for each pound of body weight per day. I did a quick scan of your thread and found that Abbie weighs around 25 lbs, right? With 25 lbs that would mean that Abbie's water consumption would be approx. 25 ounces.

Hope the Lysodren tweaking does the trick, and so sorry to hear of dear Abbie's recent issue with her legs :(

Hugs, Lori

Gosh, Judy, I'm sure sorry to hear about these new issues in addition to the rebounding Cushing's symptoms. I know we've talked about this in the past, but remind me again as to why your vet does not wish to consider a switch to trilostane. Has your vet actually had bad experiences with it, or is it instead that she just has not had occasion to prescribe it? You've been playing around with the Lysodren for such a long time now, and it just does not seem as though Abbie is responding to it appropriately. It's paradoxical, because I am going to recommend the reverse to another member whose dog doesn't seem to be easily regulated on trilostane. But it does seem to be the case that different dogs do better or worse on different medications. And gosh, for as long as you have been trying to tweak Abbie, maybe it would be worth all that's involved in trying a switch.

I'm also so sorry about this new problem with her legs. Maybe you might want to hold up on further chiropractic appointments for a while, though, until you can see what develops with the leg crossing. Especially since the crossing started right after this last adjustment, I might wonder whether the treatment actually aggravated something. I know that even in the best of circumstances, sometimes physical therapy of any kind can have unintended or unexpected consequences. I have a friend who is rehabbing from knee replacement, and she is having to alter her therapy regimen because what she had been doing which was supposed to be good apparently now has caused tendonitis for her.

I'm so sorry Abbie has shifted from enjoying her birthday celebration to having these problems. But darn it, we are all gonna focus our energy on her healing!

Marianne

Lori -- thanks for input re water consumption. Abbie now weighs 24 lbs. so my vet agrees with you (he had figured her consumption based on 25 lbs.).

Marianne -- my vet has "0" experience with Vetoryl/trilostane. When I have mentioned it in the past, he has shied away from the discussion. If this current increase does not reduce symptoms/lower her numbers, I will broach the subject again and provide him with some articles to read. I am more than willing to work with him -- this would give him an option if he has another patient who isn't well controlled with Lysodren. In light of the high UPC, I think it is more important than ever that we get good cortisol control -- maybe not down to ideal levels because of inflammatory disc issues but lower than it is now.

Good point about holding off on the chiropractic treatment -- it was the second time I had seen the leg crossing but could definitely have been triggered by manipulation. Next appointment is on 6/1 -- I can easily cancel so will see how the next few weeks go.

Thankfully, Abbie is still her cheery self!

Hopefully the next few weeks go really well and Abbie continues to be her normal happy little self.

Just like with people, sometimes when they do the alignments, things can get tweaked, so have to be super careful with that if she shows signs of the back leg problems after appointments.

Hi, all! I wanted to update Abbie's various issues. She had a repeat UPC last week and, unfortunately, the last level of 5.0 barely moved after a month on once daily enalapril -- just down to 4.7. The vet and I spoke tonight and we are going to try three weeks on twice daily dosing. The UPC will be repeated after that period along with a blood pressure check and renal panel.

Since we added one more dose of Lysodren (now gets one week with 500 mg. followed by one week with 625 mg.), Abbie is doing well with regard to energy level, including consistently wanting to go on walks (even in the terribly hot and humid Florida weather) and she actually has been playful in the house a few times. Her water intake has dropped down to 17-18 oz. a day (from 22-23) with fewer times out to pee in between walks. I think her belly looks much smaller and she has maintained her weight at 24 lbs. Next ACTH is scheduled for 6/9.

Abbie has no pain in her back -- I still try to encourage her to use the steps in the bedroom but sometimes she just leaps right over them! We had another chiropractic visit scheduled for next week but I canceled it -- always know that I can take Abbie to see her if anything flares up.

Now if we could just get that darn proteinuria under control ...

Molly gets twice a day dosing for her kidneys and it has helped. She take 7.5mg morning and evening of benazepril. It is an equal dosage as using enalapril.

Glad she is feeling pretty good. Sometimes they just think they can fly over those steps. :)

Hi, all! Abbie is continuing to confound me and her vet ... very disappointing ACTH results from 6/9:

Pre 5.4 (up from 2.1 on 4/29)
Post 15.6!!! (up from 13.0 on 4/29)

She continues to have all symptoms under control so results were unexpected.

Because of the increasing cortisol levels and the proteinuria which is not under control yet, we have decided to make the switch to Vetoryl. Some of you may recall that Abbie's vet is the one who was adamant about not wanting to try Vetoryl. He made the switch with the dog of a friend of mine and wasn't following any standard protocols. The dog has been very sick ... Abbie will be the third dog he is going to treat with Vetoryl. I couldn't say anything to him about his treatment of my friend's dog but, now that Abbie will be directly impacted, you can bet that we will be following protocols. I have read all the abstracts as well as the Dechra documents but I still have some questions for all of you Vetoryl experts.

The first sticking point was that my vet did not believe that a wash-out period is necessary. I told him that I definitely wanted a wash-out and he said that it was possible Abbie's symptoms would return. From my reading, this is exactly what you want to see during the wash-out period. The other thing you want to see is a ACTH post of 9.1 or higher. Since Abbie's is already higher than that, the only issue is symptoms. Question: once symptoms return, is it necessary to wait the full 30 days in light of her already high cortisol level?

Second area is dose. My vet wants Abbie to start on 30 mg. a day. Abbie weighs 24.4 lbs. so it is my thinking that 25 mg. would be a better starting dose. Problem is that the Vetoryl only comes in 10 or 30 mg. doses. I do believe that I want to start with name brand to ensure quality. Question: do you think it would be better to start with two 10 mg., i.e., 20 mg., a day rather than start with the higher 30 mg. dose?

One of the papers I read is that dogs switching from Lysodren may be more sensitive to Vetoryl. Abbie is on Enalapril for proteinuria. (She has another UPC and blood pressure curve on 6/16 along with a renal panel.) I have read that both Enalapril and Vetoryl can lower aldosterone so am thinking that may be another reason to go with the lower 20 mg. a day.

Question: what dictates having the first ACTH at 10 days versus waiting until 14th day?

Question: should a full chemistry panel be run with the first ACTH?

My vet said that, if Abbie's cortisol levels are still high with the first ACTH, then her dose would be raised to 30 mg. twice a day ... I think I gasped but didn't say anything. I know that we would wait a full month on the initial dose (assuming no negative effects) and then do another ACTH and, even if high at that point, definitely not double the dose. I really wonder who is providing him with guidance.

Questions: I know this is anticipatory but, if Abbie's numbers are still high after a month on the 20 mg. a day (assuming we go with that as the starting point), what kind of increments are used for increases? Since the next Vetoryl dose is 30 mg., is a 10 mg. increase too much?

Curious if you think it would be a good idea to e-mail Dr. Peterson or Dr. Bruyette with questions.

Sorry for the length but was up at 5:00 this morning with thoughts running through my head ... just needed to get them out!

Gosh, Judy, I'm so sorry about these disappointing results. I'm also sorry to hear that your vet seems to be so poorly informed (or resistant?) when it comes to recommended trilostane treatment protocol. That is really puzzling to me, especially if he's had a bad experience with other patients. Dechra's technical staff is willing and anxious to talk to vets about specific patient issues. Given the complexity of Abbie's situation, I absolutely think that is the best place to start -- for you and your vet to talk to Dechra. You may want to place the first call, so as to give them a preview of the situation from your perspective as the owner. It may be a bit frustrating for you, because any direct recommendations they will pobably want to defer to a conversation with your vet. But at least you can get a file started on Abbie, and have a point of contact. With that in mind, let's turn to your questions.

Question: once symptoms return, is it necessary to wait the full 30 days in light of her already high cortisol level?

Absolutely this needs to be discussed with Dechra. Their own literature contains the warning about the lingering physiological effects of Lysodren. So I would want their feedback about Abbie's specific situation.

Question: do you think it would be better to start with two 10 mg., i.e., 20 mg., a day rather than start with the higher 30 mg. dose?

This is just my personal opinion, but I agree with your thinking -- given both the Lysodren and Enalapril, I would want to start lower rather than higher. Plus, just from a practical standpoint, you can always combine or subtract 10 mg. capsules easily. With 30 mg. capsules, they are useless to you if you start with them but need to decrease Abbie's dose. I would start lower and work up.

Question: what dictates having the first ACTH at 10 days versus waiting until 14th day?

Nothing in particular that I am aware of. Probably scheduling convenience as much as anything else.

Question: should a full chemistry panel be run with the first ACTH?

I think a lot of vets may fudge on that, but given the Enalapril and possible combined effects on aldosterone, I think I would want to make sure the sodium and potassium levels are balanced even at the first check. But you could try to opt for the cheapest, most stream-lined chem panel that contains those values.

Questions: I know this is anticipatory but, if Abbie's numbers are still high after a month on the 20 mg. a day (assuming we go with that as the starting point), what kind of increments are used for increases? Since the next Vetoryl dose is 30 mg., is a 10 mg. increase too much?

I think the size of the increase will all depend on the actual test results and symptom profile. Just no way to judge that yet.

If you want more feedback in addition to Dechra, you can indeed email Dr. Bruyette directly. He has told us he is fine with having our members write to him with questions. I don't know that Dr. Peterson will respond to personal emails; I believe posting questions to his internet blog is his preferred mode of communication.

Marianne

Marianne -- thanks so much for making your way through my long post and providing your always valuable input. I will contact Dechra on Monday. I will be at the vet's Tuesday for Abbie's next round of tests so am hoping to get a few minutes of his time then to touch on a couple of areas and see if he is willing to talk with Dechra staff. I printed out some of the Dechra documents as well as Dr. Bruyette's DVM360 interview and the vetsonline notice.

I checked around for prices and California Pet Pharmacy was considerably less expensive than anywhere else (10 mg. were $41.95 for 30). Vet has had no problem calling in prescriptions to Target and Sam's so, once a firm decision about dose is made, I am hoping he will not have an issue with contacting the California pharmacy.