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

Over our years here, I think there are few issues that have generated more discussion than the question of brandname meds vs. compounded alternatives. People have had, and probably continue to have, differing opinions. For what it’s worth, here are my own thoughts. I’ve certainly come to appreciate the fact that compounded trilostane can be a positive game-changer for folks, either because their dogs need doses that aren’t available in brand form, or because the high cost of Vetoryl would make treatment a huge financial burden. However, the downside is that compounded products are not inspected nor regulated in the same manner as FDA-approved pharmaceutical products, and some past studies have shown some dosage/efficacy irregularities in certain compounded trilostane products. So that remains somewhat of a worry to me. And for this reason, I think the reputation of any given compounder is especially important to investigate. On the thread below, we give people some tips in that regard:

https://www.k9cushings.com/forum/sho...ushingoid-Dogs

Just as you have done with Reggie, my own personal preference would be to start off with brandname Vetoryl if the dose and cost is something my dog and I could handle. I would just have greater confidence about the consistency of the dose and efficacy. Once my dog became stabilized on a dose, that would be the time I’d feel more comfortable about trying a switch to a compounded version if the ongoing cost of Vetoryl is too burdensome since, at that point, I’d have the results of the Vetoryl with which to compare.

If you do end up sticking with Vetoryl, however, one other cost-saving possibility might be to give unequal twice daily doses. For instance, if Reggie hypothetically ultimately ended up with a 90 mg. daily total, one option might be to give one 60 mg. in the morning and one 30 mg. capsule in the evening. In a situation where the doses are unequal, the maker of Vetoryl recommends giving the larger dose of the two in the morning. Your internist might not be in favor of unequal dosing at all, and instead be more in favor of a compounded equal dose. But I just thought I’d mention it as yet one other option depending upon the total daily dose you ultimately end up with.

Marianne

Thanks, this makes sense. I brought up the idea of a 60/30 split with my internist, but her preference was equal doses. Still, especially if 40/40 doesn't quite seem to do the trick, I may bring it up again if this is the general dose range we settle on.

Good to hear from you and good to hear the Reggie is showing some improvement. But, I also understand the increase and hope this does the trick for a bit.

As for compounded VS brand...you want to be sure the pharmacy is compounding using pure Trilostane, the active ingredient in Vetoryl. Some pharmacies have been using other products that are not pure Trilostane and the results aren't as positive. So just be sure what you are getting. ;) One pharmacy I feel good about recommending is CareFirst. I will give you a link below. They were more than happy to talk with the Admins of another group I work with so I would assume they would talk with his vet if desired. I use a quite a few compounded meds for my dogs and myself with no issues and they do save money.

Let us know how the increase works for your sweet boy!

Hugs,
Leslie

CareFirst:

https://www.cfspharmacy.pharmacy/

So Reggie has now been on his higher does of 40mg Vetoryl twice a day for a little over a month.

Frist the good news:
His drinking and urination seem to have improved a little bit more. It's at the point where I wouldn't consider it a major quality of life issue, although he still occasionally gets me up in the middle of the night to drink and/or pee. But he often makes it through the night, and then usually wants to eat breakfast before he goes out, so there's not a lot of urgency most mornings. Still it's clearly elevated compared to a healthy dog.
His appetite seems slightly more under control. He'll still complain if he doesn't get his usual amount of food by the end of the day, but he has gotten pickier with his kibble, sometimes waiting to see if he can score something better before eventually eating it. And his weight seems to have stabilized over the past month.

The bad news: His weight has stabilized at ~51-52 pounds. He's been as light as 38 lbs since I adopted him as a full-grown adult, and I think his ideal weight was 40-42 lbs, and that was with some pitbull musculature he doesn't really display any more. He still seems hungry a lot of the time, which can't be great for his quality of life and leads to some annoyance begging from me. Also he often is up and asking for breakfast by 4am and almost never sleeps past 5am -- he used to sleep in until I left for work in the morning (he comes with me, and would eat breakfast on the car ride in, or sometimes leave it to eat on the way home). Despite his weight gain, he seems to be losing significant muscle, and can't jump up on furniture like he used to. He rarely wants to walk very far, and is slow when he does. I'm not seeing further thinning of the fur on his flanks, and it might even be slightly filling back in, but his tail has started looking really ratty.

We did another pre-trilostane cortisol test yesterday morning. He was at 4.4 ug/dL, which my internist says is within the target range, and I understand that, but it also concerns me that Reggie's cortisol has never been particularly high, it just didn't suppress as it should, and he still shows pretty much all of the Cushing's symptoms other than calcinosis. His pre-trilostane cortisol was 4.0 ug/dL Sep 18, 2.8 ug/dL July 14, and his baseline at the start of his LDDS test on May 12 was 2.1 ug/dL.

So given that his cortisol is still trending up (though I realize there will be noise in any single measurement), he still displays significant symptoms, and shows no signs whatsoever of dangerously low cortisol, I am tempted to increase his dosage a little further. And/or I asked the internist if there was anyting else we might consider that might help with his energy levels and muscle mass/body composition. She said not really, at least if Cushing's is all he has going on. But she hasn't actually seen him in person in a long time (it's been a nurse taking the blood samples then we discuss via phone the next day), so she's going to look at him on Monday and re-assess.

Maybe I just need to be patient given that Reggie has shown a little bit of improvement lately, but it just seems like his quality of life isn't where it should be. But maybe he's just never going to respond much better than he has to date? If he was an old dog I'd be more willing to accept some of the deterioriation, but it's pretty hard to believe he's older than 9 at the absolute maximum (rescue so no way to know for sure).

I’m really glad to hear that your vet will be seeing Reggie personally on Monday. Given your description of his remaining clinical symptoms, I have to agree with you — my guess is that a medication increase may be in order. It’s true you’d be content with his pre-Vetoryl cortisol level of 4.4 as long as his clinical symptoms had resolved. But according to Dechra’s monitoring chart, a dog with a pre-pill cortisol level of 1.5 to 5.0 who continues to exhibit unresolved symptoms is a candidate for a dosage increase.

https://drive.google.com/file/d/1aQO...ZWjCrdlG4CE7p0

Like you, I’d really hope to see more improvement for Reggie. So if I were you, I’d definitely want to discuss an increase on Monday.

Marianne

One of the peculiarities of Vetoryl is that it isn't consistent across the dogs being treated with it. By that I mean one dog will do very well with a post # of 4 but another dog will be experiencing low cortisol symptoms at that level while a third dog needs an increase at that level because symptoms are not controlled. So Reggie may be one of those dogs who will do better, have better control, with a post most would consider getting dangerously low...closer to 2 than 4.

AND just to keep things interesting some dogs simply do not do well with Vetoryl and need to switch to Lysodren....and vice versa. Some dogs get very sick on any dose of Vetoryl but do very well with Lysodren....and vice versa. Some dogs get excellent control with Vetoryl but some are never controlled on Vetoryl and only find symptom relief with Lysodren....and vice versa.

Reggie is still in the very early stages of treatment so don't get discouraged just yet. Most of the time once that magic dose is found symptoms improve (with time) and folk find they have their old buddy back again. So just keep doing the great job you are so far and I am sure you will see the day when Reggie is feeling great and acting more like he used to. I have faith!

Hugs,
Leslie

The internist made note of Reggie having pretty much all the clinical signs of Cushing's (except perhaps the elevated cortisol itself) and no obvious signs of anything else. but still didn't want to increase his vetoryl dosage at this time. She did order a senior screen blood panel to see if there's anything else we're missing but it didn't seem particularly likely.

Meanwhile she did tell me one thing I hadn't heard before about why surgery for the pituitary version of Cushing's is so rare for dogs despite being fairly routine for people. She said that in addition to the obvious differences in how much people are typically willing to pay for treatment of a dog versus a person, human heads are remarkably consistent in their shape and layout whereas dog heads are anything but. So the procedure is more difficult and less standardized when it comes to dogs.

Some bloodowork results back. Back in May 2023, Reggie's T4 was at the low end of normal, but we didn't make too much of it because any of the potential symptoms of hypothyroidism he was showing were also consistent with Cushing's, and his appetite was so ravenous it seemed inconsistent with hypothyroidism. But now his T4 is very low, and this could explain a lot. The internist is waiting on a few more results before deciding how to treat the thyroid issues. This simltaneously feels like a real blow in terms of compounding multiple issues, but at least maybe it illuminates a path forward and insigt into why things weren't progressing as hoped.

Additional bloodwork shows TSH high-normal despite ~undetectably low T4, supporting a diagnosis of hypothyroidism on top of Cushing's, so were starting levothyroxine. Hopefully this is the missing piece to making Reggie feel better...

Hope this works, keep us updated!