Buddy, The Mighty Lizard Hunter - Suspected Pituitary Macro Tumor

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Originally Posted by Budster's Mom

Well, here goes....I received a response from Buddy's vet this morning. It is cut and pasted below. :D

Kathy, I don't know what to tell you on this. The forums on VIN, the database for UC Davis, cannot be cut/pasted and accessed without a passoword. All of the doctors here have been asked and we all agree is doesn't matter. This drug was given fasted for many many years with excellent treatment successs.

So that it! :eek:
Kathy and Buddy

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Well. Your vet is not giving us much help here, is she. :o

Being the obsessive person I am, I have been busy Googling my iPad to death ever since we started this conversation. All I find are repeated instructions, through the years, to administer trilostane with food. This ranges from the citations we've already supplied to treatment directives published by IDEXX Laboratories to the most recent study results published by UC Davis in which the researchers specifically note that dogs were given trilostane along with food in advance of all ACTH tests. Out of all these searches, I did find one author around 2008-2009 who stated (without any supporting citation) that it had not been proven that food improved trilostane absorption -- but even that author still noted that the prescribing recommendation is to give the drug with food. Bottom line: I have found no reference anywhere by anybody, at any time, that recommends dosing trilostane on an empty stomach. Will some of the drug still be absorbed, regardless? Yes, I suppose so. So if this is the way your vet has been dosing all her dogs, presumably they would still be getting some benefit from the drug. But I would suspect they would likely be requiring a higher dose (and hence, at greater expense) than would otherwise be the case if the drug was being absorbed maximally.

For your own peace of mind, you can certainly contact Dechra. As to whether or not this will make a difference to your vet, I do not know since she seems to be totally disregarding Dechra's published directives. I don't know whether she'd respond differently to a verbal conversation. But at her request, maybe they could supply her with some actual research data. I know at least one such study exists, although I have not been able to access the full text yet ("It has been shown that feeding immediately after the administration of trilostane increases its absorption"). But Dechra may have custody of this or other studies that could be provided to your vet:

Johnston L, Chohan A, Chapman E. Absorption of Trilostane in the Fasted and Non- Fasted Healthy Dog. Proceedings 15th ECVIM Congress, 2005; p223 (abstract).

But at this point, we've pretty much beaten this particular issue into the ground. So the big question seems to be, where do you go from here? I guess your reaction to your vet's response will be tempered by your overall relationship with her. Is this a vet whom you've used for a long period of time and generally with positive results? Do you otherwise feel comfortable with the care your dog has received? Aside from this instance, does she generally address your questions in a satisfactory manner? Do you feel as though you have other options? Right now, she is not winning me over in terms of either her receptiveness to new information or her expertise in using trilostane. But you are the far better judge as to your overall comfort level with her care.

Marianne

Good morning,
It appears obvious that my vets do not have the information regarding Cushings that you have.:rolleyes::eek:

As a recap...I rescheduled Buddy's ACTH test for next week. I hadn't been giving him his Trilo with food per doctor's orders. :mad: I was instructed to fast him before his ACTH test. :mad:I started giving him Trilo with breakfast a few days ago. I wanted to dose him according to protocol for at least a week before his ACTH test.

Buddy is taking Benadryl three times a day (every 8 hours)to control the onslaught of allergies. I don't like giving it to him that often particularly since it makes feel drugged and sleepy. If I don't, he literally cannot breathe well. He sneezes continuously with a runny nose and wheezes without relief. So, drugging him is the lesser of two evils for now.

Here's my question… Is it okay to give Buddy Benadryl on the morning of his ACTH test? If not, he is going to feel really miserable. I'm going to have to take that day off, which looks pretty bad after being off on break for two weeks. That is the only way that I know he will get his test completed in the required the 4-6 hour time window.
If I drop him off there on the way to work and pick him up after, I will have no idea when they actually started or completed the test. I've been giving Buddy his dose of Benadryl when he gets up in the morning. Then I've been giving him his trilostane a half an hour or so later with breakfast. Would it be okay if I did that the morning of the test?:confused:

Thanks for your help in advance,
Kathy and Buddy:):D

I've never read or been told that antihistamines interfere with the ACTH, but this is another thing that you could double-check with Dechra if you'd like. Here's contact information for their U.S. office in Kansas:

http://www.dechra-us.com/Default.aspx?ID=365

THey have vets and vet techs on staff who are available to field questions via phone or email. They used to be very responsive to talking directly with pet owners, but seem to have become more selective as to what they prefer to discuss only with vets. But I would think that a question like this would be something that they'd be fine with answering for you.

For what it's worth in the future, you may want to experiment with switching Buddy to one of the newer, non-drowsy antihistamines. One of my non-Cushpups has terrible seasonal allergies, but she also has to take phenobarb for a seizure disorder. The combination of phenobarb and sedating antihistamines is not a good one, so my vet has switched her to Claritin. In honesty, neither Benadryl nor the Claritin have seemed to help her very much. But you can keep experimenting with different antihistamines to see if one provides a better response for Buddy. I'm sure you can Google a list of acceptable antihistamines/dosages for doggies, or maybe one of our other members can supply one.

Hi Marianne,:)
I posted my last post before I read your email. Thank you for all of your hard work and for trying to search these things out for me as we'll as for others.

I have used that vet's office since Buddy was a puppy (10 years). I was referred there by others who are very happy with them. I have been very satisfied and comfortable with them handling Buddy's care up to this point. My regular vet was out on vacation when I ended up taking Buddy in so ill. That's how I ended up with this other doctor. I was very impressed with her, I must admit. She was the first one to suspect Cushing's. She referred us to an emergency hospital for an ultrasound, because she said we needed a specialist. She said that they could do it there, but Buddy had so many problems going on she thought he needed specialist. I appreciate her telling me that, instead of moving forth without proper testing. She referred us to a Specialty Hospital and to a specific doctor for his neural consultation.
She called ahead and talked with the neurologist, making sure they had everything they needed before my appointment. I believed everything she told me regarding Cushing's treatment until I found your forum. This form is like a very addicting drug. I couldn't get enough of it!;). The more I read, the more confused I got. :rolleyes:
I am not distressed by the fact that she didn't know. No one knows it all! What bothers me is the fact that I forwarded numerous citations from this forum and her opinion has remained the same. It also disturbs me that she said that everyone in your office felt exactly the same way about Dosing Trilo with or without food. That it makes no difference either way. If that is really true, then going back to my regular vet wouldn't help, would it? I have been really happy with my regular vet. He treats his pet parents as if he has all the time in the world to answer all of their questions. He even brought out a bin of bones once to show me how Buddy's knee worked when I didn't understand what he was telling me. I really like him, but I am afraid that office doesn't know enough about Cushings. So yes, I could find another vet. I live in a populated area where there are many. Hence my dilemma!

Marianne,
THANK YOU!!!!! I followed your device and called Dechra. They were very helpful. Not only were my all of my questions answered, they were also explained. They told me that Vetroyl was fairly new in the United States and a lot of vets are not familiar with it's protocol.

1. Trilostane must be administered with food for proper absorption.
2. ATCH testing - No fast- Meal with medication - a smaller meal is warranted if the animal tends to get carsick. Test must be
started within a 4-6 hours, but doesn't have to be completed by
then.
Vets often want to do several tests at once therefore requiring a
Fast. In that case it is advisable to do the ACTH test at a different time.
3. Benadryl - Benadryl shouldn't in any way affect the ACTH test results.

So there is your verification once more! I wish my vet would call!
There are other Cush parents who are going to be getting the same instructions that I was given and won't know enough to look further.:(

Kathy and Buddy:)

Oh Kathy, I'm so glad you called Dechra and that they were able to answer all your questions. And thank you so much for passing their information on to us. :)

I am really sorry that this conflict has come up regarding your vet's instructions. From what you've described, it does sound as though she acted very kindly and responsibly during Buddy's crisis. And the last thing we want to do here is to undermine a member's relationship with his/her vet. But I agree with you whole-heartedly that the more disturbing thing to me is not that your vet may have been originally misinformed (of course that happens), but instead that she doesn't seem to be responsive to the information that you've supplied to her now. It can be hard to have a conversation about this via email, though. Will you have the opportunity to talk face-to-face when you take Buddy in for his test? Especially now that you have had the chance to personally talk to Dechra, I'm thinking that could be the basis for your conversation with your vet. And I'm hoping that you'll get a different response from her when you have the chance to relay exactly what you've been told by Dechra, and I'm surely hoping that she will be motivated to seek further clarification herself if she remains unconvinced.

Marianne

Kathy, did they give you a case number? If so, you can give the case number to your vet and tell her what Dechra told you and that she can call, refering to the case number to verify the information you received directly from the drug's manufacturer.;)

No they just talked to me and answered all my questions. They were very helpful and didn't seem to mind that I wasn't a vet. I didn't think to ask for a case number.
I'll call ahead and get my vet's schedule for next week so that I can hopefully talk to her when I take Buddy in for his ACTH Test. We'll see how it goes. That would give her a few days to research anything that she might like to, or calm down enough to hopefully listen to what I have to say. I don't want to come across as a threat or make her feel intimidated. I just want her to be open-minded enough so we can continue to learn together. We'll see,

Kathy and the Budster ;)

I know, it is balancing act. Sometimes face to face is better than email. The written word sometimes is misunderstood; there are no facial expressions or voice tones to use as cues.

I am so glad you called Dechra.

I'm really glad that you called Dechra and they answered your questions. Now if your vet will take their responses into consideration, maybe it will all work out. It's really hard when you have been with the same vet for a long time and have had a good experience usually with them.
Hang in there, you are doing great!

hugs,
Sharlene and Molly Muffin