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

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Originally Posted by Carole Alexander

Shana, I believe that Skippy was tested (at least he was taken back) approximately 4 1/2 hours after I fed and gave him the Vectoryl dose. The food was a big bite of chicken breast with the pill enclosed and a very small handful of kibble. If the Vectoryl wasn't properly absorbed, am I correct in thinking that his cortisol level would be higher (as it was)? In our two visits to Purdue he has been tested, as Drecha and researchers recommend, at 4 to 6 hours after dosing. The mistake was in telling me explicitly not to feed.

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You've got it right. If it wasn't properly absorbed, then the cortisol may be higher. The risk then of course would be to assume that Skippy needs a higher dose when he really doesn't... and to push his cortisol too low on those days when he gets it with a normal meal.

I mentioned the timing just to be sure that was done correctly, and it was. You want to be consistent with that so you're not testing it one time at 4 hours after dosing and the next at 6 hours. My vet and I made sure we were always at nearly the exact same time every time we tested.

As for the synthetic vs the gel... I'll leave that to someone more knowledgeable, as I'm not sure if it matters to use the same one each time. I'd think so, but that's only a guess.

Thanks Shana, I appreciate your response and feedback. Skippy is doing okay, not my old new dog, but okay. No diarrhea and a little more energy but I will see with the ACTH test next week.

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Originally Posted by Carole Alexander

I recall that one is a synthetic liquid and the other a gel. Should a dog be tested with the same product each time? Does it matter? If I take him to my local vet for testing, will they use the same product as Purdue?

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Cortrosyn is the preferred stimulating agent, Acthar gel has fallen out of favor because of its cost and the compounded version may not yield reliable results, according to Dr. Mark Peterson.

One other difference between these two stimulating agents is the wait time for the post blood draw; with Cortrosyn only 1 hour is needed but when Acthar gel is used a 2 hours wait time is required.

The same stimulating agent should be used for all ACTH stimulation tests, and as Shana mentioned, the timing of these tests should be consistent so one can compare the results as equally as possible.

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Originally Posted by Carole Alexander

Another example, Purdue thinks Skippy's sex steroids should be tested; the local vet says not to bother. I ask each one "why" but got no answers.

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I see no benefit in testing the sex hormones in a dog with conventional Cushing's because if cortisol is high the sex hormones are most likely to be too.

Hugs, Lori

Lori and Shana,

Thanks to you both for this info. It is helpful and I probably should be reading more. Tonight Purdue called to remind me of Skippy's appointment on Wednesday at noon. Again, the caller advised me that I was to fast Skippy after 10pm tomorrow. I politely told her that her directions were incorrect and that Skip needed to eat breakfast with Vectoryl. She then said that she was just reading the info on her sheet of paper. I ask her to check with their docs - not for me but for other Cushings dogs that are being tested. She said that she would check but I will insistently raise this on Wednesday when Skippy is tested. BTW, Skippy is slightly improved on most symptoms but he is still not slaying his dragons.

One more question if anyone can help: Tomorrow Skippy is scheduled for another ACTH test tomorrow. Should I delay this test for another week or proceed since he has had two dosage increases since the last test.
His tests so far:
12/6 - confirmed Cushing's and started Vetoryl at 10/10 BID (Purdue)

12/20 - Pre 2.2 and post 10.8. Dosage sustained at 10/10 (Purdue)

1/23 tested, no results until 1/25 - Pre 6.3 and post 16. Dosage increased to 15/10. (Lightly fed for this test.) (Purdue)

1/30 - Consult with local vet re: continuing clinical symptoms and adenoma; she recommended and I agreed to increase dose to 15/15 BID

2/8 Scheduled at Purdue for 3rd stim test.

Aside from a little diarrhea that has cleared, Skippy has had no adverse reaction to dosage increases. He remains very slightly improved in respect to many of the usual symptoms. My fear is that the dose is still too low and waiting just delays getting the dosage correct. But, I am aware that he may not yet be responding to increases. Tomorrow is the tenth day since last increase. Thanks

If this were me, I would proceed with the ACTH test tomorrow especially knowing that the previous ACTH stimulation tests were not performed according to the Vetoryl/Trilostane monitoring protocol that is published. I am including articles that state that Vetory/Trilostane must be given with a meal, this first one is the "Vetoryl Client Brochure" which Dechra publishes, (Dechra is the maker of Vetoryl):

Vetoryl Client Brochure

On page 6 of that brochure:

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How do I give VETORYL Capsules to my dog?

Give VETORYL Capsules with a meal in the morning so they can be effectively absorbed. Administration in the morning is critical so your veterinarian can perform the monitoring test at the appropriate time after dosing.

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This second excerpt is from an article on Dr. Mark Peterson's blog (Dr. Peterson frequently contributes to Dechra's online continuing education for veterinarians) and is titled: What's the Best Protocol for ACTH Stimulation Testing in Dogs and Cats?

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Remember that the ACTH stimulation test is the most useful test for monitoring dogs being treated with trilostane (Vetoryl) or mitotane (Lysodren) see my blog entitled, Diagnosing Cushing's disease: Should the ACTH stimulation test ever be used? Both medications are fat-soluble drugs and must be given at time of meals, or the drugs will not be well absorbed.

With trilostane, it’s extremely important to give the morning medication with food, and then start the ACTH stimulation test 3 to 4 hours later.

Fasting these dogs on the morning in which the ACTH stimulation test is scheduled should be avoided since it invalidates the test results.

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http://www.endocrinevet.info/2011/03...-for-acth.html

You can print these articles for reference to prove to the vet and staff that they are wrong in directing pet parents to fast their dog when monitoring Trilostane with the ACTH stimulation test.

Hugs, Lori

I do think in this case that I would get the test done as scheduled. Especially if for some reason he hasn't responded to the increase as hoped and that post number is still real high.

Thanks so much to you both. We will go as scheduled along with Dr. Peterson's protocol. You all are the best!

The update on Skippy is a continuing slog on a very slow and costly testing treadmill. Here's where we are:

12/6 - confirmed Cushing's and started Vetoryl at 10/10 BID (Purdue)

12/20 - Pre 2.2 and post 10.8. Dosage sustained at 10/10 (Purdue)

1/23 tested, no results until 1/25 - Pre 6.3 and post 16. Dosage increased to 15/10. (Lightly fed for this test.) (Purdue)

1/30 - Consult with local vet re: continuing clinical symptoms and adenoma; she recommended and I agreed to increase dose to 15/15 BID

2/8 - Third Stim test after 10 days at 15/15 BID. They just called with results:
Pre - 6.8
Post - 12.0
Purdue student said I should increase Skippy (27.5 lbs) to 15/15 BID; I reminded her that we were already at that dose for the past 12 days with no change in level of hunger, lethargy, fear, unwillingness to walk, etc. (When they examined Skippy and I mentioned these issues again, they suggested an orthopedic work-up.) But, with his cortisol still so high couldn't the cause of these symptoms be Cushing's? We discussed the twice daily dosing again and the student said that in their experience they have had greater success with that approach. (And, I have no objection.) So, the upshot was that the student was going back to confer with the internal medicine vet regarding what to do next, if anything, and would call me back. Skippy only has been on the new 15/15 dose for 12 days so his cortisol could go lower in time. But, he is still so high that I think they should increase the dose somehow even if he needs to be tested in two more weeks. Please let me know of your experience or opinion regarding this problem. And, as always, thank you.

I spoke with Purdue again and they want to increase the dose to 20/20 BID starting tomorrow and do another Stim test in two weeks. BTW I ask that they look at his adenoma during last visit but their surgeons were too busy with emergencies. It has healed over and I have no plan to do surgery until or unless I get Skippy's cortisol under control. Is it possible that Vectoryl just won't work?
Purdue has raised the issue of switching him to Mitotane a couple of times and always puts the idea in their written report. (Likely because it could perhaps "shrink" the adenoma and reduce the level of sex steroids.) But it's also clear that Purdue and my local vet strongly prefer Vectoryl - as do I. I know that Skippy is not nearly as sick, yet, as many of the dogs on this forum, but the thought of starting over takes me to a very dark place. And continuing to watch him languish breaks my heart. Thank you,