Max test results help — Sweet Max has passed

Welp, I’ve just learned something new — which proves that you *can* teach an old dog new tricks! Cuz I’m definitely an old dog ;-).

After a lot of years on this forum, I’m just now learning that Cushing’s can cause anemia. As Lori said above, we’re much more familiar with a linkage between the disease and *elevated* red cell and platelet counts. But I just now Googled Cushing’s and anemia, and see that those two conditions can be linked. I don’t know the mechanism, and definitely need to educate myself further. But there you have it. So if no other explanation for Max’s anemia is uncovered, then I understand why Cushing’s treatment might be considered.

As you’ve already said, though, it’s a tough call since Cushing’s medication requires a lot of lab monitoring which may be stressful for Max, and in addition at his age might worsen arthritic issues that elevated cortisol might actually be easing. I wish I was able to write more right now, but I’d like to educate myself a bit more about the anemia angle before continuing. But I wanted to at least acknowledge this new piece of info — at least it’s new info for me!

Marianne

Of course! I appreciate all of your comments so very much! I am a researcher as well. I have spent the better part of today looking over his labs for the last 3 years since initial testing. His hematocrit and rbc as well as hemoglobin slightly every six months (between .8-2 point each blood draw). He's always been on the lower end of the scale.

Dr. V mentioned that high cortisol levels can lead to GI ulcers, combine that with the Galliprant that he is on and it could worsen this. This is her theory on the reason he dropped from 37.6 in July to 34.9 in Dec and 34.0 now....bleeding ulcers or a low volume bleed somewhere else. He also has GI issues anyway.

As I have researched Cushing's and anemia, it does mention Cushing's can be a cause of anemia, but I cannot find anywhere how they are related. I have scoured articles and research documents. I would love to hear if you are able to find anything.

I feel like Max is ok with blood draws and such, but he is not a dog who will lay down willingly for scans. He also does better when I am not around. :eek: He is used to appointments with his cardiologist and internal dr every 6 months or as needed for care. BUT he's an old fella and of course not his favorite thing in the world.

Sorry for the long post, just nice to be able to think outloud!

It's not a long post at all -- no need to apologize! And now I'm totally interested in trying to look into that anemia/Cushing's link, too. The notion that the combo of the elevated steroids of Cushing's in conjunction with the Galliprant would make a dog more vulnerable to GI bleeds makes a lot of sense, as well.

If Max does OK with blood draws, then that eases my mind a lot in terms of Cushing's treatment monitoring. There's a lot to think over, for sure, but please keep on thinking outloud, because it's prodding me to expand my own knowledge, too ;-).

Marianne

Max's FOBT came back positive for blood in feces. Dr. V said given his history of slow declining PCV and Cushing's and recent labs, she feels confident that it is GI bleeding that is the cause of the slowly developing anemia. She said she did not feel an ultrasound was necessary because due to his history and labs she did not feel a mass was likely.

She went over several options:

1. Treat Cushing's with Vetoryl to help the increasing ALP levels and decrease the cortisol which should help the bleeding an anemia. She said we could continue his Galiprant because (as many of you mentioned) when the cortisol drops it can make his arthritis worse. If this option is chosen we will do an ACTH stim test to see where his levels are and then begin. I inquired about beginning a very low dose and she said she would start him low and we could every try once a day for a week then move to twice which is what she recommends. Then, of course monitor from there. She said this option could be stopped at any time if we felt it was not benefiting him.

2. Not treat the Cushing's, but stop the Galiprant which is probably contributing to some bleeding. Although I think (I forgot to ask) this would only contribute to stomach bleeding not GI bleeding...maybe not...maybe NSAIDS can cause bleeds anywhere in the GI tract? She explained that this would not help his arthritis and he may be in pain or not have as good of life quality.

3. Do nothing...we know what we are dealing with now and we could keep him comfortable and monitor him until we needed to discuss end of life plans.

Some questions I had:
-Could we try gastro-protectants? Yes, but she said it would not help the entire GI tract and we certainly could, but of course meds like sucralfate must be given at specific times to not interfere with absorption which can be hard to manage. She said his whole I track is probably sludgy and there are small bleeds contributing to the issue.
-Is his age or anemia an issue with Vetoryl? No, many dogs are diagnosed and treated between the age of 10-16 and she said that it will also help the anemia.
-Is Vetoryl fairly safe? Yes, she treats many dogs safely with the medication. Most note GI upset in the beginning. She said there is a rare chance of damage to adrenals and causing Addison's.
-Does she feel that treating the Cushing's is the best option? She felt like it was an option worth exploring and she said the great thing about Vetoryl is that we can stop at any time if it is not helping him.

I want to try treating the Cushing's. I feel like he's such a healthy strong boy given all that he has been through. I feel that I need to explore it and give it a shot rather than doing nothing. Doing nothing is a certain downhill slide and I cannot in good conscience continue to let his Cushing's go untreated and treat the arthritis knowing that I am allowing the combination of those two things to cause more damage. If it does not go well or there are things that we see are taking away from his quality of life, we will stop and know we tried.

I do understand why you want to give the Vetoryl a try, and it sounds as though your vet is approaching things quite reasonably. That’s huge! It sounds as though you’ve already done a ton of research, so there may not be any information on the link below of which you’re unaware. But I’ll offer it to you nevertheless:

https://www.k9cushings.com/forum/sho...TH-Stimulation

Let us know about any preliminary questions or issues that you may be wondering about. And for sure, please keep us updated!

Hi Elizabeth,

You said something that caught my attention because of the chance of errors seen too many times. You said - "I inquired about beginning a very low dose and she said she would start him low and we could every try once a day for a week then move to twice which is what she recommends."

First - For dogs weighing over 44 lbs the starting dose is a MAXIMUM of 30 mg per day. This is based on independent studies that Dechra, the manufacturer of Vetoryl, knows about and has chosen to ignore. So the literature that vets work from to find a "low" starting dose is out of date and MUCH too high. Their literature states to start all dogs at 1-3mg per pound per day. For dogs under 44 lbs, starting at 1mg/lb/day is ok but for larger dogs that is twice the starting dose that is appropriate...which is 0.50mg (or 1/2mg)/lb/day. So be sure she doesn't offer him any dose higher than 30 mg per DAY.

Second - you never ever increase the dose unless the signs and ACTH results say the cortisol is still too high. To do so otherwise is extremely risky. SO to simply start at one dose then increase in a few days without the ACTH to support the need should not be done. The cortisol will typically continue to drop those first 30 days after starting treatment with no increase. So do not allow her to do that to your baby. Max could become very sick, or worse, if she does.

Third - dosing twice a day is often the best approach because of the short life this drug has in the body - it is usually leaving in 12 hours or less. BUT to dose twice a day does NOT mean doubling the dose and too many vets do not realize this and will double instead of halving when switching to twice a day dosing. So if the correct dose for Max is 30 mg...that is 30 per DAY and twice a day dosing would mean 15mg AM and 15mg PM. NOT 30mg AM and 30mg PM. So watch for this...twice a day means halving the dose not doubling. ;)

Here is a link from our Helpful Resource section that includes info on starting doses for larger dogs. That info is at the end of the page and there is LOTS of good info before you get there so explore!

https://www.k9cushings.com/forum/sho...TH-Stimulation

Hugs,
Leslie

Thank you so much Leslie! I actually just came her to post a couple of things I forgot!!

Dr V said they recommend .5-1mg (and I cannot for the life of me remember if that was/kg or lb...I want to say kg?? Does that sound right??) I believe that is what you are also saying in your post? He's about 38 kg. So if my math is correct ;) 38(.5) = 19...yes? Sorry....double checking! Would we begin at 20 or could I request to start at 15? I am super paranoid about any medications.

I might have been confusing the way I worded the once a day. She had said we could try once a day for a week then SPLIT the dose into twice a day! That had me thinking...wait, ok splitting the dose would be gradual instead of one big dose! So, yep...I will definitely be asking for the two dose!

Max can be sensitive to some medications...we have seen in the past. We had to decrease his sotalol because if was too much for him. He had some reactions to some things in the past (cytopoint, ciprofloxin) so I am always very very hesitant about medications.

What are the thoughts on compounded trilostane? Not good? Ok?

I really really appreciate you thinking about this and being so thoughtful to help a complete stranger and her beloved pup!

Thank for the clarification! And, yes, the literature is probably using kg VS lb. I found in an earlier post where you say he weighs 89 lbs. To find that weight in kg you divide the pounds by 2.2. So 89/2.2=40.4545...kg. It is the pound weight that we will look at. He is definitely over 44 lbs so that means he needs no more than 0.50mg (or 1/2mg) per pound per day with a max dose of 30mg a day. Even with his weight of 89 lbs a starting dose of 1/2 mg/lb/day would be 44.5mg a day...which is too high. His maximum starting dose is 30mg per day. I have seen dogs weighing more than he does doing great on 10-20 mg a day. For some reason larger dogs simply metabolize this drug differently than smaller dogs do so smaller starting doses are needed for them. I would feel comfortable with 30 mg per day but don't have a problem starting even lower, especially since he is sensitive to other meds. So if you want to start on 20mg/day I would ask for that dose. It is much easier to increase than to deal with a case of the cortisol dropping too low. ;)

I personally don't have an issue with the compounded form, Trilostane. However...not all compounded meds are the same. You want to be sure the pharmacy that does the compounding is using the licensed Trilostane, ie that they are compounding from Vetoryl and not from a bulk product that contains Trilostane. Compounding allows for more dose ranges and forms like chewable or liquid that can make giving the med easier for some dogs. Some vets allow compounded drugs, some do not, so you will want to talk to the one you use about their policies.

Hugs,
Leslie

Thank you again, Leslie...He was 38 kg or (83lbs) at the vet...I will definitely make sure they get an accurate weight on him for sure!

Hi again from me. I see that Leslie has given you a ton of good information so there’s very little for me to add right now. But since you’ve specifically asked about compounded products, I do have a bit to say about that from my own perspective. Over our years here, I’ve 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.

For this reason, just as Leslie says, people need to be careful about the compounders they select if that’s the route they need or want to go. Leslie is much more generally active in Cushing’s groups than I am right now, so she may be privy to better info about the following than I am. However, I would wonder whether any compounders are currently using actual brand Vetoryl as the basis for their trilostane product. You can always ask them, and I would be very interested to know their answers. But for reasons of both cost and practicality, I’ve assumed for some time that all compounders typically use basic chemicals that they purchase from suppliers in the preparation of their products. And for this reason, 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

My own personal preference would be to start off with brandname Vetoryl if the dose and cost was something my dog and I could handle. I would just have greater confidence about the consistency of the dose and efficacy. Once my dog was 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. At that point I’d have the experience of the Vetoryl to compare with.

One final note in that regard…if you do opt to use Vetoryl on a twice daily dosing schedule, you may not be able to exactly split the daily total into two equal doses due to the limited options in capsule size. In that situation, the maker of Vetoryl recommends giving the larger dose of the two in the morning. And having said all this, your vet may already be working with a trusted compounder and my whole lengthy blabbing here will have been unnecessary :-). But good luck with whatever you decide!

Marianne