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

Dear Carole,

I'm so sorry for you both that Skippy is having these worsening problems. Given his pattern of ACTH results, I actually can't argue with your local vet's recommendation re: the dosage increase and it would seem surprising to me for his cortisol to plummet to a level that is too low within only two days time. But having said that, no matter what the reason, clearly Skippy is not in a good place right now. Whenever a dog won't eat and/or appears unwell, our general advice around here is to temporarily withhold trilostane dosing until things improve. If Skippy was my own dog, that's probably what I would do right now -- hold the trilostane altogether for the moment and see what effect that has. I don't know that an ACTH is urgently necessary because, as I say, it's hard for me to imagine that his cortisol is really too low. But if he doesn't bounce back to his previous baseline behavior by Monday, you'll need to consult with your vet as to next steps.

Honestly, I cannot disagree with Dr. Feldman' recommendation to switch to Lysodren in this situation. The trilostane has not been as effective for Skippy as is typically the case, and he may be suffering medication side effects in addition. Has Lysodren been mentioned as a possibility by any of your vets? If not, I would definitely discuss that option next week. If you did indeed make the switch, Skippy would need to be off the trilostane for around a month, anyway. So giving him a medication break this weekend wouldn't interfere with that game plan.

If Skippy worsens even more today, then certainly you'll want to consult with Purdue before the weekend sets in. But I'm hoping maybe he'll rebound a bit on his own today. Definitely keep us updated, OK?

Marianne

Hi Shana,
Thanks so much for your feedback and suggestion. I know it may seem like I am vet "shopping" but I was referred to Purdue by my local vet and they are supposed to be collaborating. (I am not so sure that is happening as I think they may disagree philosophically about dosing.) The problem is further complicated by the fact that Skippy's Stim tests keep going up in spite of increasing the dosage. Neither Purdue or the local vet seem to have a clue as to why that is happening. My question to the online expert was to try to answer the "why" of Vetoryl failing to reduce his cortisol and symptoms. But now I perhaps have a new problem and I will call and see if they will Stim him today.
Thank you again so much for your thoughts and recommendations. I have been up all night watching Skippy and am pretty stretched out with this. (He is sleeping and slightly trembling.)

I see that you, Shana, and I were all typing at around the same time, so I'll add this additional P.S. to what I wrote above. If it is not a problem for you to take Skippy in today for the ACTH and Purdue thinks it's a good idea, then yes, you can certainly do that. I would also have them check his electrolytes, as well. And then we can all go from there.

Marianne and Shana,
Thank you again so much for your counsel. I am especially grateful that you think it is unlikely that his cortisol has gone too low. He is up, quiet but all of his parts seem to be working okay and he is not begging for food. Checking his electrolytes is a great idea and I will call now and see what is possible regarding testing. Thank you again, you guys are incredibly knowledgeable and caring and I am so grateful.

I forgot to mention that yes, Purdue raised lysodren as a possibility early on after the adenoma appeared on his butt. They prefer trilostane and I have been reluctant to change until we exhaust vetoryl treatment and I have been plain scared of lysodren. I will begin reading as soon as I get thru today!

Update: I spoke with Skippy's local vet since she had prescribed the increased dose. She said to stop the Vetoryl for the weekend. She didn't think his cortisol was too low given how high it had been last week and the increase in Vetoryl was for only two days. She also didn't think that tremors were suggestive of low cortisol. (I told her that Drecha mentions tremors as one of the symptoms of low cortisol in their monitoring guidelines.) She did not think it was necessary to Stim Skippy today. She speculated that perhaps Skippy has been misdiagnosed and may have an adrenal or macro pituitary tumor (He's had two adrenal US's.) She also mentioned switching him to lysodren. I asked about checking electrolytes and she said that lethargy was the usual symptom, not tremors. (I reminded her that he was lethargic.) In the meantime, Skippy continues to lightly tremor, is very lethargic and will barely eat anything this morning. If Skippy appears to be getting worse, I will call her or Purdue and try to secure a Stim test. Again, thank you so much for your support and advice.

Carole, thanks for these updates. As I had written initially, I doubt that Skippy's cortisol is too low, either. But whether his blood chemistries may be off, I do not know. If he doesn't rally, that would actually be the blood testing I would be more anxious to perform, rather than an ACTH. In addition to his sodium and potassium levels (electrolytes), I would want to check his kidney, liver, and blood glucose values. All of those will be on a standard panel of blood chemistries. The importance of the blood glucose check is because dogs with consistently elevated cortisol levels are vulnerable to developing diabetes, and the onset can be quite rapid.

From what you are describing behaviorally, unfortunately I do think an enlarging pituitary macrotumor may be a possibility. Imaging of the head to evaluate the size of a pituitary tumor is something I'm certain that Purdue can do, but the downside is that a CT or MRI of the head is usually quite expensive. So if it hasn't been done recently, I do think the first place I'd look right now is a basic blood panel including both chemistries and also complete cell counts ("CBC").

Marianne

How is Skippy doing off the vetroyl this weekend? Has the tremors stopped?

Hmm, seems to be that Shana's furbaby Visuddha had his cortisol be within normal range but his electrolytes still became elevated so it is possible for electrolytes to be out of whack even if the cortisol is high or in range.

Yes all of Visuddha's ACTH results were within range (5.2, 3.4 and 4.3) but his Potassium was elevated (high normal to high) and Na/K ratio was low, so his dosage was repeatedly lowered.

How's Skippy doing today?

First, Skippy did rally on Friday after sleeping deeply but tremoring slightly for half of the day; he has done extremely well all weekend after stopping the Vetoryl on Thursday. He is eating and drinking normally for him - peeing and requests to go out are no more or less than on the Vetoryl regardless of dose. No tremors whatsoever; no sudden jumping around at night and inability to settle; no picking at the butt adenoma. Skip was willing to take three long walks on Friday, Saturday and Sunday afternoon, but he’s still doing that weird thing in the morning where he poops and refuses to walk further. He is still lethargic but was a little more interactive than earlier in the week.
Here’s the update on the medical front:
• Two calls from Purdue student, Jessica: On Saturday morning she called to check in on Skippy. I filled her in on the dose increase, severe tremors and withholding Vetoryl. After speaking with the resident IMS, Jessica called me back and said to put Skippy back on a dose of 20/20 for at least three or four weeks; she said that there are research studies that document that some dogs need a much longer time on Vetoryl in order to lower their cortisol to a therapeutic range. I asked her to email the studies and she said she would. She would not speculate on the cause of the tremors but said that perhaps the increased dose was too much. I asked about securing a blood panel and CBC but she said they don’t think that further testing is warranted at this time. They also think that getting cortisol under control is top priority versus addressing the adenoma.
• Local vet (whose vet training was at Purdue) called this morning as promised. She does not think Skippy has a macro tumor either but she’s never seen a dog react with severe tremors and lethargy when his cortisol is too high. She speculated that perhaps Skippy cannot tolerate Vetoryl and raised the idea of switching him to Lidoderm but stated that she had not used it “in years”. She thought because Skippy’s cortisol is down to 13, we could induct him beginning in a week or so, which I questioned. Regardless, I said I wasn’t ready yet to go that route and we finally agreed to start him back on 20/20. I inquired about diabetes or other sick conditions that might be affecting his behavior or cortisol. She responded that Skippy would be unwell, not eating, vomiting, lethargy, etc. She did agree to review the December bloodwork from Purdue. Perhaps best of all, she agreed to call the head of Purdue’s vet clinic, Dr. Scott-Moncrieff who has done extensive endocrine and Cushing’s research, to discuss and perhaps review Skippy’s medical history. Dr. Scott-Moncrieff supervised this local vet during clinical training and although there is a potentially awkward situation of going over the heads of other vets there, she is willing to do it.
• In the meantime, I spent my weekend digging through your archives and learned a tremendous amount and felt incredible sadness, awe and respect for all of you and your dogs who have struggled bravely and are still struggling with this vile disease. I learned, among other things:
A number of other dogs here have had severe tremors and lethargy. Can I call it The I Want My Dog Back Syndrome? I didn’t find anything about the cortisol too high after three months on Vetoryl.
That Carprofen is Rimadyl by another name; I threw the bottle away.
That Drecha had (has) a vet who sometimes will consult on dog’s responses to this drug.
I am considering insisting that someone run blood tests and CBC.
After medicating Skippy this morning, he is a little jumpy but no tremoring. Also, local vet office just called back to say that Scott-Moncrieff is not in “Clinic” this week and normally doesn’t do telephone consultations. But they will send his file to her and request a consultation. Sorry this is so long and my thanks, you are the best!