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

Hello to all and thank you for this forum; I am exceedingly grateful for your knowledge and counsel on behalf of those of us who are struggling to understand this devastating disease. My dog Skippy, a nearly twelve year old Yorkie, has been diagnosed with Cushings. He is symptomatic, i.e., PU/PD, aggressive eating, significant lethargy, the classic pot belly and some weakness in his rear legs. Skippy's blood chemistry is "normal", and an ultra sound of his adrenals revealed one adrenal is enlarged with an adrenal tumor and the other is "slightly smaller". The ACTH failed to confirm whether the Cushings is pituitary or adrenal related. I believe his numbers were 4.6,5.4 at 4 hours and 3.6 at 8 hours. My vet has ruled out diabetes and renal failure. While I have read an exhausting number of articles, I am uncertain as to what I should do next and still don't know what I don't know. My options appear to be to start him on Vectoryl/Trilostane to see if the drug "works" or take him to Purdue University for a second workup and MRI? (The initial cost is estimated at approximately $1,500). (Purdue is a vet teaching hospital but they do not specialize in endocrinology as far as I can determine.) I don't know if he is a candidate for surgical removal of the adrenal gland and/or if I would subject him to surgery despite the cost.

I would appreciate any feedback that you all can offer. Should I ask the vet to perform the LDDST? I don't believe he has hypertension or proteinuria, but I will double check.

Thank you for any advice that you might offer.

Hello Carole, and welcome to you and Skippy. As you'll see, I'be moved your reply so as to create a thread that is your very own. This way, it will be easier for our members to reply to you directly. ;)

First of all, it appears that Skippy's diagnostic blood test was actually the LDDS and not an ACTH. The LDDS involves a baseline blood draw and then subsequent draws at the 4 and 8-hour marks. The results you report for Skippy are consistent with both the LDDS protocol and also with a dog who suffers from an adrenal tumor as indicated by the ultrasound imaging. So it would seem to me as though you do have the diagnosis in place, unless your vet is somehow questioning the accuracy of the ultrasound.

It is rare, but possible, for a dog to suffer from both a pituitary and adrenal tumor. When you speak about the $1500 estimate for an MRI, is that referring to imaging of the head to establish whether or not there is also a pituitary tumor? Or are you seeking more detailed imaging of the adrenals? I would not think that additional abdominal imaging would be that expensive, and in honesty, I believe I'd choose to invest my money in additional adrenal diagnostics since a tumor is known to be there. Depending upon the clarity of the initial imaging, you may want to seek another view along with the advice of a board-certified surgeon. Adrenal surgery is always a very serious undertaking, but the exact size and location of the tumor can greatly affect the risks and time frame for intervention.

There's much more we can talk about, but I'll quit for now and await your reply. Once again, welcome!

Marianne

Marianne, thanks for your quick reply. My vet is scheduled to call me at noon today. I will seek answers to the issues you raised and clarify the testing issues. I presume that if he had the LDDST as you stated, there is no reason to perform the cortisol test. I will reply with additional info about the proposed MRI shortly. Also, Skippy, a Yorkie mix is 12 not 15.
Thank you again for your help.

Carole

Whoops, so sorry about prematurely aging Skippy!! I've now edited his age so it should be correct.

And yes, given a "positive" result on an LDDS in conjunction with an adrenal tumor viewed on ultrasound, I don't think I'd spring for an ACTH right now unless it was desired in order to provide a baseline cortisol reading prior to beginning Cushing's medication. In terms of diagnostics, the ACTH often provides a "false negative" result when adrenal tumors are involved. In other words, the ACTH will fall within normal range even though an adrenal tumor may be causing hormonal abnormalities. So the LDDS is actually the better diagnostic blood test when an adrenal tumor is suspected. However, regardless of tumor type (pituitary or adrenal), the ACTH is the blood test that is used for subsequent monitoring of medication's effect on lowering cortisol levels. So for that reason, some vets prefer to document a baseline ACTH level before treatment begins, in addition to the LDDS.

Marianne

Thanks again Marianne for your reply. I spoke with Skippy's vet yesterday and ultimately I decided to proceed with an MRI of Skippy's adrenals before trying medication. The vet thinks Skippy is in excellent health and that he is very "early" onset Cushings. His enlarged adrenal is.9.7 centimeters; the other plump adrenal is .7 (If I recorded her statement correctly.) She said the tumor has not invaded Skippy's vessels and the tumor itself may be hyperplastic. She believes that further imaging of the adrenals will clarify treatment options so off to Purdue he goes as soon as I can secure an appointment.

If they recommend surgery and pursue that course of action, would it mean that Skippy will be on cortisone for the remainder of his life?

Skippy does not appear to be in pain; he is more like a chubby lump, very lethargic and disinterested in life beyond drinking, eating and peeing. The change is shocking as previously he was hyperactive, constantly playing and wanted to be outside every hour of the day.

I will update this post when I learn more. Thank you.

Skippy is scheduled for a consultation next Monday. I will post again when I know something more.

Carole, I'm hoping you'll gain some really valuable information from the consultation. One of our members has compiled a very helpful list of questions to ask when considering adrenal surgery -- I can't seem to find it right now :o, so I'm hoping one of other staffers will add it here for you, or else I will hunt again a little later on. Either way, we'll make sure you see the list before Monday.

Also, most dogs do not need steroid supplementation long-term after successful adrenal surgery. The remaining adrenal gland typically ends up being capable of producing sufficient hormonal reserves all on its own.

Marianne

I searched under "adrenal tumor" and found the article you referenced. It is indeed very helpful. Thank you and I will post the link when I have a second.

Hi Carole and welcome to you and Skippy.

I believe this is the list of questions that Marianne was referring to and you probably found. I'll post it here so it is easy for you or someone else to find

Quote:

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Part I - Questions to ask when considering if surgery is an option for your dog’s adrenal tumour:
1. What type of tumour do you suspect, ?functional, ?non-functional, pheochromocytoma, benign, metastatic
2. Expected life span for my dog in a normal situation. If your dog is close to, at or past his expected lifespan for his breed is surgery going to be of any benefit?
3. Prognosis for my dog if we treated medically i.e. with Cushings medications. AND if we do not proceed with surgery how long do you think it would be before the tumour started adversely affecting his quality of life?
4. If he is miserable now, does the benefit of potentially risky surgery outweigh his current quality of life?
5. Are there any other health problems that could impact on a positive surgical outcome, for example: if your dog is overweight or has heart, BP, liver, kidney or lung conditions
6. Is there any sign of tumour spread – imaging should be done, including ultrasound and on advice of specialists either CT or MRI to check whether there is local invasion around the tumour, into blood vessels including vena cava or spread further away in the body to lungs etc
7. Surgeon recommendations – would he/she do it for their own dog?
8. Psychological impact for the owner: It is important to understand this is risky surgery, sadly current guidelines indicate 1:5 dogs do not make it, and some recommendations are not even that high. Can you accept it if your dogs dies during or in the postoperative recovery period surgery? This is where it is important to weigh up whether the benefit of your dog being fully cured is worth the risk of possibly losing him.
9. Financially – can you afford it? Find out estimate of costs.
10. Hopefully this will not happen, but if your dog collapses, e.g his heart stops either during his surgery or afterwards what emergency measures should be undertaken, do you want your dog to have CPR, how far are you (the owner) willing to go for your dog to be saved in such circumstances

Part II - Surgery has been recommended as treatment for your dogs adrenal tumour, here are a few suggestions on what questions you should ask your surgeon:
1. Are you board certified? How many operations of this type have you done? What complications have you experienced? What were the outcomes?
2. Please explain to me how you will do the surgery, which part would likely give you the most trouble? Will you be doing the actual surgery or a resident in a teaching situation? If so, is their close supervision?
3. Will there be a specialist anaesthetist available for the surgery?
4. If it hasn’t been done, do we need a CT/MRI scan to look at the tumour more closely to check for vena cava involvement or any other tumour spread?
5. What are the risks associated with this surgery, including
• Bleeding (including trauma to blood vessels or other organs during surgery)
• clots
• Blood pressure or heart problems such as arrhythmias
• pancreatitis
• pneumonia
• kidney failure
• infection
• wound problems
• bowel problems
• anaesthetic risks
• adrenal insufficiency or electrolyte abnormalities
• death (sorry but you have to ask that risk too)
6. If we proceed with surgery does my dog need preoperative treatment with Cushing’s meds, antihypertensive if high blood pressure is a problem – phenoxybenzamine recommended preoperatively for dogs with pheochromocytoma, anticoagulants or anything else?
7. How will you treat to prevent clots postoperatively?
8. What would you do if you found anything else during the surgery i.e. nodules in other organs e.g. spleen, opposite adrenal, liver, kidney. Would you remove them and what are the risks associated when doing additional abdominal surgery together with adrenalectomy
9. How long will it take and when will you contact me so I know all is OK, when can I visit after surgery?
10. How will the postoperative period go, how long would you anticipate he would need to stay in hospital? How will we manage pain?
11. What monitoring would be needed, e.g. heart monitoring, oxygen levels in the postoperative period
12. If your dog has an adrenocortical tumour affecting cortisol production will he need to be on steroids following surgery and for how long?
13. If there are problems when I take him home, who do I contact? Hopefully the surgical team until all is stable.

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I think you'll know more after the consult at Purdue. Surgery is always a risk, so any information is always helpful in making a decision on what step to take.

As Marianne stated quite often after having an adrenal gland removed, the other one kicks in and no further medication is needed long term.

I am posting a follow-up to my earlier posts with the hope that some may find it helpful.

On 12/4 Skippy had a complete work up at Purdue (excluding neurological). They kept him overnight and did a second ultrasound and an additional test similar to the ACTH stimulation. They did not believe that the adrenal gland was tumorous and diagnosed pituitary cushing's.

Skippy has been on a regimen of 10 mg Trilostane twice daily since 12/6. On 12/19 they reevaluated and tested ACTH levels. I can't remember the pre test number but the post test was 7. something. (I will secure a copy of his test results and post them.) Purdue sustained the dosage at 10 mg twice daily.

The vets at Purdue seemed most concerned about clinical symptoms of peeing, drinking and eating. Clearly there has been a significant reduction in the first two. Not so much on the eating front as he had gained a pound between visits. I am concerned that I am seeing very little improvement in other quality of life and physical appearance symptoms. Skippy's belly remains very bloated, skin and fur still thin and his hair is not growing back. He is very lethargic, has muscle weakness in rear legs, a sore on his shoulder and an external tumor on his anus that bleeds and collects feces. (They aspirated the tumor and think it is probably benign; they speculated that it may be caused by Cushing's and will diminish in size with treatment.) Skippy will take short walks and yesterday was willing to play with a toy for a couple of minutes. However, he is now shaking when I put him in the car or try to bathe him. (The shaking first started right before diagnosis and has continued.) His legs shake when he squats to poop.

So, I am pretty disheartened after 25 days of treatment. Skippy will be retested on 1/23. Purdue did not do an MRI as they felt confident in their diagnosis. I will post his numbers when I secure a copy and provide updates as it seems appropriate. I know that reduction in symptoms takes time but I am so concerned that his quality of life sucks and will not improve.

But, tomorrow is a new year and hope springs eternal.

Best,

Carole

Welcome back, Carole, and thanks so much for this update. I'm glad to know that you are seeing improvement in Skippy's thirst and urination. Unfortunately, improvements in some of the other symptoms such as skin, coat, muscle weakness, etc. usually take a significantly longer time, even when cortisol levels are optimal. I tell you this, actually in the hope of offering encouragement. I know how upsetting and frustrating it is to await positive changes, but I want to reassure you that it is not abnormal to have to await some of these improvements. It doesn't mean the medication is not working, just that it will take some time.

Having said that, I am thinking you could ask to push up the date of Skippy's next monitoring ACTH if you are feeling really impatient about his results. It looks as though Purdue is waiting for a full 30 days after the first monitoring test (which was done at the two-week mark). Perhaps they feel this will give Skippy a better chance to stabilize on his current dose before assessing the need for a dosing change. But many clinicians follow Dechra's published recommendation to retest when the first 30 days of treatment has been completed. So that would be in just one more week for Skippy.

Personally, I might go ahead and wait until the 23rd myself, especially since you are indeed seeing some outward improvements. But I just wanted to mention retesting sooner as an option for you to consider if you become too worried about some of Skippy's symptoms.

Either way, we'll remain anxious to read your updates!
Marianne

P.S. You'll see I've edited your thread title to reflect Purdue's revised diagnosis and Skippy's treatment. ;)

Thanks Marianne, I am going to wait until the 23rd for the second ACTH test. I just read some research out ofa Davis study that said they used a standard of a 5 or less cortisol level as their standard for effective treatment' I think waiting longer will secure a more accurate assessment of how Skippy is responding to the 20 mg Trilostane.

I am concerned about the tumor on his anus as it began bleeding again last night. I have been treating it as if it is a wound but it does not seem to be healing. (Maybe the Cushings is causing slow healing.) He really, really doesn't want me to touch it so I'm spraying with a medication that is supposed to be healing and non-stinging. If anyone else has experienced the anal tumor condition, that was determined to be Cushings related, I would welcome hearing more about your experience. Purdue said that external anal tumors are common in non castrated males, but Skippy is castrated. They suggested that treating the Cushings might shrink the tumor.

Anyway, again and simply, thank you for sharing your knowledge, experience and support.

Hello Carole. high cortisol can cause healing to be slower. I don't know that I've ever heard of a tumor shrinking as cortisol gets to more optimal levels. What it does do is make it better for surgery to remove the tumor, which is probably what will need to happen. This is just a guess on my part and is something that you should probably discuss with the vet. Any risks to having it removed, etc. Did they biopsy it to confirm it is benign? I think I would want to know for sure.
I think that we are thinking the same thing, that bleeding tumors are not good and cannot be comfortable and there is a high risk of infection due to the location and fecal matter getting into the tumor.

In reading through the threads I observed that many of us are struggling with the lack of improvement in symptoms after beginning Trilostane treatment. After 35 days of twice daily treatment with 20mg of the drug, Skippy continues to show minimal improvement. While peeing/drinking are reduced, all of the other symptoms, lethargy, bloating, trembling, hair loss, weakness in his back legs are unchanged. It would be wonderful to hear from others of you whose dogs have responded/or not to treatment. When did you begin to see changes? Are some of the symptoms permanent? What kind of quality of life does/did your dog have? I feel like I am torturing Skippy right now. This drug must work for some dogs or everyone would not continue to subject their dogs to it. Thanks in advance for your feedback.

Hello! :) My dog has probably been on vetoryl for 5-6 months. I have not noticed much change at all in his belly, but one doctor told me in his experience their bellies dont reduce in size much, if at all, and another told me it takes time and is different with each dog. He has continued to lose hair. He is pretty lethargic as well. His legs will sometimes tremble as well and there does seem to be muscle loss. At times, I wonder what I'm spending so much money on medicine and testing for...however, I know it's the right thing to do. He's had very good ACTH numbers so he is responding to the medicine well. It's just kind of disheartening. I know I should probably get diabetes and thyroid testing (but those were fine when we last got him tested for it), but I don't have the money.

I want to add that hes either 14 or 15+. I think a lot of this has to do with age. Probably slower recovery just like a person since he's older and also just general decline in health. Not to say that he's not happy; I truly believe he is. He plays and eats and drinks and does all the stuff he is supposed to do, but I sometimes have to remind myself he is a very old dog and it can't all be because of the Cushings. Sorry for the disjointed thoughts! I just wanted to chime in because you asked and give my perspective. It's a long, weird, uncertain journey, but you've taken the right steps and are doing everything you can. I'm praying for you and your dog and hoping for the best! :)

My dog never lost her belly, she always had a round, rubbably belly. Her rear leg weakness never really got better either, but we adjusted by putting doggie steps up to the window seat and lifting her to the couch when she wanted up and she'd bark if she needed a lift down. If she didn't feel up to a step, she'd stop in front of it and wait for her "lift" (yes she got to know that word well) and if she felt good, she bounce right up the stairs no problem.

I think that the adjustments we made for her gave her a good life for several more years and that the medication (she was on trilostane) helped too in that her liver didn't get worse. She managed to rule out world like the diva she was with no problem till the very end.

Hi Sharlene,
Thanks for replying to my questions. I posted in response to Jane and Jess and will post Skippy's numbers from the ACTH tests tomorrow. Purdue aspirated Skippy's perianal tumor in December - no biopsy. They suggested I just remove the thing then as it is likely benign. Today, they were suggesting that I consider Mitotane instead of Trilostane as it might "shrink" it. Also, the Resident was going to consult with their expert in-house at Purdue as she had not seen this problem. Their estimated fee for removal is a hefty $1,500 and the Resident said that if it were her dog she would want a Board Certified Surgeon to do the surgery. I must be brain dead as I had not considered the possibility of infection, duh! I will follow-up tomorrow. Thanks so much, Carole

Hi RandomGuy,
Your reply is very helpful to me and I thank you. Skippy just turned 12 and before diagnosis was very active, if not wild. I too wonder how much is age, maybe some neurological changes, etc. The suddenness of the changes in his personality and physical condition are startling and saddening. But at least you help me undestand what I may be up against. Thanks again, Carole

I would Only ever want a board certified surgeon, as there are risks with any surgery so anything that can lower the risks is good.

Skippy was seen on 1/23 and I finally received the results today. Also, I secured a copy of his 12/19 results. Here's the update:

12/19/16
Pre Test Cortisol - 2.2 (Reference range 1.0- 6.0) Marked Lipemia
Cortisol (1hr post) - 10.8 (Reference range 7.0 - 17) Moderate Lipemia, Slight Hemolysis

1/23/17
Pre Test Cortisol - 6.3
Cortisol (1hr post) - 16

I haven't actually spoken with the Dr.; the student relayed this info and as I expected they want to increase the Trilostane dose from 10mg morning and evening to 15mg morning and 10 in the evening. Additionally, we discussed the perianal adenoma at length. They think Skippy may have Atypical Cushings in addition to Pituitary Cushings and are offering to run a panel to assess. I have stated pretty firmly that I'm not prepared to switch Skippy to Mitotane at this point. So I asked if there are other treatments (in addition to surgery, which may lead to the return of the tumor) to address the Atypical symptoms. The student didn't know. In respect to the tumor bleeding and the possibility of infection, the best she could offer was that it is not currently infected. I did ask about supplementing Skippy with Lignans and Melatonin but she didn't know about that either.

Clinically, Skippy is barely improved by my assessment and greatly improved by theirs, mostly because of the reduction in PU/PD. He continues to be extremely lethargic, barely interacts and this morning refused to walk and ran back home in fear. Yesterday and several other times he turns around and falls down; he stares off in space sometimes like he is disoriented. Except for his ravenous appetite I could be a lamp post or fire hydrant.

I will schedule the surgery because I am terrified that the tumor will become infected. However, I feel that my interaction with the staff at Purdue is troubling. On Monday, I waited four hours to complete the Stem test; the vet was to call me yesterday with results, but no call; I called them at noon today and was told the vet would call me back shortly but that Skippy was "fine" . I called again late this afternoon and spoke with the student who couldn't answer many of my questions. They were supposed to have a surgeon look at Skippy's tumor on Monday; it didn't happen. I am losing confidence that they are sufficiently professional and knowledgeable about Cushings to appropriately treat Skippy and he continues to suffer. I know that they have senior staff there who are endocrinology experts but I don't know how to get to them. So frustrating and scary.

Molly, I get it about the Board Certified Surgeon. Skippy has enough problems! Thank you.

I spoke with the student at Purdue again today and she tried to answer my questions. She said that they recommended the Atypical Cushings test; they could offer no opinion as to whether the tumor will or will not return when removed but the cost is now 1 to 3,500k and that they hope the increased dosage to 15/10 will improve Skippy's response. They had no opinion on herbal treatments and no idea of what other conditions might arise if Skippy has Atypical Cushings and Cushing's. Just shoot me.

Omigoodness Carole, I feel your pain! I wish I had more time to post right now, but I'll have to wait and come back at a later time to add some thoughts. Hang in there, but I totally get your frustration. :o :(

Marianne

Skippy continues on the Cushings Merry go round; today I took him back to the local vet for a consultation and a look at the adenoma on his butt. The vet is of the opinion that the Trilostane dosage is still too low at 15/10 for the past four days; she said to at least increase to 15/15 which would be in accord with the current Drecha guidelines as Skippy remains at 29lbs. So today I will up the dosage. Overall, she would be inclined to increase the dose even more. The vet did not think Skippy needs a sex steroids test - yet. And, she thought we should try to get the Cortisol under control before addressing the adenoma. I feel a little like I am vet opinion shopping right now and I don't mean to do that. But, I am looking for some symptomatic relief for Skippy. After nearly two months, Skippy's cortisol on the 1/23 stim test was higher than the two week stim test (pre 2.2 and post 10.8), i.e., pre - 6.3 and post - 16. He remains quite shaky,belly still bloated, no hair growth, lethargic, does not want to be outside, runs back in after pooping, no interest in playing, appears fearful and is still ravenous. I did order Melatonin and Flax and will start that soon but his butt problem aside, I am at a loss. Oh, yes peeing and drinking has lessened. Please let me know if you think I'm being too demanding or unrealistic. Thanks everyone.

Of course you are not being too demanding or unrealistic. You are trying to find answers. With the post number continuing to increase, the increase in medication seems to be warranted.
I do wish that he seemed to be feeling more like his usual self. Maybe the melatonin and flax will help.

Four days ago, we upped Skippy's Vectoryl from 15/10 to 15/15. Today for the first time in over four months, Skippy is beginning to return to his previous self. He is alert, interacting and sleeping less. No, no hair regrowth; yes, he's still very hungry, but the trembling is mostly gone and he's a little sphinx arising from his own ashes. I am so relieved and very happy that he may actually live with this awful disease. I thought that such a day would never come and I have learned so much from all of your experience, experiences and knowledge and am truly grateful.

Wow, cross fingers that this is the right dose and Skippy continues to get better and better.

Sharlene,
I should have know better than to speak too soon; Skippy had a diarrhea attack on his walk this morning - not a horrible one but definitely very soft stool. Called the vet who said that she couldn't imagine that a 5mg bump caused this. She put him on Imodium 3X a day and a bland diet for the week end. He seems to feel fine and I just took him for a good walk but no poops. I hope this is the right decision as I really don't want to stop the Vectoryl after he's finally responding. I will watch him like a hawk. This vet's opinion of dosing is much more risk taking than Purdue (She told me that their practice just put a 12lb dog on 30mg of Vectoryl.) I'm not sure that is a good thing after all I've read on here about low and slow. But, if I can't get the diarrhea stopped soon, I will stop the drug. Anyway Skippy will be ACTH tested next Wednesday.

The final thing: Skippy's high numbers on the last test on 1/23 (pre - 6.3 & post -16) may be incorrect since Purdue told me to fast him for the test. I challenged that and they said to just feed him enough to ingest the Vectoryl. I fed him a little more than that because I didn't know any better. But, now I wonder if the drug was absorbed? Maybe you all could put together the latest research, Drecha's new recommendations, etc. and we all could start leaving the info with vets as we come into contact with them. Or you could get a grant and create an e-book! Just a thought and thanks again.

Hi Carole,

First of all, you absolutely need to feed Skippy a full meal when you give him his Vetoryl. This includes the day of the ACTH test. You also want to be consistent about the timing of the test, so you can compare apples to apples so to speak. Do you know how many hours after you gave Skippy his Vetoryl they started each of the tests?

Shana

Quote:

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Originally Posted by Carole Alexander

After nearly two months, Skippy's cortisol on the 1/23 stim test was higher than the two week stim test (pre 2.2 and post 10.8), i.e., pre - 6.3 and post - 16.

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Quote:

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Originally Posted by Carole Alexander

The final thing: Skippy's high numbers on the last test on 1/23 (pre - 6.3 & post -16) may be incorrect since Purdue told me to fast him for the test. I challenged that and they said to just feed him enough to ingest the Vectoryl. I fed him a little more than that because I didn't know any better. But, now I wonder if the drug was absorbed?

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As Shana has mentioned, it is critical that the Vetoryl be given with a meal to be properly absorbed.

We have a wealth of information regarding Cushing's; the medications used and the treatment protocols, that can be found in our Helpful Resource Forum and it also includes articles written by some of the most renown veterinarians that specialize in endocrinology such as David Bruyette, Mark Peterson, and Edward Feldman. In this forum you will find a thread that pertains to Vetoryl/Trilostane so please utilize it and if you have any questions do not hesitate to ask them. ;)

Here's a link to our Helpful Resource Forum Helpful Resources for Owners of Cushing's Dogs

And to the Vetoryl/Trilostane thread: Trilostane/Vetoryl Information and Resources

Hugs, Lori

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.

Lori, I agree that there is a wealth of information on this web site and I applaud you all for bundling the research. Certainly, I could have done more reading at the outset, but I am not the doctor. And, the devil is in the details. For example, I read that there are two different products used for ACTH testing. 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? 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. I could offer additional examples but my point in my earlier post was that vets and their staff need to be better informed about Cushing's and best practices in diagnosis, treatment and testing. Recommendations from the researchers seem to be clear, compelling and most importantly, evidence-based. And yet...

Quote:

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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.

Quote:

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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.

Quote:

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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:

Quote:

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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?

Quote:

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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,