Newly diagnosed 7 1/2 year old Boston Terrier - precious Harold has passed

[Carrie loves Harold]

Hi,
My sweet 7 1/2 year old Boston, Harold, was officially diagnosed yesterday with Cushing's Disease. I first noticed increased drinking and urination over the summer, however, we were dealing with other health issues with him (in July he lost his eye to glaucoma) and since it was summer (hotter weather), I didn't think much of the increased drinking. I finally got a full bloodwork panel done on him in the fall (don't have the results of that, but do remember that the thyroid level was low and the urine was very dilute). The vet wanted to do more bloodwork to rule out Cushing's, which the vet thought was unlikely since Harold did not look like the "traditional" Cushing's dog. Unfortunately at that time, Harold was on a prednisone drop for his eye, so we had to discontinue the drop and wait 6 weeks before we could run the test. Harold stayed with family for 6 weeks over the holidays due to personal circumstances and my traveling and when I came to pick him up he had gone way downhill. He was very lethargic, having accidents in the house (he was potty trained within 3 weeks of my getting him as a puppy and never had accidents in the house), and just wasn't my Harold. He also had blistering, peeling skin on his belly. I took him to the vet ASAP and we did the low-dose dexamethasone suppression test on 1/14/2014. The results were 2.9 at the start, 2.4 at about 5 hours, and 2.4 at about 8 hours. The vet wanted to have Harold come back in for an ultrasound to confirm the diagnosis, which he did yesterday. The ultrasound was consistent with a diagnosis of pituitary-dependent hyperadrenocorticism since his adrenal glands were enlarged, but with retention of normal shape (e.g., no indication of tumors on the adrenals). He also has some "mineral foci" in his kidneys and "small cystic calculi" in his bladder, which the vet said was likely secondary to the Cushing's disease.

Sorry for all of the info, but in the other posts I saw, people were always asking for the specific information related to the disease, so I figured I would post it proactively.

I started Harold on his first dose of Trilostane about 7 hours ago. He is getting a 30 mg capsule once a day and he weighs 24.3 lbs. (I am pretty nervous having him on the drug, but if it brings Harold back to me, it will be totally worth it!)

The couple of questions I have for the more experienced owners out there are:
1) On average, how long did it take before you saw an improvement after starting the Trilostane (specifically, how long did it take before they started acting like themselves and when did the increased urination stop)
2) Have you noticed tremors/shaking in your dogs? Harold has a pretty regular tremor even when he is not under stress. Is this common with Cushing's? The vet has mostly overlooked this concern when I have brought it up.
3) Have you heard of/had any experience with using melatonin in addition with/or as a substitution for the more traditional medications for Cushings?
4) Any dietary recommendations or other recommendations for taking care of a Cushing's dog?
5) Anything that I should be watching out for with the Trilostane?

Thank you for any feedback and advice you can give. I am pretty new to this diagnosis and want to provide the best care I can to my little pup, so any help from more experienced owners would be greatly appreciated.

Carrie P. and Harold

[doxiesrock912]

Welcome Carrie and Harold,

Cushings is really unique for each dog. Some see improvement within days, weeks, and even months.

If Harold becomes lethargic. has diarrhea and/or vomiting, eats less or not at all and the same with water intake - these are signs of Addison crisis which means that his Cortisol has dropped too low and that the prescription is too high. If any of this happens, stop giving the medicine immediately and call your vet.

In the beginning of treatment, monitoring is essential to be sure that you have the correct dosage. It could take several tries before finding the right one.

It is best to start low with Trilostane and work up from there. Many dogs do better with giving 1/2 of the recommended dosage twice a day, twelve hours apart with food. ALWAYS give it with a meal to ensure proper absorption.

Tremors are concerning, especially since you've just begun treatment and I would insist that your vet find the cause.

Educating yourself is key to this and I encourage you to read through the information in the "helpful resources" section on this forum.

If you post all of the results along with their normal ranges here, there are several people who are great at interpreting them for you here.

[Renee]

I'm definitely not one of the experts... but, I can answer your questions from my perspective.

I saw symptoms somewhat resolving within the first week, especially around the 10 day mark, I saw a big improvement in personality. Then, they kind of rebounded and came back somewhat. After a month on her initial dose, we increased by 10mg. I think the safest way to increase is in 10mg increments. We have done one increase so far, and plan to recheck in two weeks before considering another increase.

I have not noticed tremors, but you should definitely bring that up. I have not used melatonin either.

I think that diet is very specific to the dog, although lower fat food may be a good consideration because cushings dogs can get pancreatitis.

Did you have an ACTH done before starting the vetoryl? It is good to establish that baseline before starting the treatment phase.

[Harley PoMMom]

Hi Carrie,

Welcome to you and Harold! So sorry for the reasons that brought you here but glad you found us. Thank you for giving us such detailed information about your sweet boy.

I started Harold on his first dose of Trilostane about 7 hours ago. He is getting a 30 mg capsule once a day and he weighs 24.3 lbs. (I am pretty nervous having him on the drug, but if it brings Harold back to me, it will be totally worth it!)

Although 30mg is a reasonable dose for Harold's weight of 24.3 lbs we have seen that dogs have the minimal side effects when started at the lower end of the dosage scale, say 1mg per pound. Did Harold's vet prescribe any prednisone to keep on hand in case of an emergency?

The couple of questions I have for the more experienced owners out there are:
1) On average, how long did it take before you saw an improvement after starting the Trilostane (specifically, how long did it take before they started acting like themselves and when did the increased urination stop)

The increase in drinking/urinating should abate within 2 weeks. Improvements to skin/hair issues can take much longer.


2) Have you noticed tremors/shaking in your dogs? Harold has a pretty regular tremor even when he is not under stress. Is this common with Cushing's? The vet has mostly overlooked this concern when I have brought it up.

We have occasionally seen tremors/shaking in dogs that are taking Trilostane. Trilostane is the active ingredient in Vetoryl, Dechra is the manufacturer of Vetoryl, and muscle tremors are listed as a side effect on Dechra's product insert. Link to the product insert: Dechra's U.S. Product Insert

3) Have you heard of/had any experience with using melatonin in addition with/or as a substitution for the more traditional medications for Cushings?

Usually melatonin along with lignans are used for the treatment of Atypical Cushing's. Atypical Cushing's is when one or more of the adrenal sex hormones are elevated but the cortisol is not. Although melatonin and lignans do have cortisol lowering abilities they can not decrease a dog's elevated cortisol to within the therapeutic ranges.

4) Any dietary recommendations or other recommendations for taking care of a Cushing's dog?

Dogs with Cushing's can be predisposed to pancreatitis so a diet that has a high quality protein with moderate fiber and is low in fat may be better suited for a Cush dog. Also high blood pressure is common and should be checked for.

5) Anything that I should be watching out for with the Trilostane?

Hypoadrenocorticism (too low cortisol) can develop at any dose of Trilostane so the side effects need to be watched for. These side effects are but not limited to: lethargy, vomiting, diarrhea, or Harold just not acting himself. If any one of these are noticed a trip to the vets is needed.

It is very important that the Trilostane be given with food especially the day of any monitoring ACTH stimulation test. Also very important is that the ACTH stimulation test be performed 4-6 hours after the dose of Trilostane is given.

Thank you for any feedback and advice you can give. I am pretty new to this diagnosis and want to provide the best care I can to my little pup, so any help from more experienced owners would be greatly appreciated.

Carrie P. and Harold

We are here to help in any way we can so do not hesitate to ask any questions you have. Also, here's a handy link from our Resource Thread with info regarding Trilostane/Vetoryl: Trilostane/Vetoryl Information and Resources

Hugs, Lori

[Carrie loves Harold]

I did not have a baseline ACTH stim test done at the start because my vet did not recommend it.

The tremors/shaking have existed long before he was diagnosed with Cushings, so it isn't a side effect of the medication. I have noticed the shaking for a couple of years. It may be an anxiety thing because it usually resolves if you distract him or pet him? Not really sure though.

The vet did not give me an emergency dose of prednisone/steroid, however, I live very close to his vet and also to two emergency vets, so I am not too concerned about getting him quick treatment if he starts having issues. One question I do have related to the potential drop in cortisol is how quickly these symptoms are typically noticed? I am currently in class from 8 AM to noon M-F and have to take the bus to class, so he is typically alone from 7 AM to 1 PM. My concern is if he starts having the symptoms while I am at class is it going to be life threatening to leave him alone or should he be okay as long as I get him to the vet as soon as possible after I return?

I am really glad I found this site! It's nice to know that despite the terrible circumstances that have brought us together, at least we are not going through it alone! Thanks for the warm welcomes so far. Harold and I both appreciate it!

[doxiesrock912]

Carrie,

Daisy has had a reaction a few times and it usually happens within the first few days or the first week.

[Harley PoMMom]

After giving the dose of Trilostane, peak concentrations are seen within 1.5 hours and it can take up to 18 hours for it to totally leave a dog's system. So usually, after Trilostane administration adverse side effects are seen within 2 hours.

Hypoadrenocorticism can be life threatening so it is imperative that when symptoms of too low cortisol are displayed that the dog be seen by a vet. Not only can the cortisol drop too low but sometimes the electrolytes can become imbalanced, principally aldosterone, in this case not only does the dog need some kind of supplemental steroid but also mineralocorticoid.

I really do not think that at 30mg of Trilostane that Harold will have an Addison's crisis, and it is not my intention to scare you. But like I mentioned before, Hypoadrenocorticism can happen at any dose of Trilostane so I just want you to be aware of this, ok?

Hugs, Lori

[Renee]

I stayed home from work for the first 10 days of vetoryl dosing. I am sure it was overkill on my part, and we started at 20mg per day for a 19 pound pug, which is at the low end. I am not saying you should stay home for that long, but I think staying for the first few days is not a bad idea.

Are you dosing in the morning with Harold's breakfast?

[Carrie loves Harold]

Thanks for all of the advice. I have actually been trying to give the dose around 1 PM when I get home from class so that I can be here with him for the rest of the night to watch him. I give him a smaller than normal breakfast and then give him more food at lunchtime when I give him his pill. I make sure that he eats the lunchtime food prior to giving his pill as I know it is supposed to be given with food. I know that you should give the pill in the morning, but the only way that I will be able to watch him after the dosing is giving it at 1 PM. Do you think this is a problem?

He did fine through the night after his first dose. Woke up this morning and his stool was normal, appetite was normal, etc. so I am staying positive!

Thanks for all the advice and encouragement!

[labblab]

Depending upon your vet's office hours, the 1:00 dosing could present a problem for the monitoring ACTH stimulation testing. It is very important that all subsequent monitoring tests be performed within the same time frame so that you are comparing "apples-to-apples" with the results.

Dechra, the manufacturer of brandname Vetoryl, recommends that the tests be performed 4-6 hours after dosing. Some specialists opt for an earlier time frame of 2-3 hours after dosing in the desire to catch the cortisol level at its very lowest after drug administration. Either way, you will want to establish a consistent schedule with your vet and continue to adhere to it. So if your normal pattern ultimately will be to dose earlier with breakfast, I'd probably go ahead establish that regimen now. It is really unlikely that your dog will have a reaction to the trilostane serious enough that you cannot wait to deal with it a few hours later when you arrive home after class.

Marianne