Yogi has crossed the Bridge - questions about Trilostane

[AngieB]

Sorry for any confusion. The testing would be to confirm diagnosis, not to do the ACTH stimulation test. I talked with the ICM. They do not automatically go with the first vet's diagnosis, and will evaluate the test results to date and then determine if they want to test anything independently before giving their own diagnosis.

If the ICM wants to do additional testing to confirm diagnosis, Yogi taking Vetoryl a week before could impact bloodwork. So, I decided to hold off on giving additional Vetoryl until the ICM confirms diagnosis this week (Yogi has had only 1 pill to date). If the ICM agrees it's Cushing's, I can start Vetoryl this week at the ICM's recommended dosage level, then schedule the ACTH test.

Angie

[Harley PoMMom]

Thanks so much for the clarification. When you get the results of the tests that the ICM wants to perform could you share those with us, please? And good luck!

[AngieB]

Thank you. I will! It's such a comfort to be on this forum.

[AngieB]

Yogi was seen at NC State Vet School Internal Medicine (NCSU ICM). Based on the prior bloodwork and ultrasound, they suspect he is Cushinoid (Cushing's). However, they have concerns about some of the test results that are atypical, so performed additional bloodwork and also a vector borne panel. Two test results are pending and should arrive next week.

Problems & Diagnoses: suspected pituitary dependent hyperadrenocorticism & decreased platelets

Meanwhile, I am tracking his food & water intake and urine/stool. NCSU ICM started him on 30 mg every 12 hours of Vetoryl, and other than appearing sleepy & tired, seems to be tolerating it. He will have an ACTH test scheduled on day 11 of the Vetoryl at my regular vet (NCSU ICM is booked). NCSU ICM will adjust meds pending test results and he will be seen on day 20 of the meds for a follow up exam. ACTH test is also scheduled for day 32 of the Vetoryl (holidays).

Results are below. I have it in excel, but the table format didn't copy so have bolded anything LOW or HIGH.

GLUCOSE 87 MG/DL 70-131
UREA NITROGEN 10 MG/DL 6-26
CREATININE 0.5 LOW MG/DL .7-1.5
PHOSPHORUS 5.5 MG/DL 2.5-5.6
CALCIUM 10.6 MG/DL 9.4-11.4
MAGNESIUM 2.2 MG/DL 1.8-2.5
PROTEIN-TOTAL 6.5 G/DL 5.2-7.3
ALBUMIN 4.4 HIGH G/DL 3-3.9
GLOBULIN 2.1 G/DL 1.7-3.8
ALB/GLB RATIO 2.10 HIGH .9-1.8
CHOLESTEROL 249 MG/DL 124-344
BILIRUBIN-TOTAL <.2 MG/DL 0-.2
ALKALINE PHOSPHATASE 88 IU/L 16-140
ALT 49 IU/L 12-54
AST 21 IU/L 16-140
GGT 3 IU/L 0-6
CK 108 IU/L 43-234
SODIUM 150 MMOL/L 140-156
POTASSIUM 4.3 MMOL/L 4-5.3
CHOLORIDE 108 MMOL/L 108-122
BICORBANATE 20 MMOL/L 18-26
ANION GAP 26.3 HIGH 11.2-19.9
NA / K RATIO 34.9 27.7-35.9
OSMOLAITY-CALC. 295.4 MOSM/KG 278.7-311.6
AMYLASE 480 IU/L 236-1337
LIPASE 246 HIGH IU/L 12-147
ICTERIC INDEX 0
HEMOLYSIS INDEX 55
LIPEMIA INDEX 6

11/30/17
URINALYSIS CYCTOCENTESIS 12:12 PM REF RANGE
PHYSICAL PROPERTIES
COLOR LIGHT YELLOW
TURBIDITY CLEAR
SPECIFIC GRAVITY 1.003 LOW 1.015-1.045
CHEMICAL CHARACTERISTICS
PH 7 4.5-8.5
PROTEIN, BUMIN NEG
PROTEIN, DIPSTICK NEGATIVE
GLOCOSE NORMAL
KETONES NEGATIVE
BILIRUBIN, DIPSTICK NEGATIVE
BLOOD NEGATIVE
MICROSCOPIC EXAM
WBCS RARE /HPF
EPITHELIAL CELLS RARE /HPF
CRYSTALS-AMORPHOUS RARE /HPF
FAT DROPLETS FEW /HPF

HEMATOLOGY
WBC 5.67 X10^3/UL 4.39-11.61
RBC 8.12 HIGH X10^3/UL 5.7-8.01
HEMOGLOBIN 19.4 G/DL 13.8-20.3
HEMATOCRIT 55.7 % 39.2-55.9
MCV 68.5 FL 61.8-75.1
MCH 23.9 PG 20.2-25.3
MCHC 34.9 G/DL 30.8-35.4
RDW 12.2 % 11.3-13.5
PLATELETS 176 LOW X10^3/UL 190-468
MPV 10.7 FL 7.9-13.8
PCT 0.19 LOW % .2-.58
RETICULOCYTE % 0.62 % .11-1.26
RETICULOCYTE # 0.051 X10^3/UL
RETICULOCYTE ABSOLUTE 51000 /UL 8040-93730
PACKED CELL VOLUME 52 % 39-58
PLASMA PROTEIN 7.5 HIGH G/DL 5.9-7.3
SEGMENTED NEUTROPHILS 4.423 X10^3/UL 2.841-9.112
BAND NEUTROPHILS 0.113 X10^3/UL
LYMPHOCYTES 0.51 LOW X10^3/UL .594-3.305
ABNORMAL LYMPHS 0.284 X10^3/UL
MONOCYTES 0.34 X10^3/UL .075-.85
PLATELET CLUMPING FEW
PLT. NUMBER APPEARS DECREASED
LARGE PLATELETS FEW
SUMDGED WBCS OCCASIONAL
ANISOCYTOSIS MILD
POIKOLOCYTOSIS SLIGHT

[Harley PoMMom]

Those blood panel results are not what we usually see in dogs with Cushing's but all dogs are different so their reactions to Cushing's can be just as different as well. Is the vector borne panel one of the tests that the results are pending?

How much does Yogi weigh? I believe it was mentioned that the recommended starting dose for Trilostane, which is the active ingredient in Vetoryl, is 1 mg per pound of a dog's weight. If the dose is too high symptoms that can be seen are; vomiting, loss of appetite, diarrhea, or Yogi just not acting his normal self. If any one of these are observed an ACTH stimulation test should be performed to make sure the cortisol hasn't dropped too low.

Also, most clinicians recommend leaving the starting dose unchanged for around the first month of treatment, this is because cortisol levels tend to continue to drift downward during the first month, even when the dose is left unchanged. Please keep us updated.

Lori

[AngieB]

Yes, the vector borne panel is one of the results that are pending.

Yogi weighs close to 58 pounds, so I think the dosage of 60 mg (30 mg every 12 hours) seems in line. I will keep an eye to see if any symptoms appear. Thanks for that info on keeping the dosage unchanged!

Angie

[AngieB]

Yogi had his ACTH Test after 11 days on Veteroyl (30 mg every 12 hours for a 60 pound dog. Here are the results:

Cortisol - Pre ACTH 4.1 ug/dL
Cortisol - Post ACTH 12.5 ug/dL

These were at my regular vet and she is going to forward these to NC State Internal Medicine (ICM) for response. She noted that he may need to go up in dosage, and NCSU would need to respond. NCSU (the ICM) has not yet responded re: the other testing that they did re: the low platelets and bloodwork not entirely consistent with Cushings.

He appears to now be able to go 3.5 hours without urinating - most times, but not all. Otherwise, he seems like he has not changed symptom-wise.

Are there any questions I should ask?

Angie

[Harley PoMMom]

Although his post result isn't within the therapeutic ranges I still wouldn't increase the dose as cortisol can continue to drift downward during the first month of treatment. I would also want to wait until the vector borne panel results are known. Are they planning to do another urine culture to make sure that the UTI is completely gone?

Lori

[AngieB]

The vector borne panel results came back negative, and the ICM does not know why his platelets are low and other unusual bloodwork. The ICM has no action plan re: that and only reached out through the receptionist after 3 tries to follow up. The information I got from her was reading the communications log from NCSU to my regular vet.

The ICM did respond to the ACHT test and reached out to my regular vet, who later emailed me. The ICM advised my regular vet to increase Yogi's dosage to 40 mg Vetoryl every 12 hours instead of 30 mg very 12 hours. It took me four calls to confirm the correct Rx to pick up, which was concerning.

At this point, I am getting my new Rx from my regular vet and have a follow up with the ICM on Nov 20th. Neither addressed the UTI, so per your recommendation, I requested the regular vet do another urine culture to make sure the UTI is completely gone. I will take this in today and pick up the new Rx.

Bottom line - I'm not confident I have the right care team at this point. It feels like ping pong between the two and I my goal was to transition to one point of care with the ICM. If they do not have availability, I may need a new provider.

Is this craziness with multiple providers what other people experience?

Angie

[Squirt's Mom]

With the ITU in play PLUS having started Vetoryl less than 30 days ago, no way I would increase his dose now.