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Thread: Potential Cushings diagnosis

  1. #21
    Join Date
    Sep 2018
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    Default Re: Potential Cushings diagnosis

    Hi,
    Just wanted to check in with an update. After several dose increase, we've seen some noticeable improvements in her PU/PD (PU is pretty much gone, PD is slightly elevated still but much better). We're randomly panting less (although still has some occasional bits of panting), and overall she's been much more sociable and less irritable. Still waiting for the fur to grow back, but I expect that will take some time. Her incontinence has also improved somewhat. She still seems to have some bits where her cortisol levels seem high, seems kind of episodic, but overall she's having more good days than bad days. Is this the right dosage now, or should I expect all the symptoms to be gone? I've kind of been waiting to see if her fur starts growing back to confirm we're at the appropriate dose, since her ACTH tests don't seem to show much effect after various dose changes. Any thoughts? She's currently at 30 mg twice a day (she's a 23 kg dog). Overall I'm pretty happy with her current dose, but am curious about the meaning of her ACTH tests (results are below). Thanks!

    ACTH Results (vetoryl dose, pre-values, post-values)
    10 mg 1x/day 3.9. 9.7
    20 mg 1x/day 5.0 7.7
    20 mg 2x/day. 4.0. 10.2
    30 mg 2x/day. 1.6 9.5

  2. #22
    Join Date
    Apr 2009
    Location
    York, PA.
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    11,037

    Default Re: Potential Cushings diagnosis

    Improvements usually aren't seen in their fur until at least 6 months of treatment has occurred, and sometimes their fur may look/feel different (curlier, different color. etc.). A few questions regarding her ACTH stimulation tests, is she getting the Vetoryl with a meal? And the timing of the tests, are they being done 4-6 hours after the Vetoryl has been given with a meal and are they being performed around the same time? What I mean about the time, as an example: if her first ACTH test was done at 11 am, were all other tests performed close to that time?

    Lori

  3. #23
    Join Date
    Sep 2018
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    14

    Default Re: Potential Cushings diagnosis

    Thanks! I'll hold off on looking for the fur improvements for a little bit then. She does always get the vetoryl with a full meal, although I'm not very confident that the vet is performing the ACTH testing at a consistent time (or even precisely within the 4-6 hr window).

  4. #24
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    Apr 2009
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    York, PA.
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    11,037

    Default Re: Potential Cushings diagnosis

    I firmly believe that ACTH numbers are not the sole guide of how a dog is doing on Vetoryl. The goal of treatment is to control the clinical symptoms of Cushing's, so since Bella's symptoms have improved, if this were me, I wouldn't get so stressed about those ACTH stim results, I realize that may be hard to do and we're here for you.

  5. #25
    Join Date
    Apr 2009
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    Georgia
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    15,292

    Default Re: Potential Cushings diagnosis

    Quote Originally Posted by Doggy_David View Post
    Thanks! I'll hold off on looking for the fur improvements for a little bit then. She does always get the vetoryl with a full meal, although I'm not very confident that the vet is performing the ACTH testing at a consistent time (or even precisely within the 4-6 hr window).
    Hi David,

    I do agree with Lori that a dog’s clinical appearance is generally equally as important as test results. But given those ACTH results, I encourage you to confirm with your vet the exact testing protocol that is being followed. Those test results are really weird — I just don’t know any other way to say it. It is very strange to me that the post-ACTH numbers show very few changes whatsoever after increasing the Vetoryl dose from 10 mg. to 60 mg. as a daily total. That’s a *big* dosing increase, and I really can’t fathom why you’d see virtually no effect on the post-ACTH cortisol level. The resting cortisol level is lower on this final test, and actually you don’t want it to drop much lower. But the post-ACTH results are really puzzling.

    Something about this doesn’t seem right, and if you have doubts as to whether your vet is performing the test properly, that’s the first place I’d start. Has your vet commented at all on the apparent lack of testing response to the dosing increases? Are you still using brand name Vetoryl at this point?

    Marianne

  6. #26
    Join Date
    Sep 2018
    Posts
    14

    Default Re: Potential Cushings diagnosis

    Thanks for the comments. I've been less worried since the clinical signs are *mostly* improved, but those results have also been very puzzling. Bella's primary vet at the practice doesn't really seem to have much experience with Cushing's (one of the other doctors seems to have more experience, but has been out the past two months). They are still basically viewing the ACTH test results through the lab provided "good" ranges, not taking into account that modified test ranges for dogs on vetoryl, so they have basically viewed almost all of the results as being acceptable. We've been using brand-name vetoryl the whole time (either combinations of the 10mg pills or now the 30 mg pills). I am planning a follow-up with Bella's internal medicine specialist, so I will see what they say about the results history. When last I saw them they recommended the switch to 2x/day vs 1x/day.

    Overall, the only concern is that her cortisol still seems to flare up periodically. She'll be doing great for a week (minimal panting, no incontinence, etc), then have several days where she's panting more, leaking more urine again, etc. Overall its still definitely much improved and she's acting much happier, but I do get concerned when she still has these "down" patches.

  7. #27
    Join Date
    Sep 2018
    Posts
    14

    Default Re: Potential Cushings diagnosis

    Hi all,
    Following up with an update and a question. Bella's been on a 40mg 2x/day dose of Vetoryl for the past 6-7 months and has been doing great. Her fur has grown back in, her energy level and personality are back, it's been a dramatic turnaround from the pre-Cushings treatment days. The only catch is that she has started having some recurring diarrhea issues over the last few weeks. Diarrhea starts up, we get her seen, her electrolytes look fine so they put her on metronidazole, the diarrhea clears up, but a few days to a week after ending the metro, the diarrhea returns. This has happened 3 times now. I know that diarrhea is a common side effect of too large a dose of vetoryl, but she'd been stable on the current dose for many months. Anyone else have experience with issues occurring after long periods at the same dose?

    If it occurs again we're doing an early ACTH stim test (had her last 3-4 months ago, it was 1.2 and 2.3, which according the vetoryl documentation is ok), but trying to get a grip on whether this is the likely culprit. She has no other symptoms other than the diarrhea when this occurs (no fever, etc). Would've done the ACTH sooner, but electrolytes and behavior were fine and the test is just so expensive. After talking with vet we did lower her dose of vetoryl to 30mg 2x/day with so far no return of the incontinence/panting/extra water intake that are her initial high cortisol level symptoms.

  8. #28
    Join Date
    Apr 2009
    Location
    Georgia
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    15,292

    Default Re: Potential Cushings diagnosis

    Welcome back to you and Bella. It’s great to hear that, overall, she’s been doing so well. However, I think it’s safest if you repeat the ACTH right away if the diarrhea occurs. Back when you posted in April, this had been the ACTH monitoring history up until that point in time:

    ACTH Results (vetoryl dose, pre-values, post-values)
    10 mg 1x/day 3.9. 9.7
    20 mg 1x/day 5.0 7.7
    20 mg 2x/day. 4.0. 10.2
    30 mg 2x/day. 1.6 9.5
    Now her most recent test 3-4 months ago had dropped clear down to 1.2 and 2.3. That is a significant drop from all those previous readings, without much wiggle room to go even lower. Trilostane doses frequently do need to be modified over time, both up and down, and that’s why the manufacturers of Vetoryl recommend that cortisol testing be performed every 3 months throughout the lifetime of treatment.

    You had mentioned earlier that you had doubts as to whether or not your vet had been conducting the ACTH testing within a proper and consistent timeframe. This time around, I encourage you to confirm beforehand that the test will be run 4-6 hours after the morning dose of trilostane is given along with a full breakfast. Good luck, and we’ll be anxious to hear the results!

    Marianne

  9. #29
    Join Date
    Mar 2009
    Location
    rural central ARK
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    14,549

    Default Re: Potential Cushings diagnosis

    In addition to what Marianne said about the testing....it should also be done around the same time every time. So if Bella had the firs test at 10AM then all the ACTHs following need to be done as close to 10AM as possible. This way the cortisol is tested at around the same level in the body every time since Vetoryl has such a short life. Varying testing times means the cortisol level is varied making it hard to get a true picture of how well the drug is working.
    "May you know that absence is full of tender presence and that nothing is ever lost or forgotten." John O'Donahue, "Eternal Echoes"

    Death is not a changing of worlds as most imagine, as much as the walls of this world infinitely expanding.

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