Buddy - How long should it take for the Vetroryl to reduce the symptoms?

[MichelleBuddy]

Thank you so much for the information.
I have left a message with our vet to talk later this week. He is not finishing his breakfast in the morning, but I think he is just 'off'. He is focused on getting outside to urinate, getting water and eating all at once.
His stools are normal and all else is good.
It is just the need to drink so much and urinate.

[lulusmom]

Hi and a belated welcome from me too.

I went through your posts and there are some inconsistencies that I would like to clarify. You mention that Buddy's only symptom of cushing's is his excessive drinking and peeing. You then mentioned the urine test was normal. If Buddy's drinking and peeing is caused by cushing's, the urine test would not be normal. The urine specific gravity would be low in which case a culture should have been done to rule out a urinary tract infection. Actually a culture is routine for any dog suspected of cushing's as a fair amount of cushingoid dogs have a UTI at the time of diagnosis. Can you recheck the results and let us know what the USG number is and whether a culture was done? I also see that only the ALT and SAT are abnormal. These are liver specific enzymes that can be mildly elevated by liver problems. It is the ALKP that almost always is moderately to severely elevated in dogs with cushing's. Can you please look at the blood chemistry and reconfirm that the ALKP (aka ALP) is normal? Thirdly, the results of the LDDS is consistent with cushing's but unfortunately because Buddy had very little suppression at 4 and 8 hours, we can't tell if he has pituitary dependent cushing's or an adrenal tumor. With so few symptoms and lab abnormalities that don't raise a lot of red flags for cushing's, your vet should have suggested an abdominal ultrasound to make that determination as well as look for the usual liver and adrenal gland abnormalities that would validate the results of the LDDS. Validation is important as this test can yield false positive results if there is a non-adrenal illness that has not been ruled out or even extreme stress in highly anxious dogs. Did Buddy have an abdominal ultrasound done and if so, can you share the interpretation with us? I'm not saying Buddy doesn't have cushing's, I'm saying that based on the information you have shared, his case is far from textbook. I was also concerned about the large dose that was prescribed and I'm happy to see that Buddy isn't one of those large dogs that is uber sensitive to Vetoryl. However, there is always a possibility that could change so keep a close eye out for signs of low cortisol. Are you giving the Vetoryl with a meal in the morning and was his acth stimulation test done 3 to 5 hours after dosing with a meal? Sorry for asking so many questions but it's difficult to provide appropriate feedback without putting all of the pieces of the puzzle together. I look forward to your response.

Glynda

[MichelleBuddy]

Hi Glynda,
I am very happy for all of your questions and I thank you for them!

So I should be clearer. He did have a very low concentration of urine. So - yes that was not normal. But as for the culture that came back normal and just in case that the low concentration of urine was hiding an infection, we did put him on antibiotic treatment. So the culture was normal but his concentration is very low.

And you caught an error in my reporting so I apologize. His ALT was 148 and his ALK was 297 - so I reported it wrong.

The vet did suggest an ultrasound, but right now I can't really afford it. I am sorry to say that. She also said we could have one done and it could come back inconclusive.

I do give him his dose first thing in the morning with his breakfast. He is very normal except for his needing to drink large amounts and go out every 2 - 3 hours.

Also the Acth test was done after a dosage and a meal.

Lately he is not thrilled with eating his whole breakfast. He eats about 5/6 of it and leaves a little behind. But within 2 hours he is ready to finish his meal. He still has a wonderful appetite and is still very active.

I appreciate all the help you are giving me. I am also keeping a very close eye on his health. We can't leave him for long because he has to go out so often.

Thank you - please keep the questions coming.
I have a call into his vet also.

[Harley PoMMom]

Could you check on his chemistry blood work panel and see if his creatinine level is normal? Also, diabetes can come on suddenly in dogs with Cushing's, which makes them drink/urinate more, so you may want to ask the vet to have his blood sugar checked.

Lori

[MichelleBuddy]

Hi Lori,
His Creatinine levels are normal - .8

His glucose is also normal 113
And not sugar was found in his urine.

Please keep the questions coming.

I just talked to the vet and asked more questions. We are hoping to see a change soon (honestly it is exhausting as many of you know.) He goes out every 2 - 3 hours. Also I am going to give him some anti anxiety meds at night to help him sleep more.

Thank you everyone for your support!

[Squirt's Mom]

In a prior post you had asked about the DI - diabetes insipidus - that someone mentioned. Here is the link I posted just to make sure you see it -

https://vcahospitals.com/know-your-p...ipidus-in-dogs

And a few more links -

https://www.merckvetmanual.com/endoc...etes-insipidus

https://www.diamondbackdrugs.com/dea...us-in-animals/

https://www.vin.com/apputil/content/...147&id=3846170

The test for DI is a water deprivation test and is rather risky so many vets simply start treating. If the treatment takes care of the signs and abnormal labs then there is the diagnosis. Treatment is easy - nasal drops. So check out these links and see if they could fit Buddy. His Cushing's diagnosis is questionable in my mind. It's worth looking into and talking over with his vet if you think it fits his profile. Remember - DI and Cushing's share signs so it is easy to confuse the two.

[MichelleBuddy]

I specifically asked the vet this questions and she stated that he did not have DI. His glucose is normal and there are no proteins found in his urine. I do know he has a low concentration of urine given because we did run that test. I think it was somewhere like 1.008? I don't have those notes in front of me.

Should I be asking more questions along that line?

He was given the 8 hour test for Cushings where his Cortisol level never went down after the injections of the synthetic. To me that is a sure sign of Cushings and my vet said he is definitely Cushings given that test.

Could I be missing something else?

I plan on talking to her again maybe at the end of this week or next. What other questions should I be asking in terms of DI? His only sign is the drinking and excessive urine. Would something else in his CBC or urine test point to DI?

[MichelleBuddy]

Hi
I am newly concerned. Buddy's appetite has decreased.
He did eat his breakfast, but it took two tries. The initial feeding and a second feeding an hour later.
And for the first time ever he spit out part of a banana.
I was shocked.

Advice?

[labblab]

As Lori warned earlier, my worry right now would be that Buddy’s cortisol may be dropping too low for comfort on his 120 mg. dose. I know the ongoing thirst/urination remains an issue, and makes you wonder whether his Cushing’s remains somewhat out of control. But as other folks have suggested, there may be other factors that are affecting the thirst/urination. On the other hand, this worsening inappetance — which seems likely to be directly related to the trilostane — is decidedly a concern. Even if Buddy’s cortisol level is not low enough to actually be a safety issue, it may be the case that a dramatic decrease in cortisol over a short period of time may make him feel unwell. This is one reason why we encourage folks to start at a lower dosage and work upward if need be, rather than vice versa. Starting lower allows a dog to adapt to the endocrinological changes more gradually and more comfortably.

Bottom line: I would give no more trilostane until you can report the inappetance to your vet. Since this can be a symptom of a cortisol level that has dropped too low, I would not resume dosing until Buddy’s appetite normalizes. And even then, likely at a lower dose for at least the first month of treatment.

Perhaps Buddy is doing better this evening, and our worry is unfounded. But if not, I would give no more trilostane until you can get this sorted out.

Marianne

[Squirt's Mom]

I specifically asked the vet this questions and she stated that he did not have DI. His glucose is normal and there are no proteins found in his urine.

Blood glucose has nothing to do with DI...that is related to DM - diabetes mellitus. It is concerning that this vet doesn't know the difference!