15 yr old Maltese just diagnosed. So overwhelmed! Vetoryl questions

[Harley PoMMom]

Im worried for the stim. I hope she doesn’t have a bad reaction. Is this possible? I haven’t discussed any specifics with the vet regarding the stim. What is it? Can she get sick!?!

The "stim" is the ACTH stimulation test and is used to monitor dogs taking medication for Cushing's (it is also performed for other diagnostic purposes). An ACTH stim test contains synthetic forms of ACTH (Adrenocorticotrophic Hormone) such as Cortrosyn, ACTHAR gel, or another agent called Synacthen, ACTH and the synthetic forms of ACTH stimulates the adrenal glands to release Cortisol.

In an ACTH stim test a sample of blood is taken from an animal (the "pre-level"); then the animal is injected with a small amount of the synthetic form of ACTH, a second blood test is taken an hour later (the "post-level") to measure the change in circulating cortisol. The results of the two blood tests are then compared.

Some dogs do have a reaction to the ACTH stim test, they may become restless or agitated.

Lori

[Maggiemoo1]

Well the 5 mg is not sufficient. The results from the stim are

Pre 2.4 ug dL
Post 15 ug dl

Vet wants to start another 5 mg at night for total of 10 mg day

The diarrhea finally stopped! I’m not sure if it was the pumpkin or her little body getting used to the vetoryl. We are going to increase her dose on Friday just in case the diarrhea starts again so we can be around with her all weekend.

Any thoughts?!?

[labblab]

The standard recommendation is *not* to increase a Vetoryl dose until the first month of treatment has been completed. This is because cortisol levels can continue to drift downward during that time, even when the medication dose is unchanged. Thus, you can more accurately judge whether, and how much, the medication should be increased by waiting until the 30-day test results are in.

If I’m calculating correcting, this first monitoring ACTH test was performed after 2-3 weeks of treatment. So the general recommendation would be to hold off on an increase for a bit longer. However, your internist may feel that an earlier increase is warranted since Maggie’s initial dose was reduced due to the diarrhea, and her post-ACTH number is still relatively high. His decision is not crazy, by any means. However, in honesty, due to the diarrhea issues, I personally would prefer waiting a while longer to institute the increase. That’s great that the diarrhea has stopped, and I would want to give her a bit longer to stabilize further before upping the dose. This is just my laypersons opinion, but I don’t think you have a lot to lose by allowing her to plateau for a couple more weeks, and much to gain if this eases her GI system. I would repeat the ACTH in a couple more weeks, and wait until then to increase the dose if her GI system remains stable and the test results still suggest that fully doubling her dose seems appropriate.

And BTW, thanks so much for the info re: the CBD chews!

Marianne

[fkhan]

Well the 5 mg is not sufficient. The results from the stim are

Pre 2.4 ug dL
Post 15 ug dl

Vet wants to start another 5 mg at night for total of 10 mg day

The diarrhea finally stopped! I’m not sure if it was the pumpkin or her little body getting used to the vetoryl. We are going to increase her dose on Friday just in case the diarrhea starts again so we can be around with her all weekend.

Any thoughts?!?

I'm not licensed or a pro, but the post seems really high for sure. Pookie's post only doubled, which my vet said didn't mean she had Cushing's. Your post is over 6 times, which seems like alot. My vet also was going to start Pookie at 10mg and her tests were not as high as yours. I agree with the waiting period, but given the post number and your vets recommendation, I would probably follow their orders. It would also depend on your dogs clinical signs. I would take that into account with what your vet is saying, before increasing the dose. I hope it works out whichever way you choose, because I'm right around the corner from where you are. I would also inquire about keeping a steroid injection on hand and ask your vet what signs to look for during an Addisonian crisis if god forbid one did occur. Just so you are ready to help your pooch if need be.

[fkhan]

I'm not licensed or a pro, but the post seems really high for sure. Pookie's post only doubled, which my vet said didn't mean she had Cushing's. Your post is over 6 times, which seems like alot. My vet also was going to start Pookie at 10mg and her tests were not as high as yours. I agree with the waiting period, but given the post number and your vets recommendation, I would probably follow their orders. It would also depend on your dogs clinical signs. I would take that into account with what your vet is saying, before increasing the dose. I hope it works out whichever way you choose, because I'm right around the corner from where you are. I would also inquire about keeping a steroid injection on hand and ask your vet what signs to look for during an Addisonian crisis if god forbid one did occur. Just so you are ready to help your pooch if need be.

I was also curious on what your dogs diet is? I am just starting to try this:
https://www.drharveys.com/products/d...erfood-pre-mix for Pookie. They appear to have a great response with helping you with diet considerations to consider for your pet. I'm going to take their advice and try it.

[labblab]

Evaluating the results of an ACTH stimulation test can be very confusing, that’s for sure. This is especially true because the test can be used either for diagnostic purposes prior to beginning Cushing’s treatment, and also for monitoring purposes subsequent to starting either Vetoryl or Lysodren. Depending upon the purpose of the test — diagnostic vs. monitoring — the desired reference ranges for the post-ACTH results are very different. For diagnostic purposes, you have to check the actual printed “normal” range for the lab that has performed the analysis. But even though 15 ug/dL may seem high, for most labs that value generally still falls within the normal diagnostic range for a dog that does not have Cushing’s.

In Maggie’s case, though, the test is instead being used quite differently to monitor the appropriateness of the Vetoryl dose once treatment has begun. In this situation, a post-ACTH result as high as around 9 ug/dL is considered acceptable as long as symptoms appear to be well-controlled. If symptoms persist, a lower post-ACTH result is recommended. So as we can see, after 2-3 weeks of Vetoryl treatment, Maggie’s cortisol is higher than the “cut-off” of 9. However, it may still drop lower over the next couple of weeks even if the dose is unchanged.

Also, just as a side note, in terms of Cushing’s, laboratories don’t make a diagnosis based on how much higher the post-ACTH result is than the initial baseline cortisol level. Instead, when diagnosing Cushing's, they compare the post-ACTH result to an expected range for that result alone. Baseline cortisol levels can be highly variable for any given dog, and therefore don’t have as much value as part of a diagnostic ACTH stimulation test for Cushing’s. Baseline cortisol does have a more prominent role in the ACTH when Addison’s is suspected, and also when interpreting the results of a diagnostic LDDS test. But not so much for a diagnostic ACTH test for Cushing’s.

[fkhan]

Well the 5 mg is not sufficient. The results from the stim are

Pre 2.4 ug dL
Post 15 ug dl

Vet wants to start another 5 mg at night for total of 10 mg day

The diarrhea finally stopped! I’m not sure if it was the pumpkin or her little body getting used to the vetoryl. We are going to increase her dose on Friday just in case the diarrhea starts again so we can be around with her all weekend.

Any thoughts?!?

Did you get the lab results as to what is normal for the post? If not, I would ask for it. I wish all labs used the same standard. It just makes us cush parents more confused and stressed.

[labblab]

In Maggie’s case, since the ACTH is being used for monitoring purposes rather than diagnostic purposes, the lab’s printed norms may or may not be relevant to her situation. Many times, the printed lab norms only reflect test results when the ACTH is initially being used to diagnose whether or not a dog suffers from Cushing’s (or Addison’s Disease). The printout may not list the desired range after treatment has begun.

In Maggie’s case, we are instead guided by the therapeutic recommendations published by Dechra, the company that manufactures brand name Vetoryl. Here’s a link to a Dechra publication that offers a testing/monitoring/dosing flowchart that is applicable to dogs being treated with Vetoryl (trilostane). This flowchart reflects the post-ACTH testing norms that we all refer to after trilostane treatment has begun:

http://www.dechra.us/Admin/Public/Do...US-046-TEC.pdf

[Maggiemoo1]

Thank you everyone for your thoughts and suggestions!

The internist said a dose increase is usually not made until the second check but he felt (and dr b agreed) that in this instance her initial dose was just too low. As you pointed out we did that because of the GI issues.

I initially wanted to keep her at this dose but given her blood pressure is still very high I’m concerned about the other damage this terrible disorder is causing. I want to get this under control and I know that I’m going to have to increase at some point so we bit the bullet and did it today. Fingers crossed no GI issues.

We will retest in 30 days. Just to be sure is it 30 days from today or from her last stim?

[labblab]

The internist said a dose increase is usually not made until the second check but he felt (and dr b agreed) that in this instance her initial dose was just too low. As you pointed out we did that because of the GI issues.

I initially wanted to keep her at this dose but given her blood pressure is still very high I’m concerned about the other damage this terrible disorder is causing. I want to get this under control and I know that I’m going to have to increase at some point so we bit the bullet and did it today. Fingers crossed no GI issues.

We will retest in 30 days. Just to be sure is it 30 days from today or from her last stim?

That’s pretty much what I had guessed — that the internist is basing this increase on Maggie’s extenuating circumstances. I can’t argue with that, especially since Dr. B agrees ;-). It’s very good to know, though, that he’s explained his reasoning to you.

As far as the retesting, usually the 30-days are counted from the very first day of dosing. So the first test is done 10-14 days after starting treatment, and the second test is done 30 days after starting treatment. In Maggie’s case and considering the dosage change, I’m not sure exactly what the internist has in mind. But don’t be surprised if he does want to proceed with another test as soon as two weeks from now. If not, I wouldn’t think he’d want to wait beyond 30 days from the last test, but I’d contact him to find out for sure.

Marianne