Cushing’s diagnosos 14+ yr old Vizsla - Vetoryl start dose?

[cken]

Hello, We have a 14 1/2 yr old Vizsla (Rumor) . Her appetite, water guzzling, weight , urination, panting, all increased rapidly over 4-8 wks so we took her into the vet for lab work. She was a lean 36 lbs but jumped to 42 very noticeably and she has been very unsettled in comparison. We just found out yesterday as suspected a Cushing’s diagnosis (pituitary dependent). She had been other wise healthy active and well for a dog of advanced years and still liked her long walks and runs so if he can help her comfortably in her twilight years

We’ve read up a bit about Vetoryl dose and the followup testing. The vet isn’t in today but the tech said she wanted to start with a 60 mg dose. This surprised me since she said she would start low yesterday. Based what I’ve read this seems a good bit higher than the 1 mg/lb. Does 60 mg seem right or high for a starting dose for a 36-43 lb ? Is it better to start low and adjust up or vice versa if necessary? Does it depend on her numbers. Baseline precort=8 vs 4hrs=3.4, 8hrs=4.7

TIA and glad we found this site.

[labblab]

We’ve read up a bit about Vetoryl dose and the followup testing. The vet isn’t in today but the tech said she wanted to start with a 60 mg dose. This surprised me since she said she would start low yesterday. Based what I’ve read this seems a good bit higher than the 1 mg/lb. Does 60 mg seem right or high for a starting dose for a 36-43 lb ? Is it better to start low and adjust up or vice versa if necessary? Does it depend on her numbers. Baseline precort=8 vs 4hrs=3.4, 8hrs=4.7

Hello, and welcome! To cut to the bottom line, I would not feel comfortable starting a dog of your girl’s weight on a 60 mg. dose. Your reading is exactly correct. The currently accepted formula is to start at a dose that does not exceed 1 mg. per pound. In order to lessen the risk of overdose or unwanted side effects caused by significantly lowering cortisol levels quite rapidly, it is indeed much better to start low and work upward rather than vice versa.

There’s also a practical reason as to why it’s better to start with smaller dosage capsules rather than larger dosages. This is because you can always combine smaller capsules if dosing increases are warranted. But you cannot open and divide a larger capsule if the dose needs to be decreased. Especially given her age and the fact that you’re hoping to keep your girl as comfortable as possible through this process, I’d honestly advocate for starting at a dose of 30 mg. As I say, you can always combine additional 10 or 30 mg. capsules should an increase be warranted. Two boxes of 30 mg. capsules will indeed cost more than one box of 60 mg. capsules. But you’ll have greater confidence that all the 30 mg. capsules can be put to use over time as you arrive at a stable, longterm dose.

And lastly, no, the diagnostic test result numbers do not influence the recommended starting dose. That decision is based on weight alone. Since dogs respond very individually to the medication, all subsequent decisions are then based on monitoring blood testing in combination with observed symptom resolution. Some small dogs may end up needing larger doses than big dogs, based on their individual physiological response. But in starting off, you’re looking at weight alone.

Once again, welcome to you both!
Marianne

[cken]

This makes sense to me. I’m more concerned with quality of life for her and getting this started than drug costs at this point in her twilight years. 30+10 makes sense for now and once we are started we can find the better price.

Thanks much.

[cken]

We are just starting the dosing on our dog Rumor and didn’t want to delay starting so we went with the Vet clinic drug stock for now and the drug cost were almost triple what it can be purchased for elsewhwere. I understand clinics charge more but almost triple? ... Since changing hands their drug costs are crazy high but we will get the Vetrosyn elsewhere next time.

But I also suspect this Vet clinics labs are way higher too...?

The recommended testing at 10-14 days is the ACTH pre and post cortrosyn stim ($377)
Electrolyte ($40)
Chem17 panel ($105)
Total $522.

I haven't yet broached the pre Vetrosyn cortisol test alternative with them. It this still not done in the US routinely? Communication with this new vet in these COVID times is tough right now, but I will be calling around for alternatives if these costs seem out of line for Central Florida. The former vet was excellent.

Thanks for any thoughts or advice on this testing plan and costs of they seem out of line.

Ken

[Harley PoMMom]

Hi and a belated welcome to you and Rumor!

It would seem to me that the Chem 17 panel would have the electrolytes included, so you wouldn't need to have the electrolytes done separately which would save $40. Now, if you have had a Chem 17 panel done recently I would only have the electrolytes done along with the ACTH stimulation test.

I also want to include a link from our Resource forum that has cost saving ideas for parents with cushdogs: https://www.k9cushings.com/forum/sho...096#post211096

If this were me, I would start Rumor at a Vetoryl dose of no higher than 30 mg, because there is a published study that has found that larger dogs require less of the recommended dose of Trilostane (active ingredient in Vetoryl) to control cortisol, here's a link to that study:https://onlinelibrary.wiley.com/doi/...6.2012.00956.x

Welcome to our family and please do not hesitate to ask all the questions you have, and know we will help in any way we can.

Lori

[cken]

Thanks Lori, I did see the info earlier on cost saving ideas and one is the “pre-Vetoryl cortisol monitoring as an alternative to the ACTH test, which is why I referenced this above. Simpler, and less expensive. The argument for this approach (cost aside) also seems to make sense.

https://www.dechra.co.uk/therapy-areas/companion-animal/endocrinology/canine-hyperadrenocorticism/vetoryl-monitoring-1?utm_source=directmailing&utm_medium=link&utm_cam paign=PreVetorylCortisolSuperPage

https://www.dechra.co.uk/therapy-are...l-monitoring-1 .

Apparently more accepted in the UK. But is anyone here in the US doing this routinely.

[labblab]

It would seem to me that the Chem 17 panel would have the electrolytes included, so you wouldn't need to have the electrolytes done separately which would save $40. Now, if you have had a Chem 17 panel done recently I would only have the electrolytes done along with the ACTH stimulation test.

I wanted to first start off in total agreement with what Lori suggested above. The two electrolytes that you’re most concerned about in relation to Vetoryl are postassium and sodium. Those values ought to be included on a comprehensive blood chemistry panel, anyway, so it would be duplicating the testing to run both panels simultaneously.

As far as how commonplace the pre-pill testing has become in the U.S., I’m afraid I really can’t say. We’ve had a few members who have introduced the procedure to their vets, and are continuing to use it subsequently as an available option as long as everything is looking stable. But we probably haven’t yet had anybody come here whose vet has suggested it first, on their own.

By the way, what dose of Vetoryl did you settle on using?

Marianne

[cken]

By the way, what dose of Vetoryl did you settle on using?

Marianne

Thanks for the responses Lori and Marianne,

We started Rumor on 40mg just under 1 mg/lb. We reconnected with Rumor’s breeder who is also a veterinarian and very experienced and focused on this breed and she thought it was a conservative place to start. So far Rumor is handling the dose OK after a few days. Not getting us up a few times a night now which the biggest improvement, not throwing up, still loose stool even on a rice chicken, whole fat cottage cheese diet. A bit less anxiety and definitely less panting, breathing less noisy..., still has an increased appetite and water guzzling though and still more sensitive to the Florida heat. Its only been a few days. Should we drop the 10mg down to just 30mg or stay the course?

BTW, These were her elevated liver enzymes. ALT: 608 ALP: 1618. GGT: 43. Everything else was in range. How concerning is that?

Thanks,

Ken

[labblab]

Hi again, Ken. From the reaction you’re describing, I think it’s fine to stick with the 40 mg. until Rumor is tested. And I just want to make sure you’ve been advised to give Rumor her Vetoryl alongside a full breakfast. Vetoryl must be given with food to be metabolized properly. Also, the same holds true on the day of her monitoring ACTH test. She should *not* be fasted, or else you run the risk of a cortisol reading that is falsely skewed upward (because the Vetoryl was not metabolized efficiently that morning). Because she needs to be fasted for the ACTH, your vet may choose to hold off a broad chemistry panel until another day since some of those values, such as glucose and cholesterol, do require fasting to be accurate. If only the basic eletrolytes (e.g., potassium and sodium) are to be checked, however, I don’t think they’d be affected by food. That’s something you can check on.

As far as Rumor’s liver elevations, yes, we do commonly see increases in those enzymes. ALP can be dramatically elevated, even higher than this. You’ve not given the normal range for the ALT or GGT, but I’m assuming these are more moderate elevations. These elevations do not necessarily signal functional liver damage, but rather just the effect the steroid (cortisol) is having on her liver. Effective Cushing’s treatment can lower these elevations, but sometimes Cushpups never do completely resolve back to baseline. But that’s typically not cause for significant worry.

Marianne

[cken]

Thanks much for the advice Marianne. I think I misunderstood the starting at 30mg and after discussion with with Rumor breeder/vet who thought 1mg/kg to start for a Viszla (not large) . One 30mg would certainly be better and cheaper if she responds but here we are on 40mg and doing OK and better. She had a more normal-ish poop today this morning finally. We are certainly giving the drug with a full breakfast and adding some whole milk cottage cheese for a bit of fat and know we don’t want to change that for the 10-14 day test.

I will ask about the Chem17 separately with fasting. I will also ask about the pre-Vetoryl cortisol level in what we hope is a maintenance mode.

Here are those liver numbers with ranges. I wish I could figure out how to attach images here.

ALT: 608 Normal Range 10-125
ALP: 1618 Normal Range 23-212
GGT: 43 Normal Range 0-11

Thanks much again.

Ken